More on Crowd Funding

Let’s say you need to fly from Sydney to London. You are a member of the frequent flyer program with Qantas.  If possible, you’d like to fly with Qantas because you feel loyal to the brand.  The problem arises in that you do not have the money to buy a ticket.  You set up a public crowd funding appeal and you explain how your Nanna is sick and you really need to visit her because it might be the last time you ever see each other again.  We all empathise and hope that you get some support.  

Somebody then points out that for the particular dates you are flying, that you could could save a significant amount of money by flying a different airline of equal quality such as Cathay Pacific or Emirates. You decline to consider this because you’d prefer to fly Qantas.  Your crowd funding campaign gets some publicity and both Singapore Airlines and Etihad hear about your plight and offer to fly you for free. You gracefully decline these offers as you have always been with Qantas.  People will either wish to donate to your crowd funding campaign or they won’t. That’s fair enough.  You are getting bit emotional and say your confused because you’re worried about your Nanna.

You are starting to get a few donations. What if your donors knew that you had turned down the option of flying a lower cost carrier? What if your donors knew that you had turned down offers to be flown for free? If they were to find out, would donors now look upon similar crowd funding exercises with cynicism. 

So what is this all about?  This piece needs to be considered in the context of this previous blog piece (click link to read) about crowd funding for prostate surgery.  

Crowdfunding for Prostate Cancer Surgery - Just Shouldn't Be Necessary in Australia.

It has always saddened me to see crowdfunding campaigns to raise money for individuals to undergo live saving surgery in the private hospital sector.  Notoriously, we have seen campaigns for particular specialties and we could go further if we wanted, in specifying particular surgeons whose names come up repeatedly.  I was grateful that this was not something that we tended to see in my specialty of prostate cancer surgery but I guess it was only a matter of time.

The reason why I have thought that this would only be a matter of time was the intense competition that we see for robotic radical prostatectomy cases amongst Australian based urologists. Do a Google search and you will see a plethora of robotic surgery marketing in Australia. The fancy websites will have surgeons boasting about their extraordinary achievements in becoming experts in this aspect of surgery in their quest to entice you to utilise their services. Often there is the line of ‘most', ‘first', ‘pioneer' and so on. I was the first to do a robotic surgery operation in my hospital - I say 'big deal'. There is also the goading of site visitors to seek out a second opinion with the subtle suggestion of an expectation that they will be in better hands if they do so. 

There is also an issue of cost as the out of pocket expenses can be very high.

One reason why the out of expense costs can be high are the costs of consumables.  The consumables are the throw away items associated with the use of the technology.  It’s an amazing cash cow for the technology companies.  Hospitals have to spend huge amounts of money to buy the instrumentation and then have to pay for the privilege to use the machines by virtue of expensive servicing contracts and disposables (consumables).  Private health funds are not obliged to cover the costs of the consumables used in robotic surgery. Some funds will cover part or all of the consumables costs but if your health fund does not cover these costs, you could be up for as much as an additional $4000 out of pocket.  The other reason for the huge out of pocket expenses is that some surgeons feel a sense of entitlement to charge what they think they are worth. In some instances, this out of pocket expense of what is above the amount that can be claimed back from Medicare or Private Health Insurance could be over $10,000.  Robotic surgery is sexy and expensive. 

Thankfully, robotic surgery is available to non-insured patients at Nepean Public Hospital. Most people would not be aware that this is the case. I personally have had no issue in referring patients to Nepean Hospital and stand on my record for doing so.  There is however, no incentive for surgeons to notify patients who have financial difficulties that this service exists.  My colleagues performing surgery at Nepean Hospital are well trained and very competent at what they do.  It would be a brave prostate surgeon to claim and prove that they were significantly better than these surgeons.

I saw this appeal appear in my Facebook feed and not surprisingly caught my attention. I do not know the circumstances behind this case at all. I wish there was some way to tell him that he can receive ‘robotic keyhole surgery’ with a ‘top surgeon’ at the Nepean Public Hospital. He seeks to raise $35000 which suggests to me that he is either uninsured or his surgeon is charging an extraordinary surgical fee.  Most surgeons (I would like to think), no matter how good they think they are, will try to help out with the surgical fee if the patient is experienceing financial difficulties. Once again, I do not know the details of this case but I am saddened see a case of where prostate cancer surgery costs necessitate a crowd funding campaign.

