February Blog – Is that a smell of burning wax, if so please call the London Fire Brigade!


In January I discussed radiographer retention and training and so this month I have included at the end a new article on Apprenticeships – “therapeutic and diagnostic radiography education moving forwards” specially written for this blog by Louise Coleman of the SCoR

My last year as a student radiographer

Entering my final year as a student was a benchmark time for me. The fact that I had passed my half-time hospital exams, had made an impact as a valued member of the radiotherapy department and wanted to be a radiotherapy radiographer (please note: I have been asked to use the term “therapeutic radiographer” so that any potential new students reading this know what profession I am taking about but old habits die hard) I had decided that it would also be great to work at the Middlesex Hospital once qualified if any jobs were available but believe it or not “therapeutic radiography” vacancies were scarce in those days and some students were un-employed for some time after qualification, especially in London.

There were also now some new students to mentor (many whom are still very good friends and colleagues today) and to take the pressure off our set dusting the trendy blue MEL Linac that has caused so much interest in this blog and its bunker!

Fascination with the mould room

There were four students in my set and while I was the only “boy” I actually enjoyed the mould room environment, it being creative professionally, artistically and manually. The facility was run by Ms Mills, who took it upon herself to “ensure” that all students were fully immersed in all aspects of radiotherapy immobilisation. Some liked it and others didn’t! The sickness rates increased when students and staff were rotated to the mould room but I loved it. There were no clean, simple to use and instant perforated thermoplastic masks of today and everything revolved around the use of plaster of Paris, dental alginate, wax and lead sheet. However, when I worked at Mount Vernon a few years later, we were the first site to trial “Orfit” the first ever instant perforated thermoplastic masks used on patients in the UK, I’ll refer to this in the next blog in March.

We had to make a plaster of Paris impression of each other to start with that involved covering our head and neck in bandages that were very messy and became very hot, uncomfortable and claustrophobic when setting but if you want to convince a patient to go through this then its good to know what it feels like and offer some psychological support. The only link to the outside world for 15 minutes was a breathing straw and it was a compulsory exercise for all students! The set impression was filled with plaster, a plastic sheet vacuum formed on top and a bespoke immobilisation mask created to be fitted to the patient and marked out in planning later.


Pic Standard issue plaster bandages are used to make a mould.

However, this technique was the first smoke and fire hazard for unsuspecting patients and administration staff in the hospital as the mould room was strategically placed between a cancer ward and corridors of offices high up on the third floor and often the plastic sheet would smoke if the heater was left on too long. Getting the temperature just right so that it would mould to the plaster cast and stretch in a uniform way without burning was a skill in its own right.

Life and Death Masks!

When in Edinburgh recently in the Library of the Scottish National Portrait Gallery they were exhibiting life and death masks of famous and infamous Scots such as Burke and Hare. Gruesome reminders of their acts I know but a technique almost identical to our mould room practice!

Some images are quite graphic but use this link to find out more: https://www.timeout.com/edinburgh/blog/burke-and-hare-keats-and-voltaire-life-and-death-masks-in-edinburgh

When I created my company DHA many years later I came up with a product called Virtual Mask Maker based on a 3D laser scanner, imaging software from the UCL medical graphics department and rapid prototyping (CNC/STL) machine that manufactured a 3D head on which you could create an immobilisation mask without any direct contact with the patients or taking a messy plaster impression. The rapid rise of the use in thermoplastics meant this idea didn’t catch on in radiotherapy but we did sell some units to leading government forensic departments.

Read more on 3D scanning: https://polhemus.com/scanning-digitizing/fastscan

Using electrons for treating non-melanoma skin cancer (NMSC)

At the Middlesex, Dr Margaret Spittle was one of the UK’s leading lights in treating skin cancers.

Our electron facility enabled NMSC overlying cartilage to be treated successfully where using low energy x-rays could cause considerable treatment complications and additional morbidity.

The mould room would regularly see tumours located close to the nose and ears and so personalised lead masks were fabricated for these cases and appropriate electron energies chosen to suit the required treatment depth with a wax insert in the cut-out to provide build up.

Each patient had a dental alginate impression made that was filled with yellow “Kaffir D” plaster, that when set was extremely hard and suitable to forge lead sheet over using wooden bossing mallets.

A word of warning here in that dental alginate and hair do not mix and should you pour it over the patient’s head or hairy parts it’s almost impossible to remove. You then have to explain as you spend an hour combing it out that this has never happened before! It doesn’t happen again.


Pic Typical lead electron mask and wooden bossing mallet.

