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Reading screening mammograms – Attitudes among radiologists and radiographers about skill mix
European Journal of Radiology 80 (2011) e325–e330
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European Journal of Radiology journal homepage: www.elsevier.com/locate/ejrad
Reading screening mammograms – Attitudes among radiologists and radiographers about skill mix Lena Westphal Johansen a,∗ , John Brodersen b,1 a b
Metropolitan University College, Sigurdsgade 26, 2200 Copenhagen N, Denmark Research Unit and Section for General Practice, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5, P. O. Box 2099, DK-1014 Copenhagen, Denmark
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Article history: Received 5 October 2010 Accepted 1 December 2010 Keywords: Mammography screening Attitude Radiologist Radiographer Skill mix Role development
a b s t r a c t Introduction: Because of shortage of personnel for the Danish mammography screening programme, the aim of this study was to investigate the attitudes of radiologists and radiographers towards a future implementation of radiographers reading screening mammograms. Materials and methods: Seven combined phenomenological and hermeneutical interviews with radiographers and radiologists were performed. Stratified selection was used for sampling of informants. The interviews were analysed against theory about quality, organization and profession. Results: Quality related possibilities: radiographers do routinely measure the performance quality, radiographers obtain sufficient reading qualifications, and skill mix improves quality. Quality related obstacles: radiologists do not routinely measure performance quality. Organization related possibilities: shortage of radiologists, positive attitudes of managers, and improved working relations. Organization related obstacles: shortage of radiographers and negative attitudes of managers. Professional related possibilities: positive experience with skill mix. Professional related obstacles: worries about negative consequences for the training of radiologists, and resistance against handing over tasks to another profession. Conclusion: Attitudes towards radiographers reading screening mammograms are attached to either quality-, organisational or professional perspectives. Radiographers are capable of learning to read mammograms at sufficient performance level but routine measurement of performance quality is essential. Resistance against skill mix may be caused by an emotionally conditioned fear of losing demarcations. The main motive for skill mix is improvement of the utilization of resources. No evidence was found regarding the organisational and financial consequences of skill mix. Despite of this all radiologists and radiographers experienced with skill mix were strong advocates for reading radiographers. © 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction In Denmark, a national breast screening programme has been required by law since 2008. Like in other countries, there is a shortage of personnel for the Danish mammography screening programme. This problem is partly being solved using mammography screening assistants for the imaging process. These assistants are non-radiographers given a brief course on mammography screening related radiography [1]. In the UK, this sort of skill mix is organized after The Four Tier Model in which one of the tiers also gives the opportunity for radiographers to take over at least parts of the radiologists reading of screening mammograms, i.e. as first or second readers [2].
∗ Corresponding author. Tel.: +45 72487743. E-mail addresses: [email protected] (L.W. Johansen), [email protected] (J. Brodersen). 1 Tel.: +45 35327171. 0720-048X/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrad.2010.12.023
Several papers describing the performance of radiographers reading screening mammograms have been published. Wivell et al. (2003) let two radiographers in the UK read a test set of 1000 mammograms, which had been previously read by radiologists. Ninety known interval cancers were included in the test set. The radiographers referred more women than the radiologists, but the radiographers also detected all cancers originally detected by the radiologists. Furthermore the radiographers detected 32 interval cancers of which none were detected by the radiologists. Subsequently three radiographers performed the function as second reader of 54,000 screening mammograms, which were first read by a radiologist. Neither referral rate, nor cancer detection rate, nor expenditure of time respectively was found to be significantly different between radiologists and radiographers [3]. Duijm et al. (2008) let radiologists as well as radiographers double read screening mammograms in Holland. In period A, 66,225 mammograms were double read by two certified screening radiologists. In period B, 78,325 were double read by two radiologists as well as two radiographers. All mammograms referred
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by the radiographers only were re-evaluated by the radiologists, resulting in 544 re-evaluated mammograms, 102 extra referrals and 29 extra detected cancers. The cancer detection rate per 1,000 women screened increased significantly from 4.86 to 5.62 when the mammograms were read by radiographers also, but the positive predictive value of referral decreased from 47.5% to 35.9% [4]. In a review Van den Biggelaar et al. focused on radiographers’ mammography reading performance compared to the performance of radiologists. They also looked at the effect of training. It was reported, that radiographers scored higher false-positive rates than the radiologists, however, radiographers and radiologists performed at comparable sensitivity. In one study the sensitivity was higher for the radiographers than for the radiologists. The radiographers’ performances were measured before and after training and the diagnostic odds ratio increased after training mainly because of increased specificity [5]. According to these studies, trained radiographers are capable of reading mammograms with performances similar to those of radiologists. Despite of this, there is a resistance against this type of skill mix especially among radiologists in Denmark [6]. Kletzenbauer (1996) completed a questionnaire survey on British radiographers’ attitudes to non-radiographers taking over radiographers’ tasks. The questionnaire contained topics that were mainly trade-union politically oriented. The radiographers had mainly negative attitudes to this type of skill mix, but the attitude of managing radiographers was more positive [7]. Forsyth and Robertson (2007) accomplished a questionnaire survey among 211 radiologists in Scotland, investigating the radiologists’ attitudes towards skill mix in radiography. The authors divided the results into positive and negative attitudes presented in order of priority [8]. No work has been published investigating the nature of radiologists’ and radiographers’ attitude towards radiographers reading screening mammograms. Therefore, the aim of this study was to investigate the attitudes of radiologists and radiographers to possibilities of and obstacles to a future implementation of radiographers as readers of screening mammograms in Denmark. 2. Materials and methods 2.1. Design and sampling The empirical material of this study consisted of seven individual semi-structured interviews with three radiologists and four radiographers respectively. The informants were chosen by means of stratified selection with maximum variation, representing different characteristics e.g. trade-union involvement, experience with and local organisational structure of mammography screening. The interviewees were informed in writing and orally about the aim of the present study, the interviewer’s professional background, participation being voluntary and about the possibility to withdraw. Furthermore, they were informed about anonymity of interviewees and erasure of data immediately after usage. 2.2. Data collection and analysis
The first author’s pre-understanding was influenced by her position as authorized radiographer and lecturer at the department of radiography at Metropolitan University College in Copenhagen, which has given rise to a positive attitude to radiographers’ professional development in general. Despite of the good performances of reading radiographers shown in several studies, the authors were aware of the strict quality requirements of mammography screening and of the possibility that these requirements could influence the attitudes of the informants. Therefore, a quality approach was chosen as a theme for the interview guide and the analysis. Prior to the data collection two more themes were generated from two pilot interviews. These themes were an organisational approach and a professional approach. After categorizing and reorganising the data, sixteen subcategories were generated all falling into one of the three themes. Some statements could fall into more than one theme or subcategory. For the sake of clarity, these statements were categorised according to the context in which they appeared in the interview. In this way, each statement only appears in one category. In the discussion however, results from each of the three themes are combined to achieve an overall conclusive interpretation. Both authors took part in the planning of the study’s aim, design and which methods to use. The first author conducted all the interviews, was responsible for correct transcriptions, conducted the analyses and wrote the first draft of the manuscript. The second author has contributed substantial to the final manuscript. Both authors have accepted the final version of the paper.
