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WE have known for some time that specialist consultation fees in Australia are highly variable and can involve significant out-of-pocket expenses.
This issue reached a new level of controversy recently when a social media post went viral. Taking to Twitter, urologist Professor Henry Woo expressed “deep concern about patients and their families turning to crowdfunding to cover the costs of surgical treatment”. As he explained in a subsequent article , he was referring to a large number of funding appeals on a site called GoFundMe for surgery with a particular neurosurgeon. A search of the site had revealed over 100 similar appeals to fund surgery with the same provider. In his first of two tweets, Professor Woo commented that “If it was valid surgery, it could/should be performed in the public system under Medicare”.
What followed was not only an avalanche of responses to Professor Woo – both for and against his opinion – but also a much wider discussion of the phenomenon of the maverick surgeon – the provider who is prepared to take on procedures that others will not.
Speaking in a television interview, the surgeon under discussion, Dr Charlie Teo, outlined the breakdown of the considerable fees involved for his surgery in the private hospital system. He also took on the issue that he described as “all about ego”, stating that all that was required for his participation in surgery in the public hospital system was for “a few people to swallow their egos” and admit that “sometimes other doctors do it better than (them)”.
These statements made me think again. How do we decide whether mavericks are also heroes? And is it always more courageous to proceed rather than hold back?
Dr Teo restated what most of us believe: we practise medicine to help our patients. How do we know, however, whether we are helping, and whether our patients are doing as well as others? Surely the answer is through sharing our data. If a clinician finds, under controlled conditions, that a new way of treating a particular condition yields better results, as well as less complications and better subsequent quality of life, isn’t it incumbent on that provider, or unit, to audit and publish their results? If both acute and long term outcomes are better than matched controls managed in other hands, the new regime should become the new standard. The same principle would apply whether this is a new procedure, a new indication for a procedure, or a new medication or rehabilitation regime.
Taking the discussion back to Professor Woo’s area of urology, an analogous situation occurs in robotic prostate surgery. We know that prostate-specific antigen screening can lead to overdiagnosis and overtreatment of prostate cancer, which is often said to be present at death rather than a cause of death. We also know that surgery can leave men with significant disability – incontinence and erectile dysfunction. And yet, patients may be drawn to the expensive robotic techniques offered in private hospitals, sometimes costing tens of thousands of dollars. A study published in Lancet Urology in 2018 found that robot-assisted laparoscopic prostatectomy and open radical retro-pubic prostatectomy yielded similar functional outcomes at 24 months. It’s in the data.
So what, in the end, represents clinical courage? Is it courageous to take on a procedure that nobody else will try, or is it more courageous to accept limitations and avoid doing the patient more harm? Does it take more courage to agree to do a risky procedure, or to explain the evidence rationally to a distressed family of a dying child? And what is most courageous of all? Being self-reflective, measuring our results, and sharing them.
Some heroes fight to save lives. Other heroes fight to assist families to face death. There is a time and place for both types of courage.
Dr Sue Ieraci is a specialist emergency physician. After 35 years in the public hospital system, she now works in telemedicine and health system consulting. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She is an executive member of Friends of Science in Medicine.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Dr Teo has always asserted that he takes on cases that other neurosurgeons deem ‘inoperable’. The latter, to these other neurosurgeons, often means that surgery has nothing to offer in terms of either survival or functional outcome benefit. The mere fact that an operation can be technically feasible is not, in itself, an indication to perform it. The benefits of surgery should always outweigh the risks and indeed, not all brain cancers are surgically amenable diseases and are treated primarily with chemotherapy and/or radiotherapy after biopsy diagnosis. No one doubts Dr Teo’s surgical technical ability but his claim to be the ‘best’ is merely opinion until it is supported by objective clinical outcome data. His wish to be accepted by his neurosurgical colleagues for his professed superior surgical techniques and management protocols would be easily fulfilled by publishing this data and proving that his methods have better outcomes than both the natural history of the disease processes and the current management standards. By this I mean publication in peer reviewed professional journals, not just a list of patient testimonials and praiseworthy press anecdotes in tabloid magazines. Do this Charlie, prove what you say and we will all be beating a path to your door.
