- Email: [email protected]
Radiation Safety Knowledge and Practices Among Urology Residents and Fellows: Results of a Nationwide Survey
ORIGINAL REPORTS
Radiation Safety Knowledge and Practices Among Urology Residents and Fellows: Results of a Nationwide Survey Ariella A. Friedman, MD,* Khurshid R. Ghani, MD,* James O. Peabody, MD,* Alan Jackson, MS,† Quoc-Dien Trinh, MD,*‡ and Jack S. Elder, MD* *Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan; †Department of Radiology, Henry Ford Health System, Detroit, Michigan; and ‡Cancer Prognostics and Health Outcomes Unit, University of Montréal Health Center, Montreal, Canada INTRODUCTION: Reliance upon fluoroscopy within urol-
ogy is increasing, with urologists key in determining radiation exposure to patients, themselves, and other healthcare personnel. However, education in occupational radiation safety is nonstandardized, often lacking. Consequently, residents and practicing urologists risk overexposure. We assessed occupational radiation safety attitudes and practices of training urologists. METHODS: A confidential, anonymous, internet-based sur-
vey on workplace radiation safety practices was distributed to residents and fellows via program directors identified from the American College of Graduate Medical Education and the American Osteopathic Association. Items explored included sources of education on occupational radiation exposure, knowledge of occupational dose limits, exposure frequency, and protective item utilization. Investigators were blinded to responses. RESULTS: Overall, 165 trainees responded, almost all of
whom reported at least weekly workplace radiation exposure. Compliance with body and thyroid shields was high at 99% and 73%, respectively. Almost no one used lead-lined glasses and gloves; three-quarters cited lack of availability. The principle of keeping radiation doses As Low As Reasonably Achievable (ALARA) was widely practiced (88%). However, 70% of respondents never used dosimeters, while 56% never had one issued. Only 53% felt adequately trained in radiation safety; this number was 30% among those pregnant during training. Fewer than half (46%) correctly identified the maximum acceptable annual physician exposure. Departmental education in radiation safety improved knowledge, protective practi-
Correspondence: Inquiries to Ariella Friedman, MD, Vattikuti Urology Institute, Henry Ford Health System, 2799 W. Grand Blvd., Detroit, MI 48202; fax: ⫹1-313 916 2956; e-mail: [email protected]
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ces, monitoring, and satisfaction with education in radiation exposure. CONCLUSIONS: Our findings show that protective equipment usage and occupational radiation monitoring for the training urologist are insufficient. Despite frequent exposure, resident education in radiation safety was found lacking. Efforts should be made to address these deficiencies on a local and national level. (J Surg 70:224-231. © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: radiation equipment and supplies, education,
medical, graduate, occupational health, pregnancy COMPETENCIES: Medical Knowledge, Practice-Based Learning and Improvement, Systems-Based Practice
INTRODUCTION Endourologic procedures and concomitant utilization of fluoroscopy comprise a substantial portion of modern urological practice. Urologists play a key role in controlling exposure of themselves, other personnel, and their patients to ionizing radiation. Ionizing radiation contributes to DNA and tissue damage, leading to increased risk of malignancy,1 cataract formation,2 congenital anomalies,3 and other maladies. However, despite frequent exposure to ionizing radiation, education in occupational radiation safety is nonstandardized in urology training programs and may be lacking. As a result, we hypothesize that trainees and practicing urologists might be at risk for overexposure. Moreover, as greater percentages of urology trainees are female, pregnancy during training is becoming more common, and the unique issues that pregnant women face regarding radiation safety within urology have been largely uncharacterized. Based on these considerations, the aim of our study was to assess knowledge and practice patterns regarding
Journal of Surgical Education • © 2012 Association of Program Directors in Surgery 1931-7204/$30.00 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2012.10.002
occupational radiation exposure among current urology trainees in the United States.
MATERIALS AND METHODS Survey Design A 10-question survey was created on http://SurveyMonkey. com (available at: https://www.surveymonkey.com/s/ Z2KF78Y), which asked about level of training, sources of education regarding occupational radiation exposure, impression of adequate training in radiation safety, frequency of radiation exposure, and knowledge of the occupational radiation dose limits among health-care employees. Subjects were also asked about the use of common protective items (i.e., body and thyroid lead, lead-lined gloves, and lead-lined goggles) or practices in radiologic usage [i.e., dosimeter, application of the As Low As Reasonably Achievable (ALARA) principle] and the reasoning behind nonuniversal use, if applicable. All aforementioned questions were mandatory response questions. Two questions were nonmandatory and pertained to practices and satisfaction of residents when pregnant. Questions allowed multiple answer choices when appropriate. The questions included in the survey were designed to ask broadly on a variety of aspects of radiation safety, while keeping the survey brief, to maintain as high a response rate as possible. Questions were designed with the input of residents and fellows, from both domestic and foreign residency training programs, and were agreed upon by all authors. Distribution: e-mail addresses of all urology residency program directors and coordinators nationwide were obtained from the American College of Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) urology residency programs web sites.4,5 Program directors and coordinators from 122 ACGME and 10 AOA programs were asked to forward e-mails with instructions and survey links to their residents and fellows on 2 separate occasions over a 3-week period in December 2011 and January 2012. Subjects were given 12 weeks to respond to the survey. Trainees were informed in the body of the e-mail and on the survey page that all answers were anonymous and would not be relayed to their program directors or others. The study also did not ask for any identifying information, and so, investigators were blinded to respondent identities. Participant responses were accrued through the SurveyMonkey web site and were only accessible to the investigators. Statistical Analysis All tests were 2-sided, with statistical significance set at p ⬍ 0.05. Analyses were performed with the statistical tools provided by SurveyMonkey and the R statistical package (the R Foundation for Statistical Computing, ver. 2.14.1).
