CT Education for the Nuclear Medicine Technologist performing CT fusion imaging
A Correlation Study between CT education and Job Performance of Nuclear Medicine Technologist Performing CT Fusion Imaging
Tamara L. Beck
East Tennessee State University
Research in Allied Health
Abstract
CT fusion imaging has created educational challenges for nuclear medicine technologist performing PET/CT imaging since its introduction in 2001. Obtaining CT education in order to provide quality and competent patient care is a challenge for Nuclear medicine technologists performing PET/CT. Nuclear medicine technologists in non-licensure states have particularly been affected. The main purpose of this study is to evaluate the CT Cross Trainer educational method and its impact on job performance of 16 nuclear medicine technologists in North Carolina . This is a non-experimental quantitative research study which utilizes a questionnaire to collect data. Personal and professional demographic data will be collected and used to analyze a correlation coefficient between CT education and job performance. This study will provide feedback for the study participants and may be used for other nuclear medicine technologists considering the CT Cross Trainer educational method.
Chapter 1 Introduction
Background
Nuclear Medicine has been referred to as “unclear” medicine due to its inability to distinguish anatomical information. It is very sensitize in demonstrating functional information and abnormalities but exactly where that abnormality lies anatomically is unclear with nuclear medicine images. Computerized Tomography (CT) is well respected for its high resolution anatomical images (Christian & Waterstram-Rich, 2007). Positron emission tomography (PET) or single photon emission computerized tomography (SPECT) provides sensitive physiologic information and is the most advanced imaging procedures performed in nuclear medicine today (Christian & Waterstram-Rich). The combination of PET or SPECT with CT is called fusion imaging (Christian & Waterstram-Rich). The fused image represents both anatomical information from the CT and functional information from PET or SPECT (Christian & Waterstram-Rich). Fusion images are extremely beneficial for the radiologist because they can look at one image and match the abnormality with the exact location. The first commercially available system that combined CT and PET in one scanner was available in early 2001 (Townsend, Carney, Yap , & Hall, 2004). This hybrid PET/CT scanner merges two different imaging modalities with different educational backgrounds, thus creating confusion among CT and nuclear medicine technologists.
Since both modalities require separate certification, the question of who should operate a hybrid PET/CT scanner surfaced. The American Society of Radiologic Technologists and The Society of Nuclear Medicine met in 2002 and established consensus statements regarding personnel qualifications and regulations of professionals who operate PET/CT equipment. The conference participants concluded that any registered radiographer R.T (R), or registered nuclear medicine technologist R.T (N), or CNMT could operate a PET/CT scanner with additional education or training (“Fusion Imaging,” 2002). A second conclusion was that individual states should act independently to enforce their recommendations since licensure laws vary from state to state for imaging technologist and the CARE bill is not active, (“Fusion Imaging”). The ASRT and the SNM consensus conference report “recommended that multiple pathways be created to educate or train registered nuclear medicine technologist, radiographers and radiation therapists to operate PET-CT equipment” (“Fusion Imaging,” p. 203).
One of the populations most affected by this educational dilemma is current certified nuclear medicine technologist in non-licensure states performing PET/CT or SPECT/CT. They are still faced with the problem of how to obtain additional CT education and training in order to have basic CT knowledge. They have several options such as accredited CT programs, workshops offered through the SNM or the CT cross trainer by Medical Imaging Consultants. PET/CT fusion imaging is very exciting but presents several educational challenges for technologists. Since CT fusion imaging is quickly becoming a standard of care in nuclear medicine, technologists must embrace these educational challenges.
Purpose
This study will attempt to evaluate the educational method of the CT cross trainer and the impact on job performance for the registered nuclear medicine technologist performing PET/CT fusion imaging. Through the collection of data this study will attempt to evaluate the relationship of CT education and job performance. The collected data should provide useful information for the nuclear medicine technologist at Forsyth Medical Center in Winston Salem, NC who have completed the CT cross trainer. The results may benefit other technologists who may consider using the CT cross trainer as an educational method.
