Learning from experience

Before undertaking my doctoral research, I had designed the Hybrid Imaging module at my University with perhaps too much focus on the scientific parameters and not enough on the practical / fundamental aspects of hybrid imaging.  I was initially concerned that the Masters level education attached with the module required a particular specification; however there should have been greater focus around communication skills and support for patients, workflow management and the basic principles of CT and image fusion. 

Nuclear medicine departments are now being positioned at the centre of patient services, such as cardiology etc, which is beginning to further foster relationships with staff and creating new working relationships and sharing of the patient experience.   This is removing the need for a ‘hidden organisation’ as nuclear medicine / hybrid imaging roles are being recognised and there is sense of identity, professional pride etc.

There is however still a lot of work to be done, to 'shake off' the traditional traits of the nuclear medicine community and there is a need to embrace other professions into the hybrid imaging environment, encourage flat collaboration and rise to the challenge of being evidence based professionals, who use technology to aid their role development and expertise.  

Artificial intelligence in hybrid imaging: Enabling or restricting the workforce?

The nuclear medicine environment is now undoubtedly considered to be a truly digital imaging community.  A community whereby technology exists and practitioners are integral to ensuring image optimization / acquisition, accurate processing / quantification and in the case of hybrid imaging, using the dual modality approach to further enhance the patient's diagnosis.

The pace of introducing intuitive software platforms within nuclear medicine is something which needs to be carefully considered.  This is especially the case for hybrid imaging practice, where a 'push and pull of data' culture has begun to evolve.  The hybrid imaging practitioner faces a number of challenges in terms of ensuring their role definition, development and deployment is recognized and central to the patient's journey.  Creating an environment that embraces technology, but does not allow it to control the role is a crucial element of future workforce training and there needs to be an understanding that multiple pressures exist and may impact on the creation of 'domain ownership' by the nuclear medicine workforce.  The figure below outlines the necessary pathway that needs to be undertaken by practitioners as they emerge as a new sub-society within the nuclear medicine fraternity. 

Copyright Marc Griffiths 2013



My previous blogs have explored the notion of creating a clear pathway of training and education for the nuclear medicine practitioner working within a hybrid imaging environment.  Unless there is a clearly defined role, working in a patient centric approach, technology will dominate the delivery of services.  The use of systems workflows and seamless integration of various aspects of the nuclear medicine examination can be viewed as enabling the workforce, however there is also limited potential for 'flat collaboration' as previously discussed by Fridell (2009) and cultural lag, as practitioners fail to understand how technology can be embraced and used to enhance service delivery. 

Overcoming the theory / practice gap

During my research it has become apparent that a gap between theory and practice exists.  This is linked with the need to understand / define the various roles within the hybrid imaging workforce.  Creating an environment whereby a system of work exists permitting the effective use of CT during hybrid imaging examinations is paramount.  This is only one of the integral aspects of working practices within a hybrid imaging environment, however it is crucial to the overall service delivery. 

The image below depicts the range of potential autonomy associated with using CT in a hybrid imaging environment.  There is the consideration of system / software specifications, but one of the most fundamental questions that does not seem to factor during the procurement / installation and subsequent use of a hybrid imaging system is 'how will you use it?'. 

It is pointless having a 64 slice CT unit attached to a gamma camera if all you intend to do is attenuation correction +/- localisation.  Will you use contrast agent? Will you need to specialist software which looks good, but actually it is not required.  Having the appropriate underpinning knowledge and understanding of hybrid imaging practice will always be linked to the relevant theory and principles.   

 

A committed hybrid imaging workforce should be able to flex and adapt as required, exploring new potential patient pathways and establishing their position within inter-disciplinary teams.  This is easier said than done, however we need to think about our community, the 'nuclear medicine fraternity' (image below).  There needs to be an understanding that a new workforce is emerging, those practitioner that do not have a tradition in non-hybrid practice.  This has merits in the form of a greater appreciation of anatomical imaging etc, however how does the nuclear medicine fraternity balance the development needs of the traditional workforce with the emerging workforce?  This equation does not even include the new trainees who may witness / be influenced by the sub-communities within nuclear medicine. 

