Diagnostic imaging workforce
Regardless of the modality, a highly trained workforce is essential to
obtaining high quality diagnostic images.
The Department of Health, Western Australia told the committee that having the
right workforce improves the quality of diagnostic images and increases diagnostic
I think it is important that we focus on not just having
machines around the country and reducing the travel time but also on having the
right workforce. The breadth of the workforce spans the radiologists,
radiographers, sonographers, nuclear med physicians and technicians,
physicists, nursing staff and, these days, also potentially IT support. If you
have the right workforce, the quality of the images improve, your useful
lifespan is potentially increased and the diagnostic accuracy is also
This chapter will outline that there is a shortage of diagnostic imaging
specialists and technicians—sonographers, radiographers and radiologists—to
meet Australia's current and future need, but some steps have been taken to
manage this shortage.
Sonographers are specialists in conducting and interpreting diagnostic
The Australian Sonographers Association (ASA) informed the committee that, like
other forms of diagnostic imaging, diagnostic ultrasound is 'highly operator
dependent' so there is a need for highly trained sonographers across the
The call for additional sonographers was reiterated by the WA Country Health
Service which explained that a lack of sonographers was delaying access to services
for patients in rural areas:
...some facilities may only have sonography once a week, and
that's because we can only get a sonographer once a week.
Training and clinical placement
The Australasian Society for Ultrasound in Medicine (ASUM) highlighted
that there is currently a recognised shortage of trained sonographers and there
has been for at least 10 years.
Training to become a sonographer involves both a course of study and
clinical practice, but there are not enough clinical training places for the
number of available graduates.
The ASA told the committee that clinical practice is a vital part of a sonographer's
training, but these places are becoming increasingly scarce:
There are a number of academic courses available to student
sonographers, including two and three-year postgraduate diplomas and a
four-year comprehensive course. However, the bulk of the student training needs
to be conducted in a clinical setting, and the places available for this
training are rapidly diminishing.
Both the ASA and ASUM explained that independent practices are reluctant
to incur the significant financial burden required to facilitate clinical
training for sonographers and that the number of training places is diminishing
as a result.
Both organisations noted that training a sonographer requires an independent
practice to pay both a senior staff member and the trainee for up to two years
to allow the trainee to undertake at least 2000 hours of clinical practice.
ASUM explained to the committee that the shortage of training places was
leading students seeking clinical places to work for free:
Many sonographer trainees are offering to work for free to
gain a clinical placement and open up an opportunity for employment if they are
able to prove their value. Even these students struggle to be trained due to
the cost of insurance for the practices and the issues around employment and
work health and safety.
To encourage independent practices to facilitate the clinical training
of sonographers, both ASUM and the ASA requested that a subsidy be provided to independent
In the absence of a sufficient supply of trained sonographers, ASUM told
the committee that in some cases practitioners in other fields, who may not be
trained to do so, are providing point of care ultrasound.
ASUM explained that, under current accreditation rules, any specialist
can perform and claim an ultrasound under the Medicare Benefits Schedule (MBS).
ASUM argued that allowing an unqualified practitioner to perform an
ultrasound could be detrimental to both the patients and the public health
system because it often led to scans having to be redone at additional expense:
...patients would therefore assume, if they get an ultrasound...
that person would indeed be qualified. This is an expectation the patients
should be able to have, but unfortunately it is not always the case. This will
potentially lead to many examinations, requiring an ultrasound study to be
repeated and again putting the patient at risk of potential missed diagnosis or
misdiagnosis, as well as adding a further burden on the Commonwealth purse.
The Australian College of Rural and Remote Medicine (ACRRM) notes in its
submission that a lack of specialist staff requires rural practitioners to
'take on roles ordinarily the preserve of specialists in the cities'.
This may include taking on the role of sonographer.
