Radiographer reporting: origins, demise and revival of plain film reporting

Radiography (2001) 7, 105–117 doi:10.1053/radi.2001.0281, available online at http://www.idealibrary.com on

Radiographer reporting: origins, demise and revival of plain film reporting R. C. Price,

MSc, FCR

Head of Department, Department of Radiography, University of Hertfordshire, College Lane, Hatfield AL5 1HF, Herts, U.K. (Received 12 August 2000; revised 12 January 2001; second revision 13 March 2001; accepted 15 March 2001)

Key words: radiography; radiology; image interpretation; reporting; skill mix.

Important in a profession’s identity is the knowledge of past events and how they help shape the present. This article traces the socio-political aspects of one significant aspect of radiographic history, the origins, demise and revival of plain film reporting from the beginning of the 20th century to the beginning of the 21st century. Extensive use has been made of archive material at the Society of Radiographers, the British Institute of Radiology and the Wellcome Institute for the History of Medicine. Radiographer reporting was at the centre of an ongoing conflict with the medical profession in the formative years of radiography. In just over the 100 years of X-rays, two periods take prominence, the early part of the 20th century until 1925, and the 1990s. The year 1925 saw the culmination of the long-running dispute between radiographers and radiologists over the division of labour. The decision, forced upon the Society of Radiographers to change its articles of association, prevented its non-medical members from reporting, thus determining the occupational boundaries of radiography and the direction of radiographic practice for 70 years. In the last decade of the 20th century, matters came full circle with the re-emergence of radiographer reporting, although the process of re-appraisal had begun some 20 years earlier. However, the 1990s, with rapid advancement of technology, increase in work loads, financial imperatives within the National Health Service and the aspirations of radiographers together with the support of many radiologists, contributed to the re-emergence of radiographers in reporting. © 2001 The College of Radiographers

Origins The early history of radiographer reporting is the story of a conflict surrounding the development of radiology and radiography. Unique among the stories that have been told about the formative years of radiography is the work of Larkin [1, 2] which has stood alone in considering the interoccupational dispute largely based on the issue of who should report. At the end of the 19th and the beginning of the 20th century, the development of the new X-ray technology excited many individuals. Among the early experimenters were engineers and physicists, and the application of the new technology to medicine could be described as a ‘free for all’. Those known to have undertaken radiography included 1078–8174/01/070105+13 $35.00/0

dentists, hospital porters, medical practitioners, pharmacists and photographers [3]. A number of occupational groups began to emerge, which included the medical radiographers or radiologists (as they were later to become), and the lay or non-medical radiographers including the electrical engineers. All were eager to establish and define occupational boundaries that would secure their livelihood, prestige and status. The titles ‘radiographer’ and ‘radiologist’ were used interchangeably until the 1920s when the latter became associated with medical practitioners specializing in X-ray work. To avoid confusion in this paper, radiologist and radiographer are used in their modern connotation, except where their use would detract from the original intent. © 2001 The College of Radiographers

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Ownership of X-ray work The medical practitioners who adopted the X-ray technology were keen to establish radiology as a speciality in its own right. This was not to be a straightforward affair, and it was not just a matter of trying to restrict the work of the lay radiographer, but also of convincing the wider medical profession of the merits of radiology. By 1917, radiology was not given the respect that many radiologists considered it was due. Thurstan Holland [4] was complaining of the absence of radiology from the undergraduate medical curriculum, and in an address at Liverpool University stated: ‘There is a prevalent idea abroad that a radiologist is a mere photographer, and that any medical man can interpret radiographs. Never was there a greater mistake. The techniques of plate taking can be easily acquired by anyone; the more experienced one has become in the interpretation of radiographic findings the more conservative one becomes, and the more guarded in expressing dogmatic opinions.’ C. Thurstan Holland, BMJ 1917: 288

However, it was back in 1896 that the potential for the establishment of a new medical speciality was recognized. Hall Edwards [5] writing in The Lancet set out the ethical constraints: ‘We cannot see any objection to a medical man skilled in recent photography, devoting himself to the application of it in medical and surgical cases and announcing to medical men his intention of doing so through the ordinary channels. Of course we assume that he entirely dissociates himself from any treatment of the case and works only at the instance of the practitioner in attendance.’ J. Hall Edwards, Lancet 1896: 904

In 1903, the BMJ [7] was claiming medical ownership over reporting: ‘There is no reason for professional prejudices against the practice of radiology by lay-men, so long as they confine themselves to the mere mechanical act of producing a picture and abstain from assuming scientific knowledge of their bearing of their radiographs on diagnosis or prognosis.’ Anon, BMJ 1903: 831

This became the medical position but, in 1909, in the preface of their book ‘A Manual of Practical X-ray Work’, Drs Arthur and Muir [7] staked a claim on more than just the interpretation of radiographs: ‘Three things are necessary to give radiology that position of reliability in professional work which it is surely,

