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ICRP: Free the Annals!

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Submitted by Jonathan McNulty, University College Dublin
   Commenting on behalf of the organisation
Document Education and Training
 
ICRP Draft Report for Consultation (ICRP ref 4811-3039-3350)
Radiological protection education and training for healthcare staff and students


General comments:
• Spelling of ionizing varies throughout. American spelling ‘ionizing’ should be replaced by ‘ionising’ throughout document
• Other words vary similarly throughout document e.g. ‘utilize’ and ‘utilise’, ‘organization’ and ‘organisation’, ‘optimization’ and ‘optimisation’, ‘cognizant’ and ‘cognisant’, ‘specialized’ and ‘specialised’, ‘localized’ and ‘localised’, ‘fetus’ and ‘foetus’,
• Overall lack of consistency in relation to CT and dose implications.
• Is PET and PET/CT being grouped with nuclear medicine or diagnostic radiology?
• In terms of ‘diagnostic radiology’ CT and PET/CT as high dose examinations should be mentioned separately.
• Facilities (combined clinical / academic institutions) where small animal research is undertaken on PET/CT or SPECT systems could perhaps be considered. While ‘patient’ dose is less of an issue in these units, staff radiation protection training is equally important and many researchers will not have any background in radiological professions.

Specific comments:
102-103: ‘Such education should be part of the curriculum in pursuit of medical, dental and other healthcare degrees, and for specialists such as radiologists, medical physicists and radiographers as part of the curriculum of undergraduate and postgraduate degrees.’

133-1`37: ‘Although recommendations have been made before by the Commission, this is the first report to specifically address the topic of the delivery of education and training for medical staff and other healthcare professionals involved in use of ionising radiation for diagnostic (radiography, fluoroscopy computed tomography, nuclear medicine and PET/CT) and interventional (fluoroscopically guided) procedures.’ – CT and PET/CT should be stated independently as high dose examinations. This is especially important in this paragraph as this defines ‘diagnostic’ procedures for the rest of this document.

159-161: ‘Planned education and training programmes for the personnel involved are necessary sine qua non so as to ensure reasonable RP of patients and workers.’

167-169: ‘The present document makes recommendations on training in RP for medical practitioners, radiographers, physicists, dentists, technicians and other health professionals who perform or provide support for diagnostic and interventional procedures utilising ionizing radiation.’

177-179: ‘Other than aspects of nuclear medicine therapy, this document does not address radiation therapy,modalities which should only be prescribed by medical staff who have specialized training in the relevant disciplines.’

182-184: ‘For the medical professional in particular, it is essential that courses are perceived as relevant and necessary, and require only a limited commitment of time so that individuals can be persuaded of the advantages of attending. The use of e-learning structure would allow professionals to complete training at convenient times and to pace their learning according to their previous knowledge’

190-200: this is a little repetitious on earlier content.

201-202: ‘RP education and training for medical staff should be promoted by Regulatory and Health Authorities along with Professional Bodies.’

263-265: ‘If staff are properly educated and trained in RP, doses from diagnostic procedures and for the most part from fluoroscopically guided interventional procedures should not approach the threshold for deterministic effects.’ – use of language

365-367: ‘The final responsibility for the radiation exposure lies with the physician, who should therefore be aware of the risks and benefits of the procedures involved.’ – it also lies with the person exposing the patient to ionising radiation / performing the examination (most often somebody in the RDNM category or Radiologist) so this is a little misleading as currently worded.

447-449: ‘Experience has shown that as many radiology departments have made the transition to digital equipment, patient doses have not been reduced but have increased measurably.’ – what is the evidence base for this? Many studies in the UK and Ireland have not found this to be true.

468-470: ‘2. Nuclear Medicine Specialists (NM): Physicians who are going to take up a career in which the major component involves the use of radiopharmaceuticals in nuclear medicine for diagnosis and treatment.’ – again is PET and PET / CT included in this category?


