Confessions of a Surgeon The Good, the Bad, and the
Complicated...Life Behind the O.R. Doors
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This is an original publication of The Berkley Publishing Group.
Copyright © 2012 by Dr. Paul Ruggieri.
Excerpt from The Price by Arthur Miller, copyright © 1968 by Arthur
Miller and Ingeborg M. Miller, Trustee. Used by permission of Viking
Penguin, a division of Penguin Group (USA) Inc.
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Cover design by Oceana Gottlieb.
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PRINTING HISTORY
Berkley trade paperback edition / January 2012
Library of Congress Cataloging-in-Publication Data
Ruggieri, Paul, 1959–
Confessions of a surgeon : the good, the bad, and the complicated—: life
behind the O.R. doors / Paul A. Ruggieri.—1st ed.
p. cm.
EISBN: 9781101554043
1. Ruggieri, Paul, 1959– 2. Surgeons—Biography. I. Title.
RD27.35.R84 2012
617.092—dc23
[B]
2011038205
PRINTED IN THE UNITED STATES OF AMERICA
10 9 8 7 6 5 4 3 2 1
The publisher does not have any control over and does not assume any
responsibility for author or third-party websites or their content.
The events described in this book are the real experiences of real
people. However, the author has altered their identities and, in some
instances, created composite characters. Any resemblance between a
character in this book and a real person therefore is entirely accidental.
Penguin is committed to publishing works of quality and
integrity.
In that spirit, we are proud to offer this book to our readers;
however, the story, the experiences, and the words
are the author’s alone.
To my father, John,
the most honest man I have ever known
Acknowledgments
I would like to thank all the patients whom I have had the privilege of
knowing throughout my career. Every day I continue to be humbled by the
trust and confidence they bestow on me. My patients have taught me
invaluable lessons about life and have contributed to the making of a
surgeon more so than they will ever know.
I would like to thank my agent, Donald Fehr, of Trident Media Group.
Don’s keen interest early on in this project was inspiring to me as a first-
time author and his continued guidance was invaluable.
I am eternally grateful for the friendship and professional talents of
Martha Murphy. Her enthusiasm and input into this project were
instrumental to its success.
I am also indebted to my editor, Natalee Rosenstein, who believed in me,
and all the people at the Berkley Publishing Group for their support in
seeing this project to the end.
I would also like to deeply thank my parents, John (to whom this book is
dedicated) and Irene. Their undying love and support have fostered my
ability to view life’s successes and failures with humble eyes, never
forgetting the roots of my soul.
Most important, I have been blessed with members of my own family.
They have been with me from the first to the last written word. I wish to
thank my beautiful wife, Erin, for allowing me into her life and fueling my
desire to follow a dream. Her honest and critical eye was instrumental in
helping me tell my story. I would also like to thank my stepsons, Matt,
Ryan, and Jack, along with our golden retriever, Chase, for their innocence
and honesty. Their presence continues to keep me grounded every single
day.
Contents
Introduction
Chapter 1: The Making of a Surgeon
Chapter 2: Are Surgeons Human?
Chapter 3: First, Try Not to Harm
Chapter 4: The White Coat Code of Silence
Chapter 5: Get Out of My Operating Room
Chapter 6: Surgeons Hate Surprises
Chapter 7: This Won’t Hurt a Bit
Chapter 8: Patients Are the Best Teachers
Chapter 9: Thoughts on Death and Lawsuits
Chapter 10: Will Your Surgeon Be There?
Bibliography
There are times, as you know, when if you leave someone alone he
might live a year or two; while if you go in you might kill him. And
the decision is often…not quite, but almost…arbitrary. But the odds
are acceptable, provided you think the right thoughts. Or don’t think at
all, which I managed to do till then.
—Walter, a general surgeon, in Arthur Miller’s The Price
Introduction
When I meet someone for the first time in a social setting and reveal
(sooner or later) that I’m a surgeon, the reaction is often something close to
awe (at least among those who don’t spend their days in the world of
healthcare). This unearned respect can be flattering, but the truth of the
matter is I’d rather have my new acquaintance realize that I’m a human
being, that I’m not perfect, that I’m not a demigod, and that surgery (as well
as the rest of medicine) is an art as much as a science. And some days,
calling it an art is a stretch.
