Who's Reading Your X-Ray?

ANJAY SAINI was not prepared for the hate mail. A radiologist at Massachusetts General Hospital, Dr. Saini thought he had found a clever way to relieve an acute shortage of specialists who could read X-rays and M.R.I. scans. The hospital would beam images electronically from some scans to India, to be worked on by radiologists there.

But the arrangement, made late last year with a company in India, has touched off a minor furor. It turns out that even American radiologists, with their years of training and annual salaries of $250,000 or more, worry about their jobs moving to countries with lower wages, in much the same way that garment knitters, blast-furnace operators and data-entry clerks do.

Since the news got out, Dr. Saini has received a flurry of angry e-mail messages, most of them anonymous, urging him to stop. The American College of Radiology, the professional group for the country's 30,000 radiologists, has set up a task force to look at the offshore transfer of radiology services. And the online discussion groups of AuntMinnie.com, a Web site for radiologists, have been buzzing with debate about the prospects for competition from "radiology sweatshops" abroad.

"This teleradiology thing is another nail in the coffin of the job market," wrote someone on the Web site who identified himself as a radiologist. "Who needs to pay us $350,000/yr if they can get a cheap Indian radiologist for $25,000/yr."

Daniel Courneya, a radiologist in Hibbing, Minn., fumed on the site that Massachusetts General, a Harvard teaching hospital known to its admirers as "Man's Greatest Hospital," should instead be called "Money Grubbing Hospital," another play on its initials.

On the surface, the controversy may seem a bit odd. Experts say that the number of X-rays from the United States now being read in India is minuscule and that regulatory restrictions are likely to keep it from growing rapidly. Moreover, most hospital jobs, unlike those in radiology, require close patient contact, so there is a limit to how much offshore outsourcing can be done.

Besides, employment in American health care has been growing. In the 12 months ended in August, the category added about 250,000 jobs while overall nonfarm payroll jobs shrank by nearly 500,000. Hospitals alone added about 70,000 jobs in that period.

Still, Dr. Saini's plan shows that even medical care, the most intimate and localized of services, is grappling with the globalization that has moved many jobs - first in manufacturing and more recently in white-collar work - across the ocean. And in health care, of course, there is more at stake than jobs. Dr. Courneya and other critics worry that radiologists outside the United States may not be trained properly, endangering patients' safety.

Dr. Saini says that the furor is much ado about nothing, that people are reacting based on emotion, not fact. A native of India who has lived in the United States since he was in high school, he said that any Indian radiologist reading scans from Massachusetts General would have to be licensed in that state and be certified by the hospital, so patient care would not suffer.

At the moment, he said, there are no such qualified radiologists at the outpost in India, so actual diagnoses are not being made there. Rather, the radiologists in India are converting two-dimensional images from scans into three-dimensional pictures that are more understandable to surgeons; that job is usually done by technicians in the United States.

RADIOLOGY is not the only medical service that may someday be performed for Americans by people in other countries. Other candidates are the analysis of tissue samples, the reading of electrocardiograms, the monitoring of intensive care units and even robotic surgery.

Back-office medical work has been moving offshore for several years now, particularly to India, which has a large number of educated English-speaking people. Though the number of affected jobs is only a small fraction of the total, many experts say the share is growing as hospitals face pressure to cut costs.

For example, when doctors at Children's Hospital of Wisconsin in Milwaukee dictate information about a patient's condition, their words are sometimes whisked electronically to India, where trained medical transcriptionists type them and send them back, to be incorporated into the patient's medical record.

Then there is Botsford General Hospital in Farmington Hills, Mich., which uses a company with operations in India to help collect unpaid bills. "They came in with a rate that is less than half of what a U.S.-based collection agency would charge me," said Luke Meert, corporate director for accounts receivable at Botsford Health Care Continuum, the parent company.

Coding - the assignment of numbers for medical procedures to bills - is also heading offshore. The American Academy of Professional Coders now has chapters in India. Some insurance-claims processing is moving, too: Aetna Inc., the health insurance giant, has 400 people in that country.

Bob Burleigh, the president of Alpha Thought Global, a medical billing company in Chicago that has operations in India, said he had witnessed an incident in which a worker in Chennai, India, handling the billing for an American medical practice, needed to check on the status of an insurance claim. When he called the American insurance company's "800" number, the phone was answered by someone else in Chennai.

Companies have sprung up to offer services like billing and transcription in India. For example, Ajuba International Inc., based in Novi, Mich., does the billing follow-up for Botsford Hospital. And Manor Care Inc., an operator of nursing homes, owns the majority of Heartland Information Services of Toledo, Ohio, which does the transcription in India for the Children's Hospital of Wisconsin.

The movement of back-office jobs offshore has raised some concerns about privacy, in that foreign workers could not be easily prosecuted under American laws governing confidentiality of American records.

But the outsourcing of radiology overseas raises more issues. Unlike back-office functions, radiology is performed by doctors and is directly related to patient care. A mistake could conceivably cost a patient his or her life.