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. . . namely, good apparatus, intelligent and skilled use of such apparatus, and sound general medical training and experience to interpret and control the results so obtained. The two former conditions are possible enough to operators outside the medical profession; the third is of its nature impossible to such persons, and the three cannot be efficiently separated. For a non-professional operator to offer a medical opinion on a radiogram is sheer impertinence.’ D. Arthur and J. Muir, 1909: v–vi

It was not only the ‘non-professional’ operator who was a cause of concern for radiologists. Writing in the BMJ in 1909, a correspondent using the nom de plume ‘Radiologist’ [8] was unhappy with the position where his report and diagnosis was resented by some physicians and surgeons who looked upon the radiologist as some sort of superior bottle washer, and someone to supply a skiagram from which they would draw their own conclusions. ‘Radiologist’ considered that his expert knowledge in the interpretation of a skiagram was probably greater than that required to interpret the appearances seen by ‘opthalmoscopic examination of the fundus oculi’. Another correspondent in 1909 [9] using the nom de plume ‘X-rays’ was calling for a united front to be shown by all medical practitioners. He was troubled by the situation where medical practitioners were in the habit of sending their patients for X-ray examination to large chemists or instrument makers to have their ‘X-ray photographs made’ rather than sending them to medical men engaged by hospitals. The correspondent conceded that the lay X-ray workers were usually expert photographers who turned out triumphs of photographic art. He went on to declare that the art of the photograph was more important to the photographer than the information it contained, and there was a temptation to touch up prints. This he had witnessed more than once. The last occasion was that of a hip joint in which the roughened edges of osteoarthritis had been removed, giving the appearance of a normal joint. During the second decade of the 20th century, the negative attitude towards the lay radiographer producing the radiograph lessened but the pressure to prohibit interpretation increased. The British Medical Association (BMA) was alarmed that at the end of the First World War, there would be a large number of trained X-ray assistants looking to establish themselves, and referred the matter to its Medico-Political Committee. Their attitude can be gleaned from the following extract published in 1917 [10]:

Radiographer reporting: origins, demise and revival

‘While there is a mechanical side to radiography in which the lay assistant can be extremely useful to the medical radiographers it is highly undesirable that lay persons, however, skilled in this in technique, should be encouraged to set up by themselves and pose as experts in the interpretation of skiagrams. . . . At the present time the army employs a very large number of X-ray assistants; and many . . . have attained much skill in the taking and development of radiograms. A good many of them have acquired more self confidence in diagnosis than is good for them or for the general public. . . . The Committee recommended that the practice of medical radiography by lay persons, except under the direct instruction of medical practitioners, ought not to be encouraged.’ BMJ 1917 (suppl): 707

The report resulted in a number of letters, the most vehement of these was from ‘J.H.E.’ [12] who wrote: ‘I would go much further and would suggest that the practice of radiography by laymen be made a penal offence, and that laws be passed which will render it impossible for the practice of radiography to be carried out by other than skilled and trained medical experts.’ J.H.E., BMJ 1917: 706

Kempster [12] reported that a general hospital in London had appointed a layman to the position of radiographer (radiologist) and he had been doing the work for the past 3 years. Kempster’s view was that the use of X-rays be entrusted to none but specially trained registered medical practitioners. After the First World War, attempts to exclude the lay radiographer ceased. The BMA, however, was correct in the premise that there would be many people trained in techniques and with skills that had at one time been scarce. Larkin [2], when reviewing the course of events in 1983, summed up the position by commenting that the radiologist could no longer base his expertise on the actual physical craft of X-ray production. Whether there was a real change in attitude or merely a pragmatic approach to a new situation would be in the realms of speculation. However, Hernaman-Johnson [13], a leading radiologist who was active in setting out the differences between radiologists and radiographers, was most concerned about the latter setting themselves up as independent practitioners. His solution was three-fold: ‘To organize and educate the various classes of lay helpers. To see that their status, remuneration and prospects are such as to make them contented.

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To educate the public as to why such people are at one and the same invaluable as helpers, and extraordinary dangerous when they seek to practise independently.’ F. Hernaman-Johnson, Arch Radiol Electrother 1919: 186

Hernaman-Johnson did not offer any support to those radiologists who held that even the switches on their apparatus were sacred, and must not be touched by anyone but the initiate. He completed the paper by declaring: ‘We should welcome lay assistance, and seek to organize and guide it. It is too late in the day to make a mystery of taking plates but the interpretation is ours for ever.’ F. Hernaman-Johnson, Arch Radiol Electrother 1919: 187

