Saturday, April 07, 2012

The trouble with trying to be conservative

I'm a conservative doctor and try to avoid surgical interventions as far as possible. I also try to treat all my patients as intelligent patients , who can make well-informed decisions for themselves when I explain their option to them. I think this is a sound philosophy , but I recently nearly burnt my fingers following this.

I saw a patient for whom I made a diagnosis of an unruptured ectopic pregnancy. She was one of those unlucky three percent who had an ectopic after embryo transfer . Because we were monitoring her hCG levels closely, we made the diagnosis quite early – when she was 5.4 weeks pregnant, and her hCG level was 1450 . The diagnosis was made based on the fact her HCG levels were rising slowly; and we couldn't see a in the uterine cavity on the vaginal ultrasound . I explained to her that this was an ectopic pregnancy, which needed to be treated promptly with methotrexate. I shared a website with her, which explained what an ectopic was; why it was potentially a time bomb ; and why it needed prompt intervention before it became a life-threatening condition. She was an intelligent patient , who understood what I said and agreed to follow instructions.

However, she then disappeared for six days and then came back again with a third ultrasound report from another doctor . Her hCG level had risen to 3600 by this time ; and the repeat ultrasound was reported as showing no evidence of an ectopic !

I had to sit and describe the concept of the HCG discriminatory zone to her , in order to explain why her sonographer had missed the diagnosis. A sonographer will only interpret the black and white shadow he sees on his ultrasound screen . He is not a clinician – and the eye only see what the mind knows. Ultrasound works by bouncing high frequency sound waves off the body’s tissues. In an early pregnancy, the only thing we can see is the gestational sac, which is a fluid filled structure and appears dark on a scan. It’s easy to see this when the sac is in the uterus, because the uterine wall consists of muscles. This is solid, which is why it has a different acoustic texture from a sac . This acoustic contrast makes it easy for us to pick up a very early pregnancy when it’s located inside the uterus . However, when the sac is outside the uterus in the fallopian tube , the acoustic contrast is not as pronounced; which means we have to wait till the sac becomes much larger , before we can see it. The danger is that if we wait too long , the sac may burst, leading to internal blood loss and possible death.

I was very upset that in spite my spending so much time explaining her treatment options to
her , she had chosen to just disregard my advice and potentially risk her life. While is no doubt that conservative treatment is better for patients , it actually offers an increased risk for doctors , because if the patient does not follow the advise, there's no way in which a doctor can be sure that the patient was compliant.

I was quite upset . At one level , I could understand why she was reluctant to take the methotrexate. Since her pregnancy tests were positive, she was still hoping against hope that this was an intrauterine pregnancy ; and that she would finally have a baby after so many years of waiting. However, false hope doesn't serve any useful purpose ; and while it can be hard to come to terms with the truth , it's far better to acknowledge this quickly , rather than wait for complications to occur. Part of the problem was that she was feeling absolutely fine – and when she googled the symptoms of ectopic pregnancy (which include pain and vaginal bleeding) she was perplexed that she did not have any of them. If she had no symptoms, maybe my diagnosis was incorrect ? Moreover , when she went to a sonographer to repeat the scan in order to get a second opinion, he had told her that he could not see an ectopic ! This is why she was quite hopeful that perhaps she has a very early pregnancy , which I had misdiagnosed. This is why she was keen on waiting , in the hope that everything would work out to be fine.
However, this approach can prove to be an expensive mistake , because as the hCG levels rise and the ectopic pregnancy becomes larger , the failure rate of medical treatment with methotrexate also rises.

Also from a doctor's risk management perspective, this could potentially have been a complete disaster. When I first made the diagnosis of an ectopic pregnancy, I could've admitted her in hospital and done an emergency laparoscopic surgery to remove the ectopic . This would have been definitive treatment and would have been perfectly acceptable , because it would have treated the problem quickly, cleanly and efficiently. However, as a good doctor , I wanted to avoid surgical intervention , which is why I recommended a more conservative treatment to her. However, she just pretended to agree with me and then choose to ignore my advice. If she had failed to turn up for a follow-up , it's quite possible that this ectopic pregnancy would have grown and ruptured ; and then she could have sued me , because she could claim that I was negligent in not doing an immediate laparoscopy , when I had made the diagnosis the first time. The irony is that I was trying to avoid surgical intervention in her own best interests – and yet this could have come back to haunt me , for no fault of mine.

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