By ANNIE BURNS-PIEPER
Tuesday, August 7, 2018
For 13 years, Winston Tuck Loke Tam was British Columbia's top-billing obstetrician-gynecologist, seeing as many as 90 patients a day and bringing in up to $1.7-million a year.
He said he started his days at 4 a.m. and worked nights and weekends because he loved his job in women's health. His clinic on the top floor of a beige concrete medical building in Surrey, B.C., was so busy that some pregnant women sat on the floor, sometimes waiting up to four hours for their appointments with urine samples in hand.
What Dr. Tam's patients didn't know was that his high earnings and elevated patient loads were raising troubling questions about his billings and medical care at least as far back as 2010. Yet, he continued to treat patients for another five years - collecting millions more in public dollars - as confidential provincial and regulatory investigations into his medical practice dragged on until he resigned in 2015.
Now, former patients who say they were harmed under his care are demanding to know what was done to discipline him and why it wasn't done sooner.
"The system is flawed," said Alison Pillar, who saw Dr. Tam for an infected cesarean-section incision in 2014.
"Like most of our systems, it needs to be evaluated, reviewed and changed."
Ms. Pillar is one of almost 40 former patients who allege they were poorly treated by Dr. Tam and who The Globe and Mail communicated with as part of its probe.
The newspaper also contacted the doctor's past colleagues and examined more than 1,400 pages of transcripts from an audit hearing into his billings obtained through the province's freedom-of-information legislation.
The experiences many of Dr. Tam's former patients describe are disturbing. The women allege he performed medical procedures, such as vaginal exams, without their consent and made disparaging remarks about their bodies, weight and sex life. They also accuse him of botching the births of their babies, performing unnecessary C-sections and failing to do basic tests, such as urine analysis and pelvic exams.
A government finding in 2016 exposed that he had overbilled the province and was directed to pay $2.1-million. It is the highest repayment order ever issued to a doctor in B.C. and one of the highest ever in the country.
Amanda Stewart, whose twins he delivered in 2010, asserts Dr. Tam did not care about his patients.
"He was just there to cut people open, get his money and go home."
Obstetrician-gynecologist Keith Still acknowledges that the process for dealing with problematic doctors can seem unduly long. Dr. Still was part of a fivemember audit panel that scrutinized Dr. Tam's billings.
"Unfortunately people are harmed, either mentally or physically or both, before the conclusion of these things," said Dr. Still, who worked at Surrey Memorial Hospital at the same time as Dr. Tam.
Almost from the start of his medical career in B.C., Dr. Tam was a prolific biller. Aside from his clinic, he worked at the Surrey Memorial Hospital, the largest in the area, where he once delivered 15 babies in a single shift. Dr. Tam also worked at Indigenous and youth-health clinics and with cancer patients.
He came to Canada in 1990, abandoning 41/2 years of medical training in Singapore to start his education from scratch. Dr. Tam attended the University of Toronto medical school and then did a residency program to become an obstetrician-gynecologist in B.C., which he completed in 2001.
Within only a year of finishing his five-year residency program with the University of British Columbia, he became the province's top billing obstetrician-gynecologist, jumping from $176,000 in 2001 to $875,000 the following year.
He would continue billing at a higher level than his peers - five times as much as the average feefor-service obstetrician-gynecologist between 2004 and 2014 - until he resigned from the College of Physicians and Surgeons of British Columbia in 2015 and left Canada.
His earnings had placed him in the top 2 per cent of doctors of any specialty in the province. Yet, it wasn't until 2010 that Dr. Tam's billing practices landed on the radar of the B.C. Billing Integrity Program. Less is known about when patient complaints began coming in.
The communications departments of the Fraser Health Authority, which operates 12 hospitals in its area, and the College of Physicians and Surgeons of British Columbia, which regulates the practice of medicine in the province, both declined to say when they started receiving complaints or how many they received, saying it would violate Dr.
Tam's privacy rights.
However, Dr. Peter Beresford, who has been the program medical director for the maternal infant child program at the Fraser Health Authority since 2013, estimated he was informed of more than 10 official complaints.
Two of the women who made official complaints spoke to The Globe. One of them was kindergarten teacher Charisma Jurica.
