Image Interpretation by Radiographers - Not the Right Solution Position Statement

Transcription

1 Image Interpretation by Radiographers - Not the Right Solution Position Statement The Royal Australian and New Zealand College of Radiologists

2 Name of document and version: Image Interpretation by Radiographers Not the Right Solution, Version 1 Approved by: Faculty of Clinical Radiology Council Date of approval: 3 May 2018 ABN Copyright for this publication rests with The Royal Australian and New Zealand College of Radiologists The Royal Australian and New Zealand College of Radiologists Level 9, 51 Druitt Street Sydney NSW 2000 Australia New Zealand Office: Floor 6, 142 Lambton Quay, Wellington 6011, New Zealand ranzcr@ranzcr.edu.au Website: Telephone: Facsimile: Disclaimer: The information provided in this document is of a general nature only and is not intended as a substitute for medical or legal advice. It is designed to support, not replace, the relationship that exists between a patient and his/her doctor.

3 TABLE OF CONTENTS 1. Summary 4 2. Introduction 8 3. Clinical Role of the Radiologist 8 4. Comparison of Clinical Radiologist and Radiographer Training Clinical radiologist training Radiographer training Steps involved in reporting and interpretation of imaging investigations Skills and training required to report and interpret imaging investigations Evolution of radiographer reporting and interpretation roles Standards for reporting and interpretation of imaging investigations Validity of radiographer plain film reporting performance studies Medico-legal responsibility Related documents References 18 Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists 3 May 2018 Page 2 of 19

4 About the College Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists Type approval month and year here The Royal Australian and New Zealand College of Radiologists (RANZCR) is a not-for-profit association of members who deliver skills, knowledge, insight, time and commitments to promote the science and practice of the medical specialties of clinical radiology (diagnostic and interventional) and radiation oncology in Australia and New Zealand. The Faculty of Clinical Radiology, RANZCR, is the peak bi-national body for setting, promoting and continuously improving the standards of training and practice in diagnostic and interventional radiology for the betterment of the people of Australia and New Zealand. Our Vision RANZCR as the peak group driving best practice in clinical radiology and radiation oncology for the benefit of our patients. Our Mission To drive the appropriate, proper and safe use of radiological and radiation oncological medical services for optimum health outcomes by leading, training and sustaining our professionals. Our Values Commitment to Best Practice Exemplified through an evidence-based culture, a focus on patient outcomes and equity of access to high quality care; an attitude of compassion and empathy. Acting with Integrity Exemplified through an ethical approach: doing what is right, not what is expedient; a forward thinking and collaborative attitude and patient-centric focus. Accountability Exemplified through strong leadership that is accountable to members; patient engagement at professional and organisational levels. Code of Ethics The Code defines the values and principles that underpin the best practice of clinical radiology and radiation oncology and makes explicit the standards of ethical conduct the College expects of its members. Page 3 of 19

5 1. SUMMARY 1.1 The clinical radiologist Clinical radiologists are required to integrate their knowledge of clinical medicine, disease processes, imaging procedures and radiological expertise with the individual condition of the patient to provide a specialist opinion for that patient. The integration of clinical experience with technical knowledge is critical to ensuring each patient receives medical imaging that materially contributes to a diagnosis and image-guided treatments appropriate to the management of their illness. RANZCR believes best practice in contemporary patient-centred care requires a collaborative or team-based medical practice model. Within the team, the clinical radiologist is a leader reliant on other team players to support service delivery by acquiring images, assisting patients during procedures and maintaining equipment. The clinical radiologist makes the diagnosis (including differential diagnosis where certain diagnosis is not yet possible), plans or performs biopsies and treatments, monitors responses to treatment, and advises other doctors and health professionals on the best use of imaging in the care of the patient. In practice, clinical radiologists also often provide guidance to radiographers via a protocol to ensure the appropriate imaging technique is used for the required diagnosis. In regional and rural settings where it is not possible to have a clinical radiologist onsite fulltime, it is RANZCR s view that teleradiology should be used to provide access to clinical radiologist expertise. 1.2 Clinical Radiologist and radiographer training Radiology Clinical radiologists are medical specialists who have undertaken broad medical training and practised in clinical medicine for at least two years as an intern or resident, followed by five years of dedicated specialist training in radiology. Their general and specialist medical training includes a comprehensive understanding of pathology, as well as technical knowledge of the performance and interpretation of diagnostic imaging tests across a range of imaging modalities. The RANZCR Clinical Radiology curriculum is a holistic training program based on the CanMEDS framework, originally promulgated by the Royal College of Physicians and Surgeons of Canada, and widely adapted throughout the medical world. The program comprises: three years of general radiology training (including teaching and assessment in anatomy and applied imaging technology, radiation physics and safety) and two years of systems-focussed rotations for advanced radiology training (including teaching and assessment in clinical radiology, pathology and interventional radiology). Their comprehensive medical training enables the clinical radiologist to emphasise the significance of incidental findings and determine if further follow-up is required. Clinical radiologists are trained to avoid over-servicing and the associated inconvenience and anxiety imposed on patients Radiography Radiographer training in Australia comprises a four-year diagnostic radiography bachelor s degree, or alternatively a three-year bachelor s degree (or two-year postgraduate-entry master s degree) followed by a supervised practice program (SPP). Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists 3 May 2018 Page 4 of 19

