November 8, 2004 “Half a Radiologist” By Matthew Robb Radiology Today Vol. 5 No. 23 Page 26 Radiology Practitioner Assistant Certification Offers Clinical Career Expansion for Technologists Despite his familiar credentials, Don Monroe, RT(R), isn’t your typical radiographer. On any given day, you’ll find him overseeing a community hospitalemergency department, checking films, performing protocols, reviewing cases, taking histories, and teleconferencing with physicians and hospital staff. Monroe is manager of radiology services at Newport Community Hospital (NCH). Set against the picturesque Selkirk Mountains in eastern Washington State, the facility covers a 300- square-mile territory that brushes up against the borders of Idaho and Canada. Last year, NCH administered roughly 13,500 radiologic studies. Monroe works hard and cheerfully shrugs off his 60-mile daily commute from Spokane to the rural northeast corner of Washington. But every few months, the 38-year-old RT shelves his charts, loads up his book bag, and takes to the sky for a 600-mile commute to campus. But what keeps him fueled to and from Weber State University in Utah are the career rewards that await just over the horizon: greater clinicalchallenge, a more prestigious certification, and a projected annual salary topping $100,000 as a radiology practitioner assistant (RPA). Enter the Clinician Better money and more challenging clinical duties certainly have their appeal, but Monroe says the big story behind being an RPA is theopportunity to contribute to improved patient care. More than just filling spot shortages nationwide, RPAs save lives, stretch healthcare dollars, and reaffirm the concept of the midlevel provider. “Rural America needs RPAs badly,” Monroe says. “Patient care issuffering. Radiologists are hard to come by and we don’t have midlevelproviders. Our hospital provides radiology services just six hours a day, three days a week. Our radiologist commutes 60 miles out here— usually catching a ride with me—where he reads films and does all theprocedures in that brief time frame. My giving him an extra set of handswith these procedures enables him to be more efficient and better serve
our patients. It’s a definite win-win.” Monroe’s path to Weber State grew out of a common situation: overbusy radiologists. “The physicians running our group at the timewere busy and just couldn’t get up to Newport often enough,” he notes.“They needed help doing procedures. They asked if I was interested in the RPA program.” Monroe responded with an enthusiastic “yes.” In2002, however, his choice was limited to one institution: Weber State. Loma Linda University’s fledgling radiology assistant program—thenation’s first program offering a similar midlevel credential—wouldn’tlaunch until 2003. [Editor’s note: Radiology Today wrote about Loma Linda’s radiology assistant program earlier this year. See “Coming Soon: Radiology Assistants” in the August 16 issue.]“I could have waited and gone to Loma Linda University, no problem,”Monroe says. “But I was impressed with the RPA scope of practice and Weber State’s educational approach.” James Abraham, RPA, has also noted the shortage of midlevelpractitioners in rural America. Whether at his former employer in NewMexico or currently at Northwest Imaging in Kalispell, Mont., the 19- year veteran says the RPA fills a pressing need. “We are a great extender of the radiologist,” he says. Working under direct supervision of the radiologist—which means the radiologist is on-site and available if needed—Abraham says heperforms a range of interventional procedures, including joint injectionsfor arthrograms, and minor ultrasound-guided procedures. He also does general radiology procedures such as upper gastrointestinal exams and barium enemas. While not universally true, Abraham says there is a tendency for RPAs to work in interventional radiology where their higher-level direct care skills can be best used to free radiologists to interpret images. Abraham does not interpret images. While the RPA scope of training permits film evaluation in certain situations, Montana law prohibits RPAs and technologists from interpreting films. Abraham also says theradiologists in the practice do not want him reading exams, which is OK with him. Those two factors—state law and radiologist preference— drive what each RPA does in his or her specific position. The result, Abraham says, is a flexible midlevel provider who improves patient care.RPA job duties may vary from state to state, Abraham says, but he takes
