Diagnostic Radiology
Fluoroscopy of the Upper Gastrointestinal Tract by the Radiological Technologist 1 Ann M. Lewicki, M.D. A pilot program was established to train an experienced radiological technologist to perform fluoroscopy of the upper gastrointestinal tract. Patients were prescreened and films reviewed by a staff radiologist. The quality of the films obtained by the technologist equaled that of the department's resident radiologists. INDEX TERMS:
Education, diagnostic radiology. Fluoroscopy. Gastrointestinal Tract, ra-
diography
Radiology 115:581-584, June 1975
•
•
is no general agreement as to whether a real shortage of radiologists exists in the United States (1, 5). Some apparent shortages may actually be relative and due only to maldistribution. Nevertheless, a markedly increased demand for radiologic services could develop if the United States adopts a national health insurance program. It has been recognized for some time now that many of the physician's tasks could be performed by paramedical personnel. In radiology, assistance can be offered by the prescreening of roentgen films or by assistance in roentgen procedures. Both approaches have been explored and are incorporated into existing radiology physician-assistant programs (4, 8, 9). Radiologists generally invest more time in examinations than in subsequent interpretations of roentgen findings (2). Some approach, then, which offers assistance to the radiologist in the performance of roentgen procedures would lessen the demands on his time significantly. How such assistance can be given with little compromise in quality (at least in selected patients) is the subject of this report.
T
an adjacent hall and viewing area. Videotape equipment is also available and recording can be initiated from the viewing area. Technician fluoroscopy was done during the regular morning schedule while studies were carried out in adjacent rooms by residents and attending staff. The technician learned to use the same examination technique as the physician staff (Fig. 1) and the maneuvers to check for gastroesophageal reflux. All patients were initially seen by the supervising radiologist who took their medical histories. The same criteria were used for selecting patients to be examined by the technician as are usually applied when a physician performs the examination on the remote control unit. Critically ill patients and those who need assistance during the examination for other reasons are not examined on the remote control unit except in unusual circumstances. All films were checked by a member of the attending staff whether the patient had been examined by the technologist or a resident. Only then was the patient permitted to leave the department. When necessary, supplementary fluoroscopic films were taken by the original examiner. Once the technologist had learned to do fluoroscopy unassisted, fluoroscopy time and the quality of films from randomly selected cases among the first 30 consecutive examinations were compared to 15 cases examined by radiology residents with four months of training in gastrointestinal fluoroscopy. The quality of the fluoroscopic films was evaluated by randomly intermixing the films of the 15 patients examined by the technologist with those of 15 patients examined by the resident physicians. The fluoroscopic examination was considered unsatisfactory if the films were inadequate to exclude or to establish disease and if a repeat examination was considered mandatory. The films were considered adequate even if not optimal if disease or normalcy could be established. An examination was thought to be of good quality if all required views were taken and if all of these
HERE
MATERIAL AND METHODS
The radiological technologist observed in this pilot study had had nine years of uninterrupted working experience since completion of training. Of these, she has spent three years in the gastrointestinal suite of our department. As part of her experience, residents and attending staff were observed using the same technique for examining the gastrointestinal tract in which she was subsequently instructed. The gastrointestinal suite in our department consists of three fluoroscopic rooms, one of which is equipped with a remote control unit. The training and conduct of technician fluoroscopy occurred exclusively in the room with the remote control unit. All rooms are equipped with a television viewing system with remote monitors in
1 From the Department of Radiology, Harvard Medical School, and Peter Bent Brigham Hospital, Boston, Mass. Accepted for publication in January 1975. shan
581
582
ANN
Table I:
Patient Characteristics
Examiner
In
Out
Technologist Resident
4
4
11 11
Table II: Examiner Technologist Resident
..----Diagnosi s--., Normal Abnormal
7
8 6
9
Fluoroscopic Examination
Film Quality* G A U 11 11
M. LEWICKI
4 4
Flucroscopyj Time (min.)
