O&G’s ‘needless and senseless unprofessionalism’ brought profession into disrepute

Key messages from the case

Ensure patients have enough time to explore treatment options and give their informed consent. Schedule a follow-up consultation if necessary.

Always conduct examinations in an appropriate and respectful manner. Maintain a respectful and professional tone. Never make over-familiar remarks or inappropriately comment on a patient’s appearance.

Details of the decision

Failure to obtain informed consent

Ms P, aged 48, consulted obstetrician and gynaecologist Dr J for treatment of heavy menstrual bleeding. She had been consulting Dr J periodically for over 10 years, for pregnancy care and later for tubal ligation and treatment of menorrhagia.

Dr J recommended a vaginal hysterectomy based on her history and ultrasound examination.

Ms P also reported symptoms consistent with posterior wall vaginal prolapse. Dr J did not conduct an examination or discuss treatment options with Ms P. He planned to examine the prolapse during the surgery, but made no mention of the prolapse or treatment plan in the clinical notes, nor in the report to Ms P’s GP. He did not give Ms P a copy of the relevant RANZCOG information sheet.

Ms P signed a consent form for a hysterectomy, which included a notation of “+/- vaginal repair”.

Surgery was undertaken and included a laparoscopic assisted vaginal hysterectomy and a vaginal prolapse repair.

At a three-month post-operative check, Ms P advised she was unable to separate her legs wider than shoulder width and she was experiencing pain and bleeding during sexual intercourse.

Dr J did not concede that the surgery was unsuccessful, but referred Ms P to a colleague and offered to pay any out of pocket expenses. Ms P subsequently required multiple corrective surgeries. She continued to experience symptoms including pain during sexual intercourse and difficulty with daily activities such as getting in and out of cars, lifting heavy items, sitting for extended periods or climbing stairs. She needed assistance with routine activities and suffered ongoing poor mental health.

Ms P complained to the regulator alleging she had not been informed about the prolapse repair or given the opportunity to consider alternative treatment options.

At the tribunal, Dr J’s performance of the surgery was not criticised. However it found that he failed to obtain informed consent and this constituted professional misconduct. Ms P did not know what to expect from the surgery and had no opportunity to explore less invasive treatment options.

Dr J claimed he had been short on time in the initial consultation and planned to examine the prolapse while Ms P was under anaesthetic. He accepted he should have assessed the prolapse at that follow-up consultation. He should have discussed the potential risks and complications and considered treatment options, including whether surgery was indicated. He acknowledged Ms P had not had the opportunity to provide informed consent to the procedure, or informed financial consent to additional surgical expenses.

The tribunal also concluded Dr J’s failure to make any records of any discussion with Ms P about the prolapse, treatment options and risks amounted to unprofessional conduct.

Inappropriate and disrespectful communication

After the surgery, Ms P alleged Dr J told her ‘I’ve done a tidy up of you and your husband will be very happy.’ And later ‘I don't know whether you've checked down there for a while but you were rather saggy. So that's why I've tidied stuff up for you.’

Dr J also performed a digital examination and said words to the effect ‘I don’t think you’re too tight. I can still fit two fingers in there.’

Dr J did not recall the exact words he used, but did not deny his comments were inappropriate. He suggested he had been over-familiar with Ms P because of their long-standing treating relationship. He also commented that these were the kinds of comments practitioners made to patients when he was training.

The Medical Board argued Dr J’s ‘needless and senseless unprofessionalism’ was an aggravating factor that ‘brought the profession into disrepute, suggesting practitioners are out of touch with contemporary standards in matters of sexual health and the medical treatment of women.’

The tribunal concluded, and Dr J accepted, that Ms P never understood the surgery performed. She felt violated and continued to believe the surgery was unnecessary and had been performed without her consent to improve her husband’s sexual experience and because ‘a man looked at my body during surgery and thought that it should be altered.’

Outcome

The tribunal made it clear that signing a consent form did not constitute informed consent. Without an examination or any discussion about the prolapse, Ms P could not weigh up whether to proceed with a potential vaginal repair. There was no evidence that Dr J had explained what would occur if a prolapse was identified during surgery, including the nature of any repair or the option of deferring treatment.

Dr J co-operated with the investigation into the complaint and undertook education on informed consent, professional and sexual boundaries, effective and ethical communication, and record-keeping. He accepted his comments were inappropriate and apologised to Ms P for her distress.

The tribunal concluded Dr J’s intention in conducting the surgery was to improve Ms P’s health – despite his wholly inappropriate language. It did not consider he posed an ongoing risk to patients.

The tribunal accepted the parties’ agreement for a reprimand and three-month suspension plus ongoing mentoring conditions.

Key lessons

Except in cases of life-threatening emergency, you must obtain a patient’s consent to a specific procedure.

Make sure your patients have provided their informed consent to the treatment or procedure they will be undergoing, which includes that they understand the risks involved and what might happen if one of the risks were to materialise.

Plan a follow-up consultation if there is insufficient time during a consultation to undertake an examination and fully discuss treatment options in detail so a patient can make an informed decision.

Your record of a consultation needs to include details of your examination and treatment plan.

When documenting the consent discussion, include your discussion about risks and outcomes material to the patient’s circumstances, alternatives explored, any concerns raised by the patient and your responses. Include copies of any information you provided.

Always conduct examinations in an appropriate and respectful manner and in accordance with the Medical Board guidelines on conducting physical examinations (see Medical Board of Australia, Guidelines on sexual boundaries in the doctor-patient relationship).

Consider the need for a chaperone if undertaking an intimate examination. For more details see: Observers: chaperone, protect and reassure

Recognise that patients are likely to be in a vulnerable position. Maintain a respectful and professional tone. Never make over-familiar remarks or comment on a patient’s appearance.

References and further reading

Avant factsheet – Consent: the essentials

Avant eLearning – Consent: Informed consent and more

Avant factsheet – Boundary issues