Fri January 13, 2012
A Doctor Tells All in 'Confessions Of A Surgeon'
IRA FLATOW, HOST:
This is SCIENCE FRIDAY. I'm Ira Flatow. Up next, "Confessions of a Surgeon." Have you ever sat in your doctor's office, you know, doctor's going down that long list of aches and pains, and have you ever thought to yourself: I wonder if he's really listening to me. Well, at least one doctor has confessed to not always paying attention to what his patients say.
That revelation is just one of the many secrets spilled in a new book, "Confessions of a Surgeon." I think we need music to wail up on - "Confessions of a Surgeon." And then the book is by surgeon Paul Ruggieri. He takes us behind the operating room doors, a place many of us have been but a few of us know much about because, you know, once you get in there and you start counting backwards, the lights are out, and you don't know what's happening.
Well, this book is eye-opening, and at times it's actually brutally honest in looking at what it's like to be a surgeon. Paul Ruggieri is a surgeon in private practice in Rhode Island. "Confessions of a Surgeon: The Good, the Bad, and the Complicated: Life Behind the OR Doors." Welcome to SCIENCE FRIDAY, Paul.
DR. PAUL RUGGIERI: Thank you, thank you very much. Just to correct one thing, I practice in Massachusetts.
FLATOW: Oh, you've moved.
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RUGGIERI: No, I didn't move. Massachusetts.
FLATOW: OK, we'll get that right. And this is an example of - you are brutally honest in your book. You know, you talk about your mistakes, your worries about malpractice, making your mortgage. Why are you willing to confess when other doctors are not?
RUGGIERI: Well, I've been wanting to write this book for a very long time. I want to give people an honest view of what I do and what many like me do on a daily basis. And it finally came to fruition. Surgeons are human beings. I wanted to educate the public that we are human beings.
And we're put often in extraordinary circumstances, to make life-and-death decisions quickly, and we have to. We have to do something. And this is - this is our job every day. This is what we face.
FLATOW: So you, like in any profession, you make mistakes.
RUGGIERI: Correct, as a human I'm imperfect. I'm not perfect every day. As much as I would like to be, because I know when I'm not perfect, people get hurt. People suffer. But we strive to be perfect, and most of us are perfect every day. That's the beauty of it. Surgery is so safe in this country, and most of us are perfect every day, and we have to be.
FLATOW: Is the surgeon that we're likely to face if we need surgery, you know, one of these storybook celebrity surgeons, or are they going to be just sort of a middle, average surgeon?
RUGGIERI: Most of us are regular people who are dedicated to what we do. I mean, we have families. We have hobbies. Most of us are regular people who are dedicated to our profession.
FLATOW: You talk in your book, let's talk about some of the things that you mention in your book. You talk very openly about a mistake you made. You were taking out a colon cancer, and when you stitched the person back together, there was a problem. Take us through that.
RUGGIERI: As far as the stapling device that's required or...
RUGGIERI: That incident?
RUGGIERI: Well, yes, as we do colon resections, we usually connect the colon together with a stapling device, and we rely on medical instruments every day to what we - what I do. And most surgeons do. And they have to be perfect as well, just like us. And if they're not, we have to recognize that, and we have to correct that.
And once we - when they're not perfect, and we don't recognize that – again, patients suffer.
FLATOW: 1-800-989-8255 if you'd like to have the doctor, Ruggieri, answer your questions about surgery. Also you can tweet us @scifri, @-S-C-I-F-R-I. Here's a question from Tom Beauchamp(ph). He says: Why do some patients regain awareness during the operation? How can that be detected earlier?
RUGGIERI: Well, actually, some patients not wake up, but the anesthesia may wear off somewhat, and during the operation they may sense something, sense an awareness. It doesn't last, it's very fleeting. I'm assuming that's what he means.
FLATOW: You also mentioned in your book that sometimes you as a surgeon have to clean up virtually a mess made by another surgeon while the operation is still going on.
RUGGIERI: Well, there are times when other surgeons get into trouble. I've been into trouble myself, and I've had to call for help. And you have to help the other surgeon because the patient is the most important factor here. No matter what's been done, you have to do your best to go in there and help. We've all been there. Every one of us has been there.
FLATOW: Well, why are these doctors, if they're incompetent, why are they still practicing medicine and especially surgery?