Significance
Since CT fusion imaging is becoming a standard of care in nuclear medicine, the information gained by conducting this study should provide useful information regarding CT education and the impact on job performance for practicing nuclear medicine technologists performing PET/CT. Technologists may use the data collected when choosing the CT cross trainer as an additional education method.
Research Question
The main question addressed in this study is: Does the CT education improve job performance for the nuclear medicine technologist performing PET/CT fusion imaging?
As a result of using one particular educational method, one other research question should be answered: How would the technologist score the CT cross trainer as a CT educational training method? Personal and professional demographic questions of participants should also be answered.
Assumptions
The data will be collected through a questionnaire given to nuclear medicine technologist who perform PET/CT and have completed the CT cross trainer. One can assume that the technologist will complete and answer the questions honestly and the questionnaire will be reliable and valid.
Limitations
Limitations in this study include:
1. The lack of a control group since it would be unacceptable to perform a PET/CT procedure without training
2. The use of only one CT educational training method
3. The lack of standardized instruments to measure data
4. The use of a convenience sample may result in the lack of generalization
Chapter 2 Review of Literature
This chapter contains the review of literature regarding CT fusion imaging, particularly to PET. The review will be organized in the following order: the importance of PET/CT; the nuclear medicine technologist’s education challenges, and CT educational methods for the nuclear medicine technologist.
Importance of PET/CT
The introduction of the combined PET/CT scanner led to several documentations on the importance and advantages of PET/CT fusion imaging. Townsend and Beyer (2002) state, “…the combined PET/CT scanner will have a significant impact on patient care, survival and quality of life” (p. S29). An article entitled “PET/CT Today and Tomorrow” from the Journal of Nuclear Medicine states “…migration from PET to PET/CT appears to be irreversible as an increasing number of physicians become familiar with the new technology” (Townsend, Carney, Yapp & Hall, 2004, p. 135). Mettler and Guiberteau (2006) list “…more efficient and accurate attenuation correction, shorter imaging times, more precise anatomic localization of lesions, and acquisition of diagnostic CT and PET scans in one effort” as advantages of PET/CT fusion imaging (p. 376). As a result of these advantages PET/CT fusion imaging has become a valuable imaging procedure for both the patient and physician.
Challenges for PET/CT technologists
The combination of different imaging modalities resulted in many questions and challenges for the technologist performing CT fusion imaging. The fundamental differences of PET and CT, education challenges and non-standardization of certification and licensure are challenges reviewed in this section. The fundamental differences of CT and PET reside in physics and instrumentation. While both imaging modalities use ionizing radiation, the type of radiation differs among the two modalities. CT uses x-rays that originated in the electron shell of an atom and PET uses gamma rays that originated from instability in the center of an atom (Christian & Waterstram-Rich, 2007). Therefore the type of equipment used to image is very different. CT uses an x-ray tube to provide the source of x-rays that will be transmitted through the patient and ultimately produce an image (Christian & Waterstram-Rich). PET uses a radioisotope that is injected into the patient. A PET scanner is used to detect the gamma rays emitted from the patient and produces an image.
