Advanced Practices in Mammography - Literature review Example

Advanced practices in mammography Research Objectives: Mammography or breast screening is now freely available and has also been very successful, but currently, there is a shortage of radiologists and most of them appear disinterested in the job of breast screening. One of the possible causes for this could be the increased litigation associated with the practice or the lack of incentives offered to the radiologists. This study aims to examine advanced practices in mammography or breast screening and the reasons why radiologists are not demonstrating an adequate level of interest in the job. In view of increasing workloads and time constraints, many of the functions solely performed by radiologists are now being performed by radiographers, leading to increased medical malpractice claims. Hence the specific objectives associated with this study are as follows: (a) Determine the accuracy of radiographer reporting of breast cancer (b) The benefits of mammograms despite the shortage of radiologists (c) Is there an optimum number of films radiographers should look at in a specific time period in order to improve accuracy outcomes in reporting (d) Causes for litigation against radiologists and how this could be addressed, perhaps through greater time allocation and cheaper labour. Literature Review: Since the introduction of the new NHS Plan in 2000, based upon reforms in the way the staff of the NHS worked, nurses and staff members were allowed to extend their roles beyond their traditional boundaries, in the expectation that it would make care more patient centred. Greater workforce flexibility and a team approach have contributed towards the provision of a high quality patient service (Woodford, 2006). The availability of skilled radiologists is limited, but financial constraints, increases in workloads and financial imperatives in the NHS have mandated a transfer of some of the functions of the radiologist to radiographers (Price, 2007). To specifically address the needs of radiographers, the proposed method was to introduce a four tiered service delivery model, wherein advanced practitioners, i.e., radiographers, were to play a key role.(Buttress and Marangon, 2008). In a recent editorial (2010), it has been argued that there is a need for a wider service perspective that can be provided by radiographers, but there is little evidence available to suggest that individual radiographers have grasped the full implications of the nature of leadership and vision that is required to perform these roles successfully. The distinction between an “advanced” versus “extended” role for radiographers has been clarified by ­­­­­­­­Hardy and Snaith (2006), who point out that role extension is the acquisition of additional skills, duties and responsibilities beyond those expected of the post while “advancement” assumes the attainment of a higher level of professional knowledge and ability. Radiographers fall under the category of extended practitioners while radiologists conform to the advanced category. For instance, Snaith(2008) suggests that an extension of radiographer roles (McKay and White, 2002) has led to radiographer-led discharge, but the lack of effective training in aspects such as writing management plans has caused problems which have legal implications. The breast screening program was initiated for eligible women in north Staffordshire on 21st of March 1988. This was part of the Brest Screening Program of the National Health Service, which made routine mammography screening available to women between the ages of 50 and 64, using the four tier system wherein advanced practitioner radiographers undertake tasks like clinical examination, film reading, biopsy, X ray and mammograms, among others that were previously performed by radiologists (Woodford, 2006). According to Williams (2008) who carried out the study in north Staffordshire, with advanced skill practitioners regularly working with a single radiologist in the assessment process, accuracy in diagnosis is improved, because there is a higher level of professional knowledge and skill which becomes available. The disadvantages associated with such a practice lie however, in appropriately assigning the legal liability of such practitioners, especially in the event there is a malpractice claim. As Buttress and Marangon(2008) have also pointed out, this places the radiologist in an anomalous position, because on the one hand, he is expected to conform to the assessment of the skilled practitioners, but on the other hand, he “owes a duty to the patient” and also needs to use “diligence, care, knowledge, skill and caution in administering the treatment.” (Jackson, 2006:122). Hence, a radiographer who performs an extended role as a radiologist who performs an extended role may be placed in a difficult legal position because s/he must meet the rigorous standard of care of a person who would normally carry out that role. Hence, in effect, radiologists now have to extend their responsibilities into clinical areas which are outside their traditional spheres of interest into those which would normally fall into the doctor domain.(Alderson and Hogg, 2003). Since radiologists are now required to practice at such an advanced clinical level places a huge demand on them in terms of levels of competence and professional expertise required, and thereby leaves them open to malpractice suits. There is a basic conflict that arises in the case of procedures such as mammography, because it is intended as a public health service and is performed on an outpatient basis through a low cost, imaging examination while the imaging process itself involves an onsite, full diagnostic workup for every patient (Brenner, 1991). In a table outlining the variables involved in a delayed diagnosis of breast cancer through mammograms, Brenner (1991:722) also shows how this disease is the second most common cause for indemnity payments because some of the reasons cited against radiographers in claiming damages from them are poor record keeping and inferior mammograms, delays in consultation and inadequate communication with other physicians and negative or misread mammogram reports. With all these and many more legal implications/grounds that lead to Malpractice suits, Brenner (1991) is of the view that the reluctance of the radiographers to practice good medicine due to the overwhelming nature of legal medicine is understandable. McKay and White(2004) have detailed the need to delineate the limits of professional responsibility, as well as the monitoring and control of radiographer work in order to address the unease that radiologists feel about legal and accountability issues. In assessing the potential impact of the four tier profession on the development of radiography through an extensive literature review, Woodford (2006) found that the four tier model had a positive effect on certain services, such as cost effectiveness and improvement in patient waiting