A surgeon’s confessions expose corporate influence and physician struggles [PODCAST]

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Join us in this captivating podcast episode as we delve into the world of health care with Paul Ruggieri, an esteemed general surgeon and the author of the compelling book, Confessions of a Surgeon: A Deeper Cut. Through his personal experiences and insightful storytelling, Paul unveils the challenges and pressures faced by surgeons in today’s rapidly evolving health care landscape. From the corporate influence on patient care to the diminishing autonomy of physicians, we explore the impact of these dynamics on the quality of health care and the well-being of medical professionals. Don’t miss this eye-opening conversation that sheds light on the inner workings of the medical industry and the profound effects it has on those who dedicate their lives to serving patients.

Paul Ruggieri is a general surgeon.

He shares his story and discusses his book, Confessions of a Surgeon: A Deeper Cut.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Paul Ruggieri. He’s a general surgeon, and he’s the author of the book Confessions of a Surgeon: A Deeper Cut. Paul, welcome to the show.

Paul Ruggieri: Great, thanks. Great to be here, Kevin. Thank you.

Kevin Pho: So we’ll get into your book and excerpt in a little bit, but just briefly share your story and journey to where you are today.

Paul Ruggieri: Well, as I said, I’ve been a general surgeon for over 25 years, mostly in private practice. The last 10 years have seen a lot of changes in medicine, as most doctors have, particularly with the invasion of corporate medicine. I’m kind of at the end of my journey. I’ve got a few more years to practice, and I’m grateful for that, and I decided to write a few books on my experiences and some opinions.

Kevin Pho: All right, so we’re going to talk about this in your excerpt. So when you talk about some of the corporate influences on medicine, especially on private practice, from your lens as a general surgeon, how does that affect you the most?

Paul Ruggieri: Well, as far as practicing surgery with patients, I don’t want it affecting that clinically. It can very easily. You know, the patient-doctor relationship is very different today. There’s so much chaos trying to come in between that relationship, and you can let it come in between that relationship. So it doesn’t affect that part of what I do. It’s all the other chaos around that relationship that you have to deal with.

Kevin Pho: All right, so you talk more about that in your excerpt from your book, “Health care for profit: How corporate pressures threaten independent medical practices.” Talk about some of these influences. You mentioned that you’re resisting some of these changes so they don’t get in between you and the patient, but short of your resistance, tell us about some of the influences that you have to fight.

Paul Ruggieri: Well, when I was my own boss, I controlled my own life, my own time off, who I wanted to operate on, and who I didn’t want to operate on. When you’re not your own boss, you lose that control, and so it’s a different ball game as an employee of a major for-profit hospital chain.

Kevin Pho: So in terms of your control, tell us about some of the things that corporations would control if you weren’t your own boss.

Paul Ruggieri: Well, there’s always pressure to produce. As you know, as most surgeons or any physician knows, there’s always pressure to produce for the bottom line. And it’s just fascinating. You know, I get monthly reports about what I produce and what it equates to as far as RVUs and dollars. I never get a monthly report on my outcomes and how well I’m doing with my outcomes, how much my patients like me, or how efficient I am in the operating room. Those reports are nonexistent. They weren’t there in private practice, and they’re definitely not going to be there now.

Kevin Pho: So when they say that you’re under pressure to produce, talking to your colleagues and from what you read from other surgeons, are they literally telling you that you have to do more operations? Tell us about some of that pressure. Is it just implied pressure that you need to do more, see more patients, and do more procedures, or is it something explicit?

Paul Ruggieri: It’s inherent pressure. I mean, you sign up for a salary; you have to make that salary. So it’s implied. There’s no direct pressure, no, but you know it’s there, and you have to be busy, which is fine. Most surgeons want to be busy. But you know, sometimes expectations are unrealistic, they are, and that’s when problems arise. But it’s just that I didn’t feel this way when I was in private practice. You know, I love to operate. I wanted to be busy, but I didn’t have this.

Kevin Pho: Now, have you had any experiences where they told you, whether it’s a corporation or whoever, that you weren’t producing? How did that go?

Paul Ruggieri: It was kind of an experience, because I never had that approach to me before. So, you know, I’m just honest with people. I wasn’t producing enough, maybe because I went on vacation for two or three weeks, maybe because I was sick for a couple of weeks. I don’t know what the answer is there. But you know, they’re like any corporation today. My wife worked for a major corporation, and she felt the same. Whether that’s appropriate in medicine today is just a whole other argument.

Kevin Pho: So how did that change you? Tell us about that meeting when you were told to produce more. How did that make you feel? Well, take us into that room. What was it like?

Paul Ruggieri: I was disappointed. It made me, you know, feel like I’m worth more than this. And that’s a whole other argument; we are worth more. But it just, I don’t know, it just made me feel insecure for a few seconds. I didn’t realize it bothered me after, you know, it was over, because I knew what the situation was. I’m a realist. I know what we are and where we are. It’s just that this is going to be part of what I have to be aware of, and that’s fine. You know, they pay me a good salary. I’ll try to do what I can.