2.3. Theoretical approaches The theoretical basis of the quality approach was described in terms of measurement and calculation of sensitivity, specificity, positive and negative predictive values [11]. This theory constitutes the foundation of quality assessment of the reading of mammograms but it turned out to be difficult to make the interviewees deliver precise theoretically based statements on this subject. The organisational approach was described in terms of organisational culture and the organisation of hospitals as bureaucracies in which effective utilization of resources is given a high priority [12]. Bureaucracies are influenced by functionalism and rationalism in which culture is viewed as means to achieve the aims of the organization. Inter and intra professional teamwork can be supported by a symbolism, in which members of an organization are bound together creating a common frame of understanding [13]. Especially interviewees with a positive attitude to skill mix were very much aware of this approach. Abbotts’ theories of professional jurisdictional attachment, was used for the professional approach. According to Abbott, academic traditions, superior jurisdiction as well as assignments based on fixed rules are all obstacles to handing over assignments to another profession [14]. Especially interviewees with a negative attitude to skill mix delivered statements relevant for this approach.
3. Results 3.1. The quality approach
An interview guide was developed ad modum Kvale [9]. The results were validated during the interviews by means of specifying questions. Transcription as well as translation from Danish to English was done by the interviewer verbatim to the statements of the interviewees but sometimes slightly moderated in order to create meaningful translations. The transcribed interviews were analysed by means of Dahlager and Fredslunds’ four step model [10]. This model includes a phenomenologically inspired open categorization as well as a hermeneutically inspired interpretation.
3.1.1. Radiographers’ quality Most screening radiographers do routinely measure quality of their imaging performance.
RAD1: “I completely vouch for the quality of their mammograms – we review their mammograms quarterly and if they don’t pass, they have to start all over with 200 mammograms. . .”
L.W. Johansen, J. Brodersen / European Journal of Radiology 80 (2011) e325–e330
Implementation of reading or reporting radiographers increases quality. RAD2: “We have proven that the departments’ standard of quality increases. . .” DOC1: “I can easily picture that, because that’s how it is for radiologists.” One radiographer does not measure quality of her own imaging performance. RAD4: “We haven’t got that yet. . .we have nothing concerning the mammograms. . .” 3.1.2. Radiologists’ quality Radiographers reading of mammograms must be organized in a way, that the amount of mammograms is large enough to maintain the quality of their performance. RAD2: “If you engaged a radiographer. . .who could do the first reading from the whole region and then the radiologist could do the second reading. . .you must have a large amount of mammograms, the amount is essential for the expertise. . .” A high recall rate is a beginners’ phenomenon. DOC2: “When the radiologists begin to perform the reading. . .the recall rate. . .it decreases but it takes time, it takes time. . .that’s absolutely normal.” The radiologists did not routinely measure quality of their own performance. DOC3: “We have a group in which 11 categories have been chosen. . .but it’s relatively early yet. . .the first data are entered during 2010. . .” DOC1: “The doctors are not controlled in that way, I never thought about that. . .” 3.1.3. Quality requirements Some informants claim that radiographers should only function as first readers. DOC1: “. . .then I would use the radiographers as first readers. . .they should be permitted to bypass all those mammograms, in which they were not certain there wasn’t anything wrong.” Others do not consider it relevant to distinguish between first and second reader. DOC3: “. . .actually that’s of no interest. . .well, you do the same task whether you do the first or the second reading. . .the conditions are the same. . .” 3.1.4. Radiographers’ competence Radiographers and radiologists had positive attitudes towards radiographers’ competences. DOC1: “. . .and it’s not because they can’t rise to the challenge. . .I believe, they can easily undertake it.” RAD2: “. . .well, the message in British articles is, that experienced radiographers are just as good readers as experienced radiologists. . .”. One radiologist states that radiographers cannot obtain a suitable level of knowledge for reading mammograms.
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DOC2: “. . .but I’m not certain it’s a good idea. . .you have to obtain knowledge about pathology, physiology, anatomy eh. . . and extensive experience of breast diagnostics. . .” 3.1.5. Alternative readers Some informants state that alternative readers, as privately held radiologists can become an obstacle to reading radiographers, but there is also a risk that this way of organizing the reading may lead to increased referral rates. DOC3: “. . .private-held radiologists . . .they could be the radiographers’ rival.” RAD2: “. . .they have a private-held company reading . . .but we have three times as many referred.” 3.2. The organisational approach 3.2.1. Utilization of resources Shortage of radiologists is a serious problem, and skill mix may set them free for other tasks. DOC3: “. . .there are not enough radiologists, that’s reality . . . and then you have to look around” RAD1: “. . . the radiologists are set free to perform tasks which they should undertake but just never manage to do.” Skill mix is a financial advantage and it may help recruitment of radiographers. RAD2: “Well, it’s a financial advantage, no doubt about that. . .we haven’t had any deficit during the years with reporting radiographers. . .we get at least two radiographers for the price of one consultant radiologist. . .well, it also helps recruitment. . .we have also no problems with shortness of applicants. . .” 3.2.2. Organisational culture Managers’ positive attitude of skill mix as well as an organisational culture in which skill mix is the natural way to organize work is important for the success of skill mix implementation. RAD2: “That’s what the culture of the department should reflect. . .we simply presuppose skill mix, and actually it is a success. . .it comes all the way from the top. . .when radiologists arrive for an interview, the first thing they are asked is in which areas they see possibilities for skill mix.” Radiologists’ and radiographers’ attitudes towards skill mix may be influenced by their age. RAD3: “No, I’m brought up with the king-radiologist. . .he almost ruled the whole village. . .Maybe some of the old fogeys could be a obstacle. . .but I think, the younger radiologists will make us think differently.” RAD2: “some radiographers are not happy when younger radiographers obtain certain qualifications. . .I simply believe it is due to insecurity.” Inter professional teamwork is essential for the skill mix process and may even be improved by the implementation of skill mix. DOC3: “We have multi-disciplinary meetings in the radiology department in which the radiographers should also participate.” RAD1: “. . . you will improve teamwork when radiographers start reading mammograms. . . you will have a different dialogue between radiographer and radiologist. . .”
