5 Miss Godly
If like all human beings, he is made in the image of the Almighty, and if he is kind, then his kindness and concern for his patient may provide her with a glimpse of God's image.
The World of a Gynaecologist by Russel C Scott
The world of another gynaecologist was splashed over the newspapers in late 1994 when the wife of Dr Wrong was tried for the murder of his mistress. On their marriage 13 years previously Mrs Wrong had given up her own medical career to concentrate on wifely tasks like rearing their four children. When Dr Wrong took a middle-aged, married, mother of two, mistress Mrs Dr Wrong was devastated and after attempting suicide three times redirected her anger, so slashing her rival with a knife that the dental records of the deceased were consulted to be sure that it was indeed she. Being a fully domesticated female Mrs Dr Wrong had used a Kitchen Devil, not a scapel, to perpetrate the mutilation. Dr Wrong did not bother to visit his jailed wife, said one paper - he was too busy with his new mistress.
There are some mightily unkind gods about.
At Miss Godly's clinic on 17 July 1992 I was seen by her associate, young Dr Curry. I gave him a copy of the letter I had written to Dr Amicable. After taking the usual details he had an external feel of the lump and then said it might not be uterine, it could be ovarian. And it could be malignant. He said, if I agreed, he would request that a copy of the Helton ultrasound report be sent to the Royal? I made an appointment to return in a month.
I did not see why he would want to see an old ultrasound report. Didn't they have ultrasound at the Royal University Hospital? I made an appointment to see a herbalist.
Dr Curry's notes recorded "I have given a fully detailed explanation of all available and alternative medical treatment for fibroids and for menorrhagia." I must have nodded off. I don't remember any of this. He did mention hormone treatment for heavy bleeding before finding out just how big the lump was. He never mentioned it again and I was, of course, prescribed no treatment whatsoever either for fibroids or for bleeding.
Dr Curry wrote to Mrs Languid on 20 July, asking for a copy of the scan report.
On the same day he wrote to my GP:-
Dear Dr Amicable
Thank you for referring this 44 year old woman who has had a 3 year history of menorrhagia and previous anaemia. However, she feels that she has coping well with her heavy periods since being on iron therapy. She has a chequered history of having disappointing and unsatisfactory outcomes with past medical practitioners and appears to have a significant distrust of the medical profession as well as the National Health Service. I understand that there is potential for legal proceedings with a previous general practitioner that she was under the care of. She was seen by Mrs Languid who diagnosed a large fibroid uterus following an ultrasound scan and the recommendation from Mrs Languid, as you know, was for a total abdominal hysterectomy. I understand that she was very angry and disappointed with her recommendation and has sought refuge in the medical literature. She is full of suggestions of alternative therapy that have been performed throughout the world such as laser ablation, endometrial resection, laser myolysis and treatment with GnRH-a.
On examination today I noted that she had a large abdomino-pelvic mass which was firm to hard and approximately 23 weeks in size. The mass was tender and there was no other swelling and no evidence of ascites. I did not perform a vaginal examination because she is virgo intacta and at this stage I offered her various options. I have explained to Pamela that my concern is that if no operation is performed it is impossible to be certain as to the diagnosis of this abdomino-pelvic mass. It most likely is a benign fibroid or multiple fibroids. However, a ovarian neoplasm cannot be completely excluded even despite the ultrasound report. I have asked for a few weeks while we obtain the results from ultrasound which was performed at the other hospital and at the next visit I will see her and also discuss the case in full with Miss Godly.
Thank you for referring this lady.
Yours sincerely
A Curry MRACOG
LECTURER IN GYNAECOLOGY
I had never heard of laser myolysis and when I searched Medline I could find no mention of it. This was the first time I found Medline lacking in information. I later found references to myolysis in the book for the masses by Felicity Smart called Fibroids and a paragraph in the Womens Endoscopic Laser Foundation's booklet. During a conference on GnRH-a held in Kuala Lumpur in 1991 Donnez reported shrinking submucous fibroids by repeatedly inserting and firing a laser into them. This might have been the myolysis which interested Dr Curry, though at the time I had no idea what he was taking about.
On 14 August 1992 I saw Miss Godly only. I have no idea what happened to Mr Curry - perhaps like Jack Ketch he was off to greener pastures, and fatter pay cheques. She said that she couldn't be sure that the mass WAS uterine but that if it was a myomectomy would be a long operation, recovery would take a long time and there was the risk of fibroid recurrence. She said no investigation could be done to ascertain the true nature of the mass. Ultrasound was inadequate, CAT scanning was no better, magnetic imaging might distinguish fibroids but it was rare and expensive. And obviously not to be wasted on mere fibroid wombs. Now wouldn't I like a nice hysterectomy?
I lost any confidence I might have had in her and said I was not going to be cut.
I continued taking the herbal mix. It mightn't be doing any good but I was quite sure it would do no harm. And at least the herbalist gave me the impression that she was attempting to improve my health and not trying to add another womb to her trophy collection.
On 17 August Miss Godly wrote to my GP:-
Dear Dr Amicable
I saw your patient for review today. We managed to get a copy of the ultrasound report which confirmed the presence of a fibroid uterus. I discussed the matter with Mrs Nomark today. She basically does not wish surgery. I explained the problem to her in full, firstly that we could not be certain without doing a laparotomy whether the mass was ovarian or uterine; that it probably was uterine but one couldn't be 100% certain just by going on ultrasound reports.
Secondly I discussed the options if it were a fibroid uterus. The options were that firstly we did nothing, and I pointed out that this would mean that the fibroids would certainly continue to grow in size until she reached the menopause and that accompanied by that she would get increased bleeding. I certainly pointed out that this would not change until she reached the menopause. I also discussed the question of myomectomy with her and I pointed out that this would require a fairly long operation as she almost certainly had multiple fibroids and it was important that all the fibroids were removed. It would necessitate a fairly long recovery and that there was a risk of recurrence of the fibroids.
The third option I put to her was hysterectomy. Miss Nomark informed me that her periods had only been a problem for the last 3 years and that as she had managed to put up with them for the last 3 years, she could continue to do so. I did point out to her that during this time her haemoglobin had dropped to 8.8 g/dl and that she required iron treatment and that she would be required to continue with this and that this was not in the best interests of her health. At this point Miss Nomark terminated the interview by saying that she wished no surgery and left the clinic. I have, therefore, not arranged to see her again.
Kind regards
Yours sincerely
A S Godly
CONSULTANT GYNAECOLOGIST
Professor Tinker, who later did a report for my solicitor, said about observing patients whose symptoms were not so severe that a major operation was worthwhile, "I have carried on such an "observation" for more than 10 years in some women, some of whom needed to be on oral iron therapy for several months of every year, without the need for hysterectomy or myomectomy."
I wonder if he warned them that this continued iron therapy was not "in the best interests" of their health.
Since I had started reading up on medical matters I had become very suspicious of the steroid inhalers I had been put on and decided that I would not use them any more. I was regarding modern medicine in a much more critical light and at the beginning of September I wrote to my GP requesting a referral to the homeopathic hospital which was not too far away. If homeopathy could do nothing about the lump it might at least improve my general health by helping me to cope with my allergies without taking harmful drugs.
