Adding value through preliminary image evaluation: If you see something, say something

June’s blog was written by Andrew Murphy. Andrew is a radiographer based in Brisbane, Australia. He creates radiographic image interpretation pathways for a wide audience of health care professionals and is currently a managing editor of Radiopaedia.

Over the years, the dialogue around image interpretation by Australian radiographers has become a debate of semantics. It’s a discussion that with each iteration seems to be gaining nothing but circular momentum. In Australia, the question is often asked: ‘should we introduce radiographer image interpretation into this workplace?’, but really, the more pressing questions we should be asking ourselves are, ‘what are the regulatory implications of our staff not working to the expectation of the Medical Radiation Practice Board of Australia? 1’, and ‘what are the implications to both our patients and our department for ignoring significant findings because a functioning system was not in place?’. Sadly, the discussion often doesn’t move past the initial question of whether or not a radiographer image interpretation system should be implemented.

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Medical Radiation Practice Board of Australia Professional capabilities for medical radiation practice Domain 1, Key Capability 7

To be clear, this blog post is not about reporting. This is about day-to-day image interpretation, whereby a radiographer notices an abnormality, flags that abnormality, and communicates their findings to relevant parties in the form of a written and/or verbal comment. This is known in Australia as a preliminary image evaluation (PIE), or as I like to think of it, ‘if you see something, say something’.

There are radiographers in Australia who believe this is not part of their job, and it seems that no amount of evidence or regulatory policy will convince them otherwise. I personally believe this is because we tend to approach this topic from an overly academic point of view. So rather than listing and synthesizing the evidence to support radiographers participating in PIE (I have done this. It is 15 pages long and a riveting read. If you are interested, it can be found here 2), I want to reflect on what this should really be about, and that is, adding value.

‘Image interpretation is not my job’

Sure, providing a diagnostic report is not your job, but examining your images for abnormalities for patient safety? That is 100% your job.

Imagine this scenario: It’s 10pm. You’re working alone. The radiologist has gone home, there isn’t a doctor in sight. There may be one upstairs…if you call around enough. You  perform this head scan:

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Case courtesy of Dr David Cuete. Radiopaedia ID: 22907

Now, do you:

a) complete your scan and call for your next patient?

b) call the most relevant person to this patient and let them know immediately that this scan needs their attention?

This is an obvious case, but it paints a picture: you recognize the severity of these findings and you feel an obligation to your patient to ensure they are cared for in a timely matter.

The same goes for a case like this:

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Case courtesy of Dr Ian Bickle. Radiopaedia ID: 50351

Or this:

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Case courtesy of Dr Gagandeep Singh. Radiopaedia ID: 7226

Now picture yourself in a busy emergency department. You have performed this shoulder radiograph:

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Case courtesy of Assoc Prof Craig Hacking.             Radiopaedia ID: 39440

You notice all three abnormalities on the radiograph (can you find them?). You ensure that the appropriate parties are informed, in the form of a comment on your PACS (or however you convey information in your department). Why? Because you feel an obligation to your patient and to your ED team that when a patient come to your department, they not only get their scapular fracture attended to, they also have their AC joint injury and broken ribs noted as well, because when a patient come to your department, they get the best care: the type of care you’d want for your family. And overall, this is what image interpretation is about. It is about adding value: to your patient’s care, to your doctor’s request.

Should your department (in Australia) have a working image interpretation protocol to support you? Yes. If you see something, but there is not a protocol in place, are you expected to say something and write it down? Absolutely. Do you need anyone’s permission to do this in Australia? No, you don’t, because it is your job. It may mean you feel a little vulnerable, but overall you’re doing what is best for your patient.

But where do you draw the line? Great question! If a radiographer were to observe a chest CT and comment ‘There is a mass extending outside the vessel wall into adjacent lung parenchyma. This is a pulmonary angiosarcoma.’, then yes, we can all agree this is not simple recordkeeping; this is an attempted diagnosis. We must be clear that PIE is a comment, an observation, a point worth mentioning, and it is not, nor will it ever be, a diagnostic report.

This has been a bit of a whirlwind blog post about the role of the radiographer in Australia (beware there are regulatory differences across international borders). At the end of the day, if I could leave you with one thing it would be, ‘If you see something, say something’, because that is what I would want if my mother, father, friend, any member of the human race, or even my pet were a patient.

References:

  1. “Professional capabilities for medical radiation practice (the professional capabilities)”. The Medical Radiation Practice Board of Australia, 2020. [Link].
  2. Andrew Murphy, Ernest Ekpo, Thomas Steffens, Michael J. Neep. Radiographic image interpretation by Australian radiographers: a systematic review. (2019) Journal of Medical Radiation Sciences. 66 (4): 269 org/10.1002/jmrs.356

 

Understanding student attrition: A perspective from radiotherapy

This month’s blog is by educators, Jo McNamara and Zoe Grant. Jo is a senior lecturer and admissions tutor on the Radiotherapy and Oncology programme at Sheffield Hallam University and Zoe is the course leader for Radiotherapy and Oncology at the University of Suffolk.


At this time of year, academics celebrate the success of their final year students reaching the end of their training, leaving their departments where they have been nurtured for three years, applying for and receiving job offers and reflecting on their hard work and dedication. Reaching this point of qualification is no mean feat, as not all students make it this far…and here lies the focus of this blog, student attrition.

The 2017 NHS cancer workforce plan(1) highlighted our profession to be ‘at risk’, whilst it has been reported that departments are operating with a vacancy rate of 6.2%(2) we know that this is often as a result of departments managing their staffing creatively, with shift patterns and overtime and relying on the good will of staff to adapt. We know that the pandemic has affected cancer services from diagnosis, through to treatment and we await the influx of patients, as services reopen and referrals are made. Will this increase in demand on radiotherapy services, finally highlight the staffing issues we know exist? Will the Covid-19 further compound recrtuiment and retention challenges?

