Radiographer

Healthcare professional

Radiographers, also known as radiologic technologists, diagnostic radiographers and medical radiation technologists are healthcare professionals who specialise in the imaging of human anatomy for the diagnosis and treatment of pathology. Radiographers are infrequently, and almost always erroneously, known as x ray technicians. In countries that use the title radiologic technologist they are often informally referred to as techs in the clinical environment; this phrase has emerged in popular culture such as television programmes. The term radiographer can also refer to a therapeutic radiographer, also known as a radiation therapist. Radiographers are allied health professionals who work in both public healthcare and private healthcare and can be physically located in any setting where appropriate diagnostic equipment is located, most frequently in hospitals. The practice varies from country to country and can even vary between hospitals in the same country. Radiographers are represented by a variety of organizations worldwide, including the International Society of Radiographers and Radiological Technologists which aims to give direction to the profession as a whole through collaboration with national representative bodies.

For the first three decades of medical imaging's existence (1897 to the 1930s), there was no standardized differentiation between the roles that we now differentiate as radiologic technologist (a technician in an allied health profession who obtains the images) versus radiologist (a physician who interprets them). By the 1930s and 1940s, as it became increasingly apparent that proper interpretation of the images required not only a physician but also one who was specifically trained and experienced in doing so, the differentiation between the roles was formalized. Simultaneously, it also became increasingly true that just as a radiologic technologist cannot do the radiologist's job, the radiologist also cannot do the radiologic technologist's job, as it requires some knowledge, skills, experience, and certifications that are specific to it. Radiography's origins and fluoroscopy's origins can both be traced to 8 November 1895, when German physics professor Wilhelm Röntgen discovered the X ray and noted that, while it could pass through human tissue, it could not pass through bone or metal. Röntgen referred to the radiation as "X", to indicate that it was an unknown type of radiation. He received the first Nobel Prize in Physics for his discovery. There are conflicting accounts of his discovery because Röntgen had his lab notes burned after his death, but this is a likely reconstruction by his biographers: Röntgen was investigating cathode rays using a fluorescent screen painted with barium platinocyanide and a Crookes tube which he had wrapped in black cardboard to shield its fluorescent glow. He noticed a faint green glow from the screen, about 1 metre away. Röntgen realized some invisible rays coming from the tube were passing through the cardboard to make the screen glow: they were passing through an opaque object to affect the film behind it. Röntgen discovered X rays' medical use when he made a picture of his wife's hand on a photographic plate formed due to X rays. The photograph of his wife's hand was the first ever photograph of a human body part using X rays. When she saw the picture, she said, "I have seen my death." On 14 February 1896, Hall Edwards also became the first to use X rays in a surgical operation. The United States saw its first medical X ray obtained using a discharge tube of Ivan Pulyui's design. In January 1896, on reading of Röntgen's discovery, Frank Austin of Dartmouth College tested all of the discharge tubes in the physics laboratory and found that only the Pulyui tube produced X rays. This was a result of Pulyui's inclusion of an oblique "target" of mica, used for holding samples of fluorescent material, within the tube. On 3 February 1896 Gilman Frost, professor of medicine at the college, and his brother Edwin Frost, professor of physics, exposed the wrist of Eddie McCarthy, whom Gilman had treated some weeks earlier for a fracture, to the X rays and collected the resulting image of the broken bone on gelatin photographic plates obtained from Howard Langill, a local photographer also interested in Röntgen's work. X rays were put to diagnostic use very early; for example, Alan Archibald Campbell Swinton opened a radiographic laboratory in the United Kingdom in 1896, before the dangers of ionizing radiation were discovered. Indeed, Marie Curie pushed for radiography to be used to treat wounded soldiers in World War I. Initially, many kinds of staff conducted radiography in hospitals, including physicists, photographers, physicians, nurses, and engineers. The medical speciality of radiology grew up over many years around the new technology. When new diagnostic tests were developed, it was natural for the radiographers to be trained in and to adopt this new technology. Radiographers now perform fluoroscopy, computed tomography, mammography, ultrasound, nuclear medicine and magnetic resonance imaging as well. Although a nonspecialist dictionary might define radiography quite narrowly as "taking X ray images", this has long been only part of the work of "X ray Departments", Radiographers, and Radiologists. Initially, radiographs were known as roentgenograms, while Skiagrapher (from the Ancient Greek words for "shadow" and "writer") was used until about 1918 to mean Radiographer. The history of magnetic resonance imaging includes many researchers who have discovered NMR and described its underlying physics, but it is regarded to be invented by Paul C. Lauterbur in September 1971; he published the theory behind it in March 1973. The factors leading to image contrast (differences in tissue relaxation time values) had been described nearly 20 years earlier by Erik Odeblad (doctor and scientist) and Gunnar Lindström. In 1950, spin echoes and free induction decay were first detected by Erwin Hahn and in 1952, Herman Carr produced a one dimensional NMR spectrum as reported in his Harvard PhD thesis. In the Soviet Union, Vladislav Ivanov filed (in 1960) a document with the USSR State Committee for Inventions and Discovery at Leningrad for a Magnetic Resonance Imaging device, although this was not approved until the 1970s. By 1959, Jay Singer had studied blood flow by NMR relaxation time measurements of blood in living humans. Such measurements were not introduced into common medical practice until the mid 1980s, although a patent for a whole body NMR machine to measure blood flow in the human body was already filed by Alexander Ganssen in early 1967. In the 1960s and 1970s the results of a very large amount of work on relaxation, diffusion, and chemical exchange of water in cells and tissues of various types appeared in the scientific literature.

