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1 All authors: Division of Radiology, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195-5103.
Received February 23, 2000;
accepted after revision March 31, 2000.
Address correspondence to D. M. Einstein.
Abstract
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SUBJECTS AND METHODS. Ninety-four patients undergoing double-contrast barium enema examinations and 123 patients undergoing esophagographic examinations were included in the study. The study was conducted over a 4-month period, with examinations performed by eight gastrointestinal technologists, 10 radiology residents, and four staff radiologists. Four random lists were generated for each set of examinations. Each staff gastrointestinal radiologist, who was unaware of who had performed the examination, independently scored the representative radiographs.
RESULTS. For the double-contrast barium enema examinations, no statistically significant differences were found between the technologists and residents for amount of barium used, degree of distention, cecal opacification, and quality of spot radiographs. The technologist-performed examinations had a statistically significant lower mean fluoroscopy time (3.2 min, compared with 4.0 min for staff radiologists and 5.7 min for residents). For the esophagrams, no statistically significant differences between technologists and residents were found for single-contrast esophagrams; radiographs of the gastric cardia; assessment of motility, reflux, and transit of a solid bolus; and fluoroscopy time. Double-contrast esophagrams obtained by technologists received a better mean score than did those of the residents.
CONCLUSION. Radiology technologists can be trained to perform high-quality esophagography and double-contrast barium enema examinations without an unacceptably high radiation dose.
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For these reasons, we chose to determine if dedicated gastrointestinal technologists could be trained to properly perform certain fluoroscopic procedures. Double-contrast barium enema examinations were chosen because interpretation is based on radiographs rather than fluoroscopic observation. Esophagography was chosen because it entails limited anatomic coverage with little variation and because the examination is recorded on both radiographs and videotape.
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The opportunity to be trained was offered only to technologists with at least 2 years' experience in gastrointestinal radiology. An instructional tutorial for the technologists was provided, consisting of two 1-hr didactic sessions on technique, anatomy, and basic pathology. Initially, the technologists observed the staff radiologists performing several procedures. During the initial examinations performed by a technologist, a staff radiologist was present in the fluoroscopy room. These training sessions were excluded from the data. Once both technologist and supervising radiologist were comfortable with the technologist's performance, the technologist was observed by the radiologist from an outside video monitor. Eventually, no formal observation was undertaken. The staff radiologist was always available in the radiology suite for consultation if needed.
The routine spot radiographs obtained during a double-contrast barium enema examination included images of the sigmoid colon, splenic flexure, hepatic flexure, and cecum, followed by a series of overhead radiographs. The examination of the esophagus included double-contrast radiographs of the esophagus, single-contrast radiographs of the esophagus, double-contrast radiographs of the gastric cardia, assessment of esophageal motility with five separate swallows, assessment of reflux with provocative maneuvers, and administration of a 13-mm barium tablet. The entire examination of the esophagus was recorded on videotape.
Four staff radiologists evaluated all barium enema and esophagographic examinations in a randomized, retrospective fashion. Only one staff radiologist reviewed the videotapes of the esophagographic examinations. For the double-contrast barium enema examinations, each of the four staff radiologists rated the amount of barium and degree of distention as too little, optimal, or too much. Cecal opacification was graded as present or absent. Spot radiographs of the sigmoid colon, splenic flexure, hepatic flexure, and cecum were graded as poor, adequate, or good. For the esophagrams, the single- and double-contrast esophagrams, spot radiographs of the gastric cardia, and assessment of motility were rated as poor, adequate, or good. Assessment for gastroesophageal reflux and the administration of a solid bolus were graded as present or absent. Fluoroscopy time was also recorded for both examinations. Statistical analysis was performed by our departmental statistician using a variety of methods depending on the type of data set.
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The cecum was opacified in 93% of the barium enema examinations performed by technologists, in 98% performed by residents, and in 95% performed by staff (p > 0.0616, repeated-measures logistic regression). No statistically significant differences were found in the amount of barium used, in the degree of distention on the spot and overhead radiographs, and in the quality of the spot radiographs obtained (Tables 4,5,6). The mean fluoroscopy time was 3.2 min in examinations performed by technologists, 5.7 min in examinations performed by residents, and 4.0 min in examinations performed by staff radiologists (p = 0.0001, F test).
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In 1975, Lewicki [3] reported his results of upper gastrointestinal fluoroscopy by radiologic technologists. He found that a well-trained technologist produced radiographs of a quality comparable with a those of a resident, without an increase in fluoroscopy dose or problems with patient acceptance. In 1981, Somers et al. [4] reported similar results in a study of technologist-performed double-contrast barium enema examinations. The quality of examinations performed by two technologists after 1 month of training was negligibly different when compared with the quality of examinations performed by residents and attending radiologists. Lewicki, too, stressed the need for close physician supervision.
