Mina S. Makary, MD

Patient understanding and informed consent is particularly important when dealing with ionizing radiation. But, how can we expect patients to understand the risks they are taking when 28 percent of surveyed physicians are not even aware that forms of imaging like mammography utilize ionizing radiation at all?

Patient education is largely influenced by patient-physician communication, it and plays a large role in a patient’s ability to provide informed consent. Additionally, effective communication and teaching is thought to enhance the patient-physician relationship and increase patient levels of trust and satisfaction with the experience. This piece investigates patients' perceptions of radiation from magnetic resonance imaging (MRI) and computed tomography (CT) imaging in the healthcare setting. This analysis further reviews recent work that quantified the degree to which effective patient and physician education is taking place and identify areas for improvement and growth.

According to a survey of emergency department patients, when asked to compare the perceived radiation dose of MRI, CT, and a conventional chest X-ray, approximately 30 percent of individuals answered that they all had equal amounts of radiation.

 In that study, when comparing each to a conventional chest X-ray, roughly 40 percent thought that CT was 10-to-100 times greater, while 28 percent thought MRI was 10-to-100 times greater.

Right away, we can see that at least one-third of patients are unaware that MRI emits no radiation at all. Even more shockingly, when asked to compare radiation exposure levels between CT, MRI, and a nuclear power plant disaster, less than 40 percent of participants were certain that CT scans involved less radiation exposure compared to just 20 percent with MRI.

When looking at patients’ understanding of lifetime cancer risks associated with various imaging methods, the numbers were varied. When asked, “Do 3-to-5 abdominal scans increase lifetime risk of cancer?,” less than 5 percent answered yes for MRI.2 The results look encouraging, however, when posed the same question about CT. Just over 5 percent answered yes.

Roughly 25 percent for both groups reported having no idea.

 These results are unsurprising given the limited information available to patients on lifetime risks and specifically the effects of a single scan. Furthermore, a survey of physicians found that 90 percent either did not know or severely underestimated the amount of radiation associated with CT.

In a specific example, only 65 percent of patients in a study receiving a mammogram reported being informed of the risks before the procedure.

 Discouragingly, 60 percent of informed patients still over-estimated the amount of radiation they had received.

 In another study, the number of patients reporting a lack of communication about the radiation associated with their scheduled tests were as high as 92 percent.

 It is in this same study that 28 percent of surveyed physicians stated they were unaware of mammography utilizing any ionizing radiation.

Effective patient-physician communication is key to ensuring informed consent is obtainable and has even been shown to have therapeutic effects for patients.

 However, with low percentages of patients reporting communication about radiologic testing and physicians self-reporting knowledge gaps in these areas, patient education is hindered. Evidence is supportive of the benefits of educational presentations for ordering providers’ understanding of radiation exposure and risk.

Radiologists, therefore, must be aware of and work to address the knowledge gaps reported by attending physicians. Whether through direct communication with patients about risks, hosting educational conferences for colleagues, or simply re-distributing pertinent information, radiologists have a responsibility to ensure patients are educated on the radiological tests they are undergoing.

Based on the results of these studies and surveys, it can be concluded that both patients and physicians have misconceptions and lack comprehensive knowledge about the risks and benefits of diagnostic and therapeutic imaging modalities.

 Physicians that undergo radiologist-designed educational training are more informed on these risks and, therefore, can better communicate radiation risks and benefits to their patients, thus increasing patient understanding and ability to provide informed consent.

 As an additional benefit, this increased communication positively affects patients’ feelings of trust and understanding towards their providers and future procedures.

 As of now, further work is needed to clarify misconceptions surrounding radiologic imaging and the associated risks of ionizing radiation.

1. Ricketts, M. L., Baerlocher, M. O., Asch, M. R., & Myers, A. (2013). Perception of radiation exposure and risk among patients, medical students, and referring physicians at a tertiary care community hospital. 

Canadian Association of Radiologists Journal

2. Repplinger, M. D., Li, A. J., Svenson, J. E., Ehlehbach, W. J., Westergaard, R. P., Reeder, S. B., & Jacobs, E. A. (2016). Emergency department patients’ perceptions of radiation from medical imaging. WMJ: 

official publication of the State Medical Society of Wisconsin

3. Renston, J. P., Connors, J. A., & DiMarco, A. F. (1996). Survey of physicians' attitudes about risks and benefits of chest computed tomography. 

4. Hollada, J., Speier, W., Oshiro, T., Marzan-McGill, R., Ruehm, S. G., Bassett, L. W., & Wells, C. (2015). Patients’ perceptions of radiation exposure associated with mammography. 

