Introduction

Assessment of diagnostic images and communication of significant findings to responsible health practitioners is a minimum capability required of radiographers practicing in Australia.^{1, 2} Despite this communication falling legally within radiographic scope of practice, the form it should take is debated^{1, 3} and it is implemented informally or inconsistently between Australian imaging departments.⁴ Historically, input has been in the form of highlighting or ‘red-dotting’.⁵ However, the ambiguity in this system has led to support for ‘radiographer commenting’, which is recording a preliminary image evaluation (PIE) in written format.⁶ A comment is a brief description of urgent findings by the radiographer who interacted with the patient at the time of image acquisition and can be provided to other health practitioners involved in the patient's care through the electronic medical record.^{7, 8} Commenting is acknowledged as an interim measure to supplement the referrer's interpretation^{9, 10} and does not substitute a final report, which is the definitive medical diagnosis in clinical context.^{11, 12} PIE has been an expectation of standard practice in the UK since 2010 and is reported to provide numerous benefits to the healthcare system.^{13, 14} Therefore, the purpose of this narrative review was to assess if formalised and consistent radiographer image interpretation in the form of commenting on X-ray images would be valuable to the Australian healthcare system, particularly when a radiologist report is not available within a clinically relevant timeframe. Value has been defined in terms of accuracy, error reduction and positive experiences of patients and staff. Therefore, this review will assess the current context of radiology services in Australia, preparedness of radiographers to provide accurate comments, perceived value to other staff in a multidisciplinary team, the potential for error reduction in communication, diagnosis and patient management, and the impact on radiographer job satisfaction and retention.

Method

Literature was identified from CINAHL, Medline, Scopus and Web of Science databases using the search strategy outlined in Table 1. Synonyms, Boolean operators and database operators were used to maximise applicable literature returned. The resultant abstracts were divided among authors for screening to identify papers with confirmed relevance to the research question. Where authors were unsure, this was settled by consensus. Reference lists were then used to source further suitable literature from professional and governing bodies. To be included, literature had to address any image interpretation by radiographers on plain X-ray imaging. However, studies that specifically addressed X-ray commenting by Australian radiographers formed the majority of the narrative discussion.

Current Context of Radiology Service in Australia

For radiographer image interpretation to be valuable to the Australian healthcare system, there must be a contextual need for its implementation. Demand for imaging is growing, driven by an increased and ageing population with higher disease burdens and hospital admission rates.^{4, 12} In Queensland, emergency department presentations are increasing by 50,000 per year with half of presentations referred for imaging.^{15, 16} X-ray accounts for most examinations and is continuing to grow, but an increase in cross-sectional modalities has limited focus on service provision issues related to X-ray.^{8, 15-17} In an ideal system, radiologists would be positioned to meet the imaging demand; however, growth in specialist numbers has fallen short of increases in imaging.¹² There has been a sustained shortage and maldistribution of radiologists, disproportionately affecting the public and rural healthcare sectors.^17-19 The most recent Radiologist Workforce Census in 2016 showed that 87% of radiologists surveyed were in major cities, 11% in inner regional, 2% in outer regional and 0% in remote or very remote regions.¹⁸ Almost one-third of the workforce is part time, with a quarter intending to reduce their hours.¹⁸ Conversely, radiographers are trained and recruited in adequate numbers.²⁰ The Australian Council on Healthcare standards expects that a non-urgent report should be provided within 24 hours to effectively influence clinical management²¹ and urgent emergency presentations should have reports enabling admission, discharge or transfer within 4 hours.¹⁵ However, high demand and workforce shortages have resulted in reporting turnarounds outside these clinically useful timeframes.⁵ Delays of 1–3 days are common,^{12, 15} and in a study by McConnell,²¹ it was found that 67% of reports took over 3 days.

