Better patient pathways in medical radiation sciences

Today the use of ionising radiation for medical imaging and radiation therapy is such a core part of both diagnosis and treatment that much is taken for granted.  It is commonly seen as a small part of the total hospital experience and yet there has been an extraordinary evolution both in the technology available and the techniques used by trained practitioners. The impact of these advances is significant, with new imaging techniques being constantly applied across the medical specialties, writes David Collier.
The past ten years have also seen major developments in how treatment is taking place, particularly around the patient pathway from first contact through referral, to the completion of their treatment.  Greater emphasis is being placed on planning to ensure the patient is fully informed of the process and faces minimal disruption as they move from one point in the treatment pathway to the next. All the health professionals involved work closely as part of a multi-disciplinary team; however, the practitioners delivering the treatment – radiographers and radiation therapists – are in a prime position to help improve patient pathways, with developments in technology and technique providing new and better approaches to living, healing and working. This response to, and use of technology and practice, research and innovation is strongly encouraged by those professional associations which represent the people who work in this area, including the Australian Institute of Radiography (AIR).
Australian radiographers and radiation therapists are highly regarded globally for their knowledge, expertise and capacity to deliver high quality imaging and therapy treatments.  In delivery terms they are a critical component in the medical radiation sciences team in healthcare.  For the public, they are the people most closely identified with the taking of x-rays; the professional staff who position and operate the complex equipment which captures the images and delivers the therapy.
It is the radiologists, however, who provide the medical analysis and report which guides diagnosis and further treatment.  The radiologists can only complete their part of the examination after imaging by the radiographer is completed (in most exams) and can only diagnose as well as the image quality allows (particularly in ultrasound where there has now been a significant increase in both use of ultrasound machines and the associated imaging).  This means that much rests on the particular skills and knowledge of the radiographers to use the appropriate equipment to the best of their ability and the machinery’s capability.
A crucial step in the development of the patient pathway, however, is that of patient safety.  The fundamental question of safe use of ionising radiation and the impact of cumulative radiation dose in the treated population is one not widely appreciated outside of the medical radiation profession. The impact of cumulative dose is very much determined (in most cases) by the skill of the radiographer in performing their duties. The “Image Gently” campaign in paediatric radiography aims to deliver the lowest dose possible for the most effective outcome.  In radiography generally, imaging is guided by the ALARA principle - ‘as low as reasonably achievable’.  It is well recorded just how critical this understanding of the dangers of ionising radiation can be and the need for the relevant and trained professionals to not only acquire excellent images or deliver closely targeted therapy, but also fulfil their obligations as a radiation safety officer. To do this, practitioners use their knowledge and skills in the understanding of physics to ensure the safety of the patient and others around the treatment area.
Recent literature has shown just how widespread the lack of awareness can be about the cumulative impact of radiation and the risk of increased incidence of cancer among patients and population. Recent research findings have demonstrated that many clinicians may not be fully aware of the radiation dose that some imaging procedures involve. Picano et al (2014)* have aptly identified the dilemma, by highlighting that ‘The increasing use and complexity of imaging and interventional techniques have not been matched by increasing awareness and knowledge by prescribers and practitioners’. Indeed, a majority of doctors and cardiologists ‘grossly underestimate’ the radiation doses for the most commonly requested tests ^{i, ii} - an issue of prime concern if  we consider that, as Carpeggiani et al (2012) ⁱⁱⁱ have identified, cardiologists prescribe the majority of radiological testing^{iv, v} and as interventional cardiologists, are among the most exposed professionals^{vi ,vii.}
Mr David Collier
David Collier was appointed Chief Executive of the Australian Institute of Radiography (AIR) in June 2008. He began his working life in New Zealand as a social worker, then teacher and later as a 20th century history lecturer at Auckland University. He later held a position as a press secretary for the NZ government before starting a career in consulting in 1994.
In 1997 he relocated to Australia and spent the following six years as the Principal Consultant for the Compliance Management Group where he worked predominantly in the healthcare sector. In 2003 he joined the Royal Australian and New Zealand College of Psychiatrists as the Manager of Training, Assessment and Examinations with responsibility for the training and examination of candidates for entry into College fellowship.
In 2004 he became the CEO/Registrar of the Psychologists Registration Board of Victoria.
The Australian Institute of Radiography
The Australian Institute of Radiography (AIR) is the peak body representing radiographers, radiation therapists and sonographers in Australia.
Its aims are to promote, encourage, cultivate and maintain the highest principles of practice and proficiency in respect of Medical Radiation Science. The AIR facilitates educational activities, discussion and consultation among members and others. It recognises undergraduate courses across Australia, sets standards of competency in practice and encourage scholarship and continuing professional development.
For further information,  visit www.air.asn.au

