An assessment of radiation use, knowledge and concerns in trainee cardiologists in Ireland

Abstract

Objective

To evaluate knowledge, routine use and concerns of trainee cardiologists in the Republic of Ireland regarding radiation use in the cardiac catheterization laboratory.

Methods

We handed out a Radiation Questionnaire to cardiology trainees in February 2020 at the Irish Cardiac Society “Spring Meeting”. The questionnaire assessed radiation protection use amongst trainees and tested knowledge of X-ray basics.

Results

Many trainees report inadequate access to properly sized lead protection, and infrequent dosimeter usage. Over one-third of trainees report musculoskeletal issues from wearing leads, the majority of whom use correct size lead <60% of the time.

33.3% report radiation concerns will affect their decision making regarding subspeciality training, but notably 83.3% of females and only 19% of males surveyed report this, showing this is a bigger issue for females in cardiology. Less than half of trainees feel adequately educated about radiation.

Conclusion

Our assessment show deficiencies in the provision and use of personal protective equipment to trainees, highlights extra radiation concerns of female cardiology trainees, and notes gaps in knowledge in radiation use.

Advances in knowledge

Our assessment highlights deficiencies in the education of cardiology trainees regarding ionizing radiation, and suggests this area needs to be improved upon.

Background

Ionizing radiation has widespread uses in medicine as a diagnostic tool and assisting invasive interventions. Use in cardiology has expanded the role of the interventional and electrophysiological cardiologist to include more complex and prolonged patient procedures. With this comes responsibility to ensure appropriate patient and operator radiation exposure per procedure, as cumulative long-term exposure can increase risks of malignancy, fertility issues and cataracts.^1–4

Objective

To evaluate knowledge, routine use and concerns of trainee cardiologists in the Republic of Ireland regarding radiation use in the cardiac catheterization laboratory.

Methods

We handed out a Radiation Questionnaire in February 2020 at the Irish Cardiac Society “Spring Meeting” held annually in Dublin. Attendance is mandatory for trainees on the Cardiology Specialist Registrar training scheme in the Republic of Ireland, accredited through the Royal College of Physicians in Ireland.

The questionnaire was divided into two sections, the first regarding use of radiation protection and assessed background education and attitudes to X-ray among trainees, alongside use of personal protective equipment. The answers provided were reported as “always” defined as roughly >90% of the time, “usually” being “60–90% of the time, “occasionally” being 30–60% of the time, and “rarely” being <30%.

The second section tested knowledge of X-ray use in the cath lab with multiple choice answers available to chose the correct answer from.

We based the questions on the 2018 expert consensus document from JACC titled “Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for safety and effectiveness”.⁵

Results

We collected 27 completed questionnaires from trainees.

18 (66.7%) were aged 30–39 and the remainder were aged 20–29, and 21 (77.8%) were male. Training year is as represented below (Figure 1). The majority (15 of 27) work with X-ray 1–3 months of the year, 8 (29%) work with it <1 month per year, and the remainder 3–6 months.

Figure 1.

Training year of physician surveyed.

Personal protective equipent/X-ray use in the cath lab

We assessed personal protective equipment provided and worn in the cath lab, including lead and dosimeter usage, and any musculoskeletal side-effects from same. The results are summarized below.

Figure 2.

Personal protective equipment worn.

Figure 3.

Personal protective equipment usage.

Figure 4.

Musculoskeletal issues reported from lead usage.

Figure 5.

Dosimeter usage.

Only five trainees have access to Radpads, though only occasionally use them.

Regarding X-ray and table control during an angiogram, four trainees position and optimize the fluroscopy field and move the gantry during angiography, only one of whom felt they had been adequately taught how to do so. A number of trainees would prefer do to this rather then the radiographer, 9/27. Few report they always ensure X-ray exposure is optimised before contrast injection, being 5 trainees of 27, 13 of 27 say they usually do, and the remainder occasionally or rarely do.

Regarding knowing the standard frame rate in the lab, 11 of 27 report they do not know it, and 20 of 27 do not know the fluoro pulse rate used. Only 10 of 27 trainees usually or occasionally ask the radiographer to reduce the frame rate, the remainder rarely do.

Radiation education and careers

As part of the cardiology higher specialist training scheme in the Republic of Ireland, it is mandatory that all trainees complete a Radiation Protection Course to ensure they understand the principles of fluoroscopy, radiation physics and radiation safety. These courses are ran by radiology departments and are recognized by the Irish Medical Council. Course content and teaching methods vary between institutes, and spaces are usually shared with radiology trainees.

The risks of long-term occupational radiation exposure are increasingly recognised and studied, including concerns for higher rates of malignancies, cataracts, fertility issues and cognitive decline.

We assessed attendance and deemed usefulness of the course, alongside trainee radiation education, as summarized below.

Figure 6.

Radiation protection course/general education.

A number of trainees, 8 of 27, report not attending the radiation course, which is not in keeping with mandatory training requirements. We did not question reasons for lack of attendance, but possibilities include lack of awareness of needing to attend, busy clinical schedules impeding attendance, and perhaps poor recollection of attendance.

