CardioExchange Archive

In a new JACC paper, Andrew Einstein and colleagues detail the recommendations developed at an NIH-NHLBI sponsored symposium titled “Patient-Centered Imaging: Shared Decision Making for Cardiac Imaging Procedures with Exposure to Ionizing Radiation.” CardioExchange’s John Ryan interviews Andrew, who is Herbert Irving Associate Professor of Medicine and the Director of Cardiac CT Research at Columbia University Medical Center, about the clinical relevance and impact of their recommendations.

Ryan:  In your paper, you comment that “both the referring and laboratory physician should share responsibility for both justification of the test exposure to ionizing radiation and for patient education.” 

How do you think this discussion should be approached with the patient? Personally, I wonder if it should be every time a test is ordered. Or perhaps discussed during a clinic visit in and of itself with the patient?

Einstein: I think that the specifics of the shared responsibility for justification and education need to be tailored to the patient, clinical scenario, and the nature of the test.

For tests with radiation exposure that potentially could be on the higher end of the spectrum of cardiac testing, and certainly for tests with an expected effective dose of at least 20 mSv, the radiation exposure should be discussed with the patient at the time of ordering by the referring provider, in the context of a discussion of benefits and associated risks of testing.

In particular, for a justified test, the patient should be provided with reassurance that benefits outweigh risks. While the referring physician will have the most information to address the test’s justification, in general, the providers performing the study will have more detailed information about the test itself and its radiation exposure. Thus, this discussion should be continued at the point of testing.

Shared responsibility, patient education, transparency, non-alarmism, and openness to questions are some of the principles that should guide such discussions.  As we mention in the paper, such discussions are not necessary or feasible for all procedures involving ionizing radiation.
 

Ryan: The communication tools that you emphasize, including the use of “plain language” and the “teach back” method, were not components of my medical training (either medical school or residency). What is the best way to obtain and retain these skills?

Einstein: As with all patient communication skills, “practice makes perfect.”  The use of plain language is a skill that goes well beyond radiation safety — too often we speak in medical jargon that is not completely comprehended by our patients.  Asking our patients to teach back is a good way to assess whether they understood the concepts and content we have attempted to convey.

Just like it is challenging the first time we are called upon to break bad news to patients and their families, it can be challenging as we first try to process technical information about radiation and communicate it at the right level to a patient.  By taking this responsibility seriously, and getting feedback from colleagues and mentors, we can improve these skills.

Ryan: Should patients carry a radiation record card similar to those carried by power plant or cath lab workers?

Einstein: The issue of radiation tracking has some subtleties and areas of controversy, but I think most people support at least tracking procedures so we can avoid unneeded duplicate studies.  In fact, the FDA offers such a card.