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August 8, 2005

Steering Clear — Navigating Radiology’s Legal and Ethical Minefields
By Amy Sietsma
Radiology Today
Vol. 6 No. 16 P. 22

The care radiologic technologists are expected to provide is changing more than many technologists think. Ongoing education is the key to keeping up.

The American Registry of Radiologic Technologist (ARRT) Standards of Ethics are the technologists’ version of the Hippocratic oath, says Becky Britt, MSRS, RT(R), an assistant professor at Northwestern State University.

The ARRT standards, which were updated and published anew in 2004, dictate the model of ethical behavior. The standards are available at www.arrt.org.

Since Hippocrates, medical ethics has been a critical part of the life of healthcare professionals. The modern world adds legal requirements to ethical standards in healthcare. The intertwined topics were part of the curriculum at the American Society of Radiologic Technologists (ASRT)/Association of Educators in Radiological Sciences, Inc. (AERS) 2005 Annual Conference held June 4 to 7 in Orlando, Fla.

“They [technologists] protect themselves from litigation and if they’re performing the basic standards then they are doing a service to their patients,” Britt says. “But, hopefully, they are going above and beyond the standards because the standards are just a guideline—a basic premise that we have to uphold.”

Ann Obergfell, JD, RT(R), dean of health sciences at St. Catharine College, agrees. “Practice and ethics standards are imperative,” she says, “because technologists are required to respond to questions from physicians and other healthcare providers and therefore must know and understand the practice and ethical parameters under which they are obligated to follow.”

Obergfell and Britt both spoke on legal and ethical issues facing technologists at the ASRT/AERS conference.

An Ethical Education
Adhering to standards protects the patient, the practitioner, the facility, and the industry. According to the U.S. Department of Labor 2004-2005 Occupational Outlook Handbook, there are more than 174,000 practicing technologists in the United States. With that many people in an expanding, changing field, mistakes happen.

“As the practice changes, many technologists are not upgrading their education and are ‘jumping’ into areas of practice for which they are not qualified educationally or experientially,” says Obergfell. “The complexity of the practice and the litigiousness of society indicates that the ‘see one, do one’ theory of the past is not a good plan for medical imaging.”

One way the ARRT is working to combat mistakes is through certification that requires all registered technologists to uphold the published code of ethics in addition to proving that they are qualified to practice.

“The practice standards describe the assessment process that technologists should go through for every procedure. Patient assessment is critical to procedure...” says Obergfell.

Are certification and licensure enough to ensure that technologists know the ethical standards? The likely answer is “maybe.” In 2004, 591 radiography programs were accredited by the Joint Review Committee on Education in Radiologic Technology. The programs vary widely—some certification programs can be completed in one year while others require up to four years for a bachelor’s degree. Two-year associate degree programs are the most common. With such a broad range of educational requirements, courses on ethics are not guaranteed for all technologists.

“…I believe there should be a course on ethics and the law in every educational program,” says Obergfell. “But it should not be limited to that course; it should be incorporated in every portion of the curriculum. When teaching procedures, the educator should encourage the students to follow the standards as they work through the development of procedural skills. When teaching exposures or image production, they should look at the quality performance standards for guidance. When teaching patient care and assessment, the Standards and the Code of Ethics can be used as guidelines. The professional performance standards should be used in every educational program as a baseline for personal development as a professional and a human being.”

Radiologic technology is evolving and as it changes so do the ethical and legal concerns. Because of that change, Britt advises that a law and ethics course, whether it’s someone’s first or a refresher, is always a good idea.

Rapid Growth
Diagnostic imaging’s rapid growth requires quality standards to make sure it is safe growth. In his testimony before the U.S. House of Representatives Committee on Ways and Means Subcommittee on Health, this past March, Mark E. Miller, PhD, executive director of the Medicare Payment Advisory Commission, noted that diagnostic imaging was the fastest growing physician service for Medicare patients between 1999 and 2003: growing from $5.7 billion in 1999 to $9.3 billion in 2003. Such an increase in imaging spending and volume opens the door to a growing number of lawsuits as well. While technologists are unlikely targets, it still makes sense for technologists to protect themselves.

“Documentation is a key component of the practice standards and is probably the most abused area of medical imaging practice,” Obergfell says. “Technologists need to make notes on procedures and these notes should not be destroyed following interpretation. Many assessment notes that technologists write are valuable to the patient and may be evidence if the procedure is ever called into question. Why we elect to destroy a medical or business record is beyond me, yet it happens daily in medical imaging departments across the country.”

“I’ve never seen or heard of someone suing [a technologist] because they’ve gotten the wrong exam or something like that, but it is not to say that it couldn’t happen,” says Britt.

So how can technologists protect themselves? Britt suggests two key points: Know their ethical responsibilities and make the job patient-centered.

“…The most common mistake technologists make is not tending to their patients’ basic needs…” says Britt. “So, I think sometimes we just get in such a routine of trying to hurry up and get our patients in and out that we forget what their basic needs are and what our basic responsibilities are to them.”

As Britt points out, ignorance of the standards and responsibilities, regardless of the cause, does not absolve the technologist of responsibility. She says, “…If they [technologists] don’t already know what their responsibilities are, [then they should] pull a book and find out.”

“The biggest mistake technologists make,” says Obergfell, “is falling into the trap of ‘that’s the way we always did it.’ Our practice is changing dramatically and we need to keep up—which means we need to be lifelong learners. What you learned in school may not be valid, but the underlying principles should always be followed.”

