Quackery Skepticism/critical thinking Surgery

Dr. Charlie Teo is back in the news

I wrote about neurosurgeon Dr. Charlie Teo and his supposedly near-miraculous resections of “inoperable” brain tumors. He’s back, and it turns out that I was likely way too easy on him a decade ago.

And now for something completely different…sort of. Does anyone remember Charlie Teo, the Australian neurosurgeon who gained a Stanislaw Burzynski-like reputation over a decade ago for being able to cure inoperable brain tumors that other neurosurgeons supposedly couldn’t remove? I wrote about him once—and only just once over a decade ago—in the context of accusations that he had funneled some of his patients to Stanislaw Burzynski for his antineoplastons quackery after having operated on them Well, he’s back in the news again, and it’s not good.

“Surgery tomorrow or she accepts death” Wait, what??? Dr. Teo needs to work on his bedside manner STAT! Also, where have we heard bullying language like this from a doctor before? Oh, yes, that’s right. We’ve heard it from Stanislaw Burzynski.

There’s more:

Stories have been popping up in my various social media feeds and Google Alerts since Monday, leading me to an investigation by the Australian version of 60 Minutes and an investigative reporting series in the Sydney Morning Herald that is now up to 13 articles and counting under this image:

Charlie Teo
It’s never good when a newspaper changes the word “prophet” to “profit” in a headline.

Actually, this sort of topic is something that I used to write about a lot before the pandemic consumed my blogging, and I should look forward to revisiting it. However, doing so means that I might have to critically examine a take that I might have gotten wrong, lo, those many years ago, which makes it less pleasurable. It is, however, necessary. So let’s start out with the investigation, and see what Sydney Morning HeraldThe Age, and 60 Minutes reported in their joint investigation. Spoiler alert: Dr. Charlie Teo charged families of children with inoperable brain tumors like diffuse intrinsic pontine glioma (DIPG, an abbreviation that I thankfully haven’t needed to use in a long time) huge sums of money for nontherapeutic operations in a manner that reminded me a lot of how Stanislaw Burzynski charges desperate parents of children with DIPG and other inoperable and terminal brain tumors huge sums of money for ineffective treatment with his antineoplastons and unproven toxic treatment using his “everything but the kitchen sink” made-up “personalized gene-targeted therapy.” Truly, these stories now make me think of Charlie Teo as the Stanislaw Burzynski of neurosurgery.

First, let’s take a look at one of the cases discussed in the report:

In mid-September 2018, Barman, an engineer from Assam in India, was worried when his son, four-year-old Mikolaj, appeared to have difficulty walking.

He and his wife Sangeeta were devastated when their son was diagnosed with an incurable and inoperable diffuse intrinsic pontine glioma (DIPG). A second neurosurgeon confirmed the diagnosis.

Desperate for a miracle, a friend emailed the famed Australian neurosurgeon on his behalf, saying: “The doctors in Delhi have told him [Barman] that no treatment is possible” and they were hoping that “a Western doctor can offer his son a lifeline”.

Teo, 64, is arguably Australia’s best-known neurosurgeon. He is renowned for his aggressive surgical style, especially in cases other surgeons deem inoperable, and he has many grateful patients who laud his successes.

I’ve seen this story many times before investigating Stanislaw Burzysnki’s claimed successes treating children with DIPG: The neurological problems noticed by parents, which lead to a workup by the child’s pediatrician, which leads to an MRI or CT scan of the brain, which leads to this devastating diagnosis after which the families find out about a “brave maverick doctor” who claims to be able to cure what every other oncologist and surgeon has told the parents is incurable These doctors have often been aided by credulous press thusly:

In the media, he is often portrayed as a maverick, motorbike-riding outsider fighting against both the medical establishment and his colleagues who, he suggests, are jealous of his superior skills.

Burzynski shares the persecution complex and has often claimed that oncologists were envious of his success rate. Such is a very common personality trait of “brave maverick doctors.”