Dr Amicable recorded in my notes:-
19.9.92 see letter from Royal
Miss Nomark refused surgery + see letter from patient requests homeopathic referral
letter done
Dr Amicable's letter to the homeopath, dated 19 October, went like this:-
Thank you for seeing Pamela who is 44 years old and is requesting homeopathic referral for help with the management of her asthma.
A brief summary of her past history is as follows:-
Pamela has a large fibroid uterus which has now reached the level of her umbilicus and 2 gynaecologists have recommended hysterectomy. Pamela is extremely reluctant to accept this and has researched extensively into alternative options.
She is also making a formal complaint about her previous GP because of a delay in diagnosing iron deficiency anaemia. Pamela has now been reading that inhaled corticosteroids can affect the reproductive function. Consequently she has decided to stop the beclomethasone and is unhappy about taking salbutamol.
She is asking about homeopathy treatment. I would be grateful if you could see and advise.
Yours sincerely
P M Amicable
Dr Amicable said absolutely nothing about the allergic asthma I had been having treatment for over the past 17 years - and which the homeopath was supposed to be treating me for. She was once again bleating that I was "reluctant to accept" mutilation and stressing that two butchers had decided that I should have it. As if I would, of course, eventually have the nasty mutilation.
I finally got an appointment with the homeopath in January 1993 and after having a grope of the lump he wrote to Dr Amicable on the 25 January:-
Thank you for you letter referring this patient with a history of allergic rhinitis, asthma and also uterine fibroid. She is anaemic because of the loss of blood p.v.
The uterine fibroid is up to the umbilicus but she refuses to have a hysterectomy. I have suggested that she takes Aurum nat mur, Thuja and Sepia at night. Her asthma has improved since she stopped taking dairy products.
I was not anaemic when I saw the homeopath and my blood iron levels had been normal for over 6 months. He also remarked on my refusing to have a hysterectomy as if it was something remarkable. Why should any woman refuse such a nice little mutilation?
When I saw him I had been avoiding dairy foods for five months, on the advise of the herbalist, and was using salbutamol only once or twice a week. Soon after starting with his pills my inhaler use increased. I did not find homeopathy at all useful.
In the autumn of 1992 I tried to get my medical records from the Royal but eventually had to go to Helton hospital to get a copy of the ultrasound report.
I had thought that I might hear something from my GP but I did not and after two months I wrote to her:-
Dear Dr Amicable
I was seen at the Royal by a Dr Curry, who mentioned progesterone treatment but after feeling the lump he said he wasn't sure that it was fibroids - it might be a fibrous ovarian cyst, and could be malignant. Considering that the ovarian mortality rate runs at 80 to 90% I found this a very jolly prospect.
Since then I have come across the following:-
Parsons and Sommers Gynecology, 1978.
"Solid tumors of the ovary except the fibroma and thecoma have significant malignant potential. Not only is the incidence of cancer high but the salvage rate for solid tumors is appreciably lower than for cystic or semi-cystic ovarian neoplasms.....
It is a general observation that the more solid the tumor, the greater the chance of malignancy and the worse the prognosis."
As it appeared to me to change during April do you think you could arrange another ultrasound scan to establish whether the lump has in fact changed in size, shape or position in the last six months?
Yours sincerely
P Nomark
Before I saw Dr Curry it never occurred to me that the lump could be anything other than fibroids. The mass was solid, as I would expect muscle tissue to be and was associated with heavy bleeding and regular periods, typical of fibroids. Craft-Tort had thought that it was fibroids, Mrs Languid had thought that it was fibroids and Jack Ketch had quite definitely stated that I had a fibroid womb. Yet Dr Curry said that the mass could be ovarian, and possibly malignant, and Miss Godly had not only said that it could be ovarian but stated that there was no way of determining the nature of the mass without hacking me open, which I later realised was one huge, whopping, deliberate lie.
I found that not only was the survival rate for ovarian cancer low but that solid masses were not only frequently malignant but associated with a particularly low survival rate. While 90% of endometroid tumors are malignant, fluid or jelly filled cysts are far less likely to be so. Over 80% of malignant ovarian growths are found in women over 40, and 30% of ovarian growths in women aged 40-59 are either borderline malignant or malignant growths. It has been estimated that the chance of finding a cancer in women aged 40-50 with a pelvic mass is 1.6% if the lump is diagnosed as fibroids but 22% if the mass is thought not to be fibroids. It seemed to me to be important to be as certain as possible as to the origin of the mass yet I was left with no diagnosis and no intention on the part of our dedicated, caring professionals to make any attempt to establish a diagnosis.
Also ovarian cancer is associated with frequency of ovulation, that is with the number of normal menstrual cycles you had. If you stopped having normal periods because you were pregnant or were on the pill your risk of developing ovarian cancer fell. I had been having regular menstrual cycles for more than thirty years and was therefore at a higher risk of developing this cancer than many other women.
Ovarian cancer is associated with few symptoms but as the tumour presses on the surrounding tissues constipation and urinary frequence may develop often with "vague gastrointestinal complaints". I had never been bothered by gut problems but as the vaginal discharge developed I also found that I sometimes had a lot of gas in my guts and that I was regurgitating bits of food, especially after a large meal. These effects were probably due to the physical pressure of the large mass leaning on my guts and nothing at all to do with ovarian cancer.
Probably.
But for over a year I couldn't be really certain that the lump in my belly was not a deadly cancer.
Since I heard nothing from her I wrote a much longer letter to my GP on 5 December.
Dear Dr Amicable
Since I went to the Royal on 17 July not one of my questions has been answered. I am left with an increasing feeling of unease and a lengthening question list.
I was seen at the Royal by a Dr Curry, who mentioned progesterone treatment but after feeling the lump he said he wasn't sure that it was fibroids - it might be a fibrous ovarian cyst, and could be malignant.
Dr Curry had apparently never heard of the world beating American ovarian cyst, weighing in at a massive 23 stones and 6 ounces. I find my confidence in a person's abilities is shaken when I find them unacquainted with the extremes of their own subject. However he was well acquainted with the work of Dr J Donnez - though I have little doubt that his own personal experience of uterine treatment is of a much less conservative nature.
He wanted to get in touch with Languid to see what information she had. Since she only did an ultrasound scan I didn't see what good it would do - and didn't they have an ultrasound at the Royal? I would have liked to have known if the ultrasound picture changed much after the time in April when it felt like it was expanding and changing shape. However he
sent off for the old scan and a month later I went back.
I arrived more than ten minutes early for my 9.30 am appointment and was kept waiting a further fifteen minutes. I was then shown into a small, bare examination room and left to stew in isolation for a further twenty five minutes. At last Ms Godly arrived, accompanied by a nursing acolyte. She said that I had a fibrous mass, probably a fibroid but she couldn't say that it wasn't an ovarian cyst either. So of course she couldn't say how many fibroids there were (as of course I might not have any fibroids at all) or what type the putative fibroids might be. She could do a myomectomy on the supposed fibroids but it would be a long operation and it would take a long time to recover from it.
