Controversial neurosurgery: Interview with Charlie Teo

Written by Alice Weatherston

Charlie Teo is a globe-trotting neurosurgeon; travelling the world with kids in tow – operating on brain tumors most other surgeons have, or would, deem inoperable. Despite having a significant impact on many individuals’ lives, placing him in multiple lists of top neurosurgeons worldwide, Teo is considered somewhat of an outsider within the field. Many colleagues have been openly scathing of his radical approaches and branded him as irresponsible, at best.
I sat down with Teo at the recent International Symposium on Pediatric Neuro-oncology (Liverpool, 12–15th June 2016) to find out for myself whether there is method to the ‘madness’ and whether ‘reckless practitioner’ or ‘boundary-pushing life-saver’ are the most apt descriptions for this fascinating neurosurgeon.

Tackling the most complex tumors

Teo started out in general neurosurgery at Royal Prince Alfred Hospital (Sydney, Australia) before specializing in pediatric brain tumor surgery following a fellowship at The Children’s Medical Center in Dallas (TX, USA). On his return to his homeland of Australia, Teo found that there were few opportunities for specialized pediatric neurosurgeons and started to see patients who had been told that their tumors were inoperable: “I started just doing tumors that I thought I could get out and other people couldn’t. Then I started getting a reputation for taking out tumors that no-one else could take out and now that’s mostly all that I do; these really difficult cases.”

“I’ll never deny that I get my fair share of bad outcomes; unfortunately when you play with fire you get burnt”

Teo focuses on brainstem tumors, some of the most difficult tumors to operate on owing to the small size of the brainstem, approximately the size of a human thumb, and the eloquence of the region, which is responsible for many involuntary actions and through which all the fibres responsible for all voluntary actions run. This means any indiscretion during surgery is potentially disastrous. The high-level of risk surrounding the surgeries he carries out is something that is generally regarded by most as too high, leading many to come to the conclusion that these tumors are inoperable. That is not Teo’s opinion, however: “What a neurosurgeon should say when they normally say a tumor is inoperable, is that they can take it out, but that the patient needs to realize that there is a high probability of paralysis after the surgery. Then it’s up to [the patient] to consider those risks and to make a decision based on his or her risk propensity.

“I’ll never deny that I get my fair share of bad outcomes; unfortunately when you play with fire you get burnt. However, with good technique, the patient on board after a full and honest discussion and a dedicated and committed team you can get very good results in most cases.”

Community tensions

Teo has not been shy in voicing his opinions on key issues in the neurosurgery profession, highlighting bullying and defamation as rife within the community, as well as the so-called arrogance of many of his colleagues.

“It takes an honest surgeon, who isn’t arrogant, who is not hungry for work, to refer patients to another surgeon who may be able to offer the patient something they want, but that the current surgeon can’t or won’t provide. When you’re in private practice you cling onto your patients because that’s your livelihood.”

“There is no evidence in the literature to suggest that a patient seen by a mutildisciplinary team (MDT) has a better outcome than someone who isn’t”

As we drilled down into the challenges in the industry, Teo also highlighted criticism thrown at him for his solo approach to treatment. “There is no evidence in the literature to suggest that a patient seen by a mutildisciplinary team (MDT) has a better outcome than someone who isn’t,” he commented.

MDTs are widely regarded as the best way to treat patients with such complex medical needs, providing an opportunity to integrate knowledge from an array of disciplines and expertise before deciding on the best mode of treatment for the patient. However, Teo prefers to see patients on a one-to-one basis, building a rapport in order to help them make the right decision for themselves; patient autonomy is paramount.

“My take is, consult colleagues when you’re out of your depth, speak to and involve people that need to be involved, but first you need to see the patient on your own and come up with your own independent decision.

“By definition an MDT is only going to be as innovative, challenging or courageous as the least courageous person who turns up. In the ideal world, sure, everyone gets an equal say in things, but that doesn’t happen in reality.”

Clinical decision-making

Teo often spends over an hour with potential surgical candidates in his one-to-one consultations, focusing in on not only the clinical problem but also the motivation behind wanting the surgery. Clinical decision-making, particularly in life or death situations, as is often the case with brainstem tumor patients, requires consideration of a range of factors and has received increasing attention within the literature. A simple search on PubMed of ‘clinical decision-making’ brings up over 48,000 results, with over 4000 of these published within the last year alone.

