Misunderstanding between hysteroscopy and a hysterectomy

In this blog, a medical student reflects on a serious incident he witnessed during a Gynaecology placement. He observed a conversation between a patient (waiting to have an operation that morning) and one of her doctors.  The patient believed she was having a hysterectomy and the doctor believed she was having a hysteroscopy. Due to this misunderstanding, her doctor cancelled her operation and the patient was left looking visibly upset. The student outlines the problem and then reflects on his key learning. All in the hope of avoiding such a problem in the future.

The Incident

I was with the surgical team on the morning ward round. We were conducting the morning ward round to review patients scheduled for surgery that day. During this time, the surgical team completes the consenting process for the operation. They also reiterate the potential risks and benefits of the procedure to the patient and address any outstanding questions the patient may have.

The ward round is essential because it allows the surgeon and the patient to double-check that they are on the same page and everyone knows and agrees with the plan.

It is standard practice for the Consultant who consented to the patient in the clinic to see the patient before their surgery. However, during this particular instance, the ward round was completed by a speciality doctor. He had not met the patient before.

This morning, however, we ran into some complications with one patient. She was not on the same page as this doctor.

Misunderstanding

The patient had been experiencing heavy periods and was bleeding after sexual intercourse. Her symptoms were having a negative impact on her quality of life, and she was left feeling miserable. She was keen to have the operation in the hope that she would soon start to feel better again.

The doctor initially sought to gather information from this patient and invited her to describe her problems to him. He then proceeded to explain the plan for her operation. It soon became evident that there was a misunderstanding or miscommunication between the doctor and the patient.

Hysterectomy or Hysteroscopy?

As the doctor began providing information, he explained that he was going to perform a hysteroscopy under general anaesthetic and outlined his plan of action. However, the patient appeared visibly confused.

For some reason, she believed that she was having a laparoscopic hysterectomy (removal of the womb through keyhole surgery). The two types of surgery are very different and performed for different reasons. A hysteroscopy involves a camera being passed into the womb to look inside. 

The doctor explained that they scheduled the hysteroscopy to investigate the cause of her bleeding by examining the inside of her womb. They required a general anaesthetic because they also wanted to remove a polyp previously identified on a scan.

Therefore, the doctor informed her they would need to postpone the operation until they could clarify the situation and decide on the best course of action.  

The patient was left upset and frustrated

Upon realising that her surgery was postponed, the patient looked visibly upset and sounded very frustrated. It is important to note that she had high expectations for the surgery and was hopeful that she would soon start to feel much better and her symptoms would subside.

Furthermore, she described how her morning before coming into the hospital had been exceptionally difficult. Because her partner couldn’t help her, she needed to arrange childcare for her children and pay for a taxi to bring her to the hospital. All of these factors had imposed a financial strain on her.

My Reflections

Whilst I fully appreciate that this was not an ideal situation for the patient, and I feel empathetic to her situation, it was a good learning experience for me. Afterwards, I had time to reflect on this situation and consider what happened and how I might have done things differently.

I listened to the way the doctor tried to:

• Gather information from the patient to explore her concerns and understanding about her surgery.
• Listen to the patient’s concerns.
• Provide information to explain the nature of the surgery and what would happen following the postponement of the surgery.

The doctor appeared to notice the patient’s emotions but did not acknowledge them. His further questioning appeared to intensify her distress.

The discussion ended with the doctor apologising and outlining a plan of action. However, the patient openly cried.

The impact on my practice

This was both an interesting and uncomfortable encounter to observe. It was interesting because I understood where the doctor was trying to steer the consultation. However, it was uncomfortable witnessing the patient’s growing distress.

Although I was present as an observer on this occasion, I acknowledge the likelihood of encountering similar situations in the future.

Misunderstandings will happen. Encounters don’t always run smoothly and may not unfold as anticipated.

Here are a few things I will take away with me:

• In this case, the surgeon stood in front of the sitting patient. I think this body language creates an uncomfortable power dynamic. Sitting at eye level with the patient on the bed might have softened the perceived interrogation of the doctor’s questions.
• When faced with complex scenarios, it is easy to rely on the rigid communication structures taught at medical school. These are often useful, like when taking a complete medical history, but they create a robotic atmosphere at other times. In these scenarios, it’s essential to take a breath and remember that the patient is a person, too. Consider the patient’s current emotional state and what information you would seek if you were in their position. Treating patients like people can never lead you too far astray.
• Remember the aim of the consultation. Rather than questioning the patient about why she believed she needed a hysterectomy, I wonder if the doctor could have apologised for any confusion and attempted to speak to the Consultant for advice and further clarification. Potentially, the patient may have consented to the hysteroscopy, and her operation could have proceeded on this day. Fundamentally, the reason behind the patient’s expectation of a different operation was inconsequential. What mattered was what we were going to do to make things right and to help her have a better quality of life.

Finally

I am grateful for having the opportunity to reflect on this incident and to write up my thoughts. I know Lynn has given this opportunity to other students whose reflections can be found here. If you would like to share your reflections, please contact us to share your story.