However, one thing that was not all that apparent in those days to us as students was that electrons lived double lives! As previously discussed last month Quantum Mechanics (QM) was touched upon in our Physics lectures and these seemingly generated a keen interest in the subject to the extent that I have latterly read QM books from luminaries such as Steven Hawking – The Grand design, Manjit Kumar – Einstein-Bohr and the Great Debate about the Nature of Reality, Jim Al- Khalili – the Coming of Age of Quantum Biology and are all well worth a read if this floats your boat!However, if the subject confuses you as it still does for me remember that famous QM physicist Richard Feynman said: “I think I can safely say that nobody understands quantum mechanics” but here goes…..

Particle/wave duality of electrons

Quantum objects like electrons have split personalities – sometimes they behave like waves, and sometimes like particles. The way they behave depends on the kinds of questions you ask them like the “two-slit experiment”.

This is the most famous experiment in quantum mechanics, in which electrons are fired at two slits before being detected on a screen.

The experiment hinges on the different behaviour of waves versus particles for the same set up.

If you fire electrons at the slits, even one at a time, they form an interference pattern on the screen as if each electron passes through both slits at the same time, and interferes with itself. This seems to tell us electrons are waves.

Because the electron is a quantum object, we can’t know its location due to the Heisenberg uncertainty principle. The electron has some chance of going through one slit, some chance of going through the other – because both are possible, it actually goes through both or a superposition of states.

Now, the “observation” is when the electron hits the detector, showing a bright flash or wave-function collapse.

But say you try to trick the electron by putting a mechanism at the slits which tells you which one the electron goes through. Suddenly the interference pattern disappears.

Because you know which slit the electron went through, it is no longer in a superposition of states and so only travels through one of the slits. The electron’s wave-like behaviour vanishes, and it behaves just like a particle.

Other interesting facts about quantum electrons!

Louis de Broglie proposed that all particles could be treated as matter waves.

Erwin Schrödinger proposed the quantum mechanical model of the atom, which treats electrons as matter waves.

The Heisenberg uncertainty principle states that we can’t know both the energy and position of an electron. Therefore, as we learn more about the electron’s position, we know less about its energy, and vice versa.

Electrons have an intrinsic property called spin, and an electron can have one of two possible spin values: spin-up or spin-down.

Any two electrons occupying the same orbital must have opposite spins.

An atomic orbital is defined as the region within an atom that encloses where the electron is likely to be 90% of the time.

Flattening filter or no flattening filter?

Our MEL Linac also had an interlocked, metallic beam flattening filter that needed to be manually removed by us from the beam axis before electrons could be used and then run-up and so these treatments were all carried out at lunch-time as long as “Physics” were free to come down to re-calibrate. The flattening filter material is important. A more penetrating beam is produced if the flattening filter is made of aluminium rather than tungsten or lead.

Now modern Linacs such as TrueBeam from Varian have no flattening filter and so some things seemingly revert back to basics in the end but at least we knew the reasons why, even then!

 

More confessions of a student radiographer

Another good reason to be keen to work in the mould room was that Ms Mills (who I still send Christmas cards to each year some 40 years later) and the other Superintendent Radiographers from the Middlesex and St John’s met for lunch in a Thai restaurant in Soho each Friday and they always took me along too. I didn’t say no and often these lasted longer than an hour!

There was always a cauldron of boiling wax on the go in the facility that ensured bespoke wax bolus could be made to order as “build-up” to operation scars of breast cancer cases (most cases had mastectomy and not lumpectomy then) and also for the treatment field in the electron masks and this also often caught fire or smoked heavily leading to the London Fire Brigade attending on more than one occasion, a further occupational hazard for staff and patients alike and when the lift doors opened on the 3rd floor of the Meyerstein Institute of Radiotherapy you knew where you were there by the smell of burning!

Lastly, on Charlotte Street just around the corner there was London’s largest dental supplier called Cottrell & Co.’s initially a Victorian Dental Depot which was essentially an Aladdin’s cave meeting all our mould room equipment and consumable needs and so I often went out with a shopping list and was trusted to buy things on our account and return with handful of goodies.

This building is now the famous Charlotte Street Hotel and so when I get the chance on my trips to London I regularly walk by and reminisce of those good times.

Designer Kit Kemp used a ‘Bloomsbury Group’ theme throughout the hotel which features original art from the period and a mural in the brasserie reflecting scenes of ‘contemporary London life’. Read more: https://www.mrandmrssmith.com/luxury-hotels/charlotte-street-hotel


Pics Charlotte Street Hotel in London

DCR (T)

The internal “Hospital exams” are set a few months prior to the formal finals and when passed I was awarded this:

Many variations of hospital badges from all over the country were proudly worn by working radiographers. I recall some Christie Hospital ones on show in London among my colleagues; another leading teaching hospital based in Manchester.

Our final College of Radiography exams took place in London’s Queens Square where all London based students took part and in October 1982 and having passed these I was awarded the Diploma of The College of Radiographers and was offered the only Radiographer vacancy at the Middlesex Hospital that year and so my life had gone fall circle from missing my interview to having letters after my name. I was very proud of my achievement and hoped that my enthusiasm and getting stuck in as a student had stood me in good stead.


