Image problem

Should radiographers take over some work traditionally done by radiologists? The debate about skill-mix in radiology is less high-profile than some other NHS controversies, but it generates similar acrimony.

Many regard the staff operations in a radiology department as a relatively simple division of labour. Radiographers produce diagnostic images - from x-rays, computerised tomography (CT) and magnetic resonance to nuclear medicine and ultrasound. The radiologist reports on the images, or uses them to perform medical interventions.

But, increasingly, many departments employ radiographers trained as sonographers, who both perform and report on ultrasound examinations.

They also perform barium enemas and other fluoroscopic procedures, inject contrast media, oversee intravenous pyelography, CT and MRI examinations, and report on films in accident and emergency departments.

Such changes have generated opposition, particularly from some radiologists.However, given the national shortage of radiologists, such turf wars tend to strike outside observers as bizarre. The ostensible concern is with the quality of nonradiologists' reporting, and hence patient safety.

This is clearly a legitimate question, so the reported audits of such service changes are worth repeating.

An audit on the role of sonographers in nonobstetric ultrasound examined 1,046 consecutive scans performed by sonographers at St James' University Hospital, Leeds.

1 In 94 per cent of cases, the report prepared by the sonographer gave an accurate account of the findings. In 6.3 per cent of reports, the radiologist provided additional comments, while in just 0.7 per cent of cases the report was altered significantly.

Among the 630 patients for whom adequate follow-up data was available, there was only one instance of a false positive ultrasound.

The authors concluded: 'Sonographers can and should be involved more widely in the provision of non-obstetric ultrasound services.'

In the light of this, one might have expected a uniform expansion of this role, given the pressures faced by radiology departments. But there have been no circulars urging this, and no management policy documents on the issue.Neither was there any mention in the 1995 Audit Commission report Improve Your Image - how to manage radiology services more effectively.

2 Even the NHS plan contains just two lines on extending the role of radiographers.

In the absence of management input, the radiographer's role has been defined by local custom and practice. This has had the advantage of allowing progressive departments to move ahead without undue interference, but the drawback of giving conservative radiologists the opportunity to block change.

A review of 150 randomly selected hospitals, published in 1996, found that radiographers carried out general diagnostic ultrasound in 72.2 per cent of them.

3 In 57 per cent of cases the practice had started in the previous five years.

The study found a wide variation in methods of reporting, but 55.1 per cent of radiologists reported images in conjunction with the radiographer.More worryingly, the survey found that only about half the departments had procedural guidelines. The irony about the last point is that sonographer-based reporting is already well established in the UK, in the most litigious area of medical practice - obstetrics.

Given all of the above, it is logical to assume that sonographers could make a similar contribution to non-obstetric scanning. But some radiologists challenge this. One, quoted in McKenzie's study, said: 'General abdominal ultrasound is a radiologist's job. Radiographers are not qualified to carry out abdominal ultrasound, although they might think differently. Unless the radiologists re-examine, every patient will suffer because of the laziness of some radiologists and their desire to appear progressive and to please managers whose aim is simply to save money.'

3 This, however, seems to be a minority view. The survey found most radiologists in favour of radiographers performing general diagnostic ultrasound, although the Royal College of Radiologists is more cautious. Its guidance seems equivocal on whether ultrasound reporting should be anything other than a doctor's task.

It gives the impression that the college would ideally like all reporting to be undertaken by radiologists while acknowledging this is not going to happen with the current shortage of doctors. It reiterates the General Medical Council's advice: 'You must not enable anyone who is not registered with the GMC to carry out tasks that require the knowledge and skills of a doctor.'

4 So if a group of consultants feels that reporting is a doctor's job, delegation to radiographers will not be an option.

The college appears to be increasingly out of step with what happens at the grass-roots. A prospective double-blind trial found no difference between experienced sonographers and radiologists both in performing and interpreting routine abdominal sonography.

5Another hospital study showed that the introduction of sonographer reporting had significantly cut consultant workloads.

6Sonographers not only report standard abdominal and pelvic examinations but also carry out and report more complex arterial, venous, vesticular, and some head, and neck and breast ultrasound examinations.

This extension of the sonographer's role to more complex areas, such as venous ultrasound, is repeated in other centres.

Doppler ultrasound venography for suspected deep-vein thrombosis is in increasing demand across the UK, with most hospitals reporting a 20 per cent increase a year in the number of referrals.

One-stop DVT clinics are being established in many hospitals. Potential rapid diagnosis and new outpatient-based treatment plans could bring major savings in bed occupancy and patient costs.

If sonographers are as accurate as radiologists in diagnosing DVT, hospitals should be able to provide a more cost-effective service. But this extra responsibility is yet to be reflected in the take-home pay of sonographers. They are now regularly carrying out duties previously thought to be the domain of consultants, yet the annual salary of a senior 1 radiographer is£24,000.

So what steps can be taken to extend the radiographer's role safely? In building a business case for change, quality issues must be addressed from the outset. Ammunition could come in the form of research undertaken beforehand, to counter the argument that patient care will suffer, and to produce a documented set of protocols detailing what type of cases should be referred to radiographers.

Issues relating to supervision, training and any medico-legal concerns should be dealt with explicitly. A commitment to regular postimplementation audit will reassure people that the initiative will operate in the appropriate clinical governance environment.

A review of existing practices may unearth some disturbing findings. In some departments the sonographer may do the examination and report, but the radiologist signs it off, without reviewing the ultrasound.

Many view this as medico-legally unwise, while cynics could point out that it has the effect of inflating consultant workload figures.

On the latter point, some significant variations can be found in the average workload, both between consultants in the same department and between hospitals.

Too often these go unchallenged. Some departments are running seriously below a normal consultant establishment but have yet to enhance the role of their radiographers or consider off-site reporting (by another department with the capacity to do so). In such circumstances, it may be surprising to discover how many extra sessions existing staff are being paid for.

The importance of radiology departments both as a diagnostic facility and in providing direct treatment is increasing in all acute hospitals.

Consultant supply will not match growing demand and, in any case, there are tasks that suitably trained radiographers can undertake satisfactorily.

Ultimately, computers may end up replacing both professions as the first line in patient diagnosis. But in the meantime managers should use the full potential of their existing staff resources.

REFERENCES

1 Bates JA, Conlon RM, Irving HC. An audit of the role of the sonographer in non-obstetric ultrasound. Clinical Radiology 1994; 49: 617-620.

2 Audit Commission. Improve Your Image - how to manage radiology services more effectively. Audit Commission, 1995.

3 Mckenzie GA, Mathers S.A. , Graham DT, Chessom RA. Radiographerperformed general diagnostic ultrasound: current UK practice. Radiography 2000; 6:179-188.

4 Royal College of Radiologists. Medico-legal Aspects of Delegation (FCR/2/93).

5 Leslie A, Locker H, Virjee JP.Who should be performing routine abdominal ultrasound? A prospective double-blind study comparing the accuracy of radiologist and Radiographer. Clinical Radiology 2000; 55: 606-609.

6 Howlett DC.Who should be performing routine abdominal ultrasound? Clinical Radiology 2001; 56: 166.

Key points

The importance of radiology departments is growing in all acute hospitals.

A review of skill-mix could reduce pressure on radiology departments.

The role of radiographers trained in sonography should be extended.

Robert Royce is an independent consultant.