In April of 2019, the American Association of Physicists in Medicine (AAPM) released a position statement outlining reasons for limiting the routine use of fetal and gonadal shielding in medical imaging. Recognizing that removing patient shielding from routine use is a substantial shift in existing clinical practice, the AAPM formed a committee to bring together stakeholders to discuss potential changes in the use of patient shielding. The AAPM Communicating Advances in Radiation Education for Shielding (CARES) Committee includes members from over 14 professional organizations around the globe, representing medical and health physicists, RTs and organizations that oversee educational programs for RTs, radiologists, and state regulators.
The Bulletin spoke with two members of the CARES Committee about their efforts to support the radiology profession as the use of patient shielding in radiology evolves. Rebecca Milman, PhD, associate professor and medical physicist at the University of Colorado School of Medicine, and Darcy J. Wolfman, MD, clinical associate and clinical director of US at the Johns Hopkins School of Medicine, shared their journey to develop clear, consistent communication about patient shielding that will improve patient care.
How did the ACR get involved in the CARES Committee?
WOLFMAN: As the CARES Committee was being formed, the AAPM reached out to the ACR to have radiologist representation. I was approached by some of the ACR leadership to serve in that role. I’ve been involved with allied health organizations, so it was a good fit. As a radiology community, we’re all intertwined — more so even than other specialties. And that’s where the CARES Committee was so important. We have medical physicists, radiologists, RTs, healthcare administrators, and radiology healthcare administrators, all working together.
What role does the CARES Committee play in enhancing quality and safety in radiology?
MILMAN: We felt it was important to have a space where everybody could work together to answer critical questions around shielding. What do we need to do to communicate this? What communication barriers might we face? We reached out to numerous medical imaging societies and asked them to participate in that discussion.
How did the collaborative initiative unfold?
MILMAN: Over the last couple of years, we’ve had good, open, collaborative conversations about this topic, radiation risk, and communication with patients and parents. We’ve discussed how RTs, radiologists, and physicists can work better together, rather than separately, within our own pillars and speaking only among our immediate colleagues. We haven’t always communicated effectively with people outside of our subspecialties, but the CARES Committee gave us a forum to do so.
WOLFMAN: Now, the entire spectrum of radiology is working collaboratively together to inform the community as a whole. It’s important that the message is consistent because, while everyone in radiology plays their own role, everyone needs to work together to deliver quality care to patients. And that’s where we came up with this idea of creating educational modules that weren’t just for radiologists, RTs, or medical physicists, but something with a unified message across radiology.
What are the patient shielding education modules and how were they developed?
MILLMAN: The set of six education modules were developed by the CARES Committee. The modules — hosted by the ACR, the AAPM, and the Association of Educators in Imaging and Radiologic Sciences (AEIRS) — give you the information you need to either learn about the recent changes in patient shielding for the first time or bolster the knowledge you already have.
What will people learn from these courses and how will that impact quality and safety?
WOLFMAN: One of the modules focuses on the background of how we got to this point with the new recommendations about patient shielding. There has been a longstanding belief in the radiology community that any sort of radiation causes harm, especially to the developing fetus and to the gonads, and that shielding patients is an essential component of patient safety. It was ingrained even in radiology residency. But as the AAPM pointed out, the science actually doesn’t back that up.
MILMAN: The modules begin with the historic background and establish a framework for objectively considering long-held beliefs about patient gonadal and fetal shielding. They move through what the science is and why we’re doing this — and how to communicate with patients. The last module takes a broader look at patient radiation safety, including all of the ways in which we can optimize the use of radiation during medical imaging, like proper patient positioning and collimation. There is so much we can do to ensure that we are obtaining quality images safely, so that last module is key.
What are the goals of the education modules, and how did you come together to speak with one voice?
WOLFMAN: When we first started having these conversations, it became apparent that concerns and barriers differed among subspecialties. People were also concerned about how patients and parents would react. There was a scientific basis for this practice change, but there was also a strong emotional reaction that is inherent to anything safety related. So, we had to address that aspect as well — both in terms of how to communicate with patients, parents, and caregivers and how to communicate within our own medical imaging communities. A key goal was to ensure everybody has the same information.
MILMAN: One of the things that the CARES Committee has helped with was to recognize that everybody involved wants to do what’s best for patients. It’s a lot easier to overcome those feelings when you have everybody in the same “room” (because of COVID-19, this was a virtual room). That was part of breaking down some of those silos and acknowledging that we’re all on the same team. We talked about the barriers to implementing this change in clinical practice and the importance of communicating consistently with parents or patients who are concerned. We quickly realized it would be helpful to develop educational modules so that we could use our collective expertise and experience to provide useful guidance to people involved in medical imaging.
What was the process to develop the modules?
WOLFMAN: We had collaborative discussions and worked through the topics for the modules. We divided it up so that everyone on the committee was involved. It was all very collaborative, every step of the way. And then we moved forward with getting CME and CE credits and ensuring easy access through the various specialties.
MILMAN: Everybody on the committee agreed about the value of having CE credits available through various platforms. The staffs of the ACR, the AEIRS, and the AAPM all deserve significant credit for making that happen. This is truly a multi-organizational initiative that is representative of the collaborative nature of the committee.
Who should access this training and why?
WOLFMAN: From a radiologist’s perspective, we’re not on the front lines — but in the department, the buck stops with me. If a patient, parent, or RT has a concern, I’m the one they come to for answers or information. So, it’s really important that radiologists know this training is available. Without these modules, many radiologists might have peripherally heard about the AAPM shielding statement but might not know much about it. They can use these modules to help explain to RTs, administrators, and patients what the science is, why we’re doing this, and why imaging is still very safe. Everyone needs to understand where we are in this process. We owe it to our patients to use consistent language to better engage them in their healthcare decisions.
MILMAN: The CARES Committee has been explicit in saying that if a patient wants to be shielded, it’s okay. But we also strongly believe that patients deserve to have access to accurate information that is shared via a common language, regardless of who they speak with in the healthcare community.
What’s next for the CARES Committee and the shielding education program?
MILMAN: We have another education module in the works that discusses practical implementation of shielding programs and patient communication. We’re looking for input from people who have changed their patient shielding practices, so we can learn about the challenges and successes they’ve faced and what support we may be able to provide. I’m sure unanticipated issues will arise, so we want to pull from the community’s collective experiences and try to provide the appropriate resources. We’re also getting requests for patient-facing materials and translations of FAQs into other languages. We highly encourage people to reach out to us. We’re trying to keep that dialogue open and constructive.
WOLFMAN: The CARES Committee isn’t going anywhere, and we’re still working collaboratively within the various radiology communities. This can serve as a model for the entire radiology community to demonstrate how we can better serve our patients when we collaborate.