Dan Diamond, Managing Editor

Many Daily Briefing readers were struck by our Wednesday story about Dr. Paul Ruggieri, a general surgeon who shared his "secrets of the operating room" in the Wall Street Journal. 

That strong response was no surprise; Ruggieri's original essay for the Journal drew hundreds of comments, many from fellow surgeons who were unhappy with how Ruggieri depicted their profession.

One of those physicians was Skeptical Scalpel, a former surgical department chair who authors a well-read health care blog. Unlike Ruggieri, Skeptical Scalpel has chosen to maintain his anonymity when writing about medicine—and as he pointed out, never writes about his own patients.

The following is a lightly edited transcript of our interview.

DD: You (and many others with surgical backgrounds) have been critical about the author's choice of anecdotes, his temper, and so on. Is Dr. Ruggieri an extreme outlier, or just writing the uncomfortable truth? 
SS: 20 or 30 years ago, he would have been more or less a typical surgeon. Now he’s an outlier.

You just cannot throw instruments in the 21st century. As many have pointed out, instrument throwers are no longer tolerated. Nurses are much more assertive these days. In most hospitals, he would have been reported, had a hearing, and been sanctioned. He possibly would have been told to take an anger management course.

My personal view is that one cannot operate well with a state of mind that causes such rage. I would worry about the patient during a case where a stapler is thrown against a wall.

Setting aside the article's title, is Ruggieri really sharing secrets or reinforcing stereotypes about surgeons?
Both. He is sharing secrets. Surgeons face many frustrations and extreme stresses on a daily basis. I certainly have cursed in the OR when something goes wrong.

But you cannot let the stress get the better of you. You have a patient asleep and he is depending on you to keep it together and fix what’s wrong. He is reinforcing an old stereotype.

Honestly, I question whether everything that he wrote in the WSJ excerpt actually happened. Did really throw the stapler? Does he really think the colon is talking to him? Does he think about his Porsche during a case?

Especially in a difficult case, I am so focused when I operate that I am unaware of the time passing, who’s in or out of the room, whether someone has a radio on or not. I’m not thinking about anything but what I’m doing and what is coming next.

Sometimes it’s like chess. You plan several moves ahead. You ask the circulating nurse to look for something you will need in 10 minutes.

• Dealing with your own disruptive doctor? The Advisory Board's solutions to defuse bad behavior.

So what do you think are true "secrets of the OR"?
Some secrets. When we are doing something simple, we may be chatting about things other than the task at hand. Often we indulge in “gallows humor.”

[Ruggieri] is right about obese patients. They can be very difficult to operate on. You can’t help but marvel at the enormous size of some of the patients.

Have you written (or read) a piece that better reflects your own perspective?
I have not written about this sort of thing myself. I am still actively practicing [and] rarely write about patients even though I blog anonymously.

And by the way, he would have been better off to have written his book under a pseudonym. (And people wonder why some of us don’t blog using our real names.) I think it would be interesting to see how this book affects his practice.

The New York Times writer seems to be pleased that he is honest and down to earth. I think he comes off as arrogant and disrespectful to his patients. Judging from the majority of the comments, a lot of other people, including doctors, do too.

Would the people in Ruggieri's town want to go to him knowing what he’s like in the OR, not to mention that they might appear in a sequel to this book? The 330-pound man he describes could probably figure out that he is the patient in the book and so might other people in town.

There was a story from [a nearby state] about an ED physician who was fired because she blogged about a patient who many people in town recognized from the description of the injuries.

Has your own approach and attitude changed?
Yes. I was quite a bit more volatile as a young surgeon.

So did you ever have a stapler-throwing episode?
I never threw a stapler despite the urge to do so occasionally.

[But] when I was a resident, I was doing a cutdown to start an IV on a very sick infant. The clamps provided on the set of instruments were hand-me-downs from the OR. A certain clamp would not stay closed. I tossed it so hard that it went out the door of the nursery, across a wide hallway and into an elevator the doors of which had just opened.

I believe that was the distance record for my hospital. That was about 1973.

Is this a case where, by sharing more, the surgeon can actually create unnecessary tension?
I think it could. Patients don’t need to be thinking about this sort of thing when they are sick and need surgery.

To appropriate a terrible expression, should what happen in the OR, stay in the OR?
I hadn’t thought of that, but I agree.