RESULTS Overall, 165 trainees responded. Table 1 provides details on respondent demographics, frequency of radiation exposure and sources of education on radiation safety. Residents from all years of training and fellows were broadly represented. More than half reported radiation exposure 2-3 days per week (55%), with 98% of respondents reporting at least weekly exposure. The most common education source on radiation safety was mandatory Graduate Medical Education Training (55%). The combined total receiving education through their Urology department was 30% (50): 19% (31) and 8.5% (14) received mandatory training or materials from their Urology departments, respectively, and 10% (17) had a grand rounds presentation by a member of the department. Only 88 (53%) of trainees felt adequately trained in
TABLE 1. Respondent Demographics. Respondents Allowed to Choose More Than One Answer Number (Percent of Total N 165) Level of training Pre-urology/general surgery internship Second year Urology Resident Third year Urology Resident Fourth year Urology Resident Fifth year Urology Resident Completed residency/Fellow Research Fellow Frequency of occupational radiation exposure Once/mo or less Once/wk Two to 3 d/wk Four or more d/wk Other Source of education on occupational radiation safety* Mandatory Internet training modules through GME Discussion with faculty Discussion with coresidents Training through Urology Department Mandatory training through Urology Department Distributed material through Urology Department Grand rounds lecture by member of Urology Department Scholarly articles Grand rounds lecture by someone with training in radiation and/or radiation safety Internet (general) Other (fluoroscopy certifying examination, textbooks, discussion with hospital radiation specialist or technician, in-service questions, journal club, AUA update, none)
10 (6.1%) 25 (15%) 39 (24%) 24 (15%) 28 (17%) 19 (12%) 19 (12%) 1 (0.6%) 2 (1.2%) 32 (19%) 90 (55%) 39 (24%) 2 (1.2%) 90 (55%) 68 (41%) 62 (38%) 50 (30%) 31 (19%) 14 (8.5%) 17 (10%) 33 (20%) 30 (18%) 24 (15%) 14 (8.5%)
*Respondents allowed to choose more than one answer.
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radiation safety (Figure 1). There was no significant difference in this sentiment between different levels of training (p ⫽ 0.31), nor any trend towards improvement as training advanced. While 163 (99%) reported near-perfect compliance with body shields, 120 (73%) similarly utilized thyroid shields (96% reported some degree of thyroid shield utilization, but 24% used them inconsistently). Few (22 or 13%) used lead-lined glasses, and almost no one (2 or 1.2%) used lead-lined gloves (Figure 2a); three-quarters (73% and 78%, respectively) cited lack of availability (Figure 2b). One hundred forty-five (88%) and 152 (92%) practiced principles of ALARA and increasing radiation source distance, respectively, although to varying degrees. Alarmingly, 70% (115) never used dosimeters; 56% (92) were never issued one (Figure 3). Dosimeter usage did not trend with level of training (p ⫽ 0.53): in all years, most residents did not utilize them (57%–100%), and they were utilized all the time by no greater than 17% of any level trainee. Only 1 firstyear resident always used a dosimeter. Of the 165 respondents, only 15 (9.1%) wore lead aprons, thyroid shields and dosimeters all the time. All but one of these subjects additionally used at least some principles of ALARA all the time (23 utilized this combination most of the time, ⱖ 75%). Fewer than half (76, or 46%) correctly identified the occupational radiation dose limit (5 rem/y) when provided with multiple-choice prompting (Figure 4), although this number improved as training advanced (p ⬍ 0.01), with 34% of juniorlevel residents and 57% of senior-level residents and fellows answering this question correctly. The 50 trainees that received education in radiation safety by their urology departments had higher compliance with protective equipment, dosimeters, and principles of ALARA; greater
likelihood of identifying the upper exposure limit for annual radiation; and higher rates of satisfaction with their education in radiation safety (Table 2). Only 30% of those in training while pregnant (3 of 10) were satisfied with their degree of exposure.
DISCUSSION Exposure of both patients and practitioners to ionizing radiation during endourologic procedures is becoming more commonplace.6 Urologists play a key role in controlling exposure of both themselves and their patients to ionizing radiation. Multiple population-based studies have firmly established the link between environmental radiation exposure and cancer incidence and mortality.1 Specifically, patients1 and medical workers,7,8 with high cumulative radiation exposure demonstrate increased rates of multiple hematologic and solid malignancies. Moreover, exposure to ionizing radiation is also associated with adverse skin reactions,9 cataract formation, aplastic anemia, and sterility.2 In utero x-ray exposure may cause organ malformation, mental impairment,10 and a small but consistently increased incidence of and mortality from pediatric leukemias.1 Overall, the risk of malignancy increases with increased exposure, with no lower limit of ionizing radiation below which one is known to experience no harmful effects. It is disconcerting that most practitioners are unaware of the levels of radiation to which they expose themselves and their patients.11 As such, between 71% and 97% underestimate the radiation exposure received by patients for common diagnostic procedures.12 In many instances of fluoroscopic-induced injuries, the procedures are performed by physicians with little training in radiation toxicity or ways to reduce dosage.13 Based on these considerations, we performed an internet-based survey
FIGURE 1. Impression of adequate training in radiation safety among urology trainees. 226
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FIGURE 2. Utilization frequency (a) and reasons for imperfect compliance (b) of common radio-protective equipment and practices. Data tables below each figure provide percentages and response totals. Most common response for each category is highlighted in bold.
to assess knowledge and practice patterns among current urology trainees regarding occupational radiation exposure. Despite frequent radiation exposure, our study identified important gaps in knowledge and practice of radiation safety among urology trainees. We found satisfactory compliance with lead-lined body and thyroid shields, fair (albeit inconsis-
tent) usage of ALARA principles, minimal compliance with the consistent combination of all 3, and negligible usage of leadlined glasses and gloves, which in most cases was due to unavailability. Dosimeters were overwhelmingly undersupplied for and underutilized by most trainees, fewer than half correctly identified the maximum acceptable annual physician exposure dosage, and little more than half felt adequately trained in ra-
FIGURE 3. Dosimeter utilization among urology trainees.