6 Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists Type approval month and year here Radiography is recognised as a health science demanding complex skills. However, radiographers neither receive broad medical training nor do they undertake in-depth study of the nature of disease or the differential capacity of imaging techniques to elucidate disease processes. Training in pathology, if present, is usually basic. Radiographic training does not teach or require the radiographer to fully understand the patient s clinical context, offer a differential diagnosis or give guidance to a referring doctor regarding further investigation, biopsy or treatment. Academic researchers have argued that radiographers lack the training and flexibility to write medical reports and make judgments about the relevance of radiological findings. 1.3 The radiology report A radiology report constitutes a medical opinion by a clinical specialist who provides an expert interpretation of radiological images and relates her or his findings to the clinical setting. In formulating an opinion, the clinical radiologist determines if an abnormality is present or not. The information in a radiology report may include symptoms, medical history and suspected diagnosis, as well as the results of other tests. Differential diagnoses form a major component of medical image interpretation; hence, if the findings are considered abnormal, the image characteristics often need to be scrutinised further to eliminate alternative diagnoses, or at least estimate the relative probabilities of alternative diagnoses. In examining images of multiple organs or structures, clinical radiologists use their broad knowledge of disease processes to consider other potential pathologies (and their imaging manifestations) which may be unrelated to the initial request. The report may compare previous imaging findings or reference pathology results and advise the referring clinician on further investigation and management. In circumstances where a radiological investigation seeks to exclude pathology, knowledge of the negative predictive value of further tests is important. The report may also advise the referrer to recall a patient when the clinical radiologist determines that a suboptimal or incomplete image has affected diagnostic accuracy. RANZCR is of the view that the radiology report cannot be delegated to radiographers or anyone untrained initially as a medical practitioner and then as a medical imaging specialist. 1.4 Role extension in radiography Role extension in radiography has occurred both within the discipline and, in some jurisdictions, beyond the discipline into areas regarded as the professional domain of clinical radiologists. The latter includes credentialing for radiographer commenting. The trend has generally been driven by a chronic shortage of clinical radiologists in some countries (e.g. UK), rather than a desire to improve quality of service or patient care 1. In the US, radiology practitioner assistants have extended roles under clinical radiologistdelegated supervision to provide preliminary technical reports to assist clinical radiologists and referrers, but sole responsibility for the final report remains with the interpreting physician. Some Australian radiology departments informally employ a so-called red dot system or verbal communication. While unopposed to red dot flagging of potential concerns based on descriptive or technical observations, 'red dot flags should go directly to the clinical radiologist to allow her or him to prioritise their reporting accordingly. RANZCR does not consider radiographer commenting (also known as 'initial' or 'first line reporting') to be within the current scope of practice of a radiographer in Australia. Nor does RANZCR support extending the role of radiographers to include any form of written report, including scripted comments. Page 5 of 19

