CDC considers allowing nonphysicians to read complex chest x-rays: What could go wrong?

Rebekah Bernard, MD © Rebekah Bernard

On December 17, 2024, the U.S. Centers for Disease Control and Prevention (CDC) opened a request for public comment on the possibility of allowing nonphysician practitioners (NPPs) — nurse practitioners (NPs) and physician assistants (PAs) — to read chest x-rays of workers at risk for pneumoconiosis, a lung condition caused by inhaling mineral dust including coal, silica and asbestos. Currently, workers at risk for this life-threatening condition undergo an annual screening chest x-ray, which is administered by the CDC’s National Institute for Occupational Safety and Health (NIOSH). Radiologists who interpret these x-rays receive special training and certification for the program, and are called ‘B Readers.’

According to the CDC, there are 184 certified B-readers across 35 States and 2 Territories, and the program is considering allowing NPs and PAs to certify for the program to expand coverage across the country.

Sounds straight-forward, right? Not enough physicians to meet demand, so why not allow NPPs to ‘fill the gap?’ This same argument that has been used across the country to justify allowing NPPs to take on the role of physicians in other underserved areas of health care, including primary care and rural medicine. What could possibly go wrong?

Dangers of unsupervised practice of radiology by NPPs

Radiologists train for at least 13 years (4 years of college, four years of medical school, and five years of residency), completing more than 20,000 hours of clinical experience before they are certified to interpret radiologic images independently. B Reader certification requires these fully fledged radiologists to complete additional training and take an examination.

Nurse practitioners are required to complete 500 hours of clinical experience before being certified to practice advanced nursing, while physician assistants complete an estimated 2,000 clinical hours. According to Pulmonologist and Critical Care physician Gary Dudek, MD, these NP and PA training programs do not provide the training needed to interpret any x-ray, much less the subtle findings that may represent pneumoconiosis.

“I’ve worked with physician extenders my entire career, starting shortly after I finished fellowship, and there isn't a one that I've ever known, even those with 15 or 20 years of experience, that felt comfortable reading a chest X ray by themselves and making important decisions on that chest X ray,” Dudek said. “If things were to happen in the middle of the night and chest X rays were required, those chest X rays were always reviewed with the emergency room physician before they'd even call me about what was going on.”

In addition to his experience working with NPPs, Dudek also taught in a PA training program for four or five years. “I'm familiar with the training that they received, and none of it comes close to the type of radiologic teaching that I experienced in medical school and then through three years of residency.” Dudek said that without the background to interpret x-rays, he has multiple concerns. “One is under calling disease, because they don't have the ability to really see the early interstitial changes that may be present. Another concern would be to be over calling changes on the chest X ray that are unrelated to interstitial lung disease.”

Dudek noted that in addition to looking for pneumoconiosis, B readers are also responsible for identifying other potential pathologies on x-rays. “If a radiologist is doing a B reading and they see mediastinal lymphadenopathy, but not anything that would be attuned to the B reading itself, they're still going to read that and call it as an abnormality and bring it to somebody's attention,” he said. “While that may have nothing to do with their occupation, it may be a serious medical condition, and I fear that those people are going to slip through the cracks if the X rays are not reviewed by somebody with clinical experience.”

Public commentary opposing expansion of B reads to NPPs

Gary Dudek, MD shared his concerns about allowing NPPs to become B Readers on the CDC’s Request for Information website, which closes for testimony on March 17, 2025. Currently, more than 500 commenters have weighed in, most opposing expanding the B Reader program to non-physicians.

Radiologist J. Sebastein Rowe, MD, wrote that chest x-rays can be deceptively difficult to interpret, with nuances that “remain one of the most heavily studied topics by experienced diagnostic radiologists, including those who are experienced, such as subspecialty trained chest/thoracic radiologists.” He added that “patients deserve to have their imaging interpreted by individuals with the certification and experience commensurate with the education of a medical doctor…Increased access to imaging should not be a substitute for safety.”

David Wiener, a board-certified radiologist for almost 35 years and CDC/NIOSH certified B reader for 9 years, wrote: “I can attest that chest x-rays are still one of the most vexing radiologic examinations to interpret, fraught with subtlety and high potential to miss significant findings—and interpretation of chest x-rays for B reading is exponentially more complex and confounding.” In addition, Wiener wrote that , “Anyone performing B reads faces the dual daunting tasks of both having the deep breadth of knowledge and experience to evaluate specific criteria for occupational lung disease but also to recognize and correctly interpret the vast myriad of other unrelated chest x-ray findings. Every interpreter is responsible for all available information provided on the chest x-ray and it is in the patients' absolute best interest to have trained, experienced and certified specialized physicians interpreting their exams.”

