Dec 2015 Statement on Pelvic renal ultrasound incident

On October 9, 2013, at an appointment with [the doctor], he wrote out a requisition for a ‘pelvic renal’ ultrasound test, apparently related to the most recent blood test confirming once again that I had chronic kidney disease (CKD). I didn’t know why I was being sent, exactly, but I trusted that was what I had to do, for my own best interests.

From home, I called and made an appointment for the test, and talked to someone about what was required. The standard information on the back of requisitions indicated that 1 litre of water be drunk on an empty bladder 1 1\2 hours before the appointment time.

I practiced, and saw that it was possible, as long as I didn’t sneeze vigorously or my body was not put under any physical stress of that kind. I am a woman, and have given birth to two children, and am no longer young, not to mention being somewhat overweight. Moreover I had a hysterectomy, many years ago, of which [the doctor] would have been aware. My body encompasses all the features that a person would have who would very likely suffer from ‘stress urinary incontinence,’ something that has not been something of concern up to that point. But then, I don’t ordinarily drink a litre of water, wait approximately 60 minutes, then go out to keep an appointment.

There was no time to discuss such things with [the doctor], as he was always so busy, and limited his time to as short a time as possible, exiting the room even without ending the visit verbally. So I was left with questions, but no time or opportunity to express them. Any time I asked the receptionist for information  - on anything - she would say, Ask the doctor when you see him.

On October 21, 2013, the day of the ultrasound appointment, I drank more than 3 glasses of water, one after the other, then waited the 1 hour (which I read elsewhere was time enough), though the written instructions were more extreme (see document) and drove to [the imaging lab] for the ultrasound test.  No, I did not have an accident. It all went well, and that was that.  The results were never discussed by me and [the doctor]. He didn’t usually take the time to do that with reports.

Later on the doubts about why I was sent were increasing. I looked up online more about kidney disease and what causes it and so on.  I discovered it was quite common among older people, for no particular reason, just aging kidneys becoming less functional as time goes on. My mother had had kidney disease too, and I may have mentioned that to the doctor, but genetic or inherited kidney disease is usually due to something going wrong in the kidneys, not in the bladder.  I had not complained of pain. The diagnosis of kidney disfunction was based solely on the routine blood test – the eGFR – and had been at the same level for a few years – Stage 3. So there didn’t seem to be any reason for having me go through the bladder part of the ultrasound test, at least, that was so uncomfortable to prepare for, and so risky in terms of an accidental leak of urine. And then, of course, there was the renal part of the ultrasound test, which wasn’t a problem except there didn’t seem to be any good reason why it should have been done, either. My bladder function was irrelevant. And I was referred to a Nephrology Department not due to pain, or stones, or any suspected disease related to the kidneys, but for chronic kidney disease as indicated by eGFR blood test results.

Effect of Pelvic renal ultrasound incident

I went ahead with the pelvic renal ultrasound test because I thought I should do what the doctor thought best, as it must be necessary or he wouldn’t have sent me, and even though I had misgivings at the time, I went through with it. I didn’t know if I could even hold that amount for the required length of time, but I thought I should try, since the doctor had said. But I regretted not realizing at the time what it involved, and the doctor not making that clear. I felt as though I had been put on the spot and to back out after having agreed to it might give the impression I thought my body was not capable, or that I was fearful of losing control of my bladder. Having to say “No” when I had agreed to it implicitly would have been difficult.

And later, again, I thought that I should never have been placed in that situation of risking a possible loss of urine due to a violent sneeze attack while holding two or three cups of water in my bladder. And after I was no longer a patient of that doctor, and saw how rude and obnoxious he could be, I questioned his motivations, or at the very least, his sincerity in his overall treatment of me. I no longer trusted him. And I have found it difficult to trust doctors in general.

There was no reason for me to have the pelvic part of the test. In fact, there doesn’t appear to have been a reason for me to take the kidney part of the ultrasound test either. I realize the doctor is a busy person, and may not seem important to him if he makes a mistake or two, but it does make a difference to my wellbeing, in that kind of situation, being put in that stressful situation for no apparent reason. If there had been a good reason for me to have to do the test, then at least explain why, and perhaps substitute a different test, but there was no good reason, which makes it worse. And it could have been worse still, if I had not been able to hold it. Having to endure the embarassment of an accidental leak, for no good reason, would be annoying, to say the least.

Even if he didn’t know the possible risk of such a test, he didn’t give me the oppportunity to explain how my being a woman, and older, as well as being a bit overweight and having given birth to 2 children are all indications that ‘stress urinary incontinence’ are likely to be a problem.  Under ordinary circumstances, where I have some control over when I drink fluids and how much, I would never be so reckless as go around with that much fluid in my bladder.