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3.2.3. Skill mix development in Denmark The radiographers are convinced, that reading radiographers will be introduced in Denmark. RAD2: “. . .skill mix comes like beads on a string. . .there are indicators everywhere.” RAD3: “I think they will end up screaming for our help. . .” 3.2.4. Organising the skill mix Some radiographers place great emphasis on reading radiographers being still part of the imaging team. These radiographers view the reading as part of a mammography package. RAD2: “We envisage that reading radiographers from the screening also follow the referred patients.” RAD4: “I see it as a complete mamma package in which the reading easily would fit.” 3.2.5. Radiographers motivation All interviewed radiographers are motivated towards the reading because of the professional challenge and possibility of increased salary. RAD4: “The main motivation is the education. . .and possibility of advancing, and of cause an increased salary.” 3.3. The professional approach 3.3.1. Radiologists’ profession One radiographer states, there is no risk that radiologists will totally lose their task of reading mammograms. RAD2: “. . . it is not so that they will lose reading or reporting, and that’s important. . . that they don’t just take away the task, because that will have a negative influence on the radiologists’ competences.” Radiologists resistance against letting radiographers read mammograms has to do with an emotionally conditioned jurisdiction, but it can also be caused by scepticism of innovations. DOC1: “..on the other hand I have, I won’t say trade political but rather emotional. . . our basic functions are threatened, and I am definitely against that. . .” DOC3: “I think. . .sometimes there is scepticism among the colleagues . . .Well, I guess that’s always how it is, and when something is new there is scepticism. . .” 3.3.2. Radiographers’ profession Radiographers have also resistance against handing over their tasks to other professions. RAD3: “Well, in the last trade paper they talked about assistant radiographers – at that point I was close to breakdown. . .well, I have worked like a workman. . .I think, It’s emotional. . .” All interviewed radiographers have positive attitudes to radiographers’ role extension. RAD4: “Yes, I’d love to do that. . .I would say, if I’m going to read mammograms, I also expect to receive training. . .I see it as a part of a full mamma-package. . .” 3.3.3. Radiologists’ training Reading and reporting radiographers can maintain the training of junior doctors.
RAD2: “. . .well, the reporting radiographers train the junior doctors. . .the doctors are very happy about it, because it is easy for them to get supervision and help from somebody being very enthusiastic about this. They don’t have to search for a radiologist who hasn’t got time. . .” Radiologists worry about skill mix influencing their training negatively. DOC1: “. . .if you pick out an important part of the doctors training. . .which consequences will it have? 3.3.4. Skill mix experience Some informants have experience of reading or reporting radiographers as well as of imaging mammography screenings assistants. RAD1: “They are really good. . .I become quite upset when you hear that assistants are not good at screening. . .” DOC3: “. . .it worked smoothly with this reading radiographer, she was competent. . .” 3.3.5. Trade unions and National Board of Health The Society of radiographers in Denmark has started a debate on skill mix. RAD4: “. . .a debate (on assistant radiographers) was started in the last trade journal. . .that’s the first thing I have seen. . .” One radiologist states, that involvement of the National Board of Health is essential for the implementation of reading radiographers. DOC1: “If this is supposed to succeed the National Board of Health must push it – it will not come from the radiologists. . .” 3.3.6. Training of radiographers All radiographers take a positive view towards a post graduate education and training. RAD4: “I would be happy about that. . .If I was supposed to read I would also expect to get a sufficient education.” Some informants find it problematic that no qualifying education is established in Denmark. DOC1: “Right now, we haven’t got any qualified radiographers. . .It is uncertain, whether it is a financial advantage if the radiographers must be qualified in the UK.” DOC3: “. . .if you establish a Danish education. . .I look forward to that.” 4. Discussion 4.1. Discussion of results Although none of the informants expressed their statement in terms of sensitivity or specificity, most informants claimed that radiographers are capable of learning to read mammograms. This agrees with the results of Pauli et al. (1996) who found no statistically significant difference between the performance of radiographers and the radiologists after training [15]. Only one radiologist was not certain whether the radiographers can achieve skills at a sufficient level. This is confirmed by Forsyth and Robertson (2007) who characterized lack of trust in the radiographers’ capability as a lower ranged negative attitude of radiologists [8].
L.W. Johansen, J. Brodersen / European Journal of Radiology 80 (2011) e325–e330
A lower specificity may be a beginner’s phenomenon rather than a radiographer’s phenomenon. This is supported by Deans et al. (1998) who found that also radiologist’s referral rates decrease in line with increasing experience [16]. Therefore, low specificity among inexperienced and non-trained radiographers should not be considered an obstacle for the skill mix. Since high referral rates may also be associated with private-held radiologists’ reading, this way of organising the reading should be subject to quality control. The radiologists did not routinely make quality assessments of their reading. This could be an obstacle to skill mix, since it may be more difficult to hand over a task to another profession when you do not know what your own performance level is. The radiographers had a well established routine of quality assessment of their own and of the assistants’ imaging performance in the units where assistants were employed. In units with no assistants, there was no quality assurance. Maybe the skill mix process itself facilitates a stronger focus on quality assurance. This may also explain the radiologists’ resistance against skill mix, because implementation of reading radiographers implies quality assessment of the radiologists reading, which is not traditionally part of their working culture. Informants experienced with radiographers reporting emergency X-rays and radiographers reading mammograms outside Denmark, all reported an increased image quality in the departments concerned. We have not been able to identify studies on reporting and reading radiographers’ influence on image quality. Therefore, such studies are recommended. There are different ways of organizing reading radiographers. According to some informants it is important that the radiographers do only undertake one part of the double reading. According to others, this is not that important as long as the quality of their performance is measured. There were different attitudes towards the question whether the amount of screening mammograms would be large enough to maintain the radiographers reading expertise. One informant stated that reading radiographers should be localized in few central units in order to solve this problem, which is not a practical problem with the new technology of digital mammograms. Utilization of resources seemed to be the most important argument for letting radiographers read. This is supported by Forsyth and Robertson (2007) who state that most important positive attitudes to skill mix are; an increased recruitment of radiographers, a better usage of personnel, and a reduction of radiologists’ work load [8]. No evidence has been identified about the organisational quality of skill mix. Since some of the informants in this study had answers to questions of how skill mix helps recruitment and how skill mix should be organized and financed, it is highly recommended that studies on these subjects are undertaken. The working relationship between radiologist and radiographer is important for the success of skill mix and according to some informants the radiographers must participate in multi-disciplinary meetings. Some even state, that the skill mix may improve inter and intra professional teamwork. Positive or negative manifestations from the managers of the department and hospital are essential for how skill mix influences and develops organisational culture. It seems that radiographers are motivated towards undertaking the task of reading mammograms as well as towards the required training, especially if the reading is a part of a larger mamma package in which both imaging and patient interaction duties of the radiographer. The development of the skill mix area in Denmark could indicate, that implementation of radiographers in the reading of mammograms is only a matter of time. One radiologist was concerned about whether the radiographers’ reading would have a negative influence on the education of radiologists. This corresponds with Forsyth and Robertson (2007), who found negative influence on radiologists’ training to be the major concern of radiologists [8]. One radiographer, who was
