The Progression of the Advanced Practice Levels of RPA-RAs (CBRPA)

Radiology was not included in the military’s plan, however, because NPs and PA-Cs are traditionally indoctrinated in clinical health fields such as cardiology, cardiovascular surgery, emergency medicine, family medicine, internal medicine, obstetrics-gynecology, orthopedics, and so forth.² This group of advanced practice allied health professionals are neither didactically nor sufficiently clinically trained in medical imaging, which includes invasive and interventional imaging procedures. Nevertheless, due to radiology practitioner manpower shortages in both civilian and military imaging departments, radiology departments are hiring NPs and PA-Cs to: 1. Assess patients; 2. Perform procedures similar to the American College of Radiology (ACR) guidelines for a Radiologist Assistant (RA); 3. Write pre-procedure, post-procedure, and post-care orders. Unfortunately, this same group lacks the education in computed imaging, knowledge of invasive and interventional procedures, and knowledge of fluoroscopic procedures, radiographic anatomy, radiation biology, radiographic positioning, radiation safety and other disciplines that are the foundation of well-educated and well-trained radiographers. These advanced radiology-based subjects were not and are not part of the didactic and clinical training of NPs and PA-CS. Dedicated and motivated radiologic technologists, on the other hand, are well trained in these essential areas. Drs. Babu and Bender approached the Department of Radiologic Sciences at Weber State University (WSU) in Ogden, Utah, with a proposal to develop an advanced-level, modified distance-learning program to educate and clinically train radiologic technologists as radiology extenders in the United States Army Medical Corps. The proposal, which was drafted as a hospital-approved research protocol, was written by Laurence Briggs RT(R).³ The plan focused on training experienced civilian and military radiologic technologists as Radiology Physician Assistants in a pilot program in collaboration with WSU in Ogden.³ The Radiology Physician Assistant would have been deployed to a remote military teleradiology site that had no military- or a civilian-contracted radiologist.³ WSU, a top-rated state university, was selected because the two radiologists had researched the quality of the advanced radiologic science educational programs at several universities in the United States and determined that WSU had well-recognized advanced imaging programs and had already implemented outstanding online degree learning programs. It was assumed that to attract seasoned radiographers who possessed the knowledge, experience and desire to become radiologist extenders, a distance-learning model would be necessary. Weber State University Develops an RPA Program The proposal document was sent in late 1993 to Dr. Jane Van Valkenburg, former Chairperson of the Department of Radiologic Sciences at WSU. Upon reading the proposal, Dr. Robert Walker and Dr. Van Valkenburg visited the radiologists at Madigan Army Medical Center in Tacoma, Washington. Five years later in 1998, the professors’ concept for what became known as the Radiology Practitioner Assistant (RPA) program became a reality. The professors worked as a team with the physicians, who provided the professional assistance and guidance to develop a curriculum similar to the didactic training for NPs, with clinical training focused on radiographic imaging. This established course of studies is the same one that the American Registry of Radiologic Technologists (ARRT) refers to as the nationally recognized curriculum, such as the one purportedly developed by the American Society of Radiologic Technologists (ASRT) in the current ARRT Annual Report to Radiologic Technologists.⁴ The clinical training also focuses on radiology-based procedures that many experienced radiologic technologists have been quietly performing for years. Two major requirements of the RPA program were that student applicants possess at least five years of clinical experience in radiologic technology, and provide a minimum of three strong recommendations from radiologists who know them and their competency level. While they hammered out the curriculum, these men also wrote the first job description for RPAs, which is available on www.cbrpa.org. The job description has undergone changes at the hands of several radiologists who have observed how these advanced-trained technologists continue to reach higher-level clinical skills and broaden their abilities to participate in more challenging procedures. The original intent of the RPA program was to train military radiology specialists who were to be assigned to military hospitals that lacked radiologists or to field units that encompassed combat situations. These men and women would perform the imaging procedures at their duty stations, make basic interpretations so injured soldiers could be treated emergently, and then transmit the images by teleradiology to a base medical facility where a civilian-contracted or military radiologist would complete the final interpretation.³ Three important matters remained unresolved before the program could accept students for the first class. One dealt with the lack of a certification examination, another was the title for the soon-to-be highly advanced-trained radiology specialists, and the final matter involved financial support for the military students who would become distance-learning students located around the world. Another important stepping-stone involved financial support approval from the Department of the Army and the Department of Defense (DOD), with an anticipated start date of October 22, 1993.