Dr Vikki Hufnagel in her book No More Hysterectomies (What a jolly good idea) tells of spending four hours picking out over 100 fibroids from one patient. However myomectomy can be as Tim Coltart put it "quite a straightforward operation". If Ms Godly can't even tell IF the mass is uterine how can she make definite pronouncements about the difficulties of removing them (or possibly even it). Ms Hufnagel also states that her patients (who get female reconstructive surgery not gynaecological mutilation) recover quicker than hysterectomy patients. But then she has performed over 400 "reconstructions". I don't know how many myomectomies Dr Godly has performed (could you find out?) but I bet that it is very few. Unfortunately Ms Hufnagel lives in L.A. and charges, as far as I can make out, in excess of ?20,000 for her services.
Dr Llwellyn Jones Every woman: A Gynaecological Guide for Life:-
"Usually she goes to her doctor, who performs a pelvic examination and can tell from this if there is a single fibroid, or if the womb is misshapen and enlarged by several fibroid tumours"
What a joke!
To be fair Hufnagel does say that fibroid mass appearances may be deceptive - the afore-mentioned 100+ mass appeared to be a single entity until surgery when it was found to be an aggregate of many fibroids.
Dr Godly said a CAT scan was no better than ultrasound. I always got the impression that CAT was the bees knees. It always gets such a good press.
She said that magnetic resonance might confirm the ultrasound scan,. But it would take a long time. Presumably she means that an unimportant fibrous female would have to wait a long time before being attended to.1
She said that a hystersalpingogram would be of no use. Though if my uterine cavity was much enlarged by submucous fibroids, this would show up and at least demonstrate that it was a uterine and not an ovarian mass.
No mention was made of hysteroscopy. Dr Curry seemed to say that hysteroscopy was not possible on a virgin. I have since read that hysteroscopy and fibroid resection has been done on a 19 year old virgin - Lawrence, Med J Aust 1991 February.
No mention was made of the advantages of using GnRH agonists before surgery as stated in the Adamson paper.
I said I was not willing to be chopped. I'd managed the bleeding. Dr Godly said long term intake of iron was not good for my health. But she gave no advice about maintaining my iron levels while avoiding iron excess (and presumably haemochromatosis2). P M Hartman's Guide to Hematologic Disorders gives the side effects of iron therapy as including nausea, anorexia, diarrhoea and constipation. He also says that the correct dose of elemental iron administered is important. I'm glad I can apparently prescribe quite adequately for myself since I have had absolutely no guidance from any medic on this subject.
She never mentioned any drug treatment - progesterone, danazol, mefenamic acid - to control the bleeding. And finished with of course it will get bigger. And she's certainly not going to make any effort to attempt to halt it.
Botvin et al Soviet Med 1991 (10): 12-15 (in Russian)
on conservative myomectomy:-
"The choice of surgical technique is dependent on the primary site of myomatous nodes, their dimensions the patient's age and concomitant extragenital pathology."
Which presumably means you should know what you are dealing with before you cut. By the way uterine sizes varied from 6-32 weeks and one group of 16 patients had an average age of 46.3 years.
Marut E L Obstetric and Gynecology Survey vol 44 pg 308
"Once the decision has been made to treat the myoma, correct diagnosis and delineation must be made on clinical and radiologic (in the broad sense) grounds to offer the patient a therapeutic choice.... confirmation by ultrasound, at the least, is necessary to accurately assess the size. Computerized tomography and magnetic resonance imagery may be necessary to distinguish fibroids from other gynecological pathology.
In addition intravenous pyelography and hystersalpingography are useful both in decision making and in planning surgical technique...
When conservative therapy is considered definitive diagnosis may occasionally require laparoscopy and/or hysteroscopy...
The use of GnRH-a to maximally reduce the total myomatous volume makes uterine reconstructive surgery more likely to be successful...
The reduced myoma size minimises damage to normal uterine tissue, controls blood loss and improves surgical technique...
Extremely large fibroids which it had been advised be treated by hysterectomy were successfully reduced in size by leuprolide and then removed by abdominal myomectomy."
Principles and Practice of Clinical Gynecology by Kase, Weingold & Gershenson:-
"It is important to localise the lesion because the site influences both the symptomatology and the therapeutic options.
pg 556
The removal of leiomyoma with preservation of the uterus can be accomplished in almost all patients without regard to the size, location or number of fibroids."
My nursing sister still has some absurd confidence in the ability of medics to diagnose. She believes that with practice and experience comes knowledge. Dr Godly showed no sign of such practised wisdom. She never even touched the lump. Her diagnosis, or lack of a definite one, was presumably made upon the basis of a four month old scan. She might just as well have given an opinion by post.
If you took your car to a garage would you really have any confidence in a mechanic who tells you that repair will be very difficult but who makes little effort to find out exactly what is wrong and doesn't even LOOK under the bonnet?
Is my reproductive system of less importance than your mode of transport?3
I am left with the persistent feeling that if you don't want to be hacked they don't want to know you. But then to be successful in the commercial nineties they presumably have to fill beds - and operating theatres. Every carving must be a little extra in the coffers. And presurgical investigation is just a waste of time since a little mutilation rids us of this female problem - any female problem. It would appear that DCT was perfectly correct in his assessment. If you have a female problem then the National Hysterectomy Service has just the thing for you. It reminds me unpleasantly of many rape accounts where the victim is not only sexually abused (and if amputation is not the most extreme form of sexual abuse what is?) but is often coerced into saying that she likes it really.
Since typing the above I have come across an oddly titled book, with some interesting things to say.
Hysterectomy - The Positive Recovery Plan by A Dickson & N Henriques:-
"Even though the prospect of not having any more children was for Louise very painful and traumatic, there was no sensitivity shown to her in this gynaecologists approach."
However Louise's experience was not the worst:-
"Carole found the shock announcement very traumatic hearing the news while lying on her back, undergoing internal vaginal examination under the observation of a dozen strangers.
The words he used were "You need to have a hysterectomy. Do you want it?". That was it.
Without even being offered an alternative, or being told anything about what would happen in the operation, Carole then had to wait for 7 months before going to hospital, getting more and more anxious.
To confront a woman with a shock announcement and to push her into the distressing situation of being forced to decide on such an important matter without giving her alternatives or information or time to reflect, can only be described as abusive...
I have never seen anybody die from refusing to have a hysterectomy. (Gynaecologist)...
Most women have experienced being on the receiving end of harsh treatment by the medical profession at some time or other."
I wonder what they would have written if they had taken a negative approach.
Later at home I recollected my first encounter with the woman mutilators. And I was struck by several strange concordances. Both my second appointments were early. Yet both times I was kept waiting for more than half an hour. Both times I was seen by someone I had never met before. Both times a nurse was present.
All these factors tended to unsettle me. Were they meant to? Was I being subjected to deliberate psychological intimidation. In order to get me to agree to whatever the boss wanted. And we all know what they want. To the tune of 64,000 a year!
I was particularly put out by the audience. Why was a nurse present? No nurse was present at either of the first interviews. There was no intention of performing a physical examination. So why was the nurse there? Unless it was simply to psyche out the patient.
Dickson and Henriques also said that the GP's choice of consultant is important since surgical technique has a considerable effect upon recovery.
