Over the next year we’ll discuss among other things, being a student, the impact of Brexit on radiotherapy, Radiographer shortages, the psychology involved in covering patient’s heads in Plaster of Paris bandages, the art of selling expensive capital equipment, Dragon’s Den, start-up companies and other interesting stuff – This is a new blog on what is approaching a 40 year career in radiotherapy by Duncan Hynd DCR (T), Radiographer, Director of Hynd Healthcare Ltd and founder of RadPro and Duncan Hynd Associates Limited.
This month I focus on my first year in Radiotherapy as a DCR student in 1980 and the impact of staff shortages in the profession today.
The Middlesex Hospital
I started as a student radiographer at the Middlesex Hospital in London on the 15th September 1980, aged 20. It was an inauspicious beginning in that I missed my initial interview and had to be re-invited a week later. Central London in 1980 was an alien place to me having been brought up in suburban Ruislip. With no sat-nav, mobile phone or other modern directional aid I ventured unaccompanied onto the Metropolitan Line and headed for Goodge Street Tube Station via Baker Street. For those not in the know, Goodge Street station is in fact located on Tottenham Court Road and if you find Goodge Street itself, it quickly becomes Mortimer Street when passing the original Spaghetti House (opened in 1950 and Spaghetti House’s motto, which still holds good today, was a simple one – ‘spaghetti, but not on toast!) with the grand sweeping, walled and crescent shaped entrance and exit courtyard to the iconic Middlesex Hospital building itself, largely unchanged for 200 years located on the right opposite Berners Street.
Pics: Middlesex Hospital through the ages
The Middlesex Hospital was a teaching hospital located in what is known as the Fitzrovia area of London. First opened as the Middlesex Infirmary in 1745 on Windmill Street, it was moved in 1757 to Mortimer Street where it remained until it was finally closed in 2005 and became essentially “ground zero” for its past staff while a new shopping and housing development was built on the site after it was demolished. The only ghost of the past that remains is the original chapel that was refurbished and remains on the site and can be viewed in all its glory from inside the new and very trendy Percy and Founders restaurant! The listed entrance and brick façade of the Meyerstein Institute of Radiotherapy was also kept in situ and that separates the trendy new flats from Nassau St while the Middlesex Hospital Radium Wing façade was also kept.
Pic: Ground zero for Radiographers with the chapel left in situ on the left
and the hospital demolished
Pic. The chapel interior, a grade 2 listed building
Pic: The new Fitzrovia development on the hospital site,
the girl in the red skirt is standing right above the old radiotherapy bunkers.
The refurbished chapel in also seen on the right.
However, the school of Radiography is not located at the hospital at all but in Foley Street a few blocks behind and without the aid of my Dads’s A to Z, or the map supplied by the school I was lost and without any mobile phone to assist me, I kind of gave up and went home as it was now getting very late. Some-days later a letter arrived in Ruislip, written by Mary Embleton, Principal of the Radiotherapy school expressing her surprise at my non-attendance and offering me a final chance to be interviewed if I called her back. This I did and so starts a life in Radiotherapy that seems to have been my destiny! Destiny however, was a series of events starting with me being offered a place at the Turner Dental School in Manchester, messing up my A levels and my dad travelling to the BBC in the Strand at Bush House daily with a close neighbour who happened to be a Middlesex Hospital Consultant neuro-surgeon and who had been informed that some places to study radiotherapy were available for the next few weeks only.
The DCR course in 1980 was for just over 2 years duration and truly vocational by its very nature. Therefore, after dying my light blue shoes black on arrival, cutting my long hair short (ish) and being fitted for a white coat (with natty light blue epaulets, more Gordon Ramsay than a Doctor but knee length) I ended up literally a few days later in the “radiotherapy planning department” of the eponymously named Meyerstein Institute of Radiotherapy.
Edward William Meyerstein was a British merchant, stockbroker and philanthropist notable for donations to the Middlesex Hospital in Fitzrovia. He gave £250,000 in the 1930s to the Middlesex Hospital in London to establish Meyerstein Institute of Radiotherapy formed in 1936
I was now fully immersed as a part-player in the real life of a cancer patient starting a course of radiotherapy. The deep end doesn’t really sum up this shock to the system but if you want to be a radiographer it’s a great place to start and with nowhere to hide!
