Lest we hang our white coats in shame

It was the most perfect hysterectomy specimen that I had ever seen. Quite literally in the pink of health. A perfect cervix, myometrium, endometrium, fallopian tubes and ovaries. It could have been the poster child for a teaching class on the female reproductive system. There was a problem. The patient was a 16-year-old. The entire history was summed up in two words scrawled across the form that read “irregular periods”. I grossed the specimen taking extra sections or “bits”.

The next specimens were gallbladders, core biopsies and prostatic chips. I saw the second showstopper. The form read 18-year-old male-preputial biopsy performed for “Itchy prepuce”. The handwriting on the uterus and preputial biopsy forms were identical. On pouring the bulky contents into the dish I saw skin, and multiple large chunks of tissue. I hadn’t seen so much soft tissue removed along with preputial skin before. I processed multiple sections.

Two days later I received the slides of the cases. The hysterectomy was completely normal. There was no specific lesion in all the multiple sections taken including the deeper cuts. The preputial skin had skin removed with no ulcer, significant inflammation, infective lesions or malignancy. What was distressing was the presence of mutilated seminal vesicles, a portion of the urethra and penile musculature. What kind of botched-up surgery, was this?

As there was no way to decipher the doctor’s illegible handwriting, I called the patient to ask for his phone number. This was strongly discouraged by the Lab Manager who said that patients and their relatives tend to get suspicious when contacted. An alien concept to me, where my medical training had always stressed the importance of doctor-patient-pathologist interaction to provide the best clinically meaningful report to the patient.

Almost simultaneously there was a call from security to inform me that the relatives of the boy who had the preputial biopsy done had come to the lab. Three large burly men entered flanked by two armed security personnel. This was standard procedure in the city that had witnessed an increased number of doctors being violently assaulted by relatives of patients who either contested the diagnoses received, or were upset when a patient had died in the hospital.

The man in front bellowed, “So, is there a tumour or not? We have given some of the specimen to another lab also, just so you know”. “Sir there is no tumour,” I said, “I will speak to the referring doctor.” I was cut off mid-sentence when he said, “I hope my son’s discharge clears up. He has severe problems when he tries to pee, after the surgery.”

I sat down, sweating profusely as I called up the nursing home where I hoped to contact the surgeon. I was informed by his attendant that he was operating and to call at 2 PM. When I called again, he was sleeping. “He is such a senior doctor, and at 72 years of age we should respect that,” said the attendant.

By this time, the little red flags on my computer screen were blinking that indicated these reports were both past due. “The currency of any successful corporate lab is the Turn Around Time (TAT), Dr. Samuel, or do we need to remind you of this?” said the Director of the Lab, who monitored every case like a hawk.

I explained sternly, the absolute need for me to speak to the doctor as both cases were troubling with no visible lesion. The next phone call was from the Chief Executive Officer (CEO) and Chief Financial Officer (CFO) who spoke on a conference video call to sound more assertive and not-so-gently-threatening my position in their esteemed organization, if I delayed releasing the report any further. When the phone rang again I asked the Lab Manager, “Who is it now, a UFO?” It was a poor joke meant to alleviate the tension that everyone felt, as we positioned our relatives, friends or loved ones who might have had such medical procedures performed on them.

Finally, the septuagenarian surgeon came on the line. I described the specimens to him, mentioning the time that we had received it in the lab. He finally remembered the cases. “Ah, yes, the 16-year-old had irregular periods”. “Was there any previous biopsy, Sir,” I asked. “No”, he said, “the gynaecologist did an examination and thought the uterus was bulky. Better to remove it in such a situation, what if there was a tumour and it spreads rapidly? No sense in taking such a risk!”

I then asked about the 18-year-old and why the biopsy was done when there was no ulcer grossly or microscopically. “Ah, that’s why I removed a lot of tissue to be sure and maybe it is in the sample that has gone to the other lab X”. At this point the lab director who was listening in on the phone conversation piped in, “Thank you Doctor for your continued patronage of the lab. We will release the report by this evening”. She had done the necessary damage control.

I checked with a colleague at the competing lab what the preputial biopsy showed with the specimen that they had received. The findings were identical to mine, and they had released the report on the day the slides were received, with no additional sections, no conversation with the doctor and certainly no angst.

As I was typing in the reports for both as no significant pathology, the Lab Director called me again. “Can’t we say mild non-specific inflammation? Something like that”. “No, I cannot,” I said, tired, and frustrated. It had been a long day and with hypoglycemia kicking in I had no filters.

Before heading home, I heard two junior doctors in conversation.

Doctor #1 - “This is the same doctor who had that legal case filed against him. He removed the fallopian tube instead of the appendix in the 12-year-old. She developed sepsis and died. It’s no wonder patients beat up doctors, can you blame them”.

Doctor #2 - “Violence is never the answer, no matter what! They could have waited for the case to have gone to trial”.

Doctor #1 - “And how many years would that take? He would have gotten off on a technicality.

Doctor # 2 - “Can you imagine the implications of the surgeries as these young patients have had their reproductive organs removed or mutilated”.

Doctor # 1 - “Yeah, it’s cruel to say, but these two should hook up as they no one could understand their situation better than themselves”.

There was a phone call for me. It was the mother of the 16-year-old asking me if there was any tumour in the uterus. I could detect relief when I told her there was no tumour. “Thank you for this good news doctor! We were afraid that the diagnosis of a cancer could affect her marriage prospects and what if her children got cancer as well? That would have been catastrophic.”

I turned off my microscope, switched off the lights and made my way through the dark.