Kevin Pho: Now, after that meeting, did you make any changes?

Paul Ruggieri: Not really. I just kind of kept seeing patients the way my work ethic has always made me see patients. Sure, there are things I can’t control, which is bothersome, because most of the things around my job I was able to control at one time, while I was my own boss. But in today’s world, you give up certain things. Doctors give up aspects of their professional life.

Kevin Pho: Now, what are some of the reasons why they do that? We both know that in private practice, the numbers of private practice physicians are dwindling. What are the reasons physicians give up that control and move on to corporations?

Paul Ruggieri: I think there are pros and cons to anything. You know, you have security. You have a stable salary, and you don’t have to worry about where your patients are coming from, because you know where they’re coming from. You have a built-in referral base. So there are some good things to that, absolutely, that draw a lot of surgeons. So yeah, there are some things that are not so good that you have to deal with. It’s not an ideal situation, but for most people, yeah.

I hate to say it, but surgery is a calling. It’s a profession. It’s 24 hours. It may not be that way today; it may just be a job. You shift it off, you know. When you’re off call, you leave the hospital.

Kevin Pho: And how do you feel about that?

Paul Ruggieri: I’m old school, Kevin. I don’t agree with it. You know, I’ll never agree with it, to the very end. I see my patients on weekends, whether I’m on call or not. I can’t sign out. You know, my partners are good, but I just can’t do that.

Kevin Pho: What are some of the reasons that you made that transition from private practice to more of an employee-based practice?

Paul Ruggieri: Well, we were kind of late to the party. We saw the groups surrounding us getting caught up. We just kind of held out, maybe to the point where we let it go too long. Realistically, a couple of my partners were tired. We could not recruit. We didn’t have the money to recruit and pay a surgeon. We didn’t have the resources, and our patients were being divided up between the two hospitals in town. And we were the ones who, when the music stopped, didn’t have a chair.

Kevin Pho: And how many years have you been in this corporation?

Paul Ruggieri: For four years. It’s a for-profit chain, just like hundreds of them in the country. And again, there are pluses and minuses, and overall I’m fine with it, really. I’ve adapted to it. I’m fine with it. It doesn’t change the way I treat patients. It’s just that doctors coming out of training today, this is what they’re going to have to deal with.

Kevin Pho: Sure. All right, so you talk about more stories like this in your book, Confessions of a Surgeon: A Deeper Cut. So tell me, what led you to write this book?

Paul Ruggieri: Well, what led me to write this book: The first book I wrote, I don’t know if you remember it, is called Confessions of a Surgeon: The Good, the Bad, and the Complicated. That was just something that was raw, and I wanted to write that. This is almost like a sequel to that book, describing the changes in medicine over the last 10 years and using personal stories to point out those changes. And I wanted to write one more, you know. I figured, let’s do it, and we did it.

Kevin Pho: Sure. So one of the big themes, of course, is that corporate takeover of private practice. What are some other themes of your book?

Paul Ruggieri: How the patient-doctor relationship is not as strong anymore as it once was. There are so many things that come in between that relationship, and if you allow them to come in between that relationship, you know, it’s not good for the practice of medicine. EMR, for instance. EMR is necessary, but I can’t tell you how many docs I know who, when EMR came along, just left medicine because they didn’t want to deal with it. It takes up a lot of our time during the day. We all know this. It’s just part of the landscape.

And just the outsourcing of your care: There’s a chapter on the outsourcing of your care. Radiology is outsourced at night, and surgeons have a hard time, you know, trying to believe a CT scan report. Where’s the person who read this? I want to talk to the person. I can’t tell you how many times, how long it takes me to find the radiologist who read a report at nine o’clock at night. So, you know, I want to understand: What are you seeing here?

Kevin Pho: So tell us about that specific difficulty. Let’s say it’s the middle of the night. We know that there are very few in-house radiologists now. Chances are that report’s being read by some radiologist halfway around the world. Paint us a picture. How does that affect you in the middle of the night?

Paul Ruggieri: When I get called to the ER, and this is a classic story, and it’s in the book, about a patient who has abdominal pain whose CT reading was possible this, possible that. And, you know, the patient’s clinical condition didn’t look like the message, but he was sick enough that I needed to speak to the radiologist who read this, and it took me a good hour to find the person, dialing a 1-800 number first to find the person. And it just complicates your care with these patients, because the ER doctors just hand this off to you. They’re too busy. They can’t deal with it. It’s like, “Here, this is your problem. You deal with it. You find out if this is true or not.”

Kevin Pho: OK, so you talk about these obstacles that kind of impede or divide you from patients. EMR is one, and kind of the outsourcing of care. What are some other reasons why that doctor-patient relationship isn’t what it once used to be?

