Wednesday, September 19, 2007

The decline of Tech Positioning skills

I had a long discussion the other day with a Radiologist who was commenting on the decline of positioning skills demonstrated by a large number of today’s technologists. Now this is something I had noticed myself with increasing frequency in the last 5-6 years and have commented on often to Radiologists and Tech Supervisors . I thought maybe I was just being overly critical because I was always a stickler for film quality. The X-ray school I went to had a hard fast rule regarding film quality that went like this, if at any time when you are looking at an x-ray that you have taken and the thought crosses you mind “ should I repeat this film” then the answer was ALWAYS yes. I always tried to follow that line of thinking for the 16 years I took radiographs. I am sure I drove my staff nuts when I was a tech supervisor. I just always felt that the better the radiograph was the better chance that the Radiologist had of identifying any pathology that was there. Pretty obvious right? Well I thought so but recently I have noticed that positioning skills have been declining or Technologists just don’t seem to care much anymore.

I have pondered as to why this seems to be happening and have come up with a few theories that I will list below in no particular order as I think they all have a part in the decline of the skills:

1) 4 year x-ray schools that focus more on the degree than the clinical aspect of the training are partially to blame in my opinion. They just don’t seem to get the necessary clinic time to train technologist the “art” of taking x-rays on “real world” patients. Granted they can give the book names for all the positions but the ability to properly position a patient who can’t move like the ones seen in the books seems to throw some techs completely off. Taking high quality radiographs is an art that in my opinion can only be properly learned by doing. I don’t care what your test scores are or how you did on your registry, until you have been in a trauma bay and have had to produce quality radiographs on a patient that you can’t move, all the reading in the world will not help you. It always seemed to me that tech who attended 2 year hospital based programs adapted much faster to tech life in the real world.

2) PACS has both helped and added to the decline of radiograph quality. It has certainly given techs much more latitude in selecting Kv and mAs as small variations do not have as much effect on the outcome of the radiograph as it did in the film world. Now that is not to say that techs don’t still have to select the proper settings but small miscalculations will no longer instantly mean you have to repeat a film. That is the good part.. The bad part of that is that I have seen techs that don’t pay much attention to the technical factors they are setting because of that fact. I am reminded of a case quite a few years ago when a tech actually asked me what the Kv and mAs should be for a lateral cervical spine because the PACS was down and she had to go back to regular film. Needless to say I was shocked and appalled and didn’t answer her in the most polite fashion. Unfortunately this lackadaisical attitude seems to have spilled over into positioning as well. Add to this that most PACS systems don’t provide for good comprehensive film/image QA. It is too easy for a slack tech to simply make an bad image disappear once it has been repeated. The PACS/CR vendors really need to come up with a solution that not only tracks the number of repeat images but lets the QA tech see the actual images so that they can talk to the tech on how to correct the problem when they identify a pattern.

3) The third contributing factor are the Radiologists. While over the years I have heard many of them complain about image quality, quite a few of them seem reluctant to reject the image and force the techs to repeat them. While making the tech repeat the image is a hassle NOT making them repeat the image contributes to the attitude that as long as the Radiologist doesn’t make me repeat it that means must be an ok image. This past week I saw no fewer than 4 chest x-ray images that had the lateral border of one lung or the other clipped off. All 4 images were read by the Radiologist.

For years Technologists have been fighting for respect within the medical community. The ARRT has responded with requiring more education during training and CE credits bi-annually after graduation. While I think this has some merit I think a much better approach would be to increase the amount of real clinic time. A tech who can consistently produce high quality radiography in any situation will gain the respect of the doctors, nurses and fellow techs much faster and easier than one who can recite facts out of a book.

I guess it all comes down to good old fashion pride in the job you do. If you’re just punching a clock to get a paycheck go find a different career where people’s lives don’t depend on the quality of your work. If nothing else I have said sinks in remember, you are not doing the patients any good passing poorly positioned films and may actually be hurting them.


Anonymous said...

The other factor is cross sectional imaging. If there is any uncertainty about the presence or absence of a lesion, we go on to CT or MR meaning that high quality radiography is just not a priority for most busy radiologists. Sadly the art of both acquiring and interpreting films is fading.

PACS Ferret said...

I agree with you there . Thanks for reminding me of that factor. This brings up another can of worms entirely. Why are we doing and charging expensive CT and MRI scans for things that could be imaged with a good quality radiograph


Excellent Article! I am affiliated with a hospital system that has a wonderful Radiography Program. We also have PACS throughout the system. I plan to pass this article along to the Program Director for inclusion in a class discussion.

Thanks for giving us a place to discuss such topics.

PACS Ferret said...

Anonymous & PacsFerret II

I believe that the more expensive CT's and MRI are a direct result of the decline in positioning skills. If the techs could/would produce the kinds of images needed in a timely fashion it wouldn't be necessary to scan patients 80% of the time. The problem is too many images have been passed across that do not show the required anatomy for the Radiologists to be sure. I have been listening to excuse after excuse from techs as to why they couldn't obtain such and such an image. Personally this sickens me . Now granted there are times when it is not possible to obtain a clear image do to the patient's body habitus , but these are few and far between.

I am ashamed to say that this whole mindset of "lets just scan them" that the ER Physicians and Radiologists have was caused by US, the techs. Yes I said US because I am a tech and it is the responsibility of all of us in this profession to accept responsibility for our professional counterparts.

Do I have the definitive solution? No. I do however believe that part of the answer is to get the techs students back into the clinic environment where they belong. I think that more emphasis needs to be placed on imaging the non-standard patient. The other thing I would like to see happen is for the Rads to start kicking images back . Don’t accept sub-standard images. Talk to the techs, tell them why the film doesn’t meet your requirements. Your silence is giving way to complacency.

Peng Hui Lee said...

You make many good points. I've made a post about in in my blog:

Peng Hui Lee said...

I've just come across your article and mentioned in in a post on my blog

Anonymous said...

I just came across this blog and could not agree more. Since becoming the PACS Admin/Manager/QA tech, I have noticed that image quality is definitely on the decrease. We have many new techs here, some with 5 years of experience, that can not determine what a bad image looks like. After 6 months of criticizing their work, we are finally obtaining diagnostic studies. I actually had techs go crying (literally) to our director because they thought I was being too critical. It is totally unbelievable. This profession will never be taken to the next level if we can not even perform our jobs at a professional level.

Anonymous said...

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