While radiology shortages and reporting delays occur throughout the system, they are often experienced in emergency and rural settings.^{10, 12, 21} Emergency departments are frequently understaffed, with junior medical officers accounting for the majority of clinicians and imaging referrals.^{17, 22} Radiologists have noted a lack of imaging education within Australian undergraduate medical programmes, amounting to an average of 85 hours,^{20, 21} and junior doctors lack ongoing radiological support and training, which is projected to worsen as compulsory experience in medium to large emergency departments has been approved for replacement with small hospitals and general practitioner care.²⁰ In a 2018 study, clinicians at 70% (n = 7/10) of emergency departments with 24-hour imaging did not have access to an on-site radiologist out of hours¹⁵ when 40–50% of daily referrals are made.¹⁷ In rural settings, image interpretation regularly becomes the role of the referrer^{23, 24} and as the radiographer often presents the most experienced radiographic opinion, input is frequently but informally sought and provided.^{10, 17, 24, 25}

Australia has been a leader in advancing radiography particularly through education, which has been expanded to 4-year undergraduate and postgraduate level, including image interpretation and pathology content.^{26, 27} Currently mandated under National Law is the responsibility for radiographers to work collaboratively within a multidisciplinary team, assess each image for the presence of trauma or disease and convey findings to clinical staff.^{2, 26} The government's Productivity Commission has recommended the extension of radiographer X-ray interpretation and the MRPBA and ASMIRT endorse written communication of findings.^{1, 2, 4, 5, 15, 22} Despite RANZCR's rejection of radiographer input, there is evidence that unofficial interpretation and discussion of X-ray findings with clinicians has consistently been part of practice even if it has not been formally recognised.^{19, 27} Indeed, recent studies have reported that up to 82% (n = 60/73) of participants engaged with some form of informal interpretation, with 36% (n = 26/73) doing so for 80–100% of imaging cases.^{4, 5} A study of dynamics between radiographers and referrers in rural Australia indicated that in the interest of patient advocacy, radiographers frequently communicated with referring doctors to assist in image interpretation. However, communication pathways were usually varied, informal and untraceable, leaving them vulnerable to misinterpretation or dismissal.²⁴ Importantly, although implementation remains inconsistent, in a 2018 study, 100% (n = 21/21) of medical imaging departments surveyed expressed interest in radiographer input systems.¹⁵

Overall, it appears that radiographers are an available and underutilised resource to address service provision issues related to specialist shortages, lack of support for non-radiologist physicians and reporting delays through the formalisation of existing input via written PIE systems.

Preparedness of Radiographers to Produce Accurate and Confident Initial Comments

If radiographer interpretation of X-ray images is to be valuable to the Australian healthcare system, radiographers must be capable, confident and willing to undertake the task. While there is robust international evidence to support the efficacy of reporting (production of a full diagnostic report by specially credentialed radiographers in the United Kingdom and Europe) and ‘red-dotting’, research regarding the ability of radiographers to specifically localise and briefly comment on X-rays is more limited and varied in approach. During this review, research was assessed from Australasia, Europe, Africa and North America. Participant experience ranged from new graduate to senior. Some studies included short education programmes to support image interpretation, while others measured existing ability.^{16, 20-23} There was a wide range of expected documentation levels from simply recording the location of findings to complex descriptive accounts, including anatomical side, bone, exact location, description of the pathology and diagnosis.²⁸ Finally, the scope varied from only appendicular imaging to axial and paediatric.^{16, 20-23}

For the purpose of this review, studies discussed assess the accuracy of general radiographers to specifically localise abnormalities or comment on imaging. Currently, no professional body has defined a standard for image interpretation accuracy. However, a benchmark of 80% compared with radiologists has been suggested, reflecting the typical performance expected of radiographers and junior doctors.²⁹ While there is mixed or limited evidence pertaining to new graduates and non-appendicular accuracy, the data overall suggest that Australian radiographers can produce accurate descriptive comments based on their current education and experience.^{16, 20, 22, 23, 30}