Repeat** Fluoroscopy
8 9
5 2
0 0
* G = good; A = adequate; U = unsatisfactory. t I ncludes time necessary for repeat fluoroscopy. ** Repeat fluoroscopy was performed by the original examiner on the same day to obtain additional spot films.
were correctly positioned. An attending senior radiologist and a resident physician reviewed all of the films, classifying them into the above categories. RESULTS
After fluoroscoping 6 patients under close supervision and assistance, the technologist was able to perform satisfactorily on her own with only occasional assistance. Initially, her performance was watched closely on the remote television monitor. When review of continuous videotape recording on a number of cases did not yield additional information, such monitoring was discontinued. As can be seen from Table I, the patients examined by the technologist and resident physicians were similar. Her fluoroscopy time compared favorably with that of the resident group. Fluoroscopy time remained essentially at a plateau level during the four months of the study. The quality of fluoroscopic spot films and the frequency of repeat fluoroscopy was similar in the two groups (Table II). Subjectively, the films taken by the technologist seem of consistently better quality than those of the resident physicians, although it was difficult to quantitate this difference. Fluoroscopy by a technologist was well accepted by the radiology residents. It seemed, in fact, an added incentive for them to perform better. It was equally well accepted by patients. Only one patient was screened out during the pre-examination interview and examined by the supervising radiologist. He was a man who seemed to need a strong authoritative approach and might have resented examination by a technologist or even a resident. The project was followed with a great deal of interest by the remaining gastrointestinal technologists who work in the area. To some extent, they seemed to resent not being able to participate in the project at this point. DISCUSSION
This pilot project demonstrates the ease with which
June 1975
training in a limited task can be accomplished. That this training was possible over such a short period is undoubtedly due in part to several physical characteristics of the work area as well as the working routine. These include television-monitored fluoroscopy in all examination rooms so that technicians are able to observe examination techniques. Since the same basic technique is used by all physicians working in the gastrointestinal suite, considerable learning can take place by observation alone, at least by an interested technologist. The remote control unit has only one x-ray tube and positioning and collimation of large overhead films is routinely monitored fluoroscopically by the technologist. Consequently, all technologists working in the area are adept in using the shutters and in controlling table movements. The remote control unit provided another advantage in that instruction and supervision of fluoroscopic examinations could be performed without exposing the patient to the accompanying dialogue. Another factor contributing to the ease of training was that instruction was limited to performing examinations of the upper gastrointestinal tract only. While a restricted training approach does shorten the training period, it need not be as limited as the present pilot study suggests. A technologist could eventually be trained to perform many or all procedures in one specialty area of a department. Trainees in other formal programs are usually exposed to considerable didactic teaching and instructed more comprehensively so that they can function in all sections of a radiology department (8,9). Such comprehensive instruction usually requires a two-year training period. The present pilot project demonstrates that a detailed understanding of gastrointestinal anatomy and physiology is not necessary for performing a completely adequate examination in selected patients. A selection of patients was achieved here because patients with less complicated medical problems are examined on the remote control unit. As an added safeguard, the supervising radiologist, who was also the instructor, interviewed all patients prior to examination. From such a pre-examination interview, most experienced radiologists can predict whether an examination will yield significant pathologic findings. With a well-designed questionnaire, such prescreening could also be relegated to a nonphysician. Campbell et a/. (2) found that the training of technologists can be carried out in the same work setting as the residents. Nevertheless, we were surprised at how well the resident physicians accepted this and how it actually served as an incentive to most of them. Obviously, not all technologists are suitable candidates for this sort of training. It requires people with the motivation to acquire new skills, an ability to relate well. to patients, and the maturity to recognize their limitations (6). On the other hand, it would be incorrect to assume that this project is unique or could not be duplicated. In most larger radiology departments, there will be
Vol. 115
FLUOROSCOPY OF UPPER GASTROINTESTINAL TRACT BY TECHNOLOGIST
583
Diagnostic Radiology
Figs. 1 through 4. Routine fluoroscopic spot films from an upper gastrointestinal series done with the remote control unit. These 70mm films are arranged in the sequence in which they are usually taken. The routine upper gastrointestinal series in addition includes the following large "overhead" films: frontal prone and supine, right lateral and right anterior oblique views of the stomach and proximal small bowel; also a right anterior oblique view of the entire esophagus fUlly distended with barium.