Before I discuss the disasters that led to the investigation of Dr. Teo, let me revisit what I said about him in 2011. At the time, I was unclear on Dr. Teo’s status with respect to being a “brave maverick doctor.” I noted that “inoperable” is not a hard-and-fast definition in surgery and that a tumor that one surgeon might judge to be “inoperable” another, more aggressive surgeon might judge to be operable. I’m going to quote a long passage from my original post, to give you an idea of what I mean:

There is a type of surgeon who represents the true “brave maverick” in that he is highly skilled, highly confident, and willing to take on seemingly “hopeless” cases. Surgeons like this will often, as described above, operate on patients who have either been operated on before by other surgeons who couldn’t fix what was wrong or been turned down by other surgeons as “inoperable.” Of course, “inoperable” is not a hard-and-fast word in that what is inoperable to one surgeon might well be operable to another. It’s also a very fine line in that this is an area where science- and evidence-based medicine collide with personal surgical skill. There are surgeons out there who are just so good that they can physically do with their hands what other surgeons, talented and experienced as they might be, cannot. Alternatively, they are far less risk-averse than the typical surgeon in their specialty and are therefore willing to attempt things that other surgeons won’t, such as the resection of “unresectable” brainstem tumors. Where daring ends and recklessness begins is a very fuzzy line with surgeons such as these. When they fail, they fail spectacularly, but when they succeed sometimes the result is the patient described in the video above. Surgeons such as these might very well cause a lot of complications and unnecessary suffering through aggressive–even reckless–pushing of boundaries. However, they also push the envelope (which Dr. Teo even says explicitly that he is trying to do in the second video), which can lead to advances in surgery and can sometimes save patients thought to be unsavable. Where the balance between the harm and good done by such surgones lies is, again, not a trivial thing to figure out.

At the time, I also wrote about accusations that Dr. Teo selected patients who were certainly going to die to operate on because he wanted to make tens of thousands of dollars from their families before they actually did die, concluding:

It’s clear that Dr. Teo is a controversial figure. He’s wrong on mobile phones and cancer. He also seems to have a bit more of the flamboyant showman in him than is good for a surgeon to have, a point that several of the stories I’ve cited make, and he definitely seems very cocky, perhaps more so than is necessary to be a neurosurgeon. (After all, it takes a certain amount of cockiness to have the confidence in yourself that you can crack open someone’s skull and remove part of his brain without leaving him permanently disabled.) It’s also pretty clear to me that Dr. Teo is the type of surgeon who pushes the envelope, perhaps bordering on recklessness at times. If that’s the case, he should be called out for subjecting patients to operations that can’t help them. However, I’m not convinced that that’s the case. In fact, it is not in the least bit clear to me that Dr. Teo is the sort who operates on patients whom he knows he can’t cure in order to make money, and I wish I didn’t have to point that out. 

I still think it’s a much more complicated issue than Dr. Teo’s critics made it out to be whether he really believed he could cure these children with inoperable brain tumors or whether he was doing it primarily to profit before they died. Personally, I find that “brave maverick doctors” and quacks tend to exist along a spectrum from one to the other. Most genuinely believe that they are helping their patients and find ways to convince themselves that all the deaths and complications are the price to pay for “pushing the envelope” in medicine and surgery, while deluding themselves that they provided the family with genuine informed consent.

Consider this case included in the 13 articles, specifically the disconnect between what Dr. Teo says on podcasts and what he actually does with patients:

“There’s no such thing as false hope, only false promises,” said the controversial neurosurgeon Charlie Teo last week.

“It’s incumbent on a surgeon or a doctor not to give false promises, so that people can either cling on to hope or let go of hope. It’s up to them, as long as you inform them properly,” he told a podcast.

Now, contrast Dr. Teo’s assertion above, which is the correct one ethically—to a point—with how Dr. Teo actually behaves with patients and families:

Meiry Huang cries as she recalls the desperate conversation with her sisters and mother outside Teo’s Sydney office on August 8, 2017.

“She either has surgery tomorrow or she accepts death. Talk to her outside,” Meiry later told the Health Care Complaints Commission (HCCC) about the conclusion of their consultation with Teo.

Her 79-year-old mother Erny Djie was exhausted having come straight to Teo’s office from the airport after an overnight flight from Singapore. Doctors there had told her she had an inoperable tumour.

