“Biopsy does not equate radical orchiectomy”

I was taking care of a young man with a long-standing history of poorly controlled insulin dependent diabetes and a pulmonary fungal infection who came into the hospital with a scrotal mass.  To frame the story, I must inform you that this young man had a tragic childhood, fractured medical care and had developed an incredible mistrust of healthcare professionals through multiple run ins with the healthcare system.  To most of the hospital staff (ie. Phlebotomist, nursing, social workers) he appeared surly and “uncooperative” and he was labeled as such.  It took days for him to trust myself and my intern enough to start sharing his background with us and for us to begin to help him.  In regards to his care, urology was consulted and initially said that there was nothing to do.  Given patient’s history of a pulmonary fungal infection that was likely incompletely treated, my team very strongly felt that we needed some sort of sample from the scrotum to check to see if patient had disseminated (fungus outside the lungs) infection.  Additional imaging of the testicle was suspicious for a mass and thus Urology was again consulted.  Given the concern for testicular malignancy, the urology resident consented the patient for a procedure.  Urology gave me call to let me know that the patient consented for biopsy of the mass with the possibility of radical orchiectomy which meant surgical excision of the entire testicle.  I was incredulous when the urology resident told me this because the patient rarely spoke to any other hospital staff.   Furthermore, getting this young man to agree to take antifungal medication and insulin was a battle.  Although I was hopeful that urology had indeed provided informed consent I went to the young man’s room full of skepticism.

I pulled up a chair and asked him what he understood about urology’s plan and he said, “they are going to do a procedure to get a sample of the mass to check for fungus or cancer”.  I then asked him if he knew what would happen if the urologists thought the mass was malignancy.  To my dismay he had no idea.  When I shared with him that he could possibly lose his testicle he was socked and angry.  I apologized to the young man and discussed urology’s plan with him.  I also called the resident on urology and requested that he come back and do a thorough explanation.  Additionally, I submitted a report to our hospital’s anonymous reporting system.

Fortunately, the patient did not require an orchiectomy and only underwent biopsy and specimen collection.   To say that the patient was relieved would be an understatement.  This event highlighted multiple issues – the young man being labeled as uncooperative, the incomplete consent process, and many lapses in communication.