7 Optimising patient outcomes and ensuring the safety and efficiency of service must form the cornerstone of any changed medical practice. It is well recognised that practising within a highly functioning team will provide much better patient care and fewer errors. Hence, RANZCR does not support the substitution of clinical radiologists by radiographers for the sake of career development or to reduce costs, particularly at a time when there are sufficient clinical radiologists to allow for reporting in Australia. 1.5 Evidence in support of role extension Overseas research undertaken in the late 1990s (1994 to 2002) indicated that trained radiographers were able to report plain radiographs as accurately as clinical radiologists. However, most of this research relates poorly to modern radiological practice. For example, some studies compared the performance of the radiographer with that of an emergency doctor this comparison is no longer relevant as most modern emergency departments have either a clinical radiologist onsite or the benefit of a report from an off-site clinical radiologist. Moreover, reporting accuracy is only an intermediate outcome, as reporting by radiographers also affects clinical decision-making and patient outcomes. There is an absence of evidence on the clinical effectiveness of advanced radiographer practice and reporting. A recent 2016 systematic review highlights that, even after more than 15 years of advanced radiographer practice in the UK, evidence of its impact on patient outcomes and service quality is limited. Instead, the more recent research on radiographer advanced practice has focused on comparing task achievement across delegatory and substitute professional groups. Given radiographers undertake these tasks within a radiography rather than medical paradigm it can be argued that outcomes are not directly comparable. These studies have often been limited in terms of the reporting of practice interventions from within limited settings, often at a single clinical site with relatively small sample sizes and therefore they convey little transferability within country (UK) or to health care systems within other countries Medico-legal issues The final, approved radiology report is not just an important clinical assessment but also a document which may be used for medico-legal purposes and which may vary significantly from an initial or interim report. In law, a reporting radiologist often has overall responsibility for the delivery of the entire service, including the supervision of others involved in the imaging process and communication to the referring clinician. By virtue of their education and training, clinical radiologists currently represent the 'gold standard in image interpretation. If a radiographer were to issue a final report on an x-ray, and that report relied upon to protect a patient's interests, there could be a basis for a claim or a complaint if the standard of reporting was not at the same standard as or higher than that supplied by a trained clinical radiologist. RANZCR is strongly of the view that clinical radiologists should not be held medico-legally responsible for actions taken on the basis of written comments by a radiographer. 1.7 Conclusion RANZCR accepts that the delegation of some tasks undertaken by the medical imaging team may potentially improve efficiencies in the utilisation of the team's skills, but only where it is demonstrated that delegation or task substitution improves patient care and service delivery. Among a number of shortcomings highlighted in this position statement, it is our view that radiographers lack the experience and training which comes with a medical specialist qualification and clinical experience to properly interpret and report imaging examinations for the individual patient and fully understand the limitations and risks of various imaging modalities. Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists 3 May 2018 Page 6 of 19

8 Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists Type approval month and year here Efforts to achieve role extension in radiography must therefore be considered in the context of the responsibilities and core competencies within the medical imaging team in performing complex tasks to a high standard, and by taking a collaborative team-based and system-wide approach. Page 7 of 19

9 2. INTRODUCTION RANZCR has prepared this position statement in response to recent moves to expand the role of radiographers to include reporting and interpretation of imaging studies. These initiatives include: (a) (b) A proposal by the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT) to undertake a Radiographer Commenting Project aimed at defining and setting a national benchmark for radiographers and other health professionals in providing a written comment on plain film images and Proposals in the 2014 Queensland Health Ministerial Taskforce Report on Health Practitioner Expanded Scope of Practice 2 for radiographic image interpretation of plain radiographs at the point of care in the trauma setting; scripted radiographer comments and radiographers providing final reports on plain film images. RANZCR is firmly of the view that radiology reports cannot be delegated to those who are not trained as both medical practitioners and then as medical imaging specialists. The report communicates the medical interpretation of the patient s imaging examination in the specific clinical context. In principle, RANZCR supports appropriate delegation of tasks to other members of the medical imaging team when it can be demonstrated that there is an improvement in patient care and service delivery. There must also be prior agreement between the clinical radiologist and the relevant members of the imaging team regarding the level of delegation. However, RANZCR believes the standard of patient care must be maintained and does not support the extension of the scope of radiographer practice to include tasks that they have not been appropriately trained for. 3. CLINICAL ROLE OF THE RADIOLOGIST The core competence of clinical radiologists (or radiologists) is their ability to integrate knowledge of clinical medicine, disease processes, imaging findings and other radiological expertise with the patient condition to provide a specialist opinion. This is critical in ensuring that patients receive quality imaging and appropriate imaging-guided treatments that actively contribute to the diagnosis and management of their illness. Clinical radiologists are medical specialists who have undertaken broad medical training and have practised in clinical medicine for at least two years before undertaking dedicated specialist training in radiology. This training includes a comprehensive understanding of pathology and performance and interpretation of diagnostic imaging (DI) tests, utilising a wide range of imaging modalities. Clinical radiologist training also encompasses imaging-guided procedures and treatments, known as interventional radiology. This enables a clinical radiologist to render an expert medical specialist opinion that provides a valuable contribution to patient care. Furthermore, clinical radiologists are trained to add value beyond simple image interpretation by actively participating in multi-disciplinary meetings. RANZCR has an international reputation for producing highly competent clinical radiologists with a wide range of expert diagnostic and procedural skills. Working alongside other doctors and healthcare practitioners, clinical radiologists are integral to the care of patients by making accurate diagnoses; advancing a differential diagnosis where a certain diagnosis is not yet possible; planning and/or performing biopsies or treatments; monitoring response to treatment and advising on how best to use imaging in the care of patients. Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists 3 May 2018 Page 8 of 19