Robust data have been produced by McConnell,^20-22 Smith¹⁶ and Hall²³ which show consistent trends over many years. Hall studied every practicing radiographer at Alice Springs Hospital over three collection periods spanning five years with a sample of 940 examinations.²³ A full scope of examinations, including emergency, outpatients and inpatients were included and no formal education was provided, meaning results reflected the existing skill of practitioners. Radiographers had an average accuracy of 91% for identifying normal and abnormal cases, and 85% for writing a preliminary clinical diagnosis. Smith¹⁶ studied the use of a written opinion form by radiographers at John Hunter Hospital for 820 emergency images. Over three-quarters of employees participated, and their experience ranged from first-year graduates undertaking supervised practice to senior practitioners, with educational backgrounds from diplomas to degrees. No targeted training was provided. The overall accuracy was 93% and the Kappa Index showed almost perfect agreement with radiologists. Interestingly, no significant difference was found across educational backgrounds or years of experience. Therefore, while experience may increase accuracy,²⁰ recent graduates with less clinical experience but a higher level of education can perform similarly to senior practitioners. More recently, McConnell assessed written comments on adult appendicular radiographs by Australian radiographers with varying experience levels before and after image interpretation education.²² Radiographers met the benchmark standard before education with a mean accuracy of 82% and non-fitted Receiver Operating Characteristic (ROC) of 0.87.²² Following education, there was a statistically significant improvement in mean accuracy (87%), sensitivity, specificity, predictive values and positive likelihood ratios. ROC rose to 90% and Kappa values showed substantial agreement with the radiologist reference standard. Descriptive ability was noted to begin at a high level and increase with training. This study indicates the potential for continuing professional development to further improve radiographer contributions. McConnell studied this same cohort, assessing their descriptive comments for radiographs they had personally taken and found their mean accuracy rose to 95%, with all radiographers performing at or above 89%.²¹ Importantly, this showed the significant positive impact of patient contact on interpretation accuracy, which has implications for the benefit of comments to radiologists who are not afforded this interaction. Finally, McConnell assessed the commenting of Australian radiographers who were over 2 years qualified but had no additional image evaluation training on a range of appendicular and axial emergency images and found a mean accuracy of 87% with a ROC of 0.94.²⁰ Comments were detailed, including the type of abnormality, location and appearance and suggestions for further imaging.²⁰

These positive assessments of Australian radiographers were supported by subjective data. Neep found in a survey that on a scale from 1 to 10, 90% (n = 66/73) of radiographers rated their confidence to accurately detect appendicular abnormalities at the midpoint or higher.³⁰ This remained at 70% (n = 51/73) for producing a written description.³⁰ However, confidence was found to decrease for axial imaging.³⁰ Other studies have reported positive correlations between perceived and actual accuracy, indicating radiographers are reliable at predicting their abilities.^{31, 32} This is important as PIE may involve statements of uncertainty, so radiographers must be aware of the extent of their ability. Of these same participants, all reported a high desirability for education designed to support PIE as standard practice.³⁰ However, there is mixed opinion on mandatory comments both from practitioners and managers^{15, 30} with some radiographers believing participation should remain an individual choice, despite MRPBA requirements.^{33, 34} A lack of willingness has been attributed to time constraints, low confidence, concerns over monitor quality and unreliable access to continued training.^{11, 30}

Value of Commenting in a Multi-Disciplinary Team

An important aspect of the value of radiographer preliminary image evaluation is whether it is supported and perceived as useful within the multidisciplinary team. Role development can be viewed as a threat to traditional roles²⁵ and has been met with reluctance and unsupportive attitudes in some instances.^{21, 25, 35} During a 2013 study by McConnell, a participating hospital reneged on plans to provide emergency doctors with comments despite accurate performance by radiographers. Most final reports (64%) at one site in this study took in excess of 3 days, jeopardising service performance indicators and highlighting the potential value that radiographers could have offered.²¹ In another study, a radiologist had to withdraw due to the impact of negative attitudes from colleagues,²⁵ highlighting the difficulty of engaging medical professionals within this area of research and practice. However, attitudes have been shown to change once PIE is implemented, with Sonnex reporting a mixed initial reception from doctors but a complete reversal of negative attitudes following the 6-month study due to the value of PIE to junior staff.¹⁰ Other studies have shown that radiographer opinion is both valued and utilised by referring doctors, especially in rural settings.²⁵ All eight participants in a 2013 study reported that emergency consultants referenced radiographer opinions during telemedicine consultations with their patients,³⁵ while medical staff frequently look to provisional comments in contexts with delayed reporting.²³ Finally, radiographers themselves see PIE as useful to inform decision-making and perceive it as valuable to emergency staff.¹¹

Radiologist support is also a major enabler to radiographer commenting.³⁰ Multiple studies have suggested that commenting has potential to assist radiologists by indicating important cases and improving prioritisation of workload.^{10, 36} Furthermore, comments can provide additional information and a high degree of descriptive safety as radiographers have the advantage of direct patient contact and ability to expand clinical history.^{16, 17, 21, 22} In the United Kingdom, radiologists have recognised the potential of radiographer image interpretation to reduce service pressures.³⁶ In Scotland, Henderson found a younger cohort of radiologists more willing to work with radiographers, overcoming historical notions of medical dominance to guide and support radiographer development.³⁴ While progress is being made in Australia, this same support by radiologists is not always present and the official stance of RANZCR remains that image interpretation by radiographers is not the right solution.³