Demise Hernaman-Johnson was true to his word and the process of seeking to control the practice of radiography began in earnest. Hernaman-Johnson was the secretary of the British Association of Radiology and Physiotherapy, and it was that association that approached the Institute of Electrical Engineers on the subject of controlling the work of lay radiographers. The outcome was the establishment of the Society of Radiographers with a Council, whose make-up was predetermined. It comprised five medical practitioners and seven electrical engineers to which were added six selected radiographers from the London area. One of the first tasks that the new Society set itself was to apply to the Board of Trade for incorporation to become a corporate body. The proposed articles were duly sent to the Board of Trade who in turn consulted other bodies including the General Medical Council (GMC). The GMC had no jurisdiction over radiographers but were concerned about medical practitioners receiving reports and diagnoses from non-medically qualified personnel. Their main concern was Article 23 [1], and their advice to the Board of Trade was that it should be changed if incorporation was to be granted. The Article, drawn up by HernamanJohnson, stated that patients could only be accepted by non-medical members for radiographic, radioscopic or therapeutic work under the direction of a medical practitioner. The GMC’s insistence was to insert two words, ‘and supervision’, so that radiographic work was not only under the direction of medical practitioners but under their supervision as well. Furthermore, the GMC

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requested that they be notified of any proposed changes to the Articles in the future. The amended article remained unclear with regard to reporting, but on its intent to restrict radiographic practice and the autonomy of radiographers it was quite clear. Despite the efforts at organizing the division of labour, the titles ‘radiologist’ and ‘radiographer’ continued to be used interchangeably, and the term ‘medical radiographer’ remained in use. The Society of Radiographers, however, due to its successful incorporation and, certainly, through its medical members had the ‘legitimacy’ to promote the difference between the medical and non-medical radiographer. In 1923, the Society issued a pamphlet that sought to end any confusion and the matter was reported in The Lancet [14]: ‘In order to put an end to the confusion with regards to the terms ‘radiographer’ and ‘radiologist’, it has now been generally agreed that the term ‘radiologist’ shall be applied to members of the medical profession who undertake radiographic diagnosis and treatment by means of X-rays and radium, while the term radiographer be applied to their trained non-medical assistants.’ Lancet 1923: 416

By this action, the Society had relegated the majority of its members to the status of assistants. If Article 23 left any doubt as to a radiographic role in reporting, the incoming President of the Society of Radiographers, Dr Stanley Melville, was determined to consolidate the medical position. Society minutes refer to Melville’s presidential address [15]: ‘Dr Melville asked the members, one and all to do their utmost to strengthen the Society, the interest of which he had so much at heart. He laid great stress on the importance that the radiographer should not in any way undertake the duties of a radiologist and so being discredited in the Society.’ Society of Radiographers (SoR), 1923

In the same year as Melville’s address, the activities of Mr E. J. Barber, MSR of Finsbury Park, London came to the attention of the Council [16]. Someone had taken exception to a letter that Barber had written setting out his fees and services offered. Mr Barber tried to appease the Society: ‘Dear Mr Secretary, I very much regret having transgressed the unwritten law in my letter of October last. I certainly do not wish to endanger the reputation of the Society in any way and I am writing to ask you if the following advertisement, if inserted in Ask’s Dental Magazine would be in order.

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Radiographs for profession only are taken by EWD Barber MSR, 7 Station Road, Finsbury Park, London, NW4. Tel Hornsey 2044. Particulars after the fees etc., may be obtained on application to Mr Barber. Yours faithfully Edw. J. Barber’

The offending letter setting out Mr Barber’s fees had been circulated to medical practitioners to advertise his services: ‘A finger, ten shillings and sixpence; arm, leg and head one side only, one guinea. Leg (femur)—£1. 11 shillings. Pelvis, chest, kidneys, bladder, hip joint—two guineas. Teeth one exposure—10/6d; complete upper or lower, one guinea. Barium meal complete, four guineas.’

The letter concluded with the following paragraph: ‘You will notice that these fees are as low as hospital charges but I offer more facilities than a hospital, for example, I deliver films accompanied by reports next day and also patients may make appointments to suit their own convenience.’

With the exception of the cost, Mr Barber offered a service that would be the envy of some practitioners today, so what was it about the letter that caused concern? On a copy of the offending letter that had come into the Society’s possession, someone had underlined the phrase ‘accompanied by reports next day’. Mr Barber’s letter was written on 3 January 1924. A week later, on the 10th, the Council of the Society considered a motion to the effect that if any member, other than a medical member, were to give a report or diagnosis on any radiographic examination, the member will be liable to dismissal from the Society [17]. The motion was not acceptable to the non-medical members, and it was left to a Mr Blake to propose an amendment to the effect that no member would provide a report except to a medical practitioner concerned with the case [18]. The amendment was a concession in that information would no longer be given to patients, but there was no intention to forego sending the findings of an examination to medical practitioners. On the other hand, Blake’s amendment was unacceptable to the medical members who considered that only a medical qualification gave competence to report. The amendment was not carried and the meeting was adjourned. However, the medical position was strengthened when a resolution was made by the Council in April [19]:

Radiographer reporting: origins, demise and revival

‘The membership of the Society of Radiographers does not imply that the member is in possession of the necessary medical knowledge or training for the giving of diagnostic reports and that the responsibility for the diagnosis must rest with the medical man in charge of the case.’ SoR, 1924