10 Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists Type approval month and year here The RANZCR position is that contemporary patient-centred care requires a collaborative or team-based medical practice model. One clear requirement for delivering safe, high-quality imaging services is the need for on-site supervision by a clinical radiologist to supervise and guide the conduct and diagnostic quality and safety of the examination. Further, clinical radiologists oversee the clinical journey of a patient, which includes receipt of the imaging referral, and, where necessary, in accordance with established medical practice, attend on the patient personally during the conduct of the examination, with responsibility for communication of the knowledge gained. Clinical radiologists are also widely recognised as key members of multi-disciplinary teams and they play a significant role in clinical decision-making regarding patient management. Members of other medical disciplines not only recognise this valuable input from clinical radiologists they expect it. RANZCR s position is outlined in our Role and Value of the Clinical Radiologist Position Paper 3. Although the effectiveness of the clinical radiologist requires teamwork with other healthcare practitioners (including radiographers, nurses and referring medical practitioners), clinical radiologists are responsible for all components of medical imaging and assume overall medical and legal (or medico-legal) responsibility during care of their patients. 4. COMPARISON OF CLINICAL RADIOLOGIST AND RADIOGRAPHER TRAINING Within the imaging team, each professional brings a particular combination of training and experience, which defines their role and responsibilities. 4.1 Clinical radiologist training The clinical radiologist s expertise is built on a full medical degree with at least two years additional general medical training as an intern/resident, followed by five years of specialist training in clinical radiology. The RANZCR clinical radiology training program is undertaken in two phases: Phase 1: three years of general radiology training including teaching and assessment in anatomy and applied imaging technology, radiation physics and safety Phase 2: two years of systems-focused (as distinguished from subspecialty) rotations for advanced radiology training including teaching and assessment in radiodiagnosis, interventional radiology, and pathology. This framework has been adopted by many other training programs, specifically those from the UK and the European Union. Clinical radiologists therefore have comprehensive medical education and training, together with clinical experience and specific radiology training. Their clinical training, knowledge and experience extend their perspective well beyond simple pattern recognition and basic viewing of images. In relation to diagnosis, this enables them to: understand the patient clinical setting and problem(s); examine the clinical possibilities; know which questions to ask or how to advise clinicians about further tests, planning treatment and conduct of procedures; and recognise and manage complications. Page 9 of 19

11 4.2 Radiographer training Radiographers are responsible for producing high quality medical images that assist medical specialists and practitioners to describe, diagnose, monitor and treat a patient s injury or illness. They need appropriate scientific and technological background to understand and operate advanced medical imaging equipment used in radiology departments today. Typically, radiographer training courses are focused on the radiographer s traditional scope of practice around image acquisition and image presentation prior to image interpretation and diagnosis by a clinical radiologist. In addition to learning about radiographic techniques and methods, radiographers learn about radiation physics and safety, human biology, how to handle patient needs and how to communicate effectively 4. Radiographer training in Australia takes three to four years to complete and may involve completion of: An accredited three-year undergraduate diagnostic radiography bachelor s degree followed by completion of a Supervised Practice Program (SPP) An accredited four-year undergraduate diagnostic radiography bachelor s degree An accredited two-year graduate entry diagnostic radiography master s degree followed by completion of a Supervised Practice Program (SPP). Supervised practice programs, administered by the Australian Health Practitioner Regulation Agency (AHPRA) on behalf of the Medical Radiation Practice Board of Australia, are provided to ensure practitioners meet the requirements of registration and are capable of safe, independent practice as a radiographer. This practice and training is heavily centred around image acquisition, using various imaging modalities and methods. Some programs, typically four-year programs, allow students to attain full accreditation without completing the SPP, allowing students to decide whether to spend their final year of training in a classroom or a clinical setting. Radiographers technical expertise enables them to play an essential role in image acquisition with limited supervision and significant responsibility and to support the work of the clinical radiologist. However, radiographers do not undergo medical training, do not study the nature of disease in-depth or the capacity of different imaging techniques to demonstrate disease processes. Where their training covers pathology, this tends to be at a basic level. Their training does not equip them with the knowledge and skills to fully understand the patient s clinical context, offer a differential diagnosis and stage the extent of disease (which are major components of medical image interpretation), or to offer guidance to a referring doctor regarding further investigation, biopsy or treatment. A number of radiographers have retrained to become clinical radiologists by completing a medical degree and subsequently, the RANZCR training program. These individuals have reported that they had the benefit of understanding the technical aspects of image acquisition but had no head start regarding the clinical interpretation of imaging studies such as plain radiographs compared to other medical graduates. 4.3 Steps involved in reporting and interpretation of imaging investigations A radiology report constitutes a medical opinion. The purpose of the report is to provide a medical specialist interpretation of images and relate the findings to the clinical setting. This will include both anticipated and unanticipated findings in order to diagnose or contribute to the understanding of the patient s clinical condition. The report often compares previous imaging findings or pathology results and provides advice to the referring clinician about appropriate further investigation and management. Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists 3 May 2018 Page 10 of 19