494-496: ‘11. Other Healthcare Professionals (HCP): Other professionals such as Podiatrists, Physiotherapists, Speech Therapists, and Chiropractors who may be involved in the use of radiology techniques to assess patients.

506: as stated in general comments, another category ‘researchers’ e.g. clinical research units could be added.

528-529: ‘Training in RP given to interventional cardiologists in most countries is limited. The Commission considers that provision of more RP training for this group should be a priority.’ – in this section and the paragraphs above cardiac CT should be mentioned as it can again be very high dose and may be performed under the direction of radiologists or cardiologists.

541-542: ‘For these personnel, a combination of seminars and practical demonstrations is likely to be the best arrangement for their RP training.’ – only specifying seminars and practicals is somewhat limiting. It is our experience that multi-media rich e-learning content including sound, videos, etc. is an extremely useful method to deliver such content to these groups of professionals who are highly unlikely to be able to commit to taking several hours out of their busy schedules.

568-571: ‘Other healthcare professionals, such as nurse practitioners in casualty departments and podiatrists may request medical exposures for specific conditions, and will require some instruction in radiation hazards although this can be more limited because of the narrower scope of practice.’ – nurse prescribers should have their own category in section 2.2 and in theory would require the same level as knowledge as the ‘Medical Prescribers’ category rather than a lower level as indicated here. Secondly, why are only podiatrists listed – should stick with other healthcare professionals or else list all professions individually. Also there are certain core concepts related to radiation protection that should be known by all as they are fundamental. The way this sentence is worded is quite vague and should identify the core topics as highlighted in the table 2.

673-674: ‘6) The use of radiation in diagnostic radiology, interventional radiology, nuclear medicine and radiotherapy.’ – again it may be worth specifying CT, PET, PET/CT here to ensure their inclusion in course content as they are higher dose diagnostic examinations.

695: ‘19) When patients treated with radiation or undergoing diagnostic nuclear medicine or PET examinations can endanger other people.’ – this also applies to nuclear medicine and PET examinations not just therapy examinations

702-704: ‘The different groups of topics and the minimum level of training recommended for different categories of medically qualified staff and other healthcare professionals are included in Tables 1 and 2 respectively.’

713-714: ‘The number of hours indicated in the table should be considered as an indication of the minimum amount of training.’

729-732: ‘Practical exercises and practical sessions should be included in the RP training programmes for those directly involved in procedures. A minimum of a 1-2 hour practical session in a clinical installation is recommended for the simplest training programmes, while 20-40% of the total time scheduled may be devoted to practical exercises in more extensive courses.’ – with modern e-learning technology it is possible, and often easier, to achieve learning outcomes by using high quality interactive video, etc of such practical scenarios. Again this may also be more practical when looking at the professions undergoing training and the difficulty in releasing them from duties.

Table 1: suggested changes in bold based on professional requirements. Hours for dentists (who will prescribe and perform) and MD category (who will prescribe) would appear to be a little low

Training Area 1 DR 2 NM 3
CD 4
MDX 5
MDN 6
MDA 7
DT 8 MD
Atomic structure, x-ray production and interaction of radiation h h l l l l m -
Nuclear Structure and radioactivity m h l - m - - -
Radiological quantities and units h h m m m l l l
Physical characteristics of the x-ray machines m l m m l l m -
Fundamentals of radiation detection m h l l m - l -
Fundamentals of radiobiology, biological effects of radiation h h m m m l m l
Risks of cancer and hereditary disease and effective dose h h m m m l m m
Risk of deterministic effects h h h m l l m l
General principles of RP h h h m m m m l
Operational RP h h h m h m m l
Particular patient RP aspects h h h h h m h l
Particular staff RP aspects h h h h h m h l
Typical doses from diagnostic procedures h h m m m m m m
Risks from foetal exposure h h m m m l l l
Quality control and quality assurance h h m l l - m -
National regulations and international standards m m m m m l m l
Suggested number of training hours 30-50 30-50 20-30 15- 20 15- 20 10- 15 15-20 10-15