Radiographer PIE also promotes collaboration and transparency within inter-professional teams, facilitating effective and timely communication. In a large study by Snaith and Hardy, consultants felt comfortable discussing and questioning findings with a radiographer, with a majority of respondents (96.9%, n = 84/87) feeling they were able to seek advice from reporting radiographers but were less likely to do so from radiologists (65.5%, n = 57/87).³⁷ This was more apparent for emergency clinicians, where 95% (n = 39/41) were willing to speak to radiographers but fewer than half (n = 20/41) were willing to speak to a radiologist.³⁷ Although commenting is not a formal report, it has potential to promote more open communication and discussion around imaging findings and allow the value of radiographers in the emergency team to be formally recognised.³¹ Immediate availability of radiographic opinion is viewed by emergency staff as a source of support for developing image interpretation skills (75.9%, n = 66/87) and the use of input to confirm initial opinions improves the confidence of staff (70.1%, n = 61/87).^{23, 37}

Overall, PIE helps meet demand in a context with limited specialist resources by providing support to both radiologist and non-radiologist physicians. It is a tool to enhance teamwork by promoting open communication and collaborative development rather than increasing pressure on small groups of staff.²¹ This helps improve relationships, increase feelings of cooperation²⁵ and elevate the perceived value of radiographers in a multi-disciplinary system.^{4, 21}

Error Reduction and Patient Management

Radiological errors are inevitable but should be systematically analysed and addressed.³⁸ While production of high-quality radiographs is important, pre- and post-acquisition errors have stronger correlations with poor patient outcomes.³⁹ This indicates that interpretative and communicative error reduction presents the greatest opportunity for progress^{40, 41} and improvement of patient outcomes.^{42, 43} In addition to misinterpretation and miscommunication, delays in radiological input are another major source of error.³⁰

Reporting delays mean management and discharge decisions are often made without radiology department input, which can contribute to missed, incorrect, or incomplete diagnosis and management.^{5, 44} This impacts patients for whom delayed or inappropriate treatment diminishes outcomes and damages public trust in healthcare services.^{8, 40, 41} Immediate radiological input is proposed to mitigate this.⁸ A recent control trial compared the effect of immediate and delayed reporting on patient management, concluding that an immediate report reduced the number of false positives and false negatives, eliminated patient recalls and reduced the number of patients admitted.⁴⁰ A survey conducted by the same author revealed significant support for quick reporting, considering it an essential tool for patient management.³⁷ While this study involved reporting radiographers, PIE in the form of brief comments is also a documented source of input from the radiology department in the absence of an official report and so may also help mitigate risks arising from delay.

Misinterpretation is the most common diagnostic error and may arise in the emergency department, radiology department, or other service departments.^{8, 12} Errors can be perceptual, where an abnormality is not seen so a radiograph is misclassified as normal, or cognitive, where an abnormality is seen but incorrectly identified. Perceptual errors account for 80% of missed diagnoses.¹² Therefore, commenting could reduce this rate of error simply through increased perception, even if the radiographer cannot identify a precise diagnosis.¹²

Image interpretation is often the responsibility of emergency physicians, including junior doctors.^{15, 16} However, misreading of radiographs by doctors other than radiologists is the leading cause of emergency clinical error, accounting for up to 78% of cases.^{25, 45} Emergency doctors have frequently been reported to misinterpret between 1 and 7% of radiographs^{5, 12, 45, 46} with some authors reporting disagreement with radiologists in up to 46% (n = 114/248) of cases.^{47, 48} At least 2.5% of missed diagnoses are clinically significant, and mistakes are frequently made by junior doctors concerning fractures.^{5, 25, 46}