I read in the local paper that Mrs Languid is a newly appointed consultant, freshly come from great slaughter amongst Scottish reproductive systems to perform similar carnage upon Sassenach uterii.
And while Miss Godly has no doubt more experience I note that her writings, and presumably her interests, appear to be upon obstetrical topics. She certainly appeared to have no enthusiasm for female conservative surgery.
I am left with no treatments, no advice, no investigations and a lump which if malignant will probably prove lethal within three years.
I find that my encounters within the NHS have left me agitated, anxious and angry. Any more meetings with "gynaecologists" and I shall have a worse opinion of them than I have of the Gestapo. They are definitely not good for my health.
I have been wondering it Marut's "correct diagnosis and delineation" are in fact not considered applicable since the intention is not to give "therapeutic choice" but to force the victim (me in this case) into mutilation for the convenience of the National Hysterectomy Service.
Well I'm
NOT HAVING IT
NOT NOW
NOT EVER
and if you can't accept it then I think one of us should tell the FHSA to find me a GP who can - a mammoth task I'm sure.
If you have any information for me or any explanations I should love to hear them.
By the way I wrote to your practice manager over two months ago about my computer medical records. My solicitor wrote a month ago. If I do not get a reply at the least within a week I shall complain to the NHS Chief Executive that I am not getting my right to record access.
Yours sincerely
Pamela Nomark
Dr Amicable wrote her only communication to me on 15 December 1992.
Dear Mrs Nomark
Thank you for your letter dated 5 December 1992. I am sorry that you appear to be so unhappy with your medical care. I think the best course of action would be for you to come in to the Health Centre to discuss this with me further.
It would also be wise to check your Full Blood Count again in view of your previous anaemia.
You raised a point about your medical records and as I am sure you are aware we have sent all the records we hold to your Solicitor and do not have any computer records from your previous GP.
I look forward to seeing you in the Surgery soon.
Yours sincerely
DR P M AMICABLE
I had found out that if your records have been updated within the last 40 days access must be given without fee, other than photocopying charges. I decided to take my GP's advice and get both my blood tested and my records updated.
After giving my blood sample on 20 January 1993 I wrote immediately to Helton Hospital requesting my records.
On 2 February I was sent a letter saying that "As per the Act the Hospital has 21 days in which to respond to you following receipt of your Request." This I thought totally unnecessary paper, postage and time wasting. Shortly afterwards I received a telephone call from the hospital suggesting that I make an appointment to see Mrs Languid about my records. I was quite non-plussed. I had expected them to just send the photocopies, as the Royal had done, and found myself with an appointment for 18 February.
When I saw Mrs Languid again she gave me my notes to look at. They included my letter to Jack Ketch. Mrs Languid volunteered the information that she had both written to the Royal AND sent them a copy of the ultrasound scan.
They had no results from the blood sample taken a month ago. It seemed that blood was not actually tested at Helton. It was sent on to another hospital. She telephoned them for the result. It was 12.9, lower than I thought it would be, but quite respectable.
What a system! To get a simple iron test I had to make an appointment with my doctor for a form, then take this to the local hospital who collected the blood, sent it to another hospital, and later got the results which were then sent to the practice.
I had given blood at the Blood Transfusion Centre at the nearest city in November 1992. They took a sample and did an immediate haemoglobin test. As they won't take your blood if it's less than 12.5 g/dl I knew immediately that I was not anaemic.
Mrs Languid seemed rather surprised when I said I wanted copies of my records and had to have a big conflab with a dumpy, fuzzy admin woman. But they agreed to send me the photocopies I wanted.
The letter with them, from the Chief Executive, was dated 9 March 1993. It stated that "In view of the small number of copies, there will be no charge on this occasion."
I was surprised at the paucity of information on the ultrasound scan now that I finally had it. It said :-
"There is a very large fibroid uterus extending to above the level of the umbilicus. Both ovaries appeared normal."
And that was all.
There was a lot I did not understand about it. So I decided to write to the consultant radiologist who had put her name to it.
On 7 April I wrote:-
Dear Dr Fewins
I recently obtained copies of my medical records including an ultrasound report you apparently wrote nearly a year ago. I enclose a copy of the same.
It says that "Both ovaries appeared normal", a statement repeated by Mrs Languid in a letter of 30 July. However in his letter to my GP in April Jack Ketch states "There were no ovarian masses seen on the scan".
These statements confuse me. Does the scan report mean that, in fact, the ovaries were not identified and that their normality was assumed by the absence of noticeable masses? Or does it mean exactly what it implies to me, that is that the ovaries were identified on screen and their appearance was normal.
I would appreciate clarification on this point.
Yours sincerely
Pamela Nomark
I received a letter from the Chief Executive of Helton Hospital, dated 26 April 1993.
Dear Mrs Nomark
I refer to your letter, dated 7 April 1993 addressed to Dr Fewins, in respect of your ultrasound report.
Dr Fewins has confirmed that both ovaries were seen on the scan and appeared normal.
I trust this clarifies the matter but, if I can be of any further assistance, please do not hesitate to contact me.
Yours sincerely
S C E YATES
Chief Executive
This was very interesting. I wrote again on 30 April 1993.
Dear Dr Fewins
I have received a letter from Helton general concerning my ultrasound scan of 13/4/92 in which you confirmed that both ovaries were seen and appeared normal.
I have been rather concerned over the identification of this mass since July 1992, when I saw a Dr Curry at the Royal Hospital, who went on about the mass possibly not being uterine and, as the enclosed clinic note shows, possibly malignant.
And I wrote of solid, malignant ovarian tumours and their high mortality.
It would seem that if the mass is ovarian I have a good chance of dying within the next few years, while fibroids are infrequently malignant. But if both ovaries were identified on the scan the mass is obviously NOT ovarian.
However as you can see from the enclose letter extracts both Dr Curry and Dr Godly regard the ultrasound scan diagnosis as inconclusive and think I should be torn open to see what's there.
I am not keen on the hack 'em open and see approach. It appears very unscientific - medieval even - to me though from my experience and what I've heard it seems to be the usual treatment for any 'woman's complaint'. The attitude is whatever the trouble a hysterectomy will fix it.
Could you tell me why neither of these gynaecologists rely on your scan diagnosis and in the circumstances what confidence I can place in it.
Yours sincerely
Pamela Nomark
Once again the reply, dated 28 May, came from Mr Yates.
Dear Mrs Nomark
I refer to your letter dated 30 April 1993, addressed to Dr Fewins.
In answer to your letter, Dr Fewins can only confirm that the scan performed on 14 April 1992 revealed that the pelvic mass was seen to be caused by uterine fibroids and both ovaries were identified and appeared normal. Dr Ketch's statement means essentially the same as Dr Fewins'. "There were no ovarian masses on the scan" means that the ovaries appeared to be normal.
Dr Fewins is unable to comment on the interpretation of scan results by the doctors who are currently responsible for your care. I would suggest that you address this matter directly to them.
Yours sincerely
S C E YATES
Chief Executive
This sounded logical to me. So I did as Mr Yates suggested and on 14 June 1993 I wrote to Dr Godly.
Dear Dr Godly
Since I attended your clinic in July last year I have been extracting my medical records from the NHS. The Royal refused to give me a copy of the ultrasound report you received from Helton hospital and I finally got one in February from Helton.