Since the introduction of PET/CT fusion imaging, CT and nuclear medicine programs, governing organizations and practicing technologists, have been faced with educational, certification and licensure challenges. A new type of technologist has essentially been created. The educational challenges have been well documented by consensus conference reports and surveys within the Radiologic and nuclear medicine professions. Conferences have been held and project groups were formed to discuss and resolve these challenges. The first conference was held a year after the first commercially available PET/CT scanner was introduced in 2001 by the American Society of Radiologic Technologist and the Society of Nuclear Medicine. Participants met July 31, 2002 in New Orleans , La. to address the challenges of fusion imaging. The goal was to develop consensus statements for the education, qualifications and regulations of personnel who operate PET/CT scanners (“Fusion Imaging,” 2002). The conference produced two consensus statements. The first statement addressed the personnel qualifications of technologist who operate PET/CT scanners. It states that after appropriate additional training or education and competence demonstration, a technologist with the credentials of R.T.(T), R.T.(R), R.T.(N) or CNMT may perform PET/CT (“Fusion Imaging,” p.201-202). The second consensus statement regards the regulation of the personnel who operate PET/CT equipment (“Fusion Imaging”). Today there are only 38 states that fully or partially license radiographers, and 21 states that fully or partially license nuclear medicine technologist (Bolus George, Washington & Newcomer, 2009). This is a very complicated issue since there is no standardization of licensure laws among the fifty states. As a result of this dilemma many states are confused about how to handle this new type of technologist. The conference participants agreed states that require licensure should amend their laws to allow for the appropriate registered technologist to perform PET/CT after additional education and training (“Fusion Imaging,” p. 202). Non-licensure states were encouraged to adopt licensure laws for education and credentialing of these technologists (“Fusion Imaging,” p. 203). The Consistency, Accuracy, Responsibility and Excellence bill (CARE) which has not currently been passed by congress will provide help with the licensure problem. If passed the CARE bill will “require personnel performing the technical components of medical imaging and radiation therapy to meet federal education and credentialing standards in order to participate in federal health programs” (Gilmore, 2008 p. 7A).
The second meeting convened by the ASRT and SNMTS project group established a PET/CT curriculum and was published in 2004 (“Positron Emission”). This curriculum identified the necessary skills and knowledge for the technologist performing PET/CT fusion imaging (“Positron Emission”). Educational gaps for basic CT and PET for PET/CT fusion imaging were identified (“Positron Emission”). Nuclear Medicine technologist lacked education in the general areas of, contrast media agents, CT radiation protection, CT computers, CT image quality, computerized tomography process, spiral CT, cross sectional anatomy, instrumentation, procedures and procedure protocols (“Positron Emission”).
The latest consensus meeting was held in 2007 in Albuquerque , N.M. It was sponsored by the ASRT and the American Registry of Radiologic Technologist (AART) (Martino, Reid & Odle, 2008). The consensus meeting members were surveyed and seventy-three and a half percent of the “respondents agreed that even entry-level nuclear medicine technologists will use CT for fusion imaging …and more than 88% agreed that most experienced nuclear medicine technologist would as well” (Martino et al., p.25). The members produced a consensus statement on CT in nuclear medicine which states that “with the advent of fusion imaging, CT has become a core skill for nuclear medicine technologists when using hybrid technology” (Martino et al., p.12).
Educational challenges were also documented through the results and recommendations of two survey reports by the Center for Health Workforce Studies under contract with the Society of Nuclear Medicine. The first survey, conducted in 2005, consisted of a random sample of 4000 nuclear medicine technologist certified by the nuclear medicine technology certification board (NMTCB) or American registry of Radiologic technologist (AART) (Center for Health Workforce Studies). The respondents chosen answered 60 questions regarding their profession (Center for Health Workforce Studies, 2005). The survey found that “53.3% of active NMT’s reported that further training will be necessary to continue to work in NM in the future,…19.5% indicated they will need CT training” and “37.7% indicated PET/CT…”(Center for Health Workforce Studies, p. 247). A key finding from the survey was that “fusion imaging technologies seem certain to take over from the multiple machine imaging modalities typically in place today (Center for Health Workforce Studies, p. 245). The results emphasize the necessity of nuclear medicine technologist to obtain additional “traditional imaging skills and certifications” so that other imaging technologists, such as R.T.’s will not be asked to perform nuclear medicine fusion tasks (Center for Health Workforce Studies, p. 245). Nuclear medicine technologist respondents cited “…the introduction of new equipment resulting in changing technologies” as the number one workplace change “affecting their roles and functions” (Center for Health Workforce Studies, p. 247). Recommendations were made for the nuclear medicine profession to “augment the knowledge base and skill sets required for NMTs to include fusion imaging with the latest technologies” (Center for Health Workforce Studies, p. 249).
