Overview of New Technology and Future Challenges



Overview of New Technology and Future Challenges






Professional Profile



The most exciting advance in medical imaging in the last decade has been the development of fusion imaging. This advanced application, in which information from imaging modalities is merged, has brought about new challenges and opportunities for imaging professionals. This new technology was developed after the use of computer techniques to fuse an image from two separately acquired imaging procedures failed to provide precise alignment of the two studies. Functional imaging using radiotracer imaging of single photon emission computed tomography (SPECT) and positron emission tomography (PET) has been expanding in use in recent years. Both SPECT/CT and PET/CT have provided unparalleled enhancement to give physicians both high-resolution anatomic images and functional information. When hybrid systems are used to combine SPECT/CT or PET/CT in one procedure, the exact alignment may be achieved. We stand on the threshold of Food and Drug Administration (FDA) approval of new radiotracers, which will bring about the availability of radiolabeled biomarkers that will provide more information about the physiologic status of disease.


As the first commercially available PET/CT and SPECT/CT systems were installed, the immediate questions of operator training, licensure, and competency arose. Who was trained, competent, and authorized to handle and administer the radiopharmaceuticals for the physiologic studies (PET and SPECT), and who was trained and certified and had demonstrated appropriate competencies to perform the CT part of the combined procedures?


Federal regulations administered by the Nuclear Regulatory Commission (NRC) authorize the licensed handling of radiopharmaceuticals for human administration. Such licensure is given to facilities, and administration of the radiopharmaceuticals must be under the authority of an appropriately trained physician. Under the direction of the physician, technologists may be authorized to prepare and administer radiopharmaceuticals. This license in some states is granted directly by the NRC. “Agreement states” administer licensing in compliance with NRC regulations. The control of radioactive materials should be safely provided through either mechanism. However, the training and authorization of technologists are not uniform in all states and currently are not required by federal regulations. In some states there are no license, training, or certification requirements for nuclear medicine technologists, other states impose restrictions on handling of radiopharmaceuticals by any radiologic technologist, and still others limit licensing only to nuclear medicine technologists certified either by the Nuclear Medicine Technology Certification Board (NMTCB) or by the American Registry of Radiologic Technologists (ARRT). Both of these certifying bodies also have specialty examinations; the NMTCB in general nuclear medicine or nuclear cardiology (NCT), or positron emission tomography (PET), and the ARRT with radiologic technology (RT), nuclear medicine (NM), computed tomography (CT), and other specialties. At this time no states require specialty certification in CT in order to perform CT studies. All states allow the performance of CT by radiologic technologists, as long as they have appropriately demonstrated competency that has been documented by their institution.


Most states have allowed nuclear medicine technologists to perform PET/CT and SPECT/CT as long as the studies are performed as a combined procedure. This is permitted because the nuclear medicine technologist has appropriate training in radiation safety and minimal training and competency measures are required to appropriately operate the CT portion of the system. Furthermore, the nuclear medicine technologist is not allowed to perform a diagnostic CT procedure by itself. Most nuclear medicine technologists are trained in college-based programs to be only nuclear medicine technologists and are not radiologic technologists before training in nuclear medicine. At this writing there has been a recent trend in a few states to prohibit nuclear medicine technologists from operating the CT, even for combined procedures, thus requiring either two people (a nuclear medicine technologist and a radiologic technologist) or one individual with dual credentialing. This limits opportunities for nuclear medicine technologists or may require additional training and certification.


A 2002 Consensus Conference of several professional organizations determined that the number of dual-credentialed technologists was limited. The organizations formed a taskforce that developed a curriculum for core competencies for PET and CT. They also determined that credentialing pathways should be developed to allow nuclear medicine technologists to become eligible for the CT examination administered by the ARRT and for the CT and Radiation Therapy Technologist ARRT(T) to be eligible for the NMTCB(PET) examination. The shortest pathway for technologists to become dual credentialed was for the CNMT technologists to become CT certified. It was also recognized that the CNMT technologists have the most comprehensive scientific training.


Although dual certification pathways have been developed, few technologists have taken advantage of these opportunities to date. The limitation is most likely the time available in busy work schedules to create these opportunities, since few formal programs are available for full-time employees. However, state regulations continue to change rapidly, and practical and cost-effective utilization of appropriately qualified personnel is often not a consideration as rules are implemented.


