| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Perspectives |
1 From the Department of Radiological Sciences, University of California, Irvine Medical Center, Orange. Received February 16, 2000; accepted March 13. Address correspondence to the author, 18961 Castlegate Ln, Santa Ana, CA 92705 (e-mail: rmfriede@uci.edu).
Index terms: Perspectives • Radiologic Technologists • Radiology and radiologists, departmental management • Radiology and radiologists, socioeconomic issues
We are experiencing many changes in medical practice related to the introduction of managed health care. So far, most of the changes have affected the physician by increasing the workload, by causing a loss of some independence in decision making, and by some decrease in income, which in most cases has not been as severe as many expected. One of the factors in our changing medical environment is certainly the concept of "skill mix."
To the best of my knowledge, the term skill mix originated in England 8 or 9 years ago, and much of the information in this article is from that country (1,2). Skill mix, as applied to medicine, implies the utilization of expertise from individuals in related fields to complement or increase the expertise available to patients and, it is hoped, provide cost savings to the economy. For example, T. G. Ashworth (1), a British histopathologist, stated that it is incomprehensible to him that, as a highly paid consultant, he should spend hours at the microscope pronouncing on lesions that could safely be reported by someone less expensive to the national health care system. Ashworth believes that as long as there is proper training of these individuals, there is no reason why we should not accept the responsibility for their reports. He stated that it is not necessary simply to assume that more work necessitates a larger staff; perhaps we are not using the staff that is available.
This is one concept of skill mix: freeing the physician from work that could be performed by technologists with proper training. Skill mix is not a new concept. The optician relieves the ophthalmologist from performing eye examinations. The nurse anesthetist relieves the anesthesiologist from performing uncomplicated procedures. Nurse practitioners, physician assistants, and a host of other paramedical providers have assumed some of the roles that were formerly performed by physicians, in most cases without problems.
In England, with increasing pressure on the radiologist to provide prompt service and decrease costs, the question arose as to how to utilize the radiologist's and technologist's time in the most economical manner, as well as provide the best services to the patient without loss of quality. Over the past 10 years in England, there has been a marked change, which appears to be progressing, toward the use of trained technologists to perform duties previously reserved for the radiologist (2–5). Under the national health care system, where there is no fee for service, the use of technologists does not affect the radiologist's income. In the United States, this might be true in a pure health maintenance organization system, but most physicians still rely on a fee-for-service concept for much of their income. Obviously, with fee for service, the concept of technologists performing some of the radiologist's functions would not be readily accepted.
Loughran (4), in his dissertation on the clinical radiographer (technologist), noted that the performance of radiography and the interpretation of results initially were in the hands of lay scientists. Larkin (6), in his monograph on occupational monopoly, wrote that, in 1923, The Lancet defined "radiologist" as a term applied to members of the medical profession who undertake radiographic diagnosis and treatment by means of x rays and radium, whereas "radiographer" (technologist) should be applied to trained nonmedical assistants. Between 1900 and 1920, there was competition between radiographers and radiologists with regard to the performance of radiography and the interpretation of radiographs. In the middle 1920s in England, radiographers were prohibited from accepting patients for radiography except under the direction of a qualified medical practitioner (6).
An early proposal that senior technologists who underwent a period of supplementary training could triage images to normal and abnormal categories was provided by Swinburne (7) in 1971. Loughran (3) highlighted the work of L. Berman at North Park Hospital in England in 1985, where the performance of technologists in assessing accident department radiographs was compared with that of junior casualty officers. Approximately half of the abnormalities overlooked by the junior doctors were detected by the technologists. This led to the "red dot" system, used extensively in England, where technologists mark case records when they think abnormalities are present.
Starting in the early 1990s, studies were performed in which technologists performed examinations and, in many cases, reported the results of those examinations. In England, these changes were spearheaded by two radiologists, C. F. Loughran, who practiced at Macclesfield District General Hospital, and Philip Robinson, who practiced at the St James University Hospital in Leeds. For technologists to be utilized, Loughran (written communication, 1999) listed the following precautions:
After sufficient training, technologists have been utilized in England to read images of fractures in the emergency department; to perform ultrasonography (US), barium enema examinations, and upper gastrointestinal examinations and interpret their results; and to double read mammograms. The emergency room work has generally been limited to fracture images; chest and abdominal image interpretation involved too many variables, and it was thought that these required a radiologist's expertise. In addition, technologists have been utilized to perform venography, intravenous injection of contrast material, and arthrography. Loughran et al (2) reported that during 3 months in which technologists performed 134 barium enema examinations, 382 intravenous contrast agent injections, and 2,401 skeletal radiograph interpretations in the accident department, the estimated workload for technologists amounted to 8.1 h/wk of radiologist time. Loughran also published (3) what he considered to be the guidelines for the reporting of trauma cases by technologists.
