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.