A Patient’s Dilemma: To Litigate or Otherwise

Abstract

The patient, a middle-aged woman was advised hysterectomy by an Oncology Gynaecology surgeon, based on the patient’s health conditions, symptoms and clinical investigations. The patient however, decided to seek out a gynecologist for a second opinion on whether she should get a hysterectomy. The second consultation was far from a pleasant experience and it appeared as though the consultant was a leveraging an opportunity to maximize revenue. Students are asked to consider if legal action against the consultant gynecology would be fruitful in this instance.

This case was prepared for inclusion in SAGE Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.

2023 Sage Publications, Inc. All Rights Reserved

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Resources

Annexure 1: Transcription of Meetings Between the Patient and Various Consultants

May 3

Consultant What are the complaints/ailments/symptoms?

Patient A nagging pain at the back since last two months. Minimum control on bladder. These are the specialists I approached, and the tests taken.

Consultant I need to examine you physically.

Patient The Gynaecologist I consulted at my work place advised hysterectomy. I have come to consult you at the suggestion of a common friend to seek a second opinion on hysterectomy. What is your advice?

Consultant You consult this specialist (she was writing down already) and get her opinion. Also get all these investigations done. You can see me with the reports as soon as possible.

(The Consultant instructed the nurse to give an appointment to the patient next week).

Patient Doctor, we are returning to our normal working place in the next ten days (scheduled date May 17). We would appreciate an opinion before that.

Consultant I can advise you only after seeing the investigations results and report of this consultant (a Paediatrician and Neurologist PNC)

May 5

Patient The UGCM referred me to you for consultation.

(The patient explained her symptoms and causes of worry all over again).

Consultant Did you meet with any accident ever hurting your back?

Patient No

Consultant How many children? Any complication in the child birth?

Patient Two children. No complications in child birth.

Consultant Get an MRI and CT scan of the spine. Do you know any place here for an MRI scan?

Patient No, not really.

Consultant Well, you can go to this place (writes down the address). Wait, I will call them up to give you an appointment. They will give you a discount of INR 2,000. You have to pay only INR 7,500 in cash.

Patient Thank You Doctor. Whom should I approach? You (PNC) or the UGCM with the MRI report?

Consultant You can meet the UGCM.

May 5 – MRI Centre

Lab Technician What are the complications for which you are referred to a spine MRI? Do you have any problem in walking? Lack of sensation in the lower limbs, etc.?

Patient Actually none. I approached the UGCM to check if hysterectomy is advisable in my case. She guided me to a PNC who advised an MRI of spine.

Lab Technician Well, the whole process will take an hour or so. Please remove your jewellery and keep it in the locker and change into the lab dress.

(The patient was instructed in the MRI machine room not to move from a fixed position as prescribed by them)

May 7

Patient Doctor, these are the reports of the investigations you had prescribed.

Doctor (UGCM) took a quick look at the reports. She instructed the attending nurse to fix an appointment.

Patient Doctor, I am leaving on May 17 to my working place. Based on these results please tell me, if it is advisable to undergo hysterectomy.

Consultant You may have to undergo another set of additional investigations. The nurse would explain them to you. I can tender any advice only after the second set of investigations are completed.

Nurse to Patient Come on May 15 afternoon after having your lunch. Drink plenty of water and keep your bladder full. The tests will take approximately three hours. You pay (by cash) INR 12,000 for the tests.

This appointment with the Consultant lasted hardly for 2 minutes.

May 15

Patient Doctor, you said you will give your opinion after these tests. I am leaving day after tomorrow. Please advise me.

Consultant Give this sample in this lab (writing down in the lab’s letterhead, provided to her by the lab, the details of the biopsy test) wait for the biopsy result.

Patient But…I need to return back to my place of work

Consultant Wait for the biopsy result.

May 16

Consultant How dare your husband shout at my staff? He had the audacity to ask me to come on phone.

Patient But we were looking for your advice and it was not forthcoming. We are leaving tomorrow. The only way to connect with you was over phone.

Consultant I do not entertain patients on phone. I am not your servant and your husband was critical about the money spent on tests. You would have spent how much? (turning to the nurse) How much did we take from them?

Nurse INT 12,000 for the tests. Other tests were conducted outside.

Patient We have spent so far INR 20,000 to obtain a second opinion.

Consultant How dare you come to me for second opinion? I would not have touched the case had I known that you were here for a second opinion.

Patient We told you this in the first meeting itself. My husband had a point in asking about the tests because many of them are repeated here. What is the need for it?

Consultant I do not rely on other’s work.

Patient But your Sonography result do not show the multiple crystals in both the kidneys, not even a single one was present. Whereas the test done in our regular working place, 4 weeks before, showed up multiple ones.

Consultant Oh, maybe they are washed away already. What do you know? I have already started the treatment for you in the form of removal of polyp from the uterus wall.

Patient But… I came for a second opinion and not for treatment.

Consultant Had I known that you had come for a second opinion, I would not have entertained your case.

Source: Prepared by the case writers based on the detailed account recollected by the patient.

Annexure 2: List of Investigations Done at Various Locations

Name of the investigation

Work

Location

Home

Location

Stage 1

1

ECG

ECG

2

X-Ray Abdomen, Pelvis

X-Ray Abdomen, Pelvis

3

Urodynamic test (includes uroflow)

Urodynamic test (includes uroflow)

Stage 2

1

Cystoscopy

Cystoscopy

2

Uroflow

Uroflow

3

ECG

ECG

4

Chest X-Ray

Chest X-Ray

5

Pre-operational blood/urine profile

Pre-operational blood/urine profile

6

Culture and antibiotic susceptibility test

Culture and antibiotic susceptibility test

7

Immunoassay

Immunoassay

8

Biochemistry

Biochemistry

Glossary*

Biopsy: Removal of a sample of tissue for diagnosis

Cystocele: Protrusion of bladder and the front wall of the vagina into the vaginal space.

Cystoscopy: A procedure in which a lighted instrument called a cystoscope is inserted into the urethra (the tube that carries urine from the bladder to the outside of the body) to examine the urethra and bladder.

Hysterectomy: Removal of the uterus of a woman is advised by doctors for various reasons/health conditions of a woman. It is estimated that one third of women undergo this surgery. In some cases where the uterus has distended/prolapsed and put pressure on the bladder causing urinary incontinence, the uterus is removed even though there is no problem with the uterus.

Incontinence: It is the inability to control the passage of urine. This can range from an occasional leakage of urine to a complete inability to hold any urine.

Kidney stone: It is a solid mass made up of tiny crystals. One or more stones can be in the kidney or ureter at the same time.

Rectocele: Protrusion of rectum and the back wall of vagina into the vaginal space.

Urodynamic testing: A sophisticated way of seeing how much urine flow is blocked and how well the bladder contracts.

Uroflowmetry: It is a test that measures the volume of urine excreted (released) from the body, the speed with which it was excreted, and how long the excretion took.

Urogynaecology: Urogynaecology merges the expertise of both specialties.

Uterine prolapse: It is falling or sliding of the uterus from its normal position in the pelvic cavity into the vaginal canal.

Source: Public websites.

This case was prepared for inclusion in SAGE Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.

2023 Sage Publications, Inc. All Rights Reserved

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