Philip Robinson (written communication, 1999) divided the activity of the radiologist into two categories: cognitive tasks and procedural tasks. He stated that procedural tasks can be described, defined, taught, and subjected to performance standards that make them transferable to other staff with appropriate training. Cognitive tasks that are related not only to the interpretation of images but also to decisions about differential diagnosis and appropriate choice of further investigations are more difficult. At Robinson's hospital, more than half of all barium enema examinations are performed by technologists, and the results are reported by radiologists. A similarly large proportion of abdominal and vascular US examinations and almost all the obstetric US examinations are performed by technologists. Technologists also inject intravenous contrast agents and radiopharmaceuticals.
Robinson believes that radiographers could report findings from all bone images obtained in the emergency room but probably not those from chest and abdominal images. Technologists perform better when the subject is a fairly tightly circumscribed one that is not related to other parts of the body. He estimates that, in England, 40% of barium enema results and most obstetric US findings are now reported by technologists; however, reporting of abdominal US results, which requires integration with findings from other imaging examinations and clinical findings, requires a radiologist. Robinson believes that technologists could report head computed tomographic (CT) results in trauma cases because, again, the subject is fairly tightly circumscribed, with the chest and abdomen usually irrelevant to such studies. He believes mammography fits the same criterion. Interpretation by technologists is, therefore, more effective when the range of abnormalities is narrow and not as effective when there is a potentially wide range of pathologic conditions.
There have been several studies performed in the United States on the effectiveness of skill mix for mammography. In 1987, Hillman and associates (8) selected four physician assistants who underwent 5 weeks of training in breast cancer screening and mammographic interpretation. They also spent 2
weeks with two university-based mammography specialists, undertook assigned reading, received training in breast examination and history taking, attended mammography lectures, and reviewed audiovisual tapes. After this, the physician assistants reviewed 727 mammograms, and their interpretations were as sensitive and as specific as those of the six radiologists who read the same cases. The physician assistants took less time and cost less than did the radiologists. Their dispositions and follow-up costs were similar, and they had the availability of a radiologist's consultation if desired.
There have been other studies in the United States, Canada, and Europe in which trained technologists were shown to be cost-effective with no sacrifice in the quality in mammographic interpretation. However, because of the fee-for-service reimbursement that is prevalent in the United States and because of legal considerations, the only suggested use of the technologists was for double readings. Results of studies (8–11) have shown that double readings with technologists increase the "pick up" of malignancies. The majority of US examinations in the United States are performed by technologists. If legal problems can be avoided, the experienced sonographer with added training could report the majority of obstetric US findings, and perhaps basic abdominal US findings (eg, gallbladder calculi), by consulting the radiologist when necessary.
In England, approximately one-half of all patients who presented to the emergency department after an accident are referred for radiography (5). This constitutes about 27% of the total radiology workload. Between January 1996 and July 1997 at the St James University Hospital in Leeds, England, two technologists were incorporated into the radiologist group for reporting on emergency room images (5). The technologists reported on 11,322 studies and commented on the abnormalities visualized and the relevance of the abnormalities to the clinical manifestation. In 264 cases (2.3%), the technologists sought a second opinion from the supervising radiologist. The authors concluded that only one fracture of relatively minor importance was overlooked in a sample of over 11,000 cases. This study excluded patients with severe injuries that necessitated admission. The authors believe there is no substantial difference between the performance of the radiologists and that of the technologists. Both technologists had undergone an extensive period of training that included an external educational program, an MSc degree in health sciences at Leeds, and in-house training in the department of clinical radiology.
Similarly, at the Macclesfield District General Hospital in England, where fracture radiographs in the accident room were reported partially by technologists, there was no significant difference between technologists and radiologists (12). Technologist reporting of images has been an established part of the departmental routine for the past 4 years. No complications attributable to this change in practice have been brought to the attention of the radiologists. The senior reporting technologist has now reported on more than 30,000 examinations.
In a presentation at the British Institute of Radiology in May 2000, Dr C. F. Loughran (written communication, 2000) reported on barium enema studies in 669 patients in whom the image findings were reported independently by technologists and radiologists. The study did not reveal any statistically significant difference between the reports issued by the technologists and those later issued by the radiologists. When technologists perform barium enema studies, Dr Loughran believes that they could report as follows: normal findings, diverticular disease, abnormal findings other than diverticula, and uncertain. In the last two cases, the study would be read by the radiologist; in the first two, it would not.
