Saturday, July 17, 2010

When a Physican Abandons a Patient...

..what are the ethics involved?

Let me recap my situation for newbies. Pardon my redundancy but I don't want to make people chase links, although I will include them.

Here's the story:

You might be shocked to know I had breast cancer. No, really, I did! Sometimes even I find it hard to believe.

I chose the only reconstruction option a skinny chick like me can have - reconstruction with a tissue expander. After seeing the first plastic surgeon I was referred to, and not liking what I saw of his work, I got a second opinion from Dr. S, who agreed to treat me.

Or so I thought.

At the time of my mastectomy, October 21, 2009, this physician put in expander and did all my subsequent saline fills. I had numerous appointments with him, all of which he canceled and rescheduled. I got my last fill in February, and I was done.

Surgery to exchange the expander for an implant wasn't scheduled until June 8th. I prepared myself mentally for my final results, and was eager to at least be comfortable, as the expander, to say the least, is not.

The evening of June 7th, excited yet nervous for my upcoming surgery, I put a scopolamine patch behind my ear as I was instructed, and went to bed. My husband, who had taken the day off work, got up with me at 5:30 a.m. I was dizzy and light-headed from the drug, and of course, didn't eat. We arrived at the hospital by 6:30 a.m. My husband left to go home and take our son to school, and then came back.

I undressed. An IV was started. My blood pressure was taken. I was placed in a hospital bed.

And there I sat, dozing and dopey from the drug, for four hours.

At 10:00 a.m., hours after my surgery was to take place, Dr. S came in and told me that my implants had never arrived and surgery was off. Ominously (in retrospect), he said that was the reason he preferred to do operations in his own surgical center, to prevent these kinds of problems. (I couldn't go to his surgical center for insurance reasons.)

A couple of days and another canceled appointment later, he told me over the phone that he was not going to be my doctor anymore. He said it was nothing I had done, but he had decided not to do reconstructions any longer, which I took to mean he didn't want to deal with insurance companies anymore.

I was upset, naturally, but I wished him good health and accepted the decision. After the hospital fiasco, I felt it might even be for the best.

He verbally referred me to another plastic surgeon, Combat Doctor, and said he had spoken to her that weekend and she agreed to take me, and he had cleared it with my insurance. I was told to call immediately - which I did - and she'd get me right in.

When I called, I discovered that she had broken her pelvis, which, amazingly, she had failed to mention to Dr. S. Her office gave me an appointment for six weeks down the road, July 27th, when she was expected to have healed. They told me surgeries were backed up past October, which sent me into a funk.

I was clearly not getting this expander out of me any time soon.

Two weeks ago, her office canceled our appointment. She is not better.

And, of course, I feel bad for her. She has a terrible injury and I know that it's no fun.

Her office offered me an appointment with her partner. They said he was a "wonderful doctor." Googling, I see he graduated med school just a few years ago and does not have her breadth of experience. But, I am ready to get this expander out of me, and maybe he knows some new tricks. I like young people. I set up an appointment to at least meet him on July 30th.

In the mail today, I received a letter from my insurance company, which said, and I paraphrase, that they have not received enough information for me to see this new doctor. They don't have my full clinical history. My old plastic surgeon has 45 days to comply with their request or I will be denied care.

I might remind you, they said they had taken care of this right after June 8th.

Now, I don't think a doctor should be forced to treat a patient if he doesn't want to. However, I wasn't an abusive patient. I complied with all instructions. He canceled many appointments with me - I never canceled one with him. I never complained - in fact, his office staff liked me well enough to get me some free Latisse.

I was so understanding that in the hospital, on that fateful day, that when he apologized my response was, "Don't apologize, it's not your fault, things happen." At the time, I assumed it was the hospital's mistake.

But, honestly, is it the truth that it's not his fault? He is the physician. Shouldn't he have been the one responsible for making sure that my implants had arrived before surgery that day? Should surgery even have been scheduled until they arrived?