Teo told them urgent surgery was necessary because Erny had possibly only weeks to live and as he was going to the United States, it could only be done the following day.

The comparison that came to mind as I read this story is not one that is flattering to Dr. Teo. What this reminds me of most of all is the high-pressure sales pitches of timeshare salespeople, who often tell their semi-captive audience that if they don’t sign on the dotted line right there, right now, the offered price goes way, way up. The difference here is that the implied threat is far more horrific than just losing out on what seems to be a deal. It is the potential loss of the life of a loved one (or yourself). It’s emotional blackmail, pure and simple: I operate tomorrow, or your mother dies.

Never mind the outcome:

Despite Teo telling them the operation was a success and he’d removed 95 per cent of the tumour, Erny was paralysed down one side. She couldn’t eat, drink, sit up or stand and she could no longer communicate properly.

“Half of her body was dead, basically,” Claudia said.

Having paid around $100,000 for the operation, which included $40,000 for Teo personally plus a $1275 administration fee and private hospital costs, Erny’s post-operative complications and rehab left the family out of pocket another $150,000.

The family flew their mother back to her home in Jakarta where she died on 10 November 2017.

“My mother lived the last 94 days of her life in a state of complete misery … a living hell,” said Meiry in her complaint to the HCCC. “I believe he vastly downplayed the risks of the operation” and took no interest in her mother post-operatively, she wrote.

Now let’s go back to the case of the child with DIPG, Mikolaj Barman, who was brought all the way from India to Australia by his parents Prasanta and Sangeeta to see Dr. Teo after the diagnosis of DIPG

On September 27, 2018, Barman was elated when what seemed like a lifeline was offered. “Dr Teo has reviewed the scans and suggested urgent surgery, he said there is a very high likelihood of cure if he does the surgery before radiation,” the email from Teo’s office in Sydney said.

Then came the timeshare pressure tactic:

Barman explained to Teo that he had no medical insurance, so he would have to meet all the costs himself.

He was informed that the operation would cost $150,000 at Prince of Wales Private Hospital in Sydney or $80,000 in Singapore, of which $40,000 would have to be in Teo’s bank account before surgery.

Because of course Dr. Teo wanted cash up front, and what happened next echoed what happened next for so many Burzynski patients that I used to write about so frequently:

When he read Australian press reports describing Teo as “a miracle worker”, Barman was reassured that the much-hyped doctor could deliver the cure he was offering.

That same day, Barman’s friend set up a GoFundMe page to help with the steep costs for the operation to remove Mikolaj’s DIPG in Singapore.

The crowdfunding page referred to the tumour as “inoperable”.

“However there is hope. A renowned Australian neurosurgeon, Dr Charlie Teo, believes he can successfully remove the tumour using a pioneering technique. With this treatment, Mikolaj’s prognosis would be excellent, and he will hopefully live a long, normal life,” read the crowdfunding page.

Barman drained his savings and his retirement fund, Mikolaj’s school helped and friends donated money for the operation on October 11, 2018. Photos taken the night before the operation showed the happy, lively boy in his hospital bed surrounded by colourful balloons, playing with his toys.

I find it difficult not to find the Australian press complicit in Dr. Teo’s predatory practices, just as British tabloids were complicit in hyping Stanislaw Burzynski’s antineoplastons as a “miracle cure” that the UK NHS wouldn’t pay for. Indeed, apparently even as the drip-drip-drip of stories about Dr. Teo’s recklessness led to his being restricted from performing certain operations unless he obtained approval from a fellow neurosurgeon until after the results of a full investigation into the complaints that triggered them is undertaken by the Health Care Complaints Commission, one of the key tabloids that promoted Dr. Teo started working to rehabilitate his image with puff pieces. The newspaper? The Telegraph, owned by News Corp. It’s easy to find a slew of articles like this, with titles like:

You get the idea. It would be more difficult, mainly because the stories are so old, for me to compile a list of similar headlines about Stanislaw Burzynski, but probably not that much more difficult. The narrative is the same: The brave maverick doctor or surgeon who bucks his profession and saves lives that “they” had said couldn’t be saved. It’s the narrative used by all quacks and their supporters.