This proved to be just the start of a life in Radiotherapy and I worked in London at the Middlesex until 1995 when I took a Senior 1 position at Mount Vernon Hospital in Northwood with a remit to be the Lead Radiographer for Mould Room services with a salary of just over £7k per year.

Badly needed new equipment installed

Before leaving the Middlesex we eventually took delivery of a new Philips SL75/5 Linac that was a forerunner to the Elekta range which still had manual wedges and shielding block trays replacing the ageing Theratron (80 cm SSD) with an improved dose rate at 1 meter in the range 350-500 rad/min at up to 6MV and so sped up treatments and reduced any waiting lists (MLC and Asymmetric jaws were still away in the future) while a shiny new TEM Simulator replaced the mobile X-Ray unit in Planning and so everything was on the up.

Pic Philips SL 75/5 Linac in 1985

 

To come: “People buy people first!”

Next month I move to Mount Vernon in Northwood and then in 1990 take on my first job in radiotherapy equipment sales and marketing working with Theratronics in the UK and Benelux.

 


Feature Article:

 

Apprenticeships – therapeutic and diagnostic radiography education moving forwards

By Louise Coleman MSc Med Phys, PgD, PGCIPHE, BSc (Hons), Dip HE, DCR(T), Professional Officer for Education and Accreditation, The Society and College of Radiographers

I rarely have a conversation with a diagnostic or therapeutic radiographer about apprenticeships where a comparison is not made to radiographer training of the past. I regularly hear, “Apprenticeships? Great, we’re going back to the DCR and DCR(T)”. Let me be clear right from the start of this article, pre-registration apprenticeships are not the diploma with another name and the education of diagnostic and therapeutic radiographers is not going “back” almost three decades. About two thirds of radiographers today have a BSc (Hons) or MSc pre-registration qualification and education needs to move forwards.

Ok, rant over. What are these apprenticeships all about if they’re not the education of the “good old days”?

The Levy

Employers in the United Kingdom (UK) with a wage bill of more than £3 million have to pay 0.5 % of the amount to Her Majesty’s Revenue and Customs. This is known as the Apprenticeship Levy. Employers in England can claim back levy money and use it to train apprentices. For every £1 they pay in levy, they should get back £1.10 to train apprentices. In England this is paid via a digital voucher system. This makes apprenticeships very attractive to NHS and independent sector managers.

Apprenticeships are devolved in Scotland, Wales and Northern Ireland. The money is paid to the devolved administration to spend as they see fit using the Barnett formula to work out how much they get. There are apprenticeship systems in all four UK countries but when it comes to imaging and radiotherapy only employers in England have developed apprenticeship standards, watched intently by the rest of the UK.

Approved apprenticeships

There are several levels of apprenticeships in England. All apprenticeships are led by employers rather than universities or colleges and, to date, the ones relevant to the imaging and radiotherapy workforce are:

• Mammography Associate – a higher apprenticeship which has recently been approved for delivery. It has a Framework for Higher Education Qualifications (FHEQ) level 4 qualification. This is the same education level as the first year of a BSc (Hons) degree.

• Assistant Practitioner – a higher apprenticeship with a FHEQ level 5 foundation degree qualification. Approved for delivery almost three years ago.

• Diagnostic Radiographer (degree) and Therapeutic Radiographer (degree) – coming soon, a degree apprenticeship where individuals will be able to complete a BSc (Hons) or MSc qualification. Not approved for delivery yet but watch out for news in the coming weeks.

• Advanced Clinical Practitioner – degree apprenticeship with a master’s qualification. It’s approved for delivery. This apprenticeship is not just for those practitioners with a generic Advanced Clinical Practitioner job title or role. It’s for all advanced practitioners. However, diagnostic and therapeutic radiography education providers have a bit of work to do to ensure their postgraduate programmes are included within their university’s Advanced Clinical Practitioner framework.

• Consultant practitioner – we’ll will have to wait a little longer. There is currently no consultant practitioner apprenticeship, but it’s being discussed by Health Education England, the allied health professions professional bodies and others.

Why?

Why do we need apprenticeships for therapeutic and diagnostic radiographers? Why do we need education to change? Why do employers want or need to become involved in education more than they are already? The answer is simple, why not?

It’s been well publicised that it’s hard to recruit students for therapeutic radiography programmes. It’s not seen as an attractive career choice by many young people leaving secondary education with relevant A’ levels. Diagnostic radiography programmes are much easier to recruit to but the number of students leaving programmes has risen slightly over the last few years. Healthy retention of students is no longer a given for universities with diagnostic radiography programmes.

Lower recruitment and retention mean that there will be a shortage of therapeutic and diagnostic radiographers in the coming years. Combine this with expected high levels of retirement, it could be challenging to staff imaging and radiotherapy departments using traditional models of education.