Becoming a surgeon was the most difficult thing I’ve ever done. The
training is designed to test your mental and physical endurance as much as
your intelligence or skill with a scalpel. Those without a deep reservoir of
desire and drive need not apply. Yet— once through the fire, the years and
years of school and residency— working as a surgeon has provided the
most exhilarating times of my life. I wouldn’t trade it for anything. Most
days, that is . . .
On the good days, I delight in being a member of a unique club of
extraordinarily talented, complex, brilliant, driven, and compassionate
professionals. We’re saving lives. On the bad days, I realize I’m part of a
world inhabited by flawed, greedy, egotistical, and insecure practitioners
(and I include myself in that description). We’re making mistakes but
(usually) correcting them before lasting damage is done. The middle ground
looks like this: I get to work with a motley crew of healthcare professionals,
surrounded by diseased organs, blood, pus, and guts, in a room without
windows hidden behind a set of swinging doors, where we spend too much
time on our feet but get to improve the quality of someone’s life or (maybe)
extend someone’s life. At the end of the day, it usually feels pretty good.
My profession is complex and complicated. It demands a dedication to a
way of life that is like no other. For me, the road leading into the operating
room is a lonely one, the path to a place where I am responsible for all that
transpires, be it good, bad, or complicated. Most days in the O.R. do go
well (thankfully), whether the crew and I experience exhilaration, fear,
boredom, satisfaction, or humiliation before we call it quits.
I love being a surgeon. I love being able to make a clear, tangible
difference in the quality of a person’s life. Sometimes I even save a life. I
am honored every time a patient comes to me, and I’m humbled at the trust
that’s given. Confessions of a Surgeon is my love letter to all of them, but
it’s more than that, too. What you have in your hands is the result of my
desire to share an honest, open look at this startling profession, an
occupation so unfamiliar to most it may as well be taking place on the
moon.
More than thirty million people a year in this country enter hospitals to
undergo surgery, for conditions including bad joints, clogged heart arteries,
and diseased gallbladders. Once you are wheeled into an operating room, a
host of factors— the most important of which is your surgeon— come
together to influence the condition in which you will leave that room. I’ve
long wanted to push open the O.R. doors and show the public the
mysterious place where lives are improved, saved, damaged, and,
sometimes, lost. I wrote this book to take you right up to the operating room
table and give you an up-close view of what I see as a surgeon. I want you
to meet the person behind the surgical mask.
I also want you to get a glimpse of the array of demands and constraints
and desires that tug at working surgeons today: A patient’s conflicting
family members, each with a different idea of how a loved one’s condition
should be addressed. Repugnant criminals whose lives you are charged with
saving. Lawsuits. The uneven, nonsensical reimbursement system. The cost
of running a business (most surgeons are in private practice and, therefore,
running a business). Practicing surgery today is much more than being a
surgical professional— and a lot of it is stuff we never bargained for in
medical school.
This book is my story, and my examination of a unique occupation—
truly a “calling” in many respects— that requires years of arduous training,
followed by years of arduous work, where fatigue and malpractice lawyers
take turns attempting to distract us from the job at hand: a person’s life.
What in the world possessed me to write this book? This question has
floated through my mind ever since the idea was conceived. Even now, I
ask myself. I ask, yet I continue to write. I write because I seek the truth
about myself and about those I have affected, for better or worse. I believe
the truth will set you free. It has for me.
Paul A. Ruggieri, M.D., F.A.C.S.
March 2011
Chapter 1
The Making of a Surgeon
The first two fingers of my right hand were rigid with fear, frozen in
position. My crisp white doctor’s coat was beginning to wilt from the sweat
racing down my back. The tension in the room was rising. I simply had no
idea what my next move should be. Stay calm, keep it together, and listen, I
told myself. Just focus on the task in front of you.
I was a newly minted third-year medical student, officially “licensed” to
lay my hands on patients. It was about time. We were all champing at the
bit. With just two years of medical classes behind me, I was ready to be a
doctor and, ultimately (I hoped), a surgeon. I was looking forward to
touching a live human being. The surgeon in me was looking forward to
making that first scalpel cut. Today was a day for touching; cutting would
have to wait.
All of us had been prepped, briefly, by our professors for this “special”
day, but nothing too specific had been shared. The vagueness seemed a little
odd, but we were there to learn, not question. In retrospect, seeing how a
person handles the unknown was (and still is) part of the making of a
surgeon. Thinking quickly and making judgments under stress—with very
little time to evaluate—are the hallmarks of a surgeon’s daily life.
