Overall, 212 responses were received from 28 radiologists (SMOs and registrars) and 184 SLPs. After ineligible surveys were removed, 21 radiologist and 150 SLP surveys remained. Of these, four radiology and 19 SLP surveys were incomplete, yet key components (i.e., all of Section 1 and “In your opinion, do Radiology Registrars require VFSS training?”) were completed and these surveys were included in the data analysis.
Demographic Data
Most respondents were based in Australia and worked in tertiary hospital settings (Table 1). There was a wide range of SLP clinical experience in VFSS (from less than one year to over 16 years) and employment level (from junior clinician level to director of SLP services). Over half (n=87/150; 58%) of the SLP respondents had practiced for at least six years and most (n=117/150; 78%) were senior SLPs. Both SMO radiologists (n=8/21; 38.1%) and radiology registrars (n=13/21; 61.9%) responded. Radiologists and SLPs reported that their centres predominantly provided VFSS services to adult-only populations (n=99/171; 57.9%), then mixed populations (n= 61/171; 35.7%) and finally, paediatric-only populations (n=11/171; 6.4%). Specific patient population age ranges reported by respondents are displayed in Table 2.
Table 1: Location of Respondents, Setting and Type of Centre
Location and Centre
|
Radiologists
n=21
|
SLPs
n=150
|
Location
Queensland
New South Wales
Australian Capital Territory
Victoria
South Australia
Northern Territory
Tasmania
Western Australia
New Zealand
UK
|
18 (85.7%)
2 (9.5%)
1 (4.8%)
|
62 (41.3%)
37 (24.7%)
4 (2.7%)
17 (11.3%)
11 (7.3%)
1 (0.7%)
1 (0.7%)
8 (5.3%)
4 (2.7%)
5 (3.3%)
|
Type of Centre
Hospital – Quaternary
Hospital – Tertiary
Hospital – Secondary
Hospital – Regional
Hospital – Rural/Remote
Private Practice
Other
|
5 (23.8%)
16 (76.2%)
|
18 (12%)
74 (49.3%)
25 (16.8%)
26 (17.3%)
3 (2%)
2 (1.3%)
2 (1.3%)
|
Table 2: Populations Receiving VFSS
Population
|
Radiologists
n=21
|
SLPs
n=150
|
Pre-term infants (<37 weeks gestational age
Infants (birth to 1 year) |
A variety of VFSS clinic models were described, most commonly with a SLP led VFSS clinic with radiologists reviewing images outside of clinic (n= 89/171; 52%), and a joint SLP/radiology model (n=64/171; 37.4%). Other models identified included: a radiologist and SLP model with no radiographer present; a SLP led clinic with radiologists only reviewing images and/or attending clinic on request; and a SLP led clinic with no radiologist involvement at all.
Existing VFSS Radiology Registrar Training
Most of the SLP respondents (n=125/150; 83.3%) had access to formal SLP VFSS competency training programs at their facilities. This contrasted with the most of the reported VFSS training for radiology registrars, which was informal and ad hoc. Only one respondent, a SLP, reported implementing targeted VFSS training for radiologists at their site. The content delivered during the targeted training program depended on the level of experience of the radiology registrar and SLP present during the clinic. The training was delivered via several learning platforms, including face-to-face lectures, on-the-job training during VFSS clinic and small group tutorials through peer-based learning. Often, a senior radiology registrar was present during the VFSS training clinics; however, further details of radiology-delivered training were unknown. The respondent rated the training as 80% effective in their opinion and indicated that SLPs from their site would prefer to deliver a more formal training program.
Is VFSS Training Needed for Radiology Registrars?
The opinion of most respondents (91.3% of SLPs, n=137/150, and 85.7% of radiologists, n=18/21) was that VFSS training is needed for radiology registrars. Pearson’s chi-squared test revealed no relationship between respondents identifying the need for training and their employment grade: radiologists (x²=2.154, p=0.14); SLPs (x²=4.395, p=0.62). Furthermore, there was no relationship between SLPs identifying the need for radiology registrar training and the SLPs years of VFSS competence/experience (x²=2.160, p=0.83).
