MOC Summit Tackles Radiation Dose

In light of increasing demand to define standards for radiation dose regulation, the American Board of Radiology (ABR) Maintenance of Certification (MOC) Summit in Chicago demonstrated that it is radiologic professionals themselves who are being proactive.

James A. Brink, M.D. Department of Diagnostic Radiology, Yale University School of Medicine

N. Reed Dunnick, M.D. RSNA Board Liaison for Science and ABR president

"I am pleased to see how deeply our profession is committed to the safe and optimal use of radiation," said G. Donald Frey, Ph.D., a professor of radiology at the Medical University of South Carolina in Charleston and an ABR trustee. Presenters at the Aug. 9 summit addressed dose reduction concerns for both diagnostic and therapeutic procedures and encouraged cooperation with the Image Gently pediatric radiation dose campaign and participation in the National Radiology Data Registry (NRDR). More than 55 participants, including radiologists, radiation oncologists and medical physicists representing 28 professional radiology societies, then began laying the groundwork for practice quality improvement projects.

ABR is committed to making patient safety and radiation safety the main focus of its practice quality improvement (PQI) initiatives, said Dr. Frey. "The ABR acknowledges that the specialty societies possess the content expertise to develop PQI initiatives," he said. "The safe use of radiation is a defining characteristic distinguishing diagnostic radiology, radiation oncology and radiologic physics from other specialties."

"Maintenance of certification is the best tool to protect our profession right now," said keynote speaker Kevin Weiss, M.D., CEO of the American Board of Medical Specialties. "We need to change the mindset so that the board exam is not considered an exit exam from a residency, but an entrance exam into a lifetime of professional development."

Medical radiation has increased by about 600 percent since the 1990s and now contributes almost half of the population's radiation exposure, including naturally occurring sources, said James A. Brink, M.D., chair of the Department of Diagnostic Radiology at Yale University School of Medicine. "Data from the National Council on Radiation Protection & Measurements suggests that CT scanning makes up 12 percent of procedures that use ionizing radiation, but it generates 46 percent of the collective dose to the population," Dr. Brink added. He pointed to the media's angle on CT increase, citing a quote from a scientist in USA Today asserting that one-third of CT exams are medically unnecessary. "That's his opinion," said Dr. Brink, "but it does serve as a mandate for examining CT utilization as a means to reduce radiation exposure. The article also talks about potential dose reduction benefits associated with two new CT scanners. While you may not be happy about that statement if you work for competing manufacturers, it emphasizes the need to leverage technology to reduce dose as much as possible."

Summit leaders and attendees, especially physicists, emphasized that any radiation dose calculation is only an estimate and that generalizations may be misleading to the public. Presenters acknowledged conflicting findings and opinions on what constitutes dose, to what degree it affects patients and how best to reduce it.

Disputes over conundrums—such as which model best describes cancer-inducing effects or whether low doses can cause cancer—"are non-productive arguments we have permitted to invade our profession," said Louis Wagner, Ph.D., a professor in the Department of Diagnostic and Interventional Imaging at The University of Texas Houston Medical School. "Even though the answers to some of the most critical questions about risk are unknowable today, we have enough data to behave in a manner that assumes the risk is there."

Most counterproductive is the notion that there is no safe dose, said Dr. Wagner. "There is no safe hot dog, vegetable, bed, bathroom, shower, tub, jacket, cup of coffee or glass of water," he said. "But just as we can purify water, put down bath mats and keep medication out of the reach of children, we can keep radiation dose down at a low yet productive level to be of most benefit to our patients."

Added Dr. Frey: "While you can quibble with these papers from a scientific point of view, you can't quibble with the popular media. They need to understand that we are taking the initiative and steps to reduce radiation dose for the good of the population."

Identifying repeat exams and judging their usefulness is of major significance in establishing appropriate imaging protocols, presenters agreed. "If you wake up in the morning with a headache and take two ibuprofen, and a few hours later you still have a headache and take two more. If your head still hurts toward the middle of the day, you're going to start thinking about how many you've taken and start to weigh the benefits against the risks," said Dr. Brink. "I think that analogy applies here."

"Maintenance of certification is the best tool to protect our profession right now," said Kevin Weiss, M.D., CEO of the American Board of Medical Specialties, keynote speaker at the American Board of Radiology Maintenance of Certification (MOC) Summit in Chicago on Aug. 9.

The American College of Radiology (ACR) is developing tools that will identify repeat exams and measure dose estimates on a grand scale. Laura Coombs, Ph.D., director of data registries in the ACR Department of Quality and Safety, explained a project to establish a Dose Index Registry as part of NRDR. Eleven sites in the U.S. and two in Germany plan to participate. Information will be collected from DICOM headers via a patch installed on Siemens scanners and extracted by ACR-developed software. Future plans for the project will include a nationwide expansion and involve additional vendors. ACR is working with RSNA's Integrating the Healthcare Enterprise (IHE®) initiative to develop a radiation exposure monitoring profile for scanners and software.

When necessary, radiologists must also take the initiative to communicate with referring physicians, said Dr. Weiss. "If you have a situation where a separate doctor orders a CT scan, or says he didn't like the way one was performed and wants it done again, often everybody shrugs their shoulders and says, 'Send the patient in.' How often will you actually make the call?"

Speakers addressed the need for more proactive efforts to collect data on fluoroscopy and emerging techniques like intensity-modulated radiation therapy (IMRT). They also discussed new challenges to dose calculation presented by multimodality therapies and secondary risk factors such as scatter radiation. The summit also examined rising trends in cardiovascular imaging and methods for regulating increasingly popular procedures like "triple rule-out" CT angiography.

At breakout sessions during the summit, attendees brainstormed templates for performance quality improvement projects within four categories: radionuclides, CT, angiography/fluoroscopy and radiation oncology. The sessions yielded preliminary plans for more than 15 new projects, including structured reporting of radiation dose-delivering techniques, protocols to reduce radiation to the lens and orbit in children receiving repeat head CT examinations, a national data registry of estimated dose in angiography and fluoroscopy procedures, iodine therapy for thyroid cancer and IMRT targeting. ABR will work with corresponding societies in the coming months to formulate plans for executing the projects.

"If we do nothing, I'm sure the government, the payers and industry will do something, but it will be clumsy," said N. Reed Dunnick, M.D., RSNA Board Liaison for Science and ABR president. Dr. Dunnick is the Fred Jenner Hodges Professor and chair of the Department of Radiology at the University of Michigan Health System in Ann Arbor. "Nobody knows our business better than we do. We need to carry the flag for quality."