No first name terms here, Sister Wells was the overall head of department, Ms Curtis and Ms Clitherow ran planning and I was simply Mr Hynd and my initial request to go for a coffee break after a long mornings work was put down in no uncertain terms on day one.
Planning in 1980 was largely carried out with a mobile X-Ray unit, contrast, callipers and lead wire to take contours and outlines manually. Once the contours were checked and transferred to a piece of tracing paper, the target volumes were added manually with the assistance of a Consultant Radiotherapist (now Clinical Oncologist), as were critical structures as there were no simulators, CT scanners or other imaging tools in Radiotherapy at the Middlesex then while a copy of Gray’s Anatomy was the most useful tool.
The magic was really performed by Physics who entered all this data into their EMI Plan Treatment Planning System or TPS (later to become the Target TPS from GE, the gold standard in those days in the UK, we will come to treatment planning in a later blog) and based on the console of the first EMI CT Scanner. A printed treatment plan was produced with requisite isodoses and clearly defined set-up instructions hand written on a separate sheet, all contained in a plastic wallet that usually resided on top of the patient during set-up. This paper-based documentation allowed the plan to be superimposed on the patient generally using rulers and gentian violet crosses for beam entry points and shielding locations with permanent tattoos using the same ink and a hyperdermic syringe needle already applied by planning.
Treatment machines were not isocentric in 1980 and so a time consuming modified “pin and arc” technique was generally applied for each Linac beam and an A3 sized treatment sheet created to register each treatment and record monitor units, an analogue record and verify system! These machines also only delivered one field at a time and so shoe leather was in short supply with up to 60 patients booked over a very long day and 3 or 4 beams (oddly named a brick) per patient meant a great deal of walking in and out of the bunker. On service days a student’s life often (no peace for the wicked) involved dusting and cleaning the room as early Linacs didn’t like dust or so we were told and nor did senior Radiographers!
The DCR course initial year was a combined one with our Diagnostic student colleagues in the school of radiography and then we went our separate ways for year two. Anatomy and Physiology, Hospital Practice and Care of the Patient along with “Physics” where we learnt that Photons had an ethereal quality in that they were both particle and wave and essentially a “quantised unit of light”, great stuff and an early insight into quantum mechanics. SI units were just coming into vogue and so Rads became Grays, Curies Becquerels and Roentgens Sieverts just after we had learnt the former system! Year two would focus on Radiotherapy Technique, Principals of Radiotherapy and Oncology and a Viva Voce (a terrifying verbal one to one Q and A session with a Radiotherapist) to ensure that we really knew what we were doing. We also had a log book supplied by the College of Radiographers to record all the set-ups we carried out that formed part of our final examinations and proof that we had attended plenty of clinical cases, each set-up signed or initialled by qualified staff.
In our first year we also spent some time on a cancer ward, working alongside the nursing staff and having to complete a series of night shifts too. Hospital corners were mandatory and quickly learnt. Not only were we programmed to spend as much time in the hospital as possible, we also attended outlying out-patient clinics and other satellite centres such as St Johns in Soho by China Town, a specialist skin unit and clinic where Dr Margaret Spittle waved her magic wand over huge varieties of malignant and some non-malignant cases that required radiotherapy and St Mary’s in Paddington where an orthovoltage machine treated various metastases and other non-specialist cases. Living and working all over London was great fun, what’s not to like about that.
Machines for all conditions
The main treatments machines at the Middlesex in the early eighties comprised a Blue MEL 8 MV Linac with various electron energies and a TEM Mobaltron Cobalt unit. The Linac had a space aged mobile console, interlocked to the main unit by standing on the footpad, and with two joysticks one for couch up/down and the other for rotation of the machine and various collimator/field size switches. I always ran down the maze to operate this when working on this machine (picture is included below) which was the fore-runner to the Philips and then Elekta Linac Units. TEM were based at Gatwick and eventually taken over by Varian. There was also an ageing Theratron Cobalt Unit from AECL in Canada, a company whom I would eventually work for years later and was rebranded Theratronics. The NHS eventually re-invested in some Cobalt Units when I worked in sales in 1995.
There was also a TEM Cathetron, a remote loading device using 8 high activity cobalt-60 sources. This replaced intracavitary radium in the curative and palliative treatment of carcinoma of the uterine body and cervix and delivered 750 Gy to Point A in 2 or 3 additional treatments to EBRT. The process was delivered in a “semi-sterile theatre environment” using an existing treatment room.
