How Much Is Enough? A Global Perspective On Technologist Training

The introduction of hybrid imaging, particularly PET/CT, has succeeded in changing the practice of nuclear medicine imaging. Joining CT with PET has lead to calls in various corners of the globe to reappraise who should operate hybrid PET/CT units and what kind of education and training are necessary for nuclear medicine and radiologic technologists to assure safety and effectiveness of each aspect of the study.

This cry for a change in technologist training led the Canadian Association of Medical Radiation Technologists (CAMRT) to establish the CT-Operation Gap Analysis Workgroup. The group was tasked with identifying the gaps in knowledge, skills and judgment that exist across disciplines—including nuclear medicine—for technologists in each of these disciplines to operate a CT unit both within the context of their existing practice and crossing into another discipline’s current scope of practice.

What was the impetus for change?

One issue is the simple problem of RT competency to handle bigger and more advanced CT units and their associated radiation dose, according to workgroup member Sue Crowley of the Michener Institute for Applied Health Sciences at the University of Toronto, Faculty of Medicine Joint Degree/Diploma Program in Medical Radiation Sciences. Each of these different disciplines was getting big, high-powered CT units for their own purposes, she says, but the radiologic technologists weren’t learning how to use them “properly.”

“When I say properly,” she says, “I’m sure they were learning how to push buttons and take images, but the big thing with CT was the radiation dose the patients were getting. They weren’t looking at methods for minimizing dose.”

Another factor was the problematic issue of imaging wait lists in Canada, leading to the question, Crowley says, of whether cross-training could help alleviate those long wait times. “If you’re looking at a wait list in the diagnostic imaging area, why can’t you use the machine sitting in the radiation therapy area to do that diagnostic imaging? And the same would be true with nuclear medicine,” says Crowley.

So the question is, says Elaine Dever, director of education, Canadian Association of Medical Radiation Technologists, if a patient comes in for a PET/CT, but then requires a stand-alone CT, should a nuclear medicine technologist be able to perform it, “or do you take that patient off the table and take him over to the diagnostic imaging department?”

Currently, the CAMRT has, Dever says, a position statement that holds that CT could not be performed by the nuclear medicine technologist. “Nuclear medicine technologists can only operate a CT that is part of the hybrid PET/CT,” she says, but not when it is being operated as a stand-alone procedure.

So there was a realization, Dever says, based mostly on anecdotal evidence, that this kind of RT crossover was desirable, but that there would have to be some kind of determination as to what kind of gaps existed in knowledge, skills and judgment pertaining to the operation of CT. What would need to be overcome to allow a nuclear medicine technologist to do a stand-alone CT?

Thus, CAMRT established the CT-Operation Gap Analysis Workgroup, an inter-professional group consisting of six experienced professionals—two radiologic technologists, two nuclear medicine technologists and two radiation therapists. In each discipline pair, there was an educator and clinical practitioner.

To begin that analysis, the workgroup used  the 2006 CAMRT revised competency profiles and curriculum guidelines (which will be used for certification exam development beginning in Sept 2011) as a baseline.

The workgroup identified where gaps exist at the point of entry-to-practice for each discipline, with the concept of safe, effective and competent delivery of care in the operation of diagnostic CT, CT simulators and PET/CT units by technologists/therapists as a guiding principle. The workgroup put together a report that tried to answer these questions:

• If the radiologic technologist wishes to practice in diagnostic CT, CT simulator and PET/CT, what are the gaps in the RTR competency profile?
• If the radiation therapist wishes to practice in diagnostic CT, CT simulator and PET/CT, what are the gaps in the RTT competency profile?
• If the nuclear medicine technologist wishes to practice in diagnostic CT, CT simulator and PET/CT, what are the gaps in the RTNM competency profile?

The process took about 18 months to complete, with the organization coming up with gap analysis documents for each of the disciplines relating to the operation of CT within those disciplines. Armed with that information, the next steps for CAMRT will be to:

• Distribute the gap analysis documents to CAMRT members and other stakeholders
• Conduct a market study this fall to establish an evidence base for development of future educational experiences
• Investigate potential program delivery methods, which would include prior learning assessment recognition
• Invite educational institutions to consider developing the required programming and delivery methods
• Determine the process that will verify an individual’s competency to perform CT procedures in disciplines other than the one in which they were originally certified;
• Conduct another validation survey of the 2006 competency profiles to ensure they reflect the required competency at entry-to-practice.

Europe: Competency-based curriculum for PET/CT

In Europe, there is no “pan-European solution” when it comes determining PET/CT competency, according to Peter Hogg, head of the directorate of radiology at the University of Salford in the U.K. While the European Association of Nuclear Medicine (EANM) years ago set some competency standards, according to Hogg, and a pan-European school has been established that will work towards common standards in education and training for radiographers, “neither were produced by professional bodies and as such have not carried much credence, within Europe or within any specific country,” says Hogg.

Interestingly, a proposed labor mobility agreement between France and the Canadian province of Quebec would give RTs in most disciplines the opportunity to work in either location. But, according to Alain Cromp, CEO of the Ordre des Technologies en Imagerie Médicale, the signed agreement will not include reciprocity between France and Quebec for nuclear medicine technologists.

“The gap between the training of nuclear medicine technologists in Quebec and France is a major one,” Cromp says.

A Euro-American working party, of which Hogg is a member, has been established to look at advanced and basic competencies in nuclear medicine and PET/CT and, according to Hogg, a discussion document will be available by the end of September 2010.

As it stands, competency standards and the methods of achieving and assessing them vary between countries. “In the U.K., for instance, to be a registered health professional [radiographer], you have to have completed formal degree training and then undertaken post graduate study in nuclear medicine,” says Hogg. “The Government holds you personally accountable for your clinical practice to protect the patient and the public. A register is kept for this purpose and as required fitness to practice investigations are conducted.”

Things often differ by country, says Hogg. Holland, for instance, requires a four-year degree and includes nuclear medicine within it. The U.K. requires three years, with an additional 12- to 18-months postgraduate work for nuclear medicine. “In some instances, PET/CT training is done locally, in house,” says Hogg. “Of course, there is much debate about whether this would be adequate for protecting the patient and establishing competence.”

The EANM does provide two weekend courses on PET/CT, says Hogg, but neither really addresses competence. One is very basic, while the other, although called “advanced” is only advanced in the context of the basic course, he says.

“So they raise knowledge and awareness and that is all,” Hogg says. “But, this is nowhere near to a competency-based curriculum that is professionally accredited.” He has high hopes, however, the Euro-American initiative he is involved with will change that.