To ensure that its members can continue to provide high quality care,
the ACRRM offers six training courses per year in the provision of high quality
The ACRRM noted that the Commonwealth Government Department of Health
(Department), in response to a large increase in the number of ultrasounds
being conducted in Australia, is considering revising accreditation standards
to require practitioners to undertake formal training and assessment before
being allowed to claim Medicare benefits for conducting diagnostic ultrasounds.
ACRRM advised the committee that the Department is considering requiring
practitioners to complete the Diploma of Diagnostic Ultrasound from ASUM.
However, the ACRRM suggested that the 'access for candidates, content
requirements/relevance and time necessary for completion' meant that the
Diploma of Diagnostic Imaging from ASUM was not appropriate for rural doctors.
The ACRRM warned that if the wrong accreditation standard was selected,
it could end up having 'a very deleterious effect on the timely access to
services to rural and remote communities'.
The ACRRM advised the committee that it would continue to work with the
Department to identify suitable training for rural practitioners.
Nurses and nurse practitioners
One option to address the sonographer shortage is to invest additional
resources to upskill nurses and nurse practitioners to perform some diagnostic
The Queensland Nurses and Midwives' Union (QNMU) told the committee that
nurses were already well-placed to provide access to x-ray and diagnostic
ultrasound services, and in many cases already do so.
Since 2011, to address a shortage of specialist sonographers, nurse
practitioners have been trained to provide pelvic ultrasound in cases of
The QNMU advised the committee that this expanded scope of practice was first introduced
in a metropolitan hospital, but could be extended to rural areas.
The ACRRM endorsed the nurse practitioner model and agreed that nurse
practitioners could take on a larger role in some circumstances.
ACRRM also suggested that some sonography could be done with remote
supervision, provided the trainee had access to the internet:
...there's no reason why the person at the point of care can't
be moving the scan head around, with somebody remotely saying, 'Just turn it a
little bit this way or that way or shift it over here.' I've been at a medical
education conference in Sydney where we were watching medical students in
Armidale undergoing ultrasound training by a professor of ultrasonography, live
from Los Angeles, who was doing exactly the same thing. There's this weird
territoriality around radiology that doesn't have much to do with the quality
of care and access to care for rural and remote communities. You can make this
happen. It's just a matter of initiating policy that mandates that this can occur.
The committee recognises that there has been a substantial shortage of
specialist sonographers in Australia for more than a decade. The committee
considers that diagnostic ultrasound is an important and useful diagnostic
modality that requires specialist training.
The committee understands that training a sonographer is expensive and
that private radiology practices are reluctant to employ trainees. The
committee also accepts that only a limited number of sonographers can be placed
in public hospitals.
In the short term, the committee supports the upskilling of nurses and
nurse practitioners to perform some sonography in both metropolitan and rural
The committee accepts that rural and regional practice includes
particular constraints that need to be accommodated when considering an
appropriate accreditation standard. The committee welcomes the collaborative
nature of the talks between the ACRRM and the Department and expects that an
accreditation standard can be found that is mutually acceptable to both parties.
Radiographers / x-ray operators
Radiographers are highly skilled technicians who operate the various
diagnostic imaging machines. Professor Richard Zwar from the Peter
MacCallum Cancer Centre explained to the committee that radiographers
specialise in operating particular machines:
They're highly skilled technicians, and they've now become
very subspecialist... They are grouped into subgroups, basically, who operate the
different modalities... This is because they need to have specific skills.
There are hundreds of protocols on each of these instruments that need to be
tweaked and nuanced for the individual patient's situation, often in
consultation with the radiologist, who has to be on-site.
Mr Cook, Director of Medical Imaging with the Darling Downs Hospital and
Health Service advised the committee that Queensland has a lack of specialist
radiographers and that other staff have had to be trained to perform x-rays in
addition to their other duties:
...there are over 130 X-ray-capable public sites in Queensland,
and only 48 of those sites have professional and discretely employed
radiographers. The remaining sites rely on non-radiographers or X-ray operators
to perform the X-ray examinations on top of their substantive roles as doctors,
nurses or operational and administrative staff.