FIGURE 4. Knowledge of occupational dose limits.
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TABLE 2. Influence of Education from Urology Department on Occupational Radiation Safety Practice Patterns. Items achieving significance in bold
Impression of Adequate Training in Radiation Safety Correct Identification of Occupational Dose Limit Use of lead body shield: ⬍ 5% of ⬎ 95% of time time Use of thyroid shield: ⬍ 5% of ⬎ 95% of time time Use of dosimeter: < 5% of ⬎ 95% of time time Keeping radiation dosage ALARA: ⬍ 5% of >95% of time time
Education from Urology Department (50)
No Education from Urology Department (115)
Odds Ratio [CI], p Value
80% (40)
42% (48)
5.58 [2.55–12.25], p < 0.01
64% (32)
38% (44)
2.87 [1.44–5.71], p < 0.01
2% (1)
98% (49)
0% (0)
2% (1)
74% (37)
4.3% (5)
52% (26)
16% (8)
77% (89)
4% (2)
72% (36)
15.7% (18)
diation safety. Even fewer who had been pregnant while in training felt similarly. Protective equipment decreases personnel radiation exposure considerably, although literature varies on the magnitude of protection. Chest and pelvic shields protect the gonads and 80% of active marrow, and they stop through transmission of 90%-99.5% of scatter radiation, depending on thickness.14,15 Thyroid shields decrease exposure by up to 100-fold, commensurate with near-background levels.15 Lead-lined glasses reduce frontal ocular exposure by up to 10-fold16 and are effective in preventing cataracts.17 Efficacy of lead-lined gloves varies widely by brand, reducing exposure by 7%–50%18 (and their benefits may be outweighed by concerns of decreased sterility and dexterity, increased expense, and the creation of an overestimation of the degree of protection). However, while the degree of protection varies among the differing pieces of protective equipment, usage of protective equipment is justified as contributing to efforts of ALARA, and availability to those desiring achievement of that goal is warranted. Compliance with chest and pelvic shields among endourologists is generally high, at 97%, similar to the 99% found among trainees in this study. While 96% of trainees in our study reported some degree of thyroid shield utilization, 24% used them inconsistently. This is better, though, than reported rates of 46%.19 However, utilization of other equipment in general is much less commonplace, with only 26%–34%, 17%–23%, and 10%–33% reporting use of dosimeters, lead-impregnated glasses, and lead-lined gloves, respectively.19,20 Utilization to any degree among trainees in our study was similar or lower, at 30%, 13%, and 1.2%, respectively. Of those, 49%, 77%, 228
99% (114)
7.00 [0.28–174.84], p ⫽ 0.24
0.43 [0.03–7.01], p ⫽ 0.55
72% (83)
0.45 [0.05–3.95], p ⫽ 0.47
1.10 [0.52–2.33], p ⫽ 0.81
7.0% (8)
0.32 [0.16–0.64], p < 0.01
2.55 [0.90–7.23], p ⫽ 0.08
49% (56)
0.23 [0.05–1.01], p ⫽ 0.05
2.71 [1.32–5.55], p < 0.01
and 79% cited lack of availability in their reasoning for underutilization. Moreover, with greater numbers of female trainees, pregnancy during urology training is increasingly common. Thirtynine per cent of women urologists have their first child while in training (more have additional pregnancies and children during this time).21 While pregnant personnel have lower maximal limits of whole-body radiation exposure, fetal doses can typically remain within recommended limits without a shift in occupational responsibilities or even the need for pregnancy disclosure.22 Of the 165 respondents, 10 were identifiable as pregnant while in training. Of these, not a single respondent reported that her dosimeter had been checked within the past month. Alarmingly, 40% had never been issued dosimeters. Among these 10 respondents, 2 did not perform cases involving radiation; 2 avoided such cases when possible; 2 had discussions with program directors about minimizing involvement in cases utilizing radiation; and 4 took extra precautions, including the out-of-pocket purchase of a maternity lead apron (1) and use of 2 lead aprons/“double lead”(3). Only 3 women were satisfied with their level of exposure during pregnancy, one of whom actually performed cases involving radiation. Further, only 30% felt adequately trained in occupational radiation safety. These findings emphasize that greater efforts should be made to provide proper support in a standardized fashion to pregnant women, who can both safely and legally utilize fluoroscopy. Our study identified a substantial educational barrier contributing to suboptimal protective practices. When stratifying by education source, education by one’s urology department had the biggest impact on many attitudes and practice patterns.
