Radiographer

Radiographers,^[1] also known as radiologic technologists, diagnostic radiographers and medical radiation technologists^[2] are healthcare professionals who specialise in the imaging of human anatomy for the diagnosis and treatment of pathology. Radiographers are infrequently, and almost always erroneously, known as x-ray technicians. In countries which use the title radiologic technologist they are often informally referred to as techs in the clinical environment; this phrase has emerged in popular culture such as television programmes.^[3]

Radiographers work in both public and private healthcare and can be physically located in any setting where appropriate diagnostic equipment is located, most frequently in hospitals. Their practice varies country to country and can even vary between hospitals in the same country.^[4]

Radiographers are represented by a variety of organisations worldwide, including the International Society of Radiographers and Radiologic Technologists (ISRRT) which aims to give direction to the profession as a whole through collaboration with national representative bodies.^[5]

History

Until around 1918 radiographers were known as skiagraphers; the term is derived from the Ancient Greek words for 'shadow' and 'writer'.^[6]

Role in healthcare

A radiographer uses their expertise and knowledge of patient care, physics, human anatomy, physiology, pathology and radiology to assess patients, develop optimum radiological techniques and evaluate the resulting radiographic media.^[7]

This branch of healthcare is extremely varied, especially between different countries, and as a result radiographers in one country often have a completely different role to that of radiographers in another. However, the base responsibilities of the radiographer are summarised below:

• Autonomy as a professional
• Accountability as a professional
• Contribute to and participate in continuing professional development
• Enforcement of radiation protection (There is a duty of care to patients, colleagues and any lay persons that may be irradiated.)
• Justification of radiographic examinations
• Patient care
• Production of diagnostic media
• Safe, efficient and correct use of diagnostic equipment
• Supervise students and assistants

On a basic level, radiographers do not generally interpret diagnostic media, rather they evaluate media and make a decision about its diagnostic effectiveness. In order to make this evaluation radiographers must have a comprehensive but not necessarily exhaustive knowledge of pathology and radiographic appearances; it is for this reason that radiographers often do not interpret or diagnose without further training. Notwithstanding, it is now becoming more common that radiographers have an extended and expanded clinical role, this includes a role in initial radiological diagnosis, diagnosis consultation and what subsequent investigations to conduct. It is not uncommon for radiographers to now conduct procedures which would have previously been undertaken by a cardiologist, urologist, radiologist or oncologist autonomously.^[8]

Contrary to what could be inferred, radiographers conduct and contribute to investigations which are not necessarily radiological in nature, e.g. sonography and magnetic resonance imaging.

Radiographers often have opportunities to enter military service due to their role in healthcare. As with most other occupations in the medical field many radiographers have rotating shifts that include night duties.

Career pathways

Radiography is a deeply diverse profession with many different modalities and specialities. It is not uncommon for radiographers to be specialised in more than one modality and even have expertise of interventional procedures themselves; however this depends on the country in which they operate. As a result of this the typical career pathway for a radiographer is hard to summarise. Upon qualifying it is common for radiographers to focus solely on plain film radiography before specialising in any one chosen modality. After a number of years in the profession, non-imaging based roles often become open and radiographers may then move into these positions.^[4]

Imaging modalities

Generally, imaging modalities are all diagnostic, all have the potential to be used therapeutically in order to deliver an intervention. Modalities (or specialities) include but are not limited to:

