White Paper on the Radiologist Assistant
Background
The concept of an advanced-practice radiologic technologist is not new. In the 1970s, radiology physician assistant programs were initiated at the University of Kentucky, Brown University and Duke University. Although all of them eventually closed due to perceived lack of demand, some of their graduates are still in the workforce. In 1996, the Department of Defense (DOD) asked Weber State University to design a Radiology Practitioner Assistant (RPA) program in an attempt to address a shortage of radiologists in the armed forces medical programs. Although the DOD subsequently withdrew support due to budgetary cutbacks, Weber State continued the program, which has graduated roughly 100 RPAs who currently are practicing in the field. Among some of the common procedures performed by the RPAs are GI barium studies, fistulograms, genitourinary studies, arthrograms, thorocentesis, paracentesis, ultrasound and CT-guided biopsies and drainages, peripherally inserted central venous catheter line placement, angiography, and venography, Dobhoff tube placement, lumbar punctures and myelograms. Among the preliminary image evaluation reports being generated to the supervising radiologist include, but are not limited to, reports of the chest, abdomen, pelvis, orthopedics, spine and skull, as well as barium and interventional studies, CT, MRI, ultrasound, nuclear medicine, vascular/cardiac procedures, and mammograms.1 The Weber State RPA program includes five semesters of technical training leading to the awarding of a baccalaureate degree. There is a separate Certification Board for Radiology Practitioner Assistants. Due to current workforce shortages, not only is the Weber State program succeeding but other institutions have inquired the ASRT about developing similar programs.2
In March 2002 the ACR met with representatives of the American Society of Radiologic Technologists (ASRT), the American Registry of Radiologic Technologists (ARRT) and the National Society of Radiology Practitioner Assistants to discuss the development of an advanced practice radiologic technologist to be known as a radiologist assistant (RA). The panel members also included a representative from state government (Arizona Board of Medical Radiologic Technology) and a representative from E-Z-Em Inc.
Past Council Action
Two separate resolutions on this topic came before the ACR Council in 1989 and 1990. The 1989 resolution was referred to the ACR Board of Chancellors. The board subsequently referred it to the ACR Commission on Human Resources which developed a new resolution, sponsored by the Board of Chancellors, for the 1990 meeting. The 1990 proposed resolution stated that "BE IT RESOLVED, that the development of formal education programs for radiologist''s assistants is not recommended at this time, and BE IT FURTHER RESOLVED, that, when necessary, radiologic technologists with appropriate training and experience enjoy career improvement by being promoted to perform tasks as radiologist''s assistants, provided that such responsibilities conform with state law and other ACR policies.
After consideration, the ACR Council passed the following resolution:
BE IT RESOLVED,
that the ACR opposes development of formal educational programs for radiologist assistants.
That policy remained in effect until 2000 at which time the Council chose to sunset the policy.
Rationale for Participation
The ACR participated in the panel discussion for several reasons. First, the workforce shortage among radiologic technologists is well documented. Radiology groups and hospitals are having difficulty both recruiting and retaining technologists. It was hoped that by offering a step-up in the career ladder this situation might be ameliorated. Additionally, radiologists are currently experiencing workforce shortages of their own, and it was hoped that the RA might provide some basic services typically provided by radiologists, leaving them greater time to interpret films and focus more time on high end exams. Additionally, anecdotal evidence was mounting that radiologists were using nurse practitioners, radiologic technologists, physician assistants and RPAs to perform certain services typically performed by a radiologist.
The "Advanced Practice Advisory Panel" met for two days. Two documents, "The Radiologist Assistant: Improving Patient Care while Providing Workforce Solutions" (also known as the consensus paper) and the "Radiologist Assistant—Roles and Responsibilities" were produced as a result of the meeting.
Consensus Paper Development
Some revisions dealing with the envisioned title and scope of the radiologist assistant were forwarded from the ACR to the ASRT and included in the final copy of the consensus document. The document was sent to the ACR Board of Chancellors (BOC) for consideration at its meeting in June 2002. After discussing the consensus document, the BOC agreed to support the concept of the RA as expressed in the consensus paper. The BOC also requested that regular updates be provided to the ACR Executive Committee on issues involving curriculum and delineation of roles and responsibilities.
