Saturday, September 9, 2017

Informed medical costs - Well intentioned actions failing in delivery

Dr Richard Zhu is reported to be on a mission to “expose” the out of pocket expenses associated with initial consultations to see specialists in Australia.  He has created a website called SeekMedi in his “battle for greater fee transparency”.

His creation of this “one-person army” is with good intent but in its current form is more misleading than helpful. If the website is about transparency, then it needs to practice what is preached. My concerns are as follows:-

1. The website should state it’s funding (even though we know from news reports that he personally funds it) and as to how the data is collected.  We also know from media reports that he personally telephones specialist practices and following discussions with their secretaries will record the cost of initial consultations into an Excel spreadsheet - this methodology should be also be recorded for transparency.

2. The website is misleading in that the standard initial consultation fee does not factor in discretionary fee discounting or bulk billing that occurs for patients who have genuine financial hardship.  The relationship between general practitioners and the specialist to whom they refer also makes a difference.  When GP’s with whom I work regularly takes the effort to call, email, fax or write to me about a patient with financial distress, I always oblige with fee reduction if not bulk billing. I know my colleagues are no different in these circumstances.

3. The website fails to time stamp the published fees.  What may be current at the time of publication on the website may not be accurate at any time in the near future. There is the potential to create unrealistic expectation from patients as to the fees and out of pocket expenses which might actually turn out to be greater.  The most accurate indication is the quote given to patients at the time of making their appointments.  The website should include a disclaimer about the fact that fees do change over time as well as to time stamp when Dr Zhu had made a phone call to a specialist office and recorded the quoted fees.

4. The data is incomplete. Many specialists are missing from the list. The website should state that this is the case and indicate if missing specialists will be included later as well as why certain specialists are included and others not. 

5. Specialist fees as recorded do not factor in the time allocated by the specialist to review the patient. Some specialists book patients in as frequently as 5 minute time slots and are able to achieve this through the use of medical and non-medical assistants. Other specialists may spend as long as an hour with their patients on an initial consultation.  Within the same specialty, the variations in time spent with a new patient can vary considerably.  The role of assistants who play a role in initial assessment is not considered in the initial consultation fees.  It is also becoming increasingly common to see advanced specialist trainees in private rooms.

6. Specialist fees do not give accurate guidance as to the likelihood of subsequent out of pocket expenses should any intervention be required.  It is not uncommon for a number of specialists to load most of their ‘income generation’ into their procedures rather than consultation fees. It is therefore not uncommon for some of the most expensive specialists with regard to procedural costs to have very average or even below average initial consultation fees. Initial consultation fees are only one aspect of out of pocket expenses.

I am not against transparency in specialist fees but if we are to embark upon this path, it needs to be done in a professional, collaborative and transparent approach.  A divisive lone wolf approach will never achieve acceptance.  I have written to Dr Zhu to seek his comments but to date have received no reply. If and when he replies, an addendum to this piece will be published. 

Tuesday, June 28, 2016

What do you do when a patient asks to speak to another patient who has undergone cancer surgery?

Not infrequently, I am asked by my patients if they could speak with any other of my patients about their experience of having undergone radical prostatectomy surgery for prostate cancer.  In the past, I have done my best to assist with this request but in more recent years I have moved away from supporting this.  I have a couple of reasons for doing this.

Firstly, it could be argued that selecting patients for such a discussion is like cherry picking. It is arguably little different from a patient testimonial on a website where the most favourable outcomes are provided although unlike the latter, it does not breach AHPRA regulations for advertising.  

Secondly, patients under long term care for cancer treatment are potentially vulnerable.  As doctors, we should never underestimate the desire of patients to please us and the potential for some patients to fear displeasing us by refusal to submit to any request we make of them. 

In writing this, I do not mean to suggest that I am critical of those who provide their own patients as a resource for other patients seeking support or real life experiences. I know that this is done by the vast majority of clinicians with the very best intentions. There may be a time a place for this, particularly with uncommon diseases or unusual clinical circumstances.  