issue with the descriptive term “super tech.”“We are more than super techs,” he insists. “Super techs are the driven, motivated RTs who stepped up to Weber State’s RPA program.” Perhaps the ultimate compliment to Abraham comes from the radiologists in his group. In their eyes, he functions as “half a radiologist.”“I love what I do—and I feel lucky,” he says. “I work for a great group that’s very supportive of my position. I get lots of positive feedback from patients because I can spend more time with them than aradiologist can. I’m there from beginning to end, which translates into better patient care.” Weber State At a Glance Aside from rosy career opportunities, one of Weber State’s major selling points is affordability. Tuition is a bargain at $1,700 per semester. Says Jane A. Van Valkenburg, PhD, RT(R)(NM), FASRT,education director at Weber State, “We charge RPA students one-half ofout-of-state tuition. We realize technologists don’t have a lot of money.” The university is state-funded. To be considered for the RPA program, applicants must have at least five years of experience. Admissions officials count two years in an RT program toward that total. Another key selling point is accessibility. Weber State’s program isgeared to the busy medical professional. “We don’t want [our students] to have to quit their jobs and uproot their families to move here,” Van Valkenburg says. “Besides, there aren’t enough clinical slots locally.” The Weber State RPA program thus combines Internet-based learning and clinical preceptorships at local practices. “Everything is done online,” she says. “We don’t waste class time on exams.” Students and faculty keep in contact via e-mail. The bottom line is that Weber State students need to travel to campus only 10 times over the entire 22- month course. In practical terms, this means that twice a semester forfive semesters, 185 students converge from across the nation on Ogden, located approximately 25 miles from the Great Salt Lake. Weber State professors hold intensive all-day seminars in one of two sessions:Mondays through Wednesdays or Thursdays through Saturdays. Classesare scheduled one year in advance to accommodate travel arrangements. That schedule makes it feasible for Monroe to fulfill job duties inWashington and still attend class in Utah. A licensed pilot, he commutes in a private plane. “It’s about a five-hour flight to Ogden-HinckleyAirport in my Cessna. Midway, I stop for fuel, a burger, and Coke—and
then head back up. The trip is usually routine, but we have fire season up here. Last year, I got stuck in a smoke storm on the way to school. That was pretty scary.” Van Valkenburg describes a typical student as in his or her early 30s, with outliers in their mid-20s and late 40s. Incoming classes are approximately 60% male. “Attrition is quite low,” she notes, “maybe 5% to 10%. Among those, many finish the next year.” To date, Weber State has graduated 315 RPAs.“Our incoming students have had an average eight years of experience,” Van Valkenburg says. “They’ve already seen thousands of images. Instead of looking at them for technical quality, they’re now looking atthem for disease processes—at how abnormalities appear on an image.” Students focus on the art and science of differential diagnosis. While RPAs clearly do not interpret radiologic studies, they do gather pertinent information that helps guide a radiologist’s diagnoses. Says Abraham, “The on-campus seminars are three-day brainstorming sessions that connect you with students from across the country. It’simportant to find out how people are doing things in other areas because the medical world is not standard by any means. But the program’s real strength is its strong clinical base. We are training with radiologists the entire time.” Monroe agrees. “Weber State is very pro-RPA and exceptionally helpful. If I contact them with an issue, they return my call or e-mail within the hour. If I have a clinical question that my radiologist or another physician can’t answer, my professors let me know where to find the answer.” The Pioneers’ Pioneers “If the programs at Weber State and [the new radiology assistantprogram] at Loma Linda University look similar, it’s because they are,”says Van Valkenburg. “We have served as the national model. The RA programs have copied us.” Noting her institution’s leadership role, she doesn’t hesitate to pay homage to the field’s “true pioneers”—three defunct 1970s-eraprograms in New York State, North Carolina, and Kentucky. “Some of these original practitioners are still in the field today and three have passed the CBRPA examination,” she notes. “I talk to radiologists all the time who mention the Kentucky program.” When federal funding evaporated, school officials mothballed these programs.