I enclose a letter from Helton general concerning this ultrasound scan of 13/4/92 in which the radiologist, Dr Fewins, confirms that both ovaries were identified and appeared normal.
Since your letter to Dr Amicable (enclosed) states that you could not be 100% sure of identification of the mass "just by going on ultrasound reports" could you tell me what % trust you DO have in Dr Fewins diagnosis. Was there any point in her bothering to look at the scan at all?
Could you also tell me why a laparotomy is considered necessary for identification of this mass when I have read many accounts of the identification, measurement and monitoring of individual fibroids by magnetic resonance and ultrasound?
The Womans Guide to Surgery by T Coltart & F Smart says:-
A myomectomy can be quite straightforward.
Nezhat in the Int J Fertil 36: 275-80 reports an average time for laparoscopic myomectomy of 110 minutes (range 25-240 minutes) and in the J Reprod Med 37 (3) 247-50 records a time of 160 minutes for laparoscopic hysterectomy - destructive surgery taking 33% LONGER to perform.
Nezhat et al also records a TAH average time of 102 minutes while Smith (Am J Obs Gyn 1991 162 1476-9) records an average time of 120 minutes (range 55 mins to 3 hours 50 mins) for myomectomy, not a huge increase. Since operative times generally correlated with the number of tumours removed or with ancillary procedures performed can you have any idea how long a myomectomy would take in my case since you do not even have a definite diagnosis let alone an accurate (or in fact any) idea of the number, size or position of myoma to be removed?
Marut E L Obs & Gyn Sur vol 88 pg 308 says:-
And I repeated Marut and Andreko on what could be done to improve diagnosis and surgical technique.
I would have thought that a mass size of 23 weeks would have called for GnRH-a treatment if myomectomy was being considered.
Is the "correct diagnosis and delineation" mentioned by Marut not considered applicable by anybody in the National Hysterectomy Service since the intention is not to give "therapeutic choice" but to railroad any fibroid female over the age of 30 into a quick, cheap and convenient mutilation.
When I saw Dr Curry at the Royal Liverpool hospital he went on about the mass possibly not being uterine and possibly being malignant.
And I repeated what Parsons and Sommers said on solid ovarian tumours.
It would seem that if the mass is ovarian I have a good chance of dying within the next few years, while fibroids are infrequently malignant.
Would you say that it was in the best interests of a patient to tell her that she has a possibly highly malignant mass and that the only investigation you will consider undertaking is to slash her open to have a look at it?
I have been brooding on these facts for nearly a year now and would appreciate some answers along with the answer to my last questions. How many myomectomies have you performed and how successful were they?
Yours sincerely
Pamela Nomark
And on 21 June 1993 I also wrote to Mr Yates.
Dear Mr Yates
Thank you for your letter of 28 May about my ultrasound scan of 13 April 1992. I took your advice and wrote to the gynaecologist concerned.
However there are still a couple of points I am not clear about.
Firstly if the ovaries are not identified as masses by ultrasound what are they perceived as. And if they are masses Jack Ketch's statement that "no ovarian masses were seen" was at the very least misleading since it should have said no ABNORMAL ovarian masses were seen.
And second Dr Fewins has apparently said that the pelvic mass was caused by uterine fibroids. Since the plural is used here does this mean that multiple fibroid masses were seen in the uterus and if so how many and of what sizes. Or does this, in fact, mean that a large fibrous uterine mass was seen with no internal detail. I shall be interested to hear if Dr Fewins did see more than a vague mass. According to the Woman's Health leaflet on fibroids I should find out as much as I can about my fibroids including how many there are, how big they are and where they are growing. Over a year later all I have is an assertion by a radiologist that the mass IS uterine and a gynaecologist who says the lump could be ovarian (and possibly malignant). And no information at all on the number, size or location of individual masses.
I wish I could say that there were doctors responsible for my care but unfortunately I have discovered that once you tell a NHS gynaecologist that you don't want your body ripped open and your organs torn out they want nothing whatsoever to do with you. Monitoring and investigation of abdominal masses is a luxury available only to the rich who can afford to pay for their medical attention.
It's taken me over a year to get the slight information yielded by a basic ultrasound and even that is viewed with scant respect by gynaecologists.
Yours sincerely
Pamela Nomark
The reply on 8 July went like this:-
Dear Ms Nomark
I refer to your letter dated 21 June 1993, which was addressed to Mr Yates. Mr Yates has now left the Hospital and I am dealing with this matter on his behalf.
Dr Fewins has confirmed that in her reporting of Ultrasound scans she uses the word "mass" to mean an abnormal lump. For example, a normal scan would be reported as "both ovaries show normal appearances". Dr Ketch's statement would have been perfectly clear and the word abnormal would not have been necessary. In fact, your own statement in your letter dated 7 April 1993 sums up the findings very clearly, that is that the ovaries were identified on screen and their appearance was normal.
With reference to your second query about the number of uterine fibroids, Dr Fewins has stated that it can be difficult to accurately count the number of fibroids. Dr Fewins does not routinely attempt to count fibroids unless specifically requested and, in her ten years of ultrasound experience has never yet been asked by the referring clinician to provide this detailed information.*
Yours sincerely
TREVOR G COOMBS
Director of Nursing
* my emphasis
I found this information both illuminating and devastating. Fibroids are the commonest excuse given for the amputation of wombs and in this womans's experience at my local hospital NOBODY HAD MADE THE SLIGHTEST EFFORT TO CONSERVE A SINGLE FIBROID WOMB IN OVER TEN YEARS, since nobody had ever asked for the basic information necessary for conservative womb surgery.
Shortly afterwards a letter came for me dated 20 July.
Dear Miss Nomark
Your letter to Miss Godly dated 14 June 1993 has been passed to me for reply.
I was sorry to learn that you were unhappy with Miss Godly's diagnosis and suggested method of treatment. I can fully appreciate that you may be wish to avoid having a hysterectomy however, you will appreciate that Miss Godly's informed opinion was based on your medical history and her considerable experience as very senior gynaecologist.
It is Miss Godly's diagnosis that you have a uterus of 23 weeks size and it is her recommendation that the best method of treatment for your condition would be a hysterectomy and not myomectomy. I must point out that whilst the above diagnosis is Miss Godly's informed opinion, you do not have to accept her advice and it will be wholly acceptable for you to seek a further opinion elsewhere. Equally, I must point out that it would not be ethical for Miss Godly to prescribe treatment or to perform an operation that she did not think was in your best interest. Under the circumstances therefore, if you have not already done so, you should return to your General Practitioner to discuss further, the treatment of your condition.
Finally, I would like to refer you to the penultimate paragraph of your letter to reassure you that Miss Godly has never said that you have a possible highly malignant mass and that the only investigation she would consider would be to open you up to have a look at it.
Yours sincerely
S M FOBB (MISS)
ADMINISTRATION SERVICES MANAGER.
This letter sent me into a rage. I wrote on 22 July 1993:-
Dear Miss Godly
I have received a letter from Miss S M Fobb. She states that in your opinion a hysterectomy would be in my best interests.