Becker (1961) explored the notion that our social and technical order now requires us to deliver more and more (patient) services within the environment we work.  The effective delivery of these patient services depends upon esoteric knowledge and skills and it is crucial that trust exists between all practitioners, regardless of the sub-community belonging.     

Knowledge rather than reliance on policies

Despite having an apparent abundance of policies and procedures at their fingertips and visible within the clinical imaging environment, nuclear medicine practitioners often appeared to ask their colleagues for advice or feedback.  This was most noticeable in situations where experienced nuclear medicine practitioners would be approached by staff who were not as familiar with hybrid imaging techniques or technical aspects (e.g. Quality Control checks) and were asking for help / guidance.  Although there was access to a range of policies and other useful documents, the practitioners generally preferred to ask their colleagues and learn from the experience.  This often involved citing previous experiences and / or bringing up example studies to demonstrate particular aspects of image acquisition or processing etc. 

The documents pertaining to hybrid imaging practice were being produced by a mixture of professional disciplines, including hybrid imaging practitioners and clinical scientists.  There also appeared to be a notion of health competition between the professional disciplines in terms of who could produce the most documentation / policies in some incidences.  Why was this the case? This behaviour appeared very 'tribal' in nature, almost mirroring graffiti street tags and highlighting a claim on the technology that was being used. 

Issues however may arise when protocols change or new imaging pathways are introduced.  How is this information disseminated through the hybrid imaging community? This also leads to a potential lack of evidence based knowledge development and practitioners not being able to develop enquiry based learning approaches within the workplace.

Creating a sense of professional belonging and value

Understanding the needs of the hybrid nuclear medicine practitioner, in terms of their need for on-going training, knowledge, skills enhancement and optimisation of technology has been integral to my doctoral research.  However, recently I have begun to understand the additional need to ensure practitioners and patients are included in the creation / development of new treatment pathways. 

Has technology begun to remove the personal nature / approach within nuclear medicine?  Creating physical barriers in the form of control rooms (image below), intercoms, cctv and an array of computer workstations potentially retracts the practitioner from the patient and how is autonomous practice / decision making take place?

 

 

There is a need to ensure the hybrid workforce understand the new clinical environments they find themselves in and value themselves as a profession.  Also, how do you fit the humanistic aspects of work into a technologically focused environment?  For example, hybrid nuclear medicine practitioners are seeing patients earlier in the cancer treatment cycle and this requires a greater understanding of where that patient is in terms of the support required, which aspect of the Kubler Ross cycle are they currently in and how can the practitioner ensure they obtain information in the form of functional and anatomical information coupled with appropriate patient preparation.

 

 

These themes have begun to arise from my research and allowed me to have greater insight into the complex emerging culture within hybrid imaging.  

Hybrid Practitioner toolkit

It's becoming apparent that a number of nuclear medicine departments are being involved in new patient pathways, as a result of introducing hybrid imaging technology.  Creating a 'practitioner toolkit' enabling the identification of new skills and competencies is essential to future service provision.

There is also a need to include aspects such as research, innovation, mentorship and service improvement within the toolkit as well as being appreciative of the learning requirements of the assistant workforce. 

The toolkit could be developed and aimed at the entire nuclear medicine workforce who are involved specifically in hybrid imaging.  For example, the assistant workforce (titled 'Assistant Practitioners' in the UK) could develop a range of skills and experiences around delivering an effective clinical service, whether this relates to basic counselling  for patients, to undertaking CT based examinations under written protocols and being involved in audits.  The practitioner level is an interesting perspective and would in most cases be specific for each clinical environment, however there is again scope for role development in terms of involvement with multidisciplinary teams, creation of imaging protocols, creation of evidence based practice approaches, processing and reporting.  The scope for the advanced / consultant practitioner also includes aspects such as influencing new income streams / referral streams for emerging patient pathways, clinical research / trials and beyond. 

Undoubtedly there will be competition for 'professional ownership' the relevant skills and knowledge with the hybrid imaging environment and it will be important that nuclear medicine practitioners are not too possessive over traditional roles, but focus on new / emerging roles that will further enhance the profession.