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The 50 trainees that received such education had higher compliance with protective equipment, dosimeters, and principles of ALARA; greater knowledge of recommended exposure limits; and higher satisfaction rates with radiation safety education. Among those with perfect compliance with lead aprons, dosimeters, and thyroid shields, 8/15 had some mandatory training by their urology departments. While this finding was significant by only a small margin, the number with perfect compliance was small at 15. One can hypothesize that with larger numbers, an even greater degree of significance may have been achieved. Indeed, previous studies have shown that physicians receiving formal education in ionizing radiation have greater awareness of radiation dosages and risks.23 Even brief educational courses improve knowledge of regulations and of ALARA principles and reduce patient exposure.24,25 As most physician exposure is due to patient scatter, efforts that lead to improved practice of ALARA principles may, in turn, contribute to decreased practitioner exposure. It is common practice for radiology trainees to receive formal education in radiation safety. Some specialty groups (i.e., for cardiologists and interventional cardiologists), have published tutorials for member physicians,26 and some specialists, such as Interventional radiologists and Interventional cardiologists,27 must pass examinations that include testing on physics and radiation safety. However, outside the fields of radiology and cardiology, even among those practitioners ordering studies that involve radiation and among those tasked with administering radiation during procedural interventions, radiation safety is relatively untaught. Regulatory bodies are beginning to make recommendations and policies on physician certification, but requirements are not uniform. The Food and Drug Administration recommends that all physicians performing fluoroscopy receive education, so that they may assess risks, benefits, and exposure reduction variables on a case-by-case basis.28 The ACGME further states that residents in Urology must demonstrate knowledge of radiation safety.29 In its certification manual, the American Board of Urology lists urological imaging and interventional radiology as part of the material included on examination for board certification.30 However, most urologists using fluoroscopy are not required to complete any certification or licensure requirements. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) leaves all certification requirements up to individual hospitals. At the time of this publication, only 2 states (California and Colorado) require physician licensure for operating fluoroscopy. In California, for example, at least one certified physician must be present when fluoroscopy is being utilized. While many residents obtain this licensure by passing a state-administered examination in anticipation of future practice, it is not uniformly required. Thirty-six states have laws requiring fluoroscopy licensure but exempt physicians from these laws, and twelve states do not license any personnel for fluoroscopy usage.31
Radiation safety education and practices within Urology are relatively new concerns; while excellent studies and reviews are emerging, no guidelines exist for radiation safety training within urology. As a result, urologists’ education in occupational radiation safety is nonstandardized and often lacking, and compliance with radiation safety regulations is markedly inadequate. It is unclear whether improved practices among those receiving radiation safety education represents the direct effects of education or the impact of being within a departmental culture that prioritizes radiation safety. However, in order to accomplish both goals, we recommend that Urology residency training programs assume an active role in educating residents about radiation safety, perhaps at the onset of fluoroscopic responsibilities, when trainees are learning efficient and judicious radiation practices. We further propose that organized bodies within urology encourage efforts in radiation safety education, including a clear definition of acceptable dose limits, availability or maternity aprons, encouragement of measures that decrease procedural radiation emission, and recommendations for consistent monitoring practices (i.e., strict utilization of dosimetry). Notably, however, it remains to be seen which method of education would be most effective in accomplishing these goals; our study was not powered to do so. Finally, open dialogue for the concerns of pregnant trainees should be encouraged, and while pregnant residents can and should partake in clinical responsibilities, the opportunity for adjustments in rotations or responsibilities should be available if desired. Our study is not without limitations. First, the response rate was relatively low. We received 165 responses, while there are roughly 1350 residents and fellows in urology nationwide. Potential reasons for our limited response rate include failure of program directors or coordinators to distribute our survey and inability to mail trainees directly. We acknowledge that greater sampling would allow even better characterization of the degree of utilization of radio-protective equipment. We also did not e-mail representatives from fellowships that did not have accompanying residency programs, although we believe this would have resulted in few additional respondents. Additionally, fellows were proportionately represented in this study. We also limited our survey size to 10 questions to maximize response rate, although this limited our ability to ask more extensively on the topic. Our study also had a relatively small number of female respondents that had been pregnant during training, although even in small numbers, we found the degree of dissatisfaction and inadequate monitoring unacceptable. Additionally, with trainees subject to varying regulations according to hospital- and geographic-specific regulations, it is possible that disproportionate response rates from regions or hospitals with regulations on fluoroscopy usage may have skewed our data. Unfortunately, we were unable to determine the geographic distribution of our respondents, as our survey did not ask for respondents’ state of origin. Finally, we conjecture an element of reporting bias: it is possible that those most disturbed by
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radiation practices within their institutions would be most amenable to completing a survey about these issues. While limited by these considerations, our study does characterize the general state of occupational radiation safety among residents and fellows within urology in the United States and highlights the need for reform. It is vital that all urologists recommending studies that utilize ionizing radiation or performing procedures involving fluoroscopic equipment not only be knowledgeable about radiation safety but also assume responsibility in educating future colleagues on this important topic.
CONCLUSIONS
7. Yoshinaga S, Mabuchi K, Sigurdson AJ, et al. Cancer risks
among radiologists and radiologic technologists: review of epidemiologic studies. Radiology. 2004;233:313-321. 8. Zielinski JM, Garner MJ, Brand PR, et al. Health out-
comes of low-dose ionizing radiation exposure among medical workers: a cohort study of the Canadian national dose registry of radiation workers. Int J Occup Environ Health. 2009;22:149-156. 9. Koenig TR, Wolff D, Mettler FA et al. Skin injuries from
fluoroscopically guided procedures: part 1, Characteristics of radiation injury. AJR Am J Roentgenol. 2001;177:3-11. 10. Streffer C, Shore R, Konermann G, et al. Biological effects
Despite frequent exposure, urology resident education in radiation safety is inadequate, protective equipment is underutilized and often absent, and monitoring practices are insufficient. Equipment to minimize radiation exposure should be made more available to practicing residents and fellows if requested, and its use should be encouraged. Education in radiation safety improves radiation safety knowledge and practices among trainees. Radiation safety for urology residents and fellows should be a mandatory component of trainee education; training programs should assume responsibility in radiation safety teaching, and organized bodies within urology are urged to encourage radiation safety education as well, with provisions additionally encouraged for pregnant trainees.
after prenatal irradiation (embryo and fetus): a report of the International Commission on Radiological protection. Ann ICRP 2003;33:5-20. 11. Shiralkar S, Rennie A, Snow M, et al. Doctors’ knowledge
of radiation exposure: questionnaire study. BMJ. 2003; 327: 371-372. 12. Arslanog˘lu A, Bilgin S, Kubah Z, et al. Doctors’ and in-
tern doctors’ knowledge about patients’ ionizing radiation exposure doses during common radiological examinations. Diagn Interv Radiol. 2007;13:53-55. 13. Mettler FA, Koenig TR, Wagner LK, et al. Radiation
injuries after fluoroscopic procedures. Semin Ultrasound CT MR. 2002;23: 428-442. 14. Lewis WJ, Moore RJ, Balter S. Review of radiation safety
ACKNOWLEDGMENTS The authors have no conflicts of interest to report relative to the preparation or publication of this study.