Non imaging modalities vary, and are often undertaken in addition to imaging modalities. They commonly include:
Academia – Education role. Clinical Management – Clinical managerial role which can be varied; may include managing audits, rotas, department budgets, etc. Clinical Research – Research role. Medical Physics – Multidisciplinary role ensuring the correct calibration of and most efficient use of diagnostic equipment. PACS Management – Managerial role concerned with maintaining and supervising appropriate and correct use of the RIS and PACS systems. Radiation Protection – A managerial role concerned with monitoring the level of ionising radiation absorbed by anyone who comes into contact with ionising radiation at their site. Reporting Radiography – A clinical role involved with interpretation of radiographs and various other radiological media for diagnosis.

Education varies worldwide due to legal limitations on scope of practice.

In Germany radiographers must complete a 3 year apprenticeship before they qualify as a 'Medizinisch technischer Radiologieassistent'. Only after qualifying do radiographers in Germany fulfil the requirements to practise as a fully qualified MTRA. Similar to other countries, they work within the areas of radiography diagnostics (CT scans, magnetic resonance imaging, radiography, digital subtraction angiography), radiation therapy, radiation dosimeters and nuclear medicine.

Radiographers in the Republic of Ireland (ROI) must be registered with CORU before they can practice in the Republic of Ireland. Student radiographers training in the ROI will typically study for 4 years on an approved bachelor's degree program; currently degree programs only exist at University College Dublin. Applicants must have either an approved qualification, a schedule 3 qualification, an appropriate letter of recommendation/accreditation or another qualification which is deemed 'suitably relevant' by registration board in order to successfully fulfil the vocational education requirements to become a Radiographer in the ROI. Applications for registration with qualifications outside of this are considered on an individual basis; typically this includes most international applicants. The professional body representing Radiographers in the ROI is the Irish Institute of Radiography and Radiation Therapy (IIRRT). To practice as a Radiographer or Radiation Therapist in Ireland, one must register with CORU as of 31 October 2015. CORU is Ireland's multi profession health regulator. Set up under the Health and Social Care Professionals Act 2005, CORU is used to protect the public by promoting high standards of professional conduct, education, training and competence through statutory registration of health and social care professionals. If a radiographer commences clinical practice without registration then they may be prosecuted with a fine or an imprisonment of up to six months. In Malta, in order for an individual to become a Radiographer he/she first has to follow a course offered by the University of Malta. The course is BSc (Hons) Radiography and its duration is of four years. On completion of the course, the graduate will have the conditions to be eligible for registration with the council for professions complementary to Medicine

A foreign radiographer can work in Malta should the necessary documentation and competencies have been obtained and presented. Radiographers working on Malta should abide by the rules of the host country and title of radiographer will be used. An application form has to be filled along with the necessary authenticated copies of several documents. The application form includes the insertion of personal details of the individual along with the description of qualifications and the university which granted the qualifications. The individual has to declare whether he or she is registered with another Health Care Profession Register in Malta. In these cases, the professional document and theoretical and practical training are required to be equivalent to the requirements of Malta, i. e. An EQF Level 6 Bachelor's Degree with an equivalent syllabus to that of the University of Malta and their course is no more than one year shorter. Should the radiographer have a substantial difference between their professional qualifications and those required by CPCM, the radiographer has the right to provide further evidence of competence (including professional experience or CPD), otherwise, the CPCM board should offer the applicant the possibility to do an aptitude test or adaptation period (as chosen by the applicant). A Flow chart explaining this procedure for EEA applicants can be found on the government's website.