5. Travaline, J. M., Ruchinskas, R., & D'Alonzo Jr, G. E. (2005). Patient-physician communication: why and how. 

Journal of the American Osteopathic Association

, 105(1), 13.

6. Zener, R., Johnson, P., Wiseman, D., Pandey, S., & Mujoomdar, A. (2018). Informed consent for radiation in interventional radiology procedures. 

7. Hobbs, J. B., Goldstein, N., Lind, K. E., Elder, D., Dodd III, G. D., & Borgstede, J. P. (2018). Physician knowledge of radiation exposure and risk in medical imaging. 

Journal of the American College of Radiology

Articles

Improving patient communication not only augments patient understanding of their radiation exposure with imaging studies, but it bolsters trust in their healthcare providers, as well.

Patient Perceptions of Imaging Modalities and Ionizing Radiation

Interventional Radiology has grown exponentially in recent years. Embolization procedures were first performed in 1970. Three years later, balloon angioplasties were being performed. Then, in the 1980s, complex interventions, such as Transjugular Intrahepatic Portosystemic Shunt (TIPS) placements were introduced

. These therapies are now offered in nearly every hospital. Such growth has been facilitated by advances in technology, combined with the creativity of practitioners. Evolving advances in augmented reality, artificial intelligence (AI), imaging modalities, robotics, and procedural techniques will play a big role in the future and facilitate further exponential growth.

In augmented reality, virtual images can be seen alongside real images. In contrast to virtual reality where the field of vision includes no real images, augmented reality offers the ability to maneuver objects and interact with the real world. This powerful development has wide-ranging applications for image-guided interventions. For example, an interventional radiologist could visualize vital signs within the same field of vision, overlying the patient during a critical intervention. These numbers could potentially appear on command when performing a key step of a procedure or when the radiologist has a concern.

Augmented and Virtual Reality – Radiology at the Center of Medical Technology

Needle placement or a procedure with an image-guided device is another application. For instance, the operator could also view a fused ultrasound image, during simultaneous visualization of needle insertion and ultrasound probe manipulations. Augmented reality can also be used to visualize anatomy underneath procedural drapes to guide an intervention when there is poor sonographic penetration or fluoroscopic guidance is insufficient. For example, a projected 3D hologram, recreated from a pre-programmed CT scan, can help the radiologist identify – and avoid – key structures during a percutaneous intervention, which may otherwise be invisible.

Recent developments in AI represent additional revolutionary opportunities of growth in the current and future practice of image-guided interventions. Utilizing AI, outcomes of interventions can be more accurately and quickly predicted, improving patient outcomes. Machine learning algorithms will be able to augment the interventional radiologist in guiding treatment decisions and selecting patient populations that would benefit most from interventions in areas, such as interventional oncology, where multimodal therapies abound.

Other future applications will include intraprocedural augmentation for the interventional radiologist. AI will enhance image guidance through anatomical recognition, to facilitate interventions and guide the operator through complex anatomy. Lastly, promising applications exist in the treatment of patients requiring time-sensitive interventions. Conditions, such as strokes and pulmonary embolisms, have been described to benefit from AI’s impact on expediting recognition and throughput to improve patient outcomes

Furthermore, continued enhancement of current image-guidance modalities and development of new ones will enhance future procedural practice. Limitations of current imaging modalities in interventional radiology include two-dimensionality and, oftentimes, radiation exposure. One new imaging guidance modality currently being pioneered is Fiber Optic RealShape (FORS)

. This imaging technology utilizes catheters embedded with light sensing technology. Currently, physicians are challenged by tortuous and diseased vasculature, which is difficult to visualize in 2D and often presents technical challenges to operators driving the catheter. Technologies, such as FORS and other evolving modalities, could optimize vascular imaging guidance, drastically decrease the procedural time, and radiation exposure for interventions, drastically increasing the safety for patients and practitioners alike in the future.

Another area with future potential in imaging-guided interventions is robotics, which has already been integrated into many fields of medicine. Oftentimes, in order for robotic systems to flourish in utilization, there must be a proven clinical benefit. For example, the DaVinci Surgical System results in smaller incision sites and higher surgical accuracy. These factors justify the cost.

Robotics have been applied to many endovascular procedures. Uterine artery embolization, cardiac ablation, and aneurysm repair have all been successfully performed with robotic navigation systems. Radiographic procedures are uniquely positioned to benefit from robotics due to added benefits to the operators. The interventionalists can work in a separate room from the procedural suite, thereby shielding them from radiation exposure and musculoskeletal injury from heavy protective aprons. More research, however, is needed to justify the cost of such systems, but it is expected that robotics will become more prominent in interventional suites. It is essential that benefits to the operator safety will not compromise patient outcomes, and quality-control studies continue to be rigorously applied and performed.