12 Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists Type approval month and year here Radiology has been described as the classic example of clinical problem-solving 5,6. It is recognised as a complex skill involving the ability to combine information gleaned from visual pattern recognition, anatomical knowledge, knowledge from pathological processes and patient specific information 6. Donovan and Manning 7 suggested that the lack of medical training limits the scope of practice for reporting radiographers and questions whether radiographers can ever become experts in image reporting. Clarification of the essential steps involved in producing an imaging report provides a basis for assessing whether radiographers have the essential competencies to perform this task: Understanding the clinical information The referring clinician provides relevant information in the referral. The information may include symptoms, medical history and suspected diagnosis as well as previous imaging and pathology or other test results. Clinical radiologists have medical training and clinical experience and therefore understand the explicit and implied information provided by the referrer. Clinical radiologists also have extensive knowledge of commonly used medical abbreviations Technical knowledge Producing images of diagnostic quality requires skill. Radiology training includes detailed understanding of the accuracy of various imaging procedures relative to other imaging modalities. Clinical radiologists are also trained to evaluate the quality of images and their suitability to diagnose the condition under consideration. Prior to many imaging procedures, clinical radiologists provide guidance to the person acquiring images (usually a radiographer) via a protocol to ensure the appropriate imaging technique is used. This requires an understanding of clinical medicine and disease processes and knowledge of the various imaging techniques. Selection of the most appropriate imaging procedure and an appropriate protocol based on the clinical context is required to obtain the clinical information being sought. Clinical radiologists know to what extent images that may be suboptimal or incomplete are likely to affect diagnostic accuracy, which enables them to determine whether the patient should be recalled, or caveats included in the report Observation Cross-checking of patient identification is required as part of the initial assessment of the images, together with confirmation that the type and date of the examination are correct. Images must be viewed in appropriate conditions to ensure that all findings have been noted. Clinical radiologists are trained observers who use both passive and active observation, i.e. abnormalities will strike those with a trained eye. Importantly, when possible diagnoses are being considered, clinical radiologists use their knowledge of disease processes to actively observe other, potentially subtle, findings that may be associated with the diagnosis under consideration. Based on these observations the following may be found: Normal findings Unequivocal abnormal findings, both anticipated and unanticipated Findings that may be normal or abnormal Normal variants. Page 11 of 19

13 4.3.4 Analysis Definitive or equivocal abnormalities are further evaluated for relevant imaging characteristics, for example, shape, contour, density, enhancement pattern, signal intensity and echogenicity. The clinical radiologist will formulate an opinion as to whether there is an abnormality or whether the findings are within the range of normal appearances, for example age-related changes, radiographic artefact etc. If the findings are considered to represent an abnormality, the image characteristics need to be further scrutinised in order to narrow the differential diagnosis and indicate the likely probability of the diagnosis. The knowledge acquired during training also enables the clinical radiologist to emphasise the significance of incidental findings and determine if further follow up is required or not. This has significant ramifications for prevention of over-servicing of patients, not to mention the unnecessary anxiety imposed on them during follow up Integration with medical knowledge and experience Image analysis must be correlated with other factors to interpret the radiographic findings and their relevance to the patient. A wide medical knowledge is required to reach a specific diagnosis or differential diagnosis sufficient to allow good clinical decisions to be made. Essential knowledge includes potential diseases which could, in patients of a particular age, sex, ethnicity and demographic characteristic, produce those imaging findings. This must be linked with an understanding of the relative prevalence of that disease in the population and the clinical state of the patient including signs, symptoms and results of other tests, for example previous imaging studies, pathology and clinical examination findings. Taken together, these factors will allow a clinically relevant opinion to be given that encompasses all the known factors about the patient, as well as the imaging findings Advice The clinical radiologist needs to be aware of the likely accuracy of the examination for a particular patient related to the published accuracy of the technique and its applicability to the particular examination. Clinical radiologists are therefore able to appropriately weight the diagnostic confidence expressed in their report. Any level of certainty or doubt needs to be clearly indicated in the report. If a definitive diagnosis is given it is assumed that this will be used for patient management. If a definitive diagnosis cannot be provided, the clinical radiologist can advise on further investigations or other appropriate steps that should be taken, having regard to the relative accuracy, applicability and risk Communication with the referrer The author of an imaging report and her or his professional status must be clear to those reading the report. The purpose of the report is to provide a timely answer to the clinical questions posed, together with an assessment of the whole imaging examination for relevant and/or unexpected findings. The written report needs to be clear and match the referrer s expectation. Specifically, the content of a report pertaining to a rare condition that is provided to a general practitioner is likely to differ compared to a report on the same rare condition that is provided to a specialist in that particular field. Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists 3 May 2018 The usual format of a radiology report will include: Clinical details; A description of the findings and Page 12 of 19

