The Need for a Broad-based Introduction to Radiation Science within U.S. Medical Schools’ Educational Curriculum
2021; Radiological Society of North America; Volume: 301; Issue: 1 Linguagem: Inglês
10.1148/radiol.2021210665
ISSN1527-1315
AutoresMartha S. Linet, Pamela B. Davis, James A. Brink,
Tópico(s)Advances in Oncology and Radiotherapy
ResumoHomeRadiologyVol. 301, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorialThe Need for a Broad-based Introduction to Radiation Science within U.S. Medical Schools' Educational CurriculumMartha S. Linet , Pamela B. Davis, James A. BrinkMartha S. Linet , Pamela B. Davis, James A. BrinkAuthor AffiliationsFrom the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, 9609 Medical Center Dr, NCI Shady Grove Room 7E536, Bethesda, MD 20892-9778 (M.S.L.); Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio (P.B.D.); and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.A.B.).Address correspondence to M.S.L. (e-mail: [email protected]).Martha S. Linet Pamela B. DavisJames A. BrinkPublished Online:Jul 20 2021https://doi.org/10.1148/radiol.2021210665MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Medical imaging and fluoroscopically guided and nuclear medicine procedures play a central role in patient care, and radiation therapy is crucial for the treatment of cancer and other diseases. High doses of radiation may ablate or reduce the size of tumors (1) but have also been associated with increased risks of most types of cancer, cardiovascular disease, and cataracts (2,3). A growing body of studies supports small excess risks of solid cancers and leukemia with low-dose ionizing radiation (defined as <100 mGy cumulative dose) from exposures at all ages (4,5) and in childhood (6). Low-dose protracted radiation exposures experienced by adults (mostly medical radiation and nuclear workers) have been associated with increased risks of cataracts (7–10) and possibly cardiovascular disease (10,11). Some diagnostic imaging procedures involve doses up to 23 mGy (eg, PET/CT) (12).A National Council of Radiation Protection and Measurements committee estimated that annually in the United States approximately 275 million radiographic procedures, 74 million CT examinations, 8.1 million fluoroscopically guided procedures, 13.5 million nuclear medicine examinations, and 1 million courses of radiation therapy are conducted (13,14). Most physicians order imaging tests or conduct fluoroscopically guided procedures or use imaging procedures during many surgical procedures or need to consider radiation-related diseases or tissue effects in differential diagnosis. Yet, fewer than 20% of U.S. medical schools require a radiology clerkship (15), although 45%–87% of U.S. medical students believe that this should be required (16) and postgraduate year 1 residents identified key gaps in radiology medical student education (17). Medical school curricula generally lack education on other modalities involving ionizing and nonionizing radiation exposure or in radiobiology and radiation protection. The limited education on imaging during required rotations focuses on interpreting CT scans or radiographs rather than learning which imaging studies to request. Nonradiologists provide most of the radiology education without reference to trusted sources of information (eg, American College of Radiology Appropriateness Criteria) (18). These data and observations, together with estimates that 20%–50% of imaging tests ordered yield little or no clinical benefit (19), provide a compelling rationale for introductory broad-based radiation science education in medical schools. We use the term radiation science to include understanding of radiation-related health effects, radio-sensitive patient subgroups, the difference in biologic effects between ionizing and nonionizing radiation, and radiation dose differences between procedures; the clinical modalities of radiology, fluoroscopically guided procedures, nuclear medicine, and radiation oncology; and the multifaceted elements involved in radiation protection.Knowledge Gaps and Rationale for Broad-based Introduction to Radiation Science Education in Medical SchoolsStimulated by a meeting of experts at the National Academies of Sciences, Engineering and Medicine (NASEM) during November 2020 to support strategic planning for education of U.S. medical students in radiation sciences, we identified U.S. physician knowledge gaps on this topic. Misconceptions of radiation risks may lead to inappropriate risk-benefit decision-making for medically necessary procedures, to the detriment of patients. Physicians must be conversant with sources of trustworthy state-of-the-art guidance about radiologic procedures that improve clinical decision-making and limit unnecessary radiation exposure. Physicians must also be knowledgeable about radiation-sensitive populations to identify clinically beneficial diagnostic or therapeutic procedures while reducing adverse effects for patients in these populations. Moreover, physicians should be familiar with radiation protection