In 1995, Weber State rolled out its own trailblazing program—and nearly met a similar fate. Impressed with the school’s advanced radiography curriculum, U.S. military officials—bristling with lessonslearned from the first Persian Gulf War—proposed a joint public-private medical partnership with Weber State to produce medical personnel toperform radiology procedures in the field. When Department of Defense funding subsequently dried up, military officials bid adieu and left school officials scrambling to fill their newly minted slots. The RPA program owed its survival during this shaky start-up to the rising demand for midlevel civilian professionals. Today, many observers fully credit Weber State as the nation’s pioneering force of the midlevel radiology practitioner model and praise Van Valkenburg for her drive and vision. If a case needs to be made for the RPA’s efficacy, ask the radiologists who benefit from their skills. “Quite frankly,” says Robert Hannon, MD, chief of radiology at Holy Family Hospital in suburban Boston, “we are doing better medicine since we got our RPAs on board. Wetreasure them. We respect them. We are very pleased with the program at Weber State.” A “Great Bridge”He continues: “Our department does a lot of heavy-hitting neurosurgical and complicated interventional radiology. We were looking for someone other than a radiologist to help us do it better. We have oneRPA—Terry Licciardi—who graduated from Weber State in June. He’s doing a variety of interventional procedures. He’s terrific. Our RPAs give patients the TLC they need. It’s a good deal for the patients, the hospital, and the RPAs.” Richard Friedman, MD, concurs. “RPAs have been a godsend in radiology,” says Friedman, a partner with Northwest Imaging. “I think many hospitals are hesitant to use them, as I was when I first arrivedhere. I thought, ‘Man, I’m not comfortable with that idea.’ But our RPA —James Abraham—has been a critical intermediary. RPAs are a great bridge on the technical end. “They’re really clinician assistants. It’s a major advantage to any practice and the care is better. Nurse practitioners and physician assistants are available, but we favor RPAs because of their radiology experience and clinical skills.”Noting nurse practitioners and physician assistants who work within theradiologic domain, Jeff Choffel, RPA, RT(R), RVT, RDMS, says, “I’m a certified radiologic technologist with 16 years of specialized training
and certification in radiologic technology, medical diagnostic ultrasonography, vascular sonographic technology, and [have] anadditional two years of advanced radiologic technology at Weber State University, with certification as a radiology practitioner assistant.” Pausing for effect, he asks, “Who would you like performing your procedures?” What does the future hold? On the actual legislation starting to trickleout of state houses, Monroe isn’t certain—but he is generally optimistic.“No matter what,” he says, “midlevel providers in radiology are here to stay. There’s a place for both RPA and RA in the profession.” The American College of Radiology (ACR) and the American Society of Radiologic Technologists (ASRT) collaborated in developing the RA program; the backing of organized radiology will likely impact expansion efforts. Midlevel FutureMonroe does acknowledge a bumpy road ahead—and not a few ironies. While a midlevel professional who can improve patient care, dampen costs, and create exciting new synergies would seem a no-brainer to state legislators, the reality finds the RPA movement meeting sharpopposition at every turn. “We’re currently trying to make the RPA legal in Washington State,” he says. “Come July when I graduate, I may not have a job here.” Nearby Montana presents its own challenges, says Abraham. In the Big Sky state, he says, RTs find themselves with a comparatively narrowscope of practice. Abraham says getting needed RPA legislation through dozens of state houses presents a formidable challenge, but he remainshopeful. “Montana state lawmakers recognize RPAs,” he says, “but they haven’t yet defined our scope of practice.”Commenting on the legislative front in Washington State, Choffel notes that the state Department of Health has already issued an “interpretive statement” forbidding RPAs from practicing under existing RT licensure. In response, Choffel and his group at Skagit Radiologyqueried radiology practices across the state to better gauge demand forradiology-trained midlevel practitioners. An overwhelming response in the affirmative prompted Choffel’s group to draft legislation thatproposes allowing RTs with advanced training to practice under ACR-ASRT guidelines. The RPA and RA scopes of practice are similar, withthe big exception being that the RA model specifically excludes image interpretation from the RA’s scope of practice.While Choffel presses ahead with lobbying, he coolly predicts a “much
more limited scope of practice” in licensing states and the linkage ofRPA and RA credentials. “If I went to a nonlicensing state or to one that passed legislation approving advanced training in radiologic technology,” he says, “I could practice as I was trained—as an RPA.” If the stumbling blocks look insurmountable, Choffel sounds an optimistic note. “All the radiology groups around Washington want to hire midlevels, so we’re hopeful. My group is comfortable with me working in the scope I was trained.” The vision embraced by manyRPAs would find individual radiologists setting scopes of practice based on individual competencies. Practice ScopeNoting the comparatively broader scope of practice of the RPA vs. RA, Choffel says, “I honestly believe the two positions are going to meld. There’s too much competition in radiology to keep splitting the field. It’s really counterproductive. I think there’s going to have to be someevolving on both sides of the issue, however, with possibly a narrowing of the RPA scope of practice and a great widening of the RA scope of practice.” Weber State’s Van Valkenburg isn’t so sure and says the notion of a watered-down RPA doesn’t sit well with medical practices across the nation. Hannon agrees and closes with this parting thought: “…I’m trying totake care of sick patients. I’m short of radiologists and see opportunities for intelligent people with proper training to do a good job. Frankly, I’ve been thrilled with Weber State’s RPA program.” — Matthew Robb is a freelance writer based in suburbanWashington, D.C. He is a frequent contributor to Radiology Today. Subscribe to Radiology Today Magazine!