Lastly, the scope of practice of interventional radiology itself is expanding, as well. In addition to advancements in existing procedures and techniques, interventional radiologists are developing new procedures to address conditions, such as arthritis, obesity, and benign prostatic hypertrophy. Many of these procedures have been validated in small scale clinical trials. Chronic arthritis pain is being managed through embolization of hyperemic synovial tissue

. The left gastric artery has been embolized to decrease fundus blood flow, thereby restricting growth of ghrelin-producing cells and decreasing appetite

. Radiologists can also treat lower urinary tract symptoms through decreasing the size of the prostate with embolization

. Endovascular approaches continue to be identified as a way to treat conditions formerly managed with invasive surgeries and medication therapies. The future is bright as the value proposition of interventional radiology offering minimally invasive, high-quality, low-complication, cost-effective therapies aligns extremely well with the future of medicine and healthcare.

In summary, advancements in technology will foster improvements in efficiency, efficacy, and safety for interventional radiology and image-guided interventions. The degree of innovation and changing practice patterns will continue to be exponential, alongside exponential growth in technology. Interventional radiologists will be presented with ample opportunity to adapt and invent. This is an exciting challenge, and will mean a brighter future for patients.

Midulla M, Pescatori L, Chevallier O, et al. Future of IR: Emerging Techniques, Looking to the Future…and Learning from the Past. 

Keshava S, Kalva S. Artificial Intelligence in Interventional Radiology. 

Mascini L. Operate Using Live, 3D Image-Guided Navigation of the Inner Body. Innovation Origins: Your Sneak Peak of the Future. October 24, 2019. 

https://innovationorigins.com/operate-using-live-3d-image-guided-navigation-of-the-inner-body/

Balga S, Piechowiak R, Hartman T, et al. Genicular Artery Embolization for the Treatment of Knee Pain Secondary to Osteoarthritis. 

Pirlet C, Ruzsa Z, Costerousse O, et al. Transradial Left Gastric Artery Embolization to Treat Severe Obesity: A Pilot Study. 

Pisco J, Pinheiro L, Bilhim T, et al. Prostatic Arterial Embolization for Benign Prostatic Hyperplasia: Short- and Intermediate-term Results. 

From augmented reality to virtual reality to robotics to new procedural techniques – the future of interventional radiology is bright.

Future Trends and Technologies in Interventional Radiology: What to Expect

Maintaining personal wellness and preventing professional burnout have an established role in the modern medical theater. The World Health Organization differentiates personal wellness from health as it involves fulfilment and realization of that person both as an individual “physically, psychologically, socially, spiritually and economically” and their perceived role in their social circles.

This heady definition attempts to simplify esoteric components of an extremely personal idea of mental health and satisfaction that really can only be identified by that individual. Burnout on the other hand is a more specific syndrome: emotional exhaustion from stress on the job, de-personalization and detachment from patients, and a demarcated shift in projections of professional self-worth and competence

. Physicians are particularly vulnerable to experiencing burnout and sacrificing their personal wellness for their job, with radiologists facing challenges unique from their colleagues.

These vulnerabilities have only been stressed by recent accommodations necessitated by the COVID-19 pandemic’s strain on the healthcare system. Recent surges in radiologist burnout have raised alarms concerning compromised patient care and deteriorating provider wellness

. Despite these challenges, there are simple practices that the individual can take to help combat the decline of their personal wellness and stave off burnout even with the added stress of the current health emergency.

There are many factors contributing to the rise in work fatigue and declined wellness in radiology. Institutionally, the paradigm of patient-centered physician values and the growing push for productivity and cost/revenue control by the hospital and insurance industries can produce cognitive dissonance

. Specific to radiologists, an increasing emphasis on reading speed and studies per day has resulted in an accumulation of more burnout than ever with rates of burnout symptoms hovering around 50 percent by some measures

Additionally, as patient care and quality control measures get more complex, the burden of work for physicians before care can be performed has become somewhat daunting. Some may feel that more of their time is spent maneuvering bureaucratic tape than performing radiology and medicine

. As more is expected out of radiologists during the workday, the corners that are cut can frequently be those that preserve wellness, such as lunch breaks and diverse time for academics or research. Radiology inherently lends itself poorly to much meaningful personal interaction on the day-to-day with either patients or other faculty. For some, this can be a source of fatigue and should be addressed. With these challenges in the forefront, a radiologist’s risk of facing deteriorating personal motivation and wellness in the modern age of medicine is substantial.

