Angry Doctor

Thursday, March 09, 2006

Better, Faster, Cheaper 2

Teleradiology cheaper, faster and of good standard

IN THE letter, 'Isn't it cheaper and better to have in-house radiologists?' (ST, March 3), Dr Shoen Low Choon Seng asked if it would be cheaper to station a radiologist at Ang Mo Kio (AMK) Polyclinic, rather than outsource reading of X-rays to Bangalore, India, via teleradiology. It would not be cheaper. With 700 X-rays per month, his proposed arrangement would cost AMK more than $30 per X-ray just to cover the radiologist's salary. This is much more than AMK pays India.

As a trainee radiologist, Dr Low should know teleradiology has a proven track record and has brought sustained benefits to many patients in hospitals in the United States. It is not merely cost savings, but more important, faster turnaround time and often even better quality reports. Our brief experience so far has already demonstrated these benefits.

Dr Low raised the issue of legal liability. This is important in any outsourcing arrangement. It was fully and satisfactorily addressed in the US, even within the strong culture of medical litigation there. The key is to ensure that the appointed provider is appropriately accredited.

In this case, an assessment was carried out thoroughly. The Ministry of Health appointed the College of Radiologists as the accreditation body to determine the provider's suitability. The college conducted a site visit in Bangalore to assess the facilities and processes, and found them to be good. The college also noted that the provider was accredited by the Joint Commission on Accreditation of Health Care Organisations, the largest accrediting body on health care in the US. The college further tested the provider's proficiency and was satisfied with its standards.

The National Healthcare Group, which runs AMK Polyclinic, is legally accountable to its patients for the quality of its radiological services, including X-ray reports that are outsourced. Indeed, doctors are not new to cross-border consultation. Occasionally, doctors send tissue samples overseas for reading by foreign pathologists. Doctors who do so remain accountable to their patients here.

The delivery of health care will continue to be further globalised as a result of technology and the Internet. This opens up many opportunities. We should be alive to such opportunities, so we can bring such benefits to our patients, as pointed out by Mr Paul Chan Poh Hoi in his letter, 'Outsourcing is the right way to cut costs' (ST, March 4).

Teleradiology and any kind of outsourcing need not necessarily take place across borders. Our public hospitals and polyclinics will readily outsource reading of X-rays to local radiologists, when they can offer a similar or higher quality service as Bangalore at lower cost. Such competition will be good for our patients.

Karen Tan (Ms)
Corporate Communications
Ministry of Health


Globalisation of healthcare in the form of teleradiology and employment of 'foreign' healthcare workers has a very real human cost.

When you build a factory or an industrial park in a Developing Country, you provide employment for people who might otherwise be unemployed. When you employ trained healthcare workers to work for you rather than their own countrymen because you can pay them more, I think ethics come into the picture.

You are getting cheaper X-ray reports, nurses and doctors, they are losing essential healthcare workers.

Dr Crippen calls it 'exporting our healthcare problems'. It doesn't sound as grand as 'globalisation', but I think it gives a new perspective to 'progess'.



  • Be a surgeon.
    Better yet be a plastic surgen
    As long as u add value, yr job is safe

    Dr. Woffles TL Wu
    MBBS (Singapore), FRCS (Edin), FAMS (Plastic Surgery)
    Think of plastic surgery in Asia and one name immediately springs to mind – Dr Woffles Wu! This innovative and exciting plastic surgeon from Singapore has for years been the name on the lips of men and women seeking aesthetic perfection. Armed with an impeccable eye for beauty, balance and harmony Dr Wu, dubbed Asia’s Beauty Guru by the Hongkong press has reinvented and promoted the concept of Non Surgical Facial Rejuvenation(NSFR). He is today one of the most sought after speakers around the world on this topic demonstrating his combination of BOTOX, Fillers, IPL Photorejuvenation and his invention, the WOFFLES LIFT to achieve facial rejuvenation without downtime.

    Called the WOFFLES LIFT, this latest innovation by Dr Wu is creating a buzz in the aesthetic arena as doctors from around the world flock to Singapore or to the many international workshops that he conducts to learn how he manages to create a facelift without excising any skin and where the patients are able to resume activities that very day!