My approach is to now to keep an arms length. I now place my patients in contact with a choice of the local prostate cancer support group or the Prostate Foundation of Australia who are able to provide such a service in addition to their excellent information resources.  From time to time, my patient will be placed in touch with somebody who just happens to also be a patient of mine and that is absolutely fine with me.  I feel comfortable with this transparency and I am also gratified by the positive feedback from my patients who have undertaken this suggested approach.

Sunday, May 1, 2016

How I Almost Did Not Become a Urological Surgeon.

If anybody had suggested that I would become a urologist when I was a medical student or even as an intern, I would have told them that they were dreaming. My exposure to the field was fairly minimal during my time as a medical student and the thought of operating amidst urine just did not spark the slightest interest.  If anything at all, I was interested in becoming a plastic surgeon or a general surgeon. 

At the commencement of internship, we were all allocated to do at least one surgical term out of the 5 terms for the year. I was allocated urology for my surgical rotation. It was known to be horrendously busy and quite ironically, the two interns allocated to that rotation were probably lucky to ever have time to empty their bladders. I was horrified at the thought of doing the surgical specialty that was of least interest to me.  I quickly got in touch with a friend whose career interest was in psychiatry and he was completely unfazed about which surgical term he would do.  The swap was made and I got out of urology and did a plastic surgery rotation instead.  I just loved my time doing Plastics and by the end of the term, I was virtually unmovable in my desire to be in that specialty.  

For the second post graduate year (or resident medical officer year), it was again a fairly general year and to my horror, I was again allocated urology. I thought ‘hang on a sec, isn’t urology meant to be an intern rotation?’  Given that the term was so stressful for two interns, it was thought that it would be better to replace one of the interns with an RMO. Having that extra year of experience was going to make a huge difference.  I again hit the phones and on this occasion could not find anybody who was willing to do a swap. Begrudgingly, I accepted the fact that I would have to do this rotation. In spite of the adversity, I threw myself into the job and to my great surprise found the specialty extraordinarily interesting.  Urologists were both physicians and surgeons of the genitourinary tract and were not beholden to masters in any other specialty group in order to have a practice livelihood. On top of this, the urologists to whom I was to be exposed to, took great interest in my work ethic and general interest in surgery.  Their kindness and support for me had a profound impact on me although I was still steadfastly obsessed with having a career in Plastic Surgery.  

My primary career focus during my RMO year was to pass my surgical primary examination which at that time has a pass rate of around 25%. It was at that time, a clear barrier to restrict entry into the surgical profession. Fortunately I passed the examination on my first attempt which was pretty good going since my undergraduate academic record at university was fairly ordinary (after I discovered the medical revue, I never saw another credit or distinction grade for the remainder of my medical degree).  I now had to think carefully about where my next career move would be.  Something that I had noticed about the plastic surgery trainees at the time was the fact that they were all relatively old compared to other trainees.  At that time, those entering into plastic surgery training would first complete their general surgical training and then spend a year or more in non-accredited plastic surgery positions before commencing core training.  I came to realisation that the majority of those who were undertaking plastic surgery training were going to nudging 40 years of age by the time they were ready to commence independent surgical practice.  I thought that this was crazy and that I did have a life to live and made the tough decision to abandon the idea of training in plastic surgery.  My mind kept me returning to my time in urology and I soon became convinced that this was where my future lay.  

As is so often the case, it can be the mentors that you meet in the field rather than the field itself that can initially draw you towards it. 

To this day, I have no regrets.

Sunday, April 3, 2016

Payment for Citation Offer Withdrawn - but should never have been offered in the first place.

This Blog post needs to read in conjunction with the earlier entry on the same subject matter.

"Payment for Journal Citation? Possibly Academic Publishing at its Worst."

