Picture of Health

Many surgeons practise in the same hospital for years, and many will work in the same country for their entire careers. But Dr Uwe Klima, professor of surgery at Singapore National University Hospital’s department of cardiac, thoracic and vascular surgery has worked in Europe, the US and Asia.

He started his training in cardiothoracic surgery in Austria. From there he went to the US for two years – to Harvard Medical School – before returning to Austria for a year. He then spent almost ten years at Hanover Medical School in Germany. In October 2006, he moved to Singapore. So, how does Dr Klima think cardiothoracic surgical practices differ around the world?

"I think the pharmaceutical companies are most innovative in the US," he replies. "However, there are so many regulations in the US that companies usually go to Europe to do their procedures first, to get FDA approval. State-of-the-art procedures are done in Europe and the US. There is advanced cardiac surgery in Singapore, but there are many places in Asia where there is enormous demand for more cardiac surgery, diagnostics and support.

"Regarding cardiac patients, especially in the US and Europe, the number of bypass procedures is going down because interventional cardiologists are seeing more patients and are being more aggressive in their treatments. However, in Asia, the market is enormous. Many patients need a doctor but cannot afford state-of-the-art treatment.

"Singapore is very different because it’s very rich, but it is surrounded by other countries without enough cardiac surgery units where there is enormous demand."

HEALTH INEQUALITY

Klima has been to a number of Asian countries where he has seen vast differences in healthcare provision. "I have been to Myanmar, the Philippines, Vietnam, Indonesia and Malaysia," he says. "It is very clear – much clearer than in Europe – that there is a two-class society, rich people and poor people. The rich are very rich and the poor are incredibly poor. Most countries in Asia do not have a social security system that gives universal access to medical care. Many people are too poor to afford surgical procedures even though it is absolutely necessary.

"Some people are so rich they do not care about the cost, so they fly to Singapore, or other places, to get state-of- the-art treatment. There is such a big difference. In Western Europe, everybody has insurance or the state provides care, so no one slips through the net. It’s completely different in Asia. If you do not have a family to help pay for the procedure, it’s tough luck."

THE SAME, BUT DIFFERENT

Klima says that the surgical procedures used in Asia are the same as those practised in the West. He says: "[In Singapore] we use the same instruments and the same tools. And people all have insurance. But when you go to poor countries, such as Myanmar, there is so little money in the system that surgeons may be limited in what they can do. A patient may be able to pay for the oxygenator, but not the valve, so it might not be possible to do a complete procedure. It’s a really sad situation."

Although surgical procedures are the same in Asia, he has noticed a difference in the way patients are treated. He says: "Western standard medicine is the same everywhere. What can be found worldwide is that, as cardiologists are getting more aggressive with coronary arteries – by putting in more drug eluting stents – the number of coronaries is going down, not significantly, but it is a trend.

"My impression is that, the more money there is in a system, the more aggressively a doctor will approach a patient. In the US, cardiologists may use five stents because they make five times more money. In Western Europe insurance doesn’t pay every time you do a procedure, so there will be earlier referral to a cardiac surgeon. If there is a lot of money in the system, you can end up with over-treatment."

TRAINING VARIATIONS

Another major difference Klima has noticed is in the training of surgeons, particularly between Western Europe, the US, the UK and the Commonwealth systems. "There’s a very strong hierarchical system in Germany, Austria and Switzerland, where there is one guy at the top of the pyramid who is in charge of everything. It is good for him, because he makes a lot of money, but consultants are unhappy because they are paid so little. However, it is good for training because it is so structured.

"In the Commonwealth, the US and Singapore there is also a pyramid structure, but it is very flat. The senior consultants and consultants are happy because they have a good potential income. However, the training is better when you have a steep pyramid, because the roles are very clear. If you have consultants and registrars running around and everybody doing different procedures, it takes longer to get to the standard that you see in Western Europe."

MEDICAL TOURISM

The fact that surgery provided by hospitals in Singapore is equal to the best in the world, but is available at a fraction of the cost, has prompted a trend towards medical tourism. And Klima says he has noticed a marked increase in medical tourism as people have gained access to the internet.

He says: "Places like Singapore offer state-of-the-art Western-style medicine for half the price it would cost in the US. Patients now come from the US to Singapore to get their surgery done. I think there will be more tourism in the medical field in the future."

He adds: "The difference in price is due to the fact that, in the US, there is so much money in the system that people overpay and that manpower is much cheaper here [in Singapore]. An operation may only cost one tenth of what it would cost in the US. Travelling may be inconvenient. But many people are won over by the prospect of saving $15,000 on one procedure."