Note:  This blog piece reflects circumstances specific to Australia and may have little relevance to circumstances elsewhere. In Australia, we have a public health system, which in spite of its many faults, will see that all can have access to necessary cancer treatment.


Update - see following related blog piece (click link)

  

Academic Dishonesty as a Medical Student - How Prevalent? What Does the Future Hold for Them?

Earlier this evening, a media ‘exclusive’ was published in the Sydney Morning Herald.  The article is about my own institution, The University of Sydney.  This was a huge shock. This is the place where I was an undergraduate medical student and now the place where I am an academic surgeon who is intimately involved in hands on teaching of medical students.

The article makes the claim that students have been cheating in their Integrated Population Medicine assignment.  The first line of the article makes clear that this was going to be unhappy reading.

“Medical students at the University of Sydney invented patients, falsified records and even "interviewed" dead patients in a serious academic scandal which has shocked the respected medical school.”

Academic dishonesty does occur. No University and within them, no faculty can be totally immune to this.  However, in medicine, the thought of anybody cheating would not cross the minds of many.  There will in fact be some element of denial as we think of ourselves as having ethical and moral behavior as part of our DNA and we also believe that none of us should lack the intellectual capacity to pass an examinable task.   

Do we really have exemplary moral and ethical behavior that makes us stand out above the general population?  I think that see enough to the contrary in the press on an almost daily basis. It makes clear that we in the medical profession have the same human failings as any other group.  I do not need to bore you with the stories of doctors rorting the public purse, goading patients into thinking that they need cosmetic surgery, gross negligence in medical practice and more recently, the uncovering of rampant sexism and bullying culture in specialty training.  On the other hand, there are equally as many, if not more, stories of amazing things that the medical profession is doing for public health and individual patient care. The clear message is that in spite of the amazing things we can do,  we as medical students have the capability for academic dishonesty as anybody else.

However, why should we have a need for academic dishonesty as a medical student?  I am trying to get my head around this.

The pass rates for various subjects or assignments in the medical course are very high but this should not be surprising because it is regularly those who have been high academic achievers who gain entry into medical schools.  It is generally thought that if you can get into a medical course, then you should be more than capable of passing the course.  It has always been my view that if somebody ever failed a subject or assignment in the medical course, that it was a reflection of total lack of application or there being significant external distractions that have impacted upon attention to their studies, rather than anything to do with intellectual ability.  We are talking about less than 10% who might fail on their first attempt and most of these students will get through on a second attempt. Once again, there should be little need and therefore incentive for a medical student to cheat on their examinable tasks.

The SMH article asserts that there is “proven wide spread academic dishonesty.”  There is no citation or proof provided that this is the case. What follows in the next sentence is that the University has acknowledged that there have been three students who graduated last year who are under investigation for academic misconduct. The article also states “It is understood at least 70 students from a class of more than 200 were involved.”  There is no attribution to any organization or individual, even anonymously.  If we consider the class size as being say 350 students, this would suggest that we have 20% of our students who are dishonest and this simply does not fit in with my experience.

I have personally assisted students in identifying or advising them of the suitability of certain patients who would potentially volunteer to assist with their IPM assignment.  As a result of significant hands on teaching of medical students at my clinical school, I do get to know many of them quite well and to suggest that 20% of them were dishonest simply does not stack up.  In the absence of attributing a source whether anonymous or not, makes me suspicious about the validity of these claims.  I have asked the article journalist for a response through twitter and hopefully she will respond to clarify these points.

I am absolutely sure that academic dishonesty does occur in my own faculty and in my own university but I am to be convinced that it is widespread or highly prevalent.  I have personally found the vast majority of medical students that I have interacted with to be kind, personable, empathetic and committed to one day doing the best for their patients. 

If academic dishonesty is occurring whilst as a medical student, I do have concerns. If past behavior is to be the best predictor of future behavior, we have every reason to be concerned if these individuals were to be placed in a position where we count on their honesty.  Did they make up the blood test result that I asked them about because they forgot to look it up?  Did they tell me that the pedal pulses where present even though they didn’t check them and took a gamble that they probably would be?  And one day when a patient asks them as a specialist if they had spoken to the second opinion doctor as they had promised but had not, the line has already been crossed. 