Following the stalemate on Blake’s amendment, the President received a letter from seven members of the Society. The members asked that a general meeting be called so that a motion could be put forward to the effect that no non-medically qualified member be permitted to accept patients for radiographic and radioscopic work, except under the direction or supervision of a qualified medical practitioner. Furthermore, neither should any nonmedical member make a report or diagnosis on any radiograph or screen examination. A breach would be deemed improper conduct and anyone found guilty of the charge would be dismissed from the Society. The general meeting was called for May but it became clear that insufficient members would support the motion, and one member thought that if a resolution was carried, many members would resign. Mr Campbell Swinton, one of the founder members of the Society, proposed an amendment that seemed to offer a solution to the radiologists’ problem. He proposed that it would not be a breach of the Society’s Articles for a member to report, provided that prior to the date of incorporation of the Society in 1920, the member was giving reports or diagnoses at the request of a qualified medical practitioner. In support of the amendment, there was a strong argument put forward that radiographers worked without radiologists and, in many parts of the country, where a radiologist only visited infrequently, patients would be put at risk. One member who spoke at the meeting said that he had 27 years experience of reporting; however, a radiologist member held the view that it was never intended for radiographers to report, for if that had been the case, provision would have been made in the syllabus and this was not so. The pressure on the radiographers was beginning to tell and one of the radiographer members of council, Mr Blackall, said that after much thought and reflection, the welfare of the Society as a whole must be considered before that of individuals, and it was an unwritten law recognized by the members of the Society that they should not give reports [20]. This must have been the same unwritten law mentioned by Mr Barber in

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his response to the Society when his practice was challenged. However, not all present were prepared to capitulate and the existence of the ‘unwritten law’ was disputed by Mr Blake, who informed Council that when he sought membership of the Society, he had submitted letters from doctors vouching his ability to report [21]. Blake’s view was that they were accepted by the Society and there was an expectation that radiographers would supply reports to those members of the medical profession who requested Xray examinations. Nothing would shake the radiologists’ belief that reports by non-medical practitioners were bringing the Society into disrepute, although there is no record within the Society minutes of any evidence brought forward to substantiate this position. The situation was further complicated by the Society’s dependency on the British Institute of Radiology for financial support. The Institute, dominated by radiologists, did not support reporting by radiographers, and as it nominated radiologists to the Society’s Council, it held a more than privileged position. It would have been surprising, therefore, if the Institute had adopted a stance other than trying to protect the medical position. Its view, made clear by one of its medical members, was that, ‘laymen had no right to report’ [2]. Notwithstanding the bitter opposition by the electrical engineers, Mr Blackall intimated that the Society as a whole had to think carefully about its long-term position [22]. Campbell-Swinton’s amendment was lost. The next meeting was in June and a position was reached that all could agree. A resolution [23] stated: ‘That no member (i.e. who is without the qualifications entitling him to practise in Great Britain and Ireland as a physician or surgeon) shall accept patients for radiographic, radioscopic, or therapeutic work except under the direction and supervision of a qualified medical practitioner, neither shall such member make any report or diagnosis on any radiograph or screen examination, and any breach of this regulation shall be deemed conduct unfitting the member guilty thereof to remain a member of the Society, provided that it shall be considered as acting contrary to the spirit of this rule for a member under special circumstances at the request of a medical practitioner in charge of the case and in the absence of a radiologist to describe to such medical practitioner the appearances seen in an X-ray examination to such an extent as may be necessary to assist in making a diagnosis.’ SoR, 1924

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There was a caveat to the resolution that stated: ‘this rule shall not apply to such existing members of the Society as have been employed in X-ray work for not less than 15 years, except so far as is covered by the rule as to working only under the direction and supervision of a qualified medical practitioner, the names of such members to be embodied in a schedule and entered on the minutes of the Society.’ SoR, 1924

It was agreed to forward the resolution to the Board of Trade for inclusion in the Articles of Association. The Board again consulted the GMC for advice. The GMC objected even to radiographers of 15 years proven experience giving reports. In due course, a general meeting of the Society was called for 15 September 1925. The situation was deadlocked and Dr Melville, the President, informed the members present that they would have to decide the future of the Society, and if the wishes of the GMC were not met, then the medical members would resign [24]. He also drew attention to the erroneous statement in a circular letter, which had been issued by one of the members, that the medical representatives had applied to the GMC for assistance. The President invited members to address the meeting. Mr Blake, a long time advocate of radiographer reporting, questioned the legality of the meeting and he wished to know on whose authority the meeting had been called. Blake could probably see the end of his battle to preserve reporting and he suggested that a suitable name for the Society should be that of a Society of Radiologist’s Assistants [25]. Mr Ede, a council member, spoke as a radiographer of 20 years standing; his comments are also recorded in the minutes, and he stated that with the advances in radiology, it was inevitable that radiographers must suffer [26]. The electrical engineers were diametrically opposed to submitting themselves to the GMC’s wishes and were discussing the situation with the GMC via the Institute of Electrical Engineers, but to no avail. The radiographers were put in an impossible situation, the pressure from the Board of Trade, the GMC and from the Society’s own medical members proved to be too great, and the radiographers acquiesced. The electrical engineers, who had joined with the radiologists to form the Society, and who had fought against the restrictions from the start, were not going to capitulate to medical pressure, and withdrew from the Society. Campbell Swinton who had produced the first radiograph in Great Britain back in 1896 was

