January 4, 2012

The real 'secrets of the OR'

Daily Briefing

    Dan Diamond, Managing Editor

    In a much-discussed essay in the Wall Street Journal, general surgeon Paul Ruggieri revealed…

    He talks to colons.

    And for some readers, that was the least execrable part of Ruggieri's essay.

    The account opens with Ruggieri hurling a colon-stapling device against a wall, yelling in frustration during a difficult surgery on an obese patient. In the span of a few paragraphs, Ruggieri confesses his doubts about medicine, grumbles about his paltry Medicare reimbursement, and shares the conversation (within his mind, presumably) he's been having with the patient's diseased colon.

    But between his stapler-throwing episode and cracks about his new Porsche, is Ruggieri really revealing "secrets of the operating room"–or reinforcing common clichés about surgeons?

    Maybe both.

    New York Times reviewer: Praiseworthy honesty
    Abigail Zuger, a physician who reviewed Ruggieri's new book for the New York Times (the WSJ essay was an excerpt), applauded the doctor's honesty and highlighted him as "a regular Joe Scalpel."

    Unlike many doctors-turned-memoirists—think Atul Gawande or Richard Selzer—Ruggieri was "an average student, he graduated debt-ridden in the middle of his medical school class, weathered a grueling old-style residency program, and now works as in private practice at a community hospital," Zuger writes. As a result, his tale presumably captures the day-to-day reality for the majority of the nation's surgeons.

    Meanwhile, Ruggieri also wins points with Zuger by revealing "his own worst moments," she adds. Given that many surgeons "seem 15 feet tall...[like] a demigod in the OR," Ruggieri's frank discussion of his professional and personal failings helps puncture the mythos, Zuger concludes.

    Commenters: Regrettable attitude
    But many readers took a different lesson from Ruggieri's honesty.

    "I've had moments that resemble these...[during] the 10,000 operations I've performed," one commenter wrote. "I've never thrown an instrument, though. That is unprofessional." Another commenter, who said he'd served as a hospital chief executive, criticized the author's arrogant tone and cautioned readers that Ruggieri represents "a very small proportion of surgeons."

    According to Skeptical Scalpel, a longtime surgeon and former surgical chair who blogs anonymously, Ruggieri isn't doing the profession any favors by broadcasting his behavior.

    "20 or 30 years ago, [Ruggieri] would have been more or less a typical surgeon," Skeptical Scalpel told the Briefing. (See an interview transcript). "Now he’s an outlier. You just cannot throw instruments in the 21st century" without repercussions, like facing empowered nurses or being disciplined by a medical review committee.

    Why doctors might want to be tight-lipped
    In Skeptical Scalpel's opinion, Ruggieri does reveal some truths. For instance, the author "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."

    But there are good arguments for why physicians shouldn't confess all their trials and frustrations, beyond the potential impact on their practice. As many commenters noted, Ruggieri's descriptions of surgery could unnecessarily alarm patients. Even Zuger—despite picking Ruggieri's book as one of "two choices for best bedside read"—warns preoperative patients not to actually read the tales in the hospital.

    So should what happen in the OR, stay in the OR?

    Skeptical Scalpel and others are inclined to agree.

    More from today's Daily Briefing
    1. Current ArticleThe real 'secrets of the OR'

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