Those Two Tweets

It is now about 3 weeks since I posted two tweets that were to create a media storm.  A week later I wrote an Opinion Editorial in the Sydney Morning Herald to clarify those two tweets.

I have made absolutely no other comment to the media and yet this discussion has remained in the news even to this point in time.  I have kept a low profile on this subject matter and allowed others to make their commentary.

I have been told to stop harrassing Dr Teo. I am being told that my tweets are defamatory, insulting and personally critical of Dr Teo.  People have been quick to criticise me on the basis of hearing reports that describe my tweets as being as such, without having seen my tweets.

Let's take a look at my very first tweet:-

Something is seriously wrong if a terminally ill girl with a brain tumour has to raise $120K to have surgery Dr Charlie Teo has offered to do for $60-80K.
If it was valid surgery, it could/should be performed in the public system under Medicare #auspol https://t.co/8s7L5mcuAZ

— Henry Woo (@DrHWoo) May 24, 2019

The first part about "Something is seriosuly wrong if a terminally ill girl with a brain tumour has to raise....." is a valid observation.  Anybody who does not think that there is something wrong that we are seeing this happening lacks heart. It means that we must question our existing access to health care.  This is not an attack on anybody.

Now let's look at the $120K and the $60-80K part.  I have been accused of making up these figures and suggesting that this is what Dr Teo actually pockets for himself.  I have been told to get my facts right.  These are NOT my dollar amounts.

These figures are simply direct quotes from the linked article in the tweet.  The Daily Mail article derives these figures from what is stated in the Lucas family interview with Today Tonight which is linked in their article. Once again, these are just quotations from the linked article.

Now for the part about "if this was valid surgery.....".   Surgery in the public hospital system has to have evidence base in order to be permitted to be carried out.  If this surgery was not able to be performed in the public hospital system for whatever reason, is it wrong to question as to whether there is an issue with the public hospital system or as to whether there is an issue with the type of surgery being offered.

Now let's take a look at my second tweet:-

On a search on GoFundMe for “Charlie Teo” there are 113 campaigns listed, that mention him as the surgeon for which donations are sought to pay for his services.
I find this really disturbing. pic.twitter.com/j4ZQRNHXvQ

— Henry Woo (@DrHWoo) May 24, 2019

On a review of the GoFundMe website, the overwhelming number of requests for donations for surgery by any one single person was for Dr Charlie Teo.   The search term "Charlie Teo" was entered into the search bar and this returned 113 results.  The numbers on this search are dynamic but the screenshot attached to this tweet shows that on that particular day, there were 113.  The exact numbers are irrelevant.

Even if there were only 10 to 20 campaigns for just one person, I would still find this disturbing.  It was no personal attack on Dr Teo but simply an observation that there were a lot of campaigns, past and present, that were for seeking money to pay for surgery by one person.  If Dr Teo's services were so frequently sought that the system could not accommodate those who needed his help, then that must be considered to be very distubing. It is equally disturbing that one person seems to feature so much on this crowd funding website so it is therefore perfectly reasonable to question and discuss why this is the case.

There is currently a mob mentality that is propagting that I am to blame for triggering a campaign against Dr Teo.  I am disappointed in the manner to which this discussion has taken place, but through this background noise, there are at least signs that rational discussion is taking place.

I have no regrets that the issues raised are now being discussed in the public arena.  No subject matter should be so sacred that the one who raises it for discussion should be vilified.

Once again, we need to move away from personal narratives and discuss the bigger picture of access to healthcare, evidence of outcomes and the cost of cancer care.

Uber and Sydney Airport

When Uber arrived on the scene, it was like the travelling public’s revenge on the taxi industry.  We had been subjected to a lifetime of micro-aggressive behaviour directed towards passengers.  We bore the brunt of an unhealthy attitude to service delivery from taxi drivers, their front line service staff and the business owners.  

As soon as Uber arrived on the scene, the nasty attitudes to passengers was unleashed upon the Uber drivers who were accused of breaking the law and providing an unsafe travel experience.  When thinking of safety, just think of the violent demonstrations from taxi drivers in Europe who protested against Uber as it was winning the affection of the travelling public. 

Now that Uber is well and truly a part of Sydney transport, we are seeing a less palatable side to the business emerging.  Apart from contractural arrangements with drivers that sees many working for below what would be minimum award wages, we are also seeing an emergence of inappropriate behaviour from Uber drivers.  It is not uncommon to hear of news stories of Uber drivers stalking or sexually abusing passengers. Whilst totally unacceptable, these occurrences are relatively few considering the number of rides undertaken on a daily basis.

An annoying pattern of behaviour is emerging amongst Uber drivers doing pick ups from Sydney Airport.  Here is how the scam works:-

After accepting your ride, the drivers will almost immediately call you under guise of checking whether you knew the whereabouts of the pick up location and as to whether you were already there.  The signage for the Priority Pick Up area for ride share vehicles is particularly well signposted at Sydney Airport (especially at the Domestic terminal) and if you cannot follow these signs correctly, then you are beyond help.  They know that you know where the pick up area is.  This is simply the opportunity to then ask you about your destination.  As you know, they don’t know where you are going until they pick you up. If they determine that it is going to be a short ride, they promptly cancel the ride.  By cancelling the ride quickly, they will not be penalised and will not lose their place in the queue. If you won’t reveal the destination, they will assume that you wish to hide that it is a short ride and will also cancel the ride.

You could argue that this behaviour is driven by the frustrations associated with waiting for up to an hour for a pick up from Sydney Airport.  On the other hand, if the drivers are not prepared to accept that they may only pick up a short ride, then they should not join the queue.  

I have found that in more than half of the times that I have been picked up at Sydney Airport that I have received a call and on most of the occasions when I tell them that my destination in relatively close, they drop the ride. As earlier mentioned, when I do not give the destination, many will also cancel the ride because they understand my reasons for concealing the destination.  

I have drawn this to the attention of Uber. Sadly, they appear disinterested.  The public face was to appear concerned about the tweet that I sent to their Australian account but once taken off line, there was an immediate loss of interest.  Its the old story of familiarity with the travelling public breeding contempt.  Bring on competitors to Uber - I am ready to embrace it.

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. 

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.

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.

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.