Expert Articles
 
UROLOGICAL MALPRACTICE

Urologists treat diseases of the genital and urinary tracts including infections, stones, cancer, infertility, incontinence, impotence and trauma. Medical -legal issues can be evaluated using a model that will provide important information for subsequent action. The initial evaluation should include a complete review of physician and nurses records. A review of the literature can be conducted using the Bibliomed CD-ROM Urology database. Cases can be graded as to no departure, possible departure, simple departure or gross departure from applicable standards of care.

No Departure:

In these cases there has been a poor outcome often in a difficult clinical setting despite good judgment and technique.

A 50 year old overweight women with high blood pressure undergoes extracorporeal shock wave lithotripsy for a kidney stone. The preoperative discussion includes the possibility of injury to the treated kidney. The treatment records indicate that appropriate and safe technique was used. After treatment a blood clot develops around the kidney. The kidney subsequently atrophies with worsening of her high blood pressure and the development of moderate chronic renal failure.

This is an example where there is no departure from accepted treatment choice or technique. There are no consent issues. Kidney damage is an expected complication of the patients underlying hypertension. Recommendation would be to not pursue a malpractice action.

Possible Departure:

A poor outcome might have been avoided if the treating physician had been more knowledgeable or careful. Nevertheless the treatment chosen was within the realm of reasonable alternatives or, if a clear error was made, it did not alter the clinical outcome.

A 67 year old man is found to have a slightly elevated PSA and a minimally abnormal rectal examination. He is referred for follow-up in six months. At that time he is found to have a markedly abnormal PSA and widespread prostate cancer.

The ideal choice would have been to proceed with evaluation and prostate biopsy at the first contact. However it is likely that the patient was incurable at the outset. In addition there is a great deal of controversy as to the value of the screening PSA and the proper time to proceed with biopsy. It could be argued that the treating physician was in error. However the case would probably be subject to very valid doubts from the defense experts. The physician and patient evaluated the test result and came to a conclusion. This would provide enough information to pursue failure to diagnose in cases where the abnormal blood test was simply ignored.

Simple Departure:

In this category there is clear lapse of judgment or technique, often in a series of errors leading to a poor outcome.

A 27 year old man complains of testicular pain and swelling after a minor injury. He is hospitalized. Ultrasonography indicates a possible tumor or blood clot in the testis. Blood tests suggest testicular cancer. The treating physician discharges the patient who is followed in the office one week later by another doctor. The ultrasound is repeated again suggesting cancer. A third doctor sees the patient and recommends only that the patient be re-examined in six months. Five months later testicular pain recurs and the testicle is removed. Cancer is found in the testicle and there are lung and abdominal metastases.

This case demonstrates judgment well below the appropriate standard. It is likely that the patients metastases developed within the last few months. The patient has incurred a risk of death or permanent disability.

Gross Departure:

These cases reflect grossly ignorant or careless behavior. There may be evidence of attempts at falsification of records or the patient has been misinformed.

A man is to undergo removal of one epidydimis for treatment of chronic testicular pain. He is informed after surgery that both epidydimes were removed rendering him sterile. Care review of the hospital records reveals that the patient underwent erroneous surgery on the wrong testicle. The error was recognized after he had been transported to the recovery room. The patient was then returned to the operating room, given a second anesthetic and underwent surgery on the proper site.

In addition to the obvious error there is the potential issues of conspiracy to defraud among the physicians and hospital staff, deception with fraudulent intent by the treating physicians and involuntary sterilization with attendant violation of federal medical regulations and human rights law.

Conclusion:

Expert case review can assist the attorney and client decision to pursue a claim of medical malpractice. The model utilized for case evaluation provides clear advise based on objective information available in the medical record and the medical literature.




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