This scenario presents a professional challenge due to the critical nature of bone mineral density (BMD) assessments in pre- and post-transplant patients. These assessments directly inform treatment decisions, monitor the efficacy of immunosuppressive therapies (which can negatively impact bone health), and guide the management of potential complications like osteoporosis and fractures. The technologist must navigate the complexities of patient history, potential contraindications, and the specific requirements of transplant protocols while ensuring accurate and reliable data acquisition. Careful judgment is required to interpret the clinical context and apply appropriate scanning protocols. The best approach involves a comprehensive pre-scan assessment that includes a thorough review of the patient’s transplant status, current medications (especially immunosuppressants known to affect bone metabolism), and any prior BMD results or relevant medical history. This allows for the identification of potential contraindications or the need for modified scanning parameters to ensure patient safety and data integrity. This approach aligns with ethical principles of patient-centered care and professional responsibility to obtain accurate diagnostic information. It also implicitly adheres to the general principles of medical imaging practice which mandate appropriate patient evaluation before any diagnostic procedure. An incorrect approach would be to proceed with a standard BMD scan without considering the patient’s transplant status or medication regimen. This fails to acknowledge the unique physiological state of transplant recipients, where immunosuppressive drugs can accelerate bone loss and increase fracture risk. Without this contextual understanding, the scan might not be optimized for the patient’s specific needs, potentially leading to inaccurate results or overlooking critical bone health issues. This approach demonstrates a lack of due diligence and a failure to provide individualized patient care. Another incorrect approach is to rely solely on the referring physician’s order without any independent verification or clarification regarding the transplant context. While physician orders are crucial, a technologist has a professional responsibility to ensure they have sufficient information to perform the scan safely and effectively. Failing to inquire about specific transplant-related concerns or potential contraindications associated with immunosuppressive therapy represents a lapse in professional judgment and a potential deviation from best practices in patient care. Finally, an incorrect approach would be to assume that all transplant patients have the same BMD assessment needs and to apply a one-size-fits-all scanning protocol. This ignores the variability in transplant types, immunosuppressive regimens, and individual patient responses, all of which can significantly impact bone health. Such an approach risks generating suboptimal data and failing to meet the specific diagnostic requirements for this complex patient population. Professionals should employ a systematic decision-making process that prioritizes patient safety and diagnostic accuracy. This involves actively seeking and understanding relevant clinical information, critically evaluating the appropriateness of the ordered procedure in light of that information, and collaborating with the referring physician when necessary to ensure the scan is tailored to the patient’s unique circumstances, particularly in specialized populations like transplant recipients.

This scenario presents a professional challenge because the Certified Clinical Densitometry Technologist (CCDT) is tasked with interpreting and applying a fracture risk assessment tool (FRAX) in a clinical setting where patient data might be incomplete or ambiguous. The challenge lies in ensuring accurate and ethical application of the tool, which directly impacts patient care and treatment decisions, while adhering to professional standards and guidelines. Careful judgment is required to navigate potential data limitations and to communicate findings effectively. The best professional approach involves utilizing the FRAX tool as intended, by inputting all available and relevant patient data, including clinical risk factors and bone mineral density (BMD) results if available, to generate a comprehensive fracture risk assessment. This approach is correct because it aligns with the established guidelines for using FRAX, which are designed to provide a more robust risk estimation when both clinical risk factors and BMD are considered. Ethically, it ensures the patient receives the most accurate assessment possible based on the available information, facilitating informed clinical decision-making. Regulatory frameworks for diagnostic imaging and patient assessment emphasize the importance of using validated tools correctly and comprehensively. An incorrect approach involves solely relying on clinical risk factors entered into FRAX without considering or attempting to obtain BMD results, even when they are available or could be reasonably acquired. This is professionally unacceptable because it leads to a less precise fracture risk estimation, potentially misinforming treatment strategies. It fails to leverage the full capabilities of the FRAX tool and may not meet the standard of care expected for fracture risk assessment, potentially violating guidelines that advocate for integrated assessment. Another incorrect approach is to disregard the FRAX score entirely and base treatment decisions solely on BMD values, even if the FRAX score suggests a significantly different risk profile. This is professionally unacceptable as it ignores the synergistic predictive power of clinical risk factors and BMD as captured by the FRAX algorithm. It bypasses a validated tool designed to provide a more holistic view of fracture risk, potentially leading to under or over-treatment. This approach fails to adhere to best practices in osteoporosis management, which often integrate FRAX scores into clinical decision-making pathways. A further incorrect approach is to input inaccurate or incomplete patient data into the FRAX tool, either intentionally or due to negligence. This is professionally unacceptable and ethically unsound, as it fundamentally compromises the integrity of the fracture risk assessment. It can lead to erroneous risk estimations, resulting in inappropriate clinical management, and may violate patient safety regulations and professional conduct standards that mandate accurate data recording and reporting. Professionals should employ a decision-making process that prioritizes accurate data collection, thorough understanding of the FRAX tool’s components and limitations, and adherence to established clinical guidelines. This involves a systematic review of patient history, physical examination findings, and diagnostic test results. When applying FRAX, the technologist should strive to input all relevant data points and, if there are ambiguities or missing critical pieces of information, should consult with the referring physician or a qualified supervisor to ensure the most accurate and ethically sound assessment is generated.