If you have a brain tumour and it cannot be cured with surgery. If you accept that it is likely to kill you in the end. should you risk surgery for “time”?
How much should you pay for that?
What if the promise of more time does not work out or you are bed bound and cant talk or look after yourself. Was it worth it?
Is the big fee for surgery with no benefit just stealing from the family left behind if there was never going to be a benefit from surgery. Particularly if the person lost was the person who made the money.
Is that same surgery also just stealing the remaining time you may have with your family
Snake Oil Salesmen do still exist if you ask me
What evidence is there of exclusion from public hospital accreditation, and on what grounds? Such an odd claim for an under-resourced specialty.
Why no audit or published outcome analysis to support his rather extravagant claims of being “the best tumour surgeon in Australia”?
Why do the expense breakdowns for 6-figure GoFundMe’s not correspond to known costs for similar surgery in private hospitals?
If he genuinely has provably superior surgical methodology or such that improves outcomes (unlikely IMHO, but not impossible), is it not unethical to refrain from disseminating this via publication at the minimum?
Regarding the concept that difficult cases are higher risk and cannot be compared to other surgeons’ outcomes as they won’t operate on these – it doesn’t matter.
For innovative or revolutionary changes as implied, the outcomes that matter are against conventional treatment – no surgery. If Dr Teo’s patients have better outcomes than similar patients on measures such as disability, life expectancy, remission compared to no treatment at all, then the surgery does not help. If, on the other hand, he can demonstrate that his treatments are effective on some or all of these (or other relevant outcomes) then the fact that they are high morbidity / mortality can be weighed against the outcomes (and cost) of conventional treatment.
In the event that his surgery is shown to be of benefit, I expect there will be neurosurgeons lining up to perform the same procedures – even if they have to crowdfund his surgical technique courses in the future.
The anonymous comments are instructive. There have been many true innovators in medicine. What is required for acceptance is consistent demonstration that the results of the new treatment are better. There is no issue preventing effective audit – neurosurgical units in public hospitals do this routinely – and they also include highly skilled surgeons helping very sick patients with complex and rare conditions. How can one surgeon, or one unit, claim to be better than another without audit of risk-matched cases?
The comment about audit and public vs private practice is highly ironic. How can a clinician with a public hospital career talk about audit? Because the public hospital is a governed system, with multiple levels of audit and case review, risk management teams and information systems.
As the clinicians posting or reading here already know, public hospital credentialling is a formal process. If any surgeon wishes to apply for an available public hospital position, they need only submit to the selection process, like anyone else.
Joe Kosterich says “Real courage would be for big public health, government and self appointed medical officialdom to let individual patients decide, with fully informed consent, what is best for them in consultation with their treating doctor. ” Indeed, but how can a patient be fully informed without comparative data?
RACS may need to take some action and make it compulsory for surgeons to perform audits and subject the results to peer review. External auditors may be helpful in these situation. If there can be a trigger system for auditing in the settings of outrageous fees, then we may be able to pin down these outliers and take some actions. In the end of the day, patient should be the priority, not someone’s ego.
It’s distressing that CT says that no other surgeons are willing or able to perform the surgeries. This is so untrue! Other surgeons are, in fact often willing & incredibly capable, they often do significant work-up prior though.. this takes time but yields excellent outcomes. In contrast from what I have seen CT gets scan, CT makes appt & pt is told surgery can be done within a few days (sometimes longer). Results in deficit variations are VERY interesting & unfortunately it’s the surgeons that ‘didn’t have the skill’ that’s left to care for the patient rather than the incredible TC… perhaps that’s why he continues, because he doesn’t see the destruction?
In all these discussions the name Ignatius Semmelweis comes to mind. Real courage would be for big public health, government and self appointed medical officialdom to let individual patients decide, with fully informed consent, what is best for them in consultation with their treating doctor. This includes deciding to pay for that which our version of managed care (Medicare) wont cover.