    This technique is fast capturing the attention of surgeons around the world as patients demand faster recovery times from rejuvenative procedures.

    In addition, Dr Wu is an Advanced Botox trainer for the Asia Pacific region and is constantly training physicians worldwide his techniques of Botox Browlifting, Facialsculpting and Chin rejuvenation and how to incorporate the use of BOTOX at all levels of Facial rejuvenation, with or without surgery.

    Dr Wu has also refined the art of breast augmentation surgery by introducing a simple technique he developed called the WW Stealth (Invisible) Incision. This is a zig zag incision placed at the areola rim of the patients nipple that allows the breast implant to be inserted with virtually no scarring at all, a significant improvement over the sometimes unpredictable scarring that can occur in the traditional breast or armpit crease incisions.

    By Anonymous Anonymous, At March 09, 2006 6:22 pm  

  • ironic isn't it?

    like a cat shitting outside its litter cage when the litter cage is clean.

    btw, you had a nice Wed? I wanna go next time too! heh. damn sian.

    By Blogger The Rational Neurotic, At March 09, 2006 9:53 pm  

  • Hi Angry Doc,

    I think this is a real issue. We have hospital adminstrators going on all expenses paid trips abroad to recruit nurses from countries who have excellent nurse training, but pay even worse salaries than the NHS

    These girls come over, send half their salary home to their famialies, but work here.

    This is wrong.

    I hesitate to suggest that people should not be free to travel the world, but one does wonder if it would be reasonable to say "if you do not wish to work for (say) 3 years in the country that trained you, you must pay back the cost of your training."

    It is a thought


    By Anonymous Anonymous, At March 10, 2006 2:37 am  

  • Doctors fight back in vain

    Cheaper and faster with teleradiology? Not so

    I REFER to the articles on tele- radiology and, in particular, the reply by Ms Karen Tan of the Ministry of Health ('Tele- radiology cheaper, faster and of good standard'; ST, March 6) to Dr Shoen Low's letter.

    I use the X-ray facilities at the National Healthcare Group (NHG)'s Ang Mo Kio Polyclinic for some of my patients and can state categorically that I have enjoyed neither faster reports nor lower fees as a result of outsourcing. Reports still come to me several days later and the fees have remained unchanged since NHG started outsourcing their reporting.

    In fact, I used to enjoy same-day reports and lower fees from a nearby centre operated by SingHealth using local radiologists. I am still enjoying reports within an hour from a privately-run facility using local radiologists. They charge a slightly higher fee. If need be, I can call the radiologist to discuss a case. I enjoy none of these with outsourcing.

    Local radiologists are licensed to practise in Singapore and are answerable to the Singapore Medical Council (SMC). The SMC is empowered to take disciplinary action against any doctor (radiologists included) if there is evidence of wrongdoing or negligence.

    Are the overseas-based radiologists registered to practise in Singapore? Are they directly answerable to SMC?

    NHG is not a registered medical practitioner and is not accountable in the same manner. I doubt if the SMC can censure or punish NHG for the wrongdoing of a foreign-based doctor.

    Ms Tan went on at length to assure readers that the doctors in Bangalore are proficient. I am sure they are excellent doctors but this has nothing to do with accountability.

    She also stated that 'doctors who do so (refer tissue samples to overseas expertise) remain accountable to their patients'. But these are direct doctor-to-doctor referrals, hence the local doctor remains accountable.

    Teleradiology is a fantastic development. I have discussed cases with a local radiologist about patients who had X-rays done at one place, the digital images read by a radiologist at another and myself at a third location. But all three parties were in Singapore.

    Teleradiology, as with all medical or technological advances, should be used to improve quality and not simply to cut cost. I see many applications for it but associated problems must be addressed transparently.

    Dr Loh Kok Chi

    By Anonymous Anonymous, At March 10, 2006 11:11 am  

  • I REFER to the letter 'Isn't it cheaper and better to have in-house radiologists?' (ST Forum, March 3) by Dr Shoen Low Choon Seng.