The results of the work in England have shown that technologists could perform barium enema examinations and upper gastrointestinal studies with a proficiency equal to that of the radiologist, which would reduce the costs for these studies. Also, evidence is suggestive that the technologists could report barium enema study findings, although the results of gastrointestinal series were somewhat more complicated.
Loughran (written communication, 2000) believes this practice could certainly be extended to mammography and to normal CT brain scans, with the abnormal images read by the radiologist. He believes that the reporting function of radiologists in England will gradually change and that, in the future, a range of studies will initially be screened by technologists. In trauma radiology, the question is simply whether there is or is not a fracture. This is rather uncomplicated. If anything else abnormal is seen, it is referred to the radiologist. An important part of the training is for the technologist to know when to seek further opinion and advice. The evidence from England suggests that basic fracture work in emergency rooms could safely be performed by the technologist in many cases, with more efficiency and lower cost.
The authors of a study reported in 1998 (13) evaluated whether technologists increased the radiation exposure to patients during barium enema examination. The results of the study showed that there was no statistically significant difference between radiologists and technologists in terms of fluoroscopic dose.
In an article published in the United States in 1996 (14), the authors compared images obtained during gastrointestinal fluoroscopy performed by specially trained and experienced technologists with those obtained by radiology residents. Three senior radiologists examined the fluoroscopic spot images from barium enema and gastrointestinal studies in 80 patients. The radiologists did not know who performed the examination. There was no significant difference between the images obtained by the technologists and those obtained by the radiology residents. In a similar study (15) in England in which barium enema examinations performed by senior registrars (residents) were compared with those performed by technologists, with a 3-year follow-up, there was no significant difference between the two groups.
The training of the technologists is of primary importance. In one series (12), the author reported on utilizing senior technologists with at least 5 years experience who then underwent a 5-month training program. The overall error rate declined markedly during the training program. The sensitivity for fracture detection improved from 81.1% at the beginning to 95.9% at the end. The specificity for the exclusion of fractures also improved from 94.4% to 96.6% in the final 2 months. Although there was a significant difference in sensitivity for fracture detection at the beginning of the trial between radiologists and technologists, there was no such difference in the last 2 months. There was a slight difference in specificity between experienced radiologists and technologists, with the technologists overreading fractures.
A major question is whether radiologists would accept reporting by technologists. Results of a 1994 survey (12) of 84 consultant radiologists in England indicated that 51.8% considered the introduction of reports by technologists, primarily about the extremities, as acceptable if the technologists had undergone a period of training.
At St James University Hospital (Leeds, England), where sonographers for some time have performed obstetric US, Bates et al (16) attempted to expand this practice to include acquisition of nonobstetric US images. They checked 1,046 consecutive nonobstetric US studies obtained by sonographers. In 94% of the cases, the report prepared by the sonographer gave an accurate account of the finding. In 6% of the cases, the radiologist provided additional comments, but in only 0.7% of the cases was the sonographer's report substantially altered. In 630 patients with adequate follow-up, there was only one incident of a false-positive finding. The implication is that with sufficient training and consultation, the use of technologists in reporting could go beyond obstetric US studies, fracture images, and gastrointestinal studies.
It is of interest to see how these changes are regarded by the technologic and radiologic societies in England. In 1997, the College of Radiographers (technologists) in London, England, published a "vision paper" (17) on reporting by technologists. The College of Radiographers, in its code of professional conduct published in 1994, promoted the view that radiographers should provide verbal and written reports on image appearances. They stated that technologists have, throughout history, given their professional opinions on radiographs they have produced and that sonographers have a long tradition of writing reports on the spectrum of US studies. To ensure high standards, technologists who are to report study findings must have special qualifications. To report US results, they would need a Diploma in Medical Ultrasound or US qualification accredited by the Consortium for the Accreditation of Sonographic Education. To report radiographic and CT results, they must have attended a recognized college-accredited course. To report nuclear medicine or magnetic resonance (MR) imaging findings, they must have appropriate accreditation from the Consortium for the Accreditation of Nuclear Medicine Education or clinical MR imaging education, respectively. The society concluded that involvement of the technologist workforce, which numbers nearly 10,000, in a reporting role will bring enormous benefits to the patient and has the capacity to revolutionize the cost-effective treatment of patients in clinical radiology. They stated that reporting by technologists is not an option for the future, it is a requirement.