The second survey was conducted in 2006 of nuclear medicine technology education program directors. The survey consisted of a questionnaire given to directors of all 127 accredited and non-accredited programs (Center for Health Workforce Studies, 2006). There were 60 respondents to the survey. One of the key issues identified by the responding program directors were “gaps in educational curricula especially related to new and emerging technologies” such as PET/CT fusion imaging (Center for Health Workforce Studies, p.43). The survey identified two key findings related to PET/CT fusion imaging. The first was that 57 of the 60 programs offered PET instruction but “fewer programs offered CT instruction” (Center for Health Workforce Studies, p.44). Secondly, 30 offered cross sectional anatomy while only 13 programs offered clinical instruction on the subject (Center for Health Workforce Studies, p.44). The survey report states “…as fusion hardware becomes commonplace in imaging centers across the country, employers in all settings will give preference to technologists who can bridge the worlds of nuclear medicine and cross-sectional imaging” (Center for Health Workforce Studies, p.48). Recommendations were made to extend nuclear medicine technology curricula to include cross-sectional imaging and to provide continuing education credits in CT technology and cross-sectional imaging (Center for Health Workforce Studies).
The SNM technologist section presidential task force revised the scope of practice for the nuclear medicine technologist in 2007 (“Scope of”). It includes the “operation of cameras with x-ray tubes for transmission imaging when performed as part of SPECT/CT or PET/CT” as a nuclear medicine technologist’s responsibility and skill (“Scope of,” p.16A). This revision emphasizes the increasing demand and importance of CT education in nuclear medicine.
CT Educational and Training Methods for the Nuclear Medicine Technologist
It is apparent, based on the review of consensus conference reports, and surveys within the Radiologic and nuclear medicine professions, that CT education for the nuclear medicine technologist has become essential. How the practicing nuclear medicine technologist obtains the necessary CT education varies. Several CT educational methods are available such as accredited CT programs, CT education and training provided by the manufactures of PET/CT scanners, CT workshops offered through the Society of Nuclear Medicine and the CT cross trainer by Medical Imaging Consultants.
Manufactures of PET/CT equipment were thought to have provided the majority of education and training for operators at the PET/CT consensus conference in 2002 (“Fusion Imaging”). More formal education programs such as accredited CT programs would provide the nuclear medicine technologist with both the didactic instruction and the clinical instruction to become CT certified. These programs are offered through universities and community colleges throughout the country. The Society of Nuclear Medicine Learning Center has offered CT workshops for nuclear medicine technologist to gain the necessary education and training for PET/CT fusion imaging (Holbrook, 2006). Nuclear medicine technologist may choose the CT workshop to attend. Medical Imaging Consultants provides CT education through self learning modules called the CT Cross Trainer. It consists of six modules: getting to know CT, CT hardware and system operation, former CT images, CT image appearance, CT safety and the CT exam (Neilson, Kaiser & Femano, 2009). The individual taking the course completes each module and then takes a test (Neilson, et al.). The participant has six months to complete the trainer and is awarded upon satisfaction completion twenty-three continuing education credit hours (Neilson et al.). This course is purchased through Medical Imaging Consultants.
Conclusion
Fusion imaging with CT has become well accepted since its introduction in 2001. PET/CT imaging has presented the nuclear medicine profession with many questions and challenges, specifically for the practicing nuclear medicine technologist performing PET/CT. Many of the educational challenges are currently unresolved, but the consensus is that nuclear medicine technologist must obtain additional CT education and training in order to operate PET/CT scanners. All of the CT education methods previously mentioned provides additional education. Which method the technologist chooses is dependent on state licensure laws, the individual, and their employer.