Sadly, Dr. Teo’s results operating on Mikolaj Barman were even worse than the results were for Erny Djie:

The surgery was performed in Singapore on October 11, 2018. Apart from the intial $80,000 for the operation, the Barmans had to pay $40,000 to hire an air ambulance to fly Mijolaj back to India where he languished in intensive care for months. Mikolaj’s care cost nearly $250,000 and the rest of his short life was spent in a room staring at a ceiling. He never walked, talked or breathed on his own again. His only means of communication was blinking his eyes.

Ten months after the catastrophic operation, the aggressive tumour returned and Mikolaj died. In response to this news, Dr Teo emailed saying, “I’m so sorry, but you have given him every possible chance to live longer and I would like to reassure you that he has had the most aggressive treatment possible,”.

Can anyone say that this result was better than what could have been achieved with aggressive palliative care? Certainly I can’t.

Worse, in a CYA gambit (apparently) Dr. Teo told the parents right before the operation that the tumor was diffuse, “meaning that it had spread, and for the first time he suggested that he may not be able to remove it all.” By that time the parents felt that it was too late to back out. Again, it’s easy to understand how, after having ponied up so much money and traveled so far from home, the parents would have been reluctant to back out at such a late stage.

I also can’t help but mention one of Teo’s other surgical misadventures, in which he operated on the wrong side of a patient’s brain. No, seriously, he did that and told the patient that everything was OK:

In 2003 Teo operated on Michelle Smith at Prince of Wales Private Hospital to remove a tumour that was causing her epileptic seizures. Twelve weeks after surgery she had a follow-up appointment.

Showing the scans, Teo explained that he had removed some of the tumour but a second operation would be needed to remove the rest. “Everything’s great. You can stop all your meds,” Smith recalled him saying.

She followed his advice but over the years her seizures got worse and she couldn’t hold down a job let alone drive a car.

In 2014 she had a near fatal car accident. “I had a seizure behind the wheel and hit two parked cars, writing off three cars,” Smith said. After the accident a fresh brain scan showed none of the tumour had been taken out and that Teo had actually operated on the wrong side of her brain.

Thirteen years after the initial surgery, Michelle had another operation to remove the tumour. This time a neurosurgeon at a Sydney public hospital operated at no charge and since then Smith has been seizure-free and feels like she’s been given a new life. But Dr Teo’s mistake still distresses her.

The Sydney Morning Herald even included the receipts, namely the scan, and when I saw it, all I could say is: Yikes! Here it is:

Teo brain scans
Red is the tumor; green is where Teo operated.

I will admit here that during my career I’ve witnessed an excellent surgeon operate on the wrong side of the patient. This was many years ago, and it can happen, although wrong-site surgeries are much rarer since all the systemic precautions that hospitals have instituted over the last 30 years or so. Here’s the difference, and it’s an enormous one. That surgeon immediately owned up to it and offered to do their best to fix it or, if trust was gone, refer the patient to a different surgeon. The case was presented at surgical morbidity & mortality conference, leading to a robust discussion of how such an error could be avoided in the future.

In marked contrast, Dr. Teo didn’t realize the mistake, didn’t own up to it, and still denies it to this day, attacking 60 Minutes and the newspapers that jointly carried out the investigation. There is no evidence of self-reflection, of asking how such an error could have been made, of trying to do better. There’s just the supreme confidence that he did nothing wrong, made no mistakes, and is being “persecuted” because others are envious of his incredible skills. Even so, in 2018 he settled a malpractice suit brought by Smith for an undisclosed sum, who said of the lawsuit:

Smith said: “I did have a few people ask me why I would even waste my time trying to take on Charlie Teo because he’s untouchable.”

Apparently not any more, and that’s good. It’s also long overdue, taking even longer than it took authorities to finally shut down Christopher Duntsch.

