Overnight outsourcing

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 that offshore outsourcing works even in medicine.

Over 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. And while that doctor was groggy, "we didn't have the luxury of that guy taking the next day off."

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, with technology enabling the speedy transfer of medical data over the Internet to virtually anywhere there's a compatible computer. That means radiologists in Australia, India, Israel and Lebanon are reading scans on U.S. patients. Most are designed to take advantage of the time difference.

Neither Saint Francis Medical Center nor Southeast Missouri Hospital outsource radiology work.

Despite fears from some doctors, advocates insist offshore 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 doctors like Dr. Arjun Kalyanpur. A U.S.-licensed and credentialed radiologist, he got his postgraduate training at Yale University and runs a respected two-man service from Bangalore, India, called Teleradiology Solutions.

Also a Yale faculty member, Kalyanpur 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 now read 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.

Facing the same phenomenon, radiologists at Chicago's Swedish Covenant Hospital hired an Australia-based company called International Teleradiology Corp. 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 double-reads the scans the next day, and doesn't have to come in "with our tails dragging."

Some call this practice "nighthawking," and 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. A trade journal reported earlier this year that there has been an average of four vacancies per radiology department at American academic centers in the past two years.

The use of teleradiology, including outsourcing, 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 task force warned it was "very concerned about the implications of overseas radiology and its potential effect on patient care in the United States." The ACR said doctors who interpret the scanned images should meet or exceed the standards for U.S. physicians.

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, the task force said.

Dr. Arl Van Moore Jr., a Charlotte radiologist who chaired the task force, said offshore 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 untrained, unskilled 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, there is a pilot project that does rely on non-U.S. trained radiologists.

A division of Bangalore-based Wipro Ltd., 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 Wipro's Supratim Sarkar.

He refused to identify the American hospitals involved in the project, saying it was confidential. While Indian radiologists generally make about a 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," he said.

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," he said.

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