She and her husband, Emil, never expected the birth of their first child would transform their marriage, lead to post-traumatic stress disorder and, for years, prevent them from having more children.
It all started at Surrey Memorial Hospital on New Year's Day, 2013. After labouring for more than 13 hours, Ms. Jurica's midwife called Dr. Tam for a consult because she was concerned the baby's heart rate had decreased.
When Dr. Tam arrived, the midwife told him the heart rate had returned to normal and he wasn't needed, Ms. Jurica recalled. But within minutes, Dr.
Tam declared it was time for the baby to be born, telling Ms. Jurica she would have to push immediately or have a C-section. He then commented on her weight, calling her a "really big girl," Ms. Jurica recounted.
He chastised her for screaming as he put both his hands into her vagina without consent, Ms. Jurica alleges. The couple were confused. Ms. Jurica's midwife had told her she wasn't fully dilated.
Ms. Jurica remembers that after only a few attempts at pushing, Dr. Tam cut the opening of her vagina without any explanation, inserted forceps without informed consent and pulled her baby out.
Her husband began to cry. "I saw Ava's head and I said, 'Oh my god, my baby is deformed.' " The Juricas said the forceps had misshapen Ava's head and her eye was swollen shut. Photos during the early part of their daughter's life would be taken at particular angles to hide the damage. The shape of her head eventually returned to normal but she is left with a scar from the forceps.
After the delivery Dr. Tam stitched up the tears in Ms. Jurica's cervix and the episiotomy without offering pain relief, she alleges.
The Juricas were horrified. Instead of resting when she got home, Ms. Jurica spent days writing complaints to the College of Physicians and Surgeons of British Columbia and the Fraser Health Authority. She said a nurse who witnessed the birth encouraged her to speak up.
Ms. Jurica sent her complaint to the medical college in February, 2013, and received an official response about a year later. The eight-page letter includes Dr.
Dr. Tam said his reason for the rushed birth and the forceps delivery was that the baby was in distress. He said he had examined Ms. Jurica's cervix and it was fully dilated, and he claimed he had communicated clearly about what he was doing and the options.
He said he discussed Ms. Jurica's weight because a high body mass index can lead to obstetric complications. "The intention of bringing this up was never to insult or offend but a means to explain why her delivery was more challenging," he stated.
The college disagreed with Dr.
Tam's assertions. Its letter to Ms.
Jurica stated that its inquiry committee was "troubled by Dr. Tam's clinical judgment and performance" in relation to Ava's delivery. The college told the Juricas that the letter would be retained on Dr. Tam's file and that he had entered into an agreement with the Fraser Health Authority to restrict his use of forceps. The health authority never sent an official reply to Ms. Jurica.
This wasn't the only concern patients raised about Dr. Tam.
Amanda Stewart, now a 39year-old mother of three, had seen Dr. Tam for her first pregnancy in 2008 and it hadn't gone well. She remembers on two occasions waiting more than four hours for her appointments and said he repeatedly berated her over her weight. She would leave in tears.
In 2010, when she became pregnant with twins, she was relieved to have a new doctor. But Dr. Tam happened to be on duty when she went in for a routine ultrasound at 34 weeks.
When he said something looked off, she and her husband were confused. He told them that one of the babies was much larger than the other and she needed an emergency C-section.
"Dr. Tam was pushy. He said, 'Do you want your kids to die? Do you want your babies to die?
They could die,' etc. All I could hear was die," Ms. Stewart recalled.
She and her husband asked for another ultrasound but the doctor wouldn't hear of it.
"I thought, well you are in a hospital and they are really rushing us along, maybe there really is an emergency. You don't know.
You put your trust into these guys. We were scared," Jeff Stewart said.
They were taken into surgery.
Dr. Tam delivered the twins by Csection without saying anything to the couple. While still on the operating table, Ms. Stewart demanded to know the weights of the twins - the reason she was given for their premature delivery. She found out hours later that the difference was only half a pound.
After the delivery, one of their sons was blue, his undeveloped lungs failing him. "I was heartbroken," Mr. Stewart said.