times. In certain areas such as mammogram screening however, a comparative study of radiologist and radiographer performances found that radiographers scored higher false positive rates, thereby suggesting that legal implications could also be more negative. Some of the anxieties reported by radiologists where radiographers are concerned include (a) the potential impact on radiology specialist registrar training (b) a lack of clear medico-legal responsibilities and (c) radiographers needing to recognise their own limitations in performing their tasks, thereby also compromising accuracy in reporting results (Forsyth and Robertson, 2007). As opposed to the concerns expressed by radiologists over the quality of radiographers’ work, Wivell et al (2003) carried out a study that showed radiographers could read a mammogram to a standard comparable to that of a radiologist. Mammograms are undoubtedly useful despite the shortage of radiologists, therefore if radiographers are able to perform this function, it could be invaluable in early detection of cancer. Conclusions: On the basis of the above, it may be noted that an extension of the radiographer role to assume some of the responsibilities that were earlier in the domain of skilled radiologists has come about largely because of increased workloads, constraints of time and the shortage of qualified radiologists. In assessing the research objectives, it must be noted that the performance of mammograms are justified because of the benefits arising from them in early detection of breast cancer. This procedure can be performed on an outpatient basis at lower costs, therefore the specialized skills of radiologists could be addressed by radiographers to some extent on an outpatient basis, which would help reduce health care costs by treating breast cancer early on. However, other studies by researchers such as Wivell et al (2003) appear to suggest that mammograms performed by radiographers may also be largely accurate; nevertheless the practice of using radiographers with radiologists playing a consultant role for several radiographers creates a difficult situation for radiologists, because it makes them legally liable for outcomes they may not wholly be responsible for, such as carelessness or mistakes in reporting. As the literature review above has shown, there have been several instances of radiologists being used for malpractice on the basis of false positive results from mammograms and on various other grounds, which could have been caused by the extended role performed by radiographers. The scarcity of radiologists is an inconvertible fact, while the benefits of mammograms are undeniable. Since mammograms can be performed as an outpatient procedure, there is adequate justification to allot associated roles to radiographers. There may however, be a need for additional training for radiographers, to make them more aware of the legal implications of performing some of the radiologist roles such as mammograms. By ensuring that the requirements to qualify in a radiographer role are made more stringent, and by shifting a greater responsibility to the radiographers themselves in terms of making them subject to the same requirements expected of other medical professionals, it might be possible to improve the quality of the work produced by these professionals. When radiologists are made liable for the mistakes done by radiographers, it only exacerbates the radiologist shortage by making them even more reluctant to enter a profession where they will also be held legally responsible for the mistakes of other professionals and face malpractice suits. The causes for litigation against radiologists therefore appear to lie in the lack of proper delineation of medicolegal responsibilities between radiologists and radiographers. Since a single radiologist might perform the consultant task for several radiographers, but cannot deal with issues such as incorrect reports being submitted to them, etc, it is important to clearly set the boundaries and let radiographers know all the aspects that they will be held legally liable for. Additional training may be required for radiographers and limitations may need to be set out in terms of workloads that they are able to manage at any given time. Since mistakes may occur largely to haste and a lack of adequate knowledge, it may be useful to introduce specialist training and require radiographers to acquire some formal qualification that places them on a roster of qualified radiographers and makes them legally responsible for their actions. It may also be necessary to improve the record keeping part of mammography, in order to clearly specify which actions radiographers will be responsible and which would fall under the responsibility of the radiologists. In this way, it would be easier to clearly determine where the legal liability should lie in the event of a legal claim of medical malpractice that is filed by any member of the public for any reason associated with a faulty mammogram or similar lapses in the provision of a medical service. References: Alderson, C.J. and Hogg, P., 2003. “Advanced radiographic practice – the legal aspects”, Radiography, 9:305-314 Brenner, James R, 1991. “Medicolegal aspects of breast imaging: Variable standards of care relating to different types of practice”, AJR 156: 719-723 Buttress, Susan J and Marangon, Tim, 2008. “Legal issues of extended practice: where does the responsibility lie?” Radiography, 14:33-38 Editorial, 2010. “Consultant radiographers: Does the profession want them?” Radiography, 16: 5-7 Forsyth, Leslie J and Robertson, Elizabeth M, 2007. “Radiologist perceptions of radiographer role development in Scotland”, Radiography, 13: 51-55 Hardy, Maryann and Snaith, Beverly, 2006. “Role extension and role advancement – is there a difference? A discussion paper”, Radiography, 12: 327-331 Jackson, E, 2006. “Medical law: text cases and materials”, Oxford: Oxford University Press McKay, J.C. and White, P, 2004. “The specialist radiographer: does the role justify the title?” Radiography, 10: 217-27 McKay, J.C. and White, P, 2002. “Guidelines and legal requirements which inform role expansion in radiography”, Radiography, 8: 71-78 Price, R.C., 2001. “Radiographer reporting: origins, demise and revival of plain film reporting”, Radiography, 7: 105-117 Snaith, Bev, 2008. “Advanced practice: the way forward”, CPD and Education Reporting. Williams, Sue, 2008. “Breast Screening.....20 years on”, CPD and Education Mammography Ultrasound Wivell, G, Denton, ERE, Eve, CB, Inglis, JC and Harvey, I, 2003. “Can radiographers read screening mammograms?”, Clinical radiology, 58: 63-7 Woodford, Amanda J, 2006. “An investigation of the impact/potential impact of a four tier profession on the practice of radiography – A literature review”, Radiography, 12:318-326 Van den Biggelaar, F.J.H.M., Nelemans, P.J. and Flobbe, K, 2007. “Performance of radiographers in mammogram interpretation: a systematic review”, The Breast, 17:87-92 Read More