The impact on patients from these regulatory changes has varied widely. In some states two technologists must be present to perform the procedure, one nuclear medicine/PET technologist and one radiologic technologist. The sole purpose of the radiologic technologist is to set up and start the CT portion of the study. This affects the cost of patient care because of the increased personnel requirement and makes the whole imaging procedure less time efficient, since the radiologic technologist will also have other duties.


The technology of hybrid SPECT/CT and PET/CT is expanding at a rapid rate. There is a continued increase in the number of these imaging devices being installed as institutions want the latest systems and technology. In all of the complex facets that drive hybrid imaging, the bottom line is that appropriately trained, certified, and competent individuals should provide safe and technically accurate imaging procedures.


Note: Current examination criteria are defined on the websites www.arrt.org and www.nmtcb.org.




ETHICAL ISSUES


The previous chapters of this text have discussed ethical concepts, theories, and common problems faced by imaging and radiation science professionals. However, the problems discussed are not the only ethical dilemmas encountered by these health care professionals. Moreover, as the imaging profession and medical technology evolve, imaging professionals will face intense new ethical problems requiring strong problem-solving skills. Considerations of new technologies, research methodology, new reproductive methods, testing, transplant situations, quality assurance, and advanced levels of education and responsibility require that professionals have ethical awareness of the possible abuses and controversies so they can provide the best possible patient care.


Imaging and radiation science professionals should be prepared to encounter a variety of new difficulties on the path to ethical problem solving. This chapter offers a brief overview of ethical areas in which they may become involved.



IMAGING’S EXAMPLE FOR HEALTH CARE IN THE 21ST CENTURY


Former Speaker of the House Newt Gingrich, founder of the Center for Health Transformation, and Robert Egge, director of the Accelerating Health Innovation Project at the center, recognize the need for transforming the American health system for the 21st century. They explain that Hurricane Katrina is an example of how ineffectively the health care system functioned and that rebuilding a better system is imperative. Gingrich and Egge further explain1:


Radiology is one area where new technologies are rapidly emerging that could dramatically impact the rebuilding effort. Take, for example, the interventional radiology, in which scalpels are replaced by imaging-based procedures. These procedures typically require little or no anesthesia and much less cutting of skin, muscle or other tissues, resulting in less blood loss, shorter hospital stays, shorter recovery time and less expense.


Radiologic imaging is central to another health care trend that should be strongly encouraged: the move toward a greater emphasis on prevention and early detection. Steadily improving imaging technologies will allow health care professionals to identify emerging conditions earlier and with greater accuracy than ever before, enabling intervention when it is least costly and least invasive and has the greatest likelihood of success. These innovations in radiology and imaging are the kinds of development that will transform the health system.



NEW TECHNOLOGIES


Numerous new technologies have been developed and have become valuable tools in diagnosis and treatment. No sooner has a new technique, a new modality, or a new combination of existing modalities hit the headlines than yet another exciting imaging innovation has claimed its place. As a new technology is born, so are the ethical and sometimes legal complications (Table 10-1). These complications or dilemmas will call for critical thinking and problem solving as imaging professionals recognize that new technologies provide new information that requires new and sometimes difficult decisions for the professional and the consumer. Decisions concerning wellness, research, early detection, archiving, monitoring of disease processes, prediction of future health problems, and lulling of consumers into a false sense of security may complicate ethical and legal issues.





IMAGING PROFESSIONALS’ OBLIGATION TO RESEARCH


Imaging professionals have an obligation to the profession to maintain current knowledge and be critically aware of future technology and trends. Such maintenance and education require imaging professionals to read scientific journals and practice proper research methods. While reviewing various research materials, imaging professionals must analyze the data and practice critical thinking (see Box 1-2).


