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. 

Technology Determinism

The introduction of new technology within nuclear medicine appears to have shifted the traditional positioning of the nuclear medicine practitioner.  There is a need for careful consideration around the appropriate use of new technology, in order to aid patient diagnosis and potential subsequent monitoring of treatment response.

How does a workforce, which now works with hybrid imaging technology ensure they are able to control the daily workflow within the department?  Given the automated aspects of patient worklists and seemless connectivity associated with acquiring and processing data, the professional group need to ensure their involvement in the acquisition of clinical information is central to the patient's journey.  The use of technology needs to complement the role of the healthcare practitioner, rather than replace it.

Creating new identities

The introduction of hybrid imaging technology has undoubtedly begun to create a new society of members, who only have exposure to an environment whereby anatomical and functional imaging within a single environment is a possibility. 

With this notion in mind, there could be potential disengagement from members of the traditional nuclear medicine community as a new culture of roles, identities and relationships begin to emerge.  Symbolic interactionism is a means of understanding the emergence of new societies  or cultures within an organisation, along with the creation of new language, relics and behaviours. 

This is an important aspect of my research, as I need to understand the potential tensions and conflict within the nuclear medicine community as a whole, as the training needs of all practitioners needs to be considered, not just those who appear to be fully engaging with the technological changes.  So there is a collective need to consider the existing (traditional) nuclear medicine community members, who possess a wealth of experience in terms of undertaking physiological examinations and all of the associated factors (e.g. patient preparation, processing); the emerging workforce who typically would include practitioners who may have some experience with traditional nuclear medicine procedures but are more exposed to working practices involving hybrid techniques.  The final group of practitioners are those coming into the nuclear medicine environment for the first time.  This group of practitioners/ trainees may learn common behaviours from both of the aforementioned groups of practitioners, including the use of specific language, rituals and role development. 

Impact of hybrid imaging on patient management

The use of a hybrid imaging technique such as SPECT/CT or PET/CT may bring advantages to the overall patient management that may have not been initially forcasted.  From working alongside clinical nuclear medicine practitioners, there is a degree of 'incidental findings' that may occur within a hybrid imaging procedures.  Questions that immediately come to mind in this situation:

1) What are the ethics and clinical protocol/s associated with this sort of situation?
2) How are nuclear medicine practitioners trained to spot the incidental findings?
3) Can autonomous practice be adopted by practitioners, to enable them to fully utilise the diagnostic capabilities of hybrid imaging (e.g. Intravenous Contrast injection)?


There is also the matter of reporting the resultant images and ensuring the data sets acquired match highlight any additional information. 

Early adoption theory

I have begun to explore the role of 'technology ownership' within a community, such as nuclear medicine / hybrid imaging.  The introduction of new technology, such as hybrid imaging components and software has resulted in a potential shift in the ownership of such technology. 

Who actually owns this new technology and who are the early adopters? 

Early adoption theory (Rogers, 1971) highlights the percentage of people who readily accept new technology and those who 'lag'.  This is often referred to as 'cultural lag' and may demonstrate itself in varying degrees across the workforce and at a variable pace across different clinical environments

It's like being on an aeroplane!

This blog relates to comments made by practitioners working within hybrid imaging environments, liking them to being on an aeroplane.  Given the advent of hybrid imaging equipment, the footprint of most clinical imaging environments have increased, due mainly to the additional space required for the Y-axis travel of the patient handling system (couch) and cooling specifications for the CT unit. 

The noise generated by some SPECT/CT systems (air cooled) is loud and patients are forewarned before they enter the clinical imaging environment.  This is a positive action and patients are given a full explanation of the procedure before they are injected with the radioisotope and a recap is normally provided before entering the clinical room.  However, the frequency of working practice within the clinical SPECT/CT or PET/CT room by the hybrid practitioner has created a new mode of operation, in terms of the unspoken dialogue, using mnemonics, such as 'P-scope' to describe the persistence scope and phrases such as 'what's your clicks?' to highlight the individual dose level on the personal dosimeters in PET/CT. 