Chapter 3 Research Method
Research Design
The primary purpose of this study is to ascertain how the CT cross trainer educational method impacted the job performance of practicing nuclear medicine technologist at Forsyth Medical Center . The basis for this study resulted from the first consensus statement from the Society of Nuclear Medicine and the American Society of Radiologic Technologist meeting in 2002. It stated that nuclear medicine technologist performing PET/CT fusion imaging should obtain additional CT education and training (“Fusion Imaging,” 2002). Forsyth Medical Center is located in Winston Salem, NC which is a non-licensure state. The research design method consists of a non-experimental quantitative method using a questionnaire to collect descriptive data. This is a correlational research study which will try to determine the relationship of CT education (independent variable) and job performance (dependent variable) for the nuclear medicine technologist performing PET/CT. Approval from the institutional review board will be obtained prior to conducting this study.
Research Questions
The questionnaire will address the following research questions:
Question 1: What is the educational background of the nuclear medicine technologist performing PET/CT fusion imaging?
Question 2: What is the experience level of the nuclear medicine technologist performing PET/CT fusion imaging?
Question 3: How much time does the nuclear medicine technologist spend performing PET/CT fusion imaging?
Question 4: How much CT education had the nuclear medicine technologist received prior to completing the CT cross trainer?
Question 5: What is the nuclear medicine technologist’s opinion of the CT cross trainer as a CT educational method?
Question 6: What is the nuclear medicine technologist’s perception of the impact on their job performance as a result of the CT cross trainer?
Procedure
Participants. An extensive review of literature brings attention to how practicing nuclear medicine technologist performing PET/CT fusion imaging obtains additional CT training in a non-licensure state. Therefore, the targeted population in this study consists of practicing nuclear medicine technologists who perform PET/CT in North Carolina and who have completed the CT cross trainer educational method. Since the researcher is a clinical nuclear medicine technologist educator and has access to nuclear medicine technologist who meets the criteria, participants will be obtained through convenience sampling. The participants are employees of the nuclear medicine department at Forsyth Medical Center . There are 16 participants who meet the participant criteria.
Data Collection Methods. The questionnaire data collection method will be used to determine any relationship between the independent variable, CT cross trainer, and the dependent variable, job performance. A questionnaire has been developed based on the literature review and the 6 research questions introduced in this study. The following general areas will be addressed in the questionnaire:
1. Gender and professional demographics
2. Education and Experience
3. Perception and Opinions
A pilot study will be performed using the questionnaire to test the validity of the question and questionnaire construction. Upon completion of any modifications or revisions to the questionnaire following the pilot study, the questionnaire will be personally given to each practicing nuclear medicine technologist within the department. The question construction consists mostly of close ended questions and one open ended question. The types of close ended questions included on the questionnaire consist of: yes/no, choose appropriate response from a list and Likert rating scale questions. Each participant is asked to complete the self-administered questionnaire and submit them to a research box located in the department.
Data Analysis. The data collected from the questionnaire will produce descriptive and inferential statistics. The personal and professional demographic data of the nuclear medicine technologist will be analyzed using descriptive statistics such as frequency distributions and means. Since there was no randomization and a small sample size, the inferential statistics will be non-parametric in nature. The perception and opinion data produced from the questionnaire will be nominal and ordinal. Therefore to test for significant differences between the two variables, the Pearson Chi-Square test will be used. The Spearman Rho statistical test will be used to help determine if there is a significant relationship between CT education and the technologist’s job performance.
References
Bolus, N.E., George, R., Washington, J., & Newcomer, B.R. (2009). PET/MRI: The blended-modality choice of the future? Journal of Nuclear Medicine Technology, 37, 63-71.
Center for Health Workforce Studies, University at Albany , School of Public Health. (2005). Nuclear medicine technologists in the U.S. : findings from a 2005 survey. Journal of Nuclear Medicine Technology, 34, 244-249.
Center for Health Workforce Studies, University at Albany , School of Public Health. (2006). Insights about nuclear medicine technology: findings from a 2006 survey of NMT education program directors. Journal of Nuclear Medicine Technology, 35, 42-49.