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Radiation Safety Knowledge and Practices Among Urology Residents and Fellows: Results of a Nationwide Survey Ariella A. Friedman, MD,* Khurshid R. Ghani, MD,* James O. Peabody, MD,* Alan Jackson, MS,† Quoc-Dien Trinh, MD,*‡ and Jack S. Elder, MD* *Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan; †Department of Radiology, Henry Ford Health System, Detroit, Michigan; and ‡Cancer Prognostics and Health Outcomes Unit, University of Montréal Health Center, Montreal, Canada INTRODUCTION: Reliance upon fluoroscopy within urol-
ogy is increasing, with urologists key in determining radiation exposure to patients, themselves, and other healthcare personnel. However, education in occupational radiation safety is nonstandardized, often lacking. Consequently, residents and practicing urologists risk overexposure. We assessed occupational radiation safety attitudes and practices of training urologists. METHODS: A confidential, anonymous, internet-based sur-
vey on workplace radiation safety practices was distributed to residents and fellows via program directors identified from the American College of Graduate Medical Education and the American Osteopathic Association. Items explored included sources of education on occupational radiation exposure, knowledge of occupational dose limits, exposure frequency, and protective item utilization. Investigators were blinded to responses. RESULTS: Overall, 165 trainees responded, almost all of
whom reported at least weekly workplace radiation exposure. Compliance with body and thyroid shields was high at 99% and 73%, respectively. Almost no one used lead-lined glasses and gloves; three-quarters cited lack of availability. The principle of keeping radiation doses As Low As Reasonably Achievable (ALARA) was widely practiced (88%). However, 70% of respondents never used dosimeters, while 56% never had one issued. Only 53% felt adequately trained in radiation safety; this number was 30% among those pregnant during training. Fewer than half (46%) correctly identified the maximum acceptable annual physician exposure. Departmental education in radiation safety improved knowledge, protective practi-
Correspondence: Inquiries to Ariella Friedman, MD, Vattikuti Urology Institute, Henry Ford Health System, 2799 W. Grand Blvd., Detroit, MI 48202; fax: ⫹1-313 916 2956; e-mail: [email protected]
224
ces, monitoring, and satisfaction with education in radiation exposure. CONCLUSIONS: Our findings show that protective equipment usage and occupational radiation monitoring for the training urologist are insufficient. Despite frequent exposure, resident education in radiation safety was found lacking. Efforts should be made to address these deficiencies on a local and national level. (J Surg 70:224-231. © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: radiation equipment and supplies, education,
medical, graduate, occupational health, pregnancy COMPETENCIES: Medical Knowledge, Practice-Based Learning and Improvement, Systems-Based Practice
INTRODUCTION Endourologic procedures and concomitant utilization of fluoroscopy comprise a substantial portion of modern urological practice. Urologists play a key role in controlling exposure of themselves, other personnel, and their patients to ionizing radiation. Ionizing radiation contributes to DNA and tissue damage, leading to increased risk of malignancy,1 cataract formation,2 congenital anomalies,3 and other maladies. However, despite frequent exposure to ionizing radiation, education in occupational radiation safety is nonstandardized in urology training programs and may be lacking. As a result, we hypothesize that trainees and practicing urologists might be at risk for overexposure. Moreover, as greater percentages of urology trainees are female, pregnancy during training is becoming more common, and the unique issues that pregnant women face regarding radiation safety within urology have been largely uncharacterized. Based on these considerations, the aim of our study was to assess knowledge and practice patterns regarding
Journal of Surgical Education • © 2012 Association of Program Directors in Surgery 1931-7204/$30.00 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2012.10.002
occupational radiation exposure among current urology trainees in the United States.
MATERIALS AND METHODS Survey Design A 10-question survey was created on http://SurveyMonkey. com (available at: https://www.surveymonkey.com/s/ Z2KF78Y), which asked about level of training, sources of education regarding occupational radiation exposure, impression of adequate training in radiation safety, frequency of radiation exposure, and knowledge of the occupational radiation dose limits among health-care employees. Subjects were also asked about the use of common protective items (i.e., body and thyroid lead, lead-lined gloves, and lead-lined goggles) or practices in radiologic usage [i.e., dosimeter, application of the As Low As Reasonably Achievable (ALARA) principle] and the reasoning behind nonuniversal use, if applicable. All aforementioned questions were mandatory response questions. Two questions were nonmandatory and pertained to practices and satisfaction of residents when pregnant. Questions allowed multiple answer choices when appropriate. The questions included in the survey were designed to ask broadly on a variety of aspects of radiation safety, while keeping the survey brief, to maintain as high a response rate as possible. Questions were designed with the input of residents and fellows, from both domestic and foreign residency training programs, and were agreed upon by all authors. Distribution: e-mail addresses of all urology residency program directors and coordinators nationwide were obtained from the American College of Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) urology residency programs web sites.4,5 Program directors and coordinators from 122 ACGME and 10 AOA programs were asked to forward e-mails with instructions and survey links to their residents and fellows on 2 separate occasions over a 3-week period in December 2011 and January 2012. Subjects were given 12 weeks to respond to the survey. Trainees were informed in the body of the e-mail and on the survey page that all answers were anonymous and would not be relayed to their program directors or others. The study also did not ask for any identifying information, and so, investigators were blinded to respondent identities. Participant responses were accrued through the SurveyMonkey web site and were only accessible to the investigators. Statistical Analysis All tests were 2-sided, with statistical significance set at p ⬍ 0.05. Analyses were performed with the statistical tools provided by SurveyMonkey and the R statistical package (the R Foundation for Statistical Computing, ver. 2.14.1).