Paul Ruggieri: Well, you know, I think burnout is a big part of what’s going on here. You know, I can see it now that I’m at the end of my career. I mean, I sometimes have to catch myself to keep caring, you know, and to follow up on tests for patients, because these patients are more complicated today. They’re getting older. They’re more complicated to deal with, they’re harder to deal with, and you have fewer resources in certain places to deal with them. And it’s very easy to just walk away when you’re not on call. It’s like, “Oh, it’s not my problem.”

Kevin Pho: Tell us about some of those emotions and feelings. You know, you said that sometimes you have to catch yourself in order to continue caring the way you used to. So what are some of those feelings that you’re trying to express?

Paul Ruggieri: Well, it’s just a matter of following up on things with patients. I follow up on everything that I order on a patient. If I want to get a patient to a tertiary center, I do it. And I’ve been doing it, and it takes work, you know, and I do it right away. You know, maybe I don’t want to do it right away. Maybe I’m just beat and want to go home, and I do it in two days, and I’ll forget about it until I get a call. It’s just little things that add up. But you know, it’s not going to stop me from continuing to do them. It’s just harder to do it.

Kevin Pho: Yeah. So how do you keep going? I think you mentioned you’re towards the end of your journey. What are some of the things that you do to keep going despite all these changes to medicine?

Paul Ruggieri: Well, I just keep in mind what I do, and there are people a lot worse off than I am that I’m taking care of, and they’re relying on me to get them to the right person, to the right test, or to the right operation when someone comes into my office. That’s an enormous responsibility you can’t take lightly, because if you do, you make mistakes, and people die and suffer. And I’ve made them, trust me. I’ve made omission mistakes. I’ve made intraoperative mistakes. We all have; it’s just part of the job. So I just take a step back and take a breath. And again, the people coming out of training today, maybe they have a little different mindset, and it’ll make them go longer.

Kevin Pho: So let’s talk about those people coming out of training, those new physicians. You know, you’re towards the end of your journey. What kind of wisdom can you impart to them in light of these changes with the doctor-patient relationship and the changes in medicine? How would you advise them?

Paul Ruggieri: I would say, first of all, physicians and surgeons are worth a lot more than what we get paid. The public may disagree, but know your worth. If you’re a good surgeon or a good physician and have good outcomes, you can’t put a dollar sign on that. You really can’t. So if you know your worth, you can use that as leverage when you’re negotiating contracts. And, you know, we’ve given up a lot of things for free since we started training. Call, for instance, is free, but that’s maybe changing slowly. Just time on the phone, the time you spend on the phone. There are so many things that we’ve given up that you should start to take back.

And, you know, if this is what you truly love to do, then just, you know, be a realist and be aware of the environment you’re stepping into, and try to take advantage of that environment, because, you know, physicians and surgeons are getting to be a rare commodity today, I mean, people, especially good ones. And you’re worth a lot more than what they pay you every month.

Kevin Pho: So what are some tips? How can physicians know what they’re worth and express that in contract negotiations? Is this just a matter of saying no more frequently and not saying yes to things that we typically had said yes to in the past?

Paul Ruggieri: Well, I think, first of all, physicians and surgeons, and it’s starting to happen, need to talk in numbers, in one voice, in this country. And it’s starting to happen slowly in certain states, and I believe it should happen. Once you get that one voice, you have bargaining power over work hours, over what you get paid, and what you don’t get paid. You know, if you have a special skill, if you’re a bariatric surgeon, if you’re a robotic surgeon, use that. I’m a general surgeon and laparoscopic. I don’t do robotic surgery, so I’m old school. But if a lot of communities are in need of special-skill services, use it. Don’t be afraid to use it.

Kevin Pho: We’re talking to Paul Ruggieri. He’s a general surgeon. He’s the author of the book Confessions of a Surgeon: A Deeper Cut. Paul, tell me, who should read your book? Who’s the audience for your book?

Paul Ruggieri: Well, I think it’s a wide audience. Patients would really get a kick out of reading that book, because they loved the first one. They were kind of shocked by the first one, and so were some of my colleagues, but, you know, I didn’t really care. But I think clinicians as well should read that book. It really summarizes what’s been going on in the last 10 or 15 years of medicine and how it has affected patient care on a personal level.

Kevin Pho: And my final question, Paul: Tell us some of your take-home messages that you want to leave with the KevinMD audience.

Paul Ruggieri: Well, one take-home message I’d like to leave with younger physicians and surgeons who want to write, because I think a lot of us do want to write, and we have so many unique experiences: Keep a journal. You know, I didn’t really do that. I kept it in my head. Keep a journal, and if you get the desire to write about your experiences, you’ll have it all. But make sure you’re going into medicine or surgery for the right reasons. Don’t go into it for the wrong reasons, because you won’t have a happy life if you do. But if you still love the idea of surgery, if you want to be a surgeon, you know, go for it. It’s a really unique calling.

Kevin Pho: Paul, thank you so much for sharing your story, time, and insight. Thanks again for being on the show.

Paul Ruggieri: Thank you. Have a nice day.

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