The premature babies had to stay in the hospital for several weeks. After they came home, Ms. Stewart worried constantly, sleeping by their side for a month in fear they would stop breathing.
Ms. Stewart complained orally at the hospital in 2010 but was overwhelmed by caring for three small children and didn't submit an official complaint to the Fraser Health Authority until 2014, after she learned about the treatment of other patients through a Facebook group for local mothers.
The Stewarts said that they never received an official response to their complaint. The health authority told The Globe that: "We made several attempts
to connect with Ms. Stewart and get the details of her complaint.
She did not provide further information after her initial contact with us. As a result, the file was closed."
Ms. Stewart said she never received any follow-up messages.
And after recently receiving her medical records, she has more questions than ever.
She found that Dr. Tam wrote that his reason for the emergency C-section was speculation that there was placental insufficiency as a result of her type 1 diabetes.
This reason was never relayed to her, she said. The report shows that the twins were in good health.
Dr. Beresford at the Fraser Health Authority said patients were not told about the outcomes of their complaints because of Dr. Tam's privacy rights.
He said the doctor's hospital privileges were temporarily suspended after an incident, but declined to disclose further details. Dr.
Tam was allowed to resume practice at the hospital with restrictions.
When the Stewarts and Juricas heard about Dr. Tam's overbilling, they began to wonder whether their rushed deliveries were financially motivated. Because the babies were born on Dr. Tam's watch, he garnered the billings.
"I fully believe he put our kids at risk for money," Mr. Stewart said. "I was a walking price tag," added his wife.
Between 2001 and early 2015, Dr.
Tam billed $19.3-million through the taxpayer-funded Medical Services Plan. During those years, he built his dream home on a treelined street in Vancouver's upscale west side, only to put it up for sale soon after it was finished.
He sold it for $4.4-million in February, 2015, shortly before he resigned.
The province's Billing Integrity Program audits around 15 health practitioners a year to detect and deter financial abuses. A 2010 review of Dr. Tam's billings found significant abnormalities and determined there was cause to order an audit of his practice. The audit used a random sample of 44 of the doctor's 13,378 patients between Nov. 1, 2005, and Oct. 31, 2010. It found 332 possible "irregularities" in 38 of the 44 charts.
One chart alone had 58 irregularities.
Auditors found various issues driving up Dr. Tam's billings. For example, they found he was racking up charges for being called out to the hospital when he was likely already there, improperly billing around $100 extra in each case. He regularly billed for a urine examination involving a microscope, but when auditors visited his office they found he did not have the instrument. (The different billing code meant he could charge about $3 more for each of these routine tests.)
The auditors also found Dr. Tam billed for an emergency Csection when the records showed it had been scheduled. The difference meant he could bill approximately $50 more.
Dr. Tam was presented with the audit's findings in mid-2012.
He challenged the audit and asked for a hearing, which was held over 7½ days in 2015.
In his opening remarks, Robert Musto, the lawyer who represented the government, argued that: "Whatever was happening in this practice with regard to pregnant patients was not driven by medical necessity alone. There was something else at work there."
But Dr. Tam and his lawyers maintained his high earnings were a result of hard work and commitment. They contended that any errors were clerical mistakes - par for the course in the fast-paced medical world.
"There's no ulterior motive here. There was some sloppiness," Nevin Fishman, one of Dr. Tam's lawyers, said during the hearing.
The five-member audit panel disagreed. "Dr. Tam did not impress us as a wholly credible witness. He attempted to portray himself as a victim whose extreme hard work and dedication to his patients was not appreciated," they wrote in their decision.
The panel described his records as "meager," "bereft" and "unintelligible" and said the mistakes and omissions raised questions about whether Dr. Tam was providing many of the services for which he billed the province.
The audit's mandate was to examine finances, but evidence presented also revealed concerns about the care of his patients.
Obstetrician-gynecologist Mary Lynn Simpson was the medical inspector in the audit. In the hearing, she testified that she was bothered by a finding that Dr.
Tam had failed to perform pelvic examinations, even though he was billing for them. She said the exams were critical to patient care.
The audit panel was also concerned about the high number of patients Dr. Tam was seeing and the quality of care he was providing. On some audited days, the doctor saw 90 patients, which meant if he spent even 10 minutes with each, he would be working 15 hours a day without breaks.
