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Communicating Benefit to Risk Ratio From Radiology Exams to the Patient and Provider

M O'Connor1*, E Ritenour2*, S Brady3*, R Otto4*, (1) Mayo Clinic, Rochester, MN, (2) Medical University of South Carolina, Charleston, SC, (3) Cincinnati Childrens Hospital Med Ctr, Cincinnati, OH, (4) Seattle Children's Hospital, Seattle, WA


(Tuesday, 7/16/2019) 7:30 AM - 9:30 AM

Room: 304ABC

Speaker 1 - BEIR VII and its implications on risk - facts versus myths – Dr. O’Connor
Over the last 10 years, there has been considerable attention focused on the potential cancer risks from low doses of ionizing radiation, particularly those associated with medical imaging procedures such as CT. Almost all estimates of cancer risk from ionizing radiation are based on the BEIR VII report (Biological Effects of Ionizing Radiation panel formed under the auspices of the National Academy of Sciences) and the use of a hypothesis known as the Linear No Threshold (LNT) Hypothesis. Most studies treat the BEIR VII report as a solid basis for the calculation of the harmful effects of ionizing radiation at low doses. In reality, BEIR VII illustrates the large number of assumptions inherent in risk estimation at low doses. The main source of data for the BEIR VII risk estimates are the survivors of the Japanese A-bomb explosions, a population greatly different from the US population that was exposed to radiation conditions different from those of medical imaging. Data from the Japanese studies only shows increased cancer risk at doses in excess of 100 mSv, consistent with findings in other studies. As a consequence, the uncertainties in the derivation of the BEIR VII risk estimates, and the intrinsic speculative nature of the risk estimates themselves, only allow for a hypothetical estimate of cancers and cancer deaths at radiation levels associated with medical imaging. Many scientific organizations, including the Health Physics Society, American Association of Physicists in Medicine, the International Organization of Medical Physicists, the United Nations Scientific Committee on the Effects of Atomic Radiation, and the International Commission on Radiological Protection, have warned against making predictions of cancer risk from medical imaging studies because of their hypothetical nature. In conclusion, the risk projection model recommended in BEIR VII report should not be used for estimating cancer risks from low doses of radiation.
Speaker 2 - Communicating benefit versus risk to patients and providers – Dr. Ritenour
Communication of risk and benefit to patients or patient’s representative is often problematic. There is no single best method for this communication. This talk will present several methods and discuss some advantages and disadvantages of each. In order to pick the best method, it is necessary to listen to the concerns of the patient or patient’s representative. Some quick assessment of the current level of their knowledge as well as their anxiety level is key. This requires development of the skill of empathy – the ability to understand the concerns of others.
Speaker 3 - Communicating benefit versus risk to parents of pediatric patients – Dr. Brady
Every day a mix of parents/caregivers and their kids enter our Radiology Departments. These parents come with various levels of understanding of what imaging tests are to be performed on their children. Some come prepared with questions and concerns, others may not have predefined questions, but they all come with their prior biases and worries. Being able to communicate the benefit of the imaging procedure vs. the perceived risk with parents begins with (1) understanding their level of understanding and the root of their concern. As we engage parents with questions about their concerns, we must first and foremost understand the root of their concern. Some have heard their child will be radioactive after the procedure but ultimately are concerned that from the tests scheduled their child will develop cancer later in life. The root concern may be masked by superficial concerns, that are important, but not the anxiety provoking root concern that has led to the parent speaking up. To understand a parent’s root concern, the individual talking with the parent must be prepared to politely and gently ask appropriate questions, to peel back the outer layer of concerns, so that the root concern can be addressed. Once understood, (2) the individual should rephrase the question to make sure you and the parent are of the same understanding before attempting to address the concern. (3) Finally, to address the concern, the individual should be careful to be sympathetic to the experience the parent and child are experiencing. A visit to the hospital or radiology department can be a stressful and an anxiety provoking experience. To simply dismiss a parent’s concern by saying “don’t worry� is to invalidate the parent’s concern and feelings. Ultimately, the questions and requests made by parents to the radiology staff are usually rooted in a sincere and general desire for the safety and wellbeing of their ailing child. The answers we provide, should be honest, and be described in a simple and straight forward language (we must avoid jargon, scientific nomenclature, and providing too much information). In this presentation, we will discuss how methods to talk with parents begins before the parent ever enters the room, how it is a team effort (medical physicist, technologist, radiologist, child life specialist, etc.), and how to craft simple responses to maximize understanding and dispel concern.
Speaker 4 - Radiologist’s perspective on communicating benefit versus risk – Dr. Otto

The past two decades have seen an extraordinary evolution in medical imaging, including both ionizing and non-ionizing technologies. The risks from increasing use of high-speed CT, interventional techniques, and PET have also been heavily debated, in both the popular media and scientific literature, often leaving parents confused as to the risks of medical radiation. Adding to the confusion are more recently recognized risks associated with anesthesia in the pediatric population, often required by non-ionizing imaging alternatives such as MRI. More recent revisions to traditional ALARA principles reflect our evolving understanding of radiobiology, yet also introduce further uncertainty that is often poorly received by families struggling with complex care decisions. Demonstrating exam justification, judicious protocoling, and reviewing a robust dose monitoring program can often appeal to rational parental analysis and offer guidance as they assess the risks to their child. Helping parents to effectively navigate these concerns requires preparation, accurate information, and strong communication skills on the part of pediatric radiologists. Comparative dosimetry among imaging techniques, contrasting medical imaging doses to normal background radiation, and framing the risk - benefit analysis of various techniques in the setting of unmanaged pathology empowers families to participate more fully in the decision-making process.

Learning Objectives:
1. Understand the purpose of BEIR VII
2. How to communicate with patients about radiation risk and benefit of the radiology exam
3. How to communicate with parents of pediatric patients about radiation risk and benefit of the radiology exam
4. Understand the radiologist’s perspective on communicating risk versus benefit to the patient



Radiation Risk


IM- Radiation dose and risk: General (Most Aspects)

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