The physician/patient one is not equal. We are not at a cocktail party where he can notice my breath is bad, decide not to talk to me anymore, and just walk away. He has an obligation - has even taken an oath - to see that I am taken care of once he accepts me as a patient, doesn't he? Even if he decides he only wants to take cash patients in his own surgical center - shouldn't he have seen to it that he referred me to a doctor who was functional?

I depended on his knowledge, and I foolishly trusted him. I was going to allow him to cut me open, flay my muscles, restore my appearance. I believed him when he said I would not be perfectly happy with my appearance but that he would do the best he could. I undressed in front of him, allowed him to take photos, touch my breasts. I gave him intimate information and had faith he would care for it all.

And, for me.

And, he abandoned me for money, and has left me without care. It has been 38 days since I was supposed to have surgery and 6 months since my body was ready to have it - and the insurance company still doesn't have the information they need. If I have a problem; if the expander becomes infected, if it becomes damaged - I have no doctor to treat me. The expander has been in for ten months already and my last fill was in February. The valve is pushing through the skin, and is causing me discomfort, and I have permanent bruising. I cannot have MRIs, or fly without setting off an alarm, or have any other medical tests on my formerly cancerous side, and I should be doing that every six months.

I looked up the term patient abandonment. Patient abandonment is described as the unilateral withdrawal by a physician from a patient's care without first formally transferring that care to another qualified physician who is acceptable to the patient. I have been without medical care now since June 8th. Combat Doctor is certainly qualified - but she isn't functional. I believe the doctor thought he transferred my care to another doctor, but like with the missing implants, he didn't have any kind of follow-up. (Yes, I did call his office staff and tell them.)

I've never received any kind of letter or medical records or anything from this doctor. All I got was a phone call firing me - a call which I initiated.

Most women who had mastectomies the same time that I did have completed their reconstructive surgeries and have been able to get on with their lives by now.

And, I'm still waiting. In limbo. And, in discomfort.

My plan is not to do anything legally so no suggestions about that. I am not medically harmed, but I am living in discomfort much longer than I should have.

I am just curious as to whether this situation violates any medical ethics, or is normal.

Doctors, what do you think?


  1. I hope someone in the medical field reads this and you have an appointment within the week! I have engineering degrees, so I am no help. But I can help with positive thoughts. Wishing you the best!

  2. ELT, thank YOU for reading it. It's kind of long. :) I'm not holding out hope for a quick appointment. I'm just holding out hope that all this brusing isn't going to be permanent!

  3. Something is fishy with the doc who abandoned you. It isn't normal for a doc to get the patient prepped and somehow not finish the job. Even if he's tired and wants a change, he should have finished what he started. It's just not ethical to leave a patient in the lurch as he did to you. There must be something screwy going on in his personal life - that's the only thing I can figure.

    My advice would be to talk to as high-up of a person at the insurance company as you can get on the phone. Explain to them EXACTLY what happened and how this doc left you in the lurch. They could possibly help you find a good doc who is approved, or get you approved with this younger doc quicker.

    If you live in Arkansas, go to Dr. Ramona Bates (Suture for a Living blogger). I would not rule out legal action if you are harmed by waiting. I am not in love with our legal system, but if this doctor's negligence (which I believe he's shown) causes you actual harm, you should be compensated so you can get this fixed.

  4. Thanks Dr. Rob. So far, I'm not harmed medically, but am uncomfortable longer than it was necessary to be. I hate lawyers though. (Except you, TB).

    I'm in CA, by the way, but thanks for the tip on the blog. :)

    I did call my insurance company but got no help the first time. I'll try again on Monday with the number on the letter. I did make sure I wasn't billed for the hospital stay though, and I wasn't, so they know something odd happened.

    My oncologist heard the story and checked my "breast" and said, jokingly, "It looks like it's ready to blow." If it does blow, I'll reconsider whether I am harmed or not.

    You answered my question about ethics, and I thank you.

