My right knee MRI

A single fall while skiing at the Devil's Head Resort, WI, turned out to be a little more than what my knee could handle. Symptoms: Pain in right knee, no swelling (immediate or delayed), unable to straighten knee, and weakness in right knee. Hypotheses: Meniscus tear or torn ACL.

I looked up my enrolled healthcare plan choice - a HDHP (High Deductible Health Plan). It definitely made sense for me at the time when I enrolled since I am the "young invincible". My total annual premiums are $650, which has a $2.7K deductible, and an average 10% co-pay after I hit my deductible. Flashback to Leon Wyszewianski's HMP601 class, "Typical young invincibles include people in the early twenties. Individuals who have less need for health care, so HDHP which comes with lower premiums and higher deductibles is an appropriate choice for them". 


My four other choices were a 1) PPO which I would pay $1.56K annually, 2) an Open Access (almost 90% coverage for everything) pegged at $1.664K annually, 3) a basic plan (almost everything out of pocket) at $286 or 4) no coverage. There was no way I would take option 3 because that's just useless and given I'm a strong supporter of Obama's mandatory health insurance, there was also no way I would go against my own principles by taking option 4.

Well, five weeks later, I am in the midst of packing my bags to go home to Singapore for a 2 week vacation. I decided to confess my knee injury to my mum and asked her to set up an appointment with a orthopedic specialist to look at my knee. I assured her that there was nothing wrong with my knee, but I just wanted a second opinion. But deep inside, I knew that an MRI was probably imminent. But either way, I would have rather gotten an MRI in Singapore than in the states because of the ease in accessibility and cheaper cost since I was paying out of pocket.

First visit to the orthopedic specialist's office took a 45 min wait even though I had been scheduled a slot at 12.15 pm. The doctor finally waved me in at 1 pm and the whole check-up took about 5-7 min. Conclusion: Get an MRI.

"What is the turnaround time for an MRI"- me.
"Today or later this afternoon if you want. The assistant will schedule our follow up appointment". -Doctor
"Okay....I'll schedule for next week then".
"No problem".

I think to the doctor it sounded ridiculous that I asked what the turnaround time was for an MRI. Because in the states, it would take quite a few days! Granted that Mount Alvernia where I was scheduled to get an MRI was a private hospital, but I wouldn't have imagined a same turnaround time for for-profit hospitals here in the States. Turns out that the MRI would cost $588 SGD in total after taxes, which translates to about $470K in USD. Not bad at all. In  the states, an MRI would have made me USD$1K poorer, at least.

Before you start thinking that healthcare is all cheap, efficient, and accessible and all perfect in Singapore.. hang on till I finish my story.

The scheduled day of my MRI finally comes. I had asked for the first slot in the day at 8.30 am so that I wouldn't have to wait. In fact, I got to Mount Alvernia's imaging department at about 8.10 am and submitted my name for registration promptly. Not before long, I was cued by the MRI technician (last name Li) to enter the MRI room.
All too familiar to me. I can probably spew off more facts about the MRI machine than he can. Typical questions- are you pregnant? are you on drugs?  etc. and then I am off to change into my patient gown.

Patient gown was impressive! In fact, it was very comfortable. Unlike the gowns in the states which really don't protect the modesty of the patients, these gowns were made from materials with high thread count and  was worn like the Japanese yukata. The process of putting on was simple as ABC; there was even a poster on the wall explaining how to wear the patient gown.

Upon entering the MRI room, I made a special note to myself to put the locker key on a separate location. I was surprised that the technician didn't really ask. (I've heard of horror stories of MRI or X-ray imaging with metal objects). Finally I lay prostate on the imaging bed, which was  a really uncomfortable board. The bed itself was so narrow. Before long, I was lying there wondering how someone with a wider waist girth could possibly fit onto this bed. Anyway, it proceeded to be a pretty pleasant experience with Li offering me a pair of headphones, briefly explaining to me what was going to happen with the "machine making funny sounds" but "please don't move", and asked me for my favorite music channel to play.

And so I lay there listening to morning news on Channel 95.5 while lying on this uncomfortable board, right knee strapped up, unable to budge, and being semi-naked under the patient gown and a pretty thick blanket.

Ten minutes later as nothing really happens, Li walks into the imaging room and starts pushing some buttons on the machine. He seemed to shut it down and reboot it again. Then he told me that he needed to "restart the machine because it is overheated".