measures for their patients, staff, and themselves. Finally, physicians would benefit from learning how to properly address patients' questions about radiologic procedures and environmental radiation involving ionizing radiation (eg, radon, other natural background radiation, cosmic radiation, and radiation from disasters and emergencies), ultraviolet solar and tanning bed radiation, and nonionizing radiation (eg, from MRI examinations, mobile phones, 5G, wi-fi, other radiofrequency radiation). To address these knowledge gaps, we advocate an introduction to broad-based education in radiation sciences and in communication skills for patient-centered education as a critical need in U.S. modern medical school curricula.Essential Radiation Science Educational ElementsStimulated by discussions at the NASEM meeting, we have identified essential radiation science elements to include in a proposed U.S. medical school curriculum (Table). Major goals of the proposed radiation sciences education are to introduce medical students to key concepts of radiation science and teach them strategies for ordering and/or performing diagnostic and therapeutic procedures that would maximize the notable benefits and reduce risks to patients from radiation-related procedures. Other goals include an introduction to understanding of adverse radiation health and tissue effects, recognition of the need for reducing unnecessary ionizing radiation exposures to all patients (with particular attention to radio-sensitive patient subgroups), and implementation of follow-up for short- and long-term health effects of moderate-to-high-dose radiation. Additional goals include introducing medical students to the objectives, procedures, and equipment used in the diagnostic and therapeutic radiation modalities included in the proposed curriculum; trusted sources of guidance for each of these modalities (eg, American College of Radiology appropriateness criteria [21]) for ordering appropriate imaging procedures and guidance about appropriate procedures for other modalities from professional societies; and reducing unnecessary radiation exposures. In addition, students should be able to answer patient queries and provide trustworthy sources of information about environmental sources of ionizing radiation and nonionizing radiation. Finally, the medical student could gain knowledge and experience in shared patient-physician decision-making about diagnostic and therapeutic procedures involving radiation.Proposed Radiation Science Topics and Ideas for Educational StrategiesThe Table provides ideas about educational strategies and where the proposed components could be introduced. We envision that most of the proposed radiation science education would be vertically integrated in the existing curriculum or provided through self-directed websites and online modules, including a few sessions with experts to answer questions. Although some proposed components of radiation science education were designated as preclinical, knowledge of risk measures (eg, relative, absolute, and attributable risks) and uncertainty (eg, CIs around point estimates of risk) (22) is useful for planning and understanding results of clinical trials, survival studies, and risk projection for late effects of treatment. Knowledge about radiation-related biologic and tissue effects and diseases could be integrated within histology and pathology courses and is also relevant for differential diagnosis (22). Identification of radiation-sensitive patient subgroups (children, pregnant women, patients with autoimmune diseases, and patients with certain genetic syndromes) (22) has implications for tailoring the choice of radiologic procedures to achieve optimal patient benefit while also implementing radiation protection measures (21).Clinical education must include the common diagnostic and therapeutic modalities that use ionizing radiation, with radiology education that emphasizes appropriate use and leverages the American College of Radiology Appropriateness Criteria (21). Given the rapid growth in the performance of fluoroscopically guided procedures by many specialists, medical students need instruction on benefits, risks, and radiation doses to patients and operators (22) to optimize use of this modality in cardiovascular (23) and other fluoroscopically guided (24) procedures. While use of some nuclear medicine procedures have declined over time, others are increasing in use (PET and SPECT) and often involve higher doses than other radiologic procedures (25). Knowledge is needed about newer radiation therapy modalities that target neoplasms more accurately but potentially involve substantial radiation doses and scatter to healthy surrounding tissue. Students should be familiar with the American Society for Radiation Oncology clinical practice guidelines to optimize patient care (26). Short- and long-term surveillance for potential early and late adverse effects of moderate-to-high-dose radiation, systemic cancer treatments, and immunotherapy has been documented to reduce morbidity