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experienced with radiographers reporting skeletal radiographs, explained that skill mix did not mean that the radiologists would totally loose mammography reading as their task. Furthermore, reading or reporting radiographers could make an important contribution to the education of junior doctors. According to one informant this was positively experienced by doctors, since the teaching radiographers were very dedicated to their work and had more time for teaching than the radiologists. Some radiologists were concerned, that reading radiographers might take over their main tasks. Some of the radiologists explained that this view was emotionally conditioned. This concern is connected with a fear of losing demarcations, which according to Forsyth and Robertson (2007) is the radiologists’ most important reason behind a negative attitude to skill mix [8]. This may be the most important obstacle at all, and the emotional nature of the attitude even seemed to obstruct for susceptibility to skill mix as a better utilization of resources. The fear of losing demarcations was also a concern of the radiographers. None of the radiographers had negative experiences with screening mammography assistants taking over the imaging part, but especially radiographers with a workmanlike jurisdiction worried about future assistant radiographers taking over their work. Since there is a shortness of radiographers, this is also an obstacle against reading radiographers, because the radiographers’ commitment to hand over their tasks will be essential to the organisational quality. The debate on skill mix in the radiographers’ trade journal may indicate that Danish radiographers are becoming more open minded about skill mix issues. This progress could be supported by clearer statements from the National Board of Health. One radiologist and one radiographer were experienced with reading and reporting radiographers respectively. Both of them were strong advocates for having reading radiographers. None of the informants experienced with mammography assistants had negative attitudes towards this sort of skill mix. It may be that part of the obstacle against reading radiographers is caused by resistance to changes, and that time will soften up these obstacles. 4.2. Discussion of method and theory Originally, nine interviews were planned, but two were cancelled owing to ill health. The missing informants were a young doctor and a union representative radiographer, respectively. It is possible that these informants could have delivered statements relevant to especially the professional approach. The young doctor could have had an open minded professional jurisdiction and the radiographer could have had a more uncompromising professional jurisdiction. On the other hand, it is not likely that such statements would have formed completely new themes, since data saturation was already achieved through the accomplished interviews. Even though the interviewer was aware of not asking leading questions, two radiologists became more positive towards the skill mix during the interviews. This development may be caused by the dialogue itself, and one of the informants expressed after the interview, that the process itself had been illuminating. Since the recording of the interviews was successful, it was decided by the interviewer that the reliability of the transcription was acceptable even without observer triangulation. To strengthen the validity of the interviews, more specific questions could have been asked and follow-up interviews could have been done. However, the interviews produced plenty of data relevant for both possibilities and obstacles as well as for the three themes. The combined phenomenological and hermeneutical approach to the analysis was suitable, since it made both an open approach to the phenomenon and an in-depth interpretation possible.
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The theoretical approaches of the three themes all turned out to be relevant for the analysis. This, as well as inter-subjectivity of the analysis strengthened the internal validity of the results and at the same time the transferability of the results. Since the results were highly consistent with the theory and a previous study, the results from the present study are likely to be transferrable to other countries than Denmark. 5. Conclusion The results of this study indicate that there are multiple possibilities for as well as obstacles against radiographers reading screening mammograms. All the possibilities and all the obstacles can be categorized into three themes: (1) a quality approach, (2) an organisational approach and (3) a professional approach. The fact that screening mammograms are double read, that the amount of screening mammograms is large, that radiographers routinely measure the quality of their work, that radiographers can gain sufficient reading qualifications, that the skill mix itself may improve quality and that private-held radiologists may increase referral rates are all quality related possibilities. Quality related obstacles are associated with radiologists’ worries about whether radiographers can gain knowledge at sufficient level, with the fact, that radiologists do not routinely measure the quality of their performance and the availability of alternative readers. Organization related possibilities are expressed as a serious shortage of radiologists, the possibility of freeing up radiologists for other tasks, positive attitudes of managers influencing organisational culture, improved inter and intra professional working relationships, skill mix being good utilization of resources, the general expansion of skill mix in Denmark, radiographers being motivated towards new challenges and the possibility of organising the reading task along with other mammography related tasks. Organization related obstacles are presented as a shortage of radiographers and as negative attitudes of managers influencing organisational culture. Professional related possibilities are associated to skill mix being debated in radiographers’ trade journal, positive experience with reading and reporting radiographers as well as with mammography assistants. Professional related obstacles are associated with radiologists’ worries about negative consequences for the education of radiologists, the Danish National Board of Health being vague regarding skill mix, resistance among both radiologists and
radiographers against handing over tasks to other professions and some radiographers having a workmanlike understanding of their own profession and thereby being against assistant radiographers in general. The results indicate that if reading radiographers are to be implemented into the breast cancer screening programmes managers with clear positive attitudes are essential, so that an emotionally conditioned jurisdiction does not set the trend. Furthermore, establishing of a routine measurement of the radiographers’ and radiologists’ performance quality is essential. Studies on the organisational and financial quality of skill mix are highly recommended. References [1] Bro N. Screening for brystkræft ramt af store forsinkelser. Dagens Medicin; 25 April 2008. [2] Woodford A. An investigation of the impact/potential impact of a four-tier profession on the practice of radiography – a literature review. Radiography 2006;12:318–26. [3] Wivell G, Denton E, Eve C, Onglis J, Harvey I. Can radiographers read screening mammograms? Clinical Radiology 2003;58:63–7. [4] Duijm E, Groenewoud J, Fracheboud J, van Ineveld M, Roumen R, de Koning H. Introduction of additional double reading of mammograms by radiographers: effects on a biennial screening programme outcome. European Journal of Cancer 2008;10:1016–21. [5] van den Biggelaar F, Nelemans P, Flobbe K. Performance of radiographers in mammogram interpretation: a systematic review. The Breast 2008;17:87–92. [6] Dansk Forening for Radiologisk Mammadiagnostik. Formandens beretning; 2007. [7] Kletzenbauer S. Radiographers’ attitudes to skill mix changes. Radiography 1996;2:289–300. [8] Forsyth L, Robertson E. Radiologists perceptions of radiographer role development in Scotland. Radiography 2007;13:51–5. [9] Kvale S. Interview. En introduktion til det kvalitative forskningsinterview. København: Hans Reitzels Forlag a/s; 1998. [10] Dahlager L, Fredslund H, Hermeneutisk analyse In: Vallgårda S, Koch L, editors. Forskningsmetoder I folkesundhedsvidenskab. 3rd ed. København: Munksgaard Danmark; 2007. [11] Sardinelli F, Di Leo G. Biostatistics for radiologists. Italia: Springer-Verlag; 2009. [12] Bømler TU, editor. Sociale organisationer I en omstillingstid. 2nd ed. København: Hans Reitzels Forlag; 2003. [13] Bakka JF, Fivelsdal E. Organisationsteori – Struktur, Kultur, Processer. 4th ed. København: Handelshøjskolens Forlag; 2004. [14] Abbott A. The system of professions. Chicago: The University of Chicago Press; 1988. [15] Pauli R, Hammond S, Cooke J, Ansell J. Radiographers as film readers in screening mammography: an assessment of competence under test and screening conditions. The British Journal of Radiology 1996;69:10–4. [16] Deans H, Everington D, Cordiner C, Kirkpatrick A, Lindsay E. Scottish experience of double reading in the National Breast Screening Program. The Breast 1998;(7):75–9.