I have read that post-hysterectomy ovarian failure is associated with increased risks of cardiovascular disease (Centrewell), osteoporosis (Hreschyshn, Hart) and osteoarthritis (Spector). Other hysterectomy hazards are risks of vaginal prolapse, residual ovary syndrome, colovaginal fistula after colorectal surgery, vaginal cancer (Bell), sexual dysfunction (Zussman, Filiberti) and depression (Barker).
I mentioned most of this in the letter I gave Dr Curry on July 17 last year. I also quoted the Woman's Guide to Surgery, which stated that if you want to keep your womb fibroids alone can be removed, and the horror of hysterectomy as experienced by a patient. It should have been glaringly obvious that, at least psychologically, hysterectomy was the last thing I needed. And, as you know, depression after hysterectomy is related to patient acceptance of the operation.
Weingold, Kase and Gershenson state in their Principles and Practice of Clinical Gynecology that "The removal of leiomyoma with preservation of the uterus can be accomplished in almost all patients without regard to the size, location or number of fibroids". Dr Goldfarb in "The No Hysterectomy Option " states that "if a woman is 40, the chances are overwhelming that she's not going to have problems after myomectomy because the menopause will intercede."
Until I reached 40 I had never had any menstrual trouble or pain in my life and the subsequent heavy bleeding occurs for only 2-3 days month and has not changed over the last 4 years. The anaemia it induced quickly cleared with iron treatment. Given my lack of gynaecological trouble, my extremely negative view of hysterectomy and the almost certainty of no further trouble after myomectomy I fail to see how hysterectomy can be said to be the best treatment for me. Given the plethora of risks and hazards associated with hysterectomy I fail to see how it can be said to be best for any woman not suffering badly with very severe gynaecological symptoms.
While you did not say that I might have a highly malignant mass you stated, and wrote in your letter of 17 August to Dr Amicable, "we could not be certain without doing a laparotomy whether the mass was ovarian or uterine". And your associate Dr Curry raised the possibility of malignancy a month previously as recorded in the medical notes as follows:-
Discussed need for laparotomy to diagnose true nature of mass
- pt is not at all keen on this option.
- risk of malignancy mentioned
You said the mass MAY be ovarian and your colleague said it could be ovarian and MALIGNANT. And ovarian malignancies are well known for their poor survival rate.
As Dr Fewins, DRCOG, had stated that she had identified the ovaries I do not understand why you didn't accept her diagnosis but I was left with NO definite diagnosis your statement that "we could not be certain without doing a laparotomy whether the mass was ovarian or uterine" and Curry's statement to Dr Amicable on July 20 "I have explained to Pamela that my concern is that if no operation is performed it is impossible to be certain as to the diagnosis of this abdominal- pelvic mass."
When I asked about further investigation to clarify the origin of the mass you said that CAT scanning was no better that ultrasound and I couldn't have MRI. In fact you gave the impression that the only thing you would do was rip me open and mutilate me. An impression that I now realise was perfectly correct.
Jeffcoate states in his Principles of Gynaecology:-
Sonar distinguishes between ascites and abdominal tumours, and between uterine fibroids, ovarian cysts (benign/or/malignant) and other masses such as pyosalpinx. It is a poor doctor, however, who, in general, needs such expensive equipment to diagnose tumours of this kind.
You have also not answered my questions of how many myomectomies you have performed and how successful they were.
Finally Dr Goldfarb also says:-
"Furthermore, a woman, regardless of her childbearing plans or potential, may have physical and emotional reasons for wanting to preserve her uterus and her feelings must be respected."
and:-
"The number one job of the gynaecologist is to address the patient's needs and desires, and put into perspective for her within the context of those needs and desires what her chances of success will be when availing herself of any particular plan of care. Today, when so many alternatives are available and so much is known about the consequences of hysterectomy, if a gynecologist just says, "You don't need your uterus, let's take it out", his statements are both unwarranted and uncaring."
Do you know of any caring, and capable, gynaecologists operating in the National Hysterectomy Service?
Yours sincerely
P Nomark
Administration replied on 6 August.
Dear Miss Nomark
Your letter to Miss Godly dated 22 July 1993 has been passed to me for action.
Firstly, I would point out that it is national policy for hospital complaints to be dealt with in each hospital or group of hospitals by a designated officer and I am the designated officer for this group of hospitals.
It is quite clear from your letters that you have read extensively on the subject of your condition and I am aware from your previous correspondence and from discussing the matter with Miss Godly that you are unhappy with her diagnosis and suggested method of treatment. I also understand that Miss Godly attempted to discuss this with you at an appointment on 14 August but that you chose to terminate the discussion and left the Hospital. From that point on the matter was passed to this Department for further action, it is inappropriate therefore for you to write direct to Miss Godly. Furthermore I note that you sent your last letter to Miss Godly at her home address. I understand that Miss Godly has not invited you to correspond with her and I must ask you therefore to refrain from doing this. You will be aware that such mail is unsolicited and as such any further letters to her will remain unanswered.
With regard to your complaint, I am sure you will realise that clinical opinions can differ from doctor to doctor but I can only re-emphasise that Miss Godly has given you her informed opinion based on her expert knowledge. It would clearly be inappropriate therefore, for her to change her opinion because you do not agree with her. I am afraid therefore I can only reiterate the contents of my letter to you dated 16 July in that you are not obliged to accept her diagnosis or recommendations. I strongly suggest however, that you return to your General Practitioner for advice regarding your future treatment.
I am afraid I cannot help you further in this matter.
Yours sincerely
S M FOBB (MISS)
ADMINISTRATIVE SERVICES MANAGER
I was not aware that just writing for medical information to a gynaecologist was seen as a complaint. I also wondered what it was Miss Godly "attempted to discuss". She had told me quite clearly that she wasn't going to perform ANY investigation of my lump. I could trust her to butchered me or put up with the bleeding. And as what she said did not accord with what I knew I didn't trust her one jot and I wasn't going to allow her to chop me.
As her exaltedness was obviously not going to write to me on 7 August I wrote to her spokesperson, Miss Fobb.
Dear Miss Fobb
Thank you for your letter of 6 August. Since your department has been dealing with this matter since 14 August 1992, when I left Miss Godly's clinic, could you please tell me what had been done about it before I wrote in June this year.
I should also like to repeat that not only was I NOT given a definite diagnosis but that this lack of diagnosis was stated in both the clinic notes and Miss Godly's letter to Dr Amicable, copies of which are enclosed. This means that I was left with a lump which was thought to be "probably" fibroids but possibly ovarian. And solid ovarian tumors are possibly malignant. And if malignant usually lethal.
The Helton radiologist had 10 years experience and a diploma from the Royal College of Obstetricians and Gynaecologists. But Miss Godly disregarded her ultrasound report, which stated that my ovaries were SEEN and were normal, writing that she "couldn't be 100% certain just by going on ultrasound reports". Yet she suggested NO tests or investigations to ascertain the nature of the mass.
From the referring letter and the 6 page letter I gave Dr Curry (he didn't lose it did he?) Miss Godly was well aware that I was totally against hysterectomy. She completely ignored my feelings on this subject.