Scenario Analysis: This scenario presents a professional challenge because it requires the technologist to interpret complex physiological data in the context of a patient’s hormonal status, which directly impacts bone metabolism. The challenge lies in accurately correlating densitometry findings with potential underlying hormonal dysregulation, necessitating a thorough understanding of the interplay between calcitonin, parathyroid hormone (PTH), and vitamin D, and how these hormones influence bone density. Misinterpretation could lead to delayed or incorrect clinical management, impacting patient outcomes. Careful judgment is required to avoid over-interpreting findings or making assumptions beyond the scope of densitometry. Correct Approach Analysis: The best professional practice involves meticulously documenting the densitometry findings, including the specific sites measured and the T-scores and Z-scores obtained. Crucially, this approach includes noting any patient history or clinical context provided that might suggest hormonal imbalances, such as a history of thyroid disease, parathyroid issues, or vitamin D deficiency. The technologist’s role is to provide accurate and comprehensive data to the referring physician. This approach is correct because it adheres to the technologist’s scope of practice, which is to perform and report on bone mineral density measurements. It avoids making diagnostic conclusions about hormonal regulation, which is the physician’s responsibility. The ethical and professional obligation is to provide objective data that aids the physician in their diagnostic and treatment planning. Incorrect Approaches Analysis: One incorrect approach involves directly correlating a low bone density reading with a specific hormonal deficiency or excess without physician confirmation. This is professionally unacceptable because it oversteps the technologist’s scope of practice. While the technologist understands the hormonal influences on bone, they are not qualified to diagnose hormonal disorders. This could lead to premature patient anxiety or misdirection of medical investigation. Another incorrect approach is to ignore any patient history that might suggest hormonal involvement and simply report the raw densitometry numbers. This is professionally deficient because it fails to provide a complete picture to the referring physician. The technologist’s understanding of hormonal regulation of bone metabolism is a valuable asset that should be subtly communicated through comprehensive reporting, highlighting any relevant clinical context that might influence the interpretation of the densitometry results. Failing to do so hinders the physician’s ability to integrate all available information. A further incorrect approach is to suggest specific laboratory tests for calcitonin, PTH, or vitamin D levels based solely on the densitometry results. This is outside the technologist’s purview and constitutes an inappropriate medical recommendation. The ordering of diagnostic tests is a physician’s responsibility, based on their clinical assessment and differential diagnosis. Professional Reasoning: Professionals in this field should employ a systematic approach. First, ensure the technical quality and accuracy of the densitometry scan. Second, meticulously record all relevant patient demographic and clinical information provided. Third, accurately calculate and report bone mineral density scores. Fourth, in the report, subtly integrate any relevant clinical context that might inform the physician’s interpretation of the densitometry findings, without making diagnostic pronouncements. Finally, understand the boundaries of one’s professional role and refer any diagnostic or treatment decisions to the qualified physician.

