Overview. Role of a Consultant Radiographer A reflective account. Clinical roles of the breast consultant radiographer. Part 1

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1 Overview Role of a Consultant Radiographer A reflective account Judith Kelly Peter Hogg Part 1 Clinical roles of the breast consultant radiographer Part 2 A reflection on aspects of the broader consultant role 1. Expert clinical practice 2. Professional leadership 3. Practice and service development 4. Education and training Final reflective thoughts Clinical roles of the breast consultant radiographer Part 1 Decision making in imaging Imaging Image interpretation Clinical examination Further diagnostic work-up Communication Patient Multidisciplinary team members Lesion mark-up for surgical removal Imaging of resected abnormality Decision making in imaging Decision Are further images needed? back to clinician X-Ray guided biopsy Standard 2 view mammogram (or ultrasound) Request MRI (back to clinician) Ultrasound +/- intervention (FNAC/Biopsy) 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 <35. (Males also) Patient has normal mammogram but clinical abnormality Clinical suspicion of implant complication e.g rupture Post-surgical surgical seroma development 1

2 Image interpretation Mammogram and Ultrasound Description of what I see Diagnosis, if possible Advice regarding further diagnostic work-up Communicate to Referrer Clinical Examination If abnormality perceived: On mammogram, or By patient, or By General Practitioner, 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 I do image-guided guided interventional work: Cyst/seroma seroma/abscess aspiration Fine needle aspiration cytology Core biopsy Vacuum-assisted assisted biopsy Insertion of markers Communication Patient Establish what my patient knows already Make decision about what they need to know I may break bad news Multi-disciplinary Team Send the Referrer my diagnosis in writing Contribute to case conferences Lesion Mark-up for Surgery Imaging of resected specimen Image guided localisation of abnormalities X-ray, or Ultrasound, or Sometimes both Specimen is imaged (X-rayed) I report on this image direct to the surgeon, whilst patient still in theatre 2

3 1. Expert Clinical Practice Part 2 A reflection on aspects of the broader consultant role Part 1 1 outlined this Reflection on my practice The imaging care pathway Image-guided guided intervention Communicating the result to the patient The imaging care pathway Before Advanced Practice Decision Are further images needed? 2 view mammogram Potential 6 week waiting for appointments X-Ray guided biopsy Request MR 6 week wait Ultrasound With Advanced Practice (now) Decision Are further images needed? Immediate 2 hour wait X-Ray guided biopsy 2 view mammogram Potential for Immediate or 1 week Same day service Immediate 2 hour wait (MR could be 6 weeks) Request MR Ultrasound Immediate or 1 week 6 week wait Image-guided guided intervention 3

4 Image interpretation High level of job satisfaction because I complete the whole job but with this greater autonomy comes greater accountability and greater pressure, for example Negligence Claim Patient perceived that Breach of Duty occurred; Alleged that Lesion inaccurately localised by me Healthy tissue was surgically removed, consequently ity was not removed Patient disfigured because healthy tissue removed 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? It s s been dragging on for 2.5 years 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 Doctors have dealt with these sorts of legal claims for decades but it is new to us. Communicating the result to the patient Communication Patient perspective, a scenario 24 year old female Has boyfriend, going to get married, about to start 1 st job Ultrasound and Mammography Clinically large, hard mass (3-4 cms) Present for 6 months and not taken any action Imaging showed large, irregular, very suspicious mass. Prognosis poor (20% 5 year survival) Communication I gave her the bad news regarding the likely diagnosis Lots of questions raised about treatment What is the prognosis? Tearful and upset Giving bad news I answer questions I am confident to answer Afterwards I refer patient to breast care nurse Discussion takes around minutes I feel drained after having patients who take the news badly 4

5 Objective Performance indicators Image interpretation Sensitivity / Specificity ( Performs( Performs,, 2 yearly national self- audit using test film sets) To national standards Department outcomes audited. Interventional work (all self-audited) Sensitivity for image-guided guided core biopsies is >90% at first attempt. Accuracy for localisations only 1 case of missed abnormality at surgery (already discussed.) All work is open to peer scrutiny! 2. Professional Leadership What characterises leadership 1? 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, 54-60, ISBN Professional Leadership What characterises this - a reflection: Self belief Resilient in face of adversity (+ working with doctors) 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 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 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 Practice and Service Development Implementing evidence-based practice I 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 5

6 4. Education and Training Publish and present work Professional journals Conferences Study days Teach Undergraduate students Postgraduate students Medical students undergraduate Medical registrars Project supervision Undergraduate students Education and Training Project supervision: Undergraduate students 1 student per year 5-66 meetings per year support given I mark the final project Reflection on this Educational for me process and outcome I am aware this is a major responsibility Has worked successfully so far Final Reflective Thoughts It s s definitely not a job High 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 But I I really enjoy it 6

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