at least one or two capable technologists who would be interested in such training. One aspect in the performance of an upper gastrointestinal examination not assessed in this study is the im-
portance of diagnostic information retrieved from fluoroscopy. We share with Miller and Lieberman the opinion that fluoroscopy should primarily be used as a guide for obtaining adequate film studies (7). Consequently,
584
ANN M. LEWICKI
our examination technique is deslqned to cover with films those areas (esophagus, duodenum) where abnormalities are most frequently missed by the less experienced examiner. One objection to such on-the-job training is that it may not be possiole' to recognize 'the more advanced standing of these technologists formally, and to pass along some of the cost benefit derived through such an arrangement. This dilemma could be solved by establishing a mechanism for institutional licensing in which quality of care could also be,closely monitored by the institution and the supervising physicians. Under such an arrangement, quality of care would be assured by monitoring the output of the performance, allowing for variability of prior training (3). The added advantage of onthe-job training under institutional licensing is that trainees could be immediately instructed in techniques peculiar ·to' their' institution and could be shifted in assignments as departmental needs change. The author appreciates the special assistance of Lois Griffin, R. T., Nancy Buck, and Douglas ACKNOWLEDGMENT:
Cowan, M.D.
June 1975
REFERENCES 1. Abrams HL: Observations on the manpower shortage in radiology. Radiology 96:671-674, Sep 1970 2. Campbell JA, Lieberman M, Miller RE, et al: Experience with technician performance of gastrointestinal examinations. Radiology 92:65-73, Jan 1969 3. Carlson RJ: Health manpower licensing and emerging institutional responsibility for the quality of care. Law and Contemp.orary Problems 35:849-878, Autumn 1970 4. Huber EJ: A program to train physicians' assistants in diagnostic radiology. Appl RadioI3:31-35, Jan-Feb 1974 5. Janover ML: Too many radiologists? Radiology 108:219221,Ju11973 6. McDonnell TM, Dreesen RG, Hoover C, et al: Technologist experience with fluoroscopy in gastrointestinal examinations. Radiol Techn 41:344-346, May 1970 7. Miller RE, Lieberman M: Cost restraints and a better upper gastrointestinal examination. Radiology 110:67-70, Jan 1974 8. Thompson TT, Harle TS, Lester RG: The physician's assistant in radiology (editorial). Radiology 95:199-200, Apr 1970 9. Thompson TT: Radiologists look at physician's assistants In radiology. Radiology 100:199-202, Jul1971 Department of Radiology Harvard Medical School 25 Shattuck Street Boston, Mass. 02115
Fluoroscopy of the Upper Gastrointestinal Tract by the Radiological Technologist 1 Ann M. Lewicki, M.D. A pilot program was established to train an experienced radiological technologist to perform fluoroscopy of the upper gastrointestinal tract. Patients were prescreened and films reviewed by a staff radiologist. The quality of the films obtained by the technologist equaled that of the department's resident radiologists. INDEX TERMS:
Education, diagnostic radiology. Fluoroscopy. Gastrointestinal Tract, ra-
diography
Radiology 115:581-584, June 1975
•
•
is no general agreement as to whether a real shortage of radiologists exists in the United States (1, 5). Some apparent shortages may actually be relative and due only to maldistribution. Nevertheless, a markedly increased demand for radiologic services could develop if the United States adopts a national health insurance program. It has been recognized for some time now that many of the physician's tasks could be performed by paramedical personnel. In radiology, assistance can be offered by the prescreening of roentgen films or by assistance in roentgen procedures. Both approaches have been explored and are incorporated into existing radiology physician-assistant programs (4, 8, 9). Radiologists generally invest more time in examinations than in subsequent interpretations of roentgen findings (2). Some approach, then, which offers assistance to the radiologist in the performance of roentgen procedures would lessen the demands on his time significantly. How such assistance can be given with little compromise in quality (at least in selected patients) is the subject of this report.