This scenario presents a professional challenge because it requires a densitometry technologist to balance the immediate need for patient throughput with the absolute necessity of maintaining accurate and reliable diagnostic data. The pressure to see more patients can lead to shortcuts that compromise quality control, potentially resulting in misdiagnoses or unnecessary follow-up procedures. Careful judgment is required to ensure that patient care is not jeopardized by operational demands. The correct approach involves meticulously following the established manufacturer’s guidelines and the facility’s internal quality control protocols for daily calibration checks. This includes performing phantom scans, verifying system performance against established benchmarks, and documenting all results. This approach is correct because it directly adheres to the fundamental principles of quality assurance mandated by regulatory bodies and professional standards for medical imaging. Maintaining accurate calibration ensures that the densitometer is functioning within acceptable parameters, providing reliable bone mineral density (BMD) measurements. This directly supports diagnostic accuracy, patient safety, and compliance with imaging standards, which are paramount in clinical densitometry. An incorrect approach would be to rely solely on visual inspection of the densitometer’s display for any error messages without performing the scheduled phantom scans. This is professionally unacceptable because it bypasses a critical, objective measure of the system’s accuracy and precision. Visual checks alone are insufficient to detect subtle drifts in calibration or performance degradation that could impact BMD results. This failure to perform objective quality control checks violates established protocols and regulatory expectations for ensuring data integrity. Another incorrect approach would be to postpone the daily phantom scan if the technologist is running behind schedule, intending to perform it at the end of the day. This is professionally unacceptable as it introduces a significant risk of inaccurate measurements throughout the day. If the densitometer is not properly calibrated at the start of the scanning session, all patient data acquired during that period may be compromised. Regulatory guidelines and ethical practice demand that quality control procedures are performed at the beginning of each operational period to ensure the reliability of all subsequent measurements. A further incorrect approach would be to use phantom scan results from the previous day to confirm the densitometer’s performance if the current day’s scan shows a slight deviation. This is professionally unacceptable because it fails to account for potential changes in the densitometer’s performance that may have occurred overnight or since the last scan. Each daily quality control check is designed to verify the system’s current operational status. Using outdated data to justify current performance is a direct contravention of quality assurance principles and can lead to the reporting of inaccurate BMD values. Professionals should employ a decision-making framework that prioritizes patient safety and diagnostic accuracy above all else. This involves understanding and internalizing the rationale behind quality control procedures, not just their mechanics. When faced with operational pressures, technologists should first consult their facility’s policies and manufacturer guidelines. If a conflict arises, they must advocate for adherence to quality control standards, communicate potential risks to supervisors, and, if necessary, refuse to perform scans until quality control is satisfactorily completed. This proactive and principled stance ensures that diagnostic integrity is maintained.

Scenario Analysis: This scenario presents a professional challenge because it requires the technologist to interpret subtle anatomical variations in bone structure and relate them to potential physiological implications, all while ensuring the diagnostic accuracy and patient safety. Misinterpreting these findings could lead to incorrect diagnoses, inappropriate treatment plans, and potentially harm to the patient. The technologist must balance their technical skills with a thorough understanding of bone physiology and its clinical relevance. Correct Approach Analysis: The best professional practice involves meticulously reviewing the densitometry scan images, correlating the observed bone density measurements with the patient’s known medical history and relevant anatomical landmarks. This approach ensures that any deviations from expected bone density are considered within the context of the individual’s physiology and potential contributing factors. For example, if a patient has a history of a fracture in a specific area, the technologist should look for compensatory changes or localized areas of lower density that might be related. This aligns with the ethical obligation to provide accurate and comprehensive diagnostic information to the referring physician, enabling informed clinical decisions. It also implicitly adheres to professional standards that emphasize the importance of integrating imaging findings with clinical data for a complete assessment. Incorrect Approaches Analysis: One incorrect approach is to solely focus on the numerical T-score or Z-score without considering the underlying bone architecture or potential artifacts. This overlooks the physiological processes that contribute to bone density and strength, potentially leading to misinterpretation of results, especially in cases of atypical bone structure or secondary causes of bone loss. This fails to meet the standard of care by not performing a comprehensive analysis. Another incorrect approach is to dismiss any findings that deviate from textbook norms without further investigation or consultation. Bone physiology is complex and can be influenced by numerous factors, including age, sex, ethnicity, and underlying medical conditions. Failing to investigate these deviations means missing potential early signs of disease or important clinical information, which is a failure in diagnostic diligence. A third incorrect approach is to rely solely on automated software interpretations without independent critical evaluation of the images and patient data. While software is a valuable tool, it cannot replace the technologist’s expertise in recognizing subtle anatomical variations or artifacts that might influence the automated analysis. This approach risks accepting inaccurate interpretations and failing to provide the physician with the most reliable diagnostic information. Professional Reasoning: Professionals should approach densitometry analysis with a systematic process that begins with image acquisition and quality control, followed by a thorough review of the anatomical structures visualized. This review should integrate the quantitative data (T-scores, Z-scores) with qualitative observations of bone texture, cortical thickness, and any visible abnormalities. Crucially, this must be contextualized with the patient’s clinical history, including any relevant medical conditions, medications, or previous injuries. When in doubt or when encountering unusual findings, consultation with a radiologist or other qualified physician is paramount. This iterative process of observation, integration, and consultation ensures the highest level of diagnostic accuracy and patient care.

Scenario Analysis: This scenario presents a professional challenge because the technologist must accurately differentiate between bone tissue types, which have varying densities and are crucial for interpreting bone mineral density (BMD) results. Misidentification can lead to incorrect diagnoses, inappropriate treatment plans, and potentially patient harm. The challenge lies in applying theoretical knowledge of bone histology to practical image interpretation within the constraints of the densitometry equipment and established protocols. Correct Approach Analysis: The best approach involves meticulously analyzing the regions of interest (ROIs) for characteristic density patterns and structural features. This means identifying areas with the dense, outer cortical bone, which appears smooth and homogenous on the scan, and contrasting it with the inner, spongy trabecular bone, characterized by its interconnected network of struts and plates, appearing more granular. This detailed visual assessment, guided by the technologist’s understanding of bone composition and the principles of dual-energy X-ray absorptiometry (DXA) image formation, ensures accurate ROI placement and therefore accurate BMD measurements. This aligns with the professional responsibility to obtain high-quality diagnostic data, as mandated by general principles of patient care and the ethical obligation to practice competently. Incorrect Approaches Analysis: One incorrect approach would be to solely rely on the automated software’s default ROI placement without critical visual verification. While software is a valuable tool, it can misinterpret image artifacts or variations in bone structure, leading to inaccurate measurements. This failure to exercise professional judgment and critically evaluate the software’s output constitutes a lapse in due diligence and can result in diagnostic errors, violating the principle of providing accurate patient care. Another incorrect approach would be to prioritize speed over accuracy by quickly placing ROIs without careful consideration of the distinct visual characteristics of cortical and trabecular bone. This haste overlooks the fundamental differences in bone composition and density that are essential for correct interpretation. Such an approach risks including extraneous tissue or excluding relevant bone structures, leading to unreliable BMD values and potentially misinforming clinical decisions, which is a breach of professional standards. A further incorrect approach would be to assume that all bone tissue within a scanned region is uniform in density and composition, and therefore to place ROIs without differentiating between cortical and trabecular components. This demonstrates a fundamental misunderstanding of bone histology and its implications for densitometry. It fails to acknowledge that different bone types contribute differently to the overall BMD measurement and that accurate assessment requires distinguishing these components, leading to inaccurate and misleading results. Professional Reasoning: Professionals should approach densitometry scans with a systematic process that integrates technical proficiency with a deep understanding of bone biology. This involves: 1) Initial visual inspection of the scan for image quality and potential artifacts. 2) Understanding the specific anatomical region being scanned and its expected bone composition. 3) Critically evaluating automated software placements, comparing them against visual cues of cortical and trabecular bone. 4) Meticulously adjusting ROIs to accurately encompass the intended bone structures, ensuring that the distinct characteristics of cortical and trabecular bone are appropriately represented or excluded as per protocol. 5) Documenting any deviations or challenges encountered during the process. This methodical approach ensures the integrity of the diagnostic data and upholds the highest standards of patient care.