14 A conclusion or interpretation of the findings in the clinical context. Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists Type approval month and year here Processes must be in place that enable the referring doctor to discuss the imaging findings with the clinical radiologist in order to better understand the implications and reliability of the findings Taking appropriate action Effective and timely communication of imaging reports is important for good patient outcomes. Processes must be in place to allow direct communication between the clincial radiologist and the referrer when urgent treatment is required, for example a pulmonary embolism. Imaging findings that suggest serious or unexpected abnormality, for example an unexpected malignancy, should be communicated so that the patient can receive timely treatment. Urgent communication may be required to prevent potential public harm, for example when there is evidence of open tuberculosis. When additional steps have been taken to ensure urgent communication, this is recorded in the report Communication with the patient In Australia, all doctors are bound by Good Medical Practice, the code of conduct provided by the Medical Board of Australia (MBA), which allows them license to practise 8. In New Zealand, all doctors are bound by Good Medical Practice and other standards set out by the Medical Council of New Zealand (MCNZ) 9. Patients must always be treated with respect and honesty. A thorough assessment of the investigation must be completed prior to speaking to the patient about the results of the examination. Where at all possible, the clinical radiologist will have first discussed the findings with the referring clinician and can then facilitate future management (e.g. rapid return to the referrer, further imaging as agreed with the referrer to better disclose the extent of disease). 4.4 Skills and training required to report and interpret imaging investigations The RANZCR clinical radiology curriculum is based on the CanMEDS model and provides a holistic training program that not only addresses all the above essential steps involved in producing an imaging report 10 but also includes acquisition of skills well beyond image interpretation. It is clear that non-medical practitioners in the imaging team do not have the clinical background and training that comes with medical specialist qualification and experience to interpret and report imaging examinations. Understanding the limitations of different imaging examinations and their risks, radiation or otherwise, for patients is also important. With their lack of medical training, radiographers do not have the expertise to carry out all aspects of the diagnostic examination. In circumstances where the principal purpose of a radiological investigation is to exclude pathology, it is important to have knowledge of the negative predictive value of an examination and the necessity for and accuracy of further tests. In addition, multiple organs or structures are typically displayed on imaging examinations. Review of images requested for a particular purpose may therefore reveal incidental findings or pathology unrelated to the initial request, requiring a wider knowledge of disease processes and their imaging manifestations than was first expected. The final approved report is not only an important clinical record but is also a medico-legal document. Interim reports may at times be significantly different from the final report, which can potentially result in delayed or inappropriate management and compromise patient safety. It is therefore important to note that inaccurate or incomplete reports provided by an individual can create risk and additional cost for patients and entities that provide healthcare. RANZCR is firmly of the view that the radiology report cannot be delegated to radiographers and those who are not trained initially as medical practitioners and then as medical imaging specialists. Page 13 of 19

15 In regional and rural settings where it is not possible to have a clinical radiologist on site fulltime, it is RANZCR s view that teleradiology should be used to complement and support on-site radiology. RANZCR has long recognised this role of teleradiology in settings that do not have or cannot support a full-time imaging specialist. Related to this, RANZCR has a strong training program with around 100 new clinical radiologists joining the workforce in Australia every year. Work is also being done to alleviate the uneven distribution of clinical radiologists, particularly in regional and rural areas. 4.5 Evolution of radiographer reporting and interpretation roles Radiographers around the world are bound by scopes of practice which define their responsibilities and boundaries. Some have found these restrictive and have sought ways to improve and expand them to fully realise their potential as practitioners in radiation technology 11,12. The terms extended and advanced practice have been used, often interchangeably, to describe radiographer role development. Hardy and Snaith 13 define role extension as the acquisition of additional skills, duties or responsibilities beyond the statutory responsibilities and competencies at the point of professional registration, with resultant associated additional professional accountability. In the case of radiography, role extension has occurred both within radiography (to include competency in new imaging modalities) and in some jurisdictions outside the professional domain of radiography into the area previously regarded as the professional domain of clinical radiologists (including reporting). Different political and healthcare delivery systems, as well as cultural and professional differences, have impacted upon the development of advanced roles for radiographers internationally 14. Radiographer role extension has generally been driven by limited availability of radiologists in some countries and the impact this has on service delivery, rather than an assessment of service improvement or benefit in terms of patient care. In the UK, image reporting in certain selected fields (most prevalent in skeletal radiography) by specially trained radiographers has evolved over the past three decades. This role extension has been driven by a number of factors including significant and prolonged UK specialist clinical radiologist workforce shortages, increasing workloads, an appetite for health system reform and professional aspirations. Diagnostic image interpretation and clinical reporting are legally and legitimately within the scope of radiographer practice in the UK and radiographers undertaking these roles are responsible and accountable for their practice 15. Two levels of radiographer reporting are recognised by the Society and College of Radiographers from the UK: Clinical reporting refers to diagnostic reporting by radiographers and other professionals who have received accredited postgraduate training, and this constitutes advanced practice. Initial commenting refers to the assessment of image appearances by radiographers who make a judgement based on their interpretation. Commenting is seen as an advance on the widelyimplemented use of the red dot system, dispelling many of the ambiguities associated with that system. For governance purposes the comment should be in a written form, regardless of protocol, and whilst it legally constitutes a report it is not a formal clinical report as described above. A distinction is made by the UK Royal College of Radiologists (RCR) between a descriptive (or technical) report and a medical (or diagnostic) report 16. The descriptive report amounts to the recording of observations with no medical interpretation. The RCR stated that a radiographer may provide such a report, although the responsibility for the patient s management would continue to rest with the referring physician or delegating clinical radiologist. Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists 3 May 2018 Page 14 of 19