As a developing country, the health care sector in Federal Democratic Republic of Nepal has very limited resources meaning radiological services are rather limited. Nepal is still struggling to improve and manage conventional radiological examinations. Radiological Services in Nepal commenced in 1923 at Military Hospital by Dr. Rana and Dr Asta Bahadur Shrestha. The first health related training program began in 1933 at the Nepal Rajkiya Ayurved School; the Civil Medical School was later established in 1934. Radiological education in Nepal started in 1923 in a 64 bedded Military Hospital, Tri ChandraElectro Medical Institute. The post graduate (MSc) program in physics at TU began in 1965 with only Nuclear Physics specialization. In 1972, the Institute of Medicine (IOM) which is affiliated with TU started the Proficiency Certificate Level (PCL) Radiography course however this has since stopped. Radiotherapy was first introduced at Maternity Hospital in 1976 utilising radium needle treatment. CT and Nuclear Medicine was introduced in 1988 at Bir Hospital. The Radiotherapy unit with Tele Cobalt 60 machine was established at Bir Hospital in 1991. Nepal became a member of IAEA in 2008. Since 2008 onwards diploma level radiography courses have been conducted across the country by the Council for Technical Education and Vocational Training (CTEVT) and other affiliated institutions. In Nepal there are 125 vocational health training institutes however only 15 are conducting radiological technological education. Bachelor level radiography education is taught in two universities & one college whereas master level radiography course is taught
in one where another university is in pipeline. Until recently, therapeutic radiography courses have not been taught in Nepal;
radiation therapists are predominantly trained abroad. The Nepal Health Professional Council (NHPC) is the legislative body for registering, accrediting, developing & enforcing quality assurance of Health Professionals, including Radiographers, in Nepal.

Until 1997, radiographers were required to register the Evidence of Competence at the Chief of Medical Inspections. This was mandatory under the Law on Paramedic professions. After innovate the law of Individual Health Care Professions (BIG), the registration requirements for radiographers were cancelled. A voluntary register has been set up in consultation with the Health Care Inspectorate: the Paramedics Quality Register. The Paramedics Quality Register comes from the BIG. The purpose of the Paramedics Quality Register is to guarantee the quality of professional practice. Through the registration and re registration (once in five years) it becomes visible for patients, health insurers etc. that the registered radiographer professional is and remains competent in the field of professional practice. Despite the fact that the quality register is not compulsory according to the law, many hospitals are obliged to do it. The hospitals are obliged to provide good quality care. Health insurers also attach great value to the Paramedics Quality Register because they are also required to provide good care.

Radiographers who are in possession of a valid Certificate of Competence, diploma of certificate and endorse the code of professional conduct of the professional association, can be enroll in the Paramedics historical register. The official registration of the radiographer satisfies the educational requirements in the General Administrative Order (AMvB) ex. art. 34 BIG and the quality requirements of the professional group. On the basis of which is carried out radiographer is mentioned in the Diplomaregister Paramedici and / or the Quality Register Paramedics. By registration, the radiographer continues to be traced by, for example, the Health Care Inspectorate (IGZ) and the professional associations. Other organizations also intend the Quality Register Paramedics.

To be in the Paramedics Quality Register the radiographer need to request re registration every five years. The first period of five years is determined on the basis of the diploma date. In case of re registration, the radiographer must meet the requirements for that period. The start date of the period station local quality criteria. The quality criteria are set every five years by the Paramedics Quality Register, paramedical professional associations. To ensure that the requirements for the patient and the client oriented exercises and expertise enhancing activities are safeguarded for the quality of the professional practice. The quality criteria are set up in such a way that paramedics can meet the quality requirements with the set range of expertise enhancing activities.