We are assuming all surgeons are capable of doing surgery the same. Just because they are trained doesn’t mean they are excellent. Some surgeons can do it better. We all trained to drive a car before we got our driving license . That doesn’t mean there are not bad drivers on our roads we need to be aware of. For god sakes everyone against what Dr Teo is doing, realise that he has a skill no other surgeon has and the other surgeons just won’t admit he can do what they have failed to do.
It’s disgusting the public system isn’t backing him up .
If they were patients wouldn’t need to crowd fund.
Dr Teo’s minions writing a lot of the emotive and unreasonably favourable comments about him here?
Its a very common thing in the age of anonymous e-marketing and greed.
1.I agree absolutely with the above comments with respect to innovative pioneers being pilloried just as Harold Ridley , the inventor of the intraocular lens,
2. I also agree .. Audit is a joke … of course results will be worse if you are taking on the complex challenging cases…
the informed choice should lie with the patient and family , but still Hope needs to be real and yes it needs to be managed with balance and compassion.
3 There are so many non surgical costs on any procedure.. it is a shame that the “system/ status quo” does not allow Charlie Teo to operate in a public facility to minimize those costs .. access to care should be defined even on an occasional basis dictated by patient need / choice and preference. Perhaps this could be balanced by “near pro bono “ cost of surgery also on occasion… ?
4 personal audit for Self improvement is vital , but like any data is subject to bias in collection and interpretation , esp of that interpretation is by professional ? rivals .
5.Let’s not lose sight of the patients we serve and let’s have a system that serves supports and meets their needs as economically as possible.
1. So typical of organised medicine to howl down the truly innovative !!
Take the intra-ocular lens for example. The inventor, Sir Howard Ridley, was banned from operating in the UK for his entire working life because other ophthalmic surgeons of the day said he was a maverick.
2. As for doing an audit, what a joke. Of course, if any surgeon takes on the cases that other surgeons don’t want to do, then their results will be a lot worse!
3. The real reason that Dr Teo is pilloried is jealousy by other surgeons who do not want to take on the difficult cases or let them make their surgical audit look bad. I know of a so-called “cataract specialist” who refers all difficult cases to a public hoispital for cataract surgery so that he continues to have an unblemished surgical audit!!!
I love articles authored by practitioners who have spent a long time in an area of medicine insulated as an employee of a State Government pontificating with regards to practitioners who have long term commitment to patient care outside Governmental limited confines.
Nobody should ever have to crowd fund for life saving cancer surgery. If it is genuinely urgent, there will be no waiting list. If it is that complex, then the consultant will do the surgery personally rather than risk it with a trainee. If the surgery is evidenced based, then it will be backed by an MDT and be performed in the public system. Dr Teo has had almost 30 years of practice to prove that his surgery actually does patients any good – it’s high time that he come up with the evidence.
The problem with this issue is it’s being driven by lay journalists with endearing photos and liberal use of such words as “miracle”, and suddenly every second person is an instant expert. As others have said, audit and publish, because without the science it’s very difficult to have an informed debate on ethics. The one problem with having an “outlier” in terms of heroic surgery is in securing an appropriate cohort of international peers in the same “heroic” interventionist space to determine if one’s results are relatively good or bad. There certainly should be no difficulty in finding unoperated cases of similar diagnosis, age and severity with which to create outcome indices covering survival times, complications and disability.
A quick Medline search shows no clinical data or results published by Dr Teo. This should ring alarm bells very loudly . Any reputable doctor who has developed a technique , treatment , management protocol etc that advances our care of patients would surely wish to share the experience with colleagues. Dr Teo , over to you we await your data.
There is always a potential conflict of interest when the proposed treatment involves a (large) financial return to the practitiioner. This is rarely acknowledged. Should the recommendation of all such radical surgical procedures be reviewed by a colleague or neurologist or other physician prior to committing the patient to huge financial costs?
As is so often the case, the surgery is only part of caring for a patient.
Who picks up the pieces when the patient returns home from a crowd-funded excursion, particularly if things haven’t gone well?
