Radiology in Singapore, 2003

September 5, 2003

1. Dr. Mutsuhisa Fujioka, chair of the Asian & Oceanic Society for Paediatric Radiology, and Dr. John Hoe at the SRS annual

About 100 full-time equivalent diagnostic radiologists currently practice in Singapore, along with 110 registered specialist radiologists, not all of whom practice full-time. Given Singapore's small population of about four million, the per capita ratio of approximately 25 radiologists per million is low, especially compared with Western nations such as the U.S., France, and Sweden (approximately 100 per million) and Australia (about 65 per million). It even lags significantly behind Hong Kong (about 45 per million). While training has been stepped up to increase the number of specialist radiologists here, another 70 FTE radiologists will have to be added to match the current level in Hong Kong.

The direct result of this staffing shortage is that radiologists in Singapore routinely report far more studies per year than their Western counterparts; typical figures of 15,000 to 20,000 per annum are conservative and are often exceeded. Radiology accreditation bodies in the U.S. and Australia recommend that radiologists should not report more than 12,000 studies per year if they are in general practice and 8000 per year if they are in academic practice. Although the Ministry for Health is aware of these recommendations, the situation here cannot be corrected for some years; doing so would require institutions to recognize that increased staffing will lead to improved standards (not just speed) of service and skills, and that will require adjustment of remuneration and fees.

Most radiologists in Singapore have the FRCR (Fellowship of the Royal College of Radiologists, London) as their specialist qualification. Traditionally, most Singapore radiologists trained in the U.K. and sat for the FRCR there, but this trend has been changing in the last decade. The large public and university hospitals are now accredited as training centers for the FRCR in diagnostic radiology, and most trainees now do their basic training in Singapore but sit for their FRCR qualification in either Hong Kong or the U.K. Only one postgraduate degree in radiology, the master of medicine (M. Med.), is currently recognized in Singapore. This examination, conducted by the National University of Singapore, has until recently been held only sporadically, but it is evolving into a high-quality qualification similar to the FRCR Part 2B.

The FRCR Part I examinations were recently held here for the first time, and the eventual goal is to conduct the FRCR Part 2B exams in Singapore, perhaps in conjunction with the M. Med. The National University Hospital in Singapore has been accredited to train both diagnostic and therapeutic radiologists for the FRANZCR qualification; this radiology qualification is also recognized in Singapore.

Many trainees spend at least one or two years overseas at the end of their training. Although in the past this tended to be in the U.K., most now go to the U.S. to do fellowship programs in order to develop subspecialty skills. Although there is generally no formal subspecialization in diagnostic radiology within Singapore, many radiologists in the larger hospitals have subspecialty interests. Often, more than 80% of their work is in their subspecialty, particularly in highly specialized tertiary centers such as the National Neuroscience Centre and the National Cancer Centre. The shortage of radiologists, however, makes it difficult for most hospital departments to subspecialize along North American lines. At least 17 radiologists would be required for each department, with two per section and one chief. Only one department in Singapore can boast this level of staffing at this time, but it also has the highest workload of any department here.

Healthcare in Singapore is financed by a combination of taxes, employee medical benefits, compulsory savings in the form of Medisave, insurance, and out-of-pocket payment. Patients in the public sector pay a subsidized fee for their radiology examinations, as the government does not believe that all patients should receive all their medical care and examinations free and that co-payments are necessary to rein in healthcare costs. In the private sector most patients pay directly for their radiology examinations, and only about 5% to 10% are covered by private healthcare insurance.

About two thirds of the radiologists in Singapore are employed in the public sector and work at public or university hospitals; the rest are in private practice. As the remuneration of medical specialists in the public sector is quite high, and government policy is to try to retain medical staff in public hospitals by paying specialists both a basic salary and a clinical component based on fees from paying patients, there is less of a disparity between the remuneration levels in the private and public sectors. This contrasts with many other countries, including the U.S. Australian state governments have recently taken steps to substantially increase the salaries of hospital specialists to similarly reduce the drain of skilled manpower to the private sector (about 80% of radiologists in Australia are in private practice).

Another factor limiting the attractiveness of the private sector is the competitive nature of radiology practices, which do not have third-party payers such as insurance companies to keep examination fees at a relatively high level. As a result, fees charged for radiology examinations in both the private and public sectors are often much lower than in the U.S. and U.K.

Almost all radiology departments in Singapore are well equipped with the latest technology, including multidetector CT scanners, 3D ultrasound, and high-field MRI. A 3T MRI unit is installed at the National Neuroscience Centre and a cyclotron for PET isotope production became operational in July, developed by a public sector-private sector joint venture. Three PET/CT scanners are installed or being installed. Full PACS have been implemented in four hospitals and will be installed in almost all the major public hospitals by the end of 2005.

The Singapore Radiological Society (SRS) is the national radiological society that represents the interests of diagnostic radiologists, therapeutic radiologists, and nuclear medicine physicians. The society has about 165 members and is a member of regional and international societies such as AAR (ASEAN Association of Radiology), AOCR (Asian Oceanian Society of Radiology), and ISR (International Society of Radiology). The SRS is actively involved in education, and in addition to organizing congresses related to these societies, it also runs an annual scientific meeting, several smaller meetings, and CME lectures held in conjunction with the Chapter of Radiologists, Academy of Medicine, Singapore.

The SRS includes various subspecialty sections (musculoskeletal radiology, pediatric radiology, cardiovascular and interventional radiology, and neuroradiology) that act as the national representatives to international societies. The society has also created the SRS Trust Fund, a registered charity that supports and funds the training and education of radiologists, as well as radiographers in Singapore.

AcknowledgmentThe author wishes to thank Dr. Wang Shih-Chang for contributing to this article.