RUGGIERI: Well, I wouldn't say they're incompetent. Most surgeons are very competent. Most surgeons are very competent individuals, and occasionally we get into trouble. Again, I have been there, for whatever reason, for the anatomy, for the emergency of it, and we need help sometimes.
The really incompetent ones are weeded out. They are. We're doing a much better job of policing our own today. We haven't in the past. I'll be the first to admit that. But things are much better now, in the last decade particularly. It's like any profession, like any profession.
FLATOW: When you were chief of surgery, you had to make a decision to take away the privileges of another surgeon at the hospital though. Isn't that correct?
RUGGIERI: Well, I had to make a decision whether to sign his privileges. And I could live with that. I could not do that. I had to do the right thing.
FLATOW: What was wrong with that other surgeon?
RUGGIERI: It was a culmination of operations and his outcomes, and somebody had to take a stand. I mean, I was in a position of authority. I had to notify people, and I did.
FLATOW: Is there sort of a white book, a white code of honor for surgeons like there is a blue for policemen?
RUGGIERI: Well, again, I think any profession, there's a reluctance to speak out against a colleague for a lot of reasons. One is you think nobody will listen to you. Nobody wants to stick their neck out. It's like any profession. Mine is no different. I think it's a cultural thing that's been pervasive in most professions. It's much better today, again, than it has been in the past, much better, and there's more transparency in medicine than there's ever been before.
FLATOW: But you talk in your book about how there's really not a good way to know how good a surgeon is. A lot of the records aren't public.
RUGGIERI: That's true. I mean, part of the reason - another part of the reason I wrote this book is to educate the public. They need to be active in really researching who their surgeon is and ask pointed, specific questions about their experience.
FLATOW: And who do you - do you ask it of the surgeon? Is there a database? Or who do you ask this question?
RUGGIERI: Well, I would actually start with the internist who's going to refer you to a surgeon. You normally see a primary doctor, for whatever the reason is, and they're going to refer you to a surgeon. I would start there. Like why are you referring me to this surgeon? Do you have confidence in this surgeon? Do you have experience with this surgeon?
And then once you get to the surgeon's office, there are some questions you can ask about the surgeon's experience, as far as the number of operations he or she has done. Have you had complications with this surgery? Is this a new operation that you're doing? There are other things that you can ask.
But as far as researching on a database (unintelligible) that there's very few informational sites that you can go to.
FLATOW: Here's a question from Jennifer Thompson(ph), who's already has surgery scheduled and wants to know what are a couple of questions that patients should or need to ask that they typically don't ask.
RUGGIERI: Well, first of all, I mean, when you sit in front of a surgeon, you want to know what's my diagnosis, and why do I need surgery. And who's going to be doing it. And if I don't need surgery, what are the alternatives? And then once you decide I do need an operation, what is your operative plan? What do you plan to do to me? How will it affect me once you do whatever you do? And then, again, what's my recovery going to be?
And with this specific operation, what is the most common complication that you've come across, and how have you dealt with it? I mean, those are the kind of pointed questions you can ask about your upcoming operation.
FLATOW: Should you - are there times where you go in with your surgeon, but your surgeon doesn't actually do the operation?
RUGGIERI: No, there aren't. I mean, I'm in private practice. It's me. I'm the one doing the surgery. Most private practice surgeons, that's how we operate. At academic centers, there's attending surgeons, they are teaching residents how to operate there. They're constantly monitoring the resident who is doing part of the operation. There's always supervision, but I've never heard of an instance where, no, you go into an operation, somebody else is doing it.
FLATOW: No med student's going to take over learning on your body, something like that?
RUGGIERI: I doubt it, unless the surgeon passes out. But I don't think that's going to happen.
FLATOW: Have you ever heard of a surgeon passing out?
RUGGIERI: No, not particularly, I have not, but most surgeons are the ones doing the surgery that you see. It should be that way.
FLATOW: How long does it take to become a really good surgeon, how many years?
RUGGIERI: Well, that's a good question, actually, because we all train for at least five years. Some go beyond that, seven, 10 years. So when you're done with your training, you're officially stamped as a safe, competent surgeon. But in reality, when you get out there in the real world, in private practice, I mean you're on your own. For the first time you're on your own.