Table 2: suggested changes in bold based on professional requirements. For RDNM category 40-100 hors are stated and thus it is essential for these professions to have a high level of knowledge in all categories. In many jurisdictions the dentist prescribing the ionizing radiation will delegate the responsibility for performing diagnostic examinations to the dental nurse or dental hygienists providing they have completed a course in radiation protection and dental radiography – thus the hours and levels should more closely match dentists in the above table. A category for nurse prescribers should also be included with a level of knowledge similar to that of

Training Area 9 RDNM 10 ME 11
HCP 12 NU 13 DN 14 RL 15 REG
Atomic structure, x-ray production and interaction of radiation h m l - m m l
Nuclear Structure and radioactivity h m - - - m l
Radiological quantities and units h m l l l m m
Physical characteristics of the x-ray machines h h m - m l l
Fundamentals of radiation detection h h l l l m l
Fundamentals of radiobiology, biological effects of radiation h l m l m m l
Risks of cancer and hereditary disease and effective dose h l m l m m m
Risks of deterministic effects h - l l m l m
General principles of RP h m m m m m m
Operational RP h m m m m h m
Particular patient RP aspects h m h m m - m
Particular staff RP aspects h m h m m h m
Typical doses from diagnostic procedures h l l - m - l
Risks from foetal exposure h l m l m m l
Quality control and quality assurance h h l - m l m
National regulations and international standards h h m l m m h
Suggested number of training hours 40-100 40-60 15- 20 10-
15 15-20 20-40 15-

791-793: ‘In general the professions in categories 1 and 2 (Table 1), and 8 and 9 (Table 2) shall have formal education in RP and a formal examination system to test competency before the person is awarded a degree that entitles him/her to practice the profession.’ – category 8 is MD and appears in table 1 rather than table 2.

813-814: ‘Surveys have shown the level of knowledge that medical prescribers have of RP to be relatively poor.’ – what is the evidence base? Why not include appropriate references here?

862-864: ‘Practical training should be in a similar environment to the one in which the participants will be practising and provide the knowledge and skills required for performing clinical procedures.’ – as previously stated; – with modern e-learning technology it is possible, and often easier, to achieve learning outcomes by using high quality interactive video, etc of such practical scenarios. Again this may also be more practical when looking at the professions undergoing training and the difficulty in releasing them from duties.

866-867: ‘The primary trainer in RP should normally be a person who is an expert in RP in the practice with which he or she is dealing (normally a medical physicist).’ – not all education and training will be delivered within ‘a practice’, much will be delivered by Universities. Also it will not always be a medical physicist but may be ‘a professional with formal education in radiation protection (DR, NM or RDNM categories) who holds appropriate qualifications in radiation protection.

920-923: ‘The radiation doses to patients from CT examinations are also relatively high and thus the need for RP is correspondingly greater. Another factor that should be taken into account is the number of times a procedure such as CT may be repeated on the same patient.’ – inconsistency, CT not mentioned earlier.

1016-1018: ‘A simple test of multiple-choice questions may be used to evaluate the knowledge of the attendants and score some of the key aspects to identify the possible weaknesses in the training programmes.’ – it should be noted that while an MCQ can be used to assess knowledge it is not necessarily a good tool for assessing understanding and it is essential that radiation protection is understood by all.

1046-1048: ‘The involvement of the relevant medical, radiography, radiology, nuclear medicine and medical physics scientific societies is a key factor in attracting different clinicians to the training programmes.’

1149-1156: again it would be worth including cardiac CT in these 2 paragraphs as a high dose examination directed by radiologists or cardiologists.

1356: ‘RP for personnel working in PET/CT’ – specific reference to PET/CT examinations, which are high dose, should be made earlier in this document. See general comments.