When defining accuracy as true-positive and true-negative values, radiographers have been shown to perform better than emergency physicians, including junior doctors, registrars and consultants^{21, 31} who may have limited interpretation experience,^{5, 10, 26} favour sectional imaging over X-rays²⁰ and have different assessment strengths focusing on abnormal information compared with radiographers who assess images with a reference of normal.^{20, 21} Therefore, commenting is proposed as a support to reduce misinterpretation, improve outcomes and reduce instances of discharge with untreated pathologies.^{10, 17, 20, 25} Indeed, an Australian study showed that interpretation success between radiographers and emergency doctors came from different elements, such that when written radiographer comments were combined with clinician interpretation, the overall accuracy improved, reaching 98.8%, as one group identified findings missed by the other.²¹ This effect was attributed to the greater raw sensitivity of radiographers. Conjointly, more significant abnormalities were found before reporting, halving the error rate from 2.4% to 1.2%, representing 133 patients a year for whom treatment would have been delayed or absent if radiographers had not contributed via initial commenting.²¹ Similarly, Neep noted that errors between radiographers and junior doctors differed in such a way that combining opinions improved the overall diagnostic accuracy.⁵ Berman found that radiographers identified 44% (n = 28/63) of abnormality cases missed by casualty doctors,⁴⁹ while Smith noted that combined accuracy of radiographer and emergency clinicians closely approaches radiologists.²⁵ This has important implications for patients. As Paul asserted, studies within Australia have shown quantifiable evidence linking increased radiographer responsibilities to improved patient throughput and reduced wait times.⁵⁰

As a preliminary comment is not intended to replace the report, it can therefore serve as a ‘double reading’; a concept shown to reduce errors made by radiologists.^{51, 52} Although the radiologist is regarded as the gold standard of interpretation,^{16, 17, 23, 54} they make a small number of errors when measured against an absolute truth.⁵³ A review on radiologist reporting following initial assessment by an appropriately trained radiographer showed greatly increased sensitivity and specificity.⁵⁵ In an Australian study, two abnormalities were missed by the radiologist but correctly identified by the radiographer, while the radiologist identified all three clinically significant cases missed by the radiographer.¹⁷ It has been suggested that this safety net is due to a difference in accumulated expertise and search strategies,⁵² as well as the greater degree of descriptive safety in radiographer comments.^{17, 22, 26} This descriptive safety is said to stem from the advantage of direct patient contact and ability to expand on clinical histories insufficiently included in the referral.^{17, 22, 26} Radiologist review of preliminary comments also provides a feedback loop and audit system that can increase the skill of the radiographer.³⁸

Commenting has also been shown to reduce errors beyond emergency and radiology departments. A United Kingdom study involving 4398 cases of nasogastric tube placement found commenting to be an effective solution to prevent adverse events with positive predictive values of 96.8% and negative predictive values of 99.1%.⁵⁶ Other authors have noted the potential for radiographer opinion to help identify abnormalities missed by referrers in rural areas.¹⁰

Errors of miscommunication due to informal and inconsistent radiographer input systems employed in Australia such as red dot and verbal communication may also be reduced by written commenting. Red dot highlighting is restrictive, ambiguous and non-specific.^{5, 9, 44} It does not indicate normal variants, nature, location, severity, or number of abnormalities, instead leaving doctors to ‘hunt’ for them.^{5, 9} The voluntary system means that abnormalities recognised by a non-participating radiographer may not be highlighted.⁹ In systems where verbal communication is employed, there are issues with shift changes and patient handover, and such miscommunication can negatively impact continuity of care.⁴⁴ It has also been found that abnormalities verbally reported by radiographers can be dismissed, radiographers may feel intimidated and referrers can be difficult to contact.^{22, 24} Formalised written commenting presents a method to improve communication.^{5, 15} It increases the specificity and removes uncertainty and ambiguity^{9, 15} Written comments also ensure that information is consistently and reliably provided with a formal and traceable record, which is auditable and less easily dismissed.^{22, 24}

Radiographer Satisfaction and Retention

Developing the role of radiographers through written PIE remains within their legal scope of practice and is thought to improve job satisfaction³⁴ and workforce retention, both with positive effects for the health system.^{2, 33, 57} Australian radiographers have cited improved skills, career advancement and enhanced job satisfaction as benefits of PIE.⁵ Additionally, the practice is likely to increase motivation, sense of responsibility, autonomy and professional challenge, all of which are tied to increased job satisfaction for medical imaging staff.^{17, 34, 35} A 2010 study investigated the expectations for role development among a cohort of final year radiography students and how this was linked to job satisfaction and performance.³³ This cross-sectional survey revealed that 97.3% (n = 36/37) of participants held an expectation for role development within 5 years post graduation, while 75.7% (n = 28/37) expected this to occur within 2 years. Additionally, 97.3% (n = 36/37) said they would not be satisfied if their expectations were not met, indicating that misalignment could negatively impact on radiographer motivation and performance. Therefore, the adoption of written PIE practices as a form of role development could help satisfy the aspirations of radiographers.³³ Indeed, Forsyth found 68% (n = 90/132) of radiologists felt that professional development would aid radiographer recruitment and retention.³⁶

