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- Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology⁎ ()
- ↵⁎Address correspondence to:
Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 400, San Diego, California 92122.
In a previous Editor’s Page on international cardiology, I observed that the world is getting smaller. In his much discussed book The World is Flat(1), Pulitzer Prize winning author Tom Friedman argues that this process has now reached warp speed, and will likely obliterate many traditional boundaries between nations. Such flattening will have major implications for society; medicine and cardiology will be no exceptions.
The concept of a flat world is a take-off of the well-known cliché of “a level playing field.” Clearly, the industrialized societies of the world have enjoyed marked advantages in terms of information, education, and employment opportunities compared with underdeveloped countries. Moreover, geographic considerations have presented barriers that have made it difficult to overcome these differences. However, these geographic barriers were obliterated by the abundance of fiberoptic cable installed during the dot-com boom, which provided rapid low-cost communication of data everywhere in the world. The result has been a leveling of access to information so that anyone, anywhere, with access to the Internet can acquire the same data as someone in the U.S. Additionally, the fiberoptic cable enabled a broad spectrum of tasks to be outsourced to Asia and eastern Europe where they could be performed at much lower costs and the large labor pool of highly educated individuals could be exploited.
The change produced by flattening of the world that has attracted the most attention is the outsourcing of work and jobs. It has become a common experience for service calls from the U.S. to be handled by individuals in India. In addition, high-tech companies such as Dell, Hewlett-Packard, Microsoft, and General Electric operate units outside of the U.S. both for low-level “backroom” work as well as to develop new software. As time goes by it is anticipated that the tasks performed offshore will increase in complexity and involve higher levels of research and development. One of the most striking features of this disruptive evolution to me, however, is that the necessity and incentive for individuals to immigrate to industrialized countries for knowledge or challenging/interesting jobs could be largely eliminated. My impression is that the drive, ambition, and work ethic of immigrants have been major forces in sustaining the productivity and innovation in the U.S. for many years.
The flattening of the world has the ability to affect medicine and cardiology in many ways, both predictable and unpredictable. It is interesting that one of the first instances of outsourcing was by a group of physicians who sent their billings and collection work to be done back home in India. Medical records are a voluminous, terribly important, but relatively low-tech aspect of medical practice, and they are a prime candidate for increasing outsourcing. Transition to electronic medical records could likely hasten this trend.
Of much greater significance, of course, is the potential for outsourcing medical services. This has already started in regard to imaging, specifically involving interpretation of radiology services. In fact, a company called Nighthawk Radiology from Coeur d’Alene, Idaho, claims that 500 U.S. hospitals use its services and have radiology studies interpreted by Australian physicians. Similar services are provided by physicians in India. Most of these physicians have received training in the U.S., and it appears most interpretations are preliminary and are over-read by American radiologists. These services are predominantly used at night, a good arrangement because it is daytime in India and Australia. Those using these “Nighthawk” arrangements claim that there are no other radiologists available, or that eliminating night calls improves the accuracy and productively of staff radiologists during the day. (Parenthetically, the inability of U.S. radiology manpower to handle this work is surprising relative to the strong stand they have taken in seeking to provide computed tomographic angiography services.) The fact that the cost of radiology services in India is about 10% that in the U.S. is significant for some arrangements. Some have looked upon these outsourced radiology services with concern, especially with regard to quality, liability, and credentialing. Others have viewed them as a lever to reduce reimbursement for interpretation of radiographic studies.
Radiology services are not the only ones being outsourced. There are increasing reports of American patients obtaining surgical procedures in India and Thailand, coronary artery bypass grafting being prominent among them. Nearly all of these individuals cite the lower cost as the primary motivating factor; however, the addition of vacations may be an added incentive. Most patients are uninsured. They point out that they can fly to India or Thailand, have coronary bypass surgery and a side vacation, and still pay only a fraction of the cost in the U.S. I have read that the National Health Service in Britain has outsourced surgical procedures to India in the face of long waiting times. Sufficient interest exists that hospitals in India and Thailand have generated programs to attract foreign patients.
As with most things in life, medical outsourcing has its pros and cons. Without appropriate controls to ensure quality, of course, it is a nonstarter. However, the U.S. is facing a shortage of specialists, and outsourcing is one approach to the problem. Although such outsourcing could have a negative impact on those whose jobs are involved, a benefit in cost will accrue to the rest of society. On the other hand, health care is a unique service, and the doctor-patient relationship is a special one. I just do not think many medical services lend themselves to outsourcing. It would be enormously regrettable if this special aspect of medical care was sacrificed in the name of cost reduction.
Outsourcing is just one of the ways that a flat world may affect medicine/cardiology. In terms of information, the Internet provides easy access to medical knowledge for the public. Our patients will continue to be progressively better informed when seeking and deciding on health care. The flattening world will intensify competition in the business sector. In this regard, one of the major differences in the expense of conducting business here rather than abroad is the cost of health care. One can anticipate that the pressure to reduce health care spending will be markedly increased in a flat world. It seems to me, however, that this is an area in which the field should be leveled in the other direction. Society overall will be negatively impacted if the requirement to achieve lower product costs imposed by a flat world is a lesser level of health care services. Patent rights for intellectual property are one of many other issues that flattening will present. The majority of medical advances have been encouraged by the opportunity for reward, and I believe it would be important to maintain this relationship in the future.
In his book, Friedman opines that the forces currently acting to level the world are occurring more rapidly and will be more disruptive than any other change that has affected civilization. Not specifically stated, but obvious, is the fact that the leveling process has more potential to negatively impact those who begin on the higher ground. This is certainly the case for medicine in the U.S. which, for some time, has generally enjoyed the reputation as the best in the world. We have benefited by receiving patients, and much more importantly, trainees from all over the world. I think that the loss of brain power would be particularly detrimental. However, it seems to me that this flattening is inevitable. Moreover, a rising tide will raise all ships and improve the lot on both sides of the playing field. It will create challenges for sure, but that is what makes life interesting. As always, they will succeed who are best prepared.
- American College of Cardiology Foundation
- Freidman T.L.