When I think of senior doctors who behaviour rattles me, I think back to their behaviour either as medical students or junior doctors and in highsight I realise that nothing has really changed. This is not to say that people are not capable of change but it worries me.


Related Articles

Bullying in Surgery
Bullying in CardioThoracic Surgery
Academics Supporting Predatory Publishing

Disclosure

Henry Woo is a medical graduate of the University of Sydney.  He is a fractional salaried Associate Professor of Surgery of the Sydney Medical School of the University of Sydney.

Cardiac Surgeons Were Once Untouchable

About 30 years ago, coronary artery bypass graft surgery (CABG) was the mainstay of treating narrowed coronary arteries that supplied blood to the muscle of the heart.  Such surgery was predominantly, if not all, performed in the public hospital system where there were long waiting lists.  Demand outstripped supply of such service and cardiologists were at the mercy of cardiothoracic surgeons who could determine which of their patients they would accept for treatment and the priority afforded to them.  The CABG was a genuinely life saving type of surgery and the high success of this surgery by highly trained surgeons provided them with unparalleled status in the hospital pecking order.  The cardiac surgeons received the adulation of the press and public for the life saving work that they were performing and sure enough, they came to truly believe that they were the heroes of the medical profession.

The behavior of cardiac surgeons was one of self-entitlement and demand for unquestioned respect and admiration.  Whilst capable of great empathy and care for their patients, they treated members of their surgical team and own profession with disdain and at times unbelievable cruelty. As providers of essential services that were in short supply and high demand, hospital administrators would bow to unreasonable demands. They were effectively untouchables.

Whilst there are too many stories to mention, here a couple that I recall as vividly as if it happened yesterday. 

When I was a junior doctor, I had softly remarked that my nose was itchy under the theatre mask. This was overheard by “sir” who then came up to me and squeezed my nose and twisted and said “this will fix it” and went off laughing.  The pain was excruciating and I quietly slipped away outside the operating room pretending that it did not hurt at all. My nose was bleeding.  Once cleaned up, I returned to the operating room and pretended that nothing had happened.  I did not dare challenge him for this assault and I also knew that nobody in the room would dare to support me for all of us were afraid of him. 

My six months as a surgical registrar to “sir” was a tough gig psychologically, The work itself and at times long hours was never an issue but the constant barrage of abuse was taxing.  I was so ashamed of admitting that it was getting to me that I recall not even discussing it with my girlfriend of the time (who was also a junior doctor) or any friends as I felt that I could not afford to demonstrate to anybody any sign of weakness or potential inadequacy to make it through the rigors of surgical training. “Sir” loved an audience and we would usually have up to twenty people in the operating theatre to observe such as medical students and physiotherapy students.  He just adored the physiotherapy students, particularly the attractive female ones who appeared to get special attention and this was returned with blushing adulation.  Not uncommonly, I would start closing up the wound and he would go out to make a phone call. He would then return and yell to the entire room “Henry, you’re meant to be getting better, not worse” and would then storm out of the theatre.  The operating room would then be so quiet that you could hear a pin drop above the noise of the anaesthetic monitoring devices. I could go on and on, but I made it through.  I survived.

In later years I had transferred training programs and went from being a general surgical registrar to a urology registrar.  At a different hospital, I entered a service lift and the only other occupant was a cardiac surgeon, a different “sir”.  He did not acknowledge me in any way but what did I care.  The next floor, a wardsman entered the lift and tripped over the lip of the elevator floor and bumped into “sir”.  Yes, he committed the greatest possible crime and touched “sir”.  Over the next couple of floors, “sir” proceeded to abuse him “how dare you blah blah blah …..” and refusing to listen to his repeated attempts to apologise.  The wardman was petrified that the surgeon would lodge a complaint and that it would lead to his dismissal.  I was so shocked that I stared in silence and whilst he had little ability to impact on my future career, I was still too frozen in fear to say anything.  Immediately after the event, I felt enormous guilt for having said nothing. For me it will always be one of those moments that you remember where something could have and should have been said.

These stories are pretty tame compared to others I have heard. The fortunes have changed significantly for cardiac surgeons.  Coronary stents are now used where surgery was once necessary. Cardiologists control the flow of work to cardiac surgeons and can make or break the success of their practices.  I have personally seen where a cardiac surgeon at a hospital I worked at was completely starved of work to the extent that he had to take a salaried position interstate.  There was never an issue with his clinical judgment and technical skills but with a totally obnoxious personality from the cardiac surgeon old school, his private practice disappeared in favour of other surgeons who were prepared to be more personable.  Cardiac surgeons can no longer be seen to be self entitled poisonous individuals.  Everybody knows that cardiologists are the masters of cardiac surgeons and what huge fall it has been from the top of the ivory tower.