In Nigeria, these professionals are generally referred to as Radiographers or Medical Radiographers to differentiate them from Industrial Radiographers. Radiographers must complete a 5 year undergraduate BSc and a compulsory one year paid internship program in a hospital after graduation before attaining a full licensing by the Radiographers Registration Board of Nigeria. The board also registers Radiotherapists who have undergone the initial 5 year Radiography program before proceeding to the Radiotherapy training. Radiographers in Nigeria have been striving to extend their practice to include radiographic interpretation and Ultrasound services. They are also on the verge of adopting an official professional title of "Radr" or "Rr" as of 2015. Radiographers in Nigeria normally proceed for a Masters programme and a PhD programme in the profession. There is a recent rise in the number of radiographers available in the country unlike the situation of shortage between 2000 – 2010. In a typical Nigerian Teaching Hospital, radiographers do not undertake sonography examinations, this is left for the radiologists, who, in some areas, have gradually improved their relationship with the radiographers in providing services in other radiographic units. The radiologist is also in charge of specific Fluoroscopic cases where the radiographer assists only with positioning and image acquisition. Allied Health Unions (such as 'JOHESU' and 'NUAHP') that Radiographers are members of (with Nurses, Pharmacists, Physiotherapists, Laboratory Scientists, etc. ), have over the years gone on strike actions to force the Nigerian government to improve their allowances/salaries in the government owned hospitals. These strikes (when it is not a response on its own) often trigger a response from the Nigerian Medical Association who will also table some requests for the medical doctors. Apart from monetary issues, these professional bodies are also in loggerheads over non doctors requesting to be given top administrative roles in government owned hospitals. Many radiographers, however, do not particularly involve themselves in these movements as working in a private establishment is more lucrative. Some Radiographers in Nigeria are also keen on setting up a "Department of Radiography" in the government owned hospitals which will not be under the Head of the Radiology Department. Some hospitals however have an understanding between the Radiology head (a Radiologist) and the Chief Radiographer where all radiographers are directly answerable to their Chief, and not the HOD.

X Ray Technicians (فني اشعة) in Saudi Arabia must successfully undertake a degree level program at a recognised higher level education institution in Nursing before undertaking further study in radiographic imaging at university for typically 2 to 3 years; this must include a year's experience in a hospital. Upon completion, graduates are qualified X Ray Technicians and can commence clinical practice.

The SCoR is the professional body and union for UK radiographers. In the United Kingdom, there is ambiguity in the use of the term Radiographer as this does not differentiate between Therapeutic Radiographers (also known as Radiotherapists) and Diagnostic Radiographers. As a result, all of these titles are protected titles within the United Kingdom and can not be used by any persons who has not undertaken formal study and registered with the Health and Care Professions Council (HCPC). In order to practise Radiography in the United Kingdom candidates must now successfully obtain a pass in a degree level programme from an accredited institution. Degrees are offered by universities across the UK and last for at least 3 years in England, Wales and Northern Ireland; and 4 years in Scotland. Student Diagnostic Radiographers spend a significant amount of time working at various hospitals affiliated with their university during their studies to meet the requirement for registration with the HCPC. They specialise in the acquisition of radiographs of General Practitioner referred (GP) patients, Outpatients, Emergency Department (ED) referred patients and Inpatients. They conduct mobile X rays on wards and in other departments where patients are too critical to be moved and work as part of the operating team in mainly Orthopaedic and Urology cases, offering surgeons live radiographic imaging. Once qualified, Diagnostic Radiographers are able to acquire X rays without supervision and work as part of the imaging team. They will have basic head examination qualifications in CT and even basic experience of MRI, Ultrasound and Nuclear Medicine. Diagnostic Radiographers can specialise in house or through a university course as a postgraduate in CT, MRI, Ultrasound or Nuclear Medicine with opportunities to gain an MSc or PhD in their field. Diagnostic Radiographers in the UK are also taking on roles that were typically only undertaken by the Radiologist (a medical doctor who specialised in interpreting X rays), Urologist or Cardiologist in the past. This extended practice includes various interventional procedures not excluding barium enemas, barium meals/swallows, peripheral angioplasties, nerve root injections, central line insertions and many other procedures. The professional body and workers union for Radiographers in the United Kingdom is the Society and College of Radiographers (SCoR). The union has been heavily involved in extending practice of Radiographers in the United Kingdom and has helped expand the role of the Radiographer greatly.

Radiographers are now able to write reports and diagnose pathologies and/or conditions seen on differing diagnostic media after completing a HCPC and SCoR accredited university course; completing a course in this modality allows the Radiographer to become a reporting Radiographer in their chosen specialty. Diagnostic Radiographers are able to become supplementary prescribers which allows them the capacity to prescribe medications in partnership with an independent prescriber (a doctor or a dentist); the supplementary prescriber is to implement an agreed Clinical Management Plan for an individual patient with that patient's agreement. An accredited university course must be undertaken before this role extension is annotated onto a HCPC registrant's record. It is thought that in the future Diagnostic Radiographers in will gain independent prescribing rights, however this is currently limited by their restricted and varied scope of practice. In 2016, the introduction of independent prescribing right was agreed for Therapeutic Radiographers after a consultation by the Medicines and Healthcare products Regulatory Agency (MHRA)