Jeffrey Unger, MD, a radiologist and NIOSH certified B reader for almost 30 years, testified about the difficulty of the job. “I would say that reviewing chest radiographs for signs of pneumonoconiosis is one of the more challenging tasks that I do. This type of interpretation skill takes years of education and practice and in order to find the many subtle abnormalities, all while being affected by the wide-ranging quality of the images.”

Regarding the preparation of NPPs to become B Readers, radiologist Jim Thesing wrote that, “PA and NP programs do not have any formal training in interpretation of radiographic images, in addition to very limited, or nonexistent, education in pneumoconiosis. Allowing them to become B readers has the potential to harm patients/workers and compromise the program.”

Conflict of interest?

In addition to seeking testimony from health care workers, the CDC asked for comments from other interested parties, including exposed workers and their unions and representatives from coal, asbestos, and silica industry.

“The crux of the issue [regarding interpreting chest x-rays] is the decision of whether the patient truly has interstitial lung disease and needs to be removed from exposure to that dust,” said pulmonologist Gary Dudek, MD. “In silicosis, if you catch it very early on, it’s termed simple silicosis, in which tiny nodules are seen in the lungs.” But Dudek explained that with continued exposure to silica, the disease will progress to become life-threatening. “These nodules will fibrose together and pull the lung tissue into a big scar called progressive, massive fibrosis,” he said. “That’s the stage of disease that is very symptomatic, lots of shortness of breath, often hypoxic, coughing, constantly producing a lot of mucus, and it tends to be inexorably progressive and ultimately take their life.”

A B Read indicating silicosis requires an employee to immediately cease exposure and may lead to loss of employment, which is particularly challenging in areas where there are few other job options.In addition to losing a worker, Dudek said that employers are required to pay medical expenses for people diagnosed with this condition. “They may have a vested interest in not finding it,” he said.

In fact one of the few supportive comments for expanding B Reading to NPPs came from Nathaniel Collins, a Family nurse practitioner, who wrote that he has been providing occupational health services for over ten years to a large population including mine workers. Allowing NPs like him to become a B Reader, “would be greater beneficial to not only miners, but also to mine operators.”

How to increase B Readers safely

Instead of allowing nonphysicians to interpret x-rays that may be a matter of life and death, public commentary opposing the expansion focused on helping more radiologists certify for the program. “If there is an unmet need for B readers, the CDC should collaborate with the American College of Radiology (ACR) and pulmonary societies to encourage more physicians to train and certify as B readers,” wrote Jim Thesing. Former B Reader Kenneth Levin, MD focused on the time, money, and energy required to become certified, writing that, “The B-reader program should make it easier to certify physicians. I did not renew my certificate because of the expense of the certification and travel involved.”

Martha Kearns agreed that the program should focus on helping radiologists become B Readers. “Rather than expanding the reader pool to unqualified non-physician providers who receive no formal training in radiology, examine the process and identify how you could reasonably increase the number of qualified readers,” she wrote. Kearns noted a contradiction from the CDC: “The NIOSH website indicates that acquiring B-reader skills is difficult, because there is currently a single annual in-person course which teaches the skills…Given high barriers to entry and limited apparent need, are you actually surprised that you have a small reader pool?”

Kearns argued that, “The program should first make efforts to increase access to qualified and trained radiologists, before allowing unskilled interpretations which dilute the quality of interpretations,” and laid out specific recommendations to increase the number of B Readers:

• Subsidize the costs of the course and testing
• Increase access to training, with more frequent, remote/virtual options
• Broaden how the opportunity is advertised to other radiology specialties
• Increase dissemination of information about reading studies for those who are currently accredited
• Increase access to B readers by permitting reads in states where one doesn’t hold a license

Ultimately, a lack of B Readers stems from poor long term planning, wrote Jeffrey Unger, MD. “For many years, there were no training opportunities for physicians to become new B readers. This has resulted in the low number of certified readers.” Unger noted that in the last few years, the American College of Radiology has made a renewed effort to train more physicians in B reading. “Attempting to solve this shortage of readers with under-trained allied health personnel, in my opinion, is a poor solution and will lead to diminished overall quality of care.”

Rebekah Bernard, MD is a Family physician in Fort Myers, FL. Watch her complete interview with Gary Dudek, MD on her YouTube channel, "Patients at Risk."