⁵ After waiting two more years, the DOD nixed the budget. Nonetheless, the curriculum and study modules for the radiology extenders program had already been completed through the efforts of the military radiologists and the instructional staff at WSU. With the military dream shattered, the university decided to open the program to the civilian sectors. The first class of ten students commenced their formal education in August 1996. ⁶ The class of 1999 began their courses one year later, in 1997. ⁶ The RPA Credential Title Since the nationally accredited Physician Assistant programs do not offer extensive clinical training in imaging procedures and invasive imaging studies, the title Radiology Physician Assistant, mentioned in the two U.S. Army physicians’ proposal, would be inappropriate. The American Academy of Physicians Assistants (AAPA) does not have a certification process for men and women specifically trained in the subspecialty of radiology. To differentiate from the originally suggested title of Radiology Physician Assistant, the thought was to name the advanced-trained technologists Radiology Practitioners. The civilian WSU classes of 1998 and 1999 had also considered the term Radiology Physician Assistant, but the student bodies chose Radiology Practitioner Assistant (RPA) instead. ⁶ The primary reason for changing the credential term to Practitioner was to maintain parallels with the outcomes of the ASRT Educational Conference, where the model for the profession was developed. ⁶ In the ASRT documents, the label Radiology Practitioner was used for the advanced-practice level. ⁶ Further research and input revealed that the nomenclature Radiology Practitioner actually meant Radiologist. ⁶ The two class bodies decided to attach the word Assistant to the ASRT label. Hence, the new, highly advanced-trained radiologic technologists would become assistants to the radiologist, who was also known as a Radiology Practitioner. ⁶ Creating the Certification Board of Radiology Practitioner Assistants (CBRPA) Now that the name was decided upon, the next step was to determine how to certify these professionals and how to establish recognition of them in the advanced-level allied health community. Dr. Jane Van Valkenburg presented the concept to the officials at the ARRT and the ASRT House of Delegates, where some resolutions were passed, but no definitive action was taken on the resolutions. ⁶ Neither of the organizations showed interest in the RPA program and/or had a clear interest in establishing a certification program for the small group of advanced-practice level student technologists. Knowing that this group of students needed formal certification to be recognized by hospital credentialing committees, Dr. Van Valkenburg helped organize and establish the Certification Board of Radiology Practitioner Assistants (CBRPA). ⁶ The concept for certification was based on guidelines for NPs. This was a necessary process so that RPAs could be recognized as certified allied health professionals with hospital credentialing committees, similar to NPs and PA-Cs. ⁶ On March 11, 1998, the CBRPA was incorporated in the State of Utah. The office is located at 1074 East 2750 North, Ogden, Utah, 84418-2741. ⁶ The ASRT Develops the Radiologist Assistant (RA) Credential In 2001, the ASRT drafted the concept of a new career field called the Radiologist Assistant (RA). This idea, along with the addition of the curriculum and clinical requirements, was based on the original concept, proposal and developments that Drs. Babu and Bender and WSU educators created for the RPA program at WSU. The exception was that the ASRT lobbied the ACR and ARRT between 2001 and 2003 to garner their support for the new RA. The new RA concept was accepted by the ACR and ASRT in Spring 2003. RPA Program is Undermined, but Curriculum is Utilized The American College of Radiology (ACR) disputed the RPA Program at WSU on the premise that advanced-practice level technologists should not be interpreting images. However, this was never the intention of the program. During the ASRT planning stages, focusing on getting the idea for the RA program accepted by the ACR and ARRT, the ACR and ASRT used the curriculum and clinical evaluation system developed and copyrighted by the WSU program to draft their (ACR/ASRT) model. In the current ARRT Annual Report to Registered Technologists, the required didactic competency mentions that the topics for professional education requirements ...should be covered as part of a nationally recognized curriculum such as the one developed by the ASRT. ⁴ In addition, the certification process for this modified RA program was not developed. The only information that the ASRT staff was able to obtain readily came from WSU and the CBRPA website. The copyrighted course materials, which the students were required to use, were not released to the ASRT or any of the first four university-based RA programs. Development of RA Programs; RPAs Present Concerns To promote and establish the first four RA programs, the ASRT approved four $25,000 grants to seed four universities. The selected facilities were Loma Linda University in Loma Linda, California; University of North Carolina at Chapel Hill in Chapel Hill, North Carolina; Midwestern State University in Wichita Falls, Texas; and the University of