One effect of having gone through that is the realization that what doctors say cannot automatically be taken as the best decision, even in as innocuous a situation as that seemed, at irst. It’s unfair to be placed in the situation of not trusting a doctor to make good decisions, even though he should know better, but that has been one outcome of the incident. And I am annoyed that I was place in such a situation, and wonder how many other older women are, under similar circumstances.

As time passed, I considered other behaviours and decisions [the doctor] had made, such as sending me to what surely is the only ENT specialist in the city whose office is located inside a hearing clinic. I had asked [the doctor] about my ear problems while at the same time saying to him, half-jokingly, that the only thing not wrong with my ear was my hearing. That made me wonder whether it had been done on purpose, or was simply a coincidence, or a decision lacking in sensitivity, as starting out on that note, in a clinic for people with hearing problems, most of whom are probably older, could itself lead to misunderstandings, and in fact did, in that case.

Discrimination on the grounds of sex

The ultrasound test was to be on the pelvis and the kidneys, the pelvic part focusing on the bladder as I no longer had a uterus. The doctor’s error involved assuming the test on my bladder posed no risk to me of worry, or embarassment.  Was the test something he sent women for without actually thinking about their gender, and their medical history, as women? Was I simply included in the kind of referral he would make for any woman who had received a suspicious eGFR blood test report? If that was the case, then I was discriminated against by him, on the grounds of sex, through not taking into consideration my experience of pregnancy and childbirth (and the possible effect of these on taking the test). Should he have known better than to send me for the test?  Discrimination doesn’t mean that all individuals within the category (women) must be treated the same as younger women, however. Sometimes it means their specific differences should be taken into account, as I have described here.

The doctor created an environment of distrust, and thus discriminated against me, a woman (and older) by sending me for this test when he surely must have known the worry it would cause for me. If he didn’t know, then he must be lacking in awareness of these issues, though how he could be is beyond me. It did nothing to help create good relations between doctor and patient.

I wasn’t just a woman, I was a woman who had twice given birth. That puts me in a category of some risk, when it comes to the problem of ‘urinary stress incontinence’ (as opposed to ‘urge urinary incontinence’).  Stress incontinence is the largest slice of the pie when it comes to different types of urinary incontinence. See  following:

“Stress Urinary Incontinence (SUI) - 50% of individuals with UI have SUI, which is the leaking of urine when coughing, sneezing, straining, exercise or any other type of exertion” (pp 4, 5, Incontinence: The Canadian Perspective, Cameron Institute, Canadian Continence Foundation, Dec 2014, en-incontinence-a-canadian-perspective-2014.pdf) .

See also page 6 in the Incontinence pdf file for the list of causes, including pregnancy and childbirth among females exclusively. Aren’t most people aware of the problem of incontinence among older people – women in particular - even if only through being exposed to jokes on the subject? Shouldn’t he have known, being a doctor?

I believe I was discriminated against on the grounds of sex through [the doctor] sending me for the test without thinking of the effect it could have, or due to his using his knowledge to put me on the spot, submitting to a test that caused me worry. If he simply didn’t bother thinking about my gender (sex) when he sent me for the test, or failed to take into consideration my gendered life experience, then he was omitting important facts about me when making a decision, making it an incident of discrimination. If he did think about it, and sent me on purpose, then he was engaging in malicious sex-related discrimination.

In ‘Principles of Practice and Duties of Physicians’ on the CPSO website, the principles and duties of a physician are described in detail ( ).

According to the CPSO’s Ontario Human Rights Policy, explaining Ontario’s Human Rights Code:
1 (the Code) articulates the right of every Ontario resident to receive equal treatment with respect to goods, services and facilities without discrimination based on a number of grounds, including race, age, colour, sex, sexual orientation, and disability.
2 This imposes a duty on all those who provide services in Ontario – which includes physicians providing medical services – to provide these services free from discrimination  (‘Physicians and the Ontario Human Rights Code’, Policy Number:#5-08 Policy Category: Practice, Publication Date: December 2008, Introduction. Retrieved Feb 22, 2015. )

Unless we are to believe the doctor sent me for an unneccessary test out of naivety, or lack of knowledge, then the only other option is that he intended to create a situation of discomfort and  risk to me discriminating against me on the basis of my sex.

Discrimination on the grounds of family and marital status

I had been referred to the imaging lab for a pelvic renal ultrasound test.  I question why I was put through that, considering my age, and now also whether my family and marital status had something to do with it. I am an older woman, but I am also an older woman whose family lives in another city and has no husband to care for, or care for me, at a time when the health care system is encouraging families to take on caring roles.