Many respondents who felt that there was a need for radiology registrar VFSS training illustrated this through free-text comments that were coded and allocated into the following categories:
1. Opportunities for and occurrence of VFSS training for radiology registrars.
2. Level of knowledge, skills and confidence of radiology registrars in VFSS.
3. Enhancing interprofessional working and valuing the different professional roles in VFSS clinic.
4. Impact on patient care.
5. Potential outcomes of VFSS training.
From these data, the themes of perceived current limited radiology registrar involvement in VFSS clinics and desired improvements (i.e., increased radiology registrar engagement and further understanding of VFSS purpose and enhanced clinical interpretation) to VFSS clinic were discovered. Comments supporting the need for training included “[VFSS] Should be more formal training such as with ultrasound, fluoroscopy and CT procedures.” (Radiology registrar, tertiary hospital, Queensland) and “It would be great to highlight the importance of their role and look at culture change in radiology registrars along with the clinical knowledge.” (SLP, regional hospital, New South Wales). Table 3 provides examples of coded and categorised comments. The categories that were developed from coded free-text responses align with a flow of processes that can be incorporated into a training methodology, which is represented by a schematic flow diagram (Figure 1). This process flow demonstrates the impact that reduced training has on radiology registrars’ skill and confidence, the inter-professional roles within the VFSS clinic, risks to patient care and the potential outcomes that VFSS training would bring.
Table 3: Themes[1], Categories and Samples of Comments Supporting VFSS Training for Radiology Registrars
Categories
|
Number of Responses per Category
|
Respondents
|
Opportunities for and occurrence of VFSS training for radiology registrars
|
Radiologists: n=2
SLPs: n=9
|
Perceived Current Limited Involvement of Radiology Registrars in VFSS Clinics
“In general, the training from the SPs[1] is better than that provided by the radiologists.” (Senior medical officer radiologist, quaternary hospital, Qld[2])
“Should be more formal training such as with ultrasound, fluoroscopy and CT[3] procedures.” (Radiology registrar, tertiary hospital, Qld)
“The issue we have with our radiologist not wanting to review the VFSS is because he considers he is untrained and not competent at this. Thus, training radiology registrars would help solve this situation.” (Senior SLP, rural/remote hospital, NSW[4])
|
Level of knowledge, skills and confidence of radiology registrars in VFSS
|
Radiologists: n=2
SLPs: n=95
|
Perceived Current Limited Involvement of Radiology Registrars in VFSS Clinics
“Currently most radiology registrars arrive thinking that they are just a foot on the pedal and the radiographer is probably just as good if not better than them.” (Senior medical officer radiologist, quaternary hospital, UK)
Currently at our centre, we appreciate the registrars being present, however it is mainly a teaching experience for them versus actually providing useful information for us.” (Senior SLP, quaternary hospital, NSW)
“Because they frequently do not wish to comment and have disclosed that they do not feel competent to report.” (Senior SLP, tertiary hospital, NSW)
|
Interprofessional working and valuing VFSS roles
|
Radiologists: n=1
SLPs: n=98
|
Desired Improvements to Current VFSS Clinic
“Part of the challenge in a programme for radiology registrars is to show them how they add value with their broad medical knowledge. So, part of developing a training programme is to initiate a cultural shift, and a sense of clinical ownership.” (Senior medical officer radiologist, quaternary hospital, UK)
“It would be great to highlight the importance of their role and look at culture change in radiology registrars along with the clinical knowledge.” (SLP, regional hospital, NSW)
“To understand the purpose of a VFSS and their role in providing a radiologist opinion.” (Senior SLP, regional hospital, Qld)
|
Impact on patient care
|
Radiologists: n=0
SLPs: n=10
|
Perceived Current Limited Involvement of Radiology Registrars in VFSS Clinics
“Whilst they can generally identify aspiration or pharyngeal residue etc., they have limited knowledge or understanding as to why this occurred. This can impact on information provided to patients, management plans and safety of oral intake for a patient.” (Senior SLP, regional hospital, Qld)
Desired Improvements to Current VFSS Clinic
“To ensure most accurate and appropriate analysis of VFSS with SP to ensure best patient care.” (SLP, quaternary hospital, NSW)
“Objectively contribute to the interpretation of videofluoroscopic swallow findings and collaboratively ensure recommendations are made and agreed upon to enable improved clinical outcomes for patients.” (Senior SLP, tertiary hospital, WA[5])
|
Potential outcomes of VFSS training
|
Radiologists: n=2
SLPs: n=29
|
Desired Improvements to Current VFSS Clinic
“A number of education sessions from the SPs to both the registrars and consultants would be very valuable and would help also with interpretation of non VFSS barium swallows performed without a SP” (Senior medical officer radiologist, quaternary hospital, Qld)
“Sometimes working in VFSS clinic, the most satisfying sessions are when the Rad reg[6] is engaged and collaborative in their interaction with the SP. We value their role but at times a perception of disinterest and lack of importance may be inadvertently conveyed by them. This occurs infrequently, but if we could play a role in enhancing their skills in this area, perhaps this could improve the teamwork and outcomes for the pt[7] in the session.” (Senior SLP, tertiary hospital, NSW)
"Improves medical accountability for swallow dysfunction and the short and long-term consequences to respiratory health and nutrition.” (Senior SLP, tertiary hospital, WA)
|
In response to questions probing reasons why VFSS radiology registrar training is not needed, the themes of maximising existing resources and training, and maintaining professional roles and responsibilities emerged from the data. One radiologist stated, “It is like barium swallow, doesn't need specific training just for VFSS.” (Radiology registrar, tertiary hospital, New South Wales). Further, 12 SLPs each provided justification against VFSS radiology registrar training, which were categorized as follows:
