There is little debate that radiology is experiencing a crisis. “The volume of work is reaching the point where we may not be able to keep up with the flow,” says Robert Stanley, MD, professor and chairman, Department of Radiology, University of Alabama School of Medicine at Birmingham (UAB) and president of the American Roentgen Ray Society (ARRS). “Our success has been part of the problem.”

In addition to an increasing volume of work, early retirements and a lack of new students entering radiology have exacerbated the problem. Enter the radiology practitioner assistant (RPA). This new specialty-which has just a handful of practitioners and one training program-may be a key component in leveraging radiology’s shrinking manpower base.

There has already been official support for the creation of new nonphysician radiology specialties. The American College of Radiology passed a formal resolution at its annual meeting in September 2000 supporting nonphysicians doing radiological procedures under a doctor’s supervision. And, though the ARRS does not formally support the creation of any nonphysician subgroup in radiology, Stanley has found RPAs to be “a considerable help” at UAB.

Working under the supervision of a radiologist, the RPA does what a technologist cannot-perform radiological procedures. “We are not licensed physicians; we don’t function independently from the radiologist,” says John Larsen, an RPA at St Mary’s Hospital in Grand Rapids, Mich. “We do the procedures, and [the radiologists are] the ones who give the final reading. We want to be an extender of the radiologist. And, if we can keep that in mind, the radiologists are less threatened, because we’re not independent from them.”

Like other RPAs, Larsen does the work that takes radiologists away from reading films, including explaining the procedures to patients, taking a patient’s history, prepping the patient for an examination, collecting files and old films for the radiologist, and performing anywhere from 5% to 90% of the procedure. Larsen estimates that he saves 15-20 minutes per procedure for the radiologist. And this is where an RPA’s value lies, says Darrel Rosen, MD, a radiologist with the Kent Radiology Group, Grand Rapids, Mich, and one of Larsen’s superiors. “The less time we spend in the room with the patient, the more films we can read,” Rosen notes. “Films are being taken all the time, and so he helps us to keep up. He makes us more productive.”

During the past 7 months, Larsen has performed 2,100 procedures for the Kent Group, freeing Rosen and his colleagues to spend more time evaluating the results, which average-for Rosen-about 150 to 200 cases per day. Among the procedures Larsen does are upper-gastrointestinal studies, small bowel series, arthrograms, venograms, and lumbar taps-all procedures normally performed by a radiologist. With the lumbar tap, for instance, Larsen explains the procedure, washes the patient’s back, performs the spinal tap, and injects the contrast material. A technologist would just take the image and then process it, leaving the radiologist to do everything else.

Autonomy Varies

Under the rules of St Mary’s Hospital, Larsen cannot make evaluations of films and cannot dictate reports. The level of autonomy radiologists give RPAs is a function of their experience. Larsen, who has been given a high level of autonomy, was a radiological technologist for 36 years-15 with the Kent Group-prior to completing his RPA certification in February 2000.

RPAs are authorized by the Certification Board of Radiology Practitioner Assistants (CBRPA), Ogden, Utah. Currently, RPAs are not required to have any additional licenses because they work under the direct supervision of a physician, though, like a physician, they must apply for hospital privileges. For Larsen, this was the only hurdle he faced after passing his certification examination. “In the beginning there was some difficulty with credentialing because there was no such position before,” says Rosen. “It’s always hard to break new ground. But we actually had people on the medical staff who knew John because he had been our employee for 15 years. And they went to bat for him.”

Those interested in becoming an RPA, currently, have only one educational outlet to choose from: Weber State University, in Ogden, Utah.

Weber State has been offering its RPA program since 1995. About 50 students have completed the 2-year course.

The impetus for the program came from a radiologist at Madigan Army Medical Center, Tacoma, Wash, who was aware of the school’s advanced radiography courses, and requested that it develop a RPA program for the Army. Budget cutbacks forced the Army to pull out of the program.

Program is Selective

Figure. Procedures performed by RPA John Larson during the first four months of 2001.

The Weber program is selective. Only radiology technologists with 5 years’ experience, consent of a radiologist who is willing to work with the student, and access to a clinical site are accepted. The program does not accept nurses or physician assistants, only radiographers. Students are required to complete 58 credit hours of course work and 1,200 hours of clinical experience. Most course work is completed off-site. “We realize that students cannot relocate and be close to campus,” says Jane van Valkenburg, PhD, chair of the Department of Radiologic Sciences. “We had to develop a delivery system that takes the program to them. All of our courses are in a modular format with objectives and learning experiences thoroughly outlined.”

However, twice each semester students attend weekend courses at Weber State. “We’re dealing with experienced technologists who have been looking at images for a number of years,” says Van Valkenburg. “So we bring them on campus for intensive class sessions, and then they go back to their local community, and work with their radiologist there on the clinical aspect of the session. We have a clinical verification method that we use to confirm that they are getting all their clinical [experience]. We teach according to organ systems. We don’t teach procedures, because they know how to do that. We teach them to evaluate the image, determine if there is an abnormality, and, if there is, then what imaging modality would best demonstrate that, and then what they would look for.”

All tests are administered online and students keep in touch with instructors and each other via email and online discussion groups. Once they have completed their course work, students travel to Utah to take the CBRPA certification test, which includes an evaluation of eight cases. Weber just graduated a class of 13. The program’s new class will have 30 students this year. Weber students and graduates are currently working in 33 states.

Weber may not have the only RPA program for long. Van Valkenburg is currently in communication with the Air Force about setting up a RPA program, and she knows other schools are considering starting one.

Stanley says that UAB has begun inviting applicants for a new RPA concentration in its physician assistant program. However, he adds that RPAs might not be the only solution to the radiologist shortage. “There is an increasing number of places around the country where GI fluoroscopy is assisted by a supertechnologist, someone who is well beyond just the conventionally trained x-ray technologist,” he says?

Van Valkenburg says that after initial resistance, radiologists and hospital administrators have been enthusiastic in their support. “I get more calls from radiologists than I do from technologists,” she says. “At first it was an uphill battle until they saw the value of having an RPA in the department, how much more efficiently the work goes, and how the RPA can relieve them-the radiologists-of routine tasks.”

Larsen says that he found some resistance from the Kent Group when he told them he would be pursuing his RPA certification. But it was not because the group opposes the concept of the RPA, says Rosen. “We just hated to lose him because he was our chief technician,” he says. “It was strictly selfish.”

Financial Incentives

There are financial incentives for technologists to become RPAs. Salaries range from $65,000 to $72,000 per year, about $15,000 to $20,000 more than the salaries of RTs. Larsen says that there are additional motivations for him apart from higher pay and career advancement. “I like going to work everyday,” he says. “I enjoy doing my job. I enjoy working with the patients. That was one of the things I didn’t thoroughly like as an administrator: I didn’t have that patient contact. Anyone who wants to become an RPA and doesn’t want to deal with patients shouldn’t do it, because that is our job.”

The Weber graduates have found they are in high demand from radiology groups. “I have been offered jobs in different locations,” says Larsen. “I haven’t wanted to move, though it may happen sooner or later.”

For the Kent group, an RPA will probably be a continuing part of its practice. “When the time comes when John [Larsen] retires, I certainly would be in favor of replacing him with another RPA,” says Rosen.

Chris Wolski is associate editor of Decisions in Axis Imaging News.