As a student we were responsible for cleaning the room and creating its semi-sterile state by scrubbing walls and floors with anti-septic solutions. These machines would be replaced worldwide by Nucletron’s Selectron and Micro-Selectron innovation.
The Mobaltron and Theratron Cobalt units treated the bulk of the breast cancer patients, usually post-mastectomy with “tans and glands” the typical set-up and beam edges drawn on the chest in ink with wooden sticks, taking care to avoid penumbral overlap of the tangential fields and Supraclavicular fossa beams at depth with manual half-beam shielding and every now and again a posterior axillary boost was applied. Wedges were physical, heavy wedges of lead or tungsten with an interlock and shielding blocks further lumps of lead in various shapes and sizes, located on a compressible shadow tray and fixed to the machine. There were no virtual wedges or multi-leaf collimators (MLC) while on line imaging was a simple x-ray film plate exposed before treatment.
As a student I would often run up the machine and perform pre-treatment daily checks if the working radiographer was running late or otherwise occupied in the morning.
Pic: MEL 6MV Linac in 1980
There was also a Cobaltron Minor unit from TEM that was a short SSD Cobalt 60 based machine for treating bulky but superficial tumours, lymph nodes and others along with a Dermopan 50kV skin unit and Orthovoltage machine that tended to focus on whole brain treatments with an inferior border based on a line taken from the outer canthus to external auditory meatus, a technique that I can still remember to this day. I can also very much recall today the name of the first patient who died during a treatment course for Brain metastases and his young wife and family members who attended with him, something that also stays with you for life while the variety of machines and techniques provided a broad education.
I wanted to be a Radiographer
And this takes me to the main point of this month’s blog. The DCR immersed you in the life of a Radiographer form the start, you became a cog in the running of the department (rightly or wrongly) and an additional member of staff for all intents and purposes. You knew that you wanted to be a Radiographer from the start and that is what the DCR created…a supply of working Radiographers with letters after your name, what could be better than that. There was also stiff competition to be given a full-time job after qualification at the site you trained at. The vocational style suited me down to the ground and I thrived in this environment, whereas I struggled at school late in my last year with the huge pressure of exams and also when I mistakenly enrolled on an HNC course for Biochemistry after initially leaving school, a huge mistake, I hated it and left very quickly.
With the DCR you didn’t need a virtual environment to teach you the basics, you learnt them very quickly in an intensely satisfying analogue way and gained a deep understanding of the fundamentals of radiotherapy that new and current digital equipment may not offer a new student today. I am not advocating a return to the DCR but vocational training based at one hospital is something that I whole-heartedly support.
Shortages of therapy radiographers
The College of Radiographers have recently launched an apprenticeship scheme to try to solve the problems of radiographer retention and lack of new degree candidates for the future and while staff shortages will no doubt take their toll, this may be a way of bringing in dedicated vocational training that in some ways replicates the best parts of the DCR. In fact Radiotherapy Radiographers as I still refer to myself when I meet surgeons or clinical oncologists to discuss IORT (or therapy radiographers, or radiotherapists or radiation therapists, the list goes on) are now on an “endangered list” when it comes to staff shortages and vacancies in the UK.
The advent of many private radiotherapy centres, expansion of existing NHS centres or major relocations, creation of satellite NHS radiotherapy centres aligned with some of the larger NHS sites but in smaller regional towns, the potential growth of Proton Beam facilities and high attrition rates with current staff to whom their degree is a passport to other careers have all conspired against us.
Here are some useful links on the new apprenticeship standard:
Here are some links on shortages of Radiotherapy Radiographers and its impact on the NHS:
Here are some links on Radiotherapy Radiographers being on a “critical occupation list”
A link to a paper by Jo McNamara on radiographer retention in radiotherapy:
“The recruitment and retention of therapy radiographers”
Lastly, if you want to be a therapy radiographer this career prospectus will help you:
A career in Radiotherapy is an amazing and varied vocation, I can vouch for that! Any questions or comments to firstname.lastname@example.org
Next month, I will focus on student year 2, my fascination with the Mould Room (is that smell burning wax, if so please call the fire brigade), qualification and my first job in London!
I will also touch on Brexit and its likely impact on radiotherapy.