I wrote to the Editor in Chief to express my concern over his recent email about offering financial reward for citing papers from his journal.  I received a prompt response to the effect that the offer was to be withdrawn.  My plan is to now write to the President of the professional organisation to which this periodical is their official journal.  Whilst the offer is stated to have been withdrawn, it still represented poor judgement and raises a real question about integrity.

You might ask as to why I have not yet resigned from it's editorial board?  Whilst I still have a seat there, my voice can still be heard or at least I would hope more likely to be heard.  There are many reputable individuals on their editorial board and I sincerely hope that they have aired their concerns as well.

I plan to push for this matter to be heard by the Executive of the professional organisation to which the journal is attached and if the organisation is to have any integrity, there needs to be some strong action to demonstrate that even the thought of this misconduct is not to be tolerated.

I will update readers as more information comes to hand.

Payment for Journal Citation? Possibly Academic Publishing at its Worst.

Many of you who have read my blog or are following me on Twitter, would be well aware of my thoughts about academic publishing.  I have always done my best to be careful about which journals I would consent to have my name associated with in any way. 

As a general rule, I will be more receptive to invitations to review manuscripts or even invitations to join an Editorial Board if the journal is associated with a bona fide professional organisation or if the journal is indexed on Pubmed (increasingly being referred to as the ‘white list’).  Whether the journal had an impact factor was of lessor importance but if the journal were to quote any of the bogus impact factors such as the Index Copernicus, Journal Impact Factor, Global Impact Factor or Universal Impact Factor, this would also lead to rejection of any approach. There is no purpose of these bogus impact factors other than to mislead and to fool academics into believing that it was something to do with the established Thomson ISI Impact Factor.  Additionally, any journal currently listed on the Beall’s list of predatory journals was also a definite NO. 

About two years ago, I was invited to join the editorial board of a journal that was the official organ of a professional society that was known to me and the journal was indexed in Pubmed.  I was pleased to receive the invitation and gratefully accepted the invitation.  Whilst the journal has been indexed in Pubmed, it was still going through the process of being assessed for journal citation indexing and therefore receiving a Thomson ISI impact factor.  It seems that this journal’s time has come and I received an email asking me to make a special effort to cite papers from the journal, particularly from the years 2014 and 2015.  The Editor in Chief announced that for each cite, I would receive a fee of US$50 with a maximum of US$500 annually.  

I was shocked.  My immediate thought was to send in my resignation straight away.  Given that this journal is associated with a professional society, I wondered if it was better to attempt to make change from within by writing to the editor and expressing my concern.  Should I write to the EIC and give him the opportunity to have a rethink on this strategy?  Should I simply tender my resignation immediately?  I certainly am not dependent on having membership to this journal's editorial board as an indication of my professional standing. Have a look at the attached email.  

I am also absolutely and utterly appalled by the poor spelling in the email.  

What are your thoughts?  

I can reassure readers that I will certainly not accept any fees for citing papers.  I only cite papers if I consider they are relevant to a given manuscript. Nothing more and nothing less.

As a disclosure, I list my current Editorial Board memberships, minus the one in question.  I also make mention that I am an Associate Editor of the Prostate Cancer and Prostatic Diseases journal.

Additional note 2 April 2016

Please take a look at this update to see the response of the EIC to my email of concern

Payment for Citation Offer withdrawn.

Thursday, November 5, 2015

No Justice For Those Who Have Suffered Bullying, Discrimination and Sexual Harassment with Increased Surgical College Subscription Payments.

As Fellows of the Royal Australasian College of Surgeons, we pay annual subscriptions.  There is not a whole lot of practical choice but for us to pay these subscriptions if one wishes to be a practicing surgeon in Australia.  It has just been announced that the subscriptions for 2016 are going up and by a lot.  

Whilst the Consumer Price Index is sitting around 1.5%, it has just been announced that it will be going up by 6% to cover the cost of implementing recommendations of the Expert Advisory Group (EAG). 