Medicine and Dentistry of New Jersey in Newark, New Jersey. The purpose of the grants was to quickly implement the four RA programs in the schools’ radiologic science departments. In January 2002, Mr. Lynn May, CEO of the ASRT, spoke by invitation at the Third Annual Conference of the NSRPA about his proposed RA program. The RPAs in attendance developed mixed views and waited for what would ensue in the years ahead. Although willing RPAs helped, the first RA program, which was launched at Loma Linda University, did not accept students until Fall 2003. Many RPAs and interested radiographers remain skittish and are evaluating other options. The ACR established guidelines for the RA programs without consideration of the role being filled by certified RPAs. In April 2002, (article author) Charles Williams addressed each of the sections developed by the ACR and ASRT on how an RA would function under the supervision of radiologists and/or other physicians. The nineteen-page document was sent to an ACR representative, two ASRT representatives, and a representative from the CBRPA, before an adjunctive meeting held at the ASRT offices in May 2002. ⁹ Another meeting was later held with representatives of the ACR, ARRT and ASRT, along with two CBRPA-certified RPA representatives. ¹⁰ The letter focused on many concerns related to the RAs and the recommendations for RA programs that did not yet exist. The focus of the meeting centered on misinformation about image interpretation done by advanced-practice RPAs. This factor was not the intention of Drs. Babu and Bender, whose original concerns were the shortage of radiologists, the reality of training technologists to perform procedures, providing basic image review in hospitals or in remote areas to enhance patient care standards where radiologists were not available, and to transmit the images electronically from remote sites to radiologists in hospital departments, imaging centers and offices for formal interpretation. It seems that misinformation will play a major role in determining the fate of the RPA and RA professions in the years to come. RA Certification Exam: RPAs Solicited for RA Advisory Committee In mid-2002, the ACR, in conjunction with the ASRT, asked the ARRT through their Board of Trustees to begin development of a formal certification exam for RAs. To accomplish this task, the ARRT had to complete a survey analysis, which was sent to 1,000 radiologists and all certified RPAs. ^11,12 The board cordially asked two CBRPA-certified RPAs to sit on the RA Advisory Committee. Why? Because there were no certified RAs in the United States. This committee has developed the mechanism for incorporating didactic and clinical competency requirements into a comprehensive collection of documents that meet the Continuing Education Requirements, Rules and Regulations, Standards of Ethics, and Standards of Practice established by the ARRT, with ACR and ASRT input for exam eligibility. ^4,13-15 The RPAs helped to bring this about to better the profession for all technologists in radiology as well as to give much-needed relief to the many overworked radiologists in this country. RPAs and the RAs appear to be on the same page, but it seems that misinformation continues to get in the way of how things are being perceived. It is the RPA’s goal to legitimize the practice of the radiologist extender, not become rogue mid-level providers. RPAs Undermined in State Licensure Bills for Both RAs and RPAs While these somewhat political issues are being resolved, several RPAs have been working with their state house members and state senators to draft bills to license RPAs and RAs alike. The current RPAs are trying to open doors for whoever follows them, whether they are RPAs or RAs. Thus far, however, each time a state begins to work on a licensure bill, an ASRT official contacts the state legislators, requests that they eliminate the term RPA from the proposed legislation, and encourages the state officials to only include RAs. ⁶ Montana, Tennessee, Kentucky, California, Mississippi and Washington have had such interferences. In two situations, the ASRT pleaded with the states of Montana and Kentucky to hold off presenting their state licensure bills to the assembly floors until the RA criteria were established and approved for the certification process by the ARRT. ⁶ CBRPA Continues to Work for Appropriate RPA Recognition The ARRT was given an opportunity to develop the certification examination for RPAs, and the request for interest continued through early 1998. The opportunity was repeatedly declined by the ARRT. However, Jerry Reid, Executive Director of the ARRT, recently contacted Dr. Van Valkenburg and asked her if the CBRPA Board of Directors would discuss a merger with the ARRT. ⁶ The National Society of the RPA (NSRPA) Board of Directors appreciatively declined. The reason focused on the narrowed scope of practice established for RAs. The fact that the CBRPA continues to work with the ARRT offers some hope of resolution of the confusing RPA/RA issue. The decision to decline this charitable offer was based on the recognition of the currently CBRPA-certified RPAs. These RPAs function under a broader scope of practice that allows them to work in interventional radiology, whereas RAs are limited in the types of procedures they can perform. Also, there are several RPAs employed in invasive and interventional cardiology settings. CBRPA-certified RPAs are being offered jobs as directors and instructors for the starting RA programs. The