In the United States, these professionals are known as Radiologic Technologists. Formal training programs in radiography range in length that leads to a certificate, an associate or a bachelor's degree. The American Registry of Radiologic Technologists (ARRT), the primary credentialing organisation for Radiologic Technologists in the United States, requires that candidates for ARRT Certification Exams must have an associate degree at minimum as of January, 2015, effectively ending non degree granting diploma programs. Accreditation is primarily through The Joint Review Committee on Education in Radiologic Technology (JRCERT), the only agency recognised by the United States Department of Education and the Council for Higher Education Accreditation to grant accreditation to both traditional and online programs in Radiography, Radiation Therapy, Magnetic Resonance Imaging, and Medical Dosimetry. An online page where prospective students can check the accreditation of programs is maintained by JRCERT. Radiologic Technology students study anatomy, physiology, physics, radiopharmacology, pathology, biology, research, nursing, medical imaging, diagnosis, radiologic instrumentation, emergency medical procedures, medical imaging techniques, patient care, medical ethics and general chemistry. Schooling also includes significant amounts of documented practicum supervised by Registered Technologists in various clinical settings where the classroom theory is translated to practical knowledge and real world experience. The change from Film to Digital imaging has changed training as film quality assurance and quality control is largely obsolete. The role of computer workstations to produce synthetic images for Radiologists has steadily increased the need for computer skills as has electronic medical record software. After primary training and licensure, continuing education is required to maintain licensure and certification with the ARRT, who sets the accepted national guidelines. The ARRT requires 24 Units of accredited continuing education every two years and the laws and the regulations of most states accept this standard. Continuing formal education or the passing of an advanced practice speciality exam may also be accepted for continuing education credit. The American Society of Radiologic Technologists (ASRT), a professional association for people in Medical Imaging and Therapy, offers members and others continuing education materials in various media that meet the requirements of the ARRT for continuing education. Additional requirements are set forth for technologists who specialise in mammography by the US FDA.

A new and evolving career for Radiologic Technologists is that of the Registered Radiologist Assistant (RRA) who is an experienced technologist (a type of Physician Assistant) who has completed additional education, training, and has passed exams to function as radiologist extenders. A list of the 9 currently accredited RRA programs is maintained by the ARRT and can be accessed online. Candidates for the RRA certification must possess a bachelor's degree at minimum. Registered Radiologist Assistant (RRA), a new advanced practice radiographer career path in the United States for experienced technologists. RRAs do not interpret studies in the manner of the reporting radiographer. The role has been accepted by the American College of Radiology (ACR).

Epidemiological studies indicate that Radiographers employed before 1950 are at increased risk of leukemia and skin cancer, most likely due to the lack of use of radiation monitoring and shielding. The relationship between radiation and cancer was found to correlate with women who were in the menopausal stages of their lives. In today's workplace, radiation exposure is monitored very closely and cancer cases in technologists has been found to have decreased tremendously due to the current prevention methods. Ionising radiation, used in a variety of imaging procedures, can damage cells. Lead shields are used on the patient and by the Radiographer to reduce exposure by shielding areas that do not need to be imaged from the radiation source. While lead is highly toxic, the shields used in medical imaging are coated to prevent lead exposure and are regularly tested for integrity. Radiographers who develop x ray films are exposed to the various chemical hazards such as sulfur dioxide, glutaraldehyde, and acetic acid. These agents can cause asthma and other health issues. Theoretically, the strong static magnetic fields of MRI scanners can cause physiological changes. After a human neural cell culture was exposed to a static magnetic field for 15 minutes, changes in cell morphology occurred along with some modifications in the physiological functions of those cells. However, these effects have not yet been independently replicated or confirmed, and this particular study was performed in vitro. Ultrasound imaging can deform cells in the imaging field, if those cells are in a fluid. However, this effect is not sufficient to damage the cells. As with any allied health professional, exposure to infectious diseases is likely, and use of Personal Protective Equipment (PPE) and infection control precautions must be employed to reduce the risk of infection. Those with family health histories reported feeling increased amount of stress due to concern of bringing infectious diseases home. In 2016, 59% of technologists surveyed reported that being overworked lead to risking medical error and threatening patient safety. Being overworked also led to depersonalization due to the emotional drain it takes on technologists' mental health, also putting patients at risk. Due to constantly maneuvering heavy patients, technologists are at risk for work related injuries from the strain it puts on their bodies. Most technologists who develop a work related injury, later report having more work related injuries.