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therefore excluded from the Society he had helped to establish. With the resignation of the electrical engineers, the field was clear for the Articles of the Society to be amended to prohibit any non-medical member issuing reports. The dispute settled within the Society was one matter, but whether or not medical practitioners would cease to use radiographer’s reports was another. Whether it was coincidental with the changes in the Society or not is unclear, but an article entitled ‘Radiology and Radiography’ appeared in the BMJ [27] in November 1925. The intention of the article was to alert medical practitioners to the risks of not using radiologists: ‘Medical practitioners are prohibited from associating with unqualified persons who may assume medical functions, but the General Medical Council has no other power of restraining the unauthorized activities of laydiagnosticians and healers. It is therefore incumbent on medical practitioners, in the interests of their patients as well as for their own professional security, to see that the line between radiographers and radiologists is honourably observed.’ BMJ 1925: 855

In the space of 16 years, opinions had changed to suit the situation and purpose. The view of the radiologist [9], who claimed that the person taking a radiograph and knowing the relative position of tube, patient and plate at the time of the exposure was the only one who could interpret it correctly, had lost its currency.

Differences consolidated Despite the changes within the SoR, not all radiographers were prepared to abide by the Society’s ruling on reporting. The Society, however, took its responsibility in policing the work of radiographers extremely seriously. This was evident from a special meeting of Council [28] held in June 1932. A resolution passed by Council was as follows: ‘That this Council has very carefully considered the facts of Mr C. J. Dresser’s case and is prepared to allow him to remain on the register of the Society on condition that he desists immediately in the following practices about which complaints have constantly been received in the past. The Society of Radiographers does not approve of advertising, but if done at all: (a) only lists of fees with no vulgar comments may be issued, and these only to be issued to the Medical Profession.

Radiographer reporting: origins, demise and revival

(b) that the ‘Hire of X-ray apparatus’ leaflet be withdrawn. This is a particularly offensive and obnoxious document. (c) that the words ‘screen and report’ must not be merely cancelled in ink, but new forms issued so that no such words can be seen through the deleting agent. (d) that no list of diseases treated be published. (e) that nothing be said or done that is likely to lower the general tone of radiography, or the status of the Society of Radiographers. In the event of Mr C. J. Dresser not complying immediately and permanently with the above, the Council considers that there can be no alternative but to remove his name at once from the register. The period of probation cannot exceed 6 months from the date of this resolution.’ SoR, 1932

The resolution was copied to the Medical Committee of the British Institute of Radiology, the BMA, Newcastle upon Tyne, and three named doctors. There was no evidence that it was copied to any radiographers, leaving the conclusion that the Society’s priority was to do all it could to please its medical masters. Opportunities were not lost in spelling out the differences between radiology and radiography. One such instance was in November 1930, when Dr J. Duncan White, who later became President of the Society of Radiographers, delivered a paper to the Society ‘Training in Radiography’ [29]. He commented upon the comprehensive nature of the syllabus and could find no fault with it except for minor details. But he did go on to find ‘fault’ with training in some centres, which gave the impression that he did not see them as minor at all. He criticized one centre teaching pathology which he thought was entirely unnecessary. His comments on the subject were clear: ‘a smattering of knowledge may lead to an expression of opinion as to possible variations from the normal’. In the 1930s, the Board of Registration of Medical Auxiliaries (BRMA) was established under the auspices of the BMA. According to Larkin [2], radiologists were growing in strength, and brought pressure to bear on the BMA so that a resolution was passed to the effect that only radiologists or properly qualified general practitioners should interpret X-ray films. The resolution served to exert strong pressure on medical practitioners to stop the practice of reporting by radiographers for fear of falling foul of the BMA. The control sought by Hernaman-Johnson over the lay radiographer had been accomplished, medical control over radiography was complete.

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In 1942, Dr, then Major, Duncan White was invited to become the President of the Society of Radiographers. White’s views on training were set out in his presidential address [30]. In his address to the Society in 1930, he had been critical of the teaching of pathology but, by 1942, his view had changed and he was of the opinion that there were merits in a knowledge of pathology if there was to be real teamwork ‘between those who make the shadow picture and those who interpret it’. But he emphasized the difference between radiologists and radiographers, and recommended to radiographers the adage ‘never try to appear what you are not’. By that time, the days of radiographer reporting were left far behind and, if Furby was correct, radiographers had accepted their role as laid out by the Society in 1925. Furby, himself a radiographer, summarized the situation [31]: ‘The primary function of the radiographer is to be of utmost service to the radiologist. The function of the radiologist is the interpretation of the radiograph.’ C. W. Furby, Radiography 1944