Massachusetts General is not the only place where controversy has arisen. Yale-New Haven Hospital ended a program in which a doctor was reading X-rays in India.

The doctor, Arjun Kalyanpur, had been on the staff at the hospital and on the faculty of Yale but decided to move back to his native India for family reasons. "It was not that I was taking a job away from anybody," he said. "I was taking my own job with me." After a trial run, he and some Yale colleagues even published a paper showing that interpretations from India were as accurate as those done in New Haven.

But Yale stopped the program, apparently because of internal complaints. "I think Yale was not ready for it yet," Dr. Kalyanpur said.

A spokeswoman for Yale said that communications with the doctor in India were too costly and that the hospital had no need for such a program because an attending radiologist was always on call.

So far, Teleradiology Solutions, which is Dr. Kalyanpur's company, and Wipro Ltd., the one working with Massachusetts General, appear to be the main providers of radiology services in India for American hospitals.

Dr. Kalyanpur and a partner read about 100 scans a day in their office in Bangalore, a high-tech center in India. He said the scans come from more than 30 hospitals in the United States, including several community hospitals in Pennsylvania.

Wipro is one of India's largest companies, with nearly $1 billion in annual sales, mainly from handling computer programming jobs for American and other foreign companies. To the company, the outsourcing of health care jobs is a new opportunity.

Wipro now has about 12 radiologists in India and counts four American hospitals or radiology practices as clients, said T. K. Kurien, its chief executive for health sciences. He said he could not name the clients because of the sensitivity surrounding the issue. Even Massachusetts General has now prohibited Wipro from discussing its relationship with that hospital.

Marketing is difficult, he said, because the idea of patient X-rays being analyzed in a third-world country does not sound so appealing to Americans. "Wouldn't you be scared to death if it was being done in India?" he said. "That's the real issue for us." When the company takes on a client, he said, "we know the person at the other end is going to get a lot of flak."

Yet both Wipro and Teleradiology Solutions are simply responding to a widely acknowledged shortage of radiologists in the United States.

"It's almost in crisis proportions," said E. Stephen Amis Jr., chairman of the board of chancellors at the American College of Radiology and chairman of radiology at Albert Einstein College of Medicine in the Bronx. "Demand for radiologists is growing at twice the rate that we're turning out the radiologists who have the ability to read them."

Radiologists who are willing to work nights are in particularly short supply. The need for such specialists in the evening has grown because patients coming into hospital emergency rooms are often given scans to help diagnose their conditions. A radiologist on call may be awakened several times a night.

One solution, made possible by electronic transmission of images, has been so-called nighthawk services. These are companies or individual radiologists, often working from home, who handle the nighttime loads of several hospitals at once.

It didn't take long for some nighthawk companies to use radiologists stationed overseas, in places where it is day during America's night. One company, Nighthawk Radiology Services, has stationed 15 American radiologists in a building near the Sydney Opera House in Australia. A few radiology practices in the United States have bought houses in Europe, and their members take turns living there.

From nighthawk services, it was just another step to put the night readers in countries with lower costs. Besides the two companies in India, Infinity Radiology, based in Dallas, is using some radiologists in South Korea.

A big obstacle to such services' growth is the requirement of most American states that radiologists be licensed in order to analyze scans of patients treated in those states. Moreover, radiologists need to have credentials at each hospital where they practice. As a result, it takes time and administrative work to set up each new account.

THERE are other complications. Medicare does not pay for services performed out of the country. So, in most cases, the doctors overseas do a preliminary reading, which nonetheless is used to guide treatment of the patient at night. The next morning, a local staff radiologist performs the final reading and bills Medicare.

The training of overseas radiologists can vary. Both Dr. Kalyanpur and his partner are board-certified radiologists, the highest standard in the United States, and some customers say that this presents no issues.

Dr. Thomas A. Manning, a staff radiologist at Centre Community Hospital in State College, Pa., which uses Dr. Kalyanpur, said it was better to have nighttime images read by a qualified radiologist overseas than by a resident still in training, the practice at some teaching hospitals. Dr. Manning said he was pleased with the hospital's nighthawk service and did not even know where Dr. Kalyanpur worked. "Is he actually in India?" he said. "I'm unaware of it."

Wipro's radiologists are not licensed in any state or approved by any hospital, Mr. Kurien said. That makes them ineligible, by themselves, to do even preliminary readings for American hospitals. Instead, he said, they receive scans electronically and provide interpretations to Wipro-employed licensed radiologists in the United States, who in turn consult with the client radiologist.

This roundabout method, he conceded, was developed after Wipro found that it could not find licensed radiologists to directly interpret images for American doctors. He said the business would not grow unless he could use more radiologists trained in India. "That is the end state because getting U.S.-trained radiologists in huge numbers is not something we can get in India," he said.

Mr. Kurien said he pays the radiologists in India $30,000 to $100,000 a year, depending on their training. That is more than Indian radiologists working for Indian hospitals make, but still low enough to allow Wipro to interpret images for about half the cost in the United States, he said.

