The Risks of Medical Usage of Ionizing Radiation - Essay Example

?With reference to IR(ME)R 2000 differentiate between the roles of referrer and the practitioner in the imaging process Introduction Radiology is a diagnostic and curative field of medicine that uses different types of ionizing radiation technology in order to visualize, diagnose or treat diseases. Ionizing radiation is essential part of the radiology and at the core of almost every diagnostic procedure or treatment practiced by this field of medicine. Human body is sensitive to ionizing radiation and human tissues and organs can sustain acute or permanent damage with doses used in some medical radiation procedures. Radiation can also cause damage of the genetic material within the nucleus and increase the risk for carcinogenesis (Cardis et al. 2005). Also, there are studies that show that the negative effect of ionizing radiation is cumulative and the negative effect is additive over the years of exposure, therefore increased exposure during the lifespan of one individual can cause small but significant increase of the susceptibility for cancer (Parkin and Darby 2010). Imaging procedures are at the core of the modern medicine and often diagnosis is unable to be confirmed without some form of radiologic examination but there is a fine line between the benefit from the radiographic procedures complementary to the possible negative effects of the uncontrolled and uncritical usage of medical radiation. This is important because research shows that medical radiation exposure increased significantly in the last decades. Mettler et al. (2008) for example report 600% increase of average medical radiation exposure per capita in US in year 2006 compared to year 1982. Bell and McLaughlin (2001) conducted a study where they identified that 58% of the plain abdominal x-rays in UK were unjustified and unnecessary in year 2001. In many cases the responsibility for the process of implementation of radiographic techniques in the past was unclear which may cause legal difficulties (HSL 2000). In the light of the above mentioned risks of medical usage of ionizing radiation The ionising radiation (Medical Exposure) regulations 2000 or IR(ME)R came into legal force in may 2000 in order to implement the European guidelines for regulation of the medical radiation exposure (Zuur et al. 2000). IR(ME)R is a set of regulations that regulate the responsibilities of the medical and non-medical personal to assure the protection of the patients who undergo medical ionizing radiation exposure. IR(MER)R defines several categories of responsibility within every medical institution, defined as employer and three duty holders. Employer can be represented by a hospital, small medical office, clinic etc. Employer has the function to entitle the duty holders to implement the medical processes and defines written procedures and protocols for the use of medical equipment. The operator, as defined by IR(ME)R, is one of the three duty holders. His role is operational and is responsible for the implementation of the practical aspects of the procedures. However the operator as one of the duty holders can also have more active role in the process of practical application of ionizing radiation. Nevertheless the roles of the remaining two categories of duty holders (referrer and practitioner) are the key factors that influence the implementation of the safety procedures as defined by the IR(ME)R guidelines (IRMER-R5 2000). Roles of referrer and the practitioner in the imaging process IR(ME)R provides definitions of these two duty holders. Referrer is defined as: “… a registered medical practitioner, dental practitioner or other health professional who is entitled in accordance with the employer’s procedures to refer individuals for medical exposure to a practitioner … “. Referrer is therefore a medical professional who is requesting procedures to be conducted on the patient and should provide relevant clinical information’s in order to justify this procedure. This means that the referrer is the initiator of the use of medical radiation procedure and his legal responsibility is to provide relevant clinical information’s in order to justify his request (Litt et al. 2005). If the referrer does not provide complete and relevant clinical information’s about the need for some particular medical radiation exposure his request may be denied by the practitioner. For example the practitioner may deny a CT scan of a patient with chronic obstructive pulmonary disease if the referrer does not provide relevant information why plain chest radiograph is not a better solution. If the patient is heavy smoker, started coughing blood, started losing weight, developed sudden hoarseness and has some other symptoms that may indicate lung cancer, but the referrer did not presented these facts to the practitioner then the legal responsibility in this case is on the referrer because he didn’t provided the relevant information’s for the justification of the medical exposure (Alberg et al. 2007). The practitioner on the other hand is defined as: “ … registered medical practitioner, dental practitioner or other health professional who is entitled in accordance with the employer’s procedures to take responsibility for an individual medical exposure … ”. This means that the practitioner is directly responsible for the