Mr. Fishman maintained Dr. Tam's high patient loads were a service to British Columbians, by providing access to a physician in a province with a shortage of doctors.
"He's passionate about being known as the obstetrician and gynecologist in Surrey who will come in when needed, and doesn't have the ridiculously long wait lists that we've all heard about. He'll see patients quickly and make himself available," Mr. Fishman told the hearing.
Dr. Tam's patient volumes seemed excessive to Brenda Wagner, an obstetrician-gynecologist who has also worked in administrative roles for various health authorities in B.C., including Fraser Health. She told The Globe that on a busy day she sees 25 patients, each for a minimum 20-minute appointment. Appointments for high-risk patients can take up to an hour.
Forty patients on a busy day is typical of some of her colleagues, she added. She does not know how appropriate care could have been provided to the high number of patients Dr. Tam was seeing daily.
Stories of inappropriate care relayed to The Globe allege far more egregious behaviour than just rushed appointments. For example, one woman who went to see Dr. Tam for dark spots on her labia said several large chunks of her labia were taken for a biopsy without pain medication. She remembers screaming so loudly a friend could hear her from the waiting room. She said her sex life has been severely affected by the damage to her genitals and believes Dr. Tam removed too much tissue.
A nurse, who does not want to be named out of fear of losing her current employment, observed Dr. Tam when she was a student.
She said he made disparaging comments about a patient who was under general anesthesia for a tubal ligation. She remembers Dr. Tam saying he was doing the world a service because the patient already had multiple children and earned a low income.
Dr. Tam sang "burn baby burn" while cauterizing the patient's fallopian tubes to the shock of the students present, the nurse said.
The Globe heard from patients who had positive experiences with Dr. Tam as well. "Dr. Tam was the most caring, consistent and helpful doctor on the planet," wrote Bev Everest in an email.
That wasn't Ms. Pillar's experience. In August, 2014, she saw Dr.
Tam for an infected C-section incision. Without warning, she said he took a swab from her partly healed incision and ripped it from end to end, opening stitches and scar tissue. She alleges he didn't offer any explanation, pain relief or even put on gloves or wash his hands.
"I was screaming, 'What are you doing? Stop!' " Ms. Pillar said.
She is one of many patients who did not complain officially.
She said she still feels guilty for not saying something sooner but, like many of the women The Globe spoke to, life as a new mother was overwhelming and she was trying to put the trauma behind her.
In May, 2016, six years after B.C.'s Medical Services Commission began looking into Dr. Tam, it ordered him to pay $2.1-million for improperly billed medical services, interest and the cost of the hearing. The audit scrutinized only five of the 14 years Dr. Tam worked in the province. Nine years of his billings were never examined, even though for most of those years, he was billing at a similar level as the years audited.
Dr. Still says that, had an audit of those years been completed, it would have found similar problems. A spokesperson with the B.C. Ministry of Health said those years were not audited because its practice is to conclude one audit before initiating further work.
By the time Dr. Tam's initial audit was concluded, he had stopped working in the province.
The B.C. Ministry of Health will not say if Dr. Tam has repaid his overbilling. The only public record of Dr. Tam's reprimand is the 22-page audit decision posted on B.C. Medical Services Commission's website.
A search of the College of Physicians and Surgeons of British Columbia's website lists Dr. Tam as resigned - the same status given to a doctor who has retired or moved out of the province.
While the college said for privacy reasons it cannot confirm nor deny the existence of an investigation into Dr. Tam, the 2014 letter sent to Ms. Jurica by the college states that a wider investigation of his practice was planned.
The letter said that this investigation would identify and remedy any failings in the physician's practice that could put the public at risk. Ms. Jurica was assured that the investigation would "be geared towards ensuring that Dr.
Tam's future patients are provided with appropriate obstetrical care."
But none of the college's findings or the patient complaints against Dr. Tam were ever made public.
The senior deputy registrar for the college, J. Galt Wilson, said that while the regulator can offer criticism of a doctor's practice, issue reprimands and order further training, nothing can be made public until formal discipline is meted, which requires a hearing or an admission of guilt by the doctor involved.
