Assistants take on additionaltasks, inch toward payment

During 18 years as a radiologic technologist, Jeff Crowley acknowledged he sometimes thought, "Oh, I can do that," while assisting with procedures.

But since becoming a radiology assistant, a job that allows him to perform certain procedures himself, Crowley's views have evolved.

"You end up gaining a lot of respect for the radiologist. The skill of being able to delicately manipulate catheters and wires-they make it look easy, but it's difficult," he said.

He'd reached the ceiling as a technologist and found that he could advance his career by securing a certificate as a Radiology Practitioner Assistant first. But because he had a bachelor's degree, Crowley was eligible to take an exam to become a certified Radiology Assistant, a new career path that's gaining momentum in imaging, though it is far from reaching its full potential.

For Crowley, the move signaled a dramatic change at Premier Radiology in Tupelo, MS. Not only is he doing work he used to eye from the sidelines, Crowley picks up slack for the practice, allowing time-pressed radiologists to focus on reads and high-end procedures.

A typical day for him starts with a briefing on cases with a supervisor in fluoroscopy. He then checks in with the interventional radiologists to talk about any interesting assignments. And he's rolling.

"The pager goes off, and I go from one thing to another," Crowley said.

Crowley rotates from PICC lines to central venous procedures to fluoroscopy, all in a day's work at North Mississippi Medical Center, where Premier provides imaging services.

"I went back to school at age 40, which was difficult," Crowley said of juggling night school and full-time job responsibilities.

The radiologists at Premier recognized the potential in such an endeavor and invested in his education. Having completed the rigorous program, Crowley has a renewed feeling of career satisfaction. "It took me to this level where I could be content retiring from," he said. "I wouldn't look for anything higher."

Technologists-turned-RAs can see annual salaries balloon from $58,000 to $80,000-plus. But Crowley insists the money isn't the only draw. There are intangible perks, such as the challenge of clinical work and camaraderie with radiologists he admires.

"It took a while for some of the referring physicians to get used to it. But I've been at that hospital for 20 years, so they knew me," Crowley said.

"They'd see me working and say what are you doing? And I'd say, 'I went to school for this.'"

The doctors at Premier see the payoff.

"He's very helpful in doing some of our less invasive interventional procedures," said Dr. Jeffrey Howard, one of 15 radiologists at Premier.

With Crowley on hand, workflow has improved. Radiologists have more time to focus on image interpretations. Turnaround time is quicker. And everyone goes home earlier.

"We notice a big difference when he's not here," Howard said. "We get a lot more work done with him in here."

But for all Crowley has added to the group, Howard said he would not consider hiring a second RA at this time. Rather, the practice is thinking of adding a nurse practitioner.

"The reason is that (Crowley) as an RA cannot function independently," Howard said. "He has no provider number. We need to have a clinic in interventional radiology, and I need someone who can function more independently. He could probably function independently in a lot of ways, but he's not allowed to do so."

And therein is the biggest challenge facing RAs.

By all indications the career path is growing: Academic programs are sprouting, enrollment is up, and radiology groups overall seem interested in adding RAs to the staff.

But until their role is expanded, RAs find their usefulness to a radiology group will remain limited.

Crowley and others must negotiate physician supervision levels and reimbursement guidelines with the Centers for Medicare and Medicaid Services. Unlike radiology practitioner assistants (RPAs), who paved the way for radiology extenders but still struggle for respect and recognition in the field, RAs are well positioned to do this.

RAs, on the whole, have the support of major players. The American College of Radiology is agitating for them. The American Society of Radiologic Technologists has appointed Crowley to its 2007-08 Task Force on RA Membership and Governance Implementation.

"Right now, the RA is perceived to have a limited role," Crowley said. "But I want to broaden it out to fit the practice better."

His newly empowered stance illuminates a second source of tension for RAs: the ongoing turf battle with their RPA counterparts. Efforts to combine the positions have fallen apart and fundamental ideals keep the two divided.

To understand a way around these obstacles, one needs a primer on how the RA model came to be, what's happening now-on the ground and behind the scenes-to bolster its position, and what the future holds for this nascent field.

BIRTH OF A CAREER PATH

The radiology assistant was born out of necessity. Confronted with increasing workloads, a growing demand for imaging, and a nationwide shortage of radiologists (as well as technologists), the ACR and ASRT joined forces to carve out this new career path.

In 2003, the ACR council voted in support of the Joint ACR/ASRT Statement on the Roles and Responsibilities of the Radiologist Assistant. The radiologist assistant was designed to be an advanced-level radiologic technologist who works under a radiologist's supervision. RAs have the knowledge and skill to carry out certain procedures but cannot formally interpret images or bill for service. "I'm proud to say that the development and acceptance of the RA concept has occurred more quickly than we envisioned," said Dr. Charles Williams in an editorial in the June 2005 ACR bulletin.

The RA model was touted as a tangible solution to staffing pressures and an attractive opportunity for technologists interested in advancing their careers. The chances for success were greatly enhanced thanks to the concept of an advanced-practice radiologic technologist having already been tried and proven.

According to an ACR white paper posted in 2007, radiology physician assistant programs were initiated in the 1970s at the University of Kentucky, Brown University, and Duke University. Those programs eventually closed due to perceived lack of demand, but the idea was resurrected in 1996, when the Department of Defense asked Weber State University to design a radiology practitioner assistant program to address a shortage of radiologists in the armed forces medical programs.