Having said all that is above, I have great respect for my cardiac surgery colleagues. Their professionalism and care for my own family members who have needed their skills will always be appreciated.  I really believe I have seen the worst and now best that these surgeons can offer.  

At least in this surgical specialty of cardiac surgery, technology and medical advances have had a positive affect on surgeon behavior. 

Bullying Culture in Surgery - Has Nothing Changed?

The airing of the Four Corners report on an entrenched culture of bullying of surgical trainees and medical students has for the very first time pushed this matter into the public spotlight.  The obvious reason for the suppression of this ugly behavior is the enormous power imbalance that exists between perpetrators and victims.  Medical students, and particularly surgical trainees, are unwilling to come forward as their career progression is totally at the mercy of those who have significant influence over the results of their progress reports.

I hear the argument from a number of my colleagues who say that everybody is getting too soft and that they dread the ability of these ‘mollycoddled children’ to handle the stress of dealing with catastrophic bleeding at 3 am in the morning. I totally reject this assertion as justification that an intimidating bullying culture has a role to play.  I am not aware of any evidence that a non-confrontational approach to training will impacts upon the ability to perform following the completion of training.  When we look at the commercial airline industry, it is the meticulous training that prepares pilots for a variety of catastrophic events.  Being yelled at, publicly humiliated and often being left wondering what it was that was done wrong (because one could not dare ask what it was that was done wrong as one should know) is not training. 

It is bullying and harassment and nothing more.

I was on the receiving end of bullying during my training, particular at the hands of a cardiac surgeon, well before I started training in urological surgery.  At that time I felt that he had total and absolute control over my career.  However, it was far more often that I observed my junior colleagues being on the receiving end abuse and harassement. What worries me is that many of my colleagues who were bullied and harassed as junior doctors, do not reflect back as this having been the case.  This is how the cycle of bullying continues. Their interpretation of bullying has been reset by their experience to become a norm of surgical training.  They too go on to repeat the behavior experienced during their formative years as surgeons.  The words of Dr Vyom Sharma are chilling but demonstrate great clarity in the problems we face: –

"In one moment I could just see how this all happens. Someone bullied him, he bullied someone else, and now it's my turn."

The stories on Four Corners make me worry and wonder if it really could be a case of where “Nothing has changed”.

Maybe I should provide some context of how things were different when I was training.  I was absolutely everything that was atypical and confrontational to the surgical establishment when I wished to undertake surgery as a career in the late 1980's. 

I was Asian, went to a public high school and at that time, hated rugby. 

I was definitely not “one of the boys”. Tearoom discussions were often lonely as I had no ability or real interest to discuss the results of the last weekends’ private school rugby game or who should play fly half for the upcoming Bledisloe Cup.  Apart from clinical matters, I had very little in common with my surgical seniors.  My colleagues who fitted the perfect surgical role model would regularly get the pat on the back for being a ‘good bloke’ and were rewarded with more opportunities to try their hand at surgery. The diversity of surgical trainees and subsequently trained surgeons has changed enormous since then due to surgical training programs being taken out of the hands of individual hospitals and therefore the hands of a very few powerful individuals.  Centralised selection for surgical training was a very positive step forward although for general surgery it was introduced after my time.  I remember having little support base as none of the surgeons were really my ‘mates’ but I was fortunate to have sufficient numbers of surgeons who saw that I had talent and were prepared to put their reputations on the line to help me achieve my career aim.  I always remember this as a reminder that there was also a lot of good in many of the surgeons who mentored me as a junior doctor and it was not all bad.


*****


(Note for those outside of Sydney - back in the 1980's Rubgy Union was a game that was almost exclusively played in elite private schools. Public schools and non-elite private schools tended to play Rugby League.  Back then, the vast vast majority of surgeons had been educated in the private school system apart from a handful from exclusive selective public schools)

Robert H. Farnsworth - my hero in urology

At the Gala Dinner of the Urological Society of Australia and New Zealand (USANZ) Annual Scientific Meeting on 13 April 2015, a special man was the recipient of the Society Medal (USANZ Medal). 