Other non-verbal communication modes are also beginning to shape given the advent of noisy hybrid imaging environments, such as the use of what can only be described as a form of sign language to initiate imaging procedures, or the use of the intercom by some practitioners to warn other practitioners to vacate the imaging environment, as a CT exam is about to commence.  This is in additional to the inclusion of bright lights and environmental monitoring systems in ceilings and pathways carved out in the corridors to inform radioactive patients which is their resting bay (images below). 


   



There is a need for practitioners to evolve their working practices within the hybrid environment so is does not become technocentric.  The imaging procedure needs to revolve around the patient, i.e. be patientcentric.

Additional accountability when using CT within a Hybrid Imaging Environment

Following some research research and discussions at conferences, the potential impact of using CT within a SPECT/CT examination inappropriately can be a concern for clinical departments. The additional record keeping associated with using a transmission imaging source and potential for detecting incidental findings (e.g. liver mets) is a possibility, even when using low dose CT and the spatial resolution isn't great. This presents an ethical dilemma with regards to the documenting of findings, as under IR(ME)R (2000) all examinations involving the use of ionsing radiation should have an associated report attached.

The use of assistive software, such as "guided SPECT" may offer practitioners greater confidence when setting up the acquisition parameters in a SPECT/CT examination. Familarisation with the SPECT cine may help practitioners, especially those with limited cross sectional anatomy knowledge to set the topogram appropraitely within the CT examination. This is a major consideration for areas where a specific field is required for the CT data set, purely to provide attenuation correction / localisation parameters.

New technology presents many advantages to both patients and practitioners, however appropriate training, familarisation and experience is essential for optimal operation.

I miss being able to talk to my patients...........

Many practitioners prefer not to use the intercom devices within the control rooms of hybrid imaging environments. This appears to go against the grain in terms of traditional nuclear medicine practice, whereby contact with patients is maintained (albeit at a distance) during the clinical procedure.  The advert of hybrid imaging has inevitably created a physical barrier, which protects the practitioner from X-ray scatter radiation produced during the CT aspect of the hybrid procedure. 

Conventionally, the majority of operations to control the actions of a gamma camera would have been conducted using a handset, either hardwired to the system (image below) or via a radio frequency / wifi mode.  Obviously the nuclear medicine practitoner needs to ensure they follow the practical domains of minimising time near a radioactive source, keeping a safe distance from a radioactive source and ensuring adequate shielding is in place to minimise dose and optimise image quality.  The is however a sense of a 'connection' between the patient and practitioner when using the handset, which creates in itself a environment of trust, role identity and autonomous practice. 

Given the advent of hybrid imaging environments, such as SPECT/CT and PET/CT, there is consideration for the safe use of the x-ray source, which is used to create the transmission date for the attenuation correction and anatomical detail (if appropriate) for the fused data sets.  The introduction of an x-ray source has re-shaped the traditional nuclear medicine environment, especially in terms of the creation of a physical barrier and the use of communication intercoms (image below), CCTV and increased automatic / remote position aids for examinations. 

Being able to remotely position aspects of a hybrid scan (especially in PET/CT) is reducing the visible contact with patients, which on one hand is positive from a minimisation of personal dose levels, however practitioners working within these emerging environments are having to remap their working practices, redefine clinical protocols and even redesign departments to accommodate aspects such as dedicated changing rooms for patients. 





Barley's Technology as an occasion for structuring

It's been a while since my last post, so I thought I'd link to something related to my professional doctorate. As part of the literature review section, I came across an article which referred to something called the 'Barley's Technology effect'. Barley wrote a seminal article in 1986 related to the installation and structuring of two CT units in two different imaging departments.

Of particular interest to Barley was the different outcomes for each of the imaging departments, despite having similar organisational structures. Undertaking s subsequent search for other primary based research studies, looking at the effect of introducing technology within the workplace, has resulted in finding a number of articles by Stephen Barley. All the work by Barley relates to understanding the interactions of people within cultures / organisations, following the introduction of technology and / or the symbolic influences within the workplace. Barley's work is cited in numerous research papers and provides a very useful platform for the critical evaluation of work within this field.

SUV calculations and decision making abilities

From my time in clinical PET, I've noticed a variation in the calculations of Standard Update Values (SUV) between different manufacturers software platforms. I'm not sure why this occurs and perhaps it could be down to the use of different calculation algorithms being utilised.