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European Journal of Radiology journal homepage: www.elsevier.com/locate/ejrad
Reading screening mammograms – Attitudes among radiologists and radiographers about skill mix Lena Westphal Johansen a,∗ , John Brodersen b,1 a b
Metropolitan University College, Sigurdsgade 26, 2200 Copenhagen N, Denmark Research Unit and Section for General Practice, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5, P. O. Box 2099, DK-1014 Copenhagen, Denmark
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Article history: Received 5 October 2010 Accepted 1 December 2010 Keywords: Mammography screening Attitude Radiologist Radiographer Skill mix Role development
a b s t r a c t Introduction: Because of shortage of personnel for the Danish mammography screening programme, the aim of this study was to investigate the attitudes of radiologists and radiographers towards a future implementation of radiographers reading screening mammograms. Materials and methods: Seven combined phenomenological and hermeneutical interviews with radiographers and radiologists were performed. Stratified selection was used for sampling of informants. The interviews were analysed against theory about quality, organization and profession. Results: Quality related possibilities: radiographers do routinely measure the performance quality, radiographers obtain sufficient reading qualifications, and skill mix improves quality. Quality related obstacles: radiologists do not routinely measure performance quality. Organization related possibilities: shortage of radiologists, positive attitudes of managers, and improved working relations. Organization related obstacles: shortage of radiographers and negative attitudes of managers. Professional related possibilities: positive experience with skill mix. Professional related obstacles: worries about negative consequences for the training of radiologists, and resistance against handing over tasks to another profession. Conclusion: Attitudes towards radiographers reading screening mammograms are attached to either quality-, organisational or professional perspectives. Radiographers are capable of learning to read mammograms at sufficient performance level but routine measurement of performance quality is essential. Resistance against skill mix may be caused by an emotionally conditioned fear of losing demarcations. The main motive for skill mix is improvement of the utilization of resources. No evidence was found regarding the organisational and financial consequences of skill mix. Despite of this all radiologists and radiographers experienced with skill mix were strong advocates for reading radiographers. © 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction In Denmark, a national breast screening programme has been required by law since 2008. Like in other countries, there is a shortage of personnel for the Danish mammography screening programme. This problem is partly being solved using mammography screening assistants for the imaging process. These assistants are non-radiographers given a brief course on mammography screening related radiography [1]. In the UK, this sort of skill mix is organized after The Four Tier Model in which one of the tiers also gives the opportunity for radiographers to take over at least parts of the radiologists reading of screening mammograms, i.e. as first or second readers [2].
∗ Corresponding author. Tel.: +45 72487743. E-mail addresses: [email protected] (L.W. Johansen), [email protected] (J. Brodersen). 1 Tel.: +45 35327171. 0720-048X/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrad.2010.12.023
Several papers describing the performance of radiographers reading screening mammograms have been published. Wivell et al. (2003) let two radiographers in the UK read a test set of 1000 mammograms, which had been previously read by radiologists. Ninety known interval cancers were included in the test set. The radiographers referred more women than the radiologists, but the radiographers also detected all cancers originally detected by the radiologists. Furthermore the radiographers detected 32 interval cancers of which none were detected by the radiologists. Subsequently three radiographers performed the function as second reader of 54,000 screening mammograms, which were first read by a radiologist. Neither referral rate, nor cancer detection rate, nor expenditure of time respectively was found to be significantly different between radiologists and radiographers [3]. Duijm et al. (2008) let radiologists as well as radiographers double read screening mammograms in Holland. In period A, 66,225 mammograms were double read by two certified screening radiologists. In period B, 78,325 were double read by two radiologists as well as two radiographers. All mammograms referred
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by the radiographers only were re-evaluated by the radiologists, resulting in 544 re-evaluated mammograms, 102 extra referrals and 29 extra detected cancers. The cancer detection rate per 1,000 women screened increased significantly from 4.86 to 5.62 when the mammograms were read by radiographers also, but the positive predictive value of referral decreased from 47.5% to 35.9% [4]. In a review Van den Biggelaar et al. focused on radiographers’ mammography reading performance compared to the performance of radiologists. They also looked at the effect of training. It was reported, that radiographers scored higher false-positive rates than the radiologists, however, radiographers and radiologists performed at comparable sensitivity. In one study the sensitivity was higher for the radiographers than for the radiologists. The radiographers’ performances were measured before and after training and the diagnostic odds ratio increased after training mainly because of increased specificity [5]. According to these studies, trained radiographers are capable of reading mammograms with performances similar to those of radiologists. Despite of this, there is a resistance against this type of skill mix especially among radiologists in Denmark [6]. Kletzenbauer (1996) completed a questionnaire survey on British radiographers’ attitudes to non-radiographers taking over radiographers’ tasks. The questionnaire contained topics that were mainly trade-union politically oriented. The radiographers had mainly negative attitudes to this type of skill mix, but the attitude of managing radiographers was more positive [7]. Forsyth and Robertson (2007) accomplished a questionnaire survey among 211 radiologists in Scotland, investigating the radiologists’ attitudes towards skill mix in radiography. The authors divided the results into positive and negative attitudes presented in order of priority [8]. No work has been published investigating the nature of radiologists’ and radiographers’ attitude towards radiographers reading screening mammograms. Therefore, the aim of this study was to investigate the attitudes of radiologists and radiographers to possibilities of and obstacles to a future implementation of radiographers as readers of screening mammograms in Denmark. 2. Materials and methods 2.1. Design and sampling The empirical material of this study consisted of seven individual semi-structured interviews with three radiologists and four radiographers respectively. The informants were chosen by means of stratified selection with maximum variation, representing different characteristics e.g. trade-union involvement, experience with and local organisational structure of mammography screening. The interviewees were informed in writing and orally about the aim of the present study, the interviewer’s professional background, participation being voluntary and about the possibility to withdraw. Furthermore, they were informed about anonymity of interviewees and erasure of data immediately after usage. 2.2. Data collection and analysis
The first author’s pre-understanding was influenced by her position as authorized radiographer and lecturer at the department of radiography at Metropolitan University College in Copenhagen, which has given rise to a positive attitude to radiographers’ professional development in general. Despite of the good performances of reading radiographers shown in several studies, the authors were aware of the strict quality requirements of mammography screening and of the possibility that these requirements could influence the attitudes of the informants. Therefore, a quality approach was chosen as a theme for the interview guide and the analysis. Prior to the data collection two more themes were generated from two pilot interviews. These themes were an organisational approach and a professional approach. After categorizing and reorganising the data, sixteen subcategories were generated all falling into one of the three themes. Some statements could fall into more than one theme or subcategory. For the sake of clarity, these statements were categorised according to the context in which they appeared in the interview. In this way, each statement only appears in one category. In the discussion however, results from each of the three themes are combined to achieve an overall conclusive interpretation. Both authors took part in the planning of the study’s aim, design and which methods to use. The first author conducted all the interviews, was responsible for correct transcriptions, conducted the analyses and wrote the first draft of the manuscript. The second author has contributed substantial to the final manuscript. Both authors have accepted the final version of the paper.
