Thrall weighs pros and cons of radiology outsourcing

Although the globalization of everything from transcription to equipment assembly permeates medical imaging, radiologists need not fear that outsourcing will threaten their jobs, according to Dr. James Thrall, radiologist-in-chief at Massachusetts General Hospital.

In the opening session of the RSNA meeting, Thrall explored unresolved issues associated with global teleradiology and identified safeguards against the exportation of radiology jobs.

Teleradiology is a fact of life for a growing proportion of practices, he said. Up to 30% of group practices use teleradiology for off-hours coverage. The best data on the use of overseas radiology, however, suggest that no more that 15% of this work is transmitted outside the U.S. for interpretation.

Many U.S. radiologists still feel threatened by the possibility of outsourcing, however. The magnitude of those fears became apparent to Thrall in news coverage of his department's teleradiology research project in Bangalore, India in 2003.

"Suddenly, we were on the front page of The New York Times, and every radiology resident in the country thought that I was destroy-ing their career opportunities," he said.

In reality, radiologists are concerned about the quality of global teleradiology services and the ability of the profession to control it, he said. Evidence suggests that global teleradiology performed by overseas radiologists at midday can be more competent than work done by weary U.S.-based radiologists at night. The medical literature has established a strong relationship between medical mistakes and long working hours.

"Rested radiologists make fewer mistakes," Thrall said. "Outsourcing call can address this quality issue."

In terms of radiology turf, Thrall argued that foreign competition is a nonissue. Global teleradiology is controlled by U.S. radiology groups or academic radiology departments. Their offshore providers must be board-certified in the U.S. and licensed in the states where the imaging they interpret is performed. They must have malpractice insurance. The growth of outsourced radiology is limited by Medicare's ban against payment for services performed outside the U.S.

A loophole in this scheme is the possibility of shadow interpretation by foreign-trained radiologists who interpret studies under the authority of a board-certified radiologist.

"This loophole has not yet been exploited, but it surely will be explored," Thrall said.

Compared with the 30,000 radiologists in the U.S., no more than 100 radiologists provide remote site teleradiology from outside the U.S., Thrall said.

Despite their small numbers, offshore teleradiologists may pose some risk to their U.S. peers. The reputation of radiology is potentially threatened if U.S. healthcare administrators should come to believe that medical imaging interpretation is a fungible commodity.

"Under the control of radiologists, to improve their practices, globalization may be all right," he said. "But other physicians, hospital administrators, and even entrepreneurs may co-opt the control of globalized radiological service, if it is proven that outsourcing works too well."