During the pandemic, academic Therapeutic Radiographers have been extremely busy redesigning lectures and seminars, putting plans in motion for a distance learning alternative to the courses for September, spending hours redesigning the academic calendar, accelerating assessment marking times and bringing award boards forward to allow final year students to qualify earlier. They have been supporting those students wishing to join the temporary register, and those who dont, supporting those students pastorally who are really struggling with such a drastic change in their way of life, continuing to interview applicants online and supporting those hoping to start University in September, along with countless other tasks to ensure that the future therapeutic radiography workforce is not affected by the pandemic but it will take 2-4 years before we can truly assess the impact of Covid-19 on student attrition in radiography.

Efforts to raise the profile of radiography undoubtedly help – It has been so inspiring to see the huge increase in promotion of the profession recently, with the ‘I see the difference’ campaign, Health Education England’s (HEE) investment in recruitment resources, SoR’s Radiography careers activity and HEI’s development of marketing campaigns. With so much emphasis on promotion and recruitment, it would be easy to overlook the issue of student attrition…

Still the definition of attrition varies significantly across the entire sector and the way in which attrition data is recorded is specific to each HEI. Without a consistent approach to recording this across HEI’s, issues around attrition could go unnoticed.  As educators, we know that students don’t always have exit interviews and don’t always give the real reasons as to why they are leaving the programme, adding to the complexity of understanding this issue. ‘Wrong career choice’ and ‘not meeting academic standards’ are typical to see(3),  the RePAIR project highlighted the impact of clinical placement experience on attrition(4). A recent study identified poor clinical experiences and ‘wrong career choice’ as two of the main factors for considering leaving the course(5).

To try and address ‘wrong career choice’ and adhering to the recommendations made from RePAIR project(4), prospective students applying at Sheffield Hallam University (SHU) and University of Suffolk (UoS) are required to visit a Radiotherapy department prior to enrolling. Since the outbreak of Covid-19, we have needed to approach this  differently e.g using the 360 Virtual Reality film ‘A Day in the Life of a Therapeutic Radiographer‘ to give potential students an opportunity to gain an insight into the profession.

Looking at the reasons why students temporarily withdraw from study gives us an insight into the factors affecting attrition. Anecdotally, finances, mental health and caring responsibilities are typical reasons for students taking a break in study. Financial difficulties can be a significant problem for many students. The impact of abolishing the student bursary may not have had a significant imapct on applications numbers, however its impact on attrition has yet to be realised (and indeed may never be highlighted). Often students experiencing financial difficulties take part-time work alongside their academic weeks and clinical placements, sometimes working night shifts or weekends. This can impact their ability to meet assessment deadlines and achieve the required grades to continue on the programme, posing a risk that they exit due to academic failure. Working alongside the course is discouraged, but with the financial demands on students it isn’t surprising that some have no choice, and even if they can keep up with academic and clinical pressures whilst working, burnout is often observed. Sometimes what can be perceived as unprofessional behaviour is actually students struggling to cope with the demands of the course and working: “I have to work 25 hours a week to support myself and my family financially whilst at Uni and my employer isn’t flexible around shift patterns and so they are the same whether I am in academic or clinical. I am often late for clinical placement and what the staff don’t realise is that it’s because I am coming straight from a night shift in a care home. I worry that I am perceived as ‘THAT’ student and yet I am working so hard to become a Therapeutic Radiographer and make my family proud” (Anonymous quote from a year 2 student).

As academics, Zoe and I have observed a significant increase in the amount of pastoral support we are having to provide our students. HEI’s are under considerable financial pressures and the reduction in student support services places more pressure on academics to support students and refer them onto services. I have used my counselling skills far more in my capacity as a lecturer than I ever did in clinical and Zoe is a trained mental health first aider, to try and support those students experiencing mental health issues. Having witnessed colleagues lose students on their programmes to suicide, the reality of mental health issues is overwhelming. We have to support our students, whilst also pushing them to meet deadlines and gain competencies  – the two often conflict with each other. Attempting to complete the Radiotherapy degree is hard work academically, but attending University has its own pressures. Being away from home and feeling isolated, whether that be socially or geographically. We have seen students who’ve never experienced mental health issues previously start to develop them under the increased pressure whilst being on the course. Universities are always a reflection of society and there are pressures and demands on our students that we have not observed in previous years, such as managing social media platforms, pressures of technology, competition for jobs, competitive behaviours and an increased awareness of mental health. We have to consider all this when we go to make that statement……. ‘back in my day………..’

The impact of Covid 19 on attrition has yet to be observed, but what we do know is that everyone involved in education is working extremely hard to ensure that programmes continue and students are supported throughout the changes to the courses, with the hope that they will continue and hopefully qualify as a Therapeutic Radiographer in the years to come!


  1. NHS Cancer Workforce Plan. Phase 1: delivering the cancer strategy to 2021. 2017.
  2. SCoR census of the UK radiotherapy radiographic workforce Nov 2017.
  3. College of Radiographers. report. Approval and Accreditation Board. Annual Report 1st September 2016 – 31st August 2017 https://www.sor.org/sites/default/files/document-versions/cor_aab_annual_report_2016-2017.pdf.
  4. Health Education England. Reducing pre-registration attrition and improving retention (RePAIR) report. (Available at: https://www.hee.nhs.uk/our-work/reducing-pre-registration-attrition-improving-retention Date: 2018
  5. Clarkson, M., Heads, G., Hodgson, D., and Probst, H. Does the intervention of mindfulness reduce levels of burnout and compassion fatigue and increase resilience in pre-registration students? A pilot study. Radiography. 2019; 25: 4–9