Revival Changing Attitudes The exclusion of radiographers from reporting remained unchallenged for nearly 50 years. It took a radiologist, Swinburne [32], who, in 1971, proposed that radiographers and other nonradiological staff could be utilized to distinguish between normal and abnormal films, thus alleviating radiological workloads. Swinburne justified his suggestion on two counts, ‘the chronic shortage of radiologists’ and the fact that radiographers seemed to function below their full potential. On the latter point, he compared radiographers with laboratory technicians who accepted greater professional responsibilities. His opinion was that recruitment would be improved and an enhanced role could lead to an advancement in a radiographer’s career structure at graduate level. Swinburne considered it was time that ‘official’ recognition was made of the fact that radiographers all over the world assisted in the interpretation of X-ray films. He recognized the interdependency between radiology and radiography, but his view was that, under the best conditions, there was no need for boundary disputes. Swinburne had proposed both a training programme and a system of working which were radical and ahead of their time. There is no trace of a response from the SoR to Swinburne’s ideas.

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In 1975, the British Journal of Radiology published an editorial ‘Must radiologists do all the reporting?’ [33] and, in the same edition, a letter was published from a leading general practitioner [34] who thought that it was a waste of time for radiologists to attempt to report every image. Indeed, he went as far to say that it was heresy to even raise the issue. The editorial and the letter prompted a number of responses, including those from Aberdour [35] and McLachlan [36] who suggested that there was a role for radiographers. Swinburne’s ideas had obviously not fallen on totally deaf ears, but it was radiologists and not radiographers who had taken the initiative. In the 1980s, ultrasound signalled a new role for radiographers; it included providing results to patients, and reports to medical practitioners of both numerical and interpretational data [37]. Any return to plain film reporting still seemed remote, but the work of Cheyne et al. [38] on abnormality detection by radiographers, which became known as the ‘red dot’ system, was launched. The ‘red dot’ system allowed a radiographer to place a small red dot on the outside of an envelope to indicate to the casualty officer that, in the radiographer’s opinion, an abnormality had been demonstrated. Interest in the feasibility of radiographers playing a role in abnormality detection grew and in the early 1990s, Renwick et al. [39] conducted a study to investigate how well radiographers could triage films in an accident and emergency department. In effect, this appeared to be a variation of the ‘red dot’ system. Unselected radiographers were asked to place films in one of four categories, normal, abnormal, insignificantly abnormal and further advice required. The radiographers’ selections were compared independently to an assessment made by radiologists. The study concluded that unselected radiographers could offer useful advice on radiographs to casualty officers but, because of a high false-positive rate, they could not perform to the required level of accuracy to extend their role. The results were not surprising given that the radiographers had not undergone any training, and the study was criticized for this fact by Nawrocki and Nawrocki [40], who suggested that radiographers had considerable potential in abnormality detection and should undergo a short period of training for the task. In response [41], Renwick agreed that radiographers were an under-used resource, believing that they should be given the opportunity of extra training, and that his department was seeking funding for such an initiative.

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By 1991, reporting was a live issue and Rose and Gallivan [42] reported a national survey of consultant radiologists to investigate the extent of nonreporting and delayed reporting in U.K. hospitals. Questionnaires were sent to all consultant radiologists in the U.K. and 565 (45%) replied. The paper revealed some important findings that included the following; only 16.1% of the sample stated that all films were reported; 33.6% stated that 10% of films or more were never reported and one respondent revealed that 90% of plain films were never reported. The two main reasons for the failure to report all films were that, firstly, patient management would not be affected by a lack of a report and, secondly, a shortage of radiologists. Of the sample, a majority of 58% considered that all films should be reported by a radiologist. Of the 42% who thought not, 17% specified dental and fracture clinic follow-up films as the only categories not requiring a report. No information was given as to what the remaining 25% thought. Saxton, writing an editorial in Clinical Radiology [43] entitled ‘Should radiologists report on every film?’, raised a number of subsidiary questions and highlighted some key issues: Were all films being reported? Do reports get read? Reporting was too late to influence clinical management Radiologists were becoming overloaded. In proposing a solution, Saxton stated that:

‘Turning to the field of interpretation, there is little doubt that with careful training suitable radiographers could undertake reporting in such areas as mammography screening or fracture reporting on accident and emergency films.’ H. M. Saxton, Clin Radiol 1992; 45: 1–3

Loughran [44] and workers at Leeds [45] were probably the first to put Saxton’s ideas into practice and indeed implemented Swinburne’s proposals more than 20 years after the original paper. ‘The Extended Role of the Radiographer’ project based at the Leeds College of Health in conjunction with St James’s University Hospital, Leeds had financial support from the Department of Health, and involved the College of Radiographers and the Royal College of Radiologists in the steering group. The basis for the project were deficiencies [paper submitted to steering group] in the existing system for plain film reporting. These were stated as:

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25% or so of films were never reported a subset of unreported films included some significant missed diagnoses reports were not issued quickly enough it was costly to dedicate radiologists for hot reporting, especially out of hours.

by the College of Radiographers. After this first hurdle, other courses were approved with little difficulty.