final approval of the procedure, evaluates the clinical relevance of the information’s provided by the referrer and evaluates if they justify the prescribed treatmen. . This is why maybe the term “justifier” is more appropriate instead of the term practitioner since its primary role is to evaluate if the procedure is justified based on the presented clinical information’s. The practitioner may demand for additional information’s regarding the procedure because the referrer is responsible to provide them. This means that the practitioner must have in mind all the positive and negative aspects of the procedure in relation to the information’s provided by the referrer. . For example if the referrer demands CT scan for diagnosis of suspicious recurrent cerebrovascular insult, the practitioner may suggest diffusion weighted MRI scan instead because the patient already had several CT scans for his condition. DWI MRI is proven to be more efficacious in detecting ischemic lesions in the brain and as effective in detecting brain haemorrhage compared to CT scan (Chung et al. 2003) (Schellinger et al. 1999). However the referrer can than provide additional information that he is suspicious of re-ictus and patients has some old CT scans that may be better compared with a new CT scan and not by DWI MRI scan. Therefore the practitioner has to account for the risk from the procedure and in the same time to evaluate if the benefit is in correlation with the risks of the amount of medical exposure (John 2005). This means that the legal responsibility of the practitioner is equal (or even greater) compared to the referrer since both the referrer and the practitioner must conduct their roles accurately and competently, other ways there may be error in the process of application of the radiological procedure. For example in the above case if the prctitioner does not approve another CT scan for the patient the diagnosis of small re-ictus will be more difficult and maybe even missed. Discussion The function of the referrer and the practitioner is connected by a mechanism of negative feedback, a mechanism that is often used in order to regulate complex processes (Raven and Johnson 1999). This conclusion can be further analyzed and it can be stated that referrer and practitioner has opposite roles and their duties are complementary or in essence conflicting. Referrer can be monitored as a duty holder that wants to maximize the use of medical exposure because this procedure will help him in the process of diagnosis or treatment of the patient. This was clearly shown by the study conducted by Litt et al. (2005) where they found that orthopaedists, podiatrists, rheumatologists and other medical professionals will tend to maximize the radiological examinations when they have the jurisdiction to do that. A study conducted by Gazelle et al. (2007) also found that when the physicians have the jurisdiction to self-refer to imaging procedures, without any monitoring the patient is up to 3.2 times more likely to be referred to imaging examination compared to the physician who can't self refer a patient to imaging examination. On the other hand the practitioner can be monitored as a duty holder that tries to minimize the application of medical exposure because eventual injury due to application of medical exposure is his professional responsibility (John 2005). This opposition between these two roles is the essence of their roles and in fact is the key factor that will lead to safer application of medical ionizing radiation exposure. As previously mentioned, both referrer and practitioner must be registered healthcare professionals and therefore their opinions are competent. But based on their defined functions as stated in IR(ME)R, their roles in the process of justification are in essence conflicting and this ensures a mechanism of negative feedback that should be the key factor in regulation of the unnecessary medical exposure. Based on the above discussion it can be stated that the responsibility of the practitioner is greater compared to the responsibility of the referrer. Practitioner is the last step before the process of implementation of the medical exposure and he has the jurisdiction to approve or cancel the procedure. This process is mainly based on his level of professional competence because the field of medical exposure is so complex that it cannot be strictly regulated by protocols at every level and every case. But this cannot be monitored as “unfair” distribution of the responsibilities between the referrer and the practitioner because IR(ME)R states that one professional can conduct the duties of both the referrer and practitioner in the same time (GUIR(MA)R 2008). This means that the function of the practitioner can be viewed with much greater simplicity than previously. The “institution” called practitioner can be simply viewed as an effort to add one additional step, one conscious step before the initiation of the procedure of medical exposure. Therefore the very existence of these procedures and the demand for signing of every document by a referrer and practitioner means that they should be aware not only by the benefits of the radiologic procedure but should be constantly aware about the negative consequences of the procedures (John 2005). This fact should also address the other concern of the implementation of IR(ME)R