And there's an old saying in surgery which really is true: The first 10 years when you're in practice, you really learn how to operate. I mean, you do know how to operate, but you're getting the finer details, becoming more confident. The next 10 years, you know when to operate. You manage to get the judgment on deciding when to operate in tough situations.
And the last 10 years, which is probably the most important, is you when know not to operate, because what I do, if I have to operate on somebody, I mean, sure, I can help them very much, but I could also hurt them very much.
FLATOW: And are you willing to not do the surgery? Because we hear stories of what do surgeons do - they surge - they operate. And so if you go to a surgeon, they're going to say you need an operation when you might not need one.
RUGGIERI: Well, most surgeons I know, if you truly do need an operation, there's a truly good indication for it, they will offer that to you. I don't know many surgeons who just operate just because they want to operate. I mean, they're out there, I'm sure. But if you truly need an operation and there's a good indication for it, a surgeon will recommend that.
FLATOW: Mm-hmm. Let's go to...
RUGGIERI: I would recommend getting a second opinion if you have any questions about it, even a third opinion.
FLATOW: Yeah. What's the biggest misconception people have about surgeons and surgery?
RUGGIERI: Well, I think there's a - there's still a very thick wall between surgeons and patients. I think patients are afraid of their surgeon, afraid to ask questions. I think they're afraid to ask for a second opinion. I think patients need to become more active. They're going to find out they we're very receptive to this. We want patients to ask questions. We want them to be actively involved in their upcoming operation and thinking about their upcoming operation, because we want them to be realistic about their outcomes.
FLATOW: Well, I think patients feel that, you know, surgeons are so - they're educated. They're surgeons. They're doctors, and they have - some of them have an attitude about being a surgeon, and they're just fearful, you know. So...
RUGGIERI: Yes, I agree. Some of us do have an attitude, and that needs to change. It's changing. But I think there's more transparency in medicine today, and people are becoming more aware of what they need to ask their doctors - not just their surgeon, but the regular doctors as well. They need to become more actively involved in their care, particularly surgery.
FLATOW: Yeah. Talking with Paul Ruggieri, author of "Confessions of a Surgeon: The Good, the Bad, and the Complicated...Life Behind the O.R. Doors." Let's go to David in Dayton, Ohio. Hi, David.
DAVID: Hello. Dr. Ruggieri, I just read your article about informed consent, and that's an article that I found very important to me. I had surgery at the Cleveland Clinic about four years ago. The surgeon promised to do my surgery. I actually put on the consent form that only he was authorized to do my surgery. And I found out when I did not recover and suffered multiple injuries that residents were involved in doing most of my surgery. I also learned that this doctor, who's head of a department, was denied of medical license in Iowa and was not given his board certification.
I'm unable to break through any barrier to find out what his credentials are, what happened during my surgery. And I learned that there's a whole cluster of patients - many of them contacted me - too, who suffered life-threatening injuries. One fellow three months in the hospital after his surgery, underwent five additional surgeries for reconstruction of his bowel. And I'm just wondering what a patient can do. I've run into a through a brick wall with CMS...
FLATOW: OK. Let me - let's get an answer because we're running out of time. Dr. Ruggieri?
RUGGIERI: Yeah, I understand. I completely understand that. I mean, I'm in private practice. I'm the one doing the operating, and there are no residents. And academic centers who - must know that residents may be participating in part of their operation. That's a fact. And if you don't want to be involved in resident care, then you shouldn't go to an academic center. But there is. There's still a big wall between what patients come to find out about the quality and qualifications of their surgeon, and that needs to change. And I'm hoping this book adds to that. But it's a very difficult situation from a patient's standpoint. I agree.
FLATOW: This SCIENCE FRIDAY, from NPR. I'm Ira Flatow, talking with Dr. Paul A. Ruggieri, author of "Confessions of a Surgeon." So you don't have any concrete answers to give him about how to find out the information he's looking for.
RUGGIERI: Well, I think what he can do is actually contact the hospital specifically and ask to speak to the department of surgery chairman. I think you'd find that chairman to be very receptive to talking to you.
FLATOW: Aren't his records - doesn't he not own his own records of the surgery?
