Physician and Tech Shortage Fuels Drive for 'Supertechs'
By C.P. Kaiser
Three years ago, special procedures technologist James Abraham left
New Mexico to work in rural Montana. Unfortunately, many procedures allowed in
New Mexico were off limits for technologists in the Big Sky Country. Although
the 19-year veteran had brought some much-needed organizational and medical
skills to the interventional suite at Kalispell Regional Medical Center, he was
essentially operating at 50 percent capacity. That is, until he began training
as a radiology practitioner assistant.
With less than a year
remaining in a two-year RPA program, Abraham is already saving radiologists
precious time. "In a typical 10-hour workday, he doubles the time I have for
reading and interpreting images," said Dr. Hugh Cecil, who recruited Abraham
after working with him in New Mexico. "If he left, it'd be like replacing half a
Where Cecil used to spend half an hour performing a
CT-guided biopsy, he now spends five minutes. Abraham obtains informed consent
and handles other patient management duties, positions the patient, and lines up
the needle. The nurse administers the appropriate medications. Cecil walks in,
places the needle, takes the biopsy, and leaves to read more films. Abraham
performs the lion's share of other procedures.
Abraham works under
radiologist supervision, but as he progresses through the program and his group
becomes more comfortable with his skills, he'll perform these procedures
autonomously. Earlier this year, the Montana legislature joined two other states
in recognizing RPAs, essentially giving them authority to perform duties that
registered technologists cannot. These so-called supertechs may be an answer to
today's acute shortage of both radiologists and technologists, but their
acceptance has been hard-won, particularly within organized radiology.
In the mid-1990s, Jane Van Valkenburg, Ph.D., chair of radiological sciences
at Weber State University in Ogden, UT, was asked by the Department of Defense
to create a program to train physician extenders. Military hospitals, like their
civilian counterparts, are suffering an acute shortage of both radiologists and
technologists and are searching for ways to stretch thinning resources. But when
the military scrapped the project, Van Valkenburg found enough civilian support
to start the program at her institution. The program, the only one of its kind,
has averaged 15 graduates a year, but the numbers are growing: 53 technologists
are currently enrolled, and 108 have been accepted for the fall class.
"That tells you something about the demand," Van Valkenburg said. "At first
radiologists felt threatened, but then they realized that these people make
their jobs easier."
As much as the ACR might try to distance itself
from RPAs, radiologists have been involved with the program since day one, she
said. Students must be registered technologists with at least five years'
experience and must be recommended by a radiologist at their practice or
facility. Radiologists work with and teach the students, and the curriculum has
changed based on radiologists' feedback.
North Carolina's High Point
Regional Health System has two RPAs and one in training. The RPAs do most of the
fluoroscopy, help with minimally invasive procedures, and act as intermediaries
between radiologists and referring clinicians, said Dr. Mark Lukens of High
Point Radiological Services. Lukens joined the practice in 1998, after the group
had already sent its first technologist to the Weber State program. Today, he
serves as an advisor to Van Valkenburg.
The advisory panel that gave
shape to the radiologist assistant concept consisted of representatives from the
ACR, ASRT, and American Registry of Radiologic Technologists, representatives
from industry, and the president and vice president of the National Society of
Radiology Practitioner Assistants. Many members of the NSRPA felt betrayed by
their officers' acquiescence to this "watered down" version of an RPA, Van
"It was bitter, and some RPAs called for the
officers' resignation," she said. Van Valkenburg said she empathizes with the
NSRPA representatives. Not being too politically savvy, they may have felt
intimidated by the ACR and ASRT representatives. Nevertheless, the ACR is now
onboard, throwing its
weight behind the concept of the physician
The name chosen for this new entity was especially
important to the ACR. The advisory panel rejected "radiology practitioner
assistant." It noted that the inclusion of the word "practitioner" is
potentially misleading to the public and other health professionals because it
implies that the individual is an assistant to any medical practitioner, not
just to radiologists. Panel members also agreed that the title "radiologist
assistant" clearly links the advanced level technologist to the radiologist.
Although the scope of practice for RAs will evolve, it is slightly
narrower than that of RPAs. RAs will still take responsibility for patient
assessment, management, and education. Duties might include determining whether
a patient has been appropriately prepared for a procedure, obtaining patient
consent prior to a procedure, and adapting exam protocols to improve diagnostic
quality. But they will not differentiate normal from abnormal imaging
examinations or assess the radiographic findings to determine whether immediate
radiologist interpretation is needed.
RAs will perform selected
radiology procedures including but not limited to dynamic and static
fluoroscopy, cyst aspiration, needle biopsies, and lumbar punctures. RPAs also
perform fluoroscopy, biopsies, and fluid drainage, as well as arthrograms,
placement of nasogastric and enteroclysis tubes,
myelograms, and any other
procedures in which competency has been demonstrated and which the radiologist
is comfortable delegating to the RPA.
The ACR panel did not like the
fact that RPAs "evaluate and review" images. It suggested that the phrase
confers too much authority on the technologist, bordering on image
interpretation. Additionally, RPAs report unusual findings to staff radiologists
and then to the supervising radiologist. The RA, on the other hand, makes
initial image "observations" and communicates those directly to the supervising
At present, 38 states license radiologic technologists.
Advanced-level technologists do not need additional licensure in those states
because the job is an extension of the radiologic technologist profession. In
the states that do not license radiologic technologists, physician extender
should be recognized as an advanced role for the radiologic technologist,
according to the ACR's Williams.
The general trend, however, has been
for political bodies to broaden the scope of practice for non-M.D.s, said Dr.
Leonard Berlin, radiology chair at Rush North Shore Medical Center in Chicago.
"Contrary to the wishes of physicians, the non-MD ancillary people have gotten
more authority to perform medical procedures," Berlin said. "Just look at the
optometrists versus ophthalmologists. Whether that happens in radiology remains
to be seen. But it won't surprise me."