At about the same time as the Leeds project was getting underway, Loughran [44] was running in-house training in fracture reporting for radiographers in Macclesfield, and demonstrated that, with structured training, radiographers could report with consistently high levels of diagnostic accuracy, comparable with scores recorded for consultant radiologists. The work at Leeds went further than that of Loughran in that it included radiology of the chest and abdomen. In 1995, the Audit Commission [46] published a report on the effectiveness of radiology services and commented on the softening of traditional demarcation lines between the work carried out by radiologists and radiographers. The report considered that radiographers might be trained to interpret certain images because of the difficulty experienced by some departments in providing a full reporting service. A survey of role developments in radiography already showed that in four hospitals in the U.K. radiographers were issuing written reports [47], and by the time the Audit Commission report was published, a number of reporting courses were being developed in response to local clinical needs. At the end of 1996, five higher education institutions, Canterbury Christ Church College, University of Bradford, University of Hertfordshire, University of Salford and South Bank University, were offering postgraduate programmes in plain film reporting. These were soon to be followed by courses at St Martin’s College Lancaster and the University of the West of England. The first course to be validated and accredited by the College of Radiographers was at Canterbury, but validation was not a straightforward affair. A radiologist member of the course team and another acting as an external adviser were apprehensive about the consequences of the validation process. They were particularly concerned about any adverse reaction that the Royal College of Radiologists might have, despite the position it had taken in its 1995 publication ‘Statement on Reporting in Departments of Clinical Radiology’ [48]. The course team persevered with their efforts and were successful in gaining approval of the course and accreditation

In a review of radiographer reporting, it would be remiss not to consider the position of those professional and statutory bodies that influence practice either directly or indirectly. In the early years, the Society’s own medical members, the British Institute of Radiology and the GMC were influential and exerted pressure on the SoR to change its Articles of Association to prevent radiographers reporting. In the 1930s, pressure was brought to bear on the Board of Registration of Medical Auxiliaries [2] to make a resolution to the effect that only radiologists or properly qualified general practitioners should interpret X-ray films. This position persisted despite the Professions Supplementary of Medicine Act 1960, although Moodie [49] claimed that the Act gave radiographers full professional status. Successive statements of conduct issued by the Radiographers Board at the Council for Professions Supplementary to Medicine prohibited radiographers from making written comments on image appearances. It was 1987 before the Radiographers Board modified their statement of conduct in response to the new role radiographers had developed in ultrasound. The change had no impact upon plain film reporting, but one of the main obstacles to a return to such reporting was removed. The College of Radiographers, who had been pressing the Board to change its statement, amended its own code of professional conduct in 1988 to state that a radiographer might provide a description of images, measurements and numerical data especially in medical ultrasound. In 1994, the College of Radiographers’ Code of Conduct was further modified [50] to include the following:



The position of the professional and statutory bodies

‘Radiographers may provide a verbal comment on image appearance to the patient and should provide a written report to the referring clinician.’ College of Radiographers, 1994: 10

These were positive moves on the part of the College and the first on reporting since 1925. The College also issued a document [51] which suggested protocols that not only covered radiographer reporting but also dealt with requests for X-ray examination by nurse practitioners.

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The latter had always been a controversial issue, since X-ray requests to radiographers had hitherto only been accepted from medical or dental practitioners. It was only in 1990 that the Radiographers Board changed their statement of conduct to allow radiographers to accept requests from other non-medical professionals, provided that it was done within agreed procedures. Although a number of radiologists, beginning with Swinburne in 1971, had suggested that there was a role for radiographers in reporting, it was not until 1995 that the Royal College of Radiologists [48] stated their position in a publication that included the following statement: ‘After suitable training there may be no statutory impediment to a non-medically qualified person reporting a radiological examination and making clinical observations, but a person without a medical training cannot reasonably be expected to provide a medical interpretation.’ Royal College of Radiologists, 1995: 6

Of course, any ‘statutory impediment’ was removed by the Radiographers Board in 1987 and although one could argue that the Royal College of Radiologists statement was guarded, it was also pragmatic and certainly a U-turn given the historical perspective. However, it was clear that the Royal College of Radiologists were making a distinction between what was regarded as a clinical observation as opposed to a medical interpretation. It was also the position of The Royal College that reporting by non-medical staff should be seen as a delegated task which fell within guidance from the GMC. By the time the College of Radiographers published its vision document [52] in 1997, a number of radiographer reporting courses had been established, and radiographer reporting was once again a reality. However, the College of Radiographers and the Royal College of Radiologists adopted similar positions inasmuch that they responded to the lead taken by practitioners in the field. Nevertheless, the College of Radiographers’ vision ended with a robust statement: ‘Reporting by radiographers is not an option for the future, it is a requirement.’ College of Radiographers, 1997: 4

The continuing pressure for change was sufficient for the Royal College of Radiologists and

