When Will Radiologists Do the Right Thing About CT Radiation?

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Medscape Radiology > Semelka's Spin: Pathways to Imaging Excellence

When Will Radiologists Do the Right Thing About CT Radiation?

Richard C. Semelka, MD

Disclosures

Jul 26, 2006

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Primum non nocere. The 4 pillars: (1) patient information, (2) avoid unnecessary CTs, (3) reduce radiation doses per CT procedure, (4) seek alternative, nonradiation-based imaging when feasible. I was watching the Wimbledon tennis championships the other day, and I witnessed something that I do not recall having seen, or at least having seen so extremely rarely that I don't recall the last time seeing it: Kim Clijsters was playing in the quarterfinals of the women's singles, and she overruled the line-judge to call the second serve of her opponent in, giving

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her opponent the point with an ace, and taking away the game-winning point from herself. Here was someone doing the right thing despite it being against her self-interest. Along the same lines, enclosed are 2 emails sent to me by radiologists

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who are working toward changing the practice of Radiology despite it not being in their self-interest, and my responses to their inquiries.

These emails were sent in reaction to my Medscape article, "Imaging X-rays Cause Cancer: A Call to Action for Caregivers and Patients" (see http://www.medscape.com/viewprogram/5063). I am a radiologist and like you, Dr. Semelka and apparently too few others, am deeply concerned about the profligate use of CT that is currently the norm. I am especially concerned about the deep state of denial (or ignorance) that practicing radiologists manifest about the radiation burden CT is imposing on the public. In my conversations with residents and staff at the university hospital I taught at for many years, I am able to summon only grudging acceptance of the realities of adverse biological effects of what has become a nearly reflex use of CT both in the ER and in the rest of the practice. When I asked if anyone had been following the material that has been running in Medscape, one person offered the dismissive rejoinder: Oh you mean the stuff that the MR guy from North Carolina is writing. I must say that I think that a bit of the urgency of the Medscape CT message has been somewhat blunted by the occasional references you make to your own recently published text. I am certain that no self promotion is intended but would recommend that his future pieces not mention the book lest such a charge gain traction and compromise the extraordinary leadership role you have

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When Will Radiologists Do the Right Thing About CT Radiation?

http://www.medscape.com/viewarticle/540733?src=mp

taken in confronting what I believe is the central issue in clinical radiology today. I do not receive directly derogatory emails, primarily because all the points I have made are based upon the scientific literature, and although a few radiologists may erroneously perceive that it is a betrayal to caution against excessive use of CT, in reality it is very difficult to come out against the importance of providing full information to patients about potential hazards. What is the retort to telling patients that there is a 1 in 1000 chance of developing cancer from a single pass of a body CT that patients may decide not to undergo CT? Morally that is a difficult position to take, especially publicly. I questioned whether I should reference my textbook in articles I have written. My explanation then and now is that it is one thing to state that CT carries with it a certain risk of cancer, but that statement on its own does not provide alternative strategies, which I believe is essential, as imaging has become the modern physical exam. Stating the simple facts of the dangers of CT on its own provides anxiety but without direction similar to the position that to avoid teenage and other unwanted pregnancies one must practice abstinence true but impractical advice and naively oblivious to the realities of life. One of the major methods of curbing the risk to the general public from excessive radiation is to perform other imaging studies that do not involve radiation, when feasible, which include MRI and ultrasound. Since I can only attest to the accuracy of everything that appears in my own textbook, which is the only one that I referenced there are other, recent major textbooks that are likely very good, but I have not read all the material within them, and therefore cannot advocate them in their entirety. Probably one must focus on the correctness of the message and not focus on the messenger. Focusing on the messenger is a form of obscuring the facts. I wish that more CT experts would be prepared to call their opponent's second serve in. In fairness, many CT experts are at work on reducing radiation dose, in order to reduce the risk of cancer induction. Now on to another note received in response to the CT radiation piece, which to date has awarded close to 9000 CME/CE credits in only a few months on Medscape. To me, the number of continuing education credits the piece has awarded points out the urgency of the messages therein and the relevance of the article to a wide array of practitioners and patients:

r. Semelka:

A quick, but giant thanks for your influential words and efforts regarding cancer risks associated with radiation exposure. I have read many of your articles on Medscape, and have been extremely motivated to make changes at my institution. I am a radiologist within the Northern California Kaiser Permanente system and am now trying to educate myself, as well as my fellow colleagues and clinicians, regarding this issue.

At Kaiser Permanente, we are fortunate to have a robust system for the sharing of information amongst each other. I have the support of my local leaders to move forward with the information that you have provided in the form of letters and guidelines. The potential for rapid and appropriate change is exciting. Before doing so, I was hoping to run some things by you. I don't want to misrepresent the information that I have gathered, but at the same time, I want to hurry up and make some changes.

I appreciate your time and effort. Thank you.

Cindy Dirkx Sacramento/North Valley Kaiser Permanente

It is extremely encouraging that an organization as large as Kaiser Permanente is taking steps to curtail the excessive use of CT. Not only does this show excellent corporate ethics, but in the capitalist system, also will serve to inspire their competitors to undergo similar steps. What is fundamentally more appealing in a healthcare insurer than that they are keenly interested in the health and welfare of their customers, both today and 20 years down the road? Dr. Dirkx must be commended on her efforts to act in the best interest of patient safety. I should also acknowledge the efforts of Dr. Steven Birnbaum in New Hampshire, and the efforts he and Blue Cross in the Northeastern US are engaged in to reduce the number of unnecessary CT studies. Perhaps Steve, a radiologist with CT fellowship training, is the most advanced in his efforts to ensure that patients do not undergo excessive CT studies and will not unnecessarily sustain the risks of cancer induction from medical radiation.

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When Will Radiologists Do the Right Thing About CT Radiation?

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Medscape Radiology. 2006;7(2) 2006 Medscape

Cite this article: When Will Radiologists Do the Right Thing About CT Radiation? Medscape. Jul 27, 2006.

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