    Teleradiology is not something new. Many advanced countries are practising it and this signals the fact that this trade is profitable and sustainable. Medical industries are often highly regulated and it is unthinkable that the governments of these advanced countries would invest in a form of trade that is as unprofitable as described.

    Addressing Dr Low's first concern, I would like to point out that the overhead costs of any new business or trade dealings will always be high. To reject this path because of the $2.3 million initial cost resembles a minority who rejected the initial stages of the Industrial Revolution because of the cost of buying and maintaining machines. Thanks to the majority who believed in moving forward, today we stand as grateful beneficiaries of the revolution.

    The sum of $2.3 million might not seem so high if medical practitioners in Singapore are willing to utilise and support this system, for in so doing the cost per X-ray reported will be decreased. Spending this amount of money might also be justified if we understand 18th-century economist David Ricardo's theory which states that 'each country should specialise in producing the good for which its comparative cost is lower'. Comparative advantage is the main basis for most economists' belief in free trade today. The idea is this: A country that trades for products that it can get at lower cost from another country is better off than if it had made the products at home.

    Clearly, the comparative advantage (cheaper labour costs in India, the allocation of local radiologists to more promising industries) will outweigh the $2.3 million cost.

    Dr Low's second concern of whether the radiologists in India are legally liable to our laws or medically well-trained is a relevant one.

    As a medical industry, the overriding principle that the welfare of patients is maximised must be enforced and cannot be compromised for the sake of profit. From this perspective, many might see a dead end to the path of globalisation for this industry. However, I see an endless spectrum of opportunities.

    For isn't this the best time to export our legal and medical professions, and in so doing make Singapore both a medical and legal hub in this region? Koo Zhi Xuan

    By Anonymous Anonymous, At March 10, 2006 11:12 am  

  • More cost-effective to have teleradiology in Singapore itself

    I AGREE with Dr Shoen Low Choon Seng's letter, 'Isn't it cheaper and better to have in-house radiologists?' (ST Forum, March 3).

    Indeed, $2.3 million spent on Pacs (Pictures Archiving and Communication System) may be on the high side and it can take many years to prove to be cost-effective.

    Teleradiology is an enhancement feature of Pacs which allows images in Dicom (Digital Communications in Medicines) format to be transmitted from one node (computer terminal) to another over dedicated leased lines.

    It would be more cost-effective to have teleradiology within Singapore itself. In this case, images made in Ang Mo Kio Polyclinic can be 'tele-d' to a local tertiary institution's reporting centre. The reporting turnaround time can be even faster than that of India.

    The system implementation costs could be even lower as most radiological settings in our local tertiary institutions have Pacs. Dedicated leased lines would not cost much too, with our strong local network markets.

    This could also further reduce operational costs and human resource issues.

    And it would allay the legal responsibility concerns raised by Dr Low, as the images will be reported by Singapore-based radiologists.

    One more important issue to note is that of patient confidentiality. As images are transmitted via Dicom format, a patient's particulars are hard-coded into the image Dicom files. Any tech-savvy person can easily extract a patient's name, address and other details from the images. No doubt a non-disclosure agreement might have been signed, but then again, it has to be enforced in order to prevent any abuse.

    Achieving a local teleradiology hub would be more beneficial to our healthcare system, without compromising underlying healthcare and legal issues.

    We can also expand this capability to our regional, and even global, clients, enhancing Singapore as a medical hub. Lim Boon Teck

    By Anonymous Anonymous, At March 10, 2006 11:13 am  

  • Wow. A flurry of letters about the teleradiology outsourcin in the Straits Times forum again.

    I wonder what the Singapore Radiological Society's stand is on this?

    Where are these people? Why aren't they writing in to the forum?

