A Surgeon Cuts to the Chase

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The next time you find yourself on your back, staring at the operating room ceiling, about to be put to sleep for an operation, ask yourself how much a good surgeon is really worth. You might find the word priceless in your mind as you drift off. My hope is that you never have to think otherwise.

—Paul A. Ruggieri, MD


Title: The Cost of Cutting: A Surgeon Reveals the Truth Behind a Multibillion-Dollar Industry
Author: Paul A. Ruggieri, MD
Publisher: Berkley Books
Publication date: September 2014
Price: $16.00; paperback, 320 pages

The woman seated on the exam table was lean and fit and seemed perfectly at ease. As the doctor—a general surgeon—scanned her medical history, the portrait of a person in good health came into view. Her lab work, blood pressure, weight: All were excellent. One question came into the doctor’s mind: Why was she in my office? Several weeks earlier, it turned out, the woman’s primary care doctor had ordered an abdominal computed tomography scan to investigate a nagging pain he hadn’t been able to diagnose. The radiologist noticed gallstones; hence, he referred her for a surgical consult.

As the surgeon finished the physical exam, he told the woman that her gallbladder was working fine and that the asymptomatic gallstones were simply incidental findings, not the cause of her abdominal discomfort. She replied, “Well, why not just take the thing out. I don’t need it anyway, right?”

The operation would have taken a stress-free 20 minutes, netting the surgeon $1,000. The only problem: There was no medical reason to do it.

The doctor describing this case history is Paul A. Ruggieri, MD, a board-certified general and laparoscopic surgeon and author of The Cost of Cutting: A Surgeon Reveals the Truth Behind a Multibillion-Dollar Industry, which is a follow-up to his previous book, Confessions of a Surgeon, in which he pushed open the doors of the operating room and revealed the inscrutable place where lives are improved, saved, and sometimes lost.

Shedding Light on Abuse

In The Cost of Cutting, Dr. Ruggieri tackles a subject that is central to the oncology community’s ongoing self-evaluation process: choosing wisely. And, as the author points out in chapter 1, the dramatic increase in the use of imaging technologies, such as magnetic resonance imaging, has produced a plethora of incidental findings that challenge the decision-making process of surgeons.

To that end, Dr. Ruggieri wades into some uncomfortable territory, taking some in the surgical community to task for abusing our fee-for-service payment system. “Like every profession, surgery is not exempt from bad seeds. As difficult as it is to write this, some surgeons operate for solely economic reasons,” writes Dr. Ruggieri. He then elucidates his concern, using simple-to-grasp data sets and literature references.

To highlight abuse, Dr. Ruggieri cherry-picks some truly dastardly acts of profit-over-patient greed that the vast majority of doctors will find incomprehensible. But never once do you feel that the author has an ax to grind; instead, he comes across as a concerned member of the medical community who wants to shed light on abuses that tarnish his discipline, stressing that “they are also, I’m glad to say, rare.”

Readers of The ASCO Post will enjoy the sections on the business of practicing medicine in today’s cost-conscious environment, during which Dr. Ruggieri navigates the complex maze that doctors must trudge through to get reimbursed for services rendered. To contrast the before and after of our system, he writes, “When my senior partner started out in surgical practice more than 30 years ago, his billing system consisted of a pen, stationery, an envelope, and a stamp…. [H]e would instruct his secretary to write a letter to the insurance company … describing the operation and how much he was charging for it.… [S]everal weeks later a check would arrive in the requested amount.” Ah, the good old days.

At the end of this section, Dr. ­Ruggieri stresses another key point in today’s evolving world of oncology: “The reimbursement system has to be changed so that doctors are financially rewarded for cost-efficient, quality outcomes, not just bulk of services.” Of course, this is easier said than done, and Dr. Ruggieri stumbles a bit in trying to find a clear path forward. This is one of the most difficult challenges in medicine, and one can’t fault a surgeon for not offering a clearer solution.

Medical Drama

Surgery, of course, is a compelling subject. There are few circumstances in human life that require more faith in another—under the glare of the operating room lights, the patient fades into the twilight of unconsciousness, left in the hands of a scalpel-wielding surgeon. And Dr. Ruggieri tells this life-and-death experience in finely honed prose:

The blood was everywhere. I was sucking it out as fast as I could, but I was losing ground. The clock was ticking. If I did not cut open Mr. Bowmore’s belly within the next 60 seconds to get a clamp on the bleeding artery … I would have some explaining to do to his family. Damn it. The artery tore right off. The jet pulse of blood hitting my camera lens and obscuring my line of sight was coming from the inferior gastric artery that had somehow ripped from the abdominal wall muscle.

Operating theater aside, this tautly rendered book offers a lot to like for clinician readers. Structured in 10 concise chapters, the book explores the medical landscape in a way that overlaps all specialties.

In chapter 8 (“The Robot Will See You Now”)—perhaps the book’s best—Dr. Ruggieri takes on another issue that ASCO Post readers will enjoy: the ineluctable move toward robotic surgery. He gives a fair and balanced review of this technology, with cautionary words about rushing into new technologies simply because they are new. While acknowledging the benefits of technologic advances, he also warns, “I worry that too much reliance on new surgical technology in the operating room has the potential to lull surgeons into a false sense of complacency and make them feel even more detached from their patients.”

Chapter 9 (“Obamacare, Medicare, and the Future of Your Healthcare”) does a splendid job in demystifying the philosophy behind the accountable care organization, a conceptual model based on improving cost-effective care and reforming our current payment system. Still a work in progress, the accountable care organization movement sends shudders down the spines of some oncologists who fear more government oversight, less autonomy, and tighter bottom lines. Dr. Ruggieri’s levelheaded and well-written discussion on these organizations will assuage many of those concerns.

Sacred Trust

In the end, Dr. Ruggieri is a doctor’s doctor, one who examines his field, his colleagues, and himself under a harsh light. He wants the reader to know that what doctors do is vitally important and emphasizes the sacred trust between doctors and their patients.

He concludes his fine book, one that is heartily recommended by this reviewer, thusly, “The next time you find yourself on your back, staring at the operating room ceiling, about to be put to sleep for an operation, ask yourself how much a good surgeon is really worth. You might find the word priceless in your mind as you drift off. My hope is that you never have to think otherwise.” ■