Most of my classmates were lined up with me. We stood outside two
doorways, like city workers waiting to get into a deli at lunchtime. There
were no pastrami sandwiches, however, on the other side of those doors.
The rooms ahead of us were filled with operating room tables and live
patients. As I stepped into the first room, lunch was the furthest thing from
my mind.
The “task” in front of me, on which I was trying to focus, was a female
“model” hired by the medical school. I could feel the tension in my fingers
migrating into my arm, neck, back, and legs. How in the world is this going
to make me into a surgeon? I thought, trying to justify my insecurity. I don’t
need this. I struggled to avoid eye contact with her.
“Hello, Dr. Ruggieri.” I could smell the whiff of sarcasm in her voice. I
always hated being called this, knowing that in reality I was one step ahead
of a glorified graduate student. The calmness of the female voice directly in
front of me jerked my ego back into place. “My name is Roxanne. Please
move your fingers in deeper and gently place your left hand here.” She
grabbed my stiff left hand and placed it just above her pubic bone. I was
unable to utter a word. “Now, sweep your right two fingers to the left and
simultaneously put pressure down with your left hand. Can you feel my
right ovary as it moves across your fingers?” I nodded sheepishly, stuttering
something resembling a yes. Hell, in this situation, I wasn’t going to feel an
ovary if it hit me between the eyes. I tried to focus, tried to fight off the
mental and physical distractions. The whole thing felt like a bowl of warm
jelly.
This was my first clinical pelvic exam and, in my mind, I was failing
miserably. The situation was out of my control. My fingers, arm, and neck
were so tensed up I would have admitted to anything to get the “exercise”
over with. We were eyeball to eyeball, my right hand deep in dark territory.
Her legs were in stirrups, while mine were about to buckle. Her confident
voice was trying to educate me while I was privately praying for a power
failure. I was experiencing very mixed emotions. Just three years earlier I
had been working as an ironworker, saving money to attend medical school.
My hands were constantly being traumatized by wire and metal rods.
Interestingly enough, the guys I worked with then regularly discussed their
“examination” of various parts of the female anatomy. Although, their
“exams” were in a somewhat different setting from the one I now found
myself in. Now, my gloved hands probed into a living stranger’s body while
a voice directed their every move. It was all very surreal. I felt
uncomfortable on several levels. For one thing, my fingers were stuck in
someone’s vagina and I didn’t know what the hell I was feeling. For
another, I was shy about where I was, because my overall experience with
women was not as robust as that of some of my colleagues.
When Roxanne was through with me, I was allowed to move on to the
next clinical lesson: a male model, in an adjacent room, ready to educate me
in the art of…well, you get the picture. Needless to say, I was traumatized
by the entire experience and continue to have occasional flashbacks when I
see a stirrup in the operating room.
When it was over, I had learned two valuable lessons. The first: I was not
going to be a gynecologist. This was one part of a person’s anatomy I did
not want to make a career out of. The second, and more important, was
being introduced to the milieu of a surgeon’s daily life: dealing quickly with
the unknown, facing one’s insecurities and even, sometimes, one’s humility.
Looking back, I believe the entire experience was orchestrated not to fine-
tune our clinical ability to perform an adequate pelvic examination—it was,
rather, the first of many lessons that would introduce us to the world of
clinical stress, assessing the unknown and reacting to the best of our
abilities. The making of a surgeon had begun.
///
We had named her Tilly. She reminded one of the members in our group
of his Aunt Tilly, so the name stuck. Welcome to the family.
Tilly was our dissecting cadaver, introduced to us during the first week of
anatomy class, a woman whom we would get to know intimately over the
next five months. A woman who, even in death, would contribute to the
making of several surgeons throughout the weeks ahead.
She was probably in her early seventies when she died, willingly
donating her body to the future doctors of the world. We knew nothing else
about her. We did not know how she died, where she came from, or who her
family was. Her face and body appeared well-preserved, gold fillings and
purple nail polish neatly intact (the nail polish was a little freaky). If it
weren’t for the lingering odor of formaldehyde, we would not have been
surprised if she sat up suddenly and offered us some fresh baked cookies.