Radiology residents face different challenges from their full-fledged attending physician counterparts and suffer from substantially increased rates of burnout ranging from 40 percent to 80 percent – a level greater than either medical students or physicians

. They still have to deal with all the same issues that practicing radiologists do, but with the added stressors of being in the middle of a chain of educators -- being both student and teacher and being expected to internalize great amounts of information and balance that learning and teaching with their patient responsibilities.

Radiology residents have some of the worst rates of burnout of all fields. Nearly 85 percent of trainees experience some decline in emotional wellness, feelings of personal accomplishment, and other affects consistent with burnout

. This article by Mendoza and Bertino cites tedious training modules, long hours, and low levels of social interaction responsible for producing this number. Residents are also more vulnerable to feelings of inadequacy due to imagined and actual perceptions of being inexperienced.

Resident radiologists are set up to burn out during their training and carry that vulnerability into their working careers. Reinforcing the wellness of their trainees should be a high priority for programs not simply to encourage enrollment or placate concerns of overworking, but to facilitate learning and promote good practices for burnout resilience during and after residency.

While burnout and wellness statistics among radiologists, both attendings and trainees, have been morbid in recent years, the onset of practices to combat COVID-19 has disrupted even those with otherwise stable personal wellness. With long work hours and limited personal interaction already being the cause of much of the burnout radiologists currently experience, the social isolation and increased need for personnel that the pandemic brought on has surely only made this worse.

Studies looking at previous endemics and pandemics have revealed that not only is the populace at large exposed to increased mental stress, but physicians have increased rates of mental distress and even post-traumatic stress disorder following participation in managing these outbreaks

. Between the looming threat of infection and the increased scrutiny by the public and public health officials, stress levels are at an all-time high. Even though much of the public sentiment is positive regarding “healthcare heroes,” those that feel that the title is unwarranted or unfulfilled may have their self-worth damaged by the additional expectations.

Additionally, harassment by social media conspiracy activists claiming mask exemption, pandemic hoaxes, and other similar falsities may exacerbate feelings of not being able to effectively control the outbreak while individuals refuse to follow guidelines. While the focus is appropriately on patient care and increased demands during the ongoing outbreak, attention should still be directed towards maintaining wellness.

Addressing burnout and maintaining wellness can be targeted either at the institutional level or by the individual. Institutions have a vested interest in keeping their workforce healthy and fully functional. Constant interruptions and long hours lead to burned-out physicians and overlooked mistakes

As for residents, while many programs may try to implement mandatory wellness lectures or provide meditation services and other such at-will avenues to increase burnout resilience, only work-hour limits have been strongly associated with improvement in emotional exhaustion and burnout

On the individual level, many small practices can be integrated into daily life to preserve wellness and prevent oneself from being burned out. Drs. Fessell and Cherniss suggest a small list of “micropractices” to help strengthen resilience to burnout and keep wellness balanced

. These are things like diaphragmatic breathing and taking a “moment for mindfulness:” this means taking a moment to reflect inwards when doing something like hand washing, centering oneself, and analyzing their current state. This allows a chance to address feelings from the last case or make sure that personal needs are met.

Another such micropractice involves naming complex emotions as they are experienced to aid self-awareness and facilitate a return to calm. Lastly, sharing cases and frustrations with peers is a great way to acknowledge that others are facing similar problems and get practical tips to internalize

. These are things that must be consciously done regularly to keep wellness a priority during a complex and hectic workday.

Maintaining wellness can be a challenge even under ideal circumstances, let alone during a world-wide health emergency. Maneuvering the modern medical landscape of high demands, impersonal patient interactions, and complicated infectious precautions has produced a large burden of burned-out physicians. The challenges that radiologists face are different from their colleagues and require specific and deliberate attention.

Every radiologist should try to be more aware of the state of their personal wellness and take steps to remedy shortcomings and reinforce resilience to burnout. Sacrificing mental health and wellness in the name of patient care, dedication, or monetary gains in reality is harmful to both the physician and the patient. Burnout is not a burden that has to be borne, but it takes deliberate effort and acknowledgement by institutions and individuals.

1. Maslach, C., Jackson, S. E., & Leiter, M. P. (2018). 

2. Shah K, Kamrai D, Mekala H, Mann B, Desai K, Patel RS. Focus on Mental Health During the Coronavirus (COVID-19) Pandemic: Applying Learnings from the Past Outbreaks. Cureus. 2020;12(3):e7405. Published 2020 Mar 25. doi:10.7759/cureus.7405

3. Berg, S. (2020, May 28). The 12 factors that drive up physician burnout. Retrieved June 07, 2020, from https://www.ama-assn.org/practice-management/physician-health/12-factors-drive-physician-burnout

4. Cohan RH, Davenport MS. Productivity, Meet Burnout. 

. 2018;25(12):1513‐1514. doi:10.1016/j.acra.2018.08.001

5. Busireddy KR, Miller JA, Ellison K, Ren V, Qayyum R, Panda M. Efficacy of Interventions to Reduce Resident Physician Burnout: A Systematic Review. 