Most practice advancement in Australia occurs through modality specialisation.²⁶ Skilled radiographers move away from X-ray as it currently offers limited opportunities for development and professional challenge.²⁶ Opportunities for professional development through written commenting, as opposed to verbal communication, could engage and retain practitioners within the general scope. Indeed, Australian general radiographers report high desirability for all formats of education designed to promote the practice of PIE³⁰ and renewed enjoyment and interest is cited as a desirable outcome of role development.⁵⁸ In addition, it is thought that education accompanying commenting will promote lifelong learning habits, benefitting patients and the health system.³⁵ Training focussed on image interpretation is available through accredited post graduate programmes at Australian universities. However, recognition and communication of urgent findings is a minimum capability of every registered radiographer and is therefore included all in medical imaging degrees.²

Quality of radiographic work also has potential to improve as practitioners take on more responsibility, producing provisional comments for images they acquire.^{16, 23} In an Australian study, improvement in image quality was cited as a perceived benefit of radiographer commenting.⁵ Without formalised commenting, radiographers may not appreciate the importance of quality images to the same degree, feel less accountable for their work, and be less inclined to scrutinise images due to feelings that their opinion is neither desired nor required.³⁷

By encouraging radiographers to work to their potential, PIE also helps improve professional standing and respect in a multidisciplinary team.²³ McConnell concurred with this finding, suggesting that the perception of commenting as an appreciated practice is likely to contribute to radiographers' sense of team satisfaction and personal value, as well as improving service to patients.²¹ Increased contribution to patient care is seen as an advantage of commenting, with a majority of radiographers enjoying using image interpretation skills to help inform clinical decision-making and improve care in the emergency department.¹¹ Further studies have shown that recognition and appreciation from inter-disciplinary colleagues induces feelings of satisfaction and professional pride³⁵ and could provide stimulus for further education and development.³¹ Enhanced professional standing and profile was a common finding across the literature, with large majorities of both radiologists and radiographers perceiving this as an advantage of commenting and role development.^{11, 23, 36, 59}

Limitations

Even though the literature shows that radiographer preliminary commenting can help ease service pressures, reduce errors, improve radiographer performance and increase job satisfaction, few studies quantify the effect on the healthcare system in terms of cost and impact on patient outcomes. Workplace trials or further literature could address these topics to highlight other areas of benefit or cost.

Several barriers need to be overcome before written commenting is widely implemented in Australia including radiologist support, radiographer attitudes and workplace culture.⁶⁰ It is paramount that awareness is raised of employers and radiographers with respect to the MRPBA minimum requirements for alerting significant findings, as upholding this capability is not an option but rather an obligation in all workplaces.^{2, 60}

Conclusion

The MRPBA's minimum competency framework requires all Australian radiographers to identify significant pathology in radiological images and take appropriate action to alert these urgent findings and ensure patient safety. While forms of PIE including abnormality highlighting and commenting are currently in place at some medical practices within Australia, this remains inconsistent and underutilises the full potential of radiographers. This amounts to a waste of available resources in a system with persistent specialist shortages, lack of support for non-radiologist physicians and reporting delays particularly effecting emergency and rural settings. Data suggests that Australian radiographers are capable, confident and willing to produce accurate written comments based on current education and experience levels, which can be further supported by professional development training. Participation in written image interpretation, which is largely supported by other medical staff, has the potential to improve recruitment, retention, job satisfaction, sense of professional challenge and quality of imaging. Additionally, appreciation of radiographer comments and formal recognition in the multidisciplinary environment increases positive feelings associated with teamwork, communication and professional standing. The input of radiographers is complementary to clinicians, leading to an increase in combined interpretative accuracy and a decrease in errors related to misinterpretation and reporting delays, as well as miscommunication. Cumulatively, these improvements are thought to enhance patient management and improve efficiency. Further investigations into patient outcomes and financial ramifications are required, but assessment of current literature indicates that formal implementation of PIE in the form of radiographer commenting would be of value to the Australian healthcare system, particularly in instances where a radiologist report is not available in a clinically relevant timeframe.

Conflict of Interest

There are no conflicts of interest to declare.

Funding

This project has not received any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.