While radiography got its start in the 19th century, the profession of radiography in more recent years has emerged into an ever expanding field of high technology. Radiography is a relatively new health profession that has developed expansively over recent years. Advances that have resulted from an augmented use of computer technology within healthcare and the technological advancements achieved in medical equipment has caused the profession to experience growth that outweighs the recruitment of such professionals. From small beginnings and a lack of formalised training or specialisation the profession of radiography has grown in training, specialisation and responsibility. This profession is at the cutting edge of scientific development, as these professionals continue to work with and specialise in the latest technologies within medical care. Career opportunities for qualified radiographers are abundant now and will continue to be so in the future as demands of the skills for these healthcare professionals escalate and the fields of specialisations and subspecialisations increase. This article reviews the development of the profession of radiography from its history to what it is today, and provides a glimpse into the future of this exciting and indispensable profession.
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In 1895, Wilhelm Roentgen discovered X-rays. The then unknown rays (hence the X) were soon used in various applications, industrially and medically. X-rays were introduced for diagnostic purposes right from the start. One month after the discovery, Europe and the United States managed to generate several medical radiographs which were then used to guide surgeons in their work. Only 6 months after Roentgen’s announcement of his discovery, X-rays were applied by battlefield physicians to trace bullets in wounded soldiers. It took several years to develop the specialist fields of radiography within medicine based on the discovered technology and as the profession is known today.
In over a century since the discovery of X-rays, radiography has metamorphosed from a scientific interest to an important part of medicine. Coinciding with radiography’s metamorphosis was a significant transformation in the responsibilities of the operators of the radiographic equipment. The following is a summary account of the history of the profession of radiography – how it started, how it became a profession, and its developments right up to a decade ago.
Shortly after Roentgen’s discovery, there were many commercial uses for the X-ray that were devised, some true and some counterfeit, in an attempt to take advantage of the public’s curiosity in the new technology. Professional photographers were some of the first to purchase and implement X-ray equipment because radiography at the time was categorised as a type of photography (Dewing, 1962).
By the 1900s, most medical x-ray equipment was owned and operated by independent businessmen, including chemists, engineers and electricians. Medical practitioners would refer patients to these X-ray operators for diagnosis and treatment purposes.
As the needs arose and X-ray treatment and diagnosis became more established towards the 1910s, a number of medical doctors began to purchase their own X-ray machines to install in their medical offices. Some of the doctors were even trained to specialise as radiologists. Although physicians operated the X-ray equipment themselves at the beginning, advances in equipment and technique, quickly exceeded their ability to keep up and they found that more of their time was consumed by the mechanics of the x-ray machine, leaving less time for patient care.
These doctors soon recognised that they needed help with handling the set-up and operation of the X-ray equipment so that they could concentrate on treating their patients. Receptionists and secretaries with no medical training were soon handed this task of operating the machine and developing the film (Bell, 1948). Hospitals, clinics and small practises subsequently began employing their nurses as X-ray technicians, as nurses had some medical background and training.
These initial technicians were expected not only to operate the X-ray equipment, but also to perform routine machine maintenance (Allen, 1951). These technicians operated X-ray equipment before the hazards of ionizing radiation were recognised and consequently endured great personal health expenses – including loss of limbs and even death. Positioning and exposure techniques were achieved by instinctive methods by these emerging technicians (Pengelly, 1954) Nonetheless these instinctive methods applied by these technicians yielded outstanding radiographic images. Lack of procedural documentation prevented these techniques and successes to be duplicated by others that would follow.
There was no attention given to the lack of training or specialisation of X-ray technicians, until the 1920s and by the 1950s formal education and standardised curriculum were brought into play. X-ray technicians were referred to as “radiologic technologists” for a stronger accent on professionalism. A rapid progression of new technology caused a severe shortage of radiologic technologists in the late 1960s and early 1970s. Techniques such as computed tomography, mammography and sonography that were specialist knowledge were becoming commonplace, and there was great demand for qualified personnel.
In the 1990s due to increasing demands on radiologists (Swinburn,1971) alternative ways of delivering radiology services were sought, and the role of radiographers was re-examined.8 This was followed by new roles for radiographers which started to emerge in a wide range of clinical areas in an effort to improve patient care and management.
