Eradication of balanitis xerotica obliterans succeeded, but grafting skin from the scrotum resulted in a bizarre appearance.
Dr. H, age 35, recently graduated from a well-recognized urology residency and considered himself a well-trained surgeon who could deal with almost anything. He joined a large group in a pleasant Midwestern city, becoming one of four urologists. But he hadn't been in practice long when he faced his first malpractice suit.
The patient was a 54-year-old man who presented with a thickened opaque skin area on the base and sides of his glans penis. Though fairly sure in his own mind that the man had balanitis xerotica obliterans, Dr. H called in one of his partners and asked his opinion. That turned out to be a fortunate move during the trial that followed. After consulting with his partner, who confirmed the diagnosis, Dr. H informed the man that the condition was a precancerous rash that would spread further (it already covered both sides of the glans) and would become malignant if not treated immediately. He recommended steroid cream, and if it failed, resection of the affected skin and then at-tempted replacement through a skin graft or rotated flap. The patient, disturbed and frightened, left with a prescription for the steroid cream.
The man returned in two weeks, and the rash had not diminished. Dr. H recommended the resection and graft, to which the patient agreed, signing a consent form. At surgery, Dr. H resected the skin of the glans penis, and covered the defect with a flap of scrotal skin, rotated up according to the technique that he had learned in residency. The result looked bizarre but proved to be functional. After healing was complete, the man was able to sustain an erection and resume sexual relations, but he was bitterly disappointed with the appearance of his penis, calling it “deformed.” He consulted a plaintiff lawyer.
In his report, the plaintiff's expert urologist severely criticized Dr. H for removing so much skin from the glans that a rotation flap was necessary to cover the defect, and claimed that, based on the patient's complaints, genuine in-formed consent had not been obtained. The plaintiff lawyer filed a negligence suit against Dr. H.
Self-image suffers
At the deposition, the patient claimed he had received inadequate information from Dr. H, to the point where he was unable to make a reasoned decision. He said he was having sexual problems and that his masculine self-image had taken a blow. Immediately after the deposition, the plaintiff lawyer amended his complaint with a charge of inadequate informed consent, but the defense lawyer opposed the move, arguing that the statute of limitations had expired. At the subsequent hearing, the judge agreed with the defense and the case reverted to one based just on the charge of negligence.
At the next set of depositions, Dr. H worked his way through the chart, describing his interactions with the patient and the progress of the case to surgery. He claimed that the result was good in view of the amount of skin he had to remove to achieve complete resection, and that not all patients were able to resume sexual intercourse as the plaintiff was. Dr. H felt that he had described the outcome accurately, and performed the procedure as described. He was followed by the expert witness, a professor of urology from his old training institution, who commended his student on his achievement in a “very difficult technical procedure.” He said resection was appropriate and timely to prevent development of squamous cell cancer, which probably would have required amputation of the penis.
At the trial, the plaintiff lawyer valued the case at $2 million, while the defense lawyer and insurance company felt that damages justified no more than $250,000. Unable to reach an agreement, the case proceeded to trial. After hearing both sides and discussing the case among themselves for several hours, the jury found in favor of Dr. H.
Legal background
Responding to outcries from organized medicine, most states have reduced the statute of limitations to two years. But courts modified this by introducing the discovery rule, which dates the start of the two years not from the time of the alleged malpractice, but from the date that a reasonable person would have realized that malpractice had occurred. This is the day that the plaintiff lawyer receives a report from an expert consultant. In practice, this policy extends the statute of limitations by another year or two, but in some cases the extension is longer.
Risk management
The preoperative status of the patient often comes into issue in malpractice cases, especially those requiring surgery or informed consent. Plastic and cosmetic surgeons have learned the effectiveness of preoperative photos in forestalling lawsuits from patients unhappy with the appearance of the outcome. With the availability of digital cameras, pre-op photos are easy to obtain and store. In this case, photos taken preoperatively and during the procedure showing the defect needing to be reconstructed would have settled the issue of whether a rotation flap was indicated. The edges of defects typically retract after removal of the lesion, so the photos would have been more impressive than testimony and probably would have prevented litigation.
This case also illustrates the value of a consultation. Good documentation usually provides adequate protection from unfounded claims, but in some situations, consultation also is needed. Consulting with a colleague or partner can provide confirmation of an equivocal sign or finding, and confirm the treatment plan, especially in unusual situations such as this case. Such informal consultation also can confirm the diagnostic impression made by the first clinician, reassuring the patient that his management is within the mainstream. Even a medical student or resident can confirm physical findings, thus supplementing the clinical notes in the case of dispute. Formal consultation and referral is often necessary, however. And if a case does go to trial, a consultation can help sway a jury, as in this case.