2.3. Theoretical approaches The theoretical basis of the quality approach was described in terms of measurement and calculation of sensitivity, specificity, positive and negative predictive values [11]. This theory constitutes the foundation of quality assessment of the reading of mammograms but it turned out to be difficult to make the interviewees deliver precise theoretically based statements on this subject. The organisational approach was described in terms of organisational culture and the organisation of hospitals as bureaucracies in which effective utilization of resources is given a high priority [12]. Bureaucracies are influenced by functionalism and rationalism in which culture is viewed as means to achieve the aims of the organization. Inter and intra professional teamwork can be supported by a symbolism, in which members of an organization are bound together creating a common frame of understanding [13]. Especially interviewees with a positive attitude to skill mix were very much aware of this approach. Abbotts’ theories of professional jurisdictional attachment, was used for the professional approach. According to Abbott, academic traditions, superior jurisdiction as well as assignments based on fixed rules are all obstacles to handing over assignments to another profession [14]. Especially interviewees with a negative attitude to skill mix delivered statements relevant for this approach.
3. Results 3.1. The quality approach
An interview guide was developed ad modum Kvale [9]. The results were validated during the interviews by means of specifying questions. Transcription as well as translation from Danish to English was done by the interviewer verbatim to the statements of the interviewees but sometimes slightly moderated in order to create meaningful translations. The transcribed interviews were analysed by means of Dahlager and Fredslunds’ four step model [10]. This model includes a phenomenologically inspired open categorization as well as a hermeneutically inspired interpretation.
3.1.1. Radiographers’ quality Most screening radiographers do routinely measure quality of their imaging performance.
RAD1: “I completely vouch for the quality of their mammograms – we review their mammograms quarterly and if they don’t pass, they have to start all over with 200 mammograms. . .”
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Implementation of reading or reporting radiographers increases quality. RAD2: “We have proven that the departments’ standard of quality increases. . .” DOC1: “I can easily picture that, because that’s how it is for radiologists.” One radiographer does not measure quality of her own imaging performance. RAD4: “We haven’t got that yet. . .we have nothing concerning the mammograms. . .” 3.1.2. Radiologists’ quality Radiographers reading of mammograms must be organized in a way, that the amount of mammograms is large enough to maintain the quality of their performance. RAD2: “If you engaged a radiographer. . .who could do the first reading from the whole region and then the radiologist could do the second reading. . .you must have a large amount of mammograms, the amount is essential for the expertise. . .” A high recall rate is a beginners’ phenomenon. DOC2: “When the radiologists begin to perform the reading. . .the recall rate. . .it decreases but it takes time, it takes time. . .that’s absolutely normal.” The radiologists did not routinely measure quality of their own performance. DOC3: “We have a group in which 11 categories have been chosen. . .but it’s relatively early yet. . .the first data are entered during 2010. . .” DOC1: “The doctors are not controlled in that way, I never thought about that. . .” 3.1.3. Quality requirements Some informants claim that radiographers should only function as first readers. DOC1: “. . .then I would use the radiographers as first readers. . .they should be permitted to bypass all those mammograms, in which they were not certain there wasn’t anything wrong.” Others do not consider it relevant to distinguish between first and second reader. DOC3: “. . .actually that’s of no interest. . .well, you do the same task whether you do the first or the second reading. . .the conditions are the same. . .” 3.1.4. Radiographers’ competence Radiographers and radiologists had positive attitudes towards radiographers’ competences. DOC1: “. . .and it’s not because they can’t rise to the challenge. . .I believe, they can easily undertake it.” RAD2: “. . .well, the message in British articles is, that experienced radiographers are just as good readers as experienced radiologists. . .”. One radiologist states that radiographers cannot obtain a suitable level of knowledge for reading mammograms.
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DOC2: “. . .but I’m not certain it’s a good idea. . .you have to obtain knowledge about pathology, physiology, anatomy eh. . . and extensive experience of breast diagnostics. . .” 3.1.5. Alternative readers Some informants state that alternative readers, as privately held radiologists can become an obstacle to reading radiographers, but there is also a risk that this way of organizing the reading may lead to increased referral rates. DOC3: “. . .private-held radiologists . . .they could be the radiographers’ rival.” RAD2: “. . .they have a private-held company reading . . .but we have three times as many referred.” 3.2. The organisational approach 3.2.1. Utilization of resources Shortage of radiologists is a serious problem, and skill mix may set them free for other tasks. DOC3: “. . .there are not enough radiologists, that’s reality . . . and then you have to look around” RAD1: “. . . the radiologists are set free to perform tasks which they should undertake but just never manage to do.” Skill mix is a financial advantage and it may help recruitment of radiographers. RAD2: “Well, it’s a financial advantage, no doubt about that. . .we haven’t had any deficit during the years with reporting radiographers. . .we get at least two radiographers for the price of one consultant radiologist. . .well, it also helps recruitment. . .we have also no problems with shortness of applicants. . .” 3.2.2. Organisational culture Managers’ positive attitude of skill mix as well as an organisational culture in which skill mix is the natural way to organize work is important for the success of skill mix implementation. RAD2: “That’s what the culture of the department should reflect. . .we simply presuppose skill mix, and actually it is a success. . .it comes all the way from the top. . .when radiologists arrive for an interview, the first thing they are asked is in which areas they see possibilities for skill mix.” Radiologists’ and radiographers’ attitudes towards skill mix may be influenced by their age. RAD3: “No, I’m brought up with the king-radiologist. . .he almost ruled the whole village. . .Maybe some of the old fogeys could be a obstacle. . .but I think, the younger radiologists will make us think differently.” RAD2: “some radiographers are not happy when younger radiographers obtain certain qualifications. . .I simply believe it is due to insecurity.” Inter professional teamwork is essential for the skill mix process and may even be improved by the implementation of skill mix. DOC3: “We have multi-disciplinary meetings in the radiology department in which the radiographers should also participate.” RAD1: “. . . you will improve teamwork when radiographers start reading mammograms. . . you will have a different dialogue between radiographer and radiologist. . .”