If a doctor has resentment towards those who don’t appear to be fulfilling their tasks, as members of a family are expected to, then is this attitude projected onto patients – female patients especially - who are the most vulnerable – alone without spouse or family nearby? Some of the other comments he has made wouldn’t clearly put him into this category of someone who discriminates on the basis of marital and family status, but from where I’m situated, not having a family member to accompany me, or to talk to when I get home, about the doctor, for example, who remarks that if I continue to use a nasal spray to unblock my nostrils, my septum will disintegrate, is a disadvantage.  

As women grow older, they are often expected to take on care-giving roles, towards their family members, as well as receive care. Especially in this age of problems within the health care system, whereby there is said to be a shortage of funds as well as a shortage of care homes for the elderly, there will be those who question the usefulness of some older women, particularly those who are single, with no husband to care for or care for them.

If [the doctor] treated me the way he did because he saw me as not worthwhile treating with respect and consideration because I was an older woman with no husband and no family in the city, then he discriminated against me on the basis of family status, as well as on the basis of sex and age.

Discrimination on the grounds of age

First, older people are more likely to develop chronic kidney problems (or have them recognized), as I understand it, while younger people more acute problems related to kidney damage – or a more sudden onset of problems. While a renal or kidney ultrasound may help in diagnosing cancer or some kind of kidney problem among younger patients, I can’t see that it is important enough to add to the diagnosis of chronic kidney disfunction in a senior person, before the nephrologist even takes a look. [The doctor] ignored the fact that I am an older person, when it came to having the ultrasound test done on my kidneys, and was an act of discrimination on his part, on the grounds of age, treating me as he would any other person, and not considering the type of kidney disease I might have, related to my age. Is it not reasonable to think that he should know, that there is a difference, or was it acceptable that I be subjected to an unecessary pelvic renal ultrasound test?

Secondly, I was also required to have a pelvic ultrasound along with the kidney (renal) ultrasound, which was not just unecessary but caused much discomfort, concern, and the risk of having in incident of leakage of a substantial amount of urine. Due to my age, and being overweight which is a normal part of aging for some, the pelvic muscles can become weakened. The doctor may not have realized this, or even known about the medical condition among older people, women in particular (see related section on discrimination on the grounds of sex). But he never had time to discuss it; he simply referred me for the test. Was it reasonable that he not know, and that he not take the time to discuss it during one of those brief, usually less than ten-minute long appointments? But the fact is, it was unecessary that I take the test in the first place, as it was most likely age-related kidney disease, not due to the kind that can be discovered through an ultrasound test. Was it just an error, or is it reasonable to believe that he should have known I was at risk of accidentally leaking a large amount of urine due to the requirements of the ultrasound test? I believe [the doctor] should have known what the risks were when he filled out the requisition form and sent me for the pelvic renal test, and that he discriminated against me on the basis of age by doing so.

Urine sample, “street drugs,” and termination Apr 28, 2014

On April 28, 2014, while [the doctor] was with me in his office, renewing my prescriptions, he became unreasonable and informed me, first, that the next time I got my prescriptions renewed I would have to take a urine test “for street drugs,” he said. He was in the process of refilling the prescription for Tylenol 2 for me, consisting of two tablets per day, which I take for pain from a previously broken ankle with tissue and ligament damage, and which also helps with the arthritis. I had been started off in 2009 with Oxycodone, having broken my ankle, and got myself down to Tylenol 3 despite continuing pain due to tissue and ligament damage. Later, in London, I  was prescribed the lower strength, Tylenol 2, starting in March 2013, with [the doctor].

At the appointment, the doctor changed his mind within a few minutes, demanding that I take a urine test then and there. And then he changed his mind again, saying that in future I would only be able to have a renewal prescription for the Tylenol 2 for a period of one month and would have to take a urine test for “street drugs” each time I came to have it renewed. At the same time he was asking me once again, as he had two three times before, on other occasions while I was there for an appointment with him, if had I found a new doctor yet.

I said I would get him the sample, and picked up a jar at the front desk and continued on to the washroom. Once there, I changed my mind. I was rapidly becoming even more untrusting of the doctor than I had been, and when I saw that the empty jar for the sample had no name on it, that was the deciding factor. I left the washroom with the jar unfilled and took it back to the front desk and gave it to the receptionist. I understand that the reason the jar did not yet have my name on it was because the decision to have me take the test for street drugs had only been made minutes beforehand, but still, it didn’t seem like a good idea to hand in a sample of urine to a doctor who was behaving irrationally and who I no longer trusted and expect that it would be properly labelled and sent off.