    SRS Committee Members

    President: Dr. John Hoe
    Vice-President: Dr. Winston Lim
    Honourary Secretary: Dr. Tchoyoson Lim
    Honourary Treasurer: Dr. Lesley Goh
    Committee Member: Dr. Yap Swee Peng
    Committee Member: Dr. Harvey Teo
    Committee Member: Prof. David Stringer
    Committee Member: Dr Chua Gim Chuah
    Committee Member: Dr. Andrew Tan

    By Blogger Dr Oz bloke, At March 10, 2006 11:26 am  

  • You very impatient lah.

    They are preparing a CONSIDERED response.

    If not, the names you enumerated should individually give their side of the story for us ordinary folks to understand what the hoo hah is all about.

    Hee Hee. Never a dull moment living in Singapore. Who says this is a boring place.

    By Blogger uglybaldie, At March 10, 2006 12:05 pm  

  • Hey uglybaldie,

    You wanna take a bet?

    I bet there will be no word from the SRS. They look like the College of GPs and other organizations in medicine. Social club. Organizing talks and CME that's all.

    Anything political they run away.

    Cheers! :)

    By Blogger Dr Oz bloke, At March 10, 2006 12:18 pm  

  • "Anything political they run away."

    Please lah, what's so political about outsourcing?

    It's economics man.

    Face up to the new reality.

    One day, teledoctoring now being tried out will be a reality.

    So the only members of the medical fraternity surviving in Singapore are the plastic, oncological, orthopaedic, general surgeons. In any case, to me, real doctors are surgeons anyway. When they incise, their medical skills are being tested to the limits. Awesome man....

    By Blogger uglybaldie, At March 10, 2006 12:50 pm  

  • Hey the future for surgeons is teleoperating.

    There are robots that surgeons can control over the information highway

    Currently many operatiosn are going MIS (minimally invasive surgery).

    So don't be surprised patients will be operated by Indian surgeons from India in future.

    As it is remisiers also going out of biz liao right?

    Heck when not EVERYTHING done by Indians lah.

    Cheaper what.

    By Blogger Dr Oz bloke, At March 10, 2006 1:02 pm  

  • Have you applied for the taxi vocational licence yet. Better be quick. I heard that soon, we may have FT Indian and PRC taxi drivers plying our streets. Like in New York. They have taxidrivers of every nationality on Earth.

    I bless the day I retired. No more hassle about a job and earning a decent meal. Just spend my days posting hogwash and bringing my pomy, Downer to the seaside for a walk.

    If radiological services needed, just pop into the vending cubicle located in the polyclinic and get reading and diagnosis straight from the Indian radiologist in Bangalore to my computer. If medical consultation required, just have video conference with Chinese or Indian doctors and pay by Visa. If surgery required just book into the SRH (Singapore Robotic Hospital) and get operation done by telesurgery at one fifth of the cost. If medicine required, just order from the countless reputable internet pharmacies and get it delivered the next day by UPS. Wow, what a wonderful world! The future has arrived.

    A great day for the down trodden patients. Like they say, Every doc. has its day.

    By Blogger uglybaldie, At March 10, 2006 1:16 pm  

  • Way to go uglybaldie.

    I think I should go to the next MRT station and jump in front of the train.

    These days so easy to commit suicide with a BANG and guarantee to make the news!

    Woo hoo!

    By Blogger Dr Oz bloke, At March 10, 2006 1:23 pm  

  • People who disrupt the smooth running of our world class MRT are the marginalised, the down trodden, and the drug addicts.

    If you do, it would indeed be newsy.

    But don't worry, behind you queueing up to take the plunge are the displaced and jobless accountants, architects, engineers et. al. I think we should also outsource the running of some of our hospitals as well. Cheaper to pay Indian or Chinese administrators rather than our half baked ones.

    Right now, banks are outsourcing their back room operations to, yes, you guessed it, some indian back rooms in Mumbai or Bangalore or whatever. So don't be surprised if your account details are known amongst them. I get calls almost every week from some tele marketing people selling every thing from spa treatment to insurance and when I enquire further, they are calling me from some unpronounceable indian city using internet telephony to make their sales pitch.

    Jeezus, What the f##ks is going on. Not the world I know definitely.

    By Blogger uglybaldie, At March 10, 2006 2:13 pm  

  • Hey the first people we should outsource are the most expensive ones that we pay through our noses for.