T
an adjacent hall and viewing area. Videotape equipment is also available and recording can be initiated from the viewing area. Technician fluoroscopy was done during the regular morning schedule while studies were carried out in adjacent rooms by residents and attending staff. The technician learned to use the same examination technique as the physician staff (Fig. 1) and the maneuvers to check for gastroesophageal reflux. All patients were initially seen by the supervising radiologist who took their medical histories. The same criteria were used for selecting patients to be examined by the technician as are usually applied when a physician performs the examination on the remote control unit. Critically ill patients and those who need assistance during the examination for other reasons are not examined on the remote control unit except in unusual circumstances. All films were checked by a member of the attending staff whether the patient had been examined by the technologist or a resident. Only then was the patient permitted to leave the department. When necessary, supplementary fluoroscopic films were taken by the original examiner. Once the technologist had learned to do fluoroscopy unassisted, fluoroscopy time and the quality of films from randomly selected cases among the first 30 consecutive examinations were compared to 15 cases examined by radiology residents with four months of training in gastrointestinal fluoroscopy. The quality of the fluoroscopic films was evaluated by randomly intermixing the films of the 15 patients examined by the technologist with those of 15 patients examined by the resident physicians. The fluoroscopic examination was considered unsatisfactory if the films were inadequate to exclude or to establish disease and if a repeat examination was considered mandatory. The films were considered adequate even if not optimal if disease or normalcy could be established. An examination was thought to be of good quality if all required views were taken and if all of these
HERE
MATERIAL AND METHODS
The radiological technologist observed in this pilot study had had nine years of uninterrupted working experience since completion of training. Of these, she has spent three years in the gastrointestinal suite of our department. As part of her experience, residents and attending staff were observed using the same technique for examining the gastrointestinal tract in which she was subsequently instructed. The gastrointestinal suite in our department consists of three fluoroscopic rooms, one of which is equipped with a remote control unit. The training and conduct of technician fluoroscopy occurred exclusively in the room with the remote control unit. All rooms are equipped with a television viewing system with remote monitors in
1 From the Department of Radiology, Harvard Medical School, and Peter Bent Brigham Hospital, Boston, Mass. Accepted for publication in January 1975. shan
581
582
ANN
Table I:
Patient Characteristics
Examiner
In
Out
Technologist Resident
4
4
11 11
Table II: Examiner Technologist Resident
..----Diagnosi s--., Normal Abnormal
7
8 6
9
Fluoroscopic Examination
Film Quality* G A U 11 11
M. LEWICKI
4 4
Flucroscopyj Time (min.)
Repeat** Fluoroscopy
8 9
5 2
0 0
* G = good; A = adequate; U = unsatisfactory. t I ncludes time necessary for repeat fluoroscopy. ** Repeat fluoroscopy was performed by the original examiner on the same day to obtain additional spot films.
were correctly positioned. An attending senior radiologist and a resident physician reviewed all of the films, classifying them into the above categories. RESULTS
After fluoroscoping 6 patients under close supervision and assistance, the technologist was able to perform satisfactorily on her own with only occasional assistance. Initially, her performance was watched closely on the remote television monitor. When review of continuous videotape recording on a number of cases did not yield additional information, such monitoring was discontinued. As can be seen from Table I, the patients examined by the technologist and resident physicians were similar. Her fluoroscopy time compared favorably with that of the resident group. Fluoroscopy time remained essentially at a plateau level during the four months of the study. The quality of fluoroscopic spot films and the frequency of repeat fluoroscopy was similar in the two groups (Table II). Subjectively, the films taken by the technologist seem of consistently better quality than those of the resident physicians, although it was difficult to quantitate this difference. Fluoroscopy by a technologist was well accepted by the radiology residents. It seemed, in fact, an added incentive for them to perform better. It was equally well accepted by patients. Only one patient was screened out during the pre-examination interview and examined by the supervising radiologist. He was a man who seemed to need a strong authoritative approach and might have resented examination by a technologist or even a resident. The project was followed with a great deal of interest by the remaining gastrointestinal technologists who work in the area. To some extent, they seemed to resent not being able to participate in the project at this point. DISCUSSION
This pilot project demonstrates the ease with which
June 1975