16 Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists Type approval month and year here While the first commenting scheme was introduced in the UK in , implementation has been slow, with only 61 UK hospitals (around 10%) operating a commenting system by 2007, many operating a hybrid system with the red dot system. It has been reported 18 that barriers exist to a transition from the red dot system to commenting or initial/first line reporting including: lack of confidence by radiographers to provide comment in some anatomical regions, e.g. chest and abdomen; a lack of understanding of medico-legal responsibilities; the additional time required; and a resistance to commenting becoming a formal role expectation with compulsory participation. Importantly, there is also an acknowledged chronic shortage of radiographers in the UK 19. In the United States, radiology practitioner assistants have extended roles under clinical radiologist delegated supervision that include providing preliminary technical reports (either written or oral) to assist clinical radiologists and referring medical officers, but providing a final diagnosis is considered part of the practice of medicine and it is the sole responsibility of the interpreting physician to provide the final report 20. In Australia, the requirement for radiographers to draw to the attention of clinical radiologists and other medical practitioners any findings of clinical significance is indicated in The Australian Society of Medical Imaging and Radiation Therapy (ASMIRT) Guidelines For Professional Conduct for Medical Radiation Professionals, which states: Medical Radiation Professionals should alert medically significant findings to the medical personnel responsible for the patient/client's care. At the request of such personnel may provide an opinion that lies within their knowledge and expertise. It is important at all times to ensure that appropriate identification of the Medical Radiation Professional s designation is provided to the other party 21. The Medical Radiation Practice Board of Australia Code of Conduct 22 states: Standard 4.3 Delegation, referral and handover: (c) always communicating sufficient information about the patient or client and the treatment needed to enable the continuing care of the patient or client (p.10) The Australian Society of Medical Imaging and Radiation Therapy has developed the following elements within their Professional Practice Standards 23 ; Standard 2.2: Establishes and maintains appropriate collaborative relationships with colleagues and members of the healthcare team: Provides a description of images within own Scope of Practice (p.22) Standard 2.5: Operates effectively as an autonomous and responsible practitioner: Provides a professional opinion of medically significant findings to the medical personnel responsible for the patient s management (p.24). Page 15 of 19

17 RANZCR does not consider radiographer commenting to be within the current scope of practice of a radiographer as asserted by ASMIRT, based on their interpretation of the Medical Radiation Practice Board s standard 4.3. In particular, Standard 2.5 above makes no reference to advising the supervising radiologist and other members of the team as to the opinion conveyed. This is considered unsafe practice because the clinical radiologist does not know what has been conveyed to the medical personnel responsible for the patient management and therefore does not know when to communicate any corrections in the final approved report to the managing clinical team. As far as RANZCR is aware, there are some radiology departments in Australia utilising a red dot system or verbal communication between radiographers and referring clinicians, but there is currently no formal written process in place. RANZCR does not oppose red dot flagging of potential concerns based on descriptive or technical observations, which is within the radiographer s scope of practice as outlined above. RANZCR s expectation is that the red dot flag should go to the clinical radiologist to allow her or him to prioritise their clinical case reporting accordingly. However, RANZCR does not support extending the role of radiographers to provide any form of written report, including scripted comments. This includes the proposal to introduce radiographer commenting, otherwise known as initial or first line reporting. Even with red dots, there must be a clear assumption of medical responsibility for the patient s management and the quality of service provision, which would rest with the referring practitioner or the clinical radiologist. It is RANZCR s view that optimal patient outcome must form the cornerstone of any changed practice. Safety and efficiency of service to patients is paramount. RANZCR recognises that work satisfaction of all Digital Imaging team members is important; however, system changes should not be driven by the desire to create potential new career paths. RANZCR does not support the substitution of clinical radiologists by radiographers for career development or cost saving reasons, particularly when there are sufficient clinical radiologists to allow for reporting in Australia. Role evolution, including task substitution and delegation, is a potential means of better utilising the skills of the whole DI team. This must however be considered in the context of responsibilities and core competencies to perform tasks, and by taking a collaborative teambased and system-wide approach. Image reporting and interpretation by non-medical personnel assumes that pre-clinical, clinical and specialist training and experience can be fast-tracked or avoided without negative impact on the safety and quality of DI services. Radiology has become more body-system-focused rather than modality-based, reflecting radiology s increasingly clinical role and the manner in which modern clinical medicine operates. Plain x-rays are just one component of the often complex and integrated imaging required to optimise patient management. There are misconceptions that plain x-ray interpretation is simple and thus readily delegated and that the clinical radiologist s role is limited to provision of images and reports. This ignores the clinical context of the DI service 24. For example, reporting chest and abdomen films, where the anatomy is complex and multiple organ systems are displayed, requires the ability to link visual findings with a large knowledge base of diagnostic meaning and pathological features. The radiological and anatomical patterns then need to be translated into diagnostic and where relevant, management decisions 25. Robinson 26 claims the most critical element of learned expertise is the ability of the observer to understand the context of the diagnostic examination to know what to look for in the images and why; and to understand how images relate to the practical reasoning of clinical medicine. 4.6 Standards for reporting and interpretation of imaging investigations Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists 3 May 2018 By virtue of their education and training, clinical radiologists are the gold standard experts on image interpretation 27. Legally, if a radiographer reports on an x-ray instead of a clinical radiologist, then the same standard of reporting must apply to protect patient interests. If reliance is placed upon that radiographer s report, then the standard should be that of the clinical radiologist 28. Page 16 of 19

