Breaking the mould – how  radiographer reporting is better for the patient.

nigel-thomas

Professor Nigel Thomas from the University of Salford explains why allowing a radiographer to report X-rays  is not threat to the radiology profession.

 

 

 

I’ll nail my colours to the mast straight away, and state that I have been an active proponent of radiographer role extension in general, and radiographer reporting in particular, for over 20 years.

I first became involved in mid 1995 when the University of Salford (then University College Salford) asked for help in setting up a formal plain film reporting course for radiographers. The context for this was the unresolved tension between the large numbers of unreported films in most X-ray Departments and the realisation that radiographers as a group of professionals were often working below their full potential – a real untapped resource within our own departments. Becoming involved in the process seemed to me to be a very obvious thing to do, and I have never had any regrets about doing so. I don’t believe that I have contributed to the demise of my profession, and I certainly don’t feel like a “turkey voting for Christmas”.

Over the years since then, radiographers have increased the breadth of their involvement in reporting (to currently include some types of MR scanning and CT, as well as gastro-intestinal contrast studies amongst other things), as well as developing a career structure which encompasses working at Advanced Practitioner and Consultant Radiographer levels (the latter being a particular success in the world of breast imaging, where consultant radiographers can follow an entire patient journey by being able to perform and report mammograms, perform and report breast ultrasound and perform guided biopsies, as well as having counselling skills).

It was clear from the beginning that there would be opposition to the idea of radiographer reporting, both from the radiology establishment, and, to a much lesser extent, from within the radiography profession itself. In order to ensure that the process of creating reporting radiographers was as good as it could be, certain quality measures were put into place. No radiographer can report in the UK without a recognised qualification (at PgC or Pgd level) gained from a higher education institution. In the context of the workplace, reporting is done within an agreed scheme of work (signed off by the employing Trust Board), and regular audit is undertaken.

In 2017 between 15 and 20% of all plain film examinations in the UK are reported by radiographers, and there are now over 50 people in consultant radiographer grades around the country. Reporting radiographers have been “part of the furniture” in X-ray departments for over 20 years, and generations of junior doctors, nurses and physiotherapists have been familiar with using them as a port of call for advice on the interpretation of images.

And yet, despite all of the above, resistance to radiographer reporting persists. I find this particularly perplexing for several reasons:

  1. The reporting shortfall still persists, and patients are being put at risk by our failure to report their examinations in a timely and accurate way – would we rather leave them unreported?
  2. Radiologists have more than enough to do – there are too few of us, and our time is used to apply our unique skill set to report labour intensive complex examinations, undertake time-consuming interventional procedures, and provide a commitment to the support of MDTs.
  3. There is a substantial body of sound scientific evidence (published in the major UK peer-reviewed radiological journals) that radiographer reporting works, is safe, and is of a comparable standard to that provided by medical staff in many areas.
  4. Radiologists have been involved in this process from day 1 – advising on course content, giving lectures, acting as examiners and external examiners, and, most importantly, acting as mentors to radiographers in training at their places of work.

The final irony for me, as we progress into the 21st century is that, despite all the above, it is clear that some of my colleagues are much keener to gain help from computers than humans. Don’t get me wrong, I’m sure that Computer Aided Design (CAD) and Artificial Intelligence (AI)  will have a huge role to play in the routine provision of a radiology service in the near future, but reporting radiographers can help patients here and now.

References

Berman L, de Lacey G, Twomey E, Twomey B, Welch, T and Eban, R. ‘Reducing errors in the accident department: a simple method using radiographers’, British Medical Journal 1985; 290: 421-2

Loughran,C.F., Reporting of fracture radiographs by radiographers: the impact of a training programme. British Journal of Radiology, 67(802), 945 –950, 1994

Judith Kelly, Peter Hogg, Suzanne Henwood. The role of a consultant breast radiographer: A description and a reflection. Radiography, Volume 14, Supplement 1, e2-e10, 2008.

Brealey, S., Hewitt, C., Scally, A., Hahn, S., Godfrey, C., and Thomas, N.B. Bivariate meta-analysis of sensitivity and specificity of radiographers’ plain radiograph reporting in clinical practice. British Journal of Radiology, 82, (979), 600-604, 2009.

Piper, K., Buscall, K., Thomas, N.B., MRI reporting by radiographers: Findings of an accredited postgraduate programme. Radiography, Volume 16, Issue 2, 136-142, May 2010

  1. Piper, S. Cox, A. Paterson, A. Thomas, N.B. Thomas, N. Jeyagopal, N. Woznitza. Chest reporting by radiographers: Findings of an accredited postgraduate programme, Radiography, Volume 20, Issue 2, 94-99, February 2014
  1. Snaith, M. Hardy, E.F. Lewis Radiographer reporting in the UK: A longitudinal analysis

Radiography, Volume 21, Issue 2, 119-123, 2015

About Nigel Thomas

Born and raised in Cornwall, I qualified from St Bartholomew’s Hospital in London in 1981 having gained an intercalated B.Sc in Biochemistry in 1978.

My radiology training was undertaken on the North Western Training Scheme (based in Manchester), and I was appointed as Consultant Radiologist to North Manchester General Hospital in 1989.In 2005 I moved to a Consultant post at Trafford General Hospital and retired as a full-time NHS Consultant Radiologist in 2015.

I currently work as an independent Consultant Radiologist and, amongst other roles, am a mentor to Reporting Radiographers at two large Foundation Trusts in the Manchester conurbation.