As the profession of radiography graduated in roles and responsibilities it developed into a medical science that combined technology and caring. Radiographers were soon expected to apply their knowledge to assist in the diagnosis and treatment of patients. The skills of the profession included excellent interpersonal skills; a caring nature and interest in the well-being of others; computer and technical competence; strong problem-solving skills; strong sense of responsibility and team working skills. Technological advancements forced specialisation and radiographers were soon acclaimed as paramedical professionals registered in specialised fields including the following:
Radiography: specialisation in the use of radiographic, radiation therapy and magnetic resonance equipment to administer radiation treatment and produce images of body structures for the diagnosis and treatment of injury and disease.
Computerised Axial Tomography (CT): specialisation in the use of a rotating X-ray beam to scan within a narrow cross section of the body.
Magnetic Resonance Imaging (MRI): specialisation in the use of magnetism, radio waves and computers to acquire medical images.
Nuclear Medicine: is the specialisation in the application of radioactive materials to the diagnosis and management of disease. It is primarily a diagnostic specialty.
Positron Emission Tomography (PET): specialisation in the operation of emission tomography equipment that is used for measuring the concentrations of positron-emitting radioisotopes within the tissue of living subjects.
Diagnostic Medical Sonography: specialisation in the operation of ultrasound equipment to produce and record images of various parts of the body to produce an interpretive report to aid physicians in diagnosing cardiac, obstetric or gynaecological, abdominal, vascular, ophthalmic and other disease states.
The Profession of Radiography at Present
Radiographers today play a pivotal role in the diagnosis of disease, and are responsible for the examination of patients using radiation, ultrasound or magnetic fields. The following is a summary of examples of the work that is involved within this vast field:
Radiography involves interventional procedures such as the removal of kidney stones and the insertion of stents to widen blood vessels.
Sometimes two or more image projections need to be decided on and taken to form a third dimension from two-dimensional X-ray images.
Radiographers also use images to show subtle pathological changes and changes in function of organs.
Radiographers use a range of radiopaque ‘dyes’ or contrast agents to demonstrate soft tissue organs such as the arteries (angiogram), bowel (barium studies) and kidneys (Intra-Venous Urogram) that are not visible on standard x-ray examination. Modern developments in imaging technology, such as ultrasound, MRI and other specialised imaging techniques have resulted in radiographers extending their knowledge and skills that esoteric and specialised.
MRI specialists produce images in multiple planes and without the use of harmful ionising radiation. They image the central nervous system, joints for sports injuries, etc.
Ultrasound specialists produce images in real-time and examine fetal development and measure blood flow and associated pathologies.
CT specialists image cross-sections of the body and use the computer enhanced image to detect very small differences in attenuation not possible with conventional radiography.
Nuclear medical radiographers use Radio Nuclide Imaging to emit gamma rays as they decay and label pharmaceuticals which will go to the organs to be imaged. For example in the early detection of bone tumours, characterising the function of certain organs like the heart and the kidneys.
The role of the radiographer within patient care has evolved dramatically. Radiographers are trained and expected by healthcare systems to provide quality patient care. Radiographers deal with patients of all ages, from the very young patients to the elderly patients as well as patients with special needs such as visual or hearing impairment. They also examine patients with a variety of conditions, such as patients with a range of injuries or those who are terminally ill. They help prepare patients for radiographic examinations which include explaining the procedure, removing articles such as jewellery and watches that impede X-ray penetration, and position patients to ensure that the relevant parts of the body are correctly imaged or treated. They are required to correctly position the equipment used to diagnose or treat patients with radiography and ensure that the correct angle and height are achieved relative to the relevant area of the patient’s body. They need to apply their knowledge and skills to instruments with which the cross-sectional thickness of the part to be radiographed are measured and be able to set controls on radiography machines to produce radiographs of the required density, detail, and contrast. They develop images. These techniques of radiography are coupled with the ability to demonstrate compassion to patients as they are subjected to diagnostic procedures and to ensure that the mental and physical comfort of the patient is always considered. Patients require the radiographer to perform a prompt assessment of their needs, both emotional and physical. A radiographer’s work extends beyond the confines of the imaging department. Patients may become too ill to travel and a home visit may be required. At the start of their career radiographers spend a large amount of their time working in the accident and emergency department dealing with injured patients and liaising with other clinical colleagues within the hospital. Trips to the operating theatre to offer radiographic advice and assistance during the repair of broken bones are part and parcel of their tasks at this stage. Radiographers are mostly obligated to follow physicians’ orders precisely and abide by regulations concerning use of radiation (Maryland Health Careers).
