Definition of a Gynecologist
The American Board of Obstetrics and Gynecology define the field as a specialization in the general medical care of women, as well as care related to pregnancy and the reproductive tract. In the sense of separation of Obstetrics and Gynecology, the two are linked in training, commonly linked in practice, but the doctor may choose to confine himself to one or other of the fields. It is specifically stated the field of gynecology comprises women’s general health, including care of reproductive organs, breasts and sexual function. The field also includes management of hormonal disorders, treatment of infections, and training in surgery to correct or treat pelvic organ and urinary tract problems, to include cancer of the reproductive organs. It is further stated the gynecologist is taught the provision of overall health care for a range of medical problems, not just those of the reproductive system.
The practice in the United States is more embracing of general women’s health, a primary contact physician for women, than in some other countries where the gynecologist may seem him(her)self as a consultant accepting cases only by referral, and primarily engaged in surgery.
Potential for malpractice claims
If the gynecologist accepts the role, that is the duty of care as a primary contact physician for women, then he must assume responsibility, directly or indirectly, for any and all medical issues she experiences, as would a family or general physician. He will also, in view of his additional training, be expected to be particularly alert to any issues involving the genital tract, all issues relating to the normal and the abnormal, including pelvic pain and infections, cancer, and pregnancy; breast examination and care is also expected to be performed at an advanced level, and most persons would expect an interest in osteoporosis of the post-menopausal woman.
The Potential for Gynecologic Malpractice
The gynecologist, as in all litigation, may be faulted for errors of omission or errors of commission. He may have failed to make an adequate examination of breast or pelvis, he may have failed to act on information given to him by patient, referring physician, radiologist or pathologist; he may have failed to follow through with his findings to see the patient or the next physician acted on them.
In office or operating room procedures he may have performed unnecessary tests or surgery, he may have performed them incorrectly or to an excessive degree, he may have injured another structure and either not realized this, or worse realized it and failed to do anything about it; he may have thought while the pelvis was open in the operating room he would perform a procedure for which permission had not been given, which could be considered “battery.”
Cervix uteri: Papanicolaou smear is a routine test for cancer of the cervix. There has been debate how often this should be performed, the most recent task force recommendation is for every 3 years on women between the ages of 21 and 65. A failure to perform the test might cause liability, a failure to perform the test properly is more likely to leave the gynecologist open to suit. The smear is first read by a computer, next by a technician, and where necessary, by a pathologist. A failure to read the smear correctly cannot reasonably be blamed on the gynecologist. A failure to act appropriately on the results of the smear may provoke a suit.
The pap test is for routine screening, it is not appropriate in the presence of a visible lesion, for which a biopsy should be performed. The biopsy may be inadequate, or it may be excessive, causing unnecessary damage to the cervix. The gynecologist may also be faulted for failing to make a biopsy when the patient has reported abnormal bleeding, unrelated to menstruation.
Errors in the Operating Room
Some pelvic operations are notoriously difficult because of dense adhesions, which may be anticipated as a result of previous diagnostic endoscopy, in which case it is prudent to warn the patient of the potential for inadvertent injury of uninvolved organs.
Ureter: this tube which runs from the kidney to the bladder lies in close proximity to the uterus, and may become bound to the uterus by adhesion. During surgery it should be “isolated” and protected. However, on occasion it may be injured, opening the tube, or it may be involved in a ligation so that the ureter is effectively blocked. It is recognized that in particularly difficult surgery these things happen; the surgeon is expected to recognize what has happened and to correct it.
Bowel: the rectum lies behind the uterus and may be damaged when the uterus is operated on; the small bowel may be cut inadvertently when the surgeon performs laparoscopic surgery and the bowel moves into the field. It happens! It should be repaired.
Bladder: the bladder lies in front of the uterus and may be injured; it should be protected during surgery to prevent this from happening; any injury that occurs should be repaired.
Urethra: the urethra runs from the bladder to the exterior, and during repairs of the lax vagina for instance for cystocoele, may inadvertently be caught in a suture, or ligated completely.
Nerve injuries: Direct injuries to the nerves of the leg may be caused by the positioning of the patient in “stirrups” and the responsibility for this rests with the person who did the arranging, nurse, anesthetist or gynecologist. An injury to the nerves within the pelvis may occur by cautery or knife, but is more likely to result from the use of a heavy self-retaining retractor which was inadvertently placed over a nerve or was displaced to lie on, for instance, the femoral nerve.