Culture Imposed by Image Gently Carries Substantial Medical Risks

I’ve been engaged with the struggle to counter excessive fear of radiation for many years. Since I come at the battle from a perspective of the avoided benefits of nuclear energy production resulting from the imposed fear, I have been focused on that aspect of countering radiation misinformation.

My associates and I have often assumed that the practitioners of nuclear medicine were not as affected by the long-running anti-radiation efforts. It seemed from the outside that most people clearly recognized the tremendous benefits given to millions of individual humans by the use of radiation. We have often discussed how illogical it seemed to us that people readily accepted radiation doses that were hundreds to thousands of times higher for medical uses and would recoil in fear from the same doses if they happened to originate from accidental exposures because of an event at a nuclear power plant.

In the relatively recent past, I’ve learned that I was wrong assume that the nuclear medicine had escaped being affected by the increasingly negative effects of the fear campaign. Organizations are working hard to encourage an approach to the use of radiation that has limited effective medical treatment and diagnosis. There is a crying need for efforts to expose the incorrect messages focused on medical practitioners asking them to avoid using well-proven treatments and effective tools in order to limit radiation doses to essentially the equivalent of ALARA (As Low As Reasonably Achievable). As is the case in the power business, there is no established definition of the word “reasonable.”

The logical result is that some people who are naturally driven to provide the best possible service feel like they must strive to achieve a radiation dose of zero if possible. The effort to achieve a zero dose requires the imposition of other risks that are often greater than the ones that arise from using a moderate doses of radiation to achieve superior outcomes.

As part of the SARI discussion regarding Brant Ulsh’s story of how radiophobia hit home in his family, Dr. Mervyn Cohen provided a poignant response that deserves wider exposure. He has agreed to allow me to publish that response to make it more accessible for public discussion.

Dear SARI concerned friends,

I am a pediatric radiologist with great concern about what is happening. Society is frightening patients and their physicians with “CT is dangerous” rather than extolling the virtues of CT and the explaining the great risks of a missed diagnosis by not performing a needed CT scan.

I so sorry that Brant and his family had to counter a misinformed Pediatrician, in addition to all the trauma and worry of having an ill child. Thank you all so much for your e mail comments, in response to Brant’s story.

We are in a most unfortunate situation. Although most radiologists will accept that any cancer risk from CT is tiny, the Image Gently and other campaigns over the last ten years have created a new unfavorable culture.

Despite the knowledge that any CT risk is tiny in relation to normal everyday risks of living our radiology journals persist in spreading the message that CT use must be decreased. This is not rational, but it is understandable. This culture manifests in many ways in our radiology journals and is the repeated in the public media.

We’ve seen endless articles using experimental models simulating disease showing that readers can achieve an unchanged accuracy as dose is decreased; the articles fail to point out that eventually dose will be so low that disease will be missed.

We’ve seen many similar publications of CT of pathology in humans, when dose reduction is simulated by adding noise to images. Almost every article that compares modalities includes as a stated disadvantage of any imaging use x-rays “but…CT, chest x-ray, etc uses radiation”., as if this is something terrible. We seldom see statements that the best modality should be chosen to achieve an accurate diagnosis, and that this decision must be made irrespective of the use of radiation.

The American College of Radiology publishes many “Appropriateness Criteria®” with recommendations for which imaging modality to use for any specific clinical indication. Every one of the tables in these publication has a 0-4 star rating for the amount of radiation given to a patient by each imaging study. I have argued that this creates a perception that the radiation is dangerous and should strongly influence the choice of imaging modality; I am but a small voice.

I do have some comments on the appendicitis diagnosis. The choice of ultrasound as the initial imaging, rather than CT is not wrong. What is horrific and very wrong are the Pediatricians reasons for this choice i.e. not wanting to do a CT because of radiation. This resonates loudly with me. It is the prevailing culture that I describe above. At most large children’s hospitals in the USA in 2014, the management of suspected appendicitis goes like this.

  • Very certain that the child has appendicitis – go straight to surgery
  • Suspect appendicitis – do ultrasound . It is cheaper and quicker than CT. (it is not definitely wrong to do CT but consensus favors ultrasound first)
    This has three outcomes:

    • Appendix is well seen and looks normal – no appendicitis
    • Appendix is well seen and abnormal – surgery for appendicitis
    • Appendix cannot be seen (this happens for a variety of reasons such as the appendix is hidden behind something, abnormal appendix position, inexperienced technologist etc ) – perform CT scan for further evaluation.

Thus CT is used, but in a relatively small number of children with appendicitis.

Our challenge is to change the culture. At my own children’s hospital I frequently ask my Pediatrician and Pediatric Surgeons what message they are getting at their national meetings and from their journals regarding CT and radiation. The response from intelligent, wonderful people is scary. The culture I described above is dominant. Our challenge is to mount a large education campaign to change the culture – never easy.

Best wishes to all.

Mervyn

Mervyn Cohen
Pediatric Radiologist

I thank Dr. Cohen for giving permission to reprint his heartfelt, knowledge-based message. Information like the above can help people understand the widespread nature of radiophobia and the importance of spreading accurate information about radiation health effects. People, especially including medical professionals, need good information so they can make appropriate, well-reasoned decisions in what are often life-versus-death situations.

The situation has obviously gotten out of hand when busy practitioners have been inundated with incorrect information leading them to slow or stop the use of some of their most effective technology tools to find and cure disease.

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