18 Image Interpretation by Radiographers Not the Right Solution, Version 1 The Royal Australian and New Zealand College of Radiologists Type approval month and year here RANZCR supports the standards for the reporting and interpretation of imaging investigations published by the Royal College of Radiologists (RCR) in These standards attempt to define the aspects of radiological services and care which promote the provision of high highquality services to patients, regardless of who is issuing the report. 4.7 Validity of radiographer plain film reporting performance studies Much research has been undertaken into radiographer plain film reporting performance since the relaxation of restrictions on radiographer reporting in the UK in the 1990s. Most studies claim that trained radiographers can report plain radiographs to a high level of accuracy comparable to clinical radiologists. A review by Brealey et al 30 found no statistically significant difference between the reporting accuracy of selectively trained radiographers and clinical radiologists on plain radiographic examinations requested by accident and emergency departments, as well as on plain radiographic examinations not solely from A & E. They also found evidence that training significantly improved radiographers ability to report normal radiographs accurately. However, as with much published research, a combination of bias and methodological factors can influence the validity of radiographic film reporting performance studies 31,32 which could lead to erroneous conclusions being made about radiographers film reading performance. This in turn can affect radiographic reporting policy and ultimately patient safety and service efficiency. In particular, the selection of images used in such studies, and the context in which health care is practised, are crucial. Participants only being asked to determine if there is a fracture or no fracture is not a true test of their ability to pick up other important clinical findings. In addition, some studies in the meta-analysis compare performance of radiographers to that of emergency doctors and other health care professionals 33. This is not relevant in the Australian and New Zealand context as most modern emergency departments have a clinical radiologist on site or benefit from off-site clinical radiologist reports. The standard of practice must always be that of a trained clinical radiologist. Furthermore, reporting accuracy is only an intermediate outcome: radiographer reporting affects clinical decision-making and patient outcomes, the availability of reports and associated costs. There is an absence of evidence on these aspects of the clinical effectiveness of radiographer reporting 7. A 2016 systematic review 1 highlights that, even after over 15 years of practice in the UK, evidence of the impact of advanced radiographer practice in terms of patient outcomes and service quality is limited. There is a paucity of evidence of the more important subsequent effects on the referring clinician's diagnosis, management plans and patient outcomes 34. The nature of errors made, patient adverse consequences and the effort and resource expended to detect and correct them (compared to clinical radiologists) has not been studied. The strength of any argument for radiographer reporting should be based on a measurable impact of such role extension. The desire to advance professional status or to reduce costs should not be prioritised ahead of safety, quality and patient outcomes. Consequently, the success or otherwise of any role developments should be measured against impact on service quality, service delivery and patient health outcomes. 4.8 Medico-legal responsibility Healthcare involves assisting patients, improving outcomes, saving lives, and tending to a very wide range of conditions. However, the provision of healthcare, including the provision of diagnostic imaging services, also carries inherent risks. Training, evidence-based practice, clear lines of supervision, protocols and mitigating procedures are all designed to minimise these risks. Under the RANZCR Standards of Practice 35, a reporting radiologist has overall responsibility for the provision of the service, including necessary supervision of all others involved in this process. This often includes all activities from the point at which a referral is received, through image acquisition, reporting and communication back to the referring clinician. Page 17 of 19