Is it worthwhile doing difficult cases in Private Practice?

Is it worthwhile doing difficult cases in Private Practice? 

Last week was a very stressful week for me. I performed 3 difficult cases in ONE day! The first patient was related to several doctors I know. This patient had severe endometriosis with adenomyosis, for which I performed a laparoscopic cystectomy several years ago. She returned with severe dysmenorrhoea, pelvic pain and heavy menses and decided to remove the uterus. I had a tough time releasing all the bowel adhesions first, from the abdominal wall and then from the ovaries and the uterus. I had to dissect out both the ureters completely and then after 3 hours completed the laparoscopic hysterectomy. 

Exhausted from the stress of this surgery, I had to do a second laparoscopic cystectomy on another patient referred to me by my colleague, a very well known obstetrician and gynaecologist. This lady had a previous laparoscopic cystectomy for severe endometriosis and now having a recurrence with bowel endometriosis. This took another 3 hours to clear all the disease and to reconstruct the pelvic organs. 

It was already 6:30 pm and I had another difficult case to do. My nurses had to “break fast” first before we started the next difficult case at 8:00 pm . This lady had a 12 x 10 x 10 cm uterine fibroid and was planned for a laparoscopic myomectomy. Again the surgery, even though not as difficult as the previous 2, took me 2 1/2 hours. I had to first remove the fibroid from the uterus then repair the uterus and after that, morcellate and remove the fibroid from a culdotomy. 

After completing all these surgeries at 11:30 pm, I was asking myself “Is it worthwhile doing difficult cases in Private practice?” 

What is a difficult case?

First, lets look at the definition of a difficult case. In the medical profession, a difficult case refers to a patient with a complex or challenging medical condition that is difficult to diagnose, manage or treat. Difficult cases may involve rare diseases, multiple health problems, or treatment-resistant conditions that require specialized knowledge, expertise, and resources. Such cases may require a multidisciplinary approach involving different medical specialists, advanced diagnostic tests, and innovative treatment options. Managing difficult cases often requires careful coordination, patience, and persistence, as well as empathy and compassion for the patient and their loved ones. 

When confronted with a difficult case the first thing that comes to my mind is that, is it worth taking on the case or should I just refer her out to another colleague or hospital. There are advantages and disadvantages of taking on such cases. I will outline them below. 

Advantages of doing difficult cases in private practice: 

1. Professional satisfaction: Successfully managing a difficult case can provide immense professional satisfaction. It can give us a sense of accomplishment and recognition for our skills and expertise. 

2. Strong relationship: It can help to build strong relationships with patients. Patients with complex medical conditions often require a higher level of care and attention than those with more straightforward cases. By taking on these cases, we can demonstrate our commitment to providing personalized care and build a loyal patient base. 

3. Financial rewards: Difficult cases often require specialized knowledge and skills, which may command higher fees for the medical practitioner. 

4. Referral base: Managing difficult cases can enhance our reputation and increase our referral base from other medical professionals. 

5. Learning opportunity: Difficult cases provide an opportunity for us to expand our knowledge and skills, especially in areas where we may not have extensive experience. It can lead to a better understanding of complex medical conditions. By grappling with challenging cases, we can develop a deeper understanding of the underlying causes of disease and gain insight into the latest treatment options. This knowledge can be shared with other medical professionals and ultimately benefit patients. 

Disadvantages of doing difficult cases in private practice: 

1. Time-consuming: Difficult cases often require more time and r

esources than routine cases, which can lead to exhaustion and burnout in the surgeon 

2. High-risk: Difficult cases may have a higher risk of complications, which can be emotionally and professionally challenging. 

3. Liability concerns: Managing difficult cases may increase the risk of litigation and malpractice claims if the patient’s condition does not improve or if there are complications. 

4. Stressful: Managing difficult cases can be emotionally and mentally stressful, and we may require additional support and resources to manage the stress and maintain our mental health. 

5. Poor Financial Rewards: In Malaysia because of the Private Health Care Act, the remuneration for performing complex surgeries is the same as that of performing simple procedures. As such taking on difficult cases may not be financially rewarding. 

In conclusion, taking on difficult cases in private practice can be both rewarding and challenging. By weighing the pros and cons, we can make informed decisions about which cases to take on and ensure that we are providing the best possible care to our patients. It is important to recognize the potential risks and take steps to manage them effectively to ensure that we can continue to provide high-quality care to our patients for years to come.

So what advice can I give young doctors?

  1. As a young doctor you will have more time to spend with your patients. Take the opportunity to take on difficult cases. Ask colleagues from your speciality and other specialities to assist. It may not be financially rewarding but it will be a learning experience. However it will be important to disclose all eventualities with the patient and his/her family so that you don’t get into trouble if there is a poor outcome.
  2. If it is beyond your capability, refer to a colleague who is capable but let him know that you want to be involved or at least informed of the management of the patient so that it can be a learning experience. 


Picture of Dr. Selva

Dr. Selva

Dr S. Selva (Sevellaraja Supermaniam) is a Consultant Obstetrician and Gynaecologist and a subspecialist in Reproductive Medicine at a private hospital in Melaka, Malaysia. He heads the O&G unit and the IVF Centre at the hospital.

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