Recruitment and retention are not just problems for universities. Some radiotherapy and imaging departments have difficulties recruiting and retaining therapeutic and diagnostic radiographers. Apprenticeships could be one way of addressing some of these challenges. Apprenticeships will enable employers to recruit and employ individuals who are local to their department. They’ll pay these individuals while they’re training. They’ll build up employer-employee relationships with the apprentices and nurture them through their apprenticeship and qualification. In doing so, employers will possibly increase the likelihood of these individuals remaining employees once they become diagnostic or therapeutic radiographers.

Of course, we don’t know if our presumptions will turn out to be fact. We won’t know for at least three years. However, it’s got to be worth a shot.

The same

Apprentices and traditional pre-registration students may take very different routes to registration, but the baseline registerable level will be the same. On the day that one completes their qualification and the other their apprenticeship, which includes a qualification, both radiographers will be the same. Both will be eligible to apply for registration with the Health and Care Professions Council (HCPC) and once registered, each will be a therapeutic or diagnostic radiographer. There will be no difference in what they can or can’t, should or shouldn’t do. Their scopes of practice will be the same as any other therapeutic or diagnostic radiographer who has just registered for the first time.

Differences

The biggest training difference by far will be the amount of time apprentices spend in the clinical learning environment – imaging and radiotherapy departments. Traditional students spend about 50 % of their time on campus and the rest on placement. Apprentices will spend about 80 % of their time in the clinical learning environment, learning with and from diagnostic or therapeutic radiographers.

Clinical radiographers and other imaging and radiotherapy department professionals will have much greater input into what and how apprentices learn. It will be the employer, probably the department manager, who makes the decision that the apprentice has reached the baseline level of knowledge, skill and behaviour for registration and so puts them forward for the apprenticeship end point assessment. The end point assessment will make up the final few credits of their BSc (Hons) or MSc which will remain as the registerable qualification with the HCPC.

As the apprentices will be employees and not students, employers will take much greater responsibility for their study skills and pastoral support throughout their training than they need to do currently for traditional students.

Practice educators will become an even more integral and vitally important part of clinical learning environment than they are now. Where they’re in place already, apprentices and their learning and assessment needs probably won’t come as a shock to any radiographer in that department. However, if there aren’t practice educators in place now, then it could be a steep learning curve for the department manager and radiographers alike.

Opportunities

Apprentices, like all learners, come with great opportunities. Although apprentice numbers are unlikely to be high in the first couple of years, numbers could grow as the demand for diagnostic and therapeutic radiographers grows. This means there will be more opportunities for diagnostic and therapeutic radiographers to get involved in learning, teaching and assessment.

More practice educators will be needed to coordinate workplace learning with the small proportion of theory that the universities will be responsible for. Essentially, practice educators will have to ensure that apprentices are enabled to meet their learning outcomes in the workplace and out of it. Any manager interested in having apprentices in their department should not underestimate the need for experienced, qualified and College of Radiographers accredited practice educators.

Having one or more practice educators in the clinical learning environment can only be good for the rest of the department too. Creating a learning culture for apprentices will have positive knock on effects for traditional students, assistant practitioners, diagnostic and therapeutic radiographers and the wider interprofessional team. There will be opportunities for other professions within the department to become involved in workplace learning and teaching. It will be essential for medical physicists, dieticians, speech and language therapists, registered nurses, oncologists, radiologists and the whole of the interprofessional team to play an active part in the education of apprentices. Why wouldn’t diagnostic or therapeutic radiographers want to take advantage of the knowledge of the whole interprofessional team at the same time as the apprentices?

Change can be good

Therapeutic and diagnostic radiographer education is changing. It’s not the first time this has happened, and it won’t be the last. Our professions’ registerable qualifications changed significantly almost 30 years ago when the two became graduate professions equal in status, education and qualifications to the other registered allied health professions.

In this article I’ve only touched on some of the intricacies of apprenticeships and of integrating this new model with the traditional models of education. Whether apprenticeship learning will fit and work in every department is debatable and much will depend on the level of educational support that departments are willing and able to provide. However, it’s clear there is a need for apprenticeships and apprentices in imaging and radiotherapy departments if the patient and workforce demands are to be met in the very near future.

The Society and College of Radiographers supports the development of apprenticeships for all tiers of the imaging and radiotherapy workforce including therapeutic and diagnostic radiographers.

I’m very interested to hear your thoughts about apprenticeships and most importantly, your solutions to the challenges ahead. Are there enough practice educators? Will imaging and radiotherapy departments be able to support apprentices’ learning? What are the other benefits and opportunities of apprenticeships that I haven’t mentioned?

If you wish to email Louise directly use LouiseC@sor.org

Or if you want to answer the above questions use the blogs Q and A forum below.

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