1. Additional cost and radiology registrar time.
2. Radiology registrar knowledge and (ad hoc) education already exist.
3. Over-stepping boundaries in VFSS clinic.
4. Radiology registrar training would not add value to VFSS clinic or patient care.
One SLP respondent acknowledged “They [radiology registrars] would benefit from knowing the rationale for choosing VFSS versus other instrumental swallow assessments however we fear that role boundaries may be blurred when it comes to actually conducting the VFSS procedure.” (Senior SLP, tertiary hospital, Victoria).
Identified Training Requirements
Content identified, through frequency counts, as being important for a VFSS training package included:
1. Understanding the difference between VFSS and barium swallow/upper gastrointestinal studies.
2. Diagnosing structural or anatomical abnormalities impacting on swallowing and/or feeding function.
3. Detecting penetration of material into the laryngeal vestibule and aspiration of material into the trachea.
4. Understanding each of the VFSS clinic interprofessional team’s roles (Figure 2).
A senior medical officer radiologist respondent suggested linking pathology to swallowing: “Understanding implication of common pathological conditions on swallow function – e.g., Zenker’s diverticulum, cervical osteophytes, strictures” (Senior radiology medical officer, quaternary hospital, Queensland). Approximately one third of SLPs (n=42/150) recommended specific information for paediatric VFSS interpretation, for example: “Paediatric VFSS is different to adult. In relation to paediatrics - not always standard positions and changes during study, needing longer run time with some feeds or capturing beginning and middle of feed, ceasing film at the end of swallow not during, deep penetration versus aspiration, possible anatomical anomalies e.g., laryngeal cleft, TOF [tracheoesophageal fistula]” (Senior SLP, tertiary hospital, South Australia).
For specific training formats or modalities, both the SLP and radiologists’ preferences were distributed evenly across the options provided (Figure 3). The most frequently identified modalities were:
- On-the-job training during VFSS clinics.
- Face-to-face didactic lectures provided to a group.
- Problem (case)-based learning groups.
- Internet-based or smart device application-based programs.
Respondents also recommended blended, combined training modalities: “I feel a series of didactic lectures would cover the necessary material, supplemented with involvement with several live cases to illustrate the didactic content” (Radiology registrar, tertiary hospital, Queensland) and “I certainly think however that training would need to encompass a minimum of theoretical learning either through face-to-face lectures, one-on-one training, problem-based learning groups and/or web-based programs, and also practical experience and competency-based assessment.” (Senior SLP, secondary hospital, Queensland).
Duration of VFSS Training and Number of Training Sessions
The recommended duration of VFSS training in hours and weeks, and number of sessions are presented in Table 4. Overall, the recommendations for duration and sessions were similar for radiologists and SLPs: both respondent groups recommended a median of eight total number of training hours; radiologists recommended a mean of 5.05 weeks total duration of training and SLPs a mean total of 5.91 weeks; and a mean of six and five sessions were recommended by radiologists and SLPs, respectively.
Table 4: Duration and Number of Training Sessions Recommended for VFSS Training
Professionals
|
Values
|
Total Number of Hours
|
Total Duration of Training (Number of Weeks)
|
Number of Sessions
|
Radiologists
|
mean ± SD
median
min-max
|
14.8 ± 19.95
8
2-80
|
5.05 ± 6.24
6
0.1-24
|
5.53 ± 5.10
6
1-20
|
SLPs
|
mean ± SD
median
min-max
|
12.43 ± 12.37
8
1-60
|
5.91 ± 5.97
4
0.1-30
|
8.41 ± 12.70
5
1-100
|
Evaluation Methods
To evaluate radiology registrars’ VFSS competency, the most frequently identified methods were:
1. Competency as determined by the supervising radiology senior medical officer.
2. Informal observation with case discussion.
3. Formal assessment.
Other suggestions included collaborating with SLPs for assessment, online cases in assessment/exams, and multiple-choice quizzes, while only six respondents (SLPs n=5; radiologists n=1) indicated that no assessment process was needed (refer to Figure 4).
1Themes are highlighted in bold and italics within each category
2SLPs
3Queensland
4computed tomography
5New South Wales
6 Western Australia
7Radiology registrar
8patient