Looking back at Dr. Teo with the perspective of what has happened within the last couple of years, including his getting around his ban on doing surgery on brain tumors in Australia by finding a way to do such operations in Spain, by “assisting” in at least three surgeries in the past year at Hospital Universitario Fundacion Jimenez Diaz in Madrid and Hospital Quiron de Torrevieja near Alicante and, apparently, in operations in South Africa, I reluctantly have to conclude that I gave him far more of the benefit of the doubt than I should have when I wrote about him nearly 11 years ago. It’s quite possible that Dr. Teo is more skilled than the average surgeon, better at the technical and physical aspects of operating, but it’s become pretty clear that his judgment is terrible. He appears to have such a high opinion of himself that he thinks he can do things that other neurosurgeons can’t do and save patients that other neurosurgeons can’t save, and that he’s entitled to be richly rewarded for exercising those skills, which is likely why he’s following the paths of Burzynski and other quacks:

The surgeon, who is currently under investigation by the Health Care Complaints Commission, revealed he has a Sydney project in the works despite restrictions stopping him operating on anyone in Australia.

“I do have a project going on at the moment … at Blacktown, where they may be building an institute in my name that will be a centre of excellence for neurosurgery and neurosciences,” Teo told Grimshaw.

Because of course he’s founding his own neurosurgery institute.

There’s a line from an old Dirty Harry movie that I like to quote sometimes in these contexts: “A man’s got to know his limitations.” It’s quite clear that Dr. Teo doesn’t know his and, worse, appears not to feel much remorse for ruining the lives of so many patients and their families over the years with his grandiose, overconfident claims, followed all too often by predictably dismal results.

He is the epitome of the brave maverick doctor.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

20 replies on “Dr. Charlie Teo is back in the news”

Thanks for covering this. Charlie Teo has been a blot on the Australian neurosurgical landscape for decades. It’s sometimes hard to understand how the media picks its heroes (Charlie Teo) and its villains (Lindy Chamberlain)

Narratives, mate. If you ever want to win, learn how to weave more enticing, enriching ones than them.

OK, I’ll bite. How? You keep saying variations on this, but you’re woefully lacking any instructions on how to do this or concrete examples to work with.

There was a pretty good narrative about an innocent mother accused of killing her daughter, but they chose to paint her as a villain instead.

There have been questions raised about Teo in Australia for quite a long time. Teo has long attacked these as jealousy, but clearly, the questions about his behaviour had substance. He has built a cult and apparently believes in it himself.

The way he treats his patients rather suggests he is intent on fully monetising his reputation – all cost and no responsibility. He has become a predator.

Hero Shit.

And you know I’m not saying it’s the N-word, but you know it’s the N-word. It’s tremendously easy to play Glorious Savior as long as you are never forced to tally the number of humans you’ve wrecked in the process. Everyone loves a good narrative, and will eagerly bend over backwards to hear nothing else. That’s how abuse works—succeeds.

And so you get these hero pieces of shit; delighted to step into the role that everyone else wants. Stealing the remaining precious months that dying people still had for themselves, their last QoL, just to play God as Doctor. Survivor bias as a marketing stratagem; credit where due: the scum are consistent.

Henry Marsh’s Do No Harm is an excellent read. Unlike certain quacks, this man pulls no punches, honest enough to say: “I wrecked some of my patients.” That, I respect, utterly: not just as admission to everyone else, but first and foremost to himself.

From the SMH article:

“My mother lived the last 94 days of her life in a state of complete misery … a living hell,” said Meiry in her complaint to the HCCC. “I believe he vastly downplayed the risks of the operation” and took no interest in her mother post-operatively, she wrote.

Humans are terrified of death, naturally; desperate to hear easy, pleasing, evasive answers. But even the act of dying isn’t nearly as bad as dying in misery, pain, and shit.

I come from a medical family; I carry few illusions. And I’ve seen dearly loved ones decay and slow-rot, a farce of life dragged out. So if medics choose to reject heroic, futile measures for themselves, then everyone else should take note: there is powerful reason for that choice too.

Telling desperate, dying people what they want to hear isn’t a kindness; it’s a betrayal. And those like Teo (I refuse to call that shitwick “Doctor” either) who are happy to sell such service anyway, for no finer motive than their own personal profit and glory, deserve to pay that bill in full.