This topic is of great importance to Teo, especially when considering carrying out such high-risk surgeries. Last year he was invited to give a TEDx Talk discussing the problem of clinical decision-making. He focused in on key issues such as balancing the requirements of evidence-based medicine with patient autonomy, personal views and consensus. During this talk he also retold a memorable patient case study:

“When I was a young neurosurgeon a lady came to me with an ependymoma of the cranial cervical junction. She’d been told by another neurosurgeon that it was inoperable 10 years beforehand, so she had accepted the fact that it was going to paralyze her eventually, and it did. She came to me way too late; she was quadriplegic, wheeled in to the consultation room in a bed. She could breathe on her own but that was about it.

She showed me the X-rays of the tumor, which I reviewed and knew I would be able to take out and probably cure her, but I asked her one question:  ‘I just have one concern here, why do you want surgery? With all due respect, your life is pretty bad; you can’t walk, you can’t go to the beach, you can’t even scratch your nose, so all I’m going to do by removing this tumor is prolong your suffering aren’t I?’

The patient got really angry with me and said: ‘How dare you!? How dare you tell me what quality of life is for me! I have two 16 year old twin daughters and quality of life for me is being able to impart my wisdom to them at a time when they need me. They don’t need me to walk down to the beach with them, they don’t need me to cook their meals, they need my emotional support and my knowledge. That to me is quality of life.’

I then realised that it was me projecting my idea of quality of life onto someone else because not being able to walk to the beach, or exercise, or scratch my nose would be terrible for me. I was projecting my idea of quality of life onto her which is so wrong. But we do that every day.”

Educating and building knowledge

Although self-proclaimed as the “world’s most unpopular doctor”, Teo’s work has now developed to center on spreading his knowledge and teaching doctors worldwide; in his words: “things that can and should be done”. He regularly visits developing countries in an effort to improve the standard of neurosurgery available to patients in these locations, including setting up a new hospital in rural India along with state-of-the-art, locally produced neurosurgery equipment.

In 2001, Teo also set up Australia’s first dedicated NGO for brain tumor research, the Cure Brain Cancer Foundation. The charity raised approximately $300,000 in its first year of operating and within 3 years was the largest funder of brain cancer research in Australia, a status it still holds today – they aim to raise $10 million (US) this year. The charity, which funds research worldwide, as well as in Australia, aims to breakdown the silos and barriers affecting the progression of brain tumor research, including reducing the amount of time spent on grant applications and facilitating conversations and collaborations to avoid unnecessary duplication of research efforts.

“I felt that we could break down all those barriers, get people to talk to each other, get the whole world working on the same platform and doing what they do best, but all working towards one common goal,” he explained.

This has led to the funding of projects such as the AGILE-GBM trial that runs from Phoenix, Arizona (USA) and which is implementing a novel adaptive approach to testing potential agents for glioblastoma multiforme.

“If you really believe that [what you’re doing]  is in the patient’s best interests you’ve just got to ignore everyone else’s opinion sometimes”

Despite engaging so widely with the field of brain tumor research and treatment, Teo still regards himself as somewhat reviled by colleagues, but this was not always his aim: “I’d rather have the support of my colleagues and I’d rather be mainstream, but I don’t.

“If you really believe that [what you’re doing]  is in the patient’s best interests you’ve just got to ignore everyone else’s opinion sometimes.”

Once an outsider, always an outsider?

It cannot be argued that Charlie Teo’s influence on the world of neurosurgery has not been significant, contributing to knowledge of novel surgical strategies, sharing this with colleagues, facilitating research funding and undoubtedly saving lives; but he has also ruffled more than a few feathers on his way.

Teo will never be the most popular member of the neurosurgery community and his opinions will always differ from those of most, but it seems that this, in some way, is what he thrives on. Whether you agree or disagree with Teo’s approaches specifically, couldn’t we all argue that progression in science is based on pushing boundaries? Although it may not always play out in the way we would like, it may take some radical thinking, whether in neurosurgery or another discipline, to alter our success against these devastating brain tumors. And, who knows, maybe Teo won’t be alone in his thinking for too much longer.

The opinions expressed in this interview are those of the interviewee and do not necessarily reflect those of Neurology Central or Future Science Group.