When I came out of the washroom I was standing across the waiting room from him, and tried to explain to the receptionist and him that I would not be providing a urine sample. I did leave at that point, but returned just as I got into my car, to ask for a form so I could take the urine test at a lab. The receptionist and the doctor ignored me at that point so once again, I left.   April 28, 2014 was the last appointment I had with [the doctor] as my family doctor.

Two days later, on April 30, I submitted a letter to LDAM (London and District Academy of Medicine) to try to enlist their help in resolving the situation

A week or so later I developed symptoms which, along with the typical shingles rash, led me to try to make an appointment with him, on May 12, but was told on calling the office only that he was booked up and that I could go there and wait, which I did. Two hours later, and still waiting, although it was by now the doctor’s lunch break, the receptionist informed me that I was a walk-in patient now and no longer a patient of the doctor’s. I had not formally been notified and hadn’t known. I think I was expected to leave at that point but I realized I needed the anti-viral prescription for shingles, so explained my situation. I managed to get the prescription for the anti-viral medication I needed from him and left, with no followup for the condition. I did eventually receive a letter of termination from the doctor, dated April 28, although postmarked May 20, 2014.

Following that, in June, I received a response to my complaint from LDAM, advising me to find a different doctor

Conclusion for each of the incidents, the ‘Pelvic Renal’ and the ‘Urine sample, “street drugs” and termination’

The provision of treatment or diagnoses that had been appropriate does not take away from the fact that there was inappropriate treatment, unnecessary tests (as in the situation of the pelvic-renal ultrasound) and changes in medications made, and a general lack of thought and committment put into the patient/physician relationship by [the doctor]. A person may well be an upstanding citizen but still have flaws in his personality or cultural beliefs that affect decision-making and the way he interacts in his daily life, as well as affecting the lives of the people he encounters in negative ways.

The doctor took a situation of needed pain medication due to a previous injury and blew it out of all proportion, finally, at the last official appointment I had with him, demanding I take a urine test for “street drugs:” This was the last straw and it affected me deeply, to be reduced to the status of someone who, according to him, required routine monitoring for suspected drug activity on the streets of London. He may well have people with drug problems on his roster, but I am not one of them. Nor am I out there, on the streets or attempting to get enough money to buy them. Nor did I shout at him or his staff, not ever, as he has tried to claim.  

I am a 69 year old woman, living alone and trying to make ends meet, not active in the community, in part due to mobility problems including pain on a daily basis. But I am not the kind of person he has tried to make me out to be.

I have no doubt that his preconceived notions about me influenced the way he treated me.  His language and attitude towards me, at other times and not just during these two situations, indicate that he thought I wasn’t worth bothering with. Greeting me with “You’re smiling; you must be okay,” surely isn’t the best way to greet a patient, who generally is there due to an illness, injury, or other health concern. It trivializes their concerns. Perhaps that perception is due to a cultural difference. In some countries, women and even men may express emotions in order to get across how they are feeling, unlike western countries in which women have been taught to smile, no matter what. In like manner, announcing “The report’s back - you’re okay,” is a conversation-ender rather than the chance to discuss further what the problem could be.

Having to make an appointment to have prescriptions renewed in person, rather than use the pharmacist’s faxable form, doesn’t even make sense. He surely doesn’t require his patients who go on extended holidays to have to do that. One wonders why one patient gets treated one way, another, a different way.

These may not seem to be instances of discrimination, but if they reflect the doctor’s attitude on the basis of age, or sex, or marital status, they may well be.

Because I was an older woman, was not married and did not have a family nearby and lived alone, it apparently seemed to him that I was abusing or at risk of prescription drugs and possibly “street drugs” too, and should be required to submit to a urine test on a regular basis – for a prescription for Tylenol 2. I don’t know what other reason there was.

He is a physician, who has the power to dictate who will get tested for drugs and who he will allow to take narcotics without being tested at all – even if they do sign the required form to say they will, if asked. If not all patients in Ontario are being tested routinely for narcotics in their urine, (and obviously not all patients are or the results would surely stop them from getting prescribed it again and again),  perhaps it is time to consider doing just that, and not allowing Ontario’s doctors to concentrate their efforts on only some patients, for reasons more to do with social circumstances than legitimate concerns, on those who do not have the power and connections to object and be heard. I don’t take narcotics or other illegal drugs and never have (aside from trying marijuana), except for the pain of a broken ankle with ligament damage and the arthritis that often comes as one grows older, and I object strongly to the manner in which this doctor treated me throughout the time I was his patient.

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