RADIOLOGY may be just the start of patient care performed overseas. Next may be pathology. It is now possible to transmit images of tissue samples for remote diagnosis. There are also robotic microscopes that can be operated remotely, allowing a doctor at a different site to move a slide and focus the image.

As technology improves, "it would be possible for a small hospital in the United States to digitize an image, put in on their server and have a pathologist anywhere in the world, such as in India, provide a diagnosis," said Ronald S. Weinstein, professor and head of pathology at the University of Arizona College of Medicine in Tucson and director of the Arizona Telemedicine Program. He said he had heard of a pathologist in Poland who was planning an international pathology service.

Other services can also be performed remotely. Some hospitals are starting to monitor intensive care units in part from remote sites, with readings from electronic monitoring devices and video cameras sent electronically. That is not yet done across borders, but could be.

Someday, said Dr. Weinstein, who is also president of the American Telemedicine Association, a professional society, there may be virtual universities that can train doctors in foreign countries to meet American requirements. "The concept of boundary-limited medical education and licensure will fade in time," he said.

Still, what goes one way could also flow the other. Dr. Weinstein said telemedicine might provide a net gain to the United States because of the expertise here to provide diagnoses for patients in other countries.

"I think the opportunities for U.S. health care internationally probably are very large," Dr. Weinstein said. The University of Arizona plans to market its pathology services around the world, he said.

Leading American medical centers already market themselves abroad to recruit foreign patients to travel for operations. Some hospitals are setting up outposts overseas.

The University of Pittsburgh Medical Center essentially manages a transplant hospital in Italy, performing some pathology from Pittsburgh. The Armed Forces Institute of Pathology in Washington, part of the Walter Reed Army Medical Center, provides second opinions on about 60,000 cases a year, for Americans and foreigners. Most of the time, slides and tissue samples are sent in by mail, but about 300 to 500 a year are analyzed by using telepathology.

Eventually, there may be a division of labor, with high-end services performed in the United States and more routine services done in countries with lower wages. And radiologists may even come to appreciate having offshore help.

"People want to protect their turf," Dr. Saini of Massachusetts General said. "But it's very interesting that that turf battle stops at 5 p.m. on Friday. How many people say they want to do this thing on Saturday and Sunday?"

Indeed, not every posting on the radiology Web site has criticized Dr. Saini. Some favored using foreign radiologists. "If we don't hire them, we'll be working longer hours for the same pay," one person wrote. "So everyone please shut up about this."

Very true. You had better not get unlucky and get sick on a weekend.

nonsense, my grandmother has gone for Xrays and MRIs on weekends all the time.

another "acute shortage" being ginned up to hide the real desire behind offshoring. oh, let me know when the XRAY costs to consumers start declining.

Dr. Thomas A. Manning, a staff radiologist at Centre Community Hospital in State College, Pa., which uses Dr. Kalyanpur, said it was better to have nighttime images read by a qualified radiologist overseas than by a resident still in training, the practice at some teaching hospitals.

And after people wise up to what's going on, you're not going to have to worry about using residents in teaching hospitals ... as they won't be attending. Why study for 10+ years when your job can be easily shifted overseas?

oh, let me know when the XRAY costs to consumers start declining.

Not a chance. If there is any savings at all , the Doc's will pocket the difference. Ferrari mechanics need to eat too.

the point to be made here, in reference to what the article in about, is that at least when manufacturing was sent offshore, a benefit was returned to US consumers in the form of lower prices on goods. we can argue about the net effects on the economy, the quality of the goods, etc, but suffice to say that consumers did benefit.

How about now? The current wave of offshoring, any benefits to the consumer? Cheap XRAYS? What is Goldman Sachs doing with the cost savings from their offshoring efforts? Insurance companies are offshoring, see any rates reductions on your policy?

A common misconception among protectionists is that free-market competition necessarily leads to lower prices. Take Nike for example. A protectionist argues that because Nike is (re)locating in low-wage areas, that that cost-savings should be passed along to consumers. This attitude betrays a fundamental misunderstanding of economics. Nike not only has other variable costs that may be rising, but it may choose to re-invest its additional profit (if it is rising) back into the company, buy additional assets, distribute it back to shareholders, etc. Also, protectionists fail to understand that Nike spends billions on marketing and branding in order to get consumers to pay more for its product. Look at Tiger Woods.

The only thing that competition in a free(r) market guarantees is higher efficiency. To claim that prices should magically fall whenever a competitive decision is made is, well, myopic.

When my son had a closed head brain injury, I was not shopping for Wal-Mart prices among neurosurgeons. I wanted the best in the world. What is the best in care for your sick or injured child worth to you?

They're pissing into a hurricane. Non-classified knowledge jobs that can be ITed are all going offshore. A doctor in India working for $ 25/hour can just as readily diagnose you from your test results as can your $ 800/hour doc in Boston.

A few years ago Haldeman wrote a story of mid-21st century medicine. It was peopled by the equivalent of auto repairmen who simply followed the computer's instructions. It's coming soon. The fantastically wealthy physician is an historical anomaly seen only from 1955 to 2035.

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