"When we resort to naming and blaming, when we go the disciplinary route, it's often counterproductive because people fight back, they lawyer up, they defend and it's much better and much more effective to get the physicians to work with us," Dr. Wilson said.
Whether Dr. Tam would be allowed to work in B.C. or elsewhere in Canada again is unclear.
The college will not say if Dr. Tam would be accepted if he ever came back to the province.
When applying to work elsewhere, Dr. Wilson said a doctor would need to give permission for an outside licensing body to access his or her B.C. record, which would include a reference to any open investigations at the time of their resignation.
Dr. Wilson said disclosure of open investigations can cause problems for doctors wanting to work abroad. But in Dr. Tam's case, almost immediately after his resignation, he was able to resume working as a doctor in China.
According to a web archive of the department of Obstetrics & Gynecology at the Shanghai United Family Hospital, Dr. Tam was listed there as a doctor in May, 2015. His name disappeared off the website nearly one year later.
Lonna Grady, a patient-service representative from Shanghai United Family Hospital, said Dr.
Tam is no longer employed there and he said he was planning to return to Canada.
The Globe searched for Dr.
Tam's current whereabouts and reached out to three of his former lawyers, but they did not know how to contact him.
Colleen Flood, director of the University of Ottawa Centre for Health Law Policy & Ethics, said patient-complaint systems across the country need to be strengthened. Often, she said, issues brought to provincial medical colleges are the tip of the iceberg and take a long time to deal with because of the quasi-judicial nature of the colleges' disciplinary processes.
"If there is a serious problem, they don't seem to be set up to act very quickly," Ms. Flood said.
In the case of Dr. Tam, Dr. Beresford said at the health authority level, there was little that could be done to permanently keep the doctor from practising.
That decision rests with the medical college.
"Is it difficult to take privileges away? Yes, it is difficult. And so that is why there were limitations set on how he could practise," Dr.
"As frustrating as it is, there is a process that is undertaken and it has to run its course," he added.
"But from our point of view, there was an awareness of the situation and [of] a need to deal with it."
It's an outcome that is deeply unsatisfying to patients such as Ms. Jurica. More than five years after her daughter, Ava, was born, she is pregnant again. But it was a long road to get where she is today.
Her traumatic birthing experience led to postpartum depression, anxiety, PTSD and physical ailments. She would even see visions of Dr. Tam in her home and took three years off work because she was terrified of leaving Ava.
Her relationship with her husband also suffered.
"She didn't want me touching her. She didn't want to be intimate. We couldn't even kiss in the beginning," her husband said.
Ms. Jurica developed a deep distrust of doctors, and couldn't stomach the idea of getting pregnant again for years. She feels failed by institutions she thought were there to protect her and knows she's not the only one Dr.
Tam harmed. "He hurt a lot of women."
With data analysis by Michael Pereira and reporting by Xiao Xu If you have further information about this story, please e-mail firstname.lastname@example.org
Charisma Jurica of Delta, B.C., has filed an official complaint against a B.C. doctor who now faces allegations of mistreatment from almost 40 former patients.
RAFAL GERSZAK/THE GLOBE AND MAIL
Alison Pillar, seen at home in Delta, B.C., saw obstetrician-gynecologist Winston Tuck Loke Tam for an infected cesarean-section incision in 2014.
RAFAL GERSZAK/THE GLOBE AND MAIL
For about a dozen years, Winston Tuck Loke Tam was British Columbia's top billing obstetrician-gynecologist, seeing as many as 90 patients a day and billing up to $1.7-million a year.
THE GLOBE AND MAIL, SOURCE: BRITISH COLUMBIA MEDICAL SERVICES PLAN (MSP)
Instead of resting when she got home after giving birth to her first child in 2013, Charisma Jurica spent days writing complaints to the College of Physicians and Surgeons of British Columbia and the Fraser Health Authority. Ms. Jurica, photographed at her home in Delta, B.C., in April, is pregnant again, though it took her years to work through the deep distrust of doctors that she says she developed after her experience with Dr. Tam.
RAFAL GERSZAK/THE GLOBE AND MAIL
Thursday, August 09, 2018