On my last trip, an elderly woman came with a goiter. It was moderate in size-noticeable but not so large that her chin rested on it. It was soft and almost certainly benign. She could breath and swallow without difficulty. I told her to leave it be. "Save your money" "You don't need surgery"!

She wasn't happy with that answer but I encouraged (or forced) her to leave. There was no need for her to risk the potential complications of surgery.

Realistically, this would not happen in the USA. This lady would have been signed up for surgery and booked for a date (assuming she had insurance) before she left the surgeon's office. In the USA, medicine is a business. When someone comes to your business, you don't sell them the cheapest thing you have, you sell them the most expensive. Have you ever gone to a car dealership and had the salesman try to sell you the bottom of the line model? No way. They start at the top. 

In Nigeria, it is possible to do what is right for the patient. That is one reason why its my passion.