Expert Commentary

Avoiding legal pitfalls of hysteroscopy

Attorneys and Ob/Gyns trade views on informed consent, documentation, and other vulnerable areas.


 

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  • Managing and minimizing operative complications

Over the course of our careers, at least 75% of Ob/Gyns will have 1 or more medical liability claims filed against us. This naturally makes us cautious, sometimes overly so.

Though hysteroscopy is usually an effective—as well as safe—alternative to hysterectomy, many Ob/Gyns have not yet integrated this technology routinely into patient care, partly because of the fear of litigation.

In this roundtable, legal and medical experts comment on ways to minimize legal risks in 3 hypothetical cases.

OUR EXPERT PANELISTS
  • Steven R. Lindheim, MD, moderator, is associate professor, department of obstetrics and gynecology, University of Wisconsin Medical School, Madison
  • Daniel Williams, MD, is associate professor, department of obstetrics and gynecology, University of Cincinnati College of Medicine
  • Ira Newman, Esq, is an attorney at Sanocki, Newman, Turret, LLP, New York City
  • Eric H. Weitz, Esq, is an attorney at Layser & Freiwald, PC, Philadelphia
  • Jerry A. Lindheim, Esq, is an attorney at Locks Law Firm, Philadelphia

Case 1: fluid overload

“Abby” is a 30-year-old nulligravida who presents with menometorrhagia and symptomatic anemia. Sonohysterography reveals a 3-cm submucous fibroid. After 3 months of pretreatment with a GnRH agonist to decrease the size of the fibroid and relieve her anemia, Abby undergoes hysteroscopic resection of the fibroid with a monopolar instrument and 1.5% glycine as the distention medium. The surgery is prolonged, and the fluid deficit at the end of the case is 1,700 mL.

Serial labs are drawn in the recovery room, and Abby is hospitalized overnight for observation. Her fluid intake is restricted and a diuretic is administered. The next day her electrolytes are normal, and she is discharged from the hospital.

When assessing clinical risk, watch fluid deficit, large myomas

DR. LINDHEIM: Clinically speaking, the choice of distention fluid in this case is appropriate, since the surgeon is using monopolar electrical current, and glycine has low molecular viscosity. However, it is imperative to strictly monitor the fluid deficit and, whenever possible, limit infusion pressure to 60 to 75 mm Hg and keep operating time below 1 hour.

Also be aware that larger submucosal myomas may have sizeable venous channels. When these channels are opened during resection, significant fluid intravasation can result.

Should a physician say “I’m sorry”?

Dr. Lindheim:As a front-page article in the Wall Street Journal8 observed, a doctor’s best tool in fighting lawsuits may simply be owning up to errors. Yet this concept has been somewhat taboo in the medical community. What are your thoughts on a physician giving a simple apology?

Mr. Lindheim: It is in the heat of passion, usually involving anger, that families seek vindication against a physician simply because the physician wasn’t nice or failed to address questions posed by the family about an unfortunate outcome. In everyday life, when emotion clouds reason, it is hard to think logically and understand complex explanations. When a physician comes across as arrogant at such a time, the patient and her family are often motivated to contact an attorney to evaluate the standard of care.

Of course, an unfortunate outcome is not always the result of medical negligence. This is difficult to explain to a family angered by a doctor’s “attitude.” An apology may somewhat soothe the anger that drives many lawsuits, but it may not be enough to deflect litigation unless the physician is prepared to take responsibility for the adverse outcome.

Mr. Newman: Patients usually seek the advice of a lawyer out of anger or mistrust. They may believe their doctor has been evasive or inaccessible.

In cases where medical negligence may have caused injury to the patient, or complications associated with the nature of the procedure result in injury, it is my opinion that the treating doctor should forthrightly address any questions and concerns the patient has. This includes making oneself available in person or by telephone on a daily basis. In fact, picking up the phone and calling a patient who feels “wronged” may be the single most effective tool the doctor has to prevent a medical malpractice lawsuit.

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