Practitioners, physicists and consultants need to be aware however of the potential for variations in SUV calculations between different manufacturers. It would be interesting to conduct a validated comparison project between different vendors software to assess the potential variations in calculations.  This also highlights to me the need of ensuring practitioners have a strong understanding of quantification within nuclear medicine and in particular hybrid practice.  Ensuring the skills, training and education frameworks are in place is integral to the future of effective / innovative service provision.

Service Redesign in Nuclear Medicine

Developing new services in Nuclear Medicine requires careful planning and the advent of hybrid imaging technology has begun to open new avenues for nuclear medicine practitioners.

It is crucial that the nuclear medicine workforce continues to engage and work with other professions, such as cardiology, oncology and neurology to further promote the clinical value of nuclear medicine and further develop a multiprofessional approach to the whole imaging / treatment landscape.

Trying to convince financial managers to invest in a hybrid imaging system, whether it is to replace your aging gamma camera or as an additional system can be very difficult. Some centres have used the argument that the hybrid system could be used to support radiology workload (e.g. CT heads) and even conduct examinations involving the use of contrast agents. Phrases such as "one stop shop" imaging have begun to emerge where nuclear medicine departments attempt to increase their profile and workload and even perhaps justifying their new imaging system.

Having a hybrid imaging system does provide improved confidence / accuracy for clinicians and new opportunities for the nuclear medicine workforce. However, careful consideration is required to ensure the service redesign places Nuclear Medicine at the heart of the clinical provision.

patient support skills for hybrid imaging practitioners

During a weeks clinical attachment at a regional PET/CT centre in England, I began to realise the patient support skills that are required by nuclear medicine practitioners who work in PET/CT and SPECT/CT. Being able to identify the emotional levels within a patient during the first few moments of contact is crucial.

All practitioners working within an oncology environment learn to adjust their working parameters with each individual patient who requires care and treatment. Equipping nuclear medicine practitioners with patient support skills will ensure they fully appreciate and understand the patient's perspective / current state of mind and hopefully obtain optimal images. I have begun to explore the value of patient support training sessions for hybrid imaging practitioners and basic strategies that could be adopted.

We already use the Health Talk Online website within the programme of nuclear medicine education at the University of the West of England, Bristol and have begun including service users within certain modules. However, the inclusion of specific patient support sessions should further help nuclear medicine practitioners communicate with patients and provide a holistic clinical service.

Blending in Hybrid Imaging

Following some time at a clinical site recently, I noticed the knowledge and understanding required by practitioners in order to create fused image data sets in SPECT/CT and PET/CT. Having the correct amount of CT and PET or SPECT data can really highlight the presence of disease.

Image reviewing can be a subjective aspect of nuclear medicine and knowing how much "blending" is required comes from experience and an understanding of the modalities. This is particularly an issue when selective data sets are sent to PACS for reviewing by consultants.

The advent of "floating" licences has made it slightly easier to view fused hybrid data sets on remote systems, where the user has full access to imaging blending tools.

Hybrid Imaging Education

Other countries around the world seem to have a really good handle on hybrid imaging education. There is limited provision in the United Kingdom specifically for practitioners working in a hybrid imaging environment.

As part of my professional doctorate, I hope to evaluate the cultural changes brought about by the introduction of new technologies (such as SPECT/CT & PET/CT) and how traditional working relationships are being "shaped". Future workforce considerations are also required, as this is clearly an emerging aspect of clinical practice.

Hybrid Imaging in Nuclear Medicine: Changing times

I've created this blog to connect with other nuclear medicine practitioners and in particular the cultural changes that some departments are facing as a result of the introduction of hybrid imaging equipment. Hybrid imaging equipment in nuclear medicine currently includes SPECT/CT and PET/CT, however other integrated systems are on the horizon, such as PET/MRI.

The evolution of the hybrid imaging system is beginning to herald a new dawn in terms of providing greater diagnostic accuracy, which is undoubtedly beneficial to the patient.  However the role of the practitioner working in such environments is also changing.  This relates to how nuclear medicine practitioners work within a different physical environment, the uniforms they wear (see image below), the use of new 'language' (e.g. CTDi, topogram), emerging relationships with their peers and beyond (e.g. MDTs).