Interactive Learning Module Improves Resident ...

Current Problems in Diagnostic Radiology ] (2015) ]]]–]]]

Current Problems in Diagnostic Radiology journal homepage: www.cpdrjournal.com

Interactive Learning Module Improves Resident Knowledge of Risks of Ionizing Radiation Exposure From Medical Imaging Alexander Y. Sheng, MDa,n, Alan H. Breaud, MPHa, Jeffrey I. Schneider, MDa, Nadja Kadom, MDb, Patricia M. Mitchell, RNa, Judith A. Linden, MDa a b

Department of Emergency Medicine, Boston University Medical Center, Boston, MA Department of Radiology, Boston University Medical Center, Boston, MA

Physician awareness of the risks of ionizing radiation exposure related to medical imaging is poor. Effective educational interventions informing physicians of such risk, especially in emergency medicine (EM), are lacking. The SIEVERT (Suboptimal Ionizing Radiation Exposure Education – A Void in Emergency Medicine Residency Training) learning module was designed to improve provider knowledge of the risks of radiation exposure from medical imaging and comfort in communicating these risks to patients. The 1-hour module consists of introductory lecture, interactive discussion, and role-playing scenarios. In this pilot study, we assessed the educational effect using unmatched, anonymous preintervention and postintervention questionnaires that assessed fund of knowledge, participant self-reported imaging ordering practices in several clinical scenarios, and trainee comfort level in discussing radiation risks with patients. All 25 EM resident participants completed the preintervention questionnaire, and 22 completed the postintervention questionnaire within 4 hours after participation. Correct responses on the 14-question learning assessment increased from 6.32 (standard deviation ¼ 2.36) preintervention to 12.23 (standard deviation ¼ 1.85) post-intervention. Overall, 24% of residents were comfortable with discussing the risks of ionizing radiation exposure with patients preintervention, whereas 41% felt comfortable postintervention. Participants ordered fewer computed tomography scans in 2 of the 4 clinical scenarios after attending the educational intervention. There was improvement in EM residents’ knowledge regarding the risks of ionizing radiation exposure from medical imaging, and increased participant self-reported comfort levels in the discussion of these risks with patients after the 1-hour SIEVERT learning module. & 2015 Mosby, Inc. All rights reserved.

Introduction In the last quarter century, the advent of advanced imaging modalities has led to a 6-fold increase in ionizing radiation exposure to patients.1,2 This is mainly owing to an increased use of computed tomography (CT), which accounts for up to 70% of medical ionizing radiation exposure.3 It has been estimated that up to 2% of cancers diagnosed annually could be attributable to CTs performed in the United States in 2007.3,4 Current physician awareness of radiation risks from medical imaging remains poor.5-17 Proven, effective interventions to educate physicians regarding risks of radiation from medical imaging, especially in the field of emergency medicine (EM), are lacking. The objectives of this pilot study were to design and implement an interactive, clinically oriented learning module that identifies the radiation risks of medical imaging for EM residents and assess improvement in knowledge and comfort level when discussing the risks with patients using preintervention and postintervention questionnaires. We hypothesized that the learning intervention would improve learner knowledge of the risks of radiation exposure from medical

n Reprint requests: Alexander Y. Sheng, MD, Boston University Medical Center, 771 Albany St, Dowling 1 South, Boston, MA 02118. E-mail address: [email protected] (A.Y. Sheng).

http://dx.doi.org/10.1067/j.cpradiol.2015.11.002 0363-0188/& 2015 Mosby, Inc. All rights reserved.

imaging and reduce the likelihood that trainees would order CT in clinical scenarios without a clear indication. Furthermore, we hypothesized that participants would become more comfortable discussing the risks with patients postintervention.

Methods This pilot study was conducted at a single urban academic institution with approximately 130,000 annual emergency department (ED) visits that hosts a postgraduate year (PGY) 1-4 EM training program. In total, 25 EM residents participated in the educational intervention during a standing weekly educational conference. The study was deemed exempt by our institutional review board. SIEVERT (Suboptimal Ionizing Radiation Exposure Education – A Void in Emergency Medicine Residency Training) Learning Module The 1-hour module consisted of 3 segments: a 10-minute introductory lecture; a 25-minute facilitated, interactive smallgroup discussion; and a 25-minute role-playing exercise. The introductory lecture covered several key topics, including the rise of radiation exposure from medical imaging, the