Scenario Analysis: This scenario presents a professional challenge because it requires the technologist to interpret complex biological processes related to bone metabolism and relate them to diagnostic findings, even when the patient’s history is incomplete. The technologist must exercise careful judgment to ensure accurate data collection and interpretation, which directly impacts patient care and subsequent treatment decisions. Understanding the dynamic interplay of bone cells is crucial for recognizing potential abnormalities that might be indicated by densitometry results. Correct Approach Analysis: The best professional practice involves recognizing that osteoblasts are responsible for bone formation, osteoclasts for bone resorption, and osteocytes are mature bone cells embedded within the matrix that play a role in bone maintenance and mechanosensing. When interpreting densitometry results, a technologist should consider how an imbalance in the activity of osteoblasts and osteoclasts could lead to changes in bone mineral density. For instance, increased osteoclast activity relative to osteoblast activity would lead to bone loss, which is what densitometry aims to detect. Understanding these cellular roles provides a foundational framework for interpreting the significance of low bone mineral density readings, suggesting a potential disruption in the normal bone remodeling cycle. This aligns with the professional responsibility to provide accurate and contextually relevant data to the referring physician. Incorrect Approaches Analysis: One incorrect approach would be to solely focus on the densitometry reading as an isolated number without considering the underlying biological mechanisms. This fails to acknowledge the role of bone cell activity in producing the observed density. It represents a superficial interpretation that lacks the depth required for effective clinical support. Another incorrect approach would be to speculate on specific disease diagnoses based solely on the densitometry results without sufficient clinical information or diagnostic confirmation. While understanding cellular roles is important, attributing a specific pathological cause without proper medical evaluation is beyond the scope of a densitometry technologist’s role and could lead to misdiagnosis or inappropriate patient anxiety. A further incorrect approach would be to dismiss the importance of the cellular processes of bone remodeling, focusing only on the technical aspects of performing the scan. This overlooks the fundamental biological basis of bone density measurement and limits the technologist’s ability to provide meaningful context for the results. Professional Reasoning: Professionals should approach this situation by first ensuring the technical accuracy of the scan. Then, they should integrate their understanding of bone cell physiology (osteoblasts, osteoclasts, osteocytes) with the densitometry findings. This allows for a more informed interpretation of the data, recognizing that deviations in bone density are a reflection of the balance between bone formation and resorption. The technologist’s role is to provide accurate data and a basic interpretation of its physiological implications, not to diagnose. They should always defer definitive diagnosis and treatment planning to the referring physician.

The efficiency study reveals a need to optimize patient scheduling for bone density scans, particularly considering the varying physiological factors that influence bone health. This scenario is professionally challenging because it requires the technologist to balance operational efficiency with the nuanced physiological realities of bone health, ensuring that patient care is not compromised by a purely data-driven scheduling approach. Careful judgment is required to avoid oversimplifying complex biological factors into rigid scheduling protocols. The best professional practice involves a nuanced approach that acknowledges the significant impact of age, sex, and genetics on bone density and its assessment. This approach prioritizes individual patient needs and risk factors when determining scan frequency and interpretation, aligning with the ethical imperative to provide patient-centered care. While specific regulatory mandates for scheduling frequency based on these factors may not be explicitly detailed in all guidelines, the underlying principle of providing appropriate and individualized care, as often emphasized in professional standards and ethical codes for diagnostic imaging, supports this method. It recognizes that a “one-size-fits-all” approach to scheduling can lead to under- or over-assessment for certain patient populations, potentially impacting diagnostic accuracy and patient outcomes. An incorrect approach would be to implement a rigid scheduling protocol based solely on age and sex, without considering genetic predispositions or other contributing factors to bone health. This fails to acknowledge the significant variability within age and sex groups and the profound influence of genetics, which can lead to premature bone loss or increased fracture risk irrespective of age or sex. Ethically, this approach risks providing suboptimal care by not adequately addressing individual patient risk profiles. Another incorrect approach would be to prioritize scan frequency based solely on the perceived “ease” of scanning younger, healthier individuals, thereby delaying or deprioritizing scans for older patients or those with known risk factors. This is ethically unsound as it prioritizes operational convenience over the clinical necessity of timely diagnostic assessments for individuals at higher risk of osteoporosis and fractures. It also disregards the fact that bone health challenges often become more pronounced with age. Finally, an incorrect approach would be to dismiss the influence of genetics entirely, assuming that age and sex are the only significant determinants of bone health for scheduling purposes. This demonstrates a lack of understanding of the multifactorial nature of bone metabolism and disease. Ethically, it represents a failure to stay abreast of current medical understanding and to apply that knowledge to patient care, potentially leading to misdiagnosis or delayed intervention for individuals with a strong genetic predisposition to bone disorders. Professionals should employ a decision-making framework that begins with understanding the core physiological factors affecting bone health. This involves recognizing that age, sex, and genetics are not isolated variables but interact to influence an individual’s bone density and fracture risk. When developing or implementing scheduling protocols, professionals should consult relevant clinical guidelines and best practices, which often advocate for individualized risk assessment. This includes considering patient history, family history of osteoporosis, and other relevant clinical indicators. The goal is to create a flexible system that allows for adjustments based on these factors, ensuring that each patient receives the most appropriate and timely diagnostic evaluation.