Name	Examples of Professional Titles1	Technology2	Ionizing	Description
Angiography/Venography	Angiographer, Angiography Technologist, Angigographic Technologist	Fluoroscopy and/or Image Intensification Radiography mostly with intravascular contrast		Imaging of the cardiovascular system, may be diagnostic or therapeutic in nature. Is utilised under the specialities of Interventional radiology and/or cardiology within a Cath Lab (Catheterisation Laboratory).
Computed Tomography	CT Radiographer, CT Technologist, Neuroradiographer	Computed Tomography (CT) (incl. MDCT/MSCT, EBCT, Sequential CT, etc.)		Provides cross-sectional views (slices) of the body; can also reconstruct additional images from those taken to provide more information in either 2D or pseudo-3D.
Diagnostic Radiography	Diagnostic Radiographer, Radiographer, Radiologic Technologist	Plain Film Radiography (PFD)		Utilises ionising radiation in the examination of internal organs, bones, cavities and foreign objects.
Echocardiography	Sonographer, Ultrasound Radiographer, Ultrasound Technologist, Ultrasonographer	2D, 3D and Doppler Sonography		Utilises 2D, 3D and Doppler Sonography to image the heart.
Fluoroscopy	Fluoroscoper, Fluoroscopy Radiographer, Fluoroscopy Technologist, Fluoroscopic Radiographer, Fluoroscopic Technologist	Fluoroscopy		Utilises continuous and/or pulses of ionising radiation to visualise the various systems of in the body over period of time. Often used in monitoring a bolus or contrast agent in order to highlight vessels and organs, or to position devices within the body (such as pacemakers, guidewires, stents, etc.).
Mammography/Breast Radiography	Mammographer, Mammography Radiographer, Mammography Technologist, Mammographic Radiographer, Mammographic Technologist	Mammographic Plain Film Radiography		Uses low dose ionising radiation systems to produce images for the diagnosis and/or staging of breast disease, primarily breast cancer.
Magnetic Resonance Imaging	MR Radiographer, MR Technologist, Neuroradiographer	Magnetic Resonance Imaging (MRI)		Uses magnetic resonance and radiofrequency pulses for static, dynamic and function imaging.[9]
Nuclear Medicine (NM)/Radionuclide Imaging (RNI)	Nuclear Medicine Radiographer, Nuclear Medicine Technologist, RNI Radiographer, RNI Technologist	Single Photon Emission Computed Tomography (SPECT), Positron Emission Tomography, Positron Emission Tomography Computed Tomography(PET-CT) (all with or without the involvement of Radioactive Tracers)		Uses radioactive tracers which can be administered to examine how the body and organs function. Certain radioisotopes can also be administered to treat certain cancers, such as thyroid cancer.
Sonography/Ultrasonography	Sonographer, Ultrasound Radiographer, Ultrasound Technologist, Ultrasonographer	2D, 3D and Doppler Sonography		Images anatomy and related pathology (such as cancer or cardiopulmonary diseases) using ultrasound waves. Obstetric ultrasonography is the use of ultrasonography to track the course of a pregnancy and detect certain embryonic or fetal malformations or diseases, which may be genetic and/or hereditary in nature. Gynecologic ultrasonography deals with imaging diseases or defects or abnormalities of the female genital and reproductive organs (ovaries, fallopian tubes, vagina, uterus, cervix, clitoris, labia, and breasts).
Surgical/Theatre Radiography	Surgical Radiographer, Surgical Technologist, Theatre Radiographer, Theatre Technologist, Trauma & Orthopaedics (T&O) Radiographer	X-ray image intensifier, varies		Images anatomy and related pathology during surgical procedures.

¹Prefixes such as paediatric, geriatric, trauma are routinely placed used in conjunction with professional titles.

²This list of technologies is not exhaustive.

Non-imaging modalities

Non-imaging modalities vary, and are often undertaken in addition to imaging modalities. They commonly include:

• Academia - Education role.
• Clinical Management - Clinical managerial role which can be varied; may include managing audits, rotas, department budgets, etc.
• Clinical Research - Research role.
• Medical Physics - Multidisciplinary role ensuring the correct calibration of and most efficient use of diagnostic equipment.
• PACS Management - Managerial role concerned with maintaining and supervising appropriate and correct use of the RIS and PACS systems.
• Radiation Protection - A managerial role concerned with monitoring the level of ionising radiation absorbed by anyone who comes into contact with ionising radiation at their site.
• Reporting Radiography - A clinical role involved with interpretation of radiographs and various other radiological media for diagnosis.

Education and role variation

Education varies worldwide due to legal limitations on scope of practice.

Germany

In Germany radiographers must complete a 3-year, self-funded programme before they qualify as a 'Medizinisch-technischer Radiologieassistent'. Only after qualifying do radiographers in Germany fulfil the requirements to practise as a fully qualified MTR.