Whose ego? I think it is a bit disingenuous for Dr Teo to claim it is other surgeons’ egos that prevent him from acquiring temporary accreditation in their public institution to perform surgery that they might not think was indicated…whether or not he receives payment for it. As opposed to the ego of the surgeon who claims to be superior but declines to publish outcome data. No one is suggesting that he doesn’t care about his patients but it is his lack of transparency and humility that has predictably led to him being ostracised from the “mainstream”.
Is that the definition of “maverick”? Perhaps. But without outcome data we have no way of knowing whether he is giving his patients anything more than just hope…
So many questions. I thought Dr Woo’s tweets were fairly benign and more observations rather than attacks but Dr Teo quickly turned the discussion into a narrative of a bullied tall poppy surgeon that is constantly attacked by jealous and ego centric colleagues. Sadly, this narrative has distracted from many questions that need to be asked. We need to ask why one individual surgeon dominates the GoFundMe platform more than any other medical practitioner. If it isn’t ego and jealousy, then exactly why is it that his neurosurgical colleagues are not willing to operate when Dr Teo is prepared to do so? – I can’t accept that it is because they are less technically capable. What is the real reason these procedures cannot be performed in the public hospitals? Is there actually any proof that his surgery extends life as he claims? Why aren’t there any health professionals who have ever worked closely with him who actually come out in support of his practices? Why won’t he work in an MDT like other cancer surgeons – should be exempted? His breakdown of the $40,000 to pay health care workers doesn’t make sense – weren’t most of these were covered by the private hospitals.
Anonymous above states a very negative opinion. If every doctor believed in that statement there would be no advances in medicine. Dr. Teo is prepared to attempt neurosurgery whenre other surgeons refuse to tread. He is not doing it for self aggrandizement but to try and save lives when others have given up on the patients. The fact that public hospitals prevent his services is shameful.
Recently in Lismore, NSW there was a similar call out via GoFund Me pages for brain surgery for a young man a brain tumor to be operated on by Dr Teo. They managed to raise over $120,000 via donations. This is a distressing trend emerging – clearly if people are going to GoFUnd Me Pages there is an issue.
There are multiple concerns that need to be addressed:
1. Assuming any surgery being crowdfunded for is appropriate, why are other surgeons unable to perform it? Is there a failure in the training of surgeons? Are public waiting lists appropriate?
2. If there are questions raised about appropriateness of surgery, conduct an independent audit. This was done a few years ago for all medical, haematology and radiation oncologists in NSW, and is thus feasible. An audit could look at extent of resection eg reviewing pathology and pre and postop imaging, complications, hospital stay, survival, and breakdown in costs to individual patients. It will reassure all involved that the surgery is appropriate, and hence point 1. is more pertinent.
3. Are patients dying or receiving inferior outcomes due to delays required to fundraise? An audit could review that.
4. Is financial consent occurring i.e. are patients told that lifesaving surgery can be done in the public for free, with the same outcomes? Perhaps patients publicly crowdfunding could be surveyed.
State governments, private and public hospital operators, and the surgical college need to come together to resolve this urgently for our vulnerable patients.
There currently exists in our Health Care Sytem an intolerance to variance. This is because in our desire to control in our Health System recommendations become guidelines, then become protocols and then are interpreted by tribunals and lawyers as rules of treatments. Often this happens before treatments are scientifically valid. Health outcomes are often notoriously difficult to predict and that often goes against our patients’ desires as patients wish to know if they will be in the lucky group who gets a good result. That is called hope and all humans experience hope. When walking the fine line between hope and an implied reality it is important that health providers doo not to predict the future for the patient but to offer to remain faithful and support the patients wishes for whatever way they proceed. The patient can always get a second opinion and all opinions whether primary or secondary should be given without criticism of previous or possible future professional advice they may receive. When the state or others try to interfere in a patients’ ethically informed decisions and acceptance of the risk of treatment then we should leave it to the patient and patients’ carers to choose their own pathway.
Sometimes the most courageous decision is knowing when to say: “Enough”.