Imaging professionals concerned with respect and stature in the health care community should consider the options available to them to encourage others to perceive them more positively. They should educate others about the profession and describe the creative and innovative processes they have undertaken and completed. Moreover, they should expend the extra effort to describe their findings and experiences in established journals. Imaging educators should encourage or even require their students to perform and present research; unfortunately, the imaging sciences lag behind medicine and nursing in research and publishing. Professional journals, periodicals, and organizations are eager for imaging professionals and students to submit work. Given this desire for information and education, imaging professionals must look to the future and promote the recognition of the imaging sciences.2



ETHICS OF INTERPRETATION OF IMAGING PROCEDURES AND TESTING


Imaging procedures in all modalities require interpretation. Many imaging professionals have observed differences of opinion between radiologists and physicians concerning the characteristics of a high-quality image. A physician in the urgent care clinic may see a fracture and begin treatment for it. A radiologist may look at the same image and read it as negative. Such fallibility of interpretation may cause technologists to become involved in litigation.


Other imaging professionals may be asked by physicians or emergency personnel to make judgment calls concerning the outcome of tests or imaging procedures. Although the imaging technologist may believe that an image clearly shows a fractured bone, basing treatment for a fracture on the opinion of a professional who is not a radiologist may be unfair to the patient and become the source of litigation.


A less common dilemma encountered by imaging professionals occurs when they know or at least perceive that a test has been misinterpreted. Such a situation raises the question of the responsibilities a technologist has to a patient who has an unrecognized condition, perhaps a fracture, and is being sent home from the emergency room. The risks to the patient outweigh the risks to the imaging professional, indicating that the professional should intervene. This intervention may require little more than questioning a line on the cervical body. Imaging professionals who intervene on behalf of a patient in what they believe is the patient’s best interest may put themselves at risk. If the benefits outweigh the risks, however, imaging professionals may choose to intervene.



IMAGING SCENARIO


A radiographer who was hired only recently is called to the morgue to take a series of skull radiographs on a body for forensic evaluation. The county medical examiner is present and remarks that no evidence on the films indicates foul play. The radiographer, however, notes an unnatural line on the basal skull projection. The new employee is afraid to say anything to the medical examiner and thus waits until the next day to talk to the radiologist. The radiologist reads the examination as positive for fracture, but he is not inclined to call the medical examiner because they have had a previous confrontation. He does ask why the radiographer did not point out the suspicious line to the examiner. The radiographer explains that he did not believe he was qualified to interpret films. After the medical examiner receives the radiologist’s report, he is furious because he has already released the body and it has been cremated. The medical examiner corners the radiographer later that same day and asks him directly if he noticed the fracture line. The radiographer admits with a great deal of hesitation that he saw the fracture. The medical examiner accuses the radiographer of negligence and explains that if the person had been killed, the murderer would go unpunished. The family of the deceased, after being informed by an anonymous source, later sues the medical examiner, radiologist, and radiographer.



Imaging has a role in nonmedical testing and industrial testing as well. These noninvasive tests involve evaluating pipelines, casting, and fittings for their strength and structure. Other types of radiographic testing include forensic radiography on human subjects or objects to solve crimes. Archaeological imaging has been used in examining mummified remains and exploring artifacts of previous civilizations. Imaging studies of art objects have proved invaluable in discovering forgeries. Truthfulness and disclosure are as important in these nonmedical imaging areas as they are in medical imaging practice.




ETHICAL DILEMMAS OF TRANSPLANTS


Imaging professionals may find themselves involved with patients and families awaiting organ transplants; they may also have contact with donors and their families. The events surrounding organ transplantation are often emotional and must be handled with empathy and ethical awareness (Box 10-1).



The AMA Council on Ethical and Judicial Affairs has outlined three principal ethical concerns of the physician and health care team—including the radiographer2:





1. Full discussion of the proposed procedure with the donor and recipient or responsible relatives or representatives is mandatory. The physician should be objective in discussing the procedure, disclosing known risks and possible hazards, and advising of the alternative procedures available. The physician should not encourage expectations beyond those justified by the circumstances. The physician’s interest in advancing scientific knowledge must always be secondary to the primary concern for the patient.


2. The transplantation of body organs should be undertaken only by physicians who possess special medical knowledge and technical competence developed through special training, study, and laboratory experience and practice. Transplants must take place in medical institutions with facilities adequate to protect the health and well-being of the parties to the procedure.


3. Transplantation of body organs should be undertaken only after careful evaluation of the availability and effectiveness of other possible therapy.

Feb 27, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Overview of New Technology and Future Challenges
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