A number of Queensland Hospital and Health Services advised the
committee that where a non-radiographer workforce exists, there is often
supervision from radiographers in larger hospitals and the images are reported
Whilst the Hospital and Health Services noted that having trained
radiographers in rural hospitals would be ideal, the services accepted that other
staff could be trained to take on these roles safely and efficiently with
Darling Downs Hospital and Health Service expressed concern that a
better coordinated training regimen for non-radiographer staff was required:
X-ray operators are essential for the provision of basic
imaging services to a significant rural and remote population and the majority
of the geographical area of this country. There is a lack of modern and focused
vocational qualification and training at a federal level to provide consistency
of training to non-radiographer X-ray operators in low-volume rural and remote
sites. This is desperately required to build and maintain an appropriately
trained and regulated workforce. 
Radiologists are specialists in interpreting diagnostic images and also perform
some interventional image-guided procedures.
As noted in chapter one, the Royal Australian and New Zealand College of
Radiologists (RANZCR) and the Australian Diagnostic Imaging Association (ADIA)
recommend the implementation of the Quality Framework for Diagnostic Imaging
The Quality Framework requires on-site supervision by a clinical radiologist
'to improve supervision and clinical oversight' of radiology services.
ADIA told the committee that implementing the Quality Framework would
improve patient care and avoid unnecessary scans because an on-site radiologist
would be able to advise practitioners and radiographers about the right test
for a particular patient.
RANZCR President, Dr Greg Slater, provided the committee with an example
from his own practice to demonstrate the benefits of having a radiologist
I was working recently in a practice in Cairns that my
employer owns, and we received a referral for an eight-year-old child for a CT
of the head. The child had been having strange visual symptoms and headaches
and was referred for the CT. The CT radiographer came to me, concerned about
this referral, to seek advice. I contacted their referring doctor and suggested
that an MRI would be a more appropriate test. The referring doctor was unaware
that MRI was available. He thought his only option was to refer for CT. So we
performed an MRI and it turned out that the child was perfectly okay.
Nevertheless, the investigation needed to be done and it was quite clear that
MRI was the appropriate test to be done in that situation.
Some other submitters disagreed that on-site radiologists were
Primary Health Care Limited, a private radiology clinic, argued that a
more flexible model—one that permitted radiologists to provide supervision to
multiple sites—could be a more efficient way of providing supervision:
For the last, say, 15 years I've been working for Primary
[Health Care Limited] and almost sort of pioneered a model where radiologists
travel between centres every day to provide supervision, procedures and
attendance for things that require attendance. That's been tremendously
successful in allowing us to maintain bulk-billing through a huge number of
practices for a huge number of people, despite the fact that there have been no
rebate rises and despite the fact that everything else has increased in cost.
So, it's been incredibly efficient, and we've used teleradiology and other
technologies very effectively.
Primary Health Care Limited suggested that accepting the Quality
Framework could lead to some unintended consequences and negatively affect
access to imaging services for some patients.
Primary Health Care Limited suggested that some of these unintended
consequences could include increased workforce costs, reduced bulk billing,
increased out-of-pocket costs and less innovation.
Primary Health Care Limited also suggested that requiring an on-site
radiologist does not recognise that some current practice (in the case of
non-contrast CT or cases of low complexity) does not require an on-site
Primary Health Care Limited also suggested that the Quality Framework
was not supported by evidence:
...the supervision rules proposed in the 'Quality' framework
with regard to non-contrast CT imaging services are not evidence based, and
will have a negative impact on the affordability and accessibility of
diagnostic imaging services. In fact, an independent report did not support a
rules based approach to supervision of non-contrast CT.
ADIA strongly disagreed with the arguments raised by Primary Health Care
Limited. ADIA reassured the committee that the Quality Framework was developed
to apply to metropolitan centres and reiterated that the on-site supervision
requirement would not affect practices in rural and regional Australia from
being able to provide CT or MRI services.