Robert Farnsworth's achievements are well known within my profession.  

The next few tweets sum up my thoughts

I was in my final year of urology training when I worked for Bob. Just some of the things that I recalled from my time with him included

1. treating everybody with equal kindness and respect, whether a janitor or internationally acclaimed professor
2. never ever making me feel bad when there was something that I could have done better
3. always having time for me, even for what in hindsight were trivial matters (even if this meant him going home later than planned)

When I returned from additional training abroad, I entered independent practice and there were a number of occasions that I would call him for clinical advice. Even though I was now his competitor, he continued to be so willing to share his wisdom.

It was a proud moment for all of us who have had the privelege of training under him to see him awarded the USANZ medal.  He's the closest you get to a Mr Holland (as per the movie Mr Holland's Opus) that would be possible in the Sydney urology scence. 

If something happens to me, will I have done enough to enable a colleague to continue the care of my patient with newly diagnosed prostate cancer?

As an academic surgeon, I probably get to see more second opinion cases than for most in my field. My university association and digital footprint probably tends to attract these cases although I make absolutely no effort or attempt to attract these consultations. Of course there are some that arise as a result of contact with patients I have previously treated. One thing for sure is that I do not send letters out to GPs asking them to consider asking their prostate cancer patients to switch specialists. Likewise, I do not have second opinion forms on my website goading readers to switch specialists.  Maybe I am totally deluded into thinking that I see more second opinion cases and that my load of such is exactly the same as everybody else. 

Many of these consultations are for those recently diagnosed with prostate cancer. Recently, I saw a man who had undergone transperineal prostate biopsies and had been diagnosed with prostate cancer. Transperineal prostate biopsies are where the sampling needles traverse the skin of the perineum (patch of skin between the anus and the scrotum) rather than going through the rectal wall with so called transrectal ultrasound guided prostate biopsies.  

The samples were labelled A1 through to A8 and B1 through to B8.  There was no anatomical indicator as to where these biopsies were taken from within the prostate. To make an intelligent guess, it might be that A represents apex of the prostate gland and B represents the base of the gland but who knows other than the original surgeon doing the biopsies. There was an additional sample which was called the targeted biopsy.  This would have meant nothing except for the fact that there was an MRI scan of the prostate that had indicated that there was a tumour suspicious lesion towards the centre of the gland (left transition zone to be more precise).  

It was the cancer in the targeted sample that demonstrated that there was cancer that needed treating.  There was also a tiny speck of cancer in one the ‘A' samples but it was low grade and probably clinically insignificant - in other words, one that could be ignored. In this situation, knowing what the A and B samples came from was academic. I knew that the cancer was in the middle of the gland and that this patient would likely do very well with so called nerve sparing radical prostatectomy. 

This case did get me thinking.  All sorts of questions were running through my head. What if there were clinically significant cancer deposits in the A or B sets of biopsies? I would have no idea as to where they were.  The naming of these samples was not standard nomenclature but rather a special code used by the surgeon who took those biopsies. I could always write to him if I need to know to plan surgery and therefore avoid having to put a patient through another biopsy to map the cancer.  What if the surgeon was not willing or obstructive because he was ‘losing’ a patient?  Was this some ploy to make it harder for the patient to switch surgeons? What if something were to ever happen to the surgeon - we are mere mortals and not the demigods that some surgeons think of as themselves.  If another surgeon were to have to take over the care of that patient in the event that the original surgeon became serious ill or were to become deceased, access to this ‘secret code’ of labelled specimens could be an issue. I have no answers to these thoughts but I am clear on what I do in my own practice. 

I always label my prostate biopsy specimens in a way so it is crystal clear as to where they have come from. If something were to ever happen to me, I could feel assured that a colleague would be in a position to take over the care of my patient.  I think that this is a minimum standard of care but there seems to be no appetite to make change.  

Why won’t pathologists push their referring urologists to be more diligent in writing better clinical details or appropriately label the specimens? In Australia, the vast majority of prostate cancer are treated in the private sector. In a competitive pathology environment, no pathology provider would be comfortable about demanding improved clinical documentation and labelling of pathology specimens from referrers in whom they depend on for their work.  How do you think we can drive change?  I certainly have my ideas but I would like to hear yours.