contribution of RPAs to the establishment of the advanced practice level for technologists educationally, legislatively and professionally should be recognized by all entities. How can one refuse to recognize the RPAs who are educating the RAs, but then go on to only recognize the students (RAs) who learned from them? A Meeting to Discuss the RA Highlights Credential’s Challenges By invitation of Mr. Jerry Reid, Executive Director of the ARRT, Dr. Van Valkenburg attended a meeting at the ARRT offices on April 22-23, 2005, along with educators from several proposed RA programs. ⁶ The meeting was held to discuss clinical competency requirements and other issues that the ARRT developed for the RA certification requirements. Dr. Van Valkenburg was invited because no certified RA instructors with extensive experience are currently available. (This fact was well-covered in Jenny Song’s article, The Lessons of Loma Linda: Expect Challenges, that was also published in the Advance for Imaging and Radiation Therapy Individuals on January 24, 2005. ¹⁸) On September 15, 2005, Dr. Van Valkenburg, CBRPA Executive Director, Roland Clements, CBRPA President, and Terry Liccardi, CBRPA board member, attended the joint meeting of the CBRPA and ARRT. The ARRT was represented by Jerry Reid, ARRT Executive Director, and Ann Chapman, ARRT board member. ¹⁹ This group of professionals discussed: 1. The differences between the two scopes of practices; 2. How the RA role delineation, as established by the ARRT, has inhibited the use of RAs in the practical work force because of hospital credentialing guidelines; 3. The levels of supervision for each procedure required for RAs to function under radiologists, which constrict RAs; 4. The requirement of a bachelor’s degree; 5. The applicant requirements for the RA programs which differ in terms of required levels of experience ranging from accepting newly certified general radiographers to those with one year of experience.¹⁹ The CBRPA requires each exam applicant to possess a minimum of five years of postgraduate experience. ¹⁹ None of the RA programs had any educational standards to guide the programs during the development of the curriculum. ¹⁹ Another point brought up by the CBRPA representatives involved hospital credentialing committees’ requirement of documentation of clinical competency records. ¹⁹ Other subjects discussed were: 1. Why the ARRT was asking questions on disease processes, but not on the image appearance of the disease process. The explanation provided was that the organization hoped to extend into those areas, thus they made the content specifications for pathophysiology very extensive. ¹⁹ A copy of the most recent CBRPA content specifications were surrendered to the ARRT. ¹⁹ 2. The CBRPA did mention that many RPAs would not take the ARRT’s RA examination because the scope of practice was too narrow. ¹⁹ Also, Mr. Reid mentioned that constraints of the National Organization for Competency Assurance (NOCA), the accrediting agency, would not permit the current CBRPA-certified RPA-RAs to be grandfathered in as ARRT-certified RAs. ¹⁹ RPA Progress Remains Unacknowledged The ASRT and ACR continue to scrutinize and discredit the WSU program, the CBRPA and its well-trained and recognized RPAs all of whom they have refused to acknowledge. In the current Annual Report to Registered Technologists, the ARRT acknowledges several medical imaging societies, with the exception of the NSRPA (National Society of Radiology Practitioner Assistants). ^4,20-22 Ignored is the fact that any progress made in the establishment of the advanced-practice level for technologists has been accomplished solely through the efforts of the RPAs, the CBRPA and the WSU program, since there are no ARRT-certified RAs in the workforce who are actively participating in the development. We are hoping this, too, is due to misinformation and misperception issues. Concerns for RAs and Why RPAs Offer More The first RAs graduated in mid-May 2005, yet these students face two significant certification issues: 1. They do not meet the rigid requirements for the CBRPA certification examination; 2. A certification exam was not available until October 2005 for these graduates. ^16,17 Again, will the RA movement improve radiology as lobbied by the ASRT and marketed by Dr. Sal Martino in Song’s article: We believe the RA is the solution... and ...As radiology departments struggle to meet patient needs, …people are talking about using advanced level technologists as a way to make the radiology department more productive and to enhance overall quality in patient care? ⁷ What about the recent RA graduates from Loma Linda University, most of whom have been unable to find employment? We feel that the RPA-RA (CBRPA) has more to offer radiologists, hospitals and imaging centers because: 1. These professionals were accepted into their program with at least five years of experience; 2. They have undergone excellent training as radiology interns by their preceptors; ²³ 3. Their clinical training in patient assessment and management coincides with the training for other mid-level providers; 4. Their sponsoring radiologists see a need for technologists who have been trained to perform procedures and are knowledgeable about pathological processes as observed in general radiography, computed and magnetic resonance imaging, invasive, interventional and ultrasound studies. Some RAs will no doubt receive similar training and education, but there is presently no consistency in these programs. The