OVERHEATED?! My heart just skipped a beat when I heard that. What if he didn't check that I was overheated and had already sent me into that MRI machine. Would I have suffered from over-radiation? Would I get horrific visible burns like that one picture I saw a year ago of a patient who was applied too much radiation intensity during an X-ray?

Being the obedient patient who didn't want any over-radiation, I continued to lie on the uncomfortable bed, unbudging, uncomplaining. For another 30 minutes.

After what seemed like an eternity, Li walks in the door and unloosens my right knee strap and asks me to stretch a little before I get numb lying in the same position. Thanks for the heads up, really.

Another 20 minutes passed before Li finally walks in the door and gives me an apologetic face. He said, " I'm so sorry, the machine is overheated and we have to get the maintenance guys to come and add the coolant. It will be another few hours before it will be done". At this point, I was just happy to be able to get off that narrow imaging bed and change into my normal clothes rather than being mad that it took so long before he came in to tell me what the problem was. Li responded that I would be the first on the line if I wanted to re-schedule for one or two hours later when the machine was up and running.

Being the first in this situation may not necessarily had been the best thing, given my fears of over-radiation still running through my head. I said I would have to call my specialist to see what his availability would be  for later in the afternoon since I was leaving the country in two days and wanted him to read my films and give me my diagnosis.

Anyway, I proceeded to go the registration front desk myself to get my own patient card and dialed my physician's office. I got the doctor on the phone and told him about the MRI backlog. He said that I should probably still get the MRI, and although he was not available, he would give me a call later that afternoon once he got my films to give me a verbal report. I conveyed my wishes to reschedule to Li and he stated he would give me a call later when the machine was fixed. By this time, the waiting room was swamped with people, technicians were running around like crazy, and the registration assistants were just confused on what to do with so many people constantly asking them questions. I left for the cafe with my mum to get a bite and just to get away from the crowded waiting room.

In about 1.5 hours, I got that much-awaited call from Li and went back to get my MRI performed. This time it went all smoothly, with the MRI only taking 20 minutes to complete. I got my film immediately from them since I was already late for my original appointment, brought the films up to the specialist department myself, and paid for my MRI there. My doctor called about 3 hours later, telling me I have a partial ACL. Although I won't need surgery but I should get 6-10 sessions of PT to strengthen my muscles.

A few thoughts on the whole process:
1. Process improvements on work flow. Imaging department could do with a lot of process flow improvements, in terms of registration to patient departure. I overheard the nurses talking about mixed up films loudly in the waiting area. Not a very good sign of quality and patient confidence, is that? Also, why was I paying at the doctor's office instead of at the imaging department? Somebody could have clarified that better for me. (Could be because the doctor had a fee arrangement with the hospital, and then retroactively paid the hospital for the number of services provided.)
2. Technical difficulties/ patient overflow process. Imaging department should have an emergency backlog/ technical difficulties process. Really, I should not have been the person who went around dialing and asking for my own reschedules. From a continuum of care perspective, the registrars should have done that for me. Also, were they starting to call to cancel patients who were scheduled for an MRI for later that day given the backlog? Or simply just letting patients know about a new scheduled time? This way, no one would have came in later in the day and waited for 3 hours like I did, or worse, came in but never got their MRI done because of the backlog.
3. Long wait lines at the clinics. Each patient in the specialist office had been complaining of long waiting time. This was supposed to be a private clinic/hospital which offered more accessible care. I think their scheduler/registrar placed blocks of 10 mins for scheduling, but honestly they could really do with a better scheduling system to better predict their patient volume.
4. Service quality.. The registrar was the most stuck-up and rude woman I have encountered. In her flat, high-pitched tone, she said " Doctor only comes in 2,4,6 (referring to days of the week) in the morning. You can have an appointment at 11.15 am. Can or not?" The tone of itself was perhaps not the part that irked me the most, but the fact that NO EYE CONTACT was made the whole time we had this conversation, and she was looking AWAY from me. Also, she was impatiently knocking the table with her pen while waiting for me to decide the times that worked best for me.

I hope my right knee's MRI serves as an illuminating story of the differences in challenges for healthcare in the states and in Singapore. I would probably get outstanding interpersonal care and treatment here in the states, albeit a high cost and a longer horizon in scheduling an appointment. In Singapore, I get rather affordable care with high accessibility, but at perhaps dubious clinical quality and pretty poor service quality. Lots of work to be done in both areas with different challenges and different ways to work those.