I first became involved in the process of radiographer role development at the University of Salford in 1995, and was appointed as an Honorary Professor there in 2000. I have over 40 publications in scientific journals, and am a co-author of a standard textbook of Obstetric and Gynaecological Ultrasound scanning.

 

Image: Courtesy of Nottingham University Hospitals

 

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The role of the radiologist when a baby dies

3-elspeth-whitby-100-x-150As we launch our Fetal MRI portfolio, Dr Elspeth Whitby explains how a research project on MRI in early-life autopsy made her realise what an impact a radiologist can have on bereaved parents.

She found that MRI images can help to create and manage a woman’s feelings during pregnancy and increased her own understanding of her role in the process.

 

End of or start of life

When a baby or infant dies, MRI can be used as a minimally invasive method to replace formal autopsy. Dr Elspeth Whitby explains how, not only does this provide scientific information, but with the interpretive and sensitive communication skills of the radiologist it helps to provide some answers and fill gaps for devastated and grieving parents. Here she talks through the unexpected learning which came out of an innovative and groundbreaking research project.

As part of my work as a consultant radiologist I am involved in a minimally invasive autopsy service where magnetic resonance imaging (MRI) is used along with a number of other investigations that can replace the formal autopsy. Over the last 12 months I have embarked on a 30-month interdisciplinary project which aims to explore the use of visual technologies in post-mortem, bringing together researchers, medical practitioners and technology manufacturers to examine how clinical applications of these technologies (such as MRI) are impacting upon professional practice and parental experiences of loss.

1a-memory-box-black-and-whiteThis project, entitled ‘End of or Start of Life?’, developed from my previous work with a medical sociologist (Dr Kate Reed) looking at the value of the fetal MRI image to patients and professionals. A published paper from this original study argues that MRI can both create and manage women’s feelings of uncertainty during pregnancy. While it may not always provide women with unequivocal answers, the detailed information provided by the MRI images combined with the interpretative and communication skills of the radiologist enables women to navigate what can be difficult and emotional issues.

We think this current research on MRI in early-life autopsy will build on the original study about pregnancy and is important for a number of reasons:

  • It will benefit bereaved parents by providing information about potential choices they may have over fetal and infant autopsy;
  • It will raise general public awareness around prenatal and neonatal loss and contribute to reducing the silence and taboo which many parents who experience early life loss experience;
  • It will contribute to the ongoing professional development of pathologists and related professionals through informing professional guidelines and educational materials on visual technology use in autopsy;
  • It will provide information about how parents and other professionals feel about the use of this technology and therefore help to ensure that UK policy on autopsy is developed and applied in a way that is sensitive to practitioners and parents.

Personally my involvement in the work has allowed me to understand the needs of my patients and their families. I have had time to explore areas neglected by medical staff due to time pressures and the lack of insight into the importance of small details. When their baby is going to have a post-mortem, families need to know about what happens, who has contact with their most precious bundle and when. They don’t always need the detail I had assumed they’d want in terms of medical information about the post-mortem process, but rather more seemingly ‘mundane’ details for example: who holds their baby, how they hold them and place them on the scanner table.

Telling a bereaved mother that I was the person who held her baby boy, carried him, dressed and wrapped in a blanket, to the scanner and talked to him as I placed him on the scan table in the required position – as I would any baby in my clinical practice – resulted in tears from his mother and father.  These were followed by a very emotional hug and a comment from mum that she could finally ‘let go’ as I had put her mind at rest that he had been well looked after when she couldn’t be with him during the post-mortem. To them this part of his ‘life’ was a blank space that they could not fill and this left them feeling helpless. Being able to tell them about the process allowed them to fill this space and to understand what had happened. They knew that he had been cared for, and that they had done all they could as his parents.

1a-pm-mriThe most frequent request for information is ‘who will look after my baby when I can’t be there?’ No parent wants to be separated from their baby. I have underestimated the importance of such detail before, assuming that medical information is more important as this is what I have been trained to provide. I am beginning to understand more about parents’ complex needs, and hopefully I now provide an opportunity for all patients and parents I am involved with to obtain this information. The conversations I have with patients have changed from a medically-centred approach to a wider, more social approach. For example I have been able to book longer appointments and build in flexibility so no one feels rushed.

And so, I hope my continued involvement with the social research work can widen my understanding further and hopefully improve the services we provide. For instance, being part of this research has helped to inform my involvement in the production of a video that talks parents through the MRI post-mortem process which they can watch whenever, if ever, it suits them.

If you are interested in this topic, you may be interested in learning more. Take a look at the new BIR Fetal MRI Portfolio

References

Visualising uncertainty: Examining women’s views on the role of Magnetic Resonance Imaging (MRI) in late pregnancy


Dr Elspeth Whitby

Dr Elspeth Whitby is a senior lecturer at the University of Sheffield and an honorary consultant at Sheffield teaching Hospitals NHS Foundation trust.

Her clinical and research interests are based around MR Imaging of the fetus and neonate. She provides a national service for Fetal MRI and is an integral part of the team at Sheffield Children’s hospital, which has set up the world’s first clinical service for minimally invasive autopsy for the fetal and neonatal age group. Her research provides the necessary data to assess the value of new MRI techniques and then to support the transitions from research to service. The multidisciplinary nature of her more recent work is changing her as well as influencing clinical practice.

She is currently Vice President for Education at the BIR, helping to improve the educational scope and methods of delivery of educational events for all BIR members.

Dr Whitby was the recipient of the first BIR/Bayer Make it Better Award for her work in minimal fetal and neonatal invasive autopsy.