Sadly, the medical profession guards its own henhouse about as well as every other fox. But, hey, I live in hope.

I’m sorry, has, but you are reading this as if it happened in the USA. The N-word has nothing to do with it, and the medical profession has never protected this lone maverick. He simply didn’t stray far enough off the path to make a case against him – until he did, of course. It was a certain section of the media that turned this guy into a hero. A certain plastic surgeon got the same treatment. In this case, the non-sensationalist media took him down with help of other plastic surgeons.

The N-word has refers to is “narcissist”. Of course, I can’t speak to Australia, but it’s certainly true here in the US that at best the medical establishment is toothless in policing itself (e. g. Burzynski), and generally places protection of the tribe over protection of the public.

Thank you, yes, sorry. I assumed my local monomania self-documenting by now; I should’ve put in a link to clarify.

@ John Kane:

Heh. How about engineers and tech bros?

OT ( but not extremely OT because it’s probably on everyone’s mind)

Because I survey altie BS/ assorted disinformation sites I am concerned- over the past two years or so Twitter has been dropping many high profile woo-meisters/ righties/ misinformers making them have to find other avenues or create their own. Even Donald got tossed off.

Musk is an advocate of free speech: will he allow all these
people back in? Because RI discusses alt med: will woo-meisters and real-doctors-who-deceive now be eligible for accounts? Most of the anti-vaxxers I survey were dismissed ( although RFK jr, Del Bigtree and Katie Wright still tweet); big money natural health advocates ( NN, prn, Mercola) may have free reign to spread misinformation and hawk their own services/ products/ “charities”. I won’t even mention political operatives although many of these guys are already advocating for libertarian/ small government aims or violent insurrection. Nor will I discuss obvious racists, misogynists and homophobes although they will certainly enjoy an open forum.

If Twitter was accurately described as a hellscape, what will we call its next incarnation?

“small government aims or violent insurrection”

Change “or” to “and”: a small government is easier to overthrow. The world is full of examples.

They probably want government so small that it effectively does nothing and they would then have nothing to rebel against.
Plus it would cost very little so…..SURPRISE!…. no taxes!

The US might actually go there soon. I think the UK already might have but I’m still not sure about the whole Truss-to-Rishi outcome yet.

There’s no doubt the qop want to destroy government as we know it and replace it with a more authoritarian version where women are simply walking wombs and others “know their place”.

The scary thing is that they know they have to attempt appeals to the most extreme subsets of the voting population, folks who’ll buy anything as long as it attacks the enemy (members of the Democratic party).

Take this from an interview with the QOP’s candidate for governor of Michigan, tudor dixon. This was in 2020 on “real america’s voice”.

“The country today is divided, and this was the plan. It’s been in the works for years. The idea that you can topple the greatest country in the world. But to topple a country like the United States of America, you must be planning this for decades,” said Dixon. “Why wouldn’t that come from the party that lost the Civil War? The party that wanted to own people because they viewed them as less than human? Do you think that the Democrats are over losing to the north?”

She’d been ranting about the “attempted creation of the Black House Autonomous Zone outside of the White House,”

Far from the craziest stuff she’s spouted, but again: that was 2020, and yet she is the current candidate for our governor.

@ldw56old: “But to topple a country like the United States of America, you must be planning this for decades,”

Well she got that part right, the roots of the ongoing fascist flip stretching back to Goldwater and Nixon’s Southern Strategy in the 60’s, the fatal inflexion point at which the GOP decided to sell out its soul for power. As to the rest of her toss, every accusation’s a confession of shitheels projecting like IMAX.

Musk’s inability to lash down his own mania is gonna see him living out his last days in a darkened room filled with bottles of piss. Such raw energy can be useful for getting stuff done but it’s also a rolling disaster. Oh well, now he’s shackled himself to the toxic turkey, perhaps the reality of the situation will learn him “It’s a bit more complicated than that.”

Credit where due: at least Musk’s capable of making mistakes and learning by his errors (being wrong fast and often is how Falcon 1 reached orbit), unlike a lot of the tech world which is just balls deep in deeply insecure resentful martinets desperately grasping for Control they have not actually earned and have no clue how to use.

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