According to Britt, one of the most frequent and avoidable mistakes technologists make is not assisting a patient onto the exam table, which can result in falls, and in some cases, serious injury. She advises technologists to always be aware that the patient may have a condition the technologist is unaware of that can make getting on the table a potential hazard. By focusing on patient care, technologists can avoid patient falls and minimize risk of litigation.

On the Frontlines
In response to the increasing number of lawsuits and through quality assurance efforts, payors have improved risk assessment efforts. A study conducted by Blue Cross and Blue Shield of Massachusetts, published in Radiology and presented by Miller in his testimony, surveyed 1,000 imaging providers to evaluate the quality of their equipment, staff, and other aspects of care.

The study found that approximately one-third had at least one serious deficiency, 11% had severe deficiencies that were not easily remedied, and 20% had easily remedied deficiencies. A second insurer study, published in the American Journal of Roentgenology, reported that 78% of approximately 100 nonradiologist offices that provided imaging services demonstrated serious deficiencies.

The numbers suggest that the opportunity exists for technologists to be drawn into legal disputes. Legal issues will likely prove even more important to technologists who expand their careers as midlevel radiology practitioner assistants or radiology assistants.

Changing Practice
“Technologists are next,” says Obergfell. “As their practice becomes more complex, they are going to be held to a higher standard and therefore under scrutiny by the legal system when an error occurs. Even though the practice is under the ‘supervision’ of a physician, they are still making independent judgments and will be held accountable.”

“…First and foremost, they [technologists] have got to be producing high quality radiographs because, if they don’t get subpoenaed to court, certainly their films will,” Britt says. “…If the films that the radiologists are reading are poor quality, then I think that it will filter down to the technologist, whether they think it will or not.”

Obergfell agrees, saying, “The standards also require technologists to recognize and understand image quality and image production. It is the role of the radiographer to analyze images and determine their diagnostic quality. A film should never come back from a radiologist requesting a repeat because the technologist should never send them one of nondiagnostic quality unless they have documented why the film is suboptimal and explained the reason.”

For most modalities, there are currently no set government imaging standards. States’ radiation control boards govern radiation-producing equipment, but the boards’ focus is primarily on patient safety, not image quality. According to Miller, the executive director of the Medicare Payment Advisory Commission, “Standards are not always comprehensive or rigorously enforced.”

Mammography is the obvious exception and does have a national standard. It should be noted, however, that fewer practices offer mammography services as more providers face mammography-related lawsuits.

In his Congressional testimony, Miller strongly urged the Centers for Medicare & Medicaid Services to set national standards for imaging equipment, technologist qualifications, supervising physicians’ qualifications and responsibilities, technical quality of images, patient safety procedures, and education, training, and experience of physicians who interpret radiologic studies. At least three of the proposed areas—qualifications for technologists, the technical quality of the images produced, and patient safety procedures—would have a direct effect on the way technologists are trained and how they do their jobs.

Keeping Current
“They [technologists] need to continue their education either through professional continuing education or actual academic study. If a technologist does not maintain currency in their discipline, they will quickly become obsolete,” says Obergfell. “From obsolescence comes error in practice and judgment. Ethical behavior must become part of the daily practice of medical imaging professionals. It shouldn’t be something you put on a shelf until you have an emergency. The technologist must live and breathe by the ethical standards of the profession.”

At one time or another, every technologist will face an ethical concern. While knowledge of responsibilities and standards may help a technologist avoid many risky situations, errors will still occur.

“If it is something they [the technologists] have done themselves, then, of course, the right thing to do would be to document it,” advises Britt.

“The technologist needs to take responsibility for their own actions. If it is something they have done, they need to report and be prepared to take the consequences,” says Obergfell.

The documentation process gives technologists the opportunity to tell their side of the story in a timely fashion in a nonthreatening environment. Quickly reporting errors also provides technologists and their supervisors the opportunity to correct the problem promptly, reducing the chance that it progresses to a legal matter.

The situation changes if the problem is one a technologist observes in a coworker rather than his or her own error. While it is always a delicate situation to approach a colleague with criticism, it must be done when there are ethical and legal concerns. In addition to the risk to the patient, the situation puts both the observer and facility at risk.

“If it is something someone else has done, they need to follow protocol in the facility if one is established,” says Obergfell. “If reporting a violation, the technologist should have the appropriate evidence … working on rumor and innuendo is never a good plan when the well-being of patients or someone’s professional livelihood is in question. Technologists should be familiar with the ARRT Standards of Ethics, which encompasses the Code of Ethics and the Rules of Ethics. They will aid the technologist in the decision-making process.

Proper Reporting
“The technologist can speak with the department administrative director or the facilities risk management person,” Obergfell adds. “If it is a state with licensure and the infraction is serious, technologists have an obligation to report the inappropriate practice for the well-being of the patients, the organization, and the profession. A technologist should also report their concerns after careful fact gathering to the ARRT for review.”

In the course of a day, technologists navigate a minefield of potential ethical and legal problems. While most can be easily avoided through education and awareness, the technological and legal landscapes change so quickly that even the most conscientious technologist can stumble. Quick reporting and documentation of incidents help, but technologists should never assume they are immune to potential lawsuits.

Like Boy Scouts, the best technologists can do is “Be Prepared.” By periodically taking a refresher course in law and ethics, often offered as a part of continuing education curricula, and by conducting themselves in a manner that is professional and ethical according to the ARRT standards, technologists can free themselves of most concerns and concentrate on doing what they do best—serving the needs of their patients with efficiency and compassion.

— Amy Sietsma is the assistant editor of Radiology Today.

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