ADIA also pointed out that most radiology practices already employed a
full-time on-site radiologist, that current rules require a radiologist to
attend on a patient personally if required and that 81.2 per cent of CT
services were bulk billed in 2016–17.
The Department advised that the Quality Framework would have significant
implications for the diagnostic imaging sector and that the Commonwealth Government
made a 2016 election commitment to the Quality Framework and is currently considering
implementation of the Quality Framework.
Number of radiologists
A further concern raised by Primary Health Care Limited was that there
are not enough radiologists to meet current or future supply:
The practical reality is that Australia does not have enough
radiologists in the country to provide the level of supervision outlined in the
RANZCR 'Quality' framework for current diagnostic imaging services around the
country, let alone for the [diagnostic imaging] services that will be needed
over the next decade as the population grows and ages.
ADIA refuted that suggestion, claiming that there is a sufficient number
of radiologists to meet both current and future demand:
Based on the number of radiologists currently in practice and
in training, there are enough radiologists in Australia to meet the proposed
supervision requirements for CT, and meet future demand for radiology services.
Mr Jim Aspinwall, Director of X-Ray and Imaging disagreed with ADIA's
assessment and provided the committee with a graph that demonstrated the gap
between the actual number of radiologists and a projected number required to
meet future need.
Graph 4.1—Radiologist workforce projection
Source: Mr Aspinwall, Radiologist
Shortage (Tabled 13 December 2017).
The above graph demonstrates that there is a disparity between the
number of radiologists currently employed in Australia and the number that is
likely to be required to meet Australia's future radiology need.
Health Workforce Australia undertook workforce planning for the health
system to help address shortages and growing demands for healthcare prior to
its abolition in 2014. The Department considered that there was an undersupply
of radiologists and radiation oncologists in 2014.
In 2016, the Department's modelling forecast that by 2030 there would be a workforce
undersupply of radiologists and radiation oncologists of 25 per cent and 63 per
Table 4.1—2014 workforce undersupply and 2016 Department
workforce forecast for 2030
Source: Department, Review of
Specialist Training Program and Emergency Medicine Program, March 2017,
Dr Evan Jones, Director, Morayfield Family Doctors, told the committee
that he believed that RANZCR was restricting the number of radiologists in Australia:
...we see as general practitioners that there's a protectionism
within the specialist colleges. If you limit supply into your specialty, you
can then command higher incomes. And we see this in numerous professions, not
Dr Jones explained that specialist colleges are able to do this because
they are able to control how many graduates they take each year:
They're limiting the number of graduates who actually
qualify, and they can do that in various ways: training positions, who actually
passes the exam or doesn't pass the exam—all sorts of things. As a general
practitioner trying to provide services into rural Australia, this is galling,
because specialists want to stay in the cities; they want to command high
incomes. And who loses out? Patients lose out.
A review of the Special Training Program and Emergency Medicine Program
by the Department of Health recommended that the quota of training places for
specialist radiologists be increased from 47 to 82 (54 for radiology and 26 radiation
The committee considers that radiographers are an important part of the
diagnostic imaging workforce, but also understands that hospitals operate under
cost pressures. The committee commends Queensland's Health and Hospital
Services on working with its existing workforce and using technology to ensure
that patients in non-metropolitan centres continue to get access to x-ray
services, even if the images have to be interpreted by teleradiology.
The committee understands that having a radiologist on-site, as required
by the Quality Framework, may lead to better outcomes for patients as an on-site
radiologist can advise on the radiology procedure. However, the committee also
understands that more flexible ways of working may have their advantages but
quality patient outcomes must be a priority.
The committee is concerned by the prospect that Australia may be facing
a workforce shortage in radiology, especially as it is likely to further
exacerbate the health disadvantage that is already experienced by Australians
who live in regional and rural areas.
The committee welcomes the prospect that more training places for
radiologists will become available under the Specialist Training Program.
However, the committee calls on the RANZCR to do more to help increase the
supply of Australian radiologists.
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