Borders Fall for These Doctors

Her face illuminated by the fluorescent white glow of two computer monitors, Dr. Jenna Liu examined a CT scan of a car crash victim’s stomach.

Liu, a radiology resident at UC San Diego Medical Center, scanned through shots of the patient’s kidneys, noting the abnormal fluid around one.

It wasn’t long before the phone rang. A fax had arrived.

“That’s NightHawk,” Liu said.

In a time zone 17 hours ahead, a radiologist in Australia, working for a company called NightHawk Radiology Services, had been sitting before the same images. He functioned as a nighttime supervisor a world away, and through the fax confirmed her preliminary diagnosis: The patient’s kidney had a small tear.

Hundreds of hospitals around the country are engaging in a new form of outsourcing -- employing physicians abroad to assist doctors on staff -- whether to confirm a preliminary diagnosis or make it themselves.

For now, such medical outsourcing is mainly confined to radiology, because digitized images can be transferred nearly as easily as photos can be e-mailed. But doctors and experts say the practice will inevitably spread to other medical fields.

NightHawk doctors are located in Australia and Switzerland. Other companies -- including International Teleradiology, based in Australia -- have physicians in France, England and the Middle East, said Barbara Fitzgerald, a company spokeswoman.

“There’s no doubt that NightHawk or NightHawk-like companies are going to become more commonplace in the future,” said Dr. William Bradley, who heads the radiology department at UC San Diego and helped launch the Idaho-based company.

James Bentley, a senior vice president of the American Hospital Assn., agreed.

“Historically, you had to be in the presence of the patient to do an examination,” he said. Now, “you can do that at any place.”

Moving diagnostic or interpretive skills offshore is just another step along a continuum, said Dr. Blackford Middleton, chairman of the Center for Information Technology Leadership, a Boston-based research organization that focuses on how information technology can improve the quality of healthcare.

Nurse practitioners and others have gradually taken over certain aspects of patient care that were once solely doctors’ responsibilities, Middleton said. Now technology could allow for further substitution, from anywhere around the world.

A debate is brewing about whether this marks an advance or a wrong turn.

Some doctors say such services relieve the strain on radiologists in this country, who are in short supply as demand climbs in emergency rooms nationwide. Specialists stationed in time zones hours ahead of the United States have the benefit of working regular day shifts.

“If you are up all night doing this work, then essentially you’re useless the next day,” said Dr. Sanjay Saini, chairman of Emory University School of Medicine’s radiology department in Atlanta. “It’s better to have someone awake and alert doing it.”

Right now, the practice is not so much about saving money as sparing staff radiologists calls around the clock, Bradley said. However, the estimated $65 per case that the hospital pays NightHawk is “much, much less” than it would cost to pay U.S.-based radiologists at those hours, he added.

Nighttime aid also allows solo practitioners like Dr. Michael Fischer at Monterey Park Hospital to provide coverage more easily. Fischer usually has cases sent to NightHawk for preliminary readings after 11 p.m. and sometimes on weekends, depending on how busy he is. He then reviews and does final dictations on each case in the morning.

Some doctors say these international services are a dangerous expansion of the outsourcing trend -- with the potential to compromise the quality of patient care. They question the feasibility of tracking doctors and the quality of their work, and whether they can be brought to task if they make mistakes.

“It’s very hard to monitor day to day what’s going on if a person’s a world away,” said Dr. Arl Van Moore Jr., who heads a 70-doctor radiology group in Charlotte, N.C.

Companies like NightHawk only employ physicians who are American-trained and board-certified in their specialty. They are also licensed in the state from which patient images are sent, said Jon Berger, a co-founder and vice president of the company.

Yet Moore and other radiologists also fear the prospect of “ghost reading,” in which a board-certified radiologist sets up shop with foreign-trained doctors and just rubber-stamps their readings as his own.

The American College of Radiology was so concerned about outsourcing that it formed a task force to examine the potential challenges and pitfalls of using doctors outside the United States. It issued a report in February 2005, including guidelines that specify that consulting radiologists be licensed in the state in which they practice and credentialed at the hospitals receiving their reports.

“The expectation of our patients in the United States ... would be [to] have a level of training that was equal to or equivalent to the accepted standard throughout the country,” said Moore, the task force chairman.

The organization also warned that some liability insurers weren’t willing to cover physicians working overseas.

And hospitals could be held liable for an independent contractor’s malpractice, lawyers say.

A California appeals court said as much in a 2002 ruling. The case involved a woman suffering from neck pain whose X-ray was not properly read by an on-call, contract radiologist for Community Hospital of San Bernardino. Doctors told her that she only “had a twisted neck, but was otherwise all right,” according to the appellate court decision. When the patient woke up at home the next morning, she couldn’t move her arms or legs. Her neck was broken.

The hospital argued that it should not be held responsible for an incorrect diagnosis from someone who was not an employee, but an independent contractor. But the appeals court said the patient had no way of knowing “that the negligent physician was not an agent” of the hospital.

Now the patient’s lawyer wonders how it would have played out had the radiologist been across an ocean.

“You’ve got a situation where you could read diagnostic images anywhere in the world ... and not that that’s necessarily a bad thing, but what happens if there’s a screw-up and that radiologist commits malpractice? What do you do with that guy?” Martin Weniz asked.

“You want to be sure that you have somebody local that’s on the line,” he added. “You want to be sure that there’s someone who’s going to take responsibility.”

Mark Smith, president and chief executive of the California HealthCare Foundation, was more optimistic about overcoming current obstacles and about the potential for eventually using foreign-trained doctors to save money.

“Engineers do it,” he said of outsourcing. “Why can’t doctors?” Some hospitals already contract with medical-transcription or accounting companies that outsource to other countries, he added.

Smith said some of radiologists’ concerns have more to do with protecting their turf than real threats to patients.

“I think we have to be aware of a tendency that we as Americans have to assume that ‘made in the U.S.A.’ necessarily means made better,” he said.