Despite the BOC''s concurrence with the concepts embedded in the consensus agreement, some concerns were expressed. For instance, it was noted that the performance of certain radiologic exams by the RA might prompt re-evaluation of the relative value units that partially reflect the time it takes the physician to perform the service. Staff was also asked to look into what changes might need to be made to make procedures provided by radiologist assistants consistent with the many policies and standards of the College.
Roles and Responsibilities Document
The Roles and Responsibilities document proved more problematic. The original document included 16 procedures that could be performed by an RA [all of which currently require personal supervision (physician in the room) under Medicare]. An ACR subcommittee was appointed to review the roles and responsibilities document and develop an alternative that would balance the human resources needs with patient care. The subcommittee made significant amendments to the ASRT Roles and Responsibilities document, but retained a role for the RA to perform fluoroscopy for non-invasive procedures among other duties envisioned for the RA.
Negotiations with ASRT
On October 22, ACR and ASRT leaders met to discuss the roles and responsibilities document and the ACR alternative. After significant discussions, the ASRT agreed to the ACR document with some minor changes. It should be noted that the agreed-upon language specifically states that the "RA will not perform interpretations (preliminary, final or otherwise)."
Environmental Changes
In the months since the first meeting in March 2002, three states have discussed recognition of an advanced-practice radiologic technologist with an expanded scope of practice. These states are Kentucky, Washington, and Montana. The ACR is working closely with these state chapters. The ACR would like to slow state legislation pending a national solution to this issue through efforts with the ASRT and a resolution at the national meeting.
The ACR sent out an ACR E-News to members on September 22 alerting them to recent legislative and regulatory activity on the subject and discussing the ACR work on a solution that is likely to come before the ACR Council in May 2003. The E-News piece also requested feedback from members on the use of ancillary personnel to assist radiologists. The ACR received 39 responses from members. Fifteen of the responses were negative. Most of those comments focused on scope of practice with some expressing the concern that the RAs would become the nurse anesthetists of the radiology community. Twenty-four responses were quite favorable, with most stating that they already employ someone at their offices to perform a broad array of radiology procedures.
The ASRT reports that several academic institutions have initiated the development of university-based academic programs that encompass advanced clinical roles for radiologic technologists. The ASRT has entered into discussions with these programs in order to make them consistent with the RA concept.
Issues
The potential development of an RA program is not without its concerns. For instance, it is difficult to determine what effect the development of the RA will have on the radiologic technologist and radiologist workforce shortages. The ACR is quite concerned that the development of the RA will lead some to seek greater scope of practice than that currently envisioned. The ACR is also concerned about potential reimbursement issues from Medicare and other third-party payers from the increased involvement of the RA in radiological exams. Some changes in ACR policy and Medicare policy will need to be made. Further, the ACR will need to work with the ASRT and ARRT to make sure that RAs and their scope of practice are clearly delineated in state statutes and/or regulations.
The ACR is also concerned about the effects of not acting. With various programs already adopting ancillary personnel to perform a variety of services, lack of participation will affect our ability to: (1) ensure patient safety by allowing only properly trained personnel to provide radiological services to patients; (2) ensure that these ancillary personnel are not allowed to practice without appropriate physician supervision; and (3) ensure that there are not 50 different state scope-of-practice laws allowing these ancillary personnel to perform a variety of services the outcome of which may be based more on political expediency than quality patient care.
Summary
The ACR believes that the development of the RA should help alleviate the workforce shortages for radiologic technologists by creating a professionally satisfying career path. The ACR accepts that the RA, as envisioned, will alleviate some of the time pressures placed on radiologists as a result of their workforce shortages. The ACR also trusts that working with the ASRT and ARRT will increase our chances for successful scope of practice delineation at the state legislative and regulatory levels.
The RA will undoubtedly change the way radiology is currently being practiced. However, environmental forces are already changing the way radiology is being practiced. The ACR has a choice to lead on the issue and try to effect a positive outcome from the beginning or continue to allow the process to evolve as market and political pressures warrant. As the leader in the profession, the ACR believes that it is in the best interest of its members and the profession to develop reasoned solutions to the workforce shortage while doing the best it can to ensure the best for our patients. We believe this approach strikes that important balance.