RANZCR response to the MRT Board Consultation on Competencies Framework Introduction The Royal Australian and New Zealand College of Radiologists (RANZCR) is the peak body advancing patient care and quality standards in the clinical radiology and radiation oncology sectors. It represents over 4,000 members in Australia and New Zealand. RANZCR s role is to drive the appropriate, proper and safe use of radiological and radiation oncological medical services. This includes supporting the training, assessment and accreditation of trainees; the maintenance of quality and standards in both specialties; and workforce mapping to ensure we have the specialists available to support the sectors in the future. Structure of RANZCR RANZCR consists of two faculties, each representing a different speciality. The Faculty of Clinical Radiology is the bi-national body for setting, promoting and continuously improving the standards of training and practice in diagnostic and interventional radiology for the betterment of the people of Australia and New Zealand. Clinical radiology relates to the diagnosis or treatment of a patient through the use of medical imaging. Diagnostic imaging uses plain X-ray radiology, computerised tomography (CT), magnetic resonance imaging (MRI), ultrasound and nuclear medicine imaging techniques to obtain images that are interpreted to aid in the diagnosis of disease. In addition to their diagnostic role, clinical radiologists also provide treatments and use imaging equipment in an interventional capacity. The Faculty of Radiation Oncology is the peak bi-national body advancing patient care and the specialty of radiation oncology through setting of quality standards, producing excellent radiation oncology specialists, and driving research, innovation and collaboration in the treatment of cancer. Radiation oncology is a medical specialty that involves the controlled use of radiation to treat cancer either for cure, or to reduce pain and other symptoms caused by cancer. General Comments on Provision of Diagnostic and Interventional Radiology and Radiation Oncology Prior to responding to the specific questions in the survey we would like to make some general comments on the provision of clinical radiology and radiation oncology services. Clinical Radiology The speciality of clinical radiology is broad, encompassing an increasing range of imaging technologies and imaging-guided treatments including X-ray, computed tomography (CT), ultrasound, mammography and magnetic resonance imaging (MRI). With technological innovation continuing, imaging techniques are becoming ever more sophisticated and complex. In general, a team based approach works best in clinical radiology as it makes best use of different skill sets and ensures that those who provide services to patients do so efficiently, safely and to the ultimate advantage of patients. Within radiology, areas of individual responsibility must be defined clearly to ensure that those undertaking specific tasks have the competencies to perform them adequately and safely, with a clear delineation of responsibilities and accountability. Head Office: Level 9, 51 Druitt Street, Sydney NSW 2000, Australia Ph: +61 2 9268 9777 Fax: +61 2 9268 9799 Email: ranzcr@ranzcr.edu.au New Zealand Office: Floor 6, 142 Lambton Quay, Wellington 6011, New Zealand Ph: +64 4 472 6470 Fax: +64 4 472 6474 Email: nzbranch@ranzcr.org.nz Web: www.ranzcr.edu.au ABN 37 000 029 863
There are potential problems in the provision of team care in radiology if no one leader has overall responsibility. Patients would rightly assume that there be a single point of accountability in the provision of healthcare services and this must be beyond doubt. Clinical radiologists are medical practitioners who have undertaken broad medical training as well as comprehensive specialist training in performing and interpreting diagnostic imaging tests and imaging-guided procedures or treatments that involve the use of a range of imaging modalities 1.The role of the clinical radiologist is to provide this leadership and oversight to the radiology team. Radiation Oncology Radiation Oncology is a medical specialty that involves the controlled use of radiation to treat cancer or other diseases either for cure or to reduce pain and other symptoms. It is also best practised as a team involving a number of unique professions including radiation oncologists, radiation therapists, nurses and medical physicists. The Medical Radiation Technologists Board (MRTB) should be mindful that even small changes within the radiation oncology team can have significant effects on the model of care and patient access. Potential Implications of Role Extension RANZCR supports the professional development of all professions within the radiology and radiation oncology teams, however, this is a complex area requiring due consideration. We value the approach taken by the MRTB to continue to rely on clearly defined scopes of practice for medical imaging and radiation oncology professions, aligned with clear training paths and recognised qualifications. The MRTB has previously outlined a principles-based approach for extended practice outlined in an earlier consultation which RANZCR welcomed. 2 In terms of role extension and extended practice, there are some areas where we believe there is the potential for a greater role for medical imaging technologists. Some of these areas are relatively straightforward, although most will require careful consideration of training, protocols and supervision requirements. We are also aware of proposals submitted elsewhere for inappropriate role extension that are not evidencebased or in line with the principles outlined by the MRTB. We would therefore like to have additional information on the current state of play; where potential gaps lie; differences across urban and regional areas; and to work towards a common understanding of the vision for the future. 1 See: Role and Value of the Clinical Radiologist: Recognising the Value and Responding to the Challenges, Position Statement, RANZCR 2014 2 MRT Board (2014) Consultation on Scopes of Practice Review http://www.mrtboard.org.nz/scopes-of-practice-review-consultation-2 [access date 7 Jan 2015]