RESULTS Overall, 165 trainees responded. Table 1 provides details on respondent demographics, frequency of radiation exposure and sources of education on radiation safety. Residents from all years of training and fellows were broadly represented. More than half reported radiation exposure 2-3 days per week (55%), with 98% of respondents reporting at least weekly exposure. The most common education source on radiation safety was mandatory Graduate Medical Education Training (55%). The combined total receiving education through their Urology department was 30% (50): 19% (31) and 8.5% (14) received mandatory training or materials from their Urology departments, respectively, and 10% (17) had a grand rounds presentation by a member of the department. Only 88 (53%) of trainees felt adequately trained in
TABLE 1. Respondent Demographics. Respondents Allowed to Choose More Than One Answer Number (Percent of Total N 165) Level of training Pre-urology/general surgery internship Second year Urology Resident Third year Urology Resident Fourth year Urology Resident Fifth year Urology Resident Completed residency/Fellow Research Fellow Frequency of occupational radiation exposure Once/mo or less Once/wk Two to 3 d/wk Four or more d/wk Other Source of education on occupational radiation safety* Mandatory Internet training modules through GME Discussion with faculty Discussion with coresidents Training through Urology Department Mandatory training through Urology Department Distributed material through Urology Department Grand rounds lecture by member of Urology Department Scholarly articles Grand rounds lecture by someone with training in radiation and/or radiation safety Internet (general) Other (fluoroscopy certifying examination, textbooks, discussion with hospital radiation specialist or technician, in-service questions, journal club, AUA update, none)
10 (6.1%) 25 (15%) 39 (24%) 24 (15%) 28 (17%) 19 (12%) 19 (12%) 1 (0.6%) 2 (1.2%) 32 (19%) 90 (55%) 39 (24%) 2 (1.2%) 90 (55%) 68 (41%) 62 (38%) 50 (30%) 31 (19%) 14 (8.5%) 17 (10%) 33 (20%) 30 (18%) 24 (15%) 14 (8.5%)
*Respondents allowed to choose more than one answer.
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radiation safety (Figure 1). There was no significant difference in this sentiment between different levels of training (p ⫽ 0.31), nor any trend towards improvement as training advanced. While 163 (99%) reported near-perfect compliance with body shields, 120 (73%) similarly utilized thyroid shields (96% reported some degree of thyroid shield utilization, but 24% used them inconsistently). Few (22 or 13%) used lead-lined glasses, and almost no one (2 or 1.2%) used lead-lined gloves (Figure 2a); three-quarters (73% and 78%, respectively) cited lack of availability (Figure 2b). One hundred forty-five (88%) and 152 (92%) practiced principles of ALARA and increasing radiation source distance, respectively, although to varying degrees. Alarmingly, 70% (115) never used dosimeters; 56% (92) were never issued one (Figure 3). Dosimeter usage did not trend with level of training (p ⫽ 0.53): in all years, most residents did not utilize them (57%–100%), and they were utilized all the time by no greater than 17% of any level trainee. Only 1 firstyear resident always used a dosimeter. Of the 165 respondents, only 15 (9.1%) wore lead aprons, thyroid shields and dosimeters all the time. All but one of these subjects additionally used at least some principles of ALARA all the time (23 utilized this combination most of the time, ⱖ 75%). Fewer than half (76, or 46%) correctly identified the occupational radiation dose limit (5 rem/y) when provided with multiple-choice prompting (Figure 4), although this number improved as training advanced (p ⬍ 0.01), with 34% of juniorlevel residents and 57% of senior-level residents and fellows answering this question correctly. The 50 trainees that received education in radiation safety by their urology departments had higher compliance with protective equipment, dosimeters, and principles of ALARA; greater
likelihood of identifying the upper exposure limit for annual radiation; and higher rates of satisfaction with their education in radiation safety (Table 2). Only 30% of those in training while pregnant (3 of 10) were satisfied with their degree of exposure.
DISCUSSION Exposure of both patients and practitioners to ionizing radiation during endourologic procedures is becoming more commonplace.6 Urologists play a key role in controlling exposure of both themselves and their patients to ionizing radiation. Multiple population-based studies have firmly established the link between environmental radiation exposure and cancer incidence and mortality.1 Specifically, patients1 and medical workers,7,8 with high cumulative radiation exposure demonstrate increased rates of multiple hematologic and solid malignancies. Moreover, exposure to ionizing radiation is also associated with adverse skin reactions,9 cataract formation, aplastic anemia, and sterility.2 In utero x-ray exposure may cause organ malformation, mental impairment,10 and a small but consistently increased incidence of and mortality from pediatric leukemias.1 Overall, the risk of malignancy increases with increased exposure, with no lower limit of ionizing radiation below which one is known to experience no harmful effects. It is disconcerting that most practitioners are unaware of the levels of radiation to which they expose themselves and their patients.11 As such, between 71% and 97% underestimate the radiation exposure received by patients for common diagnostic procedures.12 In many instances of fluoroscopic-induced injuries, the procedures are performed by physicians with little training in radiation toxicity or ways to reduce dosage.13 Based on these considerations, we performed an internet-based survey
FIGURE 1. Impression of adequate training in radiation safety among urology trainees. 226
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FIGURE 2. Utilization frequency (a) and reasons for imperfect compliance (b) of common radio-protective equipment and practices. Data tables below each figure provide percentages and response totals. Most common response for each category is highlighted in bold.
to assess knowledge and practice patterns among current urology trainees regarding occupational radiation exposure. Despite frequent radiation exposure, our study identified important gaps in knowledge and practice of radiation safety among urology trainees. We found satisfactory compliance with lead-lined body and thyroid shields, fair (albeit inconsis-
tent) usage of ALARA principles, minimal compliance with the consistent combination of all 3, and negligible usage of leadlined glasses and gloves, which in most cases was due to unavailability. Dosimeters were overwhelmingly undersupplied for and underutilized by most trainees, fewer than half correctly identified the maximum acceptable annual physician exposure dosage, and little more than half felt adequately trained in ra-
FIGURE 3. Dosimeter utilization among urology trainees.