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Problem-solving and critical-thinking skills are a requirement for radiographers who perform medical imaging procedures by applying technical parameters that are dependent upon the procedures used to diagnose or treat the patient’s condition. The responsibilities of radiographers today include the application of physiology, anatomy, various radiographic techniques such as positioning, radiation science and radiation protection. Good communication skills are required to ensure effective communication with patients, healthcare experts and staff, and the public. The radiographers of today are required to conduct themselves with competence and with compassion when dealing with patients and patient care. Radiographers are also required to manage patient records and manage the maintenance of the equipment used in radiology. Their tasks may also be to prepare work schedules and evaluate equipment purchases. The profession also extends to the evaluation of equipment used in radiology, performance of quality assurance programmes for radiography, education of patients and the management of a radiography department or a division of a department.
Radiation safety has become widespread and includes activities such as developing appropriate monitoring instruments, physical controls, administrative procedures, monitoring radiation areas, personnel monitoring, and radioactive waste disposal. Radiographers now concern themselves more than ever with the control of radiation contact to patients, themselves, and others. Devices such as lead shields around the exposed area are used by radiographers to prevent unnecessary radiation exposure.
As for technological advancements within the profession, image quality is just an example. The images that are generated today are of higher quality and greater resolution through the use of high quality films with a larger variety of film grain sizes. More consistent film quality is produced because of advancements in film developments and by making processes more automated. Images are captured digitally through electronics and computers. Film-less radiography enables the capturing of an image, digitally enhancing the image, sending the image anywhere in the world, and archiving an image that will not spoil with time. Smaller, lighter, and very portable equipment that produce high quality X-rays have been managed by technological advancements. Generating extremely short wavelength, highly penetrating radiation, is possible now with linear accelerators.
Career developments within radiography are constantly taking place. More and more opportunities now exists for post-graduate qualifications, equipping radiographers to report on the images produced, deliver intravenous injections and conduct barium enema examinations. Other postgraduate courses offer lines of specialisation and subspecialisation (for e.g. MRI, ultrasound and nuclear medicine). Career opportunities in the private and general health sectors are both available for radiographers. Senior radiographers can also be involved in being accountable for capital and revenue expenditure and human resource management. Teaching and research are also career avenues and manufacturers employ radiographers as application specialists. Learners training in this profession may specialise in an aspect of radiography or follow careers in education, research, consultation, or administration within radiography. The extensive growth extensive growth in this profession has resulted in many new career opportunities. The profession now includes many choices and decisions.
Be it the production of x-ray images to identify bone fracture or the administration of radiation therapy in cancer treatment, etc. radiographers today affords patients with the care they need in the diagnosis, treatment, and cure of their conditions.
The Future of Radiography
Computers are gradually becoming a part of radiographic inspection even if the basis of the methods and techniques of radiography that were developed over a century ago remain in use. More and more radiography is performed without the use of film and this will continue to change.
Radiographers will be required in the future to capture images in digitised form and e-mailed them to physicians. The evaluation of film will likely be left to computers. A digitised image may be captured, fed into a computer and printed by the radiographer. Three-dimensional images will be simulated based on a scan, helping the radiographer correctly diagnose or treat the condition.
It may be possible to uncover a part layer by layer in order to evaluate the compositions or cross-sections in detail. Colour images, similar to computer generated ultrasonic C-scans, will make interpretation of indications increase reliability and reduce time spent.
Educational techniques and materials are due to be updated to accommodate technology. Computer aided design (CAD) will be used to simulate radiographic images and used to point and pick the relevant areas or cross-sections to inspect, to fine-tune the placement and orientation of the relevant area to acquire the proper part relationships, and adjust settings to achieve desired film exposure for the development or post processing of radiographic images. Computer simulation will allow students to work with and visualise real-time or almost real-time data and images and may become the primary educational tool for in the technical classroom.
Radiographers may in the future be required to be expert with the application and use of computer hardware and software in imaging. Fields of specialisation will also expand with the increased use of technology. Tomorrow’s professionals will be required to better understand the clinical context of examinations and procedures, interact more directly with patients, conduct imaging research and be truly expert in a sub-specialised field.
Conclusion
In conclusion, the discovery of radiography has impacted the medical profession in a significant way. Pioneer radiography technicians operated equipment with little education or training and sometimes at a cost to their health and life. From small beginnings of a role that was merely described as “machine operator” radiography has grown in leaps and bounds to the cutting edge profession it is today. This article has successfully reviewed the revolution within this profession. The future of radiography remains prominent and will undergo further changes, the most obvious being the computerisation of processes and analysis.
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