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the College of Radiographers to react further and attempt to re-define inter-professional roles and responsibilities [53]. The acknowledgement and recognition by The Royal College of Radiologists, in particular, was an important step in ‘legitimizing’ new work practices by radiographers, especially in the eyes of some of its members who hold key and strategic management positions in imaging departments. Although the joint publication by the two Colleges has not been without criticism [54], it set out a position that would have been untenable in the formative years of both professions. The establishment of the multidisciplinary Special Interest Group in Radiographic Reporting (SIGRR) has had an influence on the development of radiographer reporting, although it is neither a professional nor a statutory body. In 1996, a number of radiographers and radiologists established the SIGRR to provide a national forum for those with an interest in radiographic reporting. At the inaugural meeting, the debate was raised to the national level when the presidents of the Royal College of Radiologists and the College of Radiographers addressed the meeting [55]. The meeting reflected the rapidly developing situation, and even perhaps 12 months earlier, a meeting attended by the Presidents to discuss a topic that had divided the two professions for 70 years would have been inconceivable. The significance of the meeting was such that it is worth noting the key points which the Presidents put forward. The President of the Royal College of Radiologists, Dr M. Brindle, outlined the current situation in radiology in the U.K. which had seen a three-fold increase in workload with only a two-fold increase in manpower. The view was expressed that, in the U.K., there was a long tradition of non-medical practitioners’ involvement in health care. When there was a mismatch between supply and demand of medical practitioners, it resulted in role-development opportunities for non-medical healthcare practitioners, which necessitated delegation of some tasks. Dr Brindle highlighted a particular concern about the potential for development of a radiographer to the point of independent practice and departure from the principle that a report was a medical interpretation of an imaging investigation. Mrs J. Henderson, President of the College of Radiographers, welcomed the development of radiographic reporting and stated that the College was already involved in accrediting reporting courses. She believed that radiographers were the most appropriate non-medical group to undertake a

Radiographer reporting: origins, demise and revival

reporting role, and that radiographer reporting shoud bring tangible benefits to patients and the health service. In the first 18 months of operation, the SIGRR held three national meetings and began to disseminate the results of research which it had undertaken [56–58]. The work of the SIGRR continues to develop and, as a group unaffiliated to any of the professional bodies, is able to take an independent stance.

Concluson The picture of the 1990s was a reversal of the events of the 1920s, although there is one striking similarity between the demise of radiographer reporting and its revival. Both were instigated by radiologists but for totally different reasons. The demise was due to the desire to establish radiology as a medical speciality, and as a consequence pressure was brought to bear to prevent radiographers from issuing reports. The revival of radiographer reporting is a means of trying to cope with an increasing radiological workload. The dearth of evidence cited to show how dangerous it was for radiographers to report in the 1920s is in bleak contrast with the evidence to support the revival of radiographer reporting, notably the work in Leeds and that of Loughran. In other areas, reporting by radiographers in aspects of ultrasound is well established [47, 59], and there is evidence from a major centre to show that it is of a high standard [60]. There is also evidence to support the developing role of radiographers in breast image interpretation [61]. The extent of the involvement of radiographers in plain film reporting is increasing. The position changed drastically from the four departments reported in 1995 by Paterson [47] to 1998 when a survey of NHS managers revealed that radiographers were reporting on accident and emergency films in 37 Trusts, on barium enemas in 37 Trusts, on mammograms in 10 Trusts and paediatric films in one Trust [59]. Since 1925, with the important exception of the work of ultrasonographers, the work of diagnostic radiographers has centred on image acquisition. The situation is changing and if future needs are to be met, there has to be explicit recognition of the changes taking place. Undergraduate radiographer education has a major role to play and the introduction of courses that focus on image

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interpretation will need to be given priority. Such courses are essential if radiographers are to play a full role alongside medical colleagues under The Ionising Radiation (Medical Exposure) Regulations 2000, which require a clinical evaluation of the outcome of all medical exposures [62]. Studies by Loughran [44] and Robinson [63] have reported the benefits and demonstrated the ability of trained radiographers to perform to a high standard, in reporting of plain film examinations on accident and emergency patients. Furthermore, a study by Robinson et al. [64] has shown that the introduction of radiographers with appropriate training into the radiologist’s rota produced no ‘detectable adverse consequences’. A case study by Carter and Manning [65] demonstrated an improvement in performance by a radiographer over a 9-week period of a postgraduate course. The studies report on a small number of radiographers who are undoubtedly highly motivated, and have demonstrated the ability to perform to a high standard. It would be unwise to generalize that all radiographers can achieve similar standards. Similarly, without structured training, it is questionable whether such standards can be met. However, the potential of radiographer reporting is self-evident, and the positive results so far can only act as encouragement. It is certain that the pressure for change will not relent, especially after the Government pronouncements for the NHS following the 2000 budget when the Prime Minister challenged the professions to remove unnecessary demarcation and introduce more flexible training and working practices [66]. There is paradigm shift taking place in the role of diagnostic radiographers [58], and the vision of the College of Radiographers [52] that reporting by radiographers is a requirement for the future can be transformed into a realistic outcome. Acknowledgement The author wishes to thank the Society of Radiographers for access to its archive material.

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