guidelines and that is: can IR(ME)R actually reduce the effectiveness of the diagnostic process or process of treatment using medical radiation exposure? Based on the above this should be eliminated by the fact that the referrer can insist on some medical exposure and can provide additional information’s that will justify the procedure therefore oppose the practitioner. John (2005) mentions one very interesting and confusing case that may result in serious conflict between the referrer and the practitioner. Multidetector computed tomography (MCT) is capable of producing scans of the heart arteries that compete with the procedure of selective coronary angiography (Coles et al. 2005). The dilemma is that MCT delivers much higher doses of radiation compared to coronary angiography but is a noninvasive procedure that does not impose an immediate risk to the patient. This situation may stimulate both the referrer and the practitioner to present and elaborate detail medical indications why one method is better than the other: presence of congenital malformations in the heart, claustrophobia of the patient, blood coagulation state of the patient etc. Clearly the practitioner would gladly choose the MCT because there is less immediate risk for the patient and reduces his personal involvement and risk for error. But the role of the practitioner is to reduce the level of radiation and in this case he may ask for more detail explanation why MCT is more suitable than coronary angiography. This careful balance between these two functions should ensure optimal implementation of medical exposure and eliminate cases when radiographic examination is unnecessary and not essential for the diagnosis of the condition. This mechanism of negative feedback connection between the referrer and the practitioner produces several mechanisms that result in optimal and minimal irradiation of the patient. These mechanisms regulated by IR(ME)R are called justification and optimization and are part of the Regulation 6 and 7 of the IR(ME)R guidelines. Justification is defined as a process that will define a sensitive balance between the need for irradiation, the benefit of the procedure and the negative effect that this irradiation will have on the patient. The practitioner must have in mind the intention of the procedure (as defined by the referrer) and the characteristics of the individual patient in the same time. Therefore for example in radiotherapy, the practitioner can justify the whole set of treatment fractions (as part of one predefined protocol) in one step, or can chose and justify every treatment fraction individually depending on the condition of the patient. This means that the practitioner may not refuse the demand for radiotherapy from the referrer but may increase the control over the process of irradiation and can cancel the procedure at any time if the condition of the patient is getting worse. He can also accept or refuse any additional irradiations that are outside of the protocol but are demanded by the referrer (Koutalonis and Horrocks 2011). Practitioner can also implement the principles of optimization in order to protect the patient. For example he can minimize the field of irradiation in order to maximize the focus of the irradiation on target organs and minimize the irradiation of the surrounding organs and tissues. Practitioner may also accept the demand from the referrer but suggest usage of minimal doses of irradiation that still can achieve the same effect and result as intended by the referrer (John 2005). Therefore the process of justification and optimization doesn’t have to be a rigid process of refusing and acceptance but can be complex and flexible method that can achieve maximal benefit for the patient with minimal negative effects from the irradiation. Conclussion Based on the above discussion IR(ME)R is effective method for reducing the unnecessary exposure to medical ionizing radiation and it should be fully implemented in the medical practice. This is important because some studies have shown that the IR(ME)R guidelines are not fully implemented in every referral for medical exposure (Kiu et al. 2010). This should be noted in light of the research conducted by Mettler et al. (2008) who showed that medical exposure is increasing at dramatical rate in the recent decades and has sustained tendency to increase in the future also. If we compare this with the fact that medical exposure has small but significant influence on the increased susceptibility to carcinogenesis in the exposed individuals it is clear that measures implemented in IR(ME)R are justified. IR(ME)R tries to regulate this trend of constant increase of medical exposure and incorporate mechanisms that will prevent unnecessary medical exposure, and therefore protect the patient from increased risk for carcinogenesis or other morbidity. The roles of the referrer and the practitioner, as defined in the IR(MA)R, are the key factors that ensure competent and safe application of medical radiation. In the same time IR(MA)R is incorporating the mechanisms of negative feedback that is the most effective approach in order to implement this goal. References: Alberg AJ, Ford JG, Samet JM (2007), American College of Chest Physicians. Epidemiology of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). 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