FIGURE 4. Knowledge of occupational dose limits.
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TABLE 2. Influence of Education from Urology Department on Occupational Radiation Safety Practice Patterns. Items achieving significance in bold
Impression of Adequate Training in Radiation Safety Correct Identification of Occupational Dose Limit Use of lead body shield: ⬍ 5% of ⬎ 95% of time time Use of thyroid shield: ⬍ 5% of ⬎ 95% of time time Use of dosimeter: < 5% of ⬎ 95% of time time Keeping radiation dosage ALARA: ⬍ 5% of >95% of time time
Education from Urology Department (50)
No Education from Urology Department (115)
Odds Ratio [CI], p Value
80% (40)
42% (48)
5.58 [2.55–12.25], p < 0.01
64% (32)
38% (44)
2.87 [1.44–5.71], p < 0.01
2% (1)
98% (49)
0% (0)
2% (1)
74% (37)
4.3% (5)
52% (26)
16% (8)
77% (89)
4% (2)
72% (36)
15.7% (18)
diation safety. Even fewer who had been pregnant while in training felt similarly. Protective equipment decreases personnel radiation exposure considerably, although literature varies on the magnitude of protection. Chest and pelvic shields protect the gonads and 80% of active marrow, and they stop through transmission of 90%-99.5% of scatter radiation, depending on thickness.14,15 Thyroid shields decrease exposure by up to 100-fold, commensurate with near-background levels.15 Lead-lined glasses reduce frontal ocular exposure by up to 10-fold16 and are effective in preventing cataracts.17 Efficacy of lead-lined gloves varies widely by brand, reducing exposure by 7%–50%18 (and their benefits may be outweighed by concerns of decreased sterility and dexterity, increased expense, and the creation of an overestimation of the degree of protection). However, while the degree of protection varies among the differing pieces of protective equipment, usage of protective equipment is justified as contributing to efforts of ALARA, and availability to those desiring achievement of that goal is warranted. Compliance with chest and pelvic shields among endourologists is generally high, at 97%, similar to the 99% found among trainees in this study. While 96% of trainees in our study reported some degree of thyroid shield utilization, 24% used them inconsistently. This is better, though, than reported rates of 46%.19 However, utilization of other equipment in general is much less commonplace, with only 26%–34%, 17%–23%, and 10%–33% reporting use of dosimeters, lead-impregnated glasses, and lead-lined gloves, respectively.19,20 Utilization to any degree among trainees in our study was similar or lower, at 30%, 13%, and 1.2%, respectively. Of those, 49%, 77%, 228
99% (114)
7.00 [0.28–174.84], p ⫽ 0.24
0.43 [0.03–7.01], p ⫽ 0.55
72% (83)
0.45 [0.05–3.95], p ⫽ 0.47
1.10 [0.52–2.33], p ⫽ 0.81
7.0% (8)
0.32 [0.16–0.64], p < 0.01
2.55 [0.90–7.23], p ⫽ 0.08
49% (56)
0.23 [0.05–1.01], p ⫽ 0.05
2.71 [1.32–5.55], p < 0.01
and 79% cited lack of availability in their reasoning for underutilization. Moreover, with greater numbers of female trainees, pregnancy during urology training is increasingly common. Thirtynine per cent of women urologists have their first child while in training (more have additional pregnancies and children during this time).21 While pregnant personnel have lower maximal limits of whole-body radiation exposure, fetal doses can typically remain within recommended limits without a shift in occupational responsibilities or even the need for pregnancy disclosure.22 Of the 165 respondents, 10 were identifiable as pregnant while in training. Of these, not a single respondent reported that her dosimeter had been checked within the past month. Alarmingly, 40% had never been issued dosimeters. Among these 10 respondents, 2 did not perform cases involving radiation; 2 avoided such cases when possible; 2 had discussions with program directors about minimizing involvement in cases utilizing radiation; and 4 took extra precautions, including the out-of-pocket purchase of a maternity lead apron (1) and use of 2 lead aprons/“double lead”(3). Only 3 women were satisfied with their level of exposure during pregnancy, one of whom actually performed cases involving radiation. Further, only 30% felt adequately trained in occupational radiation safety. These findings emphasize that greater efforts should be made to provide proper support in a standardized fashion to pregnant women, who can both safely and legally utilize fluoroscopy. Our study identified a substantial educational barrier contributing to suboptimal protective practices. When stratifying by education source, education by one’s urology department had the biggest impact on many attitudes and practice patterns.
