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When a patient in Altoona, Pa., needs an
emergency brain scan in the middle of the night,
a doctor in Bangalore, India, is asked to
interpret the results.
Spurred by a shortage of U.S. radiologists and
an exploding demand for more sophisticated scans
to diagnose scores of ailments, doctors at
Altoona Hospital and dozens of other American
hospitals are finding overseas outsourcing works
even in medicine.
During the past few years, the number of
nighttime emergency cases was swamping Altoona's
seven radiologists.
"All of a sudden, somebody was waking up all
night to cover all this extra work," said
radiologist Dr. Richard Wertz. "We didn't have
the luxury of that guy taking the next day off"
even if the nighttime work made him groggy.
Using radiologists halfway around the world
where it's daytime "solves that problem for us,"
Wertz said.
It's part of the growing telemedicine trend, as
technology enables the speedy transfer of
medical data over the Internet to virtually
anywhere. That means radiologists in Australia,
India, Israel and Lebanon are reading scans on
U.S. patients. Most of these arrangements are
designed to take advantage of the time
difference.
Despite some doctors' fears, advocates say
outsourcing radiology is nothing like the
nightmarish vision of seedy sweatshops stealing
U.S. jobs and replacing them with unqualified
cheap labor. Most of the doctors are
U.S.-trained and licensed, although there is at
least one experiment using radiologists without
U.S. training.
More typical is the Altoona scenario, which
involves Dr. Arjun Kalyanpur, a U.S.-licensed
and credentialed radiologist who got his
postgraduate training at Yale University. He
runs a respected two-man service in Bangalore,
India, called Teleradiology Solutions.
Kalyanpur, also a Yale faculty member, earns the
equivalent of a U.S. radiologist. His equally
credentialed radiology partner also trained in
the United States.
About 40 U.S. hospitals, including Altoona, use
Kalyanpur's company.
Images of U.S. patients' radiology scans are
sent over the Internet to the Bangalore office.
Radiologists there review the image, offer a
preliminary diagnosis and fax back a written
report usually within about 30 minutes,
Kalyanpur said.
"When Kalyanpur takes over, we all can get some
sleep and really won't be tired the next day,"
Wertz said. Altoona radiologists read the
overnight scans when they arrive in the morning
and make the final diagnosis.
"Ten years ago, they didn't do all these CT
scans at night. Now, everybody gets them," Wertz
said.
Australia, Mideast help
Facing the same phenomenon, radiologists at
Chicago's Swedish Covenant Hospital hired an
Australian company called International
Teleradiology two years ago, said Dr. Bruce
Silver, one of six staff radiologists. Now,
U.S.-trained and licensed radiologists in
Australia, Lebanon and Israel read overnight
scans from Swedish Covenant.
"We didn't do it because we're lazy and didn't
want to work. We did it for quality reasons,"
Silver said. His staff also reads the scans the
next day.
One of the largest domestic companies offering
such services is NightHawk Radiology, based in
Coeur d'Alene, Idaho. The company says more than
500 U.S. hospitals now rely on its 35
radiologists "U.S.-born and trained" in
Australia and Switzerland.
In recent years, demand has far exceeded the
supply of U.S. radiologists. The use of
teleradiology has improved on-call productivity
and may have helped ease the shortage, radiology
experts say. But worries remain.
In May, an American College of Radiology (ACR)
task force warned it was "very concerned about
the implications of overseas radiology and its
potential effect on patient care in the United
States."
It said doctors who interpret the scanned images
should meet or exceed the standards for U.S.
physicians. It also said foreign radiologists
should have liability insurance and a license to
practice in the states they serve, as well as
staff privileges at hospitals where scans are
performed.
Dr. Arl Van Moore Jr., a Charlotte, N.C.,
radiologist who headed the task force, said
outsourcing teleradiology is acceptable if the
ACR guidelines are followed, but ensuring
quality is difficult "when somebody's 8,000
miles away."
"There's no way to monitor that or to ensure
that the patients are protected," he said.
Dr. David Turner, chairman of diagnostic
radiology and nuclear medicine at Rush
University Medical Center in Chicago, believes
outsourcing fears are unfounded. With concern
about medical errors and malpractice lawsuits,
no U.S. hospital would risk hiring poorly
trained doctors, he said.
"The bottom line is this is not outsourcing in
the sense that automobile jobs are going to
Mexico and call center jobs are going to India,"
Turner said. "It's something on a different
level."
However, one pilot project does rely on non-U.S.-trained
radiologists.
A division of Bangalore-based Wipro, an Indian
technology giant, is doing radiology readings
for a handful of U.S. hospitals in a pilot
project using 12 Indian doctors who are neither
U.S. licensed nor board certified.
Despite regulations that doctors be licensed in
virtually every state they serve, a Wipro
official says this collaborative arrangement is
legitimate.
"They do not do full reads, they do not pass
medical judgment," and send only a preliminary
report back to the United States, said Supratim
Sarkar, a company spokesman.
"Testing the waters"
He refused to identify the hospitals involved in
the project, saying it was confidential. While
Indian radiologists generally make about
one-tenth of the estimated $350,000 median
salary for U.S. radiologists, Sarkar said Wipro
is only "testing the waters" and poses no threat
to U.S. radiologists.
In a Dec. 9, 2003, letter to the American
College of Radiology and posted on a
radiologists' Internet discussion group, Dr.
Keith McKlendin, a medical resident at the
University of Utah, complained that companies
"such as Wipro are attempting to exploit the
difference in salary between Indian and
board-certified radiologists for commercial
gain."
Moore said reports about Wipro's practices are
"an area that would be of concern" but that he
didn't know enough about the company to comment
further.
Dr. Sanjay Saini, a former Harvard Medical
School professor and Massachusetts General
Hospital radiologist, tried to set up an
experimental teleradiology program at that
hospital two years ago. He worked with Wipro to
create an Indian site where Massachusetts
General doctors could do nighttime readings of
scans from Boston patients.
"The project came to a screeching halt" when the
hospital couldn't find U.S. doctors willing to
relocate to India, said Saini, now at Emory
University.
Saini said news about the project led to
"anonymous, threatening hate-mail" from people
who thought he was advocating sweatshop-type
outsourcing.
"People generally didn't understand ... and were
afraid that the jobs would disappear or that
income would go down."
Saini is exploring options for doing
international teleradiology with Emory and said
the practice is likely here to stay.
"It's a trend that is increasing because the
shortage of radiologists is real, and the need
for radiology services 24-7 is real."
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