RUGGIERI: Oh, yes. He can go in and request (unintelligible), correct. He can request his own medical records to find out actually what was done. It sounds like he found out after the fact that residents did operate - did do part of his operation. So he could definitely do that. Those are his records. He can go and request copies of those records. He needs somebody to interpret them for him, though.
FLATOW: Mm-hmm. You've been around a long time. You watched bodies change. You've seen this - what we, you know, this outbreak of obesity. Does that affect how you do surgery?
RUGGIERI: No doubt. We're seeing patients today who are thicker, more obese, with more advanced disease that we take into the operating room. And it's - it puts them at risk for complications after the surgery. That's a known fact. That's in the medical literature. It makes our job harder, physically, to do whatever we have to do, whether it's in the chest, the abdomen, wherever. And that's a problem. That's going to be a continued problem in this country.
FLATOW: Mm-hmm. See if can get a quick call in before we have to go. Dominic in Los Angeles. Hi, Dom.
DOMINIC: Good afternoon. I'm a trauma surgeon. I work in one of the large trauma centers in the country, and my brother is thoracic surgeon. And on any given Friday night, I probably do more surgeries in an eight-hour shift than he does in a month. And most of our patients are referred to as victims. We get gunshots, stabbings, suicides by the dozens. And I'm sure we deal with our patients a lot differently than your guest does.
FLATOW: And what's - have you got a point or question about that, that you want to make?
DOMINIC: Well, only that trauma surgery is a specialty now, and the number of surgeries that we do, the greater number of them save people's lives. We take pride in the fact that we lose very few of our victims. It's a severe trauma, and it has become a state-of-the-art type of situation. In the past, before there were certified trauma centers, there were emergency rooms. And they would take doctors off the floor who may have been eye, ear, nose and throat to handle an emergency case. And it has developed considerably in the last 25 years.
FLATOW: All right. Thanks for calling. Our number: 1...
RUGGIERI: Yeah. I agree totally. I agree totally with that statement.
FLATOW: Yeah. Surgeons are now more specialized and getting called when they need to be. We're going to take a break. When we come back, we're going to talk more about surgery. Our number: 1-800-989-8255. "Confessions of a Surgeon: The Good, the Bad, and the Complicated...Life Behind the O.R. Doors." Paul A. Ruggieri, R-U-G-G-I-E-R-I, M.D. Stay with us. We'll be right back.
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FLATOW: I'm Ira Flatow. This is SCIENCE FRIDAY, from NPR.
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FLATOW: You're listening to SCIENCE FRIDAY. I'm Ira Flatow, talking with Paul A. Ruggieri. My Italian pronunciation is close.
RUGGIERI: Oh, I knew that.
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FLATOW: Thank you. My producer, Christopher Intagliata, keeps me honest, so...
FLATOW: "Confessions of a Surgeon: The Good, the Bad and the Complicated...Life Behind the O.R. Doors." Our number is 1-800-989-8255. I guess one of the most difficult things of - part of being a doctor is dealing with the patient and the relatives and bringing bad news to patients, not just that maybe the outcome wasn't what you expected, but maybe that you made a mistake in surgery.
RUGGIERI: Oh, there's no question. It's very difficult on that front, and the other front, bad news, bringing somebody news that they have cancer. I mean, the stories in my book, particularly one - well, two actually. One is I explored a gentleman who was having abdominal problems, and got in there and found there was cancer everywhere. The family really didn't expect that, and I had to come out and tell the family that this is what I found. It was a very big shock to them. They weren't prepared for that. And it is very difficult to do, but you have to be honest with patients. I believe you really have to be honest, particularly up front, in the beginning, especially if the operation didn't go well and there was a problem with something that you did. You need to be honest with patients. Let them know. Patients respect honesty. They really do.
FLATOW: And you must develop some sort of distance, though, when somebody is on that operating table, you're - and you mentioned this in the book, there's no real personal connection to that person. And...
RUGGIERI: That's correct. I believe - this is the way I have to be. I think many like me are the same way, in the operating room, focused on what we're doing. We have to be, particularly in an emergency situation, when someone's bleeding from a ruptured spleen. You really can't think about anything else. You have to think about what you're doing, and quickly. Then once things are under control, then you can relax a little bit.
FLATOW: Mm-hmm. And you have to be good at improvising, you mention in your book.
