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.