Similar to other countries, they work within the areas of radiography diagnostics (CT scans, magnetic resonance imaging, radiography, digital subtraction angiography), radiation therapy, radiation dosimeters and nuclear medicine.^[10]

Ireland

Radiographers in the Republic of Ireland (ROI) must be registered with CORU before they can practice in the Republic of Ireland. Student radiographers training in the ROI will typically study for 4 years on an approved bachelor's degree program; currently degree programs only exist at University College Dublin.^[11][12]

Applicants must have either an approved qualification, a schedule 3 qualification, an appropriate letter of recommendation/accreditation or another qualification which is deemed 'suitably relevant' by registration board in order to successfully fulfil the vocational education requirements to become a Radiographer in the ROI. Applications for registration with qualifications outside of this are considered on an individual basis; typically this includes most international applicants.^[13]

The professional body representing Radiographers in the ROI is the Irish Institute of Radiography and Radiation Therapy (IIRRT).^[14]

Nepal

As a developing country, the health care sector in Federal Democratic Republic of Nepal has very limited resources meaning radiological services are rather limited. Nepal is still struggling to improve and manage conventional radiological examinations. Radiological Services in Nepal commenced in 1923 at Military Hospital by Dr. Rana and Dr Asta Bahadur Shrestha. The first health related training program began in 1933 at the Nepal Rajkiya Ayurved School; the Civil Medical School was later established in 1934. Radiological education in Nepal started in 1923 in a 64 bedded Military Hospital, Tri-ChandraElectro-Medical Institute. The post graduate (M.Sc.) program in physics at TU began in 1965 with only Nuclear Physics specialization. In 1972, the Institute of Medicine (IOM) which is affiliated with TU started the Proficiency Certificate Level (PCL) Radiography course however this has since stopped.

Radiotherapy was first introduced at Maternity Hospital in 1976 utilising radium needle treatment. CT and Nuclear Medicine was introduced in 1988 at Bir Hospital. The Radiotherapy unit with Tele Cobalt-60 machine was established at Bir Hospital in 1991.

Nepal became a member of IAEA in 2008. Since 2008 onwards diploma level radiography courses have been conducted across the country by the Council for Technical Education and Vocational Training (CTEVT) and other affiliated institutions.

In Nepal there are 125 vocational health training institutes however only 15 are conducting radiological technological education. Bachelor level radiography education is taught in two universities & one college whereas master level radiography course is taught in one where another university is in pipeline. Until recently, therapeutic radiography courses have not been taught in Nepal; radiation therapists are predominantly trained abroad.

The Nepal Health Professional Council (NHPC) is the legislative body for registering, accrediting, developing & enforcing quality assurance of Health Professionals, including Radiographers, in Nepal.

Nigeria

In Nigeria, these professionals are generally referred to as Radiographers or Medical Radiographers to differentiate them from Industrial Radiographers. Radiographers must complete a 5-year undergraduate BSc and a compulsory one year paid internship program in a hospital after graduation before attaining a full licensing by the Radiographers Registration Board of Nigeria. The board also registers Radiotherapists who have undergone the initial 5 year Radiography program before proceeding to the Radiotherapy training.

Radiographers in Nigeria have been striving to extend their practice to include radiographic interpretation and Ultrasound services. They are also on the verge of adopting an official professional title of "Radr" or "Rr" As of 2015. Radiographers in Nigeria normally proceed for a Masters programme and a PhD programme in the profession. There is a recent rise in the number of radiographers available in the country unlike the situation of shortage between 2000 - 2010.

In a typical Nigerian Teaching Hospital, radiographers are not allowed to handle the ultrasound unit, this is left for the radiologists, who, in some areas, have gradually improved their relationship with the radiographers in providing services in other radiographic units. The radiologist is also in charge of specific Fluoroscopic cases where the radiographer assists only with positioning and image acquisition. This practice is quite different in private owned diagnostic centres; in some cases a radiography technologist (NOT a BSc. Radiographer) handles every examination in the Radiography department.

Allied Health Unions (such as 'JOHESU' and 'NUAHP') that Radiographers are members of (with Nurses, Pharmacists, Physiotherapists, Laboratory Scientists, etc.), have over the years gone on strike actions to force the Nigerian government to improve their allowances/salaries in the government owned hospitals. These strikes (when it's not a response on its own) often trigger a response from the Nigerian Medical Association who will also table some requests for the medical doctors.

