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Submitted by Eddy Rafiqi, Institute of Physics and Engineering in Medicine (RPSIG)
   Commenting on behalf of the organisation
Document Education and Training
 
RPSIG (Radiation Protection Special Interest Group) Response to ICRP Report for Consultation on
Education and Training

IPEM
(Institute of Physics and Engineering in Medicine)
United Kingdom

The following Comments were received from Medical Physicists

As a general remark, we would like to support the report and its aims.
We believe there is a clear need for improvements in aspects of Radiation Protection (RP) training for many healthcare workers, particularly with the increasing number of procedures using ionising radiations, most particularly in interventional work where relatively high doses are involved.

Comments

Line 221: "Medical Physicists have a central role in all education and training programmes in RP." We strongly agree with this statement, which is repeated elsewhere in the document.

Section 2.2 "Categories of medical and healthcare professionals requiring education and training"
There is an important category of staff missing, namely Radiopharmacist / Technologists Radiographers who prepare radiopharmaceuticals for patient use. This group is significantly different from group 9. both in terms of the practical aspects of radiation protection of themselves and also patients. Different procedures and PPE are required.

Lines 517-519: "ICRP has proposed in Publication 85 (ICRP, 2000b) a second level of training for interventional Radiologists and Cardiologists". I think this is most important due to the relatively large patient doses that may occur, particularly with regard to Cardiologists (see also 924 - 928 and 1154 - 1156)

Line 693: "Risks to pregnant women (as patients or staff) and foetuses involved in radiotherapy, nuclear medicine...." This appears to be the only time radiotherapy is mentioned.

Lines 729-73: "Practical exercises and practical sessions should be included in Radiation Protection Programmes." In RP training, practical exercises and scenarios are most important and valuable as part of RP courses, as well as practical experience gained in the local workplace.

Table 2 Column 9 RDNM:
I would comment on some changes to the level of training required for this group of staff:
"Fundamentals of radiation detection": change m to h
It is most important that there is a good understanding of the radiation detectors used in RP, imaging and non-imaging in nuclear medicine in order to correctly select and use the instrumentation available. Lack of understanding could lead to safety consequences for staff, the public and patients.


"Risks of deterministic effects": Change m to l
Diagnostic Nuclear Medicine procedures are not likely to result in deterministic effects.
In therapy there is, clearly, a planned effect.

"Quality control and quality assurance": Change m to h
For the same reasons as radiation detection above.

Lines 825 - 832 Availability of material - I strongly agree with the aims and methods of transfer of information described in these lines. The e-IRMER project is an excellent example of using innovative e-learning techniques to make the transfer of information more interesting and memorable.

Lines 845 - 849 Improving the understanding of regulatory authorities is of great importance. This will help to resolve conflicts between opposing requirements of different legislation found in nuclear medicine (e.g. the opposing requirements of sterile production vs containment of aerosol from spilt radioactive materials in radiopharmacy).

Chapter 5: Certification of training
General comments -
1) If all RP courses are to be accredited then a clear, rapid mechanism for achieving accreditation is required.
2) The training of those prescribing imaging techniques (1157 - 1159) and targeted practical training (1195 - 1197) are very important, as is obtaining certification before practicing (1244 - 1246).

Annex A.1. Nuclear Medicine

I believe there are two topics that should be added to the list:
1) Understanding the principles, routine quality assurance and the practical use of dose calibrators
2) Understanding the principles and practice involved in Intravenous, oral and inhaled radiopharmaceutical administrations.

These topics are important in patient dose limitation and staff safety.
It is also important to emphasise that the content in the appendix only covers the radiation protection aspects of training and not all the training required to fulfil a role (e.g. this is not sufficient for a clinician to obtain an ARSAC certificate in the UK).


Having read the ICRP document I am not entirely satisfied with the level of training specified for Nuclear Medicine Physicists. As a NM physicist myself, I have trained Radiographers, clinicians, nurses and MTOs in radiation protection for unsealed sources and as such I feel that a NM Physicist should have higher level of knowledge of radiation protection - especially as we act as MPEs for the modality.

We also perform all the higher complexity QA on the equipment and have responsibility to ensure they are calibrated / working to specification to ensure that patients are not injected unnecessarily or given higher doses. I think this should be reflected in Table 2 on page 28 of the document by having a separate column and increasing the m to h for all the training areas. I also don''t feel the document addresses the fact that many nuclear medicine departments have dual modality imaging (SPECT/CT and PET/CT) and that there should be a higher level of training in the CT component to be able to advise on doses and imaging protocols.

Line 136: insert CT within brackets (radiography, fluoroscopy, Ct and nuclear medicine)…….

Lines 211-215: The referring physician should be part of the justification process because he/she has the full knowledge of the patient’s clinical history.
Line 1164-1166: to add nuclear medicine (Medical Physicist working in RP, Diagnostic Radiology and Nuclear Medicine should have………………

The report does not address the issue of who will be the authorised body to accredit training. I would like to see a central body with representation from all the key players (e.g. IPEM,RCR,COR etc)

Need to address health professionals taking on an extended role (this is probably a mainly UK issue) such as nurse practitioners who will be requesting, and speech and language therapists who may be referrer, practitioner and operator all rolled into one. I think they should match to the equivalent medical role, so a nurse practitioner who refers for exams needs the same RP training as any medically qualified person in their basic training.

Lines 180-184 talks about relevant and necessary training; I agree, a General Practitioner needs breadth and a cardiologist needs depth, but some people develop their role later on in their career – need to allow for such changes.

Given how readily cataract can be treated in developed countries, and how common they are in non occupationally exposed individuals, we don’t need such a big emphasis on this particular deterministic effect.

We tend to assume that doses from diagnostic procedures are additive, but by analogy with radiotherapy it is likely that 2 x 10 mSv CT scans spaced apart by a couple of weeks do less harm than 1 x 20mSv CT scan over the same body area. Research is definitely needed into this (and may be pertinent to staff exposures too)

Lines 320-321 – regular dose audits and rigorous reject analysis should help

Lines 465-506 -Medical Physicist should be included in addition to Nuclear Medicine Physicist in line 487.

Training of engineering staff (and indeed application specialists) by the companies is vital. With a few notable exceptions, most such staff don’t understand the dose implications of what they are doing. There is also a knowledge gap between engineers and applications specialists. Software upgrades in particular are an issue. We get told that nothing has been done which will change patient doses. Measurements tell us other wise. They simply don’t understand. Manufacturers are very reluctant to educate medical physicists about how their equipment works because they consider the information to be commercially sensitive.

Medical Physicists will need help from radiologists, cardiologists etc. I cannot foresee a situation where the clinical detail and implications of an examination are fully understood by the majority of physicist – that is why we don’t act as practitioners in diagnostic radiology.

Line 853: As well as knowledge and skill, we need to ensure that there is understanding, without this knowledge and skills can be very dangerous.

Lines 900-913: The assessment should not be restricted to formal exams. For those acting as operators, there should be some assessment of competence made on-the–job.

Lines 943-945: Feedback on training is more valid after a period of time, not immediately at the end of the course. It is not uncommon to dismiss things as irrelevant only to find that, months or years later, that they are very valuable

Line 986:. Yes training should be practical, but there are huge issues in getting machine time. It is hard enough to get in to do Quality Assurance.