. 2017;9(3):294‐301. doi:10.4300/JGME-D-16-00372.1

6. Mendoza, D., & Bertino, F. J. (2019). Why Radiology Residents Experience Burnout and How to Fix It. 

(4), 555-558. doi:10.1016/j.acra.2018.08.009

7. Fessell D, Cherniss C. Coronavirus Disease 2019 (COVID-19) and Beyond: Micropractices for Burnout Prevention and Emotional Wellness. 

. 2020;17(6):746‐748. doi:10.1016/j.jacr.2020.03.013

The role of the pandemic and what radiology can do to mitigate its burnout effect.

Radiologist Wellness and Burnout in the COVID-19 Era

Medical errors are the third most common cause of patient mortality in the United States, following cancer and cardiovascular disease, affecting more than 251,000 patients annually

Errors in diagnostic interpretative imaging are a key contributor with an estimated day-to-day error rate of 3 percent-to-5 percent for all studies reported

. With 1 billion radiographic examinations performed annually worldwide, this would translate into 30 million-to-50 million interpretative errors per year. Given the significant patient implications, it is imperative that we continually attempt to identify and eliminate diagnostic errors as best as possible.

A common diagnostic error is termed “satisfaction of search.” With this error, a radiologist fails to continue to search for additional abnormalities after finding the first one.

 This error accounts for 22 percent of radiologic errors.

Using checklists is the classic remedy. A helpful checklist is well encompassing, but not too lengthy. It can reduce errors of omission by reminding the radiologist to take a second look at certain imaging features, particularly for “do-not-miss” diagnoses

. Additionally, working smarter by simply being mindful of diagnoses that oftentimes present in combination, such as multiple fractures, foreign bodies or vascular occlusions, can help reduce the likelihood of finishing a report too early before all of the abnormalities have been identified

Under-reading is another common diagnostic error, constituting up to 42 percent or more of all radiologist errors

. It occurs when an abnormality is present on the image but is missed and not recorded in the final report. Often, the abnormality is easily identifiable in retrospect, but it was simply not perceived at the time of primary image interpretation

While there is no definitive solution, several strategies can help reduce the frequency of this type of error. For example, image enhancement and post-processing tools can help optimize images and aid in reducing under-reading errors. An example of this is bone subtraction software being used to reduce anatomic noise and help visualize pulmonary nodules on chest radiographs. In addition to enhancing the image and reducing anatomic noise, artificial intelligence is becoming increasingly more useful at identifying abnormalities in the image itself. Computer-aided detection can help reduce the likelihood of missing some radiologic abnormalities, particularly in mammography and lung nodule detection on CT

The third key error that affects imaging care is failure of effective communication, which is often a key driver of patient adverse outcomes. Effective communication between the radiologist and the referring physician relies on clear and concise reports delivered in an appropriate and timely manner.

To improve the overall structure of the report, the American College of Radiology (ACR) Reporting and Data Systems (RADS) provides a standardized framework for reporting on imaging findings. This framework can reduce the variability between reports on a diverse range of disease processes. In addition to the content of the report itself, optimal time frame for communication is also an important aspect to consider as a source of error

. To this end, the ACR Actionable Reporting Work Group categorized findings in terms of optimal time frame for communication from most-to-least urgent, which provide guidance regarding the response times to improve interdisciplinary communication and patient outcomes.

Identifying major diagnostic errors and potential strategies to reduce their occurrence is a key step towards improving radiologic care. However, perhaps the most important factor to consider is the inclusion of meta-awareness in the education of future radiologists. Providing the next generation of radiologists with an understanding of their own limitations and biases may have the greatest long-term impact on reducing the frequency of diagnostic errors.

We must never lose sight of the fact that, as humans, we are prone to error despite our best intentions, and by acknowledging our fallibility and working diligently to change them, we will continue to improve.

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Three causes of errors and three potential solutions to improve diagnostic accuracy.

Author | Mina S. Makary, MD

Articles

Patient Perceptions of Imaging Modalities and Ionizing Radiation

Future Trends and Technologies in Interventional Radiology: What to Expect

Radiologist Wellness and Burnout in the COVID-19 Era

Diagnostic Errors: Lessons Learned and Mitigation Strategies