  5. Never heard of a doctor leaving a patient this way, you are put through so much stress and being uncomfortabe throuh no fault of your own, just doesn't seem your attitude and am wishing you much good luck, keeping you in my prayers......:-) Hugs

  6. Sometimes I think you are being to nice and understanding. I can appreciate thinking you are not harmed medically but it depends on how you are looking at this. You have been harmed mentally, your family has been harmed, your work has been harmed, etc.

    If you do not get positive out come from your insurance company I think a call to the Insurance Commission office is the next step. They need to take care of your problem so you can get this done.

    Judi G

  7. Not a doctor, just putting this out there:

    Would it be possible for them to remove some saline from your expander for the duration? My experience: I needed radiation, so prior to radiation my PS partially drained my over-expanded expanders at the request of the rads onc. 6 weeks prior to exchange surgery (which was this week!) he re-filled 60 cc's each (over expanded but not as much as before). When he drained my expanders, they were much softer and became much more comfortable after a couple of days. Just something that could possibly get you by if you have to wait a long time.

    Also, just as a "chin up," I had to wait a year with expanders in (because of said radiation) and while it WASN'T fun, it was do-able. Also, my results are STELLAR. I've never looked so cute. I am honestly thrilled. I'm not from CA tho, wish you could have my doc!!!

    I'm so sorry for your situation and hope a doctor replies who can help!

  8. What a crummy situation, Ann ;(. I would call around and find a new surgeon even if I had to go out of town. The expanders are so uncomfortable - I had mine in from June through January and that was long enough. Believe me, you WILL feel a huge difference when you do have the swap out surgery - it's a major and welcomed difference and I hope you get to experience that very very soon.

    ALSO - I flew with my expanders (and port) in and didn't set off any alarms. Have you actually had that happen?

  9. I fly on the 6th - going down to SoCal to see my sister, so I'll test the expander. I have heard there is metal in there but no, it hasn't happened to me. I only heard that it has happened to others through the cancer grapevine.

    Judi, thanks for your thoughts. If I don't get any satisfaction with the insurance company, I'll go to the insurance commission but California is pretty dysfunctional. I am sure that it'll be resolved somehow - law says that they have to give me this surgery, but not by a certain time. These expanders are medical devices and designed to be in the body for a while, so as uncomfortable as it is, it's not endangering me. You are right though, my job will be impacted. This should all be over with by now and I shouldn't have to take any more time off, and yet - I will.

    I want to make sure I get a decent doctor too. That's important to me. I thought I had one but I was clearly mistaken.

  10. Ann you are one of the top bloggers and connected with the Sac Bee. It's time for some superstar doc to take your case. I would consider seeing if someone at the paper wanted to write a story about you.

    Maybe Doc Gurley who has written for Loop and the SF Chronical might know someone?

  11. Thanks Suzanne! I think being a blogger will get me a cup of coffee at Starbucks if I also have $3.50. :) I am seeing a doctor on the 30th, finally. And, it is about time as I am having some serious pain in that area right now - stabbing pains. Something is going on in there and it's not good. (I think I'm just sleeping on it wrong)

  12. Hi Ann, I'm not an MD, however I'm a women's health nurse practitioner. The doctor must give you several written referrals or it is considered abandonment. Also the doctor should have agreed to continue treating you for a specific amount of time after he "fired" you i.e. 30 days is pretty typical.

    Do you have a good primary care provider? Sometimes they can help get you to the next step with the insurer i.e. write a letter, get the medical records needed, in other words coordinate your care. If you don't like your primary care provider or they won't help you can seek a new provider by looking into the Ideal Medical Practice website.

    When our insurance company was denying my diabetic husband's insulin pump he found the name of medical director of the insurance company and called him at home several times, leaving pleasant messages on the doctors answering machine, eventually the director called my husband back and authorized his pump.

    My URL contained "illegal characters" so I have to post this as anonymous. My name is Anne Marie Moore WHNP, I practice in Eugene, Oregon.


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