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3.2.3. Skill mix development in Denmark The radiographers are convinced, that reading radiographers will be introduced in Denmark. RAD2: “. . .skill mix comes like beads on a string. . .there are indicators everywhere.” RAD3: “I think they will end up screaming for our help. . .” 3.2.4. Organising the skill mix Some radiographers place great emphasis on reading radiographers being still part of the imaging team. These radiographers view the reading as part of a mammography package. RAD2: “We envisage that reading radiographers from the screening also follow the referred patients.” RAD4: “I see it as a complete mamma package in which the reading easily would fit.” 3.2.5. Radiographers motivation All interviewed radiographers are motivated towards the reading because of the professional challenge and possibility of increased salary. RAD4: “The main motivation is the education. . .and possibility of advancing, and of cause an increased salary.” 3.3. The professional approach 3.3.1. Radiologists’ profession One radiographer states, there is no risk that radiologists will totally lose their task of reading mammograms. RAD2: “. . . it is not so that they will lose reading or reporting, and that’s important. . . that they don’t just take away the task, because that will have a negative influence on the radiologists’ competences.” Radiologists resistance against letting radiographers read mammograms has to do with an emotionally conditioned jurisdiction, but it can also be caused by scepticism of innovations. DOC1: “..on the other hand I have, I won’t say trade political but rather emotional. . . our basic functions are threatened, and I am definitely against that. . .” DOC3: “I think. . .sometimes there is scepticism among the colleagues . . .Well, I guess that’s always how it is, and when something is new there is scepticism. . .” 3.3.2. Radiographers’ profession Radiographers have also resistance against handing over their tasks to other professions. RAD3: “Well, in the last trade paper they talked about assistant radiographers – at that point I was close to breakdown. . .well, I have worked like a workman. . .I think, It’s emotional. . .” All interviewed radiographers have positive attitudes to radiographers’ role extension. RAD4: “Yes, I’d love to do that. . .I would say, if I’m going to read mammograms, I also expect to receive training. . .I see it as a part of a full mamma-package. . .” 3.3.3. Radiologists’ training Reading and reporting radiographers can maintain the training of junior doctors.
RAD2: “. . .well, the reporting radiographers train the junior doctors. . .the doctors are very happy about it, because it is easy for them to get supervision and help from somebody being very enthusiastic about this. They don’t have to search for a radiologist who hasn’t got time. . .” Radiologists worry about skill mix influencing their training negatively. DOC1: “. . .if you pick out an important part of the doctors training. . .which consequences will it have? 3.3.4. Skill mix experience Some informants have experience of reading or reporting radiographers as well as of imaging mammography screenings assistants. RAD1: “They are really good. . .I become quite upset when you hear that assistants are not good at screening. . .” DOC3: “. . .it worked smoothly with this reading radiographer, she was competent. . .” 3.3.5. Trade unions and National Board of Health The Society of radiographers in Denmark has started a debate on skill mix. RAD4: “. . .a debate (on assistant radiographers) was started in the last trade journal. . .that’s the first thing I have seen. . .” One radiologist states, that involvement of the National Board of Health is essential for the implementation of reading radiographers. DOC1: “If this is supposed to succeed the National Board of Health must push it – it will not come from the radiologists. . .” 3.3.6. Training of radiographers All radiographers take a positive view towards a post graduate education and training. RAD4: “I would be happy about that. . .If I was supposed to read I would also expect to get a sufficient education.” Some informants find it problematic that no qualifying education is established in Denmark. DOC1: “Right now, we haven’t got any qualified radiographers. . .It is uncertain, whether it is a financial advantage if the radiographers must be qualified in the UK.” DOC3: “. . .if you establish a Danish education. . .I look forward to that.” 4. Discussion 4.1. Discussion of results Although none of the informants expressed their statement in terms of sensitivity or specificity, most informants claimed that radiographers are capable of learning to read mammograms. This agrees with the results of Pauli et al. (1996) who found no statistically significant difference between the performance of radiographers and the radiologists after training [15]. Only one radiologist was not certain whether the radiographers can achieve skills at a sufficient level. This is confirmed by Forsyth and Robertson (2007) who characterized lack of trust in the radiographers’ capability as a lower ranged negative attitude of radiologists [8].
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A lower specificity may be a beginner’s phenomenon rather than a radiographer’s phenomenon. This is supported by Deans et al. (1998) who found that also radiologist’s referral rates decrease in line with increasing experience [16]. Therefore, low specificity among inexperienced and non-trained radiographers should not be considered an obstacle for the skill mix. Since high referral rates may also be associated with private-held radiologists’ reading, this way of organising the reading should be subject to quality control. The radiologists did not routinely make quality assessments of their reading. This could be an obstacle to skill mix, since it may be more difficult to hand over a task to another profession when you do not know what your own performance level is. The radiographers had a well established routine of quality assessment of their own and of the assistants’ imaging performance in the units where assistants were employed. In units with no assistants, there was no quality assurance. Maybe the skill mix process itself facilitates a stronger focus on quality assurance. This may also explain the radiologists’ resistance against skill mix, because implementation of reading radiographers implies quality assessment of the radiologists reading, which is not traditionally part of their working culture. Informants experienced with radiographers reporting emergency X-rays and radiographers reading mammograms outside Denmark, all reported an increased image quality in the departments concerned. We have not been able to identify studies on reporting and reading radiographers’ influence on image quality. Therefore, such studies are recommended. There are different ways of organizing reading radiographers. According to some informants it is important that the radiographers do only undertake one part of the double reading. According to others, this is not that important as long as the quality of their performance is measured. There were different attitudes towards the question whether the amount of screening mammograms would be large enough to maintain the radiographers reading expertise. One informant stated that reading radiographers should be localized in few central units in order to solve this problem, which is not a practical problem with the new technology of digital mammograms. Utilization of resources seemed to be the most important argument for letting radiographers read. This is supported by Forsyth and Robertson (2007) who state that most important positive attitudes to skill mix are; an increased recruitment of radiographers, a better usage of personnel, and a reduction of radiologists’ work load [8]. No evidence has been identified about the organisational quality of skill mix. Since some of the informants in this study had answers to questions of how skill mix helps recruitment and how skill mix should be organized and financed, it is highly recommended that studies on these subjects are undertaken. The working relationship between radiologist and radiographer is important for the success of skill mix and according to some informants the radiographers must participate in multi-disciplinary meetings. Some even state, that the skill mix may improve inter and intra professional teamwork. Positive or negative manifestations from the managers of the department and hospital are essential for how skill mix influences and develops organisational culture. It seems that radiographers are motivated towards undertaking the task of reading mammograms as well as towards the required training, especially if the reading is a part of a larger mamma package in which both imaging and patient interaction duties of the radiographer. The development of the skill mix area in Denmark could indicate, that implementation of radiographers in the reading of mammograms is only a matter of time. One radiologist was concerned about whether the radiographers’ reading would have a negative influence on the education of radiologists. This corresponds with Forsyth and Robertson (2007), who found negative influence on radiologists’ training to be the major concern of radiologists [8]. One radiographer, who was
