|Dear chairman, professor Vano
This document is in our opinion highly needed and seems generally thoroughly prepared. We will confine ourselves to comment only on two principle issues.
Firstly, there is major imbalance throughout the document between the RP principle of justification and optimization, in favor of the latter. As rightly pointed out in the introduction the utilization of imaging procedures are steadily rising, also procedures requiring high patient doses. At the same time we know that a significant part of the procedures are not medically justified, a commonly reported estimate is approximately 30%. It is also argued that justification is a neglected area within RP. A major concern should accordingly be to educate and train the professionals in different aspect of justification. From our point of view, this implies expansions of the content of education as well as whom to educate. Regarding the latter, the document seems to assume a clear and consistent referring system within each country, i.e. that physicians act either as prescribers or referrers. The implication for education is that referring physicians requires less training because they have less decision power (page 8). However, in many countries the system is less clear-cut. It is quite common that the physician requests a specific procedure, which in turn is reassessed by the radiologist. Such a system of shared responsibility for assessing appropriateness of procedures requires education and train of all parties. Moreover, in some countries the radiographers are delegated responsibility for assessing appropriateness of referred procedures, out of resource considerations.
Regarding the content of the education and training in justification the document is very little specific and somewhat narrow-minded. Justification is not even listed among the training areas in table 1. It seems to be assumed that knowledge about RP benefits and risks is sufficient to avoid unnecessary exposure. It is referred to studies that show poor knowledge about RP among prescribing physician (page 30). So far so good, but to our knowledge there is no research showing any effect of increased knowledge of RP (or radiation units) on referral rates. On the contrary, it is well documented from how referral decisions are influenced by a series of psychological, cultural, societal and political factors. Therefore, we argue that the document should reflect the impact of context within which decision about imaging procedures are taken. The professionals need knowledge about what strong “external” forces that are affecting the justification process, and how to meet these challenges in an appropriate manner. Hence, the education and training need a broader perceptive than benefit and risks if the professionals are supposed to curb overutilization of imaging procedures, i.e. to practice in accordance with the justification principle.
Secondly, the concepts describing the professionals are inconsistent and partly unclear. In chapter 2.2 the professions are in some cases described by their involvement with ionizing radiation use and in other cases by their tasks in the process. The division of tasks between the professionals does however vary between countries; the description is therefore not always correct. For instant, radiographers do perhaps most often perform the examinations, still it is common that others operates the x-ray equipment, e.g. chiropractors, radiologists and cardiologists. Injecting radiopharmaceuticals may be a task for nurses, radiographers as well as biomedical laboratory scientists. The level of basic training may also vary between countries even if profession label is identical. Our point is that the categorization is not feasible for determining what kind and level of education and training that is required.
This becomes particularly clear in category 9 (page 18) were Radiographers, Nuclear Medicine Physicists and Medical Physics Technologists are merged into one group. This is also strange since as much as 15 other professional categories are separately identified. As a minimum we recommend splitting this into the categories Radiographers and Medicine Physicists. From our perspective radiographers and medical physicist possess the most important positions regarding RP, in addition to radiologists and referring clinicians, with distinctly different tasks and responsibility. For our radiographers a major task is on a daily basis to utilize x-ray equipment in patient examinations. The medicine physicists are hardly ever involved in patient examinations, their task is typically performance quality control of the x-ray equipment and supervise in the optimalization of protocols.
Besides, some of the concepts to describe these positions are unclear or at least unfamiliar, e.g. ‘Medical Physical Technologist’ and ‘CT scanner operator’ (a concept that emerges elsewhere in the document). We doubt this is well defined profession, equally understood in different countries and contexts. In table 1 and 2 a new set of “professionals” are introduced, which only partly overlaps with the categories in chapter 2.2. This is confusing and again we question the clarity of the concepts. For instance, who are (and who are not) a ‘Healthcare professional involved in x-ray procedures’ (HCP)?
For these reasons we suggest to let accurately described tasks and responsibilities relevant for RP in diagnostic imaging form the basis of categories. To us it seems reasonable that the level of knowledge and training required should be determined by the tasks and responsibility the person possess, rather than his/her professional background. Examples of how the current draft becomes misleading are found in table 2. Here it is suggested that medical physicists should only have a medium level of knowledge in a number of topics regarding basic physics. In our context this is not sufficient, as medical physicists are those possessing the high expertise and are expected to educate others (physicians and radiographers) in these topics. Moreover, when radiographers are responsible for quality control and quality assurance they surely need the highest level of knowledge in this field.
We believe that a consistently used task/responsibility-based categorization could give more appropriate suggestion of training requirements, and clarify to everyone what part of the document particularly addressing their position. Of course, it is possible in addition to give examples of what professions are usually found within each category. Alternatively, one could choose a few typical professions, labeled with one concept each, and explain that these are representing tasks and responsibilities which are divided and labeled differently throughout the world.
Kristin Bakke Lysdahl, radiographer, PhD student
Audun Sanderud, associate professor, PhD in Physics
Oslo University College, Radiography Program