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Submitted by Donald L. Miller, M.D., ICRP C3
   Commenting as an individual
Document Education and Training
General comments:
This is an impressive work, and badly needed. I agree with almost all of it. I would like to point out a few issues that should receive some attention prior to publication of the Report.
First, I think that the classification of physicians does not reflect accurately the use of ionizing radiation (fluoroscopy) by these individuals. The classification used in the document gives two major classes of users: radiologists and cardiologists. All other physicians who use fluoroscopy are lumped into a group of minor users. This does not reflect the realities of practice. Physicians who perform interventional fluoroscopy include more specialties than cardiology and radiology—in the U.S., vascular surgeons and some neurosurgeons perform potentially high dose fluoroscopy procedures on a regular basis. In Japan and much of South America (and probably elsewhere as well) interventional radiology procedures are routinely performed by surgeons. On the other hand, many radiologists and cardiologists do not perform any interventional fluoroscopy procedures, but some radiologists and cardiologists perform many nuclear medicine studies.
I think it best to classify physicians according to what they do, and not by their specialty. Radiologists need a category of their own because they are responsible for optimizing patient dose for so many kinds of procedures and examinations involving ionizing radiation, but in this they are a special case. I suggest a classification of radiologists (DR), interventionalists of any specialty (MDI), nuclear medicine practitioners of any specialty (MDN), and the existing classes of MDX, MDA, and MD. An individual may be a member of more than one class: an interventional radiologist is both a DR and an MDI; an interventional cardiologist who also does nuclear cardiology is both an MDI and an MDN. This implies that if you wish to do both interventional fluoroscopy and nuclear medicine studies, you must meet the requirements for both MDI and MDN, and I think this is what we really want. However, there will be common elements in the curricula for these classifications, and it should not be necessary to repeat these common elements when training is undertaken for additional certifications. The requirements for certification in DR could also include the requirements for both MDI and MDN, so that certification as DR would also permit practice as an MDI and an MDN.
Specific comments (by line number):
103. Please add “certain other medical practitioners” after “radiologists”
143. Please delete “even”
160. Please change “necessary sine qua non” to “essential”
332. Please change “avoid” to “reduce”
568. In some countries, nurse practitioners are permitted to practice independently and prescribe medical exposures. These individuals should be required to have the same training and certifications as individuals in class MD.
962, 965. Please changed “authorized” to “authorizing”. It would also be helpful to state the criteria for an authorizing body.
1177-1179. Certification does not entitle a person to practice an activity. Certification only demonstrates an adequate knowledge of a specific subject. Privileges to practice the activity are granted by the facility on the basis of certification and the demonstration that the individual is competent clinically. You are confusing certification (also called credentialing) with the granting of clinical privileges. The two are not the same.
1291-1296. In addition to the EU guidance, the ACR Appropriateness Criteria also provide excellent guidance on justification. These criteria are constantly updated and readily available on the web, at no charge. They should be cited and referenced.
A.2, A.3. the requirements for all interventionalists should be the same.
1734. The site listed as Office of Radiation Protection (Division of Environmental Health, USA) is in fact the Washington State Department of Health, USA. This web site belongs to the State of Washington, one of the 50 states in the U.S., not to the US federal government.
1763-1766. For this reference, please use this citation: Klein LW, Miller DL, Balter S, Laskey W, Haines D, Norbash A, Mauro MA, Goldstein JA. Occupational health hazards in the interventional laboratory: time for a safer environment. J Vasc Interv Radiol 2009; 20:147-52. This is the reference for the journal that holds the copyright (JVIR); the author list follows the bibliographic data in PubMed.