Overview Role of a Consultant Radiographer A reflective account

Part 1
Clinical roles of the breast consultant radiographer

Part 2
A reflection on aspects of the broader consultant role
1. 2. 3.

Judith Kelly Peter Hogg

4.

Expert clinical practice Professional leadership Practice and service development Education and training

Final reflective thoughts

Clinical roles of the breast consultant radiographer

Decision making in imaging Imaging Image interpretation Clinical examination Further diagnostic work-up workCommunication
Patient Multidisciplinary team members

Part 1

Lesion mark-up for surgical removal markImaging of resected abnormality

Decision making in imaging

Standard 2 view mammogram (or ultrasound)

Imaging
I conduct imaging procedures as appropriate, e.g. ultrasound
For further evaluation of a perceived mammographic abnormality As first-line investigation in symptomatic women first<35. (Males also) Patient has normal mammogram but clinical abnormality Clinical suspicion of implant complication e.g rupture Post-surgical seroma development Post-

Abnormal Decision Are further images needed?

Normal (back to clinician)

Normal back to clinician X-Ray guided biopsy

Abnormal

Ultrasound +/intervention (FNAC/Biopsy) Request MRI

Image interpretation
Mammogram and Ultrasound
Description of what I see Diagnosis, if possible Advice regarding further diagnostic work-up workCommunicate to Referrer

Clinical Examination
If abnormality perceived:
On mammogram, or or By patient, or or By General Practitioner, or or By clinician/breast care nurse

Then
I may perform a physical examination of the breast prior to ultrasound scan and, I take additional, relevant clinical history

Further Diagnostic Work-up

Undertake further evaluation
Clarify the nature of the abnormality

Communication
Patient
Establish what my patient knows already Make decision about what they need to know I may break bad news news

I do image-guided interventional work: imageCyst/seroma/abscess aspiration Cyst/seroma/abscess Fine needle aspiration cytology Core biopsy Vacuum-assisted biopsy VacuumInsertion of markers

Multi-disciplinary Team MultiSend the Referrer my diagnosis in writing Contribute to case conferences

Lesion Mark-up for Surgery

Image guided localisation of abnormalities
X-ray, or or Ultrasound, or Sometimes both

Imaging of resected specimen

Specimen is imaged (X-rayed) (XI report on this image direct to the surgeon, whilst patient still in theatre

1. Expert Clinical Practice

Part 2
Part 1 outlined this 1 Reflection on my practice
The imaging care pathway Image-guided intervention ImageCommunicating the result to the patient

A reflection on aspects of the broader consultant role

The imaging care pathway

Before Advanced Practice or gf in ait kw s e e e nt 6 w tm al oin ti p t e n ap o P

2 view mammogram Abnormal
2 week wait

Normal

2 week wait

Decision

Are further images needed?

Normal

Abnormal
2 week wait

2 week wait

X-Ray guided biopsy

2 week wait

Request MR
6 week wait

Ultrasound
2 week wait

With Advanced Practice (now)

Are further images needed?

Normal

Immediate

X-Ray guided biopsy

Immediate or 1 week

r l fo ce tia vi s) en er t s ek o y P we da 6 me be Sa ld ou c R (M
Abnormal
2 hour wait

2 view mammogram

Normal

2 hour wait

Decision

Image-guided intervention Image-

Abnormal
Immediate

Request MR
6 week wait

Ultrasound

Immediate or 1 week

Image interpretation
High level of job satisfaction because I complete the whole job job but with this greater autonomy comes greater accountability and greater pressure, for example example

Negligence Claim
Patient perceived that Breach of Duty occurred; Alleged that
Lesion inaccurately localised by me Healthy tissue was surgically removed, consequently Abnormality was not removed Patient disfigured because healthy tissue removed disfigured This became a legal claim handled through lawyers Hospital is defending the claim, because There is a small risk of this occurring and the patient was made aware of this before surgery

Negligence Claim
How do I feel about this?
Its been dragging on for 2.5 years It Indignant not at fault (vindicated by enquiries) Exposed/isolated/in the dock Anxious Disappointed sense of failure Confidence reduced But, I still believe in my ability

Communicating the result to the patient

Doctors have dealt with these sorts of legal with claims for decades but it is new to us.

Communication
Patient perspective, a scenario
24 year old female
Has boyfriend, going to get married, about to start 1st job

Communication
I gave her the bad news regarding the likely diagnosis
Lots of questions raised about treatment What is the prognosis? Tearful and upset

Ultrasound and Mammography

Clinically large, hard mass (3-4 cms) (3- cms) Present for 6 months and not taken any action Imaging showed large, irregular, very suspicious mass. Prognosis poor (20% 5 year survival)

Giving bad news

I answer questions I am confident to answer Afterwards I refer patient to breast care nurse Discussion takes around 15-30 minutes 15I feel drained after having patients who take the news drained badly badly

Objective Performance indicators

Image interpretation
Sensitivity / Specificity (Performs, 2 yearly national ( Performs self- audit using test film sets) selfTo national standards Department outcomes audited.

2. Professional Leadership
What characterises leadership1?
Drive Self belief Political astuteness Leading people through change Empowering others Effective strategic influencing Facilitate collaborative working
1. Hogg P, Hogg D and Bentley HB, Leadership in the development of the radiographic profession, Imaging and Oncology, 5460, ISBN 1 871 101 360

Interventional work (all self-audited) selfSensitivity for image-guided core biopsies is >90% at imagefirst attempt. Accuracy for localisations only 1 case of missed abnormality at surgery (already discussed.) abnormality All work is open to peer scrutiny!

Professional Leadership
What characterises this - a reflection:
Self belief
Resilient in face of adversity (+ working with doctors)

Professional Leadership
Facilitating collaborative working A reflection on being a Guest Editor
Special issue on consultant and advanced practice To share ideas and experiences internationally As Editor I am facilitating this sharing process Helped bring a national team together I play a pivotal coordination role in the team I am looking forward to a high quality publication

Leading people through change

Implementing new biopsy technique

Empowering others
Develop clinical staff

Effective strategic influencing

National working group membership Member of national forum for consultants

Facilitate collaborative working

Guest editor of international journal

3. Practice and Service Development

Leadership sits hand in hand with this Examples
Initiating clinical research Initiating clinical audit Implementing new local practices Implementing evidence-based practice evidence-

Practice and Service Development

Implementing evidence-based practice evidenceI gather information from various sources I select what appears to be clinically useful information Within the local team we agree
Whether the information would be useful Whether we wish to use the information in practice How we will use the information in practice How we will implement new ways of working How we will audit our practice

4. Education and Training

Publish and present work
Professional journals Conferences Study days

Education and Training

Project supervision: Undergraduate students
1 student per year 5-6 meetings per year Email support given I mark the final project

Teach
Undergraduate students Postgraduate students Medical students undergraduate Medical registrars

Reflection on this
Educational for me process and outcome I am aware this is a major responsibility Has worked successfully so far

Project supervision
Undergraduate students

Final Reflective Thoughts

Its definitely not a 9-5 job It 9High level of commitment, time and emotional energy required. It is demanding
Difficult clinical cases Possibility of legal claims

I often worry that I am not fulfilling my job role adequately ButI really enjoy it But