A large number of trainees at 25 of 27 report they are concerned about the occupational risks from radiation exposure, and 9 of 27 feel it will affect their career pathway in subspeciality training, with a breakdown of 5 of 6 females and only 4 of 21 males. This suggests the issue appears to affect female trainees significantly higher then their male counterparts.

Regarding choosing clinical investigations for patients, 10 of 27 trainees report radiation concern for patients affects their clinical decision-making, and only 2 trainees of 27 feel there are adequate resources in non-radiation diagnostics available to test for ischemia in the Republic of Ireland.

Knowledge

A number of multiple choice questions were in the questionnaire to assess radiation knowledge of trainee cardiologists, covering X-ray physics, identifying the correct definition of side-effects, recognizing average effective doses to the patient per procedure, and recognizing table positions that would usually increase operator dose. The results are demonstrated below in graph format, as answered correctly or incorrectly. A number of trainees left many questions blank, which we triaged as incorrect.

Figure 7.

Result knowledge section-correct/incorrect response

Discussion

Ionizing radiation significantly advanced diagnostic and therapeutic abilities in the world of medicine, perhaps most notably in cardiology where it revolutionized coronary angiography, percutaneous angioplasty, electrophysiology studies and device placement. Occupational risks and concerns have been increasingly reported as long-term exposure to low-dose radiation can increase stochastic risks for clinicians.¹²

Case reports, case series and small studies have shown higher incidences of brain cancer (particularly left-sided), breast cancer and skin cancer, and cataract formation for clinicians using regular radiation.³⁴ These studies are confounded by lacking control groups, and not having dosimeter information available.

Knowledge of radiation and understanding advances in radiation safety are critical to achieving appropriate radiation use for the patient and the operator. Principles of best practice radiation use can be summarized as justification, optimization and limitation, with a focus on ALARA, keeping doses as low as reasonably achieveable.

This survey highlights educational issues, knowledge flaws and concerns amongst trainee cardiologists. Many trainees report inadequate access to properly sized and stored lead protection, and concerningly many trainees are not having their radiation dose properly monitored with infrequent dosimeter usage noted. Over one-third of trainees report musculoskeletal issues from wearing leads, the majority of whom report correct size lead use <60% of the time, suggesting a possible link.

33.3% report radiation concerns will affect their decision making regarding subspeciality training, but very notably 83.3% of females and only 19% of males surveyed report this, showing this is a significantly bigger issue for females in cardiology. The numbers of females in cardiology have been slowly progressing, but recent data show only 14% of practising cardiologists in the USA are female and only 4.5% of interventional cardiologists are female.⁶ Similar trends are seen in Australia and New Zealand.⁷ Cardiology has been long viewed as a male dominated field and perhaps the use of radiation contributes to that.

Less then half of trainees feel adequately educated about radiation while in their training scheme. This survey also highlights flaws in knowledge about the physiological basics of radiation, and many were unable to identify what X-ray positions in the cath lab usually increase operator exposure. Many participants did not attend the radiation protection course, and others did not find it useful to their clinical practice, suggesting this is an area that could be improved upon from a training perspective, and perhaps tailored to cardiology trainees rather then shared between cardiology and radiology trainees.

From a clinical implication viewpoint, we can speculate that if trainee cardiologists were further educated regarding radiation, usage in the cath lab and image optimization may be improved upon, with the possibility of lower doses being administered to patients. We found that radiation concerns for patients affects clinical decision-making for many trainee cardiologists, but many feel the Republic of Ireland is under resourced for non-ionizing radiation investigations.

The challenges with safe use of ionizing radiation is being increasingly recognized internationally for both patients and operators. This survey is likely to be representative of trainee cardiologists in other countries, suggesting training bodies may need to further expand education in the field. A large email survey of cardiology trainees from the USA showed similar findings from 2010.⁸ Similarly, this may be applicable to other specialities as shown in a similar survey of orthopaedic trainees in Ireland in 2015.⁹

We will email the 2018 expert consensus document from JACC titled “Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for safety and effectiveness” to all trainees via the RCPI training body, and feel the survey has opened the conversation to improve trainee awareness and education in the area of radiation. We plan to repeat the questionnaire next year if the Spring Meeting 2021 goes ahead, pending public health restrictions at the time.

Conclusion

Our assessment highlights deficiencies in the provision and use of personal protective equipment for trainees in the cath lab, alongside inadequate dosimeter usage. It also raises concern that trainees both are and feel inadequately educated about radiation usage, and suggests radiation concerns particularly affect female trainees in subspeciality training. We plan to share an educational consensus document to improve this, and talk to the training body to consider improving the radiation protection course.

Advances in knowledge

We feel our assessment highlights deficiencies in the education of cardiology trainees regarding the understanding and use of ionizing radiation, and suggests this area of training needs to be improved upon to ensure long-term safety of physician and patient in the cath lab.