ARRT, in the hopes of standardizing, has developed requirements that will apply to all RAs entering programs. One requirement is to possess one year of RT experience before attending what is considered a very tough RA program. ¹⁷ Some students are very bright and can manage with this level of experience, but most veterans of radiology know that several years of experience are needed to become sufficiently familiar with the profession. Once a technologists can do everything in radiology with their eyes closed, only then can they take on more challenging tasks and integrate clinical pathways, etc. There remains one major issue that current CBRPA-certified persons should consider. Since the ARRT cannot grandfather in the RPAs as RAs, and we pass the ARRT RA exam, we will be forced to work under a very narrow scope of practice.13-15 This means that the men and women who participate in interventional procedures in Massachusetts, Montana, Georgia, Florida, Colorado and other states, will become very limited in their abilities to improve departmental productivity and enhance the quality of direct patient care. The other point to ponder is that many of us have had the experience of working with radiology assistants throughout our careers. When technologist shortages increased over the past two decades, facilities created positions for darkroom technicians and technologist assistants who prepared the barium mixtures for UGI patients and barium enema patients, stocked procedure rooms, and so forth. Why? Because the technologist needed more time to care for the patients. These ancillary personnel were titled Radiology Assistants in many hospital radiology departments. Will a Radiologist Assistant be misconstrued as a Radiology Assistant among our fellow allied health peers? There are now more than 300 welltrained men and women who are known as RPA-RAs (CBRPA), and there are 165 students in the current upper and lower level classes. All of them have been stringently selected and will be trained to do what radiologists have less time to accomplish, as the number of radiologists is dwindling in medical facilities where many new radiologists have no desire to practice, particularly in small rural hospitals and military facilities. As the use of Picture Archiving and Communication Systems (PACS) becomes a reality for an increasing number of facilities, why can’t the RPA function in the capacity that was originally conceived by Drs. Babu and Bender? Do we wait until the NPs and PA-Cs saturate our imaging departments, fumble through procedures, and get reimbursement for their work, while the RPAs, who possess excellent principles and extensive clinical experience in imaging operations, are left hanging on a limb without any recognition for their skills? A Final Note: Future Plans for RPAs The controversies and misunderstandings should be addressed by the appropriate higher officers within the ACR and the ASRT. If this is not done, both RPA-RAs (CBRPA) and RAs (ARRT) risk becoming extinct, just as Radiology Physician Assistant programs at Duke University and the University of Kentucky did in the early 1970s. This means that both credentialed professionals could return to their original environments as super techs, without the ability to use what they have been trained to do as proposed by Mr. Briggs and Drs. Babu and Bender in 1993. Although the Department of Defense denied financial support for the military facilities in 1995, the concept opened doors for slow-accepting civilian and military radiologists who continue to judge RPA-RAs (CBRPA) as a result of numerous misunderstandings. The history of the original course of action was never taken into full consideration by the ASRT, ACR and ARRT. The attending radiologists at one author’s place of employment have turned a deaf ear to RPA-RAs because they have serious misunderstandings about how to incorporate them. The radiologists lack interest in hiring RPA-RAs because they have heard so much negativity about the advanced-level trained technologists. They fear the loss of reimbursements and choose instead to hire NPs and PAs who are approved by Medicare for reimbursements. However, most of these allied health professionals have never been formally educated or clinically trained to perform image-based procedures. Several radiologists who employ RPAs in their groups have canvassed WSU to begin training RPAs in the subspecialties similar to fellowships completed by physicians. Efforts are being made to initiate recognition of RPA-RAs (CBRPA) by the American College of Cardiology and by Cardiovascular Credentialing Incorporated (CCI). The main reason for these efforts is so that RPAs can be hired by cardiology groups to assist them with invasive and interventional cardiac procedures, echocardiograms and other related invasive cardiac studies. In February 2005, the CBRPA grandfathered in all certified RPAs with an additional credential, Radiologist Assistant (RA), in keeping with the political shift that was taking place. WSU is in the process of modifying the RPA program so that a RA program will be offered. The differentiating factors between the RPA and RA are: 1. The RA curriculum will be at a bachelor of science degree level; 2. The RPA will be at a master of science degree level. We are in for an evolutionary change, which is certainly not going to be easy. From our experience, once this evolution is complete, the medical field will not be able to live without radiologist extenders, just as today it cannot do without PAs and NPs.

1. Babu SS, Bender GN. Radiology Physician Assistants (RPAs) - A Proposal. Tacoma, Washington: Madigan Army Medical Center, 1993, pp. 1-6.

2. Babu SS, Bender GN. Radiology Physician Assistants (RPAs) - A Proposal. Tacoma, Washington: Madigan Army Medical Center, 1993, p. 1.

3. Babu SS, Bender GN. Radiology Physician Assistants (RPAs) - A Proposal. Tacoma, Washington: Madigan Army Medical Center, 1993, p. 4.

4. American Registry of Radiology Technologists: RA content specs, competence requirements build on role delineation. In: Annual Report to Registered Technologists. St. Paul, Minnesota: ARRT, 2005, p. 7.

5. Briggs LM. Letter to Dr. Jane Van Valkenburg, August 23, 1993.

6. Van Valkenburg J. Personal communication, April 1, 2005.

7. Song J. The radiologist assistant, new times demand a new profession, high hopes in the air as the first class of RAs prepares to enter the field of medical imaging. Advance for Imaging and Radiation Therapy Professionals 2005;15:31.

8. Van Valkenburg J. Personal communication, February 4, 2003.

9. Van Valkenburg J. Personal communication, March 15, 2002.

10. Larsen J. Personal communication at the Fourth Annual NSRPA Conference, February 4, 2003.

11. American Registry of Radiologic Technologists (January 2004). RA Job analysis survey - suitable for printing. In: ARRT Develops Radiologist Assistant Certification Program. Retrieved May 7, 2005, from http://www.arrt. org/web/rasurvey.pdf.

12. American Registry of Radiologic Technologists (December 19, 2003). Sample of ACR members to be surveyed by mail: RPAs asked as well. In: ARRT Develops Radiologist Assistant Certification Program. Retrieved May 7, 2005, from http://www.arrt.org/web/content.jsp? include=/radasst/rasurvey.htm.

13. American Registry of Radiologic Technologists (February 22, 2005). RA exam content specs, competence, requirements build on role delineation. In: ARRT Radiologist Assistant Certification Program. Retrieved May 7, 2005, from http://www.arrt.org/web/content.jsp? include=/radasst/raexamcontent.htm.

14. American Registry of Radiologic Technologists (February 22, 2005). ARRT adopts role delineation for radiology assistants. In: ARRT Develops Radiologist Assistant Certification Program. Retrieved May 7, 2005, from http://www.arrt.org/ web/content.jsp?include=/radasst/raarrtadopts.htm

15. American Registry of Radiologic Technologists (April 12, 2005). ARRT moves toward finalization of radiologist assistant eligibility requirements, administrative timing. In: Educational, Ethics, and Exam requirements. 1-2. Retrieved July 24, 2005, from http://www.arrt.org/web/content.jsp?include=/new/wn_ra_elig_req_05-04-12.html.

16. American Registry of Radiology Technologists: Broader choices: Supporting categories expand for post-primary certification. In: Annual Report to Registered Technologists. St. Paul, Minnesota: ARRT, 2005,p. 27.

17. American Registry of Radiologic Technologists (July 5, 2005). ARRT Radiologist Assistant … ARRT finalizes RA certification eligibility requirements. Announces exam format and administrative procedures. 1-2. Retrieved July 24,2005 from http://www.arrt.org/web/content.jsp?include=/new/rajuly05update.htm.

18. Song J. The lessons of Loma Linda: Expect challenges. Advance for Imaging and Radiation Therapy Professionals 2005;15:33.

19. Certification Board of Radiologist Practitioner Assistants. Report to the CBRPA Board on the CBRPA and ARRT representatives meeting. In: Report to CBRPA Board. Ogden, Utah: CBRPA, 2005.

20. American Registry of Radiology Technologists: CE consensus conference participating organizations. In: Annual Report to Registered Technologists. St. Paul, Minnesota: ARRT, 2005, p. 11.

21. American Registry of Radiology Technologists: Continuing education requirements for renewal registration: Section 19. Definition of terms. In: Annual Report to Registered Technologists. St. Paul, Minnesota: ARRT, 2005, p. 45

22. American Registry of Radiology Technologists: Continuing education requirements for renewal registration. In: Annual Report to Registered Technologists. St. Paul, Minnesota: ARRT, 2005, p. 47.

23. Tigges S. Personal communication, November 12, 2001.