Weber State continued the program well after the DOD withdrew support due to budgetary cutbacks.

RPAs were mavericks who proved radiologic extenders could work side by side with physicians, not replace them. RPAs blazed the trail for RAs but now stand to be replaced by the fledgling RA enterprise. University programs for RAs are cropping up across the country, enrollment is becoming increasingly competitive, and more practices are inquiring about how to hire an RA or put one of their own technologists through school.

"From the beginning, we were very interested in offering a pathway for technologists who enjoyed doing flouro work or patient contact and wanted a new challenge but didn't want to go into modality," said Dr. Donna Wright, program director and professor at Midwestern State University in Wichita Falls, TX, which offers both an online bachelor's degree in radiologic science and a new master'slevel track for RAs.

University programs are small by design. Midwestern State enrolled just four students into the inaugural year of its master's program.

"We will always have fairly small classes because the clinical component is very intensive," Wright said. "We are definitely not a puppy mill."

All RA programs are at a baccalaureate degree or higher and include a radiologist-directed clinical preceptor component. RAs must also get certified by the American Registry of Radiologic Technologists and fulfill continuing education requirements to maintain ARRT registration.

Though RAs need to have an undergraduate degree at minimum, some schools have created an advanced degree to give students a competitive edge.

"The advantage professionally is they are now standing shoulder to shoulder with other groups that have master's degrees," Wright said of the RAs in her program. "They have an uphill battle for professional recognition as it is." It is too soon to say whether RAs are actually answering the radiologist shortage. But those on the front lines say this is a step in the right direction.

"Even though they may be helping alleviate [the shortage] somewhat, I'm not sure we have enough RAs out there to make a noticeable difference yet," said University of Arkansas professor Rebecca Ludwig, Ph.D. "What I do hear is that these graduates are very helpful, very productive, and a help to their practice."

RACE TO REIMBURSEMENT

It helps to have a positive image, but good PR and anecdotal evidence can carry RAs only so far. To validate their utility in a clinical setting, RAs must present a strong case for reimbursement to CMS. It's a long, protracted process. It took nearly 15 years for CMS to recognize physician assistants, said Christine Lung, director of governmental relations for the ASRT.

"We've been working on this for about three years now and are getting ready to gear up [for] a congressional campaign," Lung said.

The ACR is putting some weight behind the effort, too.

But RAs aren't the only ones clamoring for recognition. Remember their predecessors, the RPAs who fell by the wayside when the RA model sprang to life?

Their relative numbers alone make RPAs a force to reckon with. The 400-member National Society of Radiology Practitioner Assistants (NSRPA) is on the move, its leaders determined to fight for members across the country who have more experience than RAs but lack their high-level support and educational pedigree.

"It comes down to power, politics, and personality. We are a bigger entity than the RAs, but they've got rich grandparents," said James Abraham, vice president of NSRPA.

The saga of relations between the groups is about as protracted as the CMS reimbursement process, but here's the skinny: RPAs have experience and longevity under their belt, the ACR does not recognize them.

"Their whole scope of practice was not vetted by the ACR," said Dr. Bibb Allen, chair of the ACR Economics Commission.

The ACR strongly encourages its members to choose RAs over any other type of extender.

"We like the idea of an RA being under direct supervision of radiologists and are very supportive of that," Allen said. "We have an interest in keeping it moving along." Efforts to grandfather RPAs into the more widely supported RA model, which all parties involved agree makes the most sense, fell flat. The ARRT, which administers the RA examination, refused to bend on the degree requirement. Meanwhile, many RPAs who lack bachelor's degrees scoff at the notion of having to go back to school.

"We started this out. There are people who are abrasive about that," Abraham said of some NSRPA members. "I think it's sad that we are not able to merge and get this together."

It comes down to pride.

"We worked hard to get where we are at," he said. "We sacrificed two years of our lives. I spent over 2500 hours of clinical time in radiology. Most PA programs don't spend 100 hours on radiology. So I think there is an underlying sense of 'gosh, haven't we paid our dues already?'" At this point there is no pathway to merge or grandfather RPAs into the RA model. The only way the groups will come together is via the ARRT examination for RA certification.

Unwilling to yield, RPAs have become mavericks once again, eschewing conventions and going straight to CMS in the hopes of gaining recognition first, said Thomas "Wade" Carrington, president of the NSRPA.

"If the RA gets reimbursement before the RPA, you'll see a lot of RPAs breaking their necks to take that test," he said.

Meanwhile, the other team has fanned out across many fronts.

There's Crowley, working hard to prove himself daily to the Mississippi radiologists who depend on him and bringing the RA perspective to the ARRT board of trustees.

The ACR has thrown its weight behind the RA reimbursement effort and is now waiting to hear from CMS.

"In the interim, we've also sort of taken the tack that maybe we need to get Congress to tell them to create this category," Allen said.

The ASRT is working with state legislatures on RA recognition, a much easier feat than convincing the federal government that RAs are to radiology practice as PAs are to physician practice.

"The issue with CMS is, first of all, there's not a significant number of RAs," Lung said.

Even if you count RPAs, the totals are still fewer than 500.