and mortality (27–29). Surveillance by medical and radiation oncologists is often limited to a few years past diagnosis, and thus there is an important ongoing role for primary care physicians and other specialists, such as ophthalmologists and cardiologists, who may see patients regularly for conditions not related to radiation (30,31). The key educational elements for these modalities (Table) need to underscore the valuable role of medical and/or health physicists in implementing radiation protection measures.Teaching medical students important elements of radiation science in patient-centered education may include interactive videos, workshops, and practice sessions with actors and volunteer patients. Trusted sources of patient information should be provided, such as the American College of Radiology patient toolkit, which includes links to RadiologyInfo.org (32), American Society for Radiation Oncology patient education information (33), information on fluoroscopy provided by the U.S. Food and Drug Administration (34), Society for Interventional Radiology patient-centered information (35), and other useful websites, including MedlinePlus from the U.S. National Library of Medicine (36) and the International Atomic Energy Agency (37).Educational Strategies and Testing of KnowledgeWe recognize that the faculty at each medical school is responsible for decisions regarding what to include in the curriculum and must guide the development of a new radiation science curriculum. We suggest vertical integration of many of the proposed radiation science components within the existing curriculum along with substantial use of online self-directed modules, including some with instructional videos and/or experts to answer questions (Table). A required rotation in radiology could be efficiently undertaken as a virtual online effort during year 4 while medical students are interviewing for residency positions (see example described by Alexander et al [20]). Development of content and strategies for integrated radiation science education would benefit from implementation of a multidisciplinary team-based approach ideally led by radiologist faculty in conjunction with course directors of required nonradiation preclinical and clinical education components, and with input and teaching of relevant content by radiologists, physicians who conduct fluoroscopically guided procedures, nuclear medicine experts, radiation oncologists, and medical and/or health physicists. The existing radiology clerkships in some medical schools (16,18), toolkits developed by the American College of Radiology (38) and the Alliance of Medical School Educators in Radiology (39), and a few clerkships on radiation oncology (40) and interventional radiology (41) provide potential starting points for development of the broad-based radiation science curriculum outlined earlier.Although online and/or video methods could be used for some preclinical components (see earlier and Table), early observation of experts and procedures would need to be followed ideally by active hands-on learning experiences. Integration of education in both basic and clinical science curricula should be a hallmark. For example, medical imaging may be integrated seamlessly with anatomy and pathology courses (Table). Knowledge about fluoroscopically guided procedures and nuclear medicine could be incorporated in required rotations. Ongoing reinforcement of key elements (eg, benefits and risks of the procedures, patient membership in a radiation-sensitive subgroup, adverse disease and tissue effects, and radiation protection measures) should be undertaken by faculty teaching all modalities that use ionizing radiation.Knowledge assessment may include written quizzes on the preclinical elements and written examinations and oral presentations on the clinical components, such as decision-making processes for ordering imaging examinations; conducting radiologic procedures; treatment planning and implementation; understanding findings and results of radiologic procedures; and monitoring adverse short- and long-term effects of radiation exposure. National web-based examinations have been developed by the Alliance of Medical Student Educators in Radiology (42); adding questions on board examinations could be considered.ConclusionDevelopment and implementation of an action plan for broad-based U.S. medical school radiation science education is needed. Benefits to patients from the knowledge gained from the proposed radiation science education by future physicians could improve clinical care and reduce unnecessary ionizing radiation exposures through referral for optimal imaging procedures; result in the use of alternatives to ionizing radiation imaging modalities for radio-sensitive and other patient subgroups; and improve radiation protection measures. Other patient benefits could include short- and long-term follow-up and surveillance for radiation-related health and tissue effects for patients who have received moderate-to-high-dose ionizing radiation exposure, improvement in shared