Scenario Analysis: This scenario presents a professional challenge because it requires the technologist to balance the need for accurate diagnostic information with the ethical imperative to avoid unnecessary patient exposure to radiation. The evaluation of metabolic bone diseases, particularly in vulnerable populations like postmenopausal women, necessitates careful consideration of the benefits of bone mineral density (BMD) testing against potential risks. The technologist must possess a thorough understanding of the indications for testing and the appropriate application of the technology to ensure patient safety and diagnostic efficacy. Correct Approach Analysis: The best professional practice involves a comprehensive review of the patient’s medical history and current clinical presentation to determine if the BMD test is medically indicated according to established guidelines. This approach ensures that the testing is not performed indiscriminately but rather targets individuals who are most likely to benefit from the diagnostic information, thereby minimizing radiation exposure for those for whom the test is unlikely to yield clinically significant results or alter management. This aligns with the fundamental ethical principle of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as the implicit regulatory expectation to use medical imaging resources judiciously and avoid unnecessary radiation. Incorrect Approaches Analysis: One incorrect approach involves proceeding with the BMD test solely based on the patient’s age without a thorough assessment of other risk factors or clinical indications. This fails to adhere to the principle of appropriate utilization of diagnostic imaging and could lead to unnecessary radiation exposure for individuals who do not meet the established criteria for testing, potentially violating guidelines for radiation safety and responsible healthcare practice. Another incorrect approach is to defer the decision entirely to the patient without providing them with sufficient information about the necessity and potential benefits or risks of the test in their specific situation. This abdicates professional responsibility and fails to ensure informed consent, which is a cornerstone of ethical patient care. Finally, performing the test without documenting the justification for its necessity in the patient’s record is a failure in professional accountability and record-keeping, making it impossible to audit or justify the use of resources and radiation exposure. Professional Reasoning: Professionals should employ a systematic decision-making process that begins with understanding the established clinical indications for the diagnostic procedure. This involves consulting relevant professional guidelines and regulatory recommendations. The next step is to gather comprehensive patient information, including medical history, symptoms, and risk factors, to assess individual suitability for the test. Open communication with the patient, explaining the rationale for testing and addressing any concerns, is crucial for informed consent. Finally, meticulous documentation of the justification for the test in the patient’s record is essential for continuity of care and professional accountability.

This scenario is professionally challenging because it requires the technologist to balance providing accurate information with managing patient anxiety and potential misinformation. Patients often have pre-conceived notions about bone density testing, influenced by anecdotal evidence, media portrayals, or fear of osteoporosis. The technologist must address these concerns effectively while adhering to professional standards and patient privacy. The best approach involves actively listening to the patient’s concerns, validating their feelings, and then providing clear, evidence-based information tailored to their understanding. This includes explaining the purpose of the test, what the results mean in general terms, and addressing specific misconceptions with factual data. This method respects the patient’s autonomy and promotes informed consent, aligning with ethical principles of patient care and professional conduct. It empowers the patient by demystifying the procedure and its implications, thereby reducing anxiety. An incorrect approach would be to dismiss the patient’s concerns outright or to provide overly technical jargon that further confuses them. This fails to acknowledge the patient’s emotional state and can erode trust. Another incorrect approach is to offer personal medical advice or interpret results beyond the technologist’s scope of practice, which could lead to misdiagnosis or inappropriate patient actions. This violates professional boundaries and regulatory guidelines that define the technologist’s role. Finally, avoiding the conversation altogether or providing vague, unhelpful responses also constitutes a failure, as it neglects the technologist’s responsibility to ensure patient understanding and comfort. Professionals should approach patient concerns by first creating a safe space for dialogue. This involves active listening and empathy. Then, they should assess the patient’s level of understanding and the specific nature of their misconceptions. Information should be delivered in a clear, concise, and understandable manner, focusing on facts and the technologist’s role. If a patient’s concern falls outside the technologist’s expertise, the appropriate referral to a physician or other qualified healthcare provider should be made.