As a reminder, the EAG had documented the serious extent to which bullying, discrimination and sexual harassment (BDSH) has existed within the male Anglo-Saxon dominated surgical establishment. 

Text from the RACS email advising of the fee increase

This increase represents a gross injustice for those who have suffered from bullying, discrimination and sexual harassment during their formative years in building a career in surgery.  Having been subjected to such treatment, they now must pay more for having had the privilege to have had such an experience.  

Meanwhile, the main perpetrators of such behavior remain unpunished and will not as they should, bear the brunt of the additional costs for the RACS to make good on their past behavior.  

These are fees that I paid in 2015 for the privilege of being a Fellow.
But the reality is that implementing EAG Recommendations is going to be a costly exercise and it is money that cannot be covered from its financial reserves.  Apart from these costs, the RACS remains at significant risk of litigation and financial settlements in the event individuals find the courage to commence legal proceedings.  The RACS doesn’t really have a choice but to fund the implementation of EAG Recommendations through a significant increase in Fellowship subscriptions and to apply this across the board.  

The fact that the RACS is understandably unable to adjust for who should or should not pay a greater or smaller contribution to cover these costs does not change the fact that it lacks justice.  It will undoubtedly leave a bitter taste for many Fellows who will begrudgingly pay their subscriptions for 2016.

I do have one axe to grind over the manner by which this increase is being applied. Rather than a general revenue surcharge buried into our overall subscription, I strongly believe the increase above CPI should be listed as a separate line entry to send a clear message to all Fellows that they are paying for the indiscretions of past and present surgeons engaging in BDSH.  Without this, the reason for the 'bumped up' subscriptions will be quickly forgotten.  The issue of BDSH and it being addressed by the EAG represents a very significant watershed moment in the history of the RACS.  It should not be devalued by being buried into general business.  I appeal to the RACS to make it a separate line entry.  Call it an "EAG Levy" or "EAG contribution" or whatever.

It is just important to make it transparent. Make it visible.  Do not allow it to be forgotten.  

Maybe it is all just about trying to make a good impression – I’m sure you will agree that the RACS needs to do everything it can do to improve the impression it gives to the general public and its Fellows.  It will cost the RACS nothing to implement this. The cost of giving a negative impression......... 

Related blog pieces

Thursday, October 8, 2015

Congratulations to Fellows of the RACS Who Have Voted For Diversity on College Council

We have seen an amazing result for the 2015 Royal Australasian College of Surgeons Council elections. 

All six women candidates were elected out of a total of 8 vacancies and from a field of 38 candidates.

In an earlier blog piece, I expressed concerns about diversity of the RACS Council. These are a few tweets expressing my concerns.

With only 6 women out of 38 candidates for the 8 vacancies on council, I held grave fears that much needed female representation on the RACS Council would not improve. The numbers of candidates, only 10 of 38,  who made any mention of issues relevant to the EAG Report was woefully low. I am so glad to be proven wrong.

Rather than just hope that RACS Fellows would take the effort to consider voting, it was important to get the message out there as to why voting was especially important on this occasion.This meant, spreading the word on social media, directly speaking with colleagues and mass emails. I hope that my efforts made a contribution to the final outcome.  

I was however, touched to receive a direct message from the RACS on Twitter stating 
"thank you for your efforts in promoting the elections, and supporting the candidates, across social media, it was greatly appreciated"

The EAG Report has had the RACS in the spotlight. To have an election result with the all too common outcome where all successful candidates were male, would have been a damning indictment on the College after all that has been said about a culture that needs to be overhauled.  

The results indicated that there is real appetite for change and demonstrates that there is indeed every reason to be hopeful about the future of the RACS as it catches up with community expectations.  

Congratulations to all of the successful candidates and let's hope that they live up to their promise to help change the culture within the field of surgery.  Congratulations also to voting Fellows of the RACS for demonstrating that there is an appetite for change.