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experienced with radiographers reporting skeletal radiographs, explained that skill mix did not mean that the radiologists would totally loose mammography reading as their task. Furthermore, reading or reporting radiographers could make an important contribution to the education of junior doctors. According to one informant this was positively experienced by doctors, since the teaching radiographers were very dedicated to their work and had more time for teaching than the radiologists. Some radiologists were concerned, that reading radiographers might take over their main tasks. Some of the radiologists explained that this view was emotionally conditioned. This concern is connected with a fear of losing demarcations, which according to Forsyth and Robertson (2007) is the radiologists’ most important reason behind a negative attitude to skill mix [8]. This may be the most important obstacle at all, and the emotional nature of the attitude even seemed to obstruct for susceptibility to skill mix as a better utilization of resources. The fear of losing demarcations was also a concern of the radiographers. None of the radiographers had negative experiences with screening mammography assistants taking over the imaging part, but especially radiographers with a workmanlike jurisdiction worried about future assistant radiographers taking over their work. Since there is a shortness of radiographers, this is also an obstacle against reading radiographers, because the radiographers’ commitment to hand over their tasks will be essential to the organisational quality. The debate on skill mix in the radiographers’ trade journal may indicate that Danish radiographers are becoming more open minded about skill mix issues. This progress could be supported by clearer statements from the National Board of Health. One radiologist and one radiographer were experienced with reading and reporting radiographers respectively. Both of them were strong advocates for having reading radiographers. None of the informants experienced with mammography assistants had negative attitudes towards this sort of skill mix. It may be that part of the obstacle against reading radiographers is caused by resistance to changes, and that time will soften up these obstacles. 4.2. Discussion of method and theory Originally, nine interviews were planned, but two were cancelled owing to ill health. The missing informants were a young doctor and a union representative radiographer, respectively. It is possible that these informants could have delivered statements relevant to especially the professional approach. The young doctor could have had an open minded professional jurisdiction and the radiographer could have had a more uncompromising professional jurisdiction. On the other hand, it is not likely that such statements would have formed completely new themes, since data saturation was already achieved through the accomplished interviews. Even though the interviewer was aware of not asking leading questions, two radiologists became more positive towards the skill mix during the interviews. This development may be caused by the dialogue itself, and one of the informants expressed after the interview, that the process itself had been illuminating. Since the recording of the interviews was successful, it was decided by the interviewer that the reliability of the transcription was acceptable even without observer triangulation. To strengthen the validity of the interviews, more specific questions could have been asked and follow-up interviews could have been done. However, the interviews produced plenty of data relevant for both possibilities and obstacles as well as for the three themes. The combined phenomenological and hermeneutical approach to the analysis was suitable, since it made both an open approach to the phenomenon and an in-depth interpretation possible.
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The theoretical approaches of the three themes all turned out to be relevant for the analysis. This, as well as inter-subjectivity of the analysis strengthened the internal validity of the results and at the same time the transferability of the results. Since the results were highly consistent with the theory and a previous study, the results from the present study are likely to be transferrable to other countries than Denmark. 5. Conclusion The results of this study indicate that there are multiple possibilities for as well as obstacles against radiographers reading screening mammograms. All the possibilities and all the obstacles can be categorized into three themes: (1) a quality approach, (2) an organisational approach and (3) a professional approach. The fact that screening mammograms are double read, that the amount of screening mammograms is large, that radiographers routinely measure the quality of their work, that radiographers can gain sufficient reading qualifications, that the skill mix itself may improve quality and that private-held radiologists may increase referral rates are all quality related possibilities. Quality related obstacles are associated with radiologists’ worries about whether radiographers can gain knowledge at sufficient level, with the fact, that radiologists do not routinely measure the quality of their performance and the availability of alternative readers. Organization related possibilities are expressed as a serious shortage of radiologists, the possibility of freeing up radiologists for other tasks, positive attitudes of managers influencing organisational culture, improved inter and intra professional working relationships, skill mix being good utilization of resources, the general expansion of skill mix in Denmark, radiographers being motivated towards new challenges and the possibility of organising the reading task along with other mammography related tasks. Organization related obstacles are presented as a shortage of radiographers and as negative attitudes of managers influencing organisational culture. Professional related possibilities are associated to skill mix being debated in radiographers’ trade journal, positive experience with reading and reporting radiographers as well as with mammography assistants. Professional related obstacles are associated with radiologists’ worries about negative consequences for the education of radiologists, the Danish National Board of Health being vague regarding skill mix, resistance among both radiologists and
radiographers against handing over tasks to other professions and some radiographers having a workmanlike understanding of their own profession and thereby being against assistant radiographers in general. The results indicate that if reading radiographers are to be implemented into the breast cancer screening programmes managers with clear positive attitudes are essential, so that an emotionally conditioned jurisdiction does not set the trend. Furthermore, establishing of a routine measurement of the radiographers’ and radiologists’ performance quality is essential. Studies on the organisational and financial quality of skill mix are highly recommended. References [1] Bro N. Screening for brystkræft ramt af store forsinkelser. Dagens Medicin; 25 April 2008. [2] Woodford A. An investigation of the impact/potential impact of a four-tier profession on the practice of radiography – a literature review. Radiography 2006;12:318–26. [3] Wivell G, Denton E, Eve C, Onglis J, Harvey I. Can radiographers read screening mammograms? Clinical Radiology 2003;58:63–7. [4] Duijm E, Groenewoud J, Fracheboud J, van Ineveld M, Roumen R, de Koning H. Introduction of additional double reading of mammograms by radiographers: effects on a biennial screening programme outcome. European Journal of Cancer 2008;10:1016–21. [5] van den Biggelaar F, Nelemans P, Flobbe K. Performance of radiographers in mammogram interpretation: a systematic review. The Breast 2008;17:87–92. [6] Dansk Forening for Radiologisk Mammadiagnostik. Formandens beretning; 2007. [7] Kletzenbauer S. Radiographers’ attitudes to skill mix changes. Radiography 1996;2:289–300. [8] Forsyth L, Robertson E. Radiologists perceptions of radiographer role development in Scotland. Radiography 2007;13:51–5. [9] Kvale S. Interview. En introduktion til det kvalitative forskningsinterview. København: Hans Reitzels Forlag a/s; 1998. [10] Dahlager L, Fredslund H, Hermeneutisk analyse In: Vallgårda S, Koch L, editors. Forskningsmetoder I folkesundhedsvidenskab. 3rd ed. København: Munksgaard Danmark; 2007. [11] Sardinelli F, Di Leo G. Biostatistics for radiologists. Italia: Springer-Verlag; 2009. [12] Bømler TU, editor. Sociale organisationer I en omstillingstid. 2nd ed. København: Hans Reitzels Forlag; 2003. [13] Bakka JF, Fivelsdal E. Organisationsteori – Struktur, Kultur, Processer. 4th ed. København: Handelshøjskolens Forlag; 2004. [14] Abbott A. The system of professions. Chicago: The University of Chicago Press; 1988. [15] Pauli R, Hammond S, Cooke J, Ansell J. Radiographers as film readers in screening mammography: an assessment of competence under test and screening conditions. The British Journal of Radiology 1996;69:10–4. [16] Deans H, Everington D, Cordiner C, Kirkpatrick A, Lindsay E. Scottish experience of double reading in the National Breast Screening Program. The Breast 1998;(7):75–9.