Apart from monetary issues, these professional bodies are also in loggerheads over non-doctors requesting to be given top administrative roles in government owned hospitals. Many radiographers, however, do not particularly involve themselves in these movements as working in a private establishment is more lucrative.

Some Radiographers in Nigeria are also keen on setting up a "Department of Radiography" in the government owned hospitals which will not be under the Head of the Radiology Department. Some hospitals however have an understanding between the Radiology head (a Radiologist) and the Chief Radiographer where all radiographers are directly answerable to their Chief, and not the HOD.

Saudi Arabia

X-Ray Technicians (فني اشعة) in Saudi Arabia must successfully undertake a degree level program at a recognised higher level education institution in Nursing before undertaking further study in radiographic imaging at university for typically 2 to 3 years; this must include a year's experience in a hospital. Upon completion, graduates are qualified X-Ray Technicians and can commence clinical practice.^[15]

United Kingdom

The SCoR is the professional body and union for UK radiographers]]In the United Kingdom, there is ambiguity in the use of the term Radiographer as this does not differentiate between Therapeutic Radiographers (also known as Radiotherapists) and Diagnostic Radiographers. As a result, all of these titles are protected titles within the United Kingdom and can not be used by any persons who has not undertaken formal study and registered with the Health and Care Professions Council (HCPC). In order to practice Radiography in the United Kingdom candidates must now successfully obtain a pass in a degree level program from an accredited institution. Degrees are offered by universities across the UK and last for at least 3 years in England, Wales and Northern Ireland; and 4 years in Scotland.^[16][17] Student Diagnostic Radiographers spend a significant amount of time working at various hospitals affiliated with their university during their studies to meet the requirement for registration with the HCPC.

They specialise in the acquisition of radiographs of General Practitioner referred (GP) patients, outpatients, Emergency Department (ED) referred patients and inpatients. They conduct mobile X-rays on wards and in other departments where patients are too critical to be moved and work as part of the operating team in mainly orthopaedic and urology cases, offering surgeons live radiographic imaging. Once qualified, diagnostic radiographers are able to acquire X-rays without supervision and work as part of the imaging team. They will have basic head examination qualifications in CT and even basic experience of MRI, Ultrasound and Nuclear Medicine.

Diagnostic Radiographers can specialise in-house or through a university course as a postgraduate in CT, MRI, Ultrasound or Nuclear Medicine with opportunities to gain an MSc or PhD in their field. Diagnostic Radiographers in the UK are also taking on roles that were typically only undertaken by the radiologist (a medical doctor who specialised in interpreting X-rays), Urologist or Cardiologist in the past.^[18] This extended practice includes various interventional procedures not excluding barium enemas, barium meals/swallows, peripheral angioplasties, nerve root injections, central line insertions and many other procedures.

The professional body and workers union for radiographers in the United Kingdom is the Society and College of Radiographers (SCoR). The union has been heavily involved in extending practice of radiographers in the United Kingdom and has helped expand the role of the radiographer greatly.

Expanded practice

Radiographers are now able to write reports and diagnose pathologies and/or conditions seen on differing diagnostic media after completing a HCPC and SCoR accredited university course;^[19][20] completing a course in this modality allows the radiographer to become a reporting radiographer in their chosen specialty.^[21]

Diagnostic Radiographers are able to become supplementary prescribers which allows them the capacity to prescribe medications in line with an agreed Patient Group Direction (PGD) or Patient Specific Direction (PSD). An accredited university course must be undertaken before this role extension is annotated onto a HCPC registrant's record.^[22] It is thought that in the future Diagnostic Radiographers in will gain independent prescribing rights, however this is currently limited by their restricted and varied scope of practice. In 2016, the introduction of independent prescribing right was agreed for Therapeutic Radiographers after a consultation by the Medicines and Healthcare products Regulatory Agency (MHRA) ^[23]