Myomectomy is possible in virtually all cases and the ease with which it is performed is dependant upon the size, number and position of the fibroids. As she had undertaken no investigations (not even a physical examination) Miss Godly had none of the basic information necessary to make assertions about operative difficulties. Yet she did so. I should point out that hysterectomy is no easy option for the patient being not only major surgery but associated with high rates of morbidity (42.8% in one study), depression, sexual dysfunction and the residual ovary syndrome besides the risks of urinary system and bowel damage.
It is becoming common practice to treat fibroids preoperatively with GnRH-agonists to decrease both fibroid size and blood loss. In spite of the large size of this mass Miss Godly made no mention of any drug treatment.
Hysterectomy is widely held by the male dominated, medical establishment to be the "operation of choice" for any female over the age of 40 with gynaecological problems, any gynaecological problems. This is not, apparently, the patients choice but the surgeons. It would appear that Miss Godly's opinion was based solely upon medical dogma and my date of birth.
I have still not been given any information about Miss Godly's experience of myomectomy. I should like to know whether she is, in fact, capable of conservative surgery. Or is hysterectomy not only "best" in her opinion but the only option she can offer? You do have this information, don't you?
As Miss Godly refuses to discuss her treatment of my case, or lack of it, whether I write to her at the hospital or her home address to whom should I complain about her inadequate attention? The RCOG? The BMA? The Secretary of State for Health? To whom are complaints about specialists referred? Or are no complaints possible as consultants are assumed, like the Pope, to be infallible?
I look forward to hearing the answers to these questions at least.
Yours sincerely
Pamela Nomark
A short note, dated 12 August, informed me that Miss Fobb would reply to me on her return from annual leave. When no reply was forthcoming I wrote again, on 22 September 1993.
Dear Miss Fobb
I have still not received a reply to my letter of more than 6 weeks ago although your secretary, B Davies, wrote on 12 August that you would reply on your return from your holidays.
In case you have lost the letter concerned I enclose a copy. I look forward to the answers to my questions.
Yours sincerely
P Nomark
In the meantime I had been told that if you were dissatisfied with your specialist you should write to the regional medical health officer. I telephoned the Community Health Council in the city and later saw Ms McD who did not seem to have a very good opinion of the state of the NHS. And on 19 October 1993 I wrote to the Regional Medical Officer.
Dear Sir
About 18 months ago I was found to have a large pelvic mass. I saw a person at the local hospital with whom I was not satisfied and my new GP, Dr Amicable, sent me to see Mrs Godly at the Royal Hospital.
I made it known on my first appointment (with Dr Curry) on 17 July 1992 that I was 100% against hysterectomy and gave him a copy of a 6 page letter which I had written on the subject to my GP.
When I saw Miss Godly on 14 August I got the impression (which I now know to be absolutely correct) that she would do nothing but a convenient (for her) mutilation.
I experienced some difficulty in getting a copy of the ultrasound report. The Royal Hospital denied that they had a copy in spite of the fact that in the records they DID send me was a request for the report from Dr Curry and a letter from Miss Godly to Dr Amicable (enclosed) stated clearly that a copy of the report had been received.
When I finally got a copy of the ultrasound from Helton I wrote for clarification to the radiologist and enclose a copy of the letter I received from Helton General.
I wrote to Miss Godly, as suggested by Mr Yates, and enclose a copy of the correspondence. I am not at all satisfied with my treatment and have been advised by the CHC that I can request an independent professional review, for which I am now asking.
The enclosed letters cover most of what I am complaining about but to summarise:-
1 The ultrasound report from Helton states that my ovaries were identified and appeared normal. The radiologist had 10 years experience and a qualification from the RCOG. Yet Miss Godly told me that it was not conclusive, refused to do any further tests and left me unsure whether the mass was uterine or an ovarian mass with significant and deadly malignant potential.
2 Neither Miss Godly nor Dr Curry did a proper examination of the lump. An experienced gynaecologist, like Professor Tizzy, can tell from examination alone whether a mass is multiple or single. I do not find it satisfactory to be despatched to the operating theatre without even an adequate examination.
3 In spite of its adverse effects, like depression, sexual dysfunction and ovarian failure, hysterectomy may be the best solution, where there is a history of severe menstrual problems. I have a total lack of gynaecological history. The fibroid mass has been my only menstrual complaint ever and the symptoms it has caused have not been severe. Hysterectomy would bring me no advantages and, in view of my extremely negative attitude to it, would very probably bring severe depression.
4 Miss Godly totally ignored my wishes with regard to hysterectomy and quite obviously tried to hustle me into having an operation I detested because she wanted to do it. I have not been told whether Miss Godly is even experienced in conservative surgery as my repeated requests for this information have been ignored.
5 Miss Godly made the incorrect assertion that my bleeding would get worse. In fact it had NOT increased during the previous 3 years and did not increase in the following year. She said I probably had multiple fibroids. If she had done a detailed scan (like the Manchester one enclosed) she would have seen that the mass was both single and fundal and would be, in the words of Professor Tizzy "technically easy" to remove. Miss Godly also went on about myomectomy being a long operation. The time taken for myomectomy depends upon the number and position of the fibroids to be removed. Miss Godly had made no investigation of the fibroid(s) present and her assertions were totally incorrect.
Finally I enclose the foreword, written by Professor Stuart Campbell, to Felicity Smart's book Fibroids. In it Professor Campbell states that a woman's attitude to her body must be respected whatever her age and that she is entitled to the treatment which she feels is right for her. I could only envisage hysterectomy as being "right for me" if it was a life saving necessity - and even then I would hate it. Miss Fobb's letter of 20 July states quite clearly that Miss Godly's opinion was that I should have a hysterectomy and that it would not be ETHICAL for Miss Godly to perform an operation she did not think was "in my best interest". Miss Godly did not tell me this was her opinion when I saw her. She tried to coerce me into having a mutilation I detested by making untrue assertions about myomectomy. I find her dishonest deviousness even more reprehensible than her superficial and inadequate consultation.
I am therefore complaining to you.
Yours sincerely
Pamela Nomark
I wrote on 19 October 1993 to Ms McD telling her that I had finally asked for an independent professional review.
After sending this letter I received a note from Miss Fobb, dated 20 October.
Dear Miss Nomark
Thank you for your letter of 22 September and please accept my apologies of the delay in responding to you.
I am afraid the investigation into your complaint is still continuing and I hope to be able to write back to you in the near future.
Yours sincerely
S M Fobb
Administrative Services Manager
Two weeks later, on 8 November, she wrote again.
Dear Miss Nomark
Further to my letter to you of 20 October, I have now had an opportunity to discuss your case with key medical staff in the Health Authority and the Region Health Authority who deal with complaints involving medical staff.
The comments I have received concur with my previous advice to you. I have been told that your case would not constitute a formal complaint as laid down by the Department of Health. As previously mentioned to you, if a patient does not wish to follow the line of treatment recommended by a particular doctor, it is that patient's right to seek a further medical opinion and they would be under no obligation what so ever to undergo a form of treatment against their wishes. This does not however mean that the doctor has been negligent in any way even if a further opinion suggested a different type of treatment. Clinical practices differ considerably and it is up to each doctor to choose the method of treatment they feel is best to deal with a particular condition. I am afraid I can only reiterate my earlier comments to you therefore that you should seek another opinion. Your General Practitioner may be able to refer you to a particular consultant who advocates the type of procedure which you would prefer.