training in a limited task can be accomplished. That this training was possible over such a short period is undoubtedly due in part to several physical characteristics of the work area as well as the working routine. These include television-monitored fluoroscopy in all examination rooms so that technicians are able to observe examination techniques. Since the same basic technique is used by all physicians working in the gastrointestinal suite, considerable learning can take place by observation alone, at least by an interested technologist. The remote control unit has only one x-ray tube and positioning and collimation of large overhead films is routinely monitored fluoroscopically by the technologist. Consequently, all technologists working in the area are adept in using the shutters and in controlling table movements. The remote control unit provided another advantage in that instruction and supervision of fluoroscopic examinations could be performed without exposing the patient to the accompanying dialogue. Another factor contributing to the ease of training was that instruction was limited to performing examinations of the upper gastrointestinal tract only. While a restricted training approach does shorten the training period, it need not be as limited as the present pilot study suggests. A technologist could eventually be trained to perform many or all procedures in one specialty area of a department. Trainees in other formal programs are usually exposed to considerable didactic teaching and instructed more comprehensively so that they can function in all sections of a radiology department (8,9). Such comprehensive instruction usually requires a two-year training period. The present pilot project demonstrates that a detailed understanding of gastrointestinal anatomy and physiology is not necessary for performing a completely adequate examination in selected patients. A selection of patients was achieved here because patients with less complicated medical problems are examined on the remote control unit. As an added safeguard, the supervising radiologist, who was also the instructor, interviewed all patients prior to examination. From such a pre-examination interview, most experienced radiologists can predict whether an examination will yield significant pathologic findings. With a well-designed questionnaire, such prescreening could also be relegated to a nonphysician. Campbell et a/. (2) found that the training of technologists can be carried out in the same work setting as the residents. Nevertheless, we were surprised at how well the resident physicians accepted this and how it actually served as an incentive to most of them. Obviously, not all technologists are suitable candidates for this sort of training. It requires people with the motivation to acquire new skills, an ability to relate well. to patients, and the maturity to recognize their limitations (6). On the other hand, it would be incorrect to assume that this project is unique or could not be duplicated. In most larger radiology departments, there will be
Vol. 115
FLUOROSCOPY OF UPPER GASTROINTESTINAL TRACT BY TECHNOLOGIST
583
Diagnostic Radiology
Figs. 1 through 4. Routine fluoroscopic spot films from an upper gastrointestinal series done with the remote control unit. These 70mm films are arranged in the sequence in which they are usually taken. The routine upper gastrointestinal series in addition includes the following large "overhead" films: frontal prone and supine, right lateral and right anterior oblique views of the stomach and proximal small bowel; also a right anterior oblique view of the entire esophagus fUlly distended with barium.
at least one or two capable technologists who would be interested in such training. One aspect in the performance of an upper gastrointestinal examination not assessed in this study is the im-
portance of diagnostic information retrieved from fluoroscopy. We share with Miller and Lieberman the opinion that fluoroscopy should primarily be used as a guide for obtaining adequate film studies (7). Consequently,
584
ANN M. LEWICKI
our examination technique is deslqned to cover with films those areas (esophagus, duodenum) where abnormalities are most frequently missed by the less experienced examiner. One objection to such on-the-job training is that it may not be possiole' to recognize 'the more advanced standing of these technologists formally, and to pass along some of the cost benefit derived through such an arrangement. This dilemma could be solved by establishing a mechanism for institutional licensing in which quality of care could also be,closely monitored by the institution and the supervising physicians. Under such an arrangement, quality of care would be assured by monitoring the output of the performance, allowing for variability of prior training (3). The added advantage of onthe-job training under institutional licensing is that trainees could be immediately instructed in techniques peculiar ·to' their' institution and could be shifted in assignments as departmental needs change. The author appreciates the special assistance of Lois Griffin, R. T., Nancy Buck, and Douglas ACKNOWLEDGMENT:
Cowan, M.D.
June 1975
REFERENCES 1. Abrams HL: Observations on the manpower shortage in radiology. Radiology 96:671-674, Sep 1970 2. Campbell JA, Lieberman M, Miller RE, et al: Experience with technician performance of gastrointestinal examinations. Radiology 92:65-73, Jan 1969 3. Carlson RJ: Health manpower licensing and emerging institutional responsibility for the quality of care. Law and Contemp.orary Problems 35:849-878, Autumn 1970 4. Huber EJ: A program to train physicians' assistants in diagnostic radiology. Appl RadioI3:31-35, Jan-Feb 1974 5. Janover ML: Too many radiologists? Radiology 108:219221,Ju11973 6. McDonnell TM, Dreesen RG, Hoover C, et al: Technologist experience with fluoroscopy in gastrointestinal examinations. Radiol Techn 41:344-346, May 1970 7. Miller RE, Lieberman M: Cost restraints and a better upper gastrointestinal examination. Radiology 110:67-70, Jan 1974 8. Thompson TT, Harle TS, Lester RG: The physician's assistant in radiology (editorial). Radiology 95:199-200, Apr 1970 9. Thompson TT: Radiologists look at physician's assistants In radiology. Radiology 100:199-202, Jul1971 Department of Radiology Harvard Medical School 25 Shattuck Street Boston, Mass. 02115