When looking at role extension or extended practice, RANZCR believes that consideration should be given to the following (which would vary depending on the extent of the change): definition of the range of competencies required for extended practice definition of training requirement and engagement in areas in which the range of knowledge and competencies required is limited to reduce risk associated with extended practice. Imaging studies with fewer organ systems encountered will have a smaller range of possible pathology or complications that may occur (e.g. review of fracture clinic films (bone, soft tissue) vs CXR (lung, mediastinum, bone, chest wall etc.), PICC placement and even breast screening). definition of the proposed model of care and the new scope of practice for the extended role i.e. how does the role fit into the model of care? assessment of cost and business case (for example the salary of those with roles extended will be higher) curriculum development training faculty - who delivers the training? What engagement with universities or other bodies is required? recognition of module or qualification is this accredited and recognised by an external entity? clarification of delegation and supervision arrangements so that responsibility is clear if patient issues arise a framework for indemnity is needed and to identify who is responsible etc. maintenance of professional skills and continuing professional development (cost and time requirements). Another area of concern for role extension is that there are already reported shortages of medical imaging technologists, radiation therapists, nuclear medicine technologists and sonographers, therefore any changes would need to be carefully planned to ensure gaps do not emerge elsewhere. 3 A related matter would be New Zealand ending up out of sync with comparable healthcare systems. As the MRTB will appreciate, as a country we are reliant on importing skilled practitioners. If the nature of the role of MRTB registered practitioners differs markedly to systems that have traditionally supplied medical imaging professionals to New Zealand, this could create problems downstream in recruitment as competences will not be directly comparable. We would appreciate it if the MRTB were to keep this in mind when considering potential changes. Care should also be given to ensure that role extension does not impact or reduce (i.e. crowding out) opportunities for trainee radiologists to build up their experience and competence through exposure to more routine procedures. Competencies Framework In general, we believe that the current mix of scopes of practice laid out by the MRTB in the competencies framework is correct. twithstanding this, we feel that the following areas need to be clarified in the scopes of practice for medical imaging technologists, nuclear medicine technologists, 3 Please refer to Long Term Skills Shortage List (2014) for details http://www.immigration.govt.nz/opsmanual/46052.htm
sonographers and MRI technologists. This is important to ensure clarity over respective roles for all stakeholders in health and avoid misunderstandings in future models of care. Firstly, in many places, the Competencies Framework is written as if the medical imaging technologist works as an autonomous entity. These practitioners work as part of a team and should consult with a supervising radiologist (or other suitable medical practitioner) where relevant. We believe it is important to reinforce appropriate imaging practices and since medico-legal responsibility rests with the medical practitioner. This would also align with the requirement for radiation therapists to work according to the prescription of the radiation oncologist (see definition of radiation therapy practice in the appendix). We have made comments to this effect in response to the questions posed below. Secondly, we do not believe that medical imaging technologists can provide an interpretation of imaging results. A clear distinction must be drawn between a medical imaging technologist s capacity to ascertain the quality of an image and detect an abnormality; and medical interpretation of the imaging findings. RANZCR believes that it is right and proper for a practitioner registered with the MRTB can be expected detect an abnormality and prioritise this case for review or further medical attention. The interpretation of medical imaging is however a far more complicated task which requires medical understanding of anatomy, patient presentation, clinical signs and symptoms. This is especially so for multiple organ systems and is beyond the training and competence of the medical imaging technologist professions. RANZCR believes that a clear distinction needs to be made in the MRTB Competencies Framework between detecting anomalies and interpretation of medical imaging. We have made comments to this effect in response to the questions below.
Consultation Survey 1. What is your scope of practice (you may select more than one)? Medical Imaging Technologist (MIT) Magnetic Resonance Imaging Technologist (MRIT) Nuclear Medicine Technologist (NMT) Radiation Therapy (RT) Sonography (Son) I am in a non-clinical role 2. Do you agree with the way the domains have been structured? Indifferent Please tell us your thoughts:. The domains are clearly structured and appear to cover the full range of competencies which would be expected of the medical imaging and radiation therapy professions under the MRT s remit. 3. Are the definitions for interpreting the competencies indicators clear? Indifferent Please tell us your thoughts: 4. Are the definitions for interpreting the notes clear? Indifferent Please tell us your thoughts: The use of must is clear. We feel that may is ambiguous. From the definition provided, is unclear what is meant by may in the tables and explanatory notes. Although we appreciate that examples are provided under each competency to illustrate, it is not clear what the specific competences should be. We think it would be clearer to indicate that any in the list are provided as examples and are not mandatory to be assessed against.