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“Recent literature has  shown just how widespread the lack of awareness can be about the cumulative impact of radiation and the risk of increased incidence of cancer among patients and population.”
DAVID COLLIER

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While targeted training in radioprotection awareness among cardiologists may go some way toward addressing this specific issue, the importance of including radiographers skilled in assessing the risk-versus-benefit ratio to patients in the decision-making process is clear.  A patient who is debilitated due to a heart condition can transform their quality of life by a procedure involving radiation and in these cases, the benefits can far outweigh the risk, and these assessments are most appropriately made by the involvement and consultation with the relevant and trained professionals.
Throughout all of these aspects of treatment, the professional body for radiographers, radiation therapists and sonographers, the AIR, supports and encourages the profession to not only aspire to the highest levels of professional practice, but to deliver.  Membership of the professional body is voluntary, and it has been heartening to see the continued growth of the AIR during the past five years (a growth of 55% over that time).  However, the fees paid for membership must compete with other financial demands in the delivery of medical radiation practice, namely the radiation license and the national registration fees.  In all, most members are paying something in the order of $1,000 per year as well as devoting increased time and costs for their mandatory CPD. This they do as part of being dedicated professionals, but the burden of such obligations must not become too onerous otherwise people will leave the profession and the only replacements will be those with lesser standards. This would be highly undesirable, particularly if we recognise the role of radiographers and radiation therapists in the accurate assessment of cumulative dose dangers and patient protection.
The AIR continuously assesses the value it can offer the profession and re-defines itself to meet new challenges. Our aims are to promote, encourage, cultivate and maintain the highest principles of practice and proficiency in respect of Medical Radiation Science. The AIR facilitates educational activities, offers online learning and encourages discussion and consultation among members and others. We support undergraduate courses across Australia, set the professional body’s standards of competency in practice and encourage scholarship and continuing professional development.
References
* Picano E, Van˜o E, Rehani M et al (2014) The appropriate and justified use of medical radiation in cardiovascular imaging: a position document of the ESC Associations of Cardiovascular Imaging, Percutaneous Cardiovascular Interventions and Electrophysiology. Eur Heart J 35(10):  665-72
i.    Einstein AJ, Tilkemeier P, Fazel R, Rakotoarivelo H, Shaw LJ; American Society of Nuclear Cardiology. Radiation Safety in nuclear cardiology—current knowledge and practice: results from the 2011 American Society of Nuclear Cardiology member survey. JAMA Intern Med 2013;173:1021–1023
ii.    Correia MJ, Hellies A, Andreassi MG, Ghelarducci B, Picano E (2005) Lack of radiological awareness among physicians working in a tertiary-care cardiological centre. Int J Cardiol 103:307–311
iii.    Carpeggiani C, Kraft G, Caramella D, Semelka R, Picano E (2012) Radioprotection (un)awareness in cardiologists, and how to improve it. Int J Cardiovasc Imaging 28: 1369-1374
iv.    Gerber TC, Carr JJ, Arai AE, Dixon RL, Ferrari VA, Gomes AS, Heller GV, McCollough CH, McNitt-Gray MF, Mettler FA, Mieres JH, Morin RL, Yester MV (2009) Ionizing radiation in cardiac imaging: a science advisory from the American Heart Association Committee on Cardiac Imaging of the Council on Clinical Cardiology and Committee on Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radiology and Intervention. Circulation 119:1056–1065
v.    Brindis R, Douglas PS (2010) President’s page: the ACC encourages multi-pronged approach to radiation safety. J Am Coll Cardiol 56:522–524
vi.    Vano E, Gonzalez L, Guibelalde E, Fernandez JM, Ten JI (1998) Radiation exposure to medical staff in interventional and cardiac radiology. Br J Radiol 71:954–960
vii.    Hirshfeld JW Jr, Balter S, Brinker JA, Kern MJ, Klein LW, Lindsay BD, Tommaso CL, Tracy CM, Wagner LK (2005) ACCF/AHA/HRS/ SCAI clinical competence statement on physician knowledge to optimize patient safety and image quality in fluoroscopically guided invasive cardiovascular procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. Circulation 111:511–532