United States

In the United States, these professionals are known as Radiologic Technologists. Formal training programs in radiography range in length that leads to a certificate, an associate or a bachelor's degree. The American Registry of Radiologic Technologists (ARRT), the primary credentialing organisation for Radiologic Technologists in the United States, requires that candidates for ARRT Certification Exams must have an associate degree at minimum as of January, 2015, effectively ending non-degree granting diploma programs.^[24] Accreditation is primarily through The Joint Review Committee on Education in Radiologic Technology (JRCERT), the only agency recognised by the United States Department of Education and the Council for Higher Education Accreditation to grant accreditation to both traditional and online programs in Radiography, Radiation Therapy, Magnetic Resonance Imaging, and Medical Dosimetry. An online page where prospective students can check the accreditation of programs is maintained by JRCERT.^[25]

Radiologic Technology students study anatomy, physiology, physics, radiopharmacology, pathology, biology, research, nursing, medical imaging, diagnosis, radiologic instrumentation, emergency medical procedures, medical imaging techniques, patient care, medical ethics and general chemistry. Schooling also includes significant amounts of documented practicum supervised by Registered Technologists in various clinical settings where the classroom theory is translated to practical knowledge and real world experience. The change from Film to Digital imaging has changed training as film quality assurance and quality control is largely obsolete. The role of computer workstations to produce synthetic images for Radiologists has steadily increased the need for computer skills as has electronic medical record software.

After primary training and licensure, continuing education is required to maintain licensure and certification with the ARRT, who sets the accepted national guidelines. The ARRT requires 24 Units of accredited continuing education every two years and the laws and the regulations of most states accept this standard. Continuing formal education or the passing of an advanced practice speciality exam may also be accepted for continuing education credit. The American Society of Radiologic Technologists (ASRT),^[26] a professional association for people in Medical Imaging and Therapy, offers members and others continuing education materials in various media that meet the requirements of the ARRT for continuing education.^[27] Additional requirements are set forth for technologists who specialise in mammography by the US FDA.^[28]

Expanded practice

A new and evolving career for Radiologic Technologists is that of the Registered Radiologist Assistant (R.R.A.) ^[29] who is an experienced Technologist- not a Physician Assistant- who has completed additional education, training and has passed exams to function as radiologist extenders.^[30][31] A list of the 9 currently accredited R.R.A. programs is maintained by the ARRT and can be accessed online.^[32] Candidates for the R.R.A. certification must possess a Bachelor of Science Degree at minimum.

Registered Radiologist Assistant (R.R.A.), a new advanced practice Radiographer career path in the United States for experienced Technologists. R.R.A.s do not interpret films/images/studies in the manner of the Reporting Radiographer.^[33] The role has been accepted by the American College of Radiology (ACR).^[34]

Risks

• Epidemiological studies indicate that Radiographers employed before 1950 are at increased risk of leukemia and skin cancer, most likely due to the lack of use of radiation monitoring and shielding.^[35]
• Ionising radiation, used in a variety of imaging procedures, can damage cells. Lead shields are used on the patient and by the Radiographer to reduce exposure by shielding areas that do not need to be imaged from the radiation source. While lead is highly toxic, the shields used in medical imaging are coated to prevent lead exposure and are regularly tested for integrity.^[36]
• Radiographers who develop x-ray films are exposed to the various chemical hazards such as sulfur dioxide, glutaraldehyde, and acetic acid. These agents can cause asthma and other health issues.^[37][38]
• Theoretically, the strong static magnetic fields of MRI scanners can cause physiological changes. After a human neural cell culture was exposed to a static magnetic field for 15 minutes, changes in cell morphology occurred along with some modifications in the physiological functions of those cells. However, these effects have not yet been independently replicated or confirmed, and this particular study was performed in vitro.^[39]
• Ultrasound imaging can deform cells in the imaging field, if those cells are in a fluid. However, this effect is not sufficient to damage the cells.^[40]
• As with any allied health professional, exposure to infectious diseases is likely, and use of Personal Protective Equipment (PPE) and infection control precautions must be employed to reduce the risk of infection.

External links

• CORU
• Irish Institute of Radiography and Radiation Therapy (IIRRT)
• International Society of Radiographers and Radiologic Technologists (ISRRT)

References