Should you remain unhappy with this response you may wish to discuss the matter further with your local Community Health Council. Their telephone number and address can be located in your local telephone directory.
Yours sincerely
S M Fobb
Administrative Services Manager
Miss Fobb was very good at reiterating (she would have made an excellent parrot), but very poor at informing. She still hadn't told me what the "matter" was that she had been dealing with since the previous July or how many myomectomies Miss Godly had performed. Or why Miss Godly had no faith in radiology. The Regional Medical Officer, who was the person who dealt with complaints involving medical staff, also wrote to me on 8 November. If Miss Fobb had discussed my complaint with him he never mentioned it.
Dear Ms Nomark
Thank you for your letter with its enclosures requesting an Independent Professional Review. May I suggest that you make an appointment to see me here so that we can discuss what an Independent Professional Review involves and what it can achieve.
I hope that you find this suggestion helpful.
Yours sincerely
Professor John Willow
Regional Director of Public Health Medicine/
Regional Medical Officer
I was already sure of what a Review would achieve - nothing. Another hysterectomist would pick over my notes and think "Old hag - over 40 - mutilation of course." The entire medical profession, the entire male world in fact, was smugly satisfied that the female reproductive system existed to satisfy the male desire for sex and offspring. Where a female is past the respectable reproductive period all bits of no use to men shall be removed so as not to cause offence.
And very rare indeed are those members of the RCOG, or indeed the entire medical profession, who do not subscribe to this view.
However I had every intention of making my disapproval heard. I sent copies of both the Medical Officer's and Miss Fobb's letters to Ms McD at the Community Health Council.
She replied on 15 November.
Dear Ms Nomark
Thank you for your letter dated 10 November regarding an Independent Professional Review and Miss Fobb's most recent letter.
The Health Authority try to be flexible with complaints, in an attempt to obtain a satisfactory outcome for the complainant. I think they may be offering you an initial appointment in order to discuss, in depth, the nature of an IPR, to ensure it will be beneficial to you. It could also be that the Regional Medical Officer is unsure if your complaint warrants/needs this kind of investigation.
Professor Willow is a newly appointed Officer to the Region and may have a different approach to his predecessor, who did not arrange a preliminary meeting with complainants before an IPR was initiated. You can of course take someone with you to the meeting, like a friend or relative for support, or I could accompany you if you preferred.
Yours sincerely
ES McD
Deputy Chief Officer
Well of course I preferred. I am very easily confused by professional bull-shitters, as my experience with Craft-Tort had showed, and realised that I badly needed one on my side. On 18 November I rang the medical officer. As it was lunch time and both he and his secretary were out. A woman took a message. In due course a letter dated 25 November arrived.
Dear Ms Nomark
I refer to your recent telephone conversation requesting an appointment to see Professor Willow. I wish to confirm the arrangements that I have made for you to see Professor John Willow on Wednesday, 15 December 1993 at 10.0 am in his office and hope that you will find the date and time convenient. If at all possible I would appreciate it if you could confirm that you will be attending.
Yours sincerely
Patsy Drivel
Secretary to the Regional Director of Public Health.
The letter was marked "IN CONFIDENCE" though I could not see what was so confidential about making an appointment. I was also annoyed at what I considered the condescending tone of it. It was after all not I, but the Medical Officer who had suggested a meeting.
When I saw him on the 15 December he went on about procedures, and rules and regulations - all boring stuff only the soulless can truly tolerate. He was all in favour of more patient participation, medical teams and league tables - or so he said. I had the impression that he wanted me to forget about complaining. I didn't.
Well if I was really going to complain it would have to be in writing. Ms McD pointed out that it was already in writing as in my original letter to him, of 18 October, I had specifically requested an Independent Professional Review. The Medical Officer couldn't find his copy of my letter. But Ms McD produced hers. So that was that. Now he would have to seriously consider having to set up a Review. However he had managed to delay it by another 2 months.
I next heard from him on 6 January 1994.
Dear Ms Nomark
I am writing to confirm that I have set in train an Independent Professional Review as you requested. I do this on the understanding that you do not intend to start litigation on this matter since, as you know, an Independent Professional Review is not possible if litigation is in progress or is contemplated. It will take about two months for the independent consultants to be selected. Once this has been done a date for the Independent Professional Review will be arranged.
I would like to remind you that it may take some time for the report of the consultants to reach me and that I then have to send a synopsis of this report to the Chief Executive of the hospital, who will communicate its content to you. The system may appear to be ponderous but it is an effective method of obtaining two independent and unbiased opinions about your complaint.
Yours sincerely
Professor John Willow
Regional Director of Public Health Medicine/
Regional Medical Officer
"Independent and unbiased opinions" from members of the same professional club? In January I heard once more from the Royal, again denying that they had ever received a copy of my scan report. I wrote to the Medical Officer on 24 January 1994.
Dear Professor Tinker
As you may recall when I wrote to you in October last year requesting an Independent Professional Review I mentioned that I had some difficulty in obtaining a copy of the report of the ultrasound, done at Helton hospital, which was the only investigation of my condition considered by Miss Godly.
I therefore wrote to the Chief Executive of the Royal University Hospital and enclose both a copy of my letter and the reply.
As you can see the hospital affirms Mrs Thomas's statement of 27 November 1992 that the scan report was not received at the hospital and that the only scan information was in a letter from Mrs Languid.
As I have said before Miss Godly neither examined me nor ordered ANY investigation or tests whatever. And her associate only had an external feel of the lump. This means that when Miss Godly wrote in her letter (enclosed) to my GP, Dr Amicable, that she had received a copy of the scan report she was not only lying (according to the Royal) but it also means that she was talking of mutilating operations on the basis of what a newly appointed, inexperienced gynaecologist SAID about an ultrasound scan report which she had NEVER seen.
I find this almost beyond belief and would be interested in any comment you might make.
Yours sincerely
Pamela Nomark
I had been reading Professor Tinker's report and that's why I put the wrong professor's name on the letter.
He didn't reply and I when I finally got a letter, dated 16 March, giving the names of the "independent professionals" who were going to do the review it was appended by an illegible scrawl "for Professor J.R. Willow".
One of these professionals was an obstetrician and the other appeared to be mainly interested in obstetrics as he had written a couple of papers on obstetric subjects.
The next letter, dated 8 April, was to confirm the date of the Independent Professional Review as 17 May. And the next, dated 18 April, was to say that one of the independent professionals had decided that she couldn't make 17 May after all so another date would have to be arranged. A phone call at the end of May wanted to hold the review on 13 June. At this was the date arranged for the myomectomy I was now to have I said that this was none too convenient for me. On 20 June I was given the new date - 23 August.
1 Actually I think she meant that no-one was going to waste valuable MRI time on boring fibroids.
2 Chronic poisoning from iron administered by mouth must be exceedingly rare but one case of haemochromatosis has been attributed to oral iron therapy (Johnson, 1968)
3 As far as the medical profession is concerned the answer to this is YES.
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chapter 5