    1. Singapore Prime Minister's Basic Salary US$1,100,000 (SGD1,958,000) a year
    Minister's Basic: US$655,530 to US$819,124 (SGD1,166,844 to SGD1,458,040) a year

    2. United States of America President: US$200,000 Vice President: US$181,400
    Cabinet Secretaries: US$157,000

    3. United Kingdom Prime Minister: US$170,556 Ministers: US$146,299 Senior Civil
    Servants: US$262,438

    4. Australia Prime Minister: US$137,060 Deputy Prime Minister: US$111,439
    Treasurer: US$102,682

    5. Hong Kong Chief Executive : US$416,615 Top Civil Servant: US$278,538
    Financial Sec: US$315,077

    Source: Asian Wall Street Journal July 10 2000

    By Blogger Dr Oz bloke, At March 10, 2006 2:26 pm  

  • Your boat just sailed across the OB markers and into Indonesian waters!

    Please start your motor and rudder back into marina bay ok?

    By Blogger uglybaldie, At March 10, 2006 2:33 pm  

  • "Please lah, what's so political about outsourcing?

    It's economics man.

    Face up to the new reality."

    By Blogger Dr Oz bloke, At March 10, 2006 2:43 pm  

  • Hee Hee,

    You're funny for someone who is suicidal.

    It's political when you make innuendoes about our respected PM's pay. Personally, I think he's worth every penny and more.

    Let's have my fond friends from the pharma fraternity voice their opinions on outsourcing their services.

    I'm off to sing the evergreens.

    Need some respite from this mad mad world of outsourcing.......

    By Blogger uglybaldie, At March 10, 2006 2:51 pm  

  • We should outsource Karaoke services also.....

    By Blogger Dr Oz bloke, At March 10, 2006 2:57 pm  

  • Hi angry doc,
    Thanks for asking me to comment on your blog. I am a radiologist practicing in Tamil Nadu, India.
    I read through your post and the ensuing comments. First I want to clarify that I am not involved in international teleradiology. I do use teleradiology to read CT scans at home on weekends. I agree with some of the previous commenters that teleradiology is a good thing and that its here to stay. But I admit that I was surprised at the vehemence of the opposition shown by some of the commenters. International teleradiology is practiced by a miniscule number of radiologists in India - mostly out of Bangalore. The issue has raised the hackles of the medical & radiological fraternity in the US too as evidenced by the perspective article in the February 16, 2006 issue of NEJM (The "Dis-location" of US Medicine - The Implications of Medical Outsourcing by Robert M Wachter).
    I don't have much to say about this - it is basically an issue for the local doctors who are within their rights to be vary of any such new venture. I also strongly agree with Dr. Crippen that we in India are losing essential healthcare workers to the lure of easy dollars.

    By Anonymous Anonymous, At March 17, 2006 12:19 am  

  • Dr Scan Man,

    Thanks for your comments.

    I hope you will continue to visit and give us your perspective.

    By Blogger angry doc, At March 17, 2006 9:27 am  

  • come on singaporeans, get used to it - you sucked, you overcharged and now someone else gets paid to do the work for u. why? cos they can do much better work without the exorbitant prices they charge here. is that reduced cost transferred to the patient? if yes, cool! if not, then good too cos ur country is just making more money for itself. whats the problem ?

    By Anonymous Anonymous, At April 08, 2006 1:44 pm  

  • My god, labour arbitration at its best. In the long term, globalisation is simply a race to the bottom for someone else's bottom-line. Consequently, globalisation results in the systematic exportation of poverty and inferior living conditions abroad.

    Many medical doctors from India would not be able to register to practice in most OECD countries and for good reasons. Apart from cultural differences and language competencies, the powers-that-be should have considered that the standards of training are different. Unless the Chinese/Indian-trained radiologists are registered in Singapore, teleradiology is the bona fide practice of medicine WITHOUT a license.

    So how different are the training standards you ask? Recall, Dr Death.

    By Anonymous Anonymous, At December 30, 2006 9:16 pm  

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