patient-physician decision-making about diagnostic and therapeutic radiation procedures, and more accurate information conveyed to patients from knowledgeable future physicians about exposures and related health effects from radon, radiation emergencies and disasters, solar and tanning bed ultraviolet radiation, and cell phones and other sources of radiofrequency radiation. Knowledge of radiation protection measures could also benefit future physicians and other medical staff who conduct procedures involving ionizing radiation. The literature on long-term benefits to future physicians from their medical school radiation science education (limited to radiology rotations) is sparse and narrowly focused. Short-term evaluations from radiology rotations (eg, scores on pre- vs postknowledge assessment based on 21 studies) generally show improvements in knowledge, but many reports describe qualitative data, do not specify the instructional approach, and generally are single-institution studies with relatively small numbers of students (43). Thus, development and implementation of radiation science education for medical students should include not only high-quality pre- and post-educational component evaluation, but also longer-term follow-up assessment to quantify knowledge retention. Recent U.S. and international radiology, radiation oncology, and other modules could provide starting points to develop broader radiation science educational curricula. Introduction, integration, and reinforcement of radiation science concepts and content is important throughout the preclinical, clinical, and postgraduate residency years with ongoing reinforcement in accredited life-long learning programs. A detailed description of the discussions coauthored by all experts participating in the NASEM November 2020 meeting is in preparation. Going forward, we recommend assembling a multidisciplinary group of medical radiation experts, medical school educators, and other stakeholders to identify detailed learning objectives and core competencies for U.S. medical school education in radiation science. These learning objectives could then be incorporated as appropriate in each individual school's curriculum.Disclosures of Conflicts of Interest: M.S.L. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: is a Scientist Emerita/volunteer at the National Cancer Institute. Other relationships: disclosed no relevant relationships. P.B.D. disclosed no relevant relationships. J.A.B. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: received payment from Accumen for board membership. Other relationships: disclosed no relevant relationships.AcknowledgmentsWe are indebted to Ourania Kosti, PhD (Senior Program Officer, Nuclear and Radiation Studies Board of the National Academies of Sciences, Engineering, and Medicine), Stephen J. Chanock, MD (Director, Division of Cancer Epidemiology and Genetics, National Cancer Institute), and Amy Berrington de Gonzalez, DPhil (Chief, Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute), for helpful suggestions. The opinions provided in this article are those of the authors; we appreciate the informative discussions of the radiation and medical education experts attending the virtual meeting entitled "Radiation Course for Medical Students and Professionals" organized by the National Academies of Sciences, Engineering and Medicine during November 10–11, 2020. 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Crossref, Medline, Google ScholarArticle HistoryReceived: Mar 11 2021Revision requested: Apr 7 2021Revision received: May 5 2021Accepted: May 14 2021Published online: July 20 2021Published in print: Oct 2021 FiguresReferencesRelatedDetailsRecommended Articles Patient Exposure from Radiologic and Nuclear Medicine Procedures in the United States: Procedure Volume and Effective Dose for the Period 2006–2016Radiology2020Volume: 295Issue: 2pp. 418-427Trends in Occupational Radiation Doses for U.S. Radiologic Technologists Performing General Radiologic and Nuclear Medicine Procedures, 1980–2015Radiology2021Volume: 300Issue: 3pp. 605-612Policies and Guidelines for COVID-19 Preparedness: Experiences from the University of WashingtonRadiology2020Policies and Guidelines for COVID-19 Preparedness: Experiences from the University of WashingtonRadiology2020Volume: 296Issue: 2pp. E26-E31Occupational Exposure in General Radiology and Nuclear Medicine: A Changing TargetRadiology2021Volume: 300Issue: 3pp. 613-614See More RSNA Education Exhibits Radioisotope Safety Exam: What Every Radiology Resident Needs to Know to Pass the ExamDigital Posters2019Radiation Exposure in Pregnancy: It's Hot in Here!Digital Posters2019Patient Dose Calculation and Counseling using Open Source Mobile AppDigital Posters2019 RSNA Case Collection Bilateral ParagangliomasRSNA Case Collection2022Pseudoprogression with Immunotherapy Treatment RSNA Case Collection2021 Interatrial septal Lipomatous hypertrophyRSNA Case Collection2020 Vol. 301, No. 1 Metrics Altmetric Score PDF download
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