RUGGIERI: Exactly. That is - and that comes with experience. That comes with experience.
FLATOW: Because you always go in there thinking something is going to go wrong and be ready for it.
RUGGIERI: Well, we do. I mean, it's not - I do. I do that, especially with emergency settings where I have to operate on somebody, not knowing what's going in the patient's abdomen. You have to expect the worst.
FLATOW: And are you trained for that in med school?
RUGGIERI: Not in med school, no. Residency, you are. You should be trained to deal with that when you come out of residency. But the reality is you need experience. You need some years under your belt, because you don't experience everything in residency.
FLATOW: Right. So if you're, quote-unquote, "shopping for a surgeon," how many years of experience do you want in that surgeon?
RUGGIERI: Well, there are data out there that shows surgeons who have experience in certain type of operations are better at them. That's been proven in several major surgeries and surgery centers. I mean, it depends what operation you're looking for, as well, what operation you need to have done. People coming out of residency are qualified. They are very qualified to do what they need to do. The problem is they need more experience to know what their limitations are, and you gain that experience.
FLATOW: Do you have music in your theater there?
RUGGIERI: I do, on occasion - not every day. I'll grab a CD on the way out the door, you know, depending on how I feel.
FLATOW: And while you're - if you're doing routine surgery, are you thinking about picking up dinner that night while, you know, you're working on somebody?
RUGGIERI: Not dinner, no.
FLATOW: Not dinner.
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RUGGIERI: Not dinner.
FLATOW: That's the wrong thing. I mean, but you're thinking of other things that may be on your mind.
RUGGIERI: Oh, you really not. You're - I mean, routine - most operations are very boring and routine. That's the great thing about what I do, too, and that's great. Boring routine is perfect. So, you know, you're concentrating on what you're doing, and usually it goes well. And - but you do think about other things after a critical part of the operation, maybe down to your closing and everything's done.
FLATOW: Let's go to the phones: 1-800-989-8255. Robert in Grass Valley, California. Hi, Robert.
ROBERT: Hi. How are you today?
FLATOW: Hi, there.
ROBERT: Good. Just a suggestion, to possibly speak to the OR nurses just to get a suggestion on who they would have to have perform surgeries, since they cannot tell you who they would not have perform the surgery. Thank you.
RUGGIERI: That's a fantastic suggestion, no question. That is a fantastic suggestion, if you know an operating room nurse or know somebody who works in an operating room where you're going to have surgery.
FLATOW: That's right. At least you can sort of weed out people you don't want rather than getting the best person's recommendation. So word of mouth is a good way to find out.
RUGGIERI: I agree.
FLATOW: Yeah. And doctors don't advertise they're great surgeons, or they do sometimes. Do you disrespect people who do a lot of advertising?
RUGGIERI: I don't, but it's rarely done, to be honest. We don't. It's not in our nature. It just is not. Maybe we should do more advertising, but we don't. Most surgeons are very quiet individuals. They let their work speak for themselves.
FLATOW: Mm-hmm. Let's go to Cathy(ph) in St. Louis. Hi, Cathy.
CATHY: Hi. This is a fascinating conversation for me. I'm a former O.R. nurse. And there are all kinds of things I would love to comment on, but the one thing I haven't heard mentioned, which I think is critically important and that the general public doesn't realize, is that when you are having surgery, there is more than one physician in the room. There's your surgeon, but there's also the person who is keeping you alive, known as the anesthesiologist. And while people will invest time in finding out who's doing their surgery, nine times out of 10, they don't have a clue who's going to be keeping them alive while they're having that surgery, and that's the job of the anesthesiologist.
FLATOW: All right. Interesting point. Doctor, a comment?
RUGGIERI: That's an excellent point. And I address that a little bit in my book, but that is an excellent point because usually you meet with anesthesiologist before your operation, and it may not be the same person that is going to do your anesthesia. But you - that is an excellent point.
FLATOW: Well, Dr. Ruggieri, thank you for taking time to be with us today.
RUGGIERI: Oh, my pleasure.
FLATOW: Paul Ruggieri is - M.D., is author of "Confessions of a Surgeon: The Good, the Bad, and the Complicated, Life Behind the OR Doors." Transcript provided by NPR, Copyright National Public Radio.