Christian, P.E., & Waterstram-Rich, K.M. (Eds.). (2007). Nuclear medicine and PET/CT technology and techniques (6th ed.). St. Louis , MO : Mosby Elsevier.
Fusion imaging: A new type of technologist for a new type of technology. (2002). Journal of Nuclear Medicine Technology 30, 201-204.
Gilmore, D. (2008). Lighting a fire for our future. Journal of Nuclear Medicine Technology, 36, 7A-8A.
Holbrook, D.S. (2006, January/February). Message from the SNMTS president-elect. Uptake, 12, 1-2.
Martino, S., Reid, J., Odle, T.G. (2008). Computed tomography in the 21st century. Retrieved October 8, 2009 from www.asrt.org/media/pdf/educators/ASRT_CT_Consensus.pdf
Mettler, F.A., Jr., & Guiberteau, M.J. (2006). Essentials of nuclear medicine (5th ed.). Philadelphia : Saunders Elsevier.
Neilson, C., Kaiser, D.A., & Femano, P.A. (2009). CT cross trainer. Clifton , NJ : Medical imaging consultants.
Positron emission tomography (PET)-computed tomography (CT) curriculum. (2004). Retrieved September 21, 2009 from http://interactive.snm.org/docs/PET/CT%20Curriculum%20Accepted%20021704.pd.pdf
SNM Technologist Section Presidential Task Force, (2007). Scope of practice for the nuclear medicine technologist 2007. Journal of Nuclear Medicine Technology, 35, 15A-17A.
Townsend, D.W., & Beyer, T. (2002). A combined PET/CT scanner: the path to true fusion imaging. [Electronic version]. The British Journal of Radiology, 75, S24-S30.
Townsend, D.W., Carney, J.P., Yapp, J.T., & Hall, N.C. (2004). PET/CT today and tomorrow. [Electronic version]. Journal of Nuclear Medicine Technology, 45, 4S-14S.
Appendix
Questionnaire for Nuclear Medicine Technologist Performing PET/CT
Instructions: Complete the following questionnaire and submit to research box.
1. Gender: ○ Male ○ Female
2. What is your highest degree earned?
A. Certificate
B. Associates degree
C. Baccalaureate degree
D. Masters degree
3. What type of Nuclear Medicine Technology Program did you graduate from?
A. Certificate program
B. Associate degree program
C. Baccalaureate degree program
D. Other___________________
4. Are you currently certified in nuclear medicine?
○ Yes ○ No
5. How many years experience do you have in nuclear medicine technology?
○ 0-5 years
○ 5-10 years
○ 10-20 years
○ > 20 years
6. How many years have you worked in the nuclear medicine department at Forsyth Medical Center ?
○ 0-5 years
○ 5-10 years
○ 10-20 years
○ > 20 years
7. List the number of days per month you spend performing PET/CT fusion imaging:
____________________days/month
8. Did you receive any didactic CT education in your nuclear medicine technology program?
○ Yes ○ No
9. Upon completion of the CT Cross Trainer, I feel I have gained a basic knowledge of CT.
○Strongly Agree ○Agree ○Neutral ○Disagree ○Strongly Disagree
10. The CT knowledge I gained through the CT cross trainer has improved my job performance in PET/CT.
○Strongly Agree ○Agree ○Neutral ○Disagree ○Strongly Disagree
11. Would you recommend the CT cross trainer to other nuclear medicine technologist who perform PET/CT or SPECT/CT and wish to obtain CT education?
○ Yes ○ No
12. When explaining a PET/CT scan to a patient, do you explain the CT portion too?
○ Yes ○ No
13. As a practicing nuclear medicine technologist, I feel that PET/CT and SPECT/CT fusion imaging is becoming the standard of care in nuclear medicine?
○Strongly Agree ○Agree ○Neutral ○Disagree ○Strongly Disagree