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
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
"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."
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
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."
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
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."