JAMA Commentary: Rads must share dose risks with patients

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The medical community should develop a system of mandatory dissemination of radiation risk to patients before relevant government agencies or the legal system takes action, according to a commentary penned by Mark Otto Baerlocher, MD, from the University of Toronto, in a Nov. 17 commentary in the Journal of American Medical Association.

“The overall response [to the proposal] has been quite positive,” Baerlocher stated in an interview with Health Imaging News. “Most of the solution has to come from within radiology,” he added.

Baerlocher and colleagues outlined the case for informed consent prior to CT scanning in the commentary. “Approximately 92 to 95 percent of patients are not informed of any radiation risks prior to their CT scan,” wrote Baerlocher.

The radiologist applauded dose cutting initiatives including the ALARA (as low as reasonably attainable principle), the Image Gently campaign, dose reduction protocols, American College of Radiology (ACR) Appropriateness Criteria and the National Radiology Data Registry and the Dose Check initiative of the Medical Imaging and Technology Alliance.

However, he identified mandatory dissemination of radiation risk to patients as a critical, but missing, link.

In his commentary, Baerlocher referred to the legal “prudent person standard” that requires communication prior to a procedure with a risk higher than the risk associated with background risk of normal activities. CT exams as well as many nuclear medicine, fluoroscopy, interventional radiology and cardiology procedures meet the threshold, according to Baerlocher.

Radiologists, in partnership with clinical colleagues, are best situated to manage such dissemination. Baerlocher suggested radiology departments collaborate with clinical departments to develop standardized forms that include pertinent information about the study. The referring physician or technologist could share the form with patients and offer them the opportunity to ask questions. The process need not disrupt radiologists’ workflow, said Baerlocher. “It could be similar to the model used to obtain consent for contrast CT studies.”

The tricky questions
In addition to workflow concerns, naysayers have voiced other challenges related to mandatory dissemination, particularly on the patient care front as they speculate that patients might refuse studies after learning about radiation risk.

However, a study at the Children’s Hospital in Denver reported that none of the 100 hundred parents of children undergoing nonemergent CT studies refused or deferred the study after reading a handout describing radiation risk ( Am J Roentgenol. 2007; 189(2):271-275).

As for concerns about patients who might refuse studies after reading about the risk, Baerlocher maintained that patients who refuse studies after an explanation of risks and benefits are no different from patients who refuse a surgical procedure based on the risks of anesthesia or surgery. As with any procedure, patients should be able to ask questions about risks and benefits, noted Baerlocher.

Baerlocher concluded the commentary by pointing to additional advantages associated with the proposal. “This initiative may have the benefit of helping to reduce the potentially substantial number of examinations and procedures that are not clinically indicated and to accelerate efforts to reduce radiation doses to these procedures.”