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The 50 trainees that received such education had higher compliance with protective equipment, dosimeters, and principles of ALARA; greater knowledge of recommended exposure limits; and higher satisfaction rates with radiation safety education. Among those with perfect compliance with lead aprons, dosimeters, and thyroid shields, 8/15 had some mandatory training by their urology departments. While this finding was significant by only a small margin, the number with perfect compliance was small at 15. One can hypothesize that with larger numbers, an even greater degree of significance may have been achieved. Indeed, previous studies have shown that physicians receiving formal education in ionizing radiation have greater awareness of radiation dosages and risks.23 Even brief educational courses improve knowledge of regulations and of ALARA principles and reduce patient exposure.24,25 As most physician exposure is due to patient scatter, efforts that lead to improved practice of ALARA principles may, in turn, contribute to decreased practitioner exposure. It is common practice for radiology trainees to receive formal education in radiation safety. Some specialty groups (i.e., for cardiologists and interventional cardiologists), have published tutorials for member physicians,26 and some specialists, such as Interventional radiologists and Interventional cardiologists,27 must pass examinations that include testing on physics and radiation safety. However, outside the fields of radiology and cardiology, even among those practitioners ordering studies that involve radiation and among those tasked with administering radiation during procedural interventions, radiation safety is relatively untaught. Regulatory bodies are beginning to make recommendations and policies on physician certification, but requirements are not uniform. The Food and Drug Administration recommends that all physicians performing fluoroscopy receive education, so that they may assess risks, benefits, and exposure reduction variables on a case-by-case basis.28 The ACGME further states that residents in Urology must demonstrate knowledge of radiation safety.29 In its certification manual, the American Board of Urology lists urological imaging and interventional radiology as part of the material included on examination for board certification.30 However, most urologists using fluoroscopy are not required to complete any certification or licensure requirements. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) leaves all certification requirements up to individual hospitals. At the time of this publication, only 2 states (California and Colorado) require physician licensure for operating fluoroscopy. In California, for example, at least one certified physician must be present when fluoroscopy is being utilized. While many residents obtain this licensure by passing a state-administered examination in anticipation of future practice, it is not uniformly required. Thirty-six states have laws requiring fluoroscopy licensure but exempt physicians from these laws, and twelve states do not license any personnel for fluoroscopy usage.31
Radiation safety education and practices within Urology are relatively new concerns; while excellent studies and reviews are emerging, no guidelines exist for radiation safety training within urology. As a result, urologists’ education in occupational radiation safety is nonstandardized and often lacking, and compliance with radiation safety regulations is markedly inadequate. It is unclear whether improved practices among those receiving radiation safety education represents the direct effects of education or the impact of being within a departmental culture that prioritizes radiation safety. However, in order to accomplish both goals, we recommend that Urology residency training programs assume an active role in educating residents about radiation safety, perhaps at the onset of fluoroscopic responsibilities, when trainees are learning efficient and judicious radiation practices. We further propose that organized bodies within urology encourage efforts in radiation safety education, including a clear definition of acceptable dose limits, availability or maternity aprons, encouragement of measures that decrease procedural radiation emission, and recommendations for consistent monitoring practices (i.e., strict utilization of dosimetry). Notably, however, it remains to be seen which method of education would be most effective in accomplishing these goals; our study was not powered to do so. Finally, open dialogue for the concerns of pregnant trainees should be encouraged, and while pregnant residents can and should partake in clinical responsibilities, the opportunity for adjustments in rotations or responsibilities should be available if desired. Our study is not without limitations. First, the response rate was relatively low. We received 165 responses, while there are roughly 1350 residents and fellows in urology nationwide. Potential reasons for our limited response rate include failure of program directors or coordinators to distribute our survey and inability to mail trainees directly. We acknowledge that greater sampling would allow even better characterization of the degree of utilization of radio-protective equipment. We also did not e-mail representatives from fellowships that did not have accompanying residency programs, although we believe this would have resulted in few additional respondents. Additionally, fellows were proportionately represented in this study. We also limited our survey size to 10 questions to maximize response rate, although this limited our ability to ask more extensively on the topic. Our study also had a relatively small number of female respondents that had been pregnant during training, although even in small numbers, we found the degree of dissatisfaction and inadequate monitoring unacceptable. Additionally, with trainees subject to varying regulations according to hospital- and geographic-specific regulations, it is possible that disproportionate response rates from regions or hospitals with regulations on fluoroscopy usage may have skewed our data. Unfortunately, we were unable to determine the geographic distribution of our respondents, as our survey did not ask for respondents’ state of origin. Finally, we conjecture an element of reporting bias: it is possible that those most disturbed by
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radiation practices within their institutions would be most amenable to completing a survey about these issues. While limited by these considerations, our study does characterize the general state of occupational radiation safety among residents and fellows within urology in the United States and highlights the need for reform. It is vital that all urologists recommending studies that utilize ionizing radiation or performing procedures involving fluoroscopic equipment not only be knowledgeable about radiation safety but also assume responsibility in educating future colleagues on this important topic.
CONCLUSIONS
7. Yoshinaga S, Mabuchi K, Sigurdson AJ, et al. Cancer risks
among radiologists and radiologic technologists: review of epidemiologic studies. Radiology. 2004;233:313-321. 8. Zielinski JM, Garner MJ, Brand PR, et al. Health out-
comes of low-dose ionizing radiation exposure among medical workers: a cohort study of the Canadian national dose registry of radiation workers. Int J Occup Environ Health. 2009;22:149-156. 9. Koenig TR, Wolff D, Mettler FA et al. Skin injuries from
fluoroscopically guided procedures: part 1, Characteristics of radiation injury. AJR Am J Roentgenol. 2001;177:3-11. 10. Streffer C, Shore R, Konermann G, et al. Biological effects
Despite frequent exposure, urology resident education in radiation safety is inadequate, protective equipment is underutilized and often absent, and monitoring practices are insufficient. Equipment to minimize radiation exposure should be made more available to practicing residents and fellows if requested, and its use should be encouraged. Education in radiation safety improves radiation safety knowledge and practices among trainees. Radiation safety for urology residents and fellows should be a mandatory component of trainee education; training programs should assume responsibility in radiation safety teaching, and organized bodies within urology are urged to encourage radiation safety education as well, with provisions additionally encouraged for pregnant trainees.
after prenatal irradiation (embryo and fetus): a report of the International Commission on Radiological protection. Ann ICRP 2003;33:5-20. 11. Shiralkar S, Rennie A, Snow M, et al. Doctors’ knowledge
of radiation exposure: questionnaire study. BMJ. 2003; 327: 371-372. 12. Arslanog˘lu A, Bilgin S, Kubah Z, et al. Doctors’ and in-
tern doctors’ knowledge about patients’ ionizing radiation exposure doses during common radiological examinations. Diagn Interv Radiol. 2007;13:53-55. 13. Mettler FA, Koenig TR, Wagner LK, et al. Radiation
injuries after fluoroscopic procedures. Semin Ultrasound CT MR. 2002;23: 428-442. 14. Lewis WJ, Moore RJ, Balter S. Review of radiation safety
ACKNOWLEDGMENTS The authors have no conflicts of interest to report relative to the preparation or publication of this study.
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