In 1996, the Board of the Faculty of Clinical Radiology of the Royal College of Radiologists issued a report (18) advising on delegation of tasks in departments of clinical radiology. Their opening statement was that there has been a marked increase in demand for radiologic services that has not been met by a commensurate increase in radiologist staffing. The Royal College of Radiologists supports proper delegation, with the overriding requirement that the benefits of delegation be achieved without exposure of the patient to unreasonable risk. Whenever a doctor delegates a medical task, the patient must be aware of the name of the responsible doctor and the status of the person delegated to undertake the task. The report stated that it is the radiologist's responsibility to ensure that each task is undertaken within the law. The radiologist must be sure that the person who is delegated is competent to undertake the procedure or therapy involved. The report emphasized that the radiologist will still be responsible for managing the patient's care. The radiologist shares management responsibility, not only with the trained person to whom the task is delegated, but also with that person's employer, to ensure that the task is properly performed. If delegation occurs improperly, the radiologist concerned may be held responsible. The Royal College of Radiologists has, therefore, given tacit approval to the concept of technologist reporting.
We are experiencing many changes in medical practice that are related to the introduction of managed health care. More patients are undergoing treatment at outpatient centers or group practices, rather than at hospitals. Managed health care centers are focused on controlling costs. We have not experienced the overwhelming workloads that appear to have developed in England under the national health care system where, because of the apparent shortage of radiologists, several institutions have experimented with the concept of skill mix by using radiographers to perform examinations and report findings. Under the British national health care system, the use of technologists as physician assistants in radiology does not affect the income of the radiologist but does decrease the radiologist's workload. This appears to be encouraged by the Royal College of Radiographers and, to a certain extent, approved by the Royal College of Radiologists. The results are really not surprising. After all, we are not born with the ability to visualize abnormalities on radiographs, we are trained to do so and for the cognitive task of relating abnormalities to the patient's symptoms and clinical findings. Intelligent technologists can certainly be trained to read certain radiographs and grade them as normal, abnormal, or uncertain. It has been shown in England that with further training in areas with limited interrelationships—such as radiographs of fractures, obstetric US scans, and barium enema studies—trained technologists can report results about as well as can radiologists. With further training, this might apply to certain types of head CT studies, gastrointestinal studies, and abnormal US studies. These concepts have not been evaluated beyond these levels.
It would appear to be unlikely that this would be a welcome change in the United States, particularly in fee-for-service practices. However, the whole concept of physician assistants and nurse practitioners is relatively new in the United States and is gaining momentum. I mentioned in a previous article (19) the possible role of "supertechnologists" or physician assistants in radiology. Since the legal requirements were altered to allow physician assistants and nurse practitioners to engage in a limited practice of medicine, then we might see the supertechnologist as the equivalent of a physician assistant in certain limited areas of radiology. In a managed health care practice, a group practice, or even a hospital practice where the radiologist is salaried, the supertechnologist might read emergency trauma images and perform and interpret gastrointestinal and US studies. This would provide cost savings for managed health care and time savings for the radiologist. The radiologist or group that hires the technologist would be equally liable for any errors by the technologists. In the United States, there are many practicing nonradiologist physicians who interpret their own radiographs. Could not a trained radiologic technologist, in selected cases, interpret radiographs as well as or better than a primary care physician? Would our clinical colleagues accept interpretations by a technologist?
There may be a day in the future when such delegation will become legal and be encouraged because of the cost-saving potential. Who is to say that this will stop with the radiologist? Could not technologists be trained to remove kidneys, provided the physician is available to cope with complications and decision making? Could not technologists be trained to perform biopsies or remove organs? A technologist who is taught the anatomy limited to a specific area of the body and who is involved only with that area might soon become proficient in the removal of an organ—perhaps as efficient as the trained surgeon and perhaps on the same level of expertise with regard to the percentage of complications. I am not recommending these changes, but I believe they could occur.
In a previous article (20) I discussed the four medical revolutions of the 20th century. Perhaps the supertechnologist will be the first medical revolution of the 21st century.
References
This article has been cited by other articles:
|
|
 |
|
  M. W. Pickett, K. Waterstram-Rich, and L. W. Turner The Future of Nuclear Medicine Technology: Are We Ready for Advanced Practice? J. Nucl. Med. Technol., December 1, 2000; 28(4): 280 - 286. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| RADIOLOGY | RADIOGRAPHICS | RSNA JOURNALS ONLINE |