In 1996, Schreiber et al. [5] reported on 40 barium enema examinations and 40 upper gastrointestinal examinations divided equally between trained technologists and residents. Their grading system revealed no statistically significant differences in the quality of the examinations between the two groups
In 1988, Halpert et al. [6] found a similar detection rate of colonic polyps and endoscopic confirmation of those polyps, whether examinations were performed by technologists or radiology residents, and also advocated the use of technologists for intubating patients before enteroclysis. Their survey of patient satisfaction revealed no complaints about technologists performing the examinations. Reports from the United Kingdom describe similar excellent results in terms of quality of examination, radiation dose, and patient and physician acceptance when technologists are trained and supervised in the performance of gastrointestinal fluoroscopy [7,8,9]. Because a shortage of radiologists exists in that country, the use of technologist-performed fluoroscopy shortened waiting times for scheduling examinations and freed the radiologist to perform other more complex diagnostic and consultative duties [8].
Law et al. [10] studied a group of 488 patients who had barium enema examinations and endoscopic examinations performed by technologists. Ninety-six percent of polyps greater than 1 cm and 97% of carcinomas were detected radiographically.
Our results confirm the findings of these previous investigations. The technologists' scores were statistically as good as or better than those of the residents and staff radiologists in all the evaluated areas for both esophagrams and double-contrast barium enema examinations. Their mean fluoroscopy times were shorter than those of the residents for both examinations. Within a short period, the technologists were comfortable performing the examinations independently and only rarely needed assistance or guidance from the attending radiologist.
Halpert et al. [6] also discussed traditional objections to technologists performing fluoroscopic examinations. Radiation exposure to the patient was one of these potential objections. All technologists are trained in radiation safety and are instructed in good fluoroscopic technique. Our analysis of fluoroscopic times, like those of Halpert et al., showed no increase in exposure when examinations were performed by technologists as compared with examinations performed by residents. The explanation for these results is likely multifactorial and includes a familiarity with the fluoroscopic equipment and a desire to keep their own radiation exposure low because all the technologists involved were women in their childbearing years.
Diminished resident education has been discussed as a potential objection to training technologists. At our institution, we found that the workload in the department is more than sufficient to adequately train residents even when technologists perform some examinations. Having technologists available to perform some examinations is, in practice, often helpful to residents because residents on other rotations do not have to be pulled to cover the gastrointestinal suite when the assigned resident is absent.
Finally, patient response to technologist-performed examinations has been discussed. Although patient satisfaction was not specifically evaluated at our institution, to our knowledge no patient expressed concern or dissatisfaction that a technologist rather than a physician was performing the examination.
We chose to initiate this training program and evaluate its results because the volume of gastrointestinal fluoroscopic studies has been increasing at our institution, and the number of radiology residents rotating through fluoroscopy has been decreasing. In addition, residents seem less interested in traditional gastrointestinal radiology than high-tech modalities such as CT, MR imaging, and angiography. Providing this career path may also lead to greater job satisfaction and retention of technologists.
We do recognize several limitations to our study. First, the cases were not prospectively randomized. Second, and more important, a wide range of resident experience was included in the study. Experience ranged anywhere from first-year residents to fourth-year senior residents. However, the technologists' scores did not differ significantly from those of four experienced gastrointestinal staff radiologists. In addition, our data were based solely on a subjective grading system. Finally, we did not evaluate the accuracy of the technologist-performed examinations for the detection of abnormalities. Several other authors [4, 6, 9, 10] studied this question and found detection rates and accuracies comparable with those of physician-performed examinations and published data.
We limited our study to ambulatory outpatients because inpatients are often relatively immobile, and their examinations are also often limited by comorbid conditions. These conditions make performance of fluoroscopy much more difficult and would not offer a fair assessment of the technologists' abilities. Examinations of these patients often require a significant degree of tailoring to answer specific clinical questions and are more suited to a radiologist.
Our results suggest that, for the most part, the technologists and residents scored equally well performing double-contrast barium enema examinations and esophagographic examinations. We confirmed prior reports that radiology technologists can be trained to perform high-quality fluoroscopic examinations. This finding may have implications for practicing radiologists if the number of gastrointestinal procedures increases, the number of practicing radiologists adequately trained in gastrointestinal fluoroscopy decreases, or the number of radiology residents decreases.
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D. M. Einstein Author's Correction Am. J. Roentgenol., January 1, 2001; 176(1): 256 - 256. [Full Text]
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