5. Please state any changes that you think should be made to the Professional and Ethical Conduct competencies including the reasons for those. 1.1h The tes need to refer to medical oversight and the role of the clinical radiologist or radiation oncologist as the supervising medical practitioner. 1.4c The tes should clarify that final determination of clinical appropriateness of imaging rests with clinical radiologist. 6. Please state any changes that you think should be made to the Communication and Collaboration competencies including the reasons for those. 2.2a The tes should clarify that discussions with referring health practitioners about clinical appropriateness or a patient s medical condition should be led by the clinical radiologist or radiation oncologist. 7. Please state any changes that you think should be made to the Evidence-based Practice and Professional Learning competencies including the reasons for those. Please refer to the comments in question 16 under Competencies Framework relating to interpretation of images. 3.1f The competency indicator should not say Interpret findings. This needs to be modified to indicate that the role of the medical imaging technologist is to assess the quality of the images and detect abnormalities. This is not the same as interpretation. 8. Please state any changes that you think should be made to the Safety of Practice and Risk Management competencies including the reasons for those. We have no comments on this section. 9. Please state any changes that you think should be made to the Practise in Medical Imaging/Radiation Therapy Sciences competencies including the reasons for those 5.4a The tes should clarify that final determination of clinical appropriateness of imaging rests with the clinical radiologist 5.4b The tes should clarify that final determination of clinical appropriateness of imaging rests with the clinical radiologist 5.4c The tes should clarify that final determination of clinical appropriateness of imaging rests with the clinical radiologist 5.5d The tes should clarify that final determination of clinical appropriateness of imaging rests with the clinical radiologist
5.6c The tes must include role of the clinical radiologist, potentially also covering emergency situations where the clinical radiologist is unavailable e.g. outside normal working hours. The title should also be corrected to say practice i.e. the noun rather than the verb practise. The same correction needs to be made to the title of other domains e.g. 5A to 5E. 10. Please state any changes that you think should be made to the Practise in Medical Imaging competencies including the reasons for those 5A.1c The tes should clarify that evaluation is an assessment of the quality of images and abnormal findings, not medical interpretation of images which is role of the clinical radiologist 5A.2c The tes should clarify that evaluation is an assessment of the quality of images and abnormal findings, not medical interpretation of images which is role of the clinical radiologist 5A.4c The tes should clarify that evaluation is an assessment of the quality of images and abnormal findings, not medical interpretation of images which is role of the clinical radiologist 11. Please state any changes that you think should be made to the Practise in Nuclear Medicine competencies including the reasons for those Please refer to the comments in question 16 under Competencies Framework relating to interpretation of images. 5B.3d The tes should clarify that evaluation is an assessment of the quality of images and abnormal findings, not medical interpretation of images which is the role of the clinical radiologist (or nuclear medicine physician). 12. Please state any changes that you think should be made to the Practise in Radiation Therapy competencies including the reasons for those. We would appreciate some clarification around the intent of some wording, for example, the use of identifying and identify : 5C.3b The tes state, Must include identifying tumour and target volumes, and normal tissue volumes. Although radiation therapists need to be aware of which volumes are tumour and target volumes, the determination of these is the role and responsibility of the radiation oncologist. A suggestion would be to include a caveat that specifies that the determining volumes is the responsibility of radiation oncologists. 5C.4c The tes state, Must identify and apply radical and palliative treatment doses and acceptable dose limits... Again, dose prescription is the responsibility of the radiation oncologist. Clarity is needed to show the radiation therapist needs to be able to recognise a radical vs palliative treatment and should be familiar with acceptable dose limits to critical structures.
13. Please state any changes that you think should be made to the Practise in Sonography competencies including the reasons for those. 5D.2d The tes should clarify that evaluation is an assessment of the quality of images and abnormal findings, not medical interpretation of images which is role of the clinical radiologist. 5D.3b The word interpretation in the tes needs to be modified to indicate that the role of the medical imaging technologist is to assess the quality of the images and detect abnormalities. This is not the same as interpretation. 14. Please state any changes that you think should be made to the Practise in MRI competencies including the reasons for those. 5E.2g The tes should clarify that evaluation is an assessment of the quality of images and abnormal findings, not medical interpretation of images which is role of radiologist 5E.3a tes should clarify that discussions with referring health practitioners should be led by clinical radiologist, potentially covering emergency situations where the clinical radiologist is unavailable e.g. outside normal working hours. 15. Do you consider that the competencies are sufficiently future-proofed for the practice of medical imaging and radiation therapy in an environment where there is ongoing rapid growth in technologies? t Sure What could we do to better future-proof the competencies? RANZCR believes that the MRT Board should build in periodic review of the competencies which would allow them to adapt over time to changing technologies and modes of practice. 16. Do you have any further comments you want to make in respect of the revised competencies framework? Please tell us your ideas Regarding the definitions of Medical Imaging Technologists, Nuclear Medicine Technologists, Sonographers, and Magnetic Resonance Imaging (MRI) Technologists provided in the Appendix, RANZCR would like to see the following statement in each, recorded electronically to allow for consultation with other health and medical
practitioners replaced with recorded electronically to allow an assessment by the referrer and interpretation by a radiologist. Dr Lance Lawler Chair, New Zealand Branch Committee A/Prof Chris Atkinson CNZM Chair, New Zealand Radiation Oncology Executive Questions and contact RANZCR would be happy to discuss any of the elements of this response further with the MRT Board. If you wish to do so, please contact: Mr Alexander Brunt Manager, New Zealand +64 4 4726470 nzbranch@ranzcr.org.nz