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A.Y. Sheng et al. / Current Problems in Diagnostic Radiology ] (2015) ]]]–]]]

carcinogenic effects of ionizing radiation, the units of measurement of radiation exposure, and radiation doses associated with common imaging tests ordered in the ED. This was supplemented by an introduction to the American College of Radiology Appropriateness Criteria (ACR-AC),18 and suggestions for having discussions with patients regarding the risks of radiation from imaging. The second segment (Appendix A) was a 25-minute guided, interactive, small-group discussion with participants working in groups of 2-3. Each group was given 4 clinical scenarios in which there were no accepted guidelines governing the appropriate use of medical imaging. Participants were encouraged to deliberate the optimal imaging decision. These “indeterminate” patient imaging scenarios allowed participants to assimilate and apply concepts that were presented during the introductory lecture. The third segment (Appendix B) was a 25-minute role-playing exercise. Participants in groups of 2-3 were assigned to play the roles of the physician, the patient, or family member and given character descriptions specific to their role. The general trajectory of the conversation was laid out. Specific details of the conversation were intentionally left vague to better simulate real patientprovider interactions. The exercise allowed participants the opportunity to discuss the risks of radiation exposure from medical imaging from various perspectives. Participants alternated roles as from case to case for 4 scenarios. Study Questionnaire Survey Demographics Demographic data, including level of training, self-reported familiarity with ACR-AC, and frequency of discussion of the risks of radiation from imaging with patients in clinical practice (part 1 of Appendix C), were collected from all participants. Learning Assessment Instrument Identical preintervention and postintervention multiple choice questions derived from material introduced in the lecture then reinforced through discussion and role-playing were used to assess participant understanding of radiation risks from medical imaging (14 questions) (part 2 of Appendix C). All responses were anonymous, with no identifiers and completed voluntarily. Survey Instrument Self-reported imaging ordering practices were assessed using the same 4 “indeterminate” patient imaging scenarios from the learning module. Participants were asked to rate their level of comfort in discussion of radiation risks with patients preintervention and postintervention using a 5-point Likert scale (part 3 of Appendix C).

evidence-based guidelines and decision rules exist. And it is in these exact scenarios where education interventions can have the greatest potential to reduce unnecessary imaging. An iterative process was used to generate the “indeterminate” patient imaging scenarios, role-playing cases, learning assessment and survey instrument; all of which were piloted with 2 EM and 1 radiology faculty with expertise in medical education and imaging utilization. Statistical Analysis Frequencies and percentages, along with mean and standard deviation were calculated in aggregate and by PGY class. Selfreported CT ordering practices were assessed by calculating frequencies and percentages for each of the 4 “indeterminate” patient imaging scenario questions. Level of comfort in discussing the risk of imaging procedures with patients was assessed using a 5-point Likert scale: “very uncomfortable, uncomfortable, neither comfortable nor uncomfortable, comfortable, and very comfortable.” Statistical analysis was conducted with SAS 9.3 (SAS Institute, Inc., Cary, NC).

Results A convenience sample of 25 EM residents (6 PGY-1, 5 PGY-2, 6 PGY-3, and 8 PGY-4) who attended a scheduled, weekly educational conference participated in the training. All completed the voluntary preintervention questionnaire immediately before and 22 completed the postintervention questionnaire within 4 hours after participation in SIEVERT (2 PGY-1 and 1 PGY-3 left before the postintervention assessment due to duty-hour work restrictions or other commitments). There were no incomplete questionnaires. For the 14-question learning assessment, the mean score pretest was 6.32 (range: 1–12); and posttest was 12.23 (range: 6–14). The mean score increased similarly for all PGY levels (Fig 1). Residents were less likely to order CT in 2 of 4 “indeterminate” patient imaging scenarios postintervention (52% vs 36% in scenario 2: first-time seizure; and 40% vs 5% in scenario 3: atraumatic headache, Appendix A). The decision to order CT in scenario 1 (first-time renal colic) and scenario 4 (suspected diverticulitis) showed no appreciable change postintervention (Fig 2). Most residents (84%) indicated that they were not familiar at all with the ACR-AC before participation. This was consistent across all PGY levels (Table). Before participation, 72% of residents reported that they discussed the risks of radiation from imaging with patients “sometimes,” “often,” or “always.” Overall, 24% of residents were comfortable discussing radiation risks with patients at baseline, 16

The SIEVERT educational module was developed in observance of the tenets of adult learning theory.19 Specifically, it was created under the assumption that our adult learners are relevancy oriented, are practical, and learn best through active participation in an informal setting.20 In turn, we minimized the length of the lecture portion to maximize time for interactive discussion and role-playing exercise. We especially designed the discussion scenarios and role-playing cases to promote open dialogue among learners. The “indeterminate” patient imaging scenarios were carefully developed as to avoid a “gold standard” answer because in our experience, residents generally do adhere to evidence-based decision rules like NEXUS21 and Canadian Head CT Rules22 when available and applicable. But imaging ordering practices vary widely in most patient presentations for which no

Respondent Mean Scores (SD)

Development and Validation

14 12 10 8 6 4 2 0 All

PGY-1

PGY-2

PGY-3

PGY-4

PG-Year Pre-Intervenon

Post-Intervenon

FIG 1. Preintervention and postintervention learning assessment mean scores and standard deviations out of a possible 14 questions.


Percentage of Survey Respondents

60% 52% 48%

50%

50%

40% 40%

3

Legend: Q1: First time renal colic Q2: First time seizure Q3: Atraumatic headache Q4: Uncomplicated diverticulitis

36%

30% 20% 10%

8%

9% 5%

0% Queson 1

Queson 2 Pre-Intervenon

Queson 3

Queson 4

Post-Intervenon

FIG 2. Preintervention and postintervention self-reported decisions to order CT in “indeterminate” patient imaging scenarios. Q1: first-time renal colic. Q2: first-time seizure. Q3: atraumatic headache. Q4: uncomplicated diverticulitis.

Discussion The SIEVERT learning module is a novel educational intervention specifically aimed at EM residents—a population of providers who would affect the amount of ionizing radiation exposure to a large number of patients in their career. Although physician awareness regarding risks of radiation exposure from medical imaging has improved over the last decade, most still lack knowledge and training in this important domain.7,9,11,13,16,23 Recent literature suggests that formal training can have significant effect and improve provider awareness.12,15 For example, Koontz and Gunderman24 demonstrated the efficacy of radiation safety modules in teaching medical students about the risks of radiation and methods to limit exposure. A prior study reported that a combination of lectures, tutorials, and workshops was the preferred method of teaching for radiation awareness.17 We deliberately designed the SIEVERT learning module to be practical and case-based using 3 complementary Table Preintervention and postintervention familiarity with ACR-AC criteria stratified by PGY class PGY-1 (%) Not at all familiar Slightly familiar Somewhat familiar Moderately familiar Extremely familiar

83.3 16.7 0.0 0.0 0.0

PGY-2 (%) Not at all familiar Slightly familiar Somewhat familiar Moderately familiar Extremely familiar

100.0 0.0 0.0 0.0 0.0


83.7 16.3 0.0 0.0 0.0


75.0 12.5 12.5 0.0 0.0

segments. The introductory lecture session was carefully designed to quickly and efficiently present clinically relevant background knowledge, thus allowing ample time for participants to apply what they have learned in case-based interactive discussion and role-playing segments. The mean correct score in the assessment of learner knowledge regarding risks of radiation exposure from medical imaging nearly doubled across all PGY levels after our learning intervention (Fig 1). Preintervention scores were similar for all levels of training, consistent with prior studies.11,12 This underscores the knowledge gap and lack of formal education regarding radiation risk awareness in graduate medical education. Of the 4 “indeterminate” patient imaging scenarios, 2 demonstrated large decreases in the number of CTs ordered, whereas scenarios 1 and 4 showed no appreciable change (Fig 2). For scenario 1 (first-time renal colic, Appendix A), we suspect that this may be due to our residents’ extensive training to bedside ultrasound during residency and recent literature supporting the use of ultrasound as the first imaging test in patients with suspected renal colic.25 For scenario 4 (suspected diverticulitis), we hypothesize that this may result from inconsistent recommendations regarding the use of imaging in the workup of acute uncomplicated diverticulitis. Despite recent evidence supporting the use of ultrasound in the workup of uncomplicated diverticulitis,26,27 CT remains the primary imaging test owing to its high accuracy and ability to detect complications.28 The low rate of familiarity with ACR-AC preintervention across all PGY levels is consistent with prior studies demonstrating low level of awareness and utilization of ACR-AC in medical students, residents, and practicing attending physicians.29-35 Interestingly, although only 24% of participants felt comfortable discussing risks of radiation exposure from medical imaging with patients, 72% indicated that they sometimes or often or always discussed those risks. These results are similar to prior study Percentage of Survey Respondents

and 41% were comfortable postintervention (Fig 3). Those who responded feeling uncomfortable discussing risks decreased from 32% at baseline to 9% postintervention.

50%

45%

45%

41%

40%

40% 35%

32%

30% 24%

25% 20% 15% 10%

9% 4%

5% 0%

Uncomfortable

Neither comfortable nor uncomfortable Pre-Intervenon

Comfortable

5%

Very comfortable

Post-Intervenon

FIG 3. Preintervention and postintervention learner comfort level with discussing risks of ionizing radiation from medical imaging with patients.

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showing that 74% of EM physicians feel that radiation exposure should be discussed yet admit doing so with only 24% of patients.36 The proportion of providers who have similar discussions with patients vary significantly,11,13,16,36 with the highest rate reported in pediatric EM providers in whom 68.8% reported disclosing risks “most of the time” or “always.”23 SIEVERT significantly increased residents’ self-reported comfort with discussing the risks and benefits of medical imaging (Fig 3).

What imaging modality, if any, would you use in your diagnostic approach? What are you looking for if you have selected a particular imaging procedure? How will the results change your management? How will the patient benefit from the imaging results? What are the risks of exposure from ionizing radiation for the patient from the imaging test? After consideration of above, what imaging modality, if any, will you order?

Limitations This study was conducted at a single center tertiary care hospital, which limits the generalizability of our results. Similarly, our institution is considered a “safety-net” hospital, caring for patients with limited access to follow-up care, which may influence participants’ decision to order imