As physician extenders (PEs) enter the medical community in large numbers, they have an increasing impact on imaging utilization and imaging-based procedures. Physician assistants (PAs) and nurse practitioners (NPs) have an advanced level of education and some practice autonomously. However, PA and NP programs are not required to provide any basic radiology education. For PEs who did receive basic radiology education during their graduate program, the curriculum is nonstandard and there is a wide variation. PEs working in primary care and nonradiology specialties place imaging orders, review report findings, and answer patient questions. Other PEs working within radiology practices operate as liaisons with patients in diagnostic radiology or perform an increasing number of interventional procedures. Basic radiology education in formal PE certificate programs as well as on-the-job education about radiology may benefit patients, radiologists, and the health-care system. What role, if any, should the radiologist assume for educating PE students and practicing PAs and NPs? This review analyzes the benefits and drawbacks of radiologists educating PEs.
Introduction
The emergence of physician extenders (PEs) across all medical specialties to meet increasing demands for health care has changed the delivery of primary care and specialty services. Two main groups of PEs, physician assistants (PAs) and nurse practitioners (NPs), have seen a dramatic increase in career growth and some practice autonomously . As both primary care and specialty PEs assume greater responsibilities in patient care, they may interact with radiology in new capacities such as reviewing imaging report findings, discussing recommendations with patients, and assisting with or performing basic interventional procedures within a radiology practice. However, despite advancements in radiology over the past several decades and increasing responsibilities of PEs, there are no formal radiology education requirements for PA and NP certification programs .
PA and NP programs were originally created in 1965 at Duke University and the University of Colorado, respectively, to combat a shortage of primary care physicians . Currently, over 95,000 PAs and 192,000 NPs work in all 50 states, with more than 6000 new PAs graduating from 219 national programs each year . Both professions have experienced higher-than-average growth; the U.S. Bureau of Labor Statistics projects continued growth at 30% for PAs and 31% for NPs between 2014 and 2024 . By contrast, the average growth for all occupations is 7% . Although matriculation prerequisites including minimum degree requirements vary between PA programs, the Accreditation Review Commission on Education for the Physician Assistant and the Physician Assistant National Certifying Exam set standards for all PAs. Both organizations require the ability to generate a differential diagnosis, to order, and to interpret laboratory and diagnostic studies . NP certification is awarded by The Accreditation Board for Specialty Nursing Certification, which similarly describes an ability to order, perform, supervise, and interpret laboratory and imaging studies . However, neither PA nor NP certification agency requirements refer to principles of radiology, radiological procedures, radiation safety, or radiobiology . The extent of radiology education is thus school dependent and variable.
The majority of PAs accept positions in family medicine or general practice . In such a context, these providers perform much of their own diagnostic workups, including what type of imaging, if any, is warranted. PEs working as part of a specialty team may also have a primary role in ordering and following up with imaging results. On the other hand, some PEs may find employment within a radiology group, where he or she may be expected to learn to perform basic fluoroscopy examinations on the job and without required formal training or certification in at least 20 states . Some may be expected to learn and perform basic procedures on the job in interventional radiology (IR). Given that many PEs may have had minimal or no radiology education yet impact imaging utilization, what role, if any, can the radiologist assume in diagnostic and IR education for PEs?
Education of PEs Working in Primary Care or Nonradiology Specialties
Determining the type of diagnostic imaging to order, answering patient questions, and understanding radiology report findings may be a difficult or uncomfortable process for PEs without sufficient prior radiology education. Inappropriate imaging studies may delay patient care, increase health-care costs, or expose patients to unnecessary ionizing radiation . Unfamiliarity with common radiology report findings may also lead to misunderstanding, miscommunication, and improper patient management. Targeted radiology education of PEs focusing on a few key points within the diagnostic radiology workflow may reduce the possibility of these negative consequences ( Fig 1 ).
Order Appropriateness
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Addressing Patient Questions
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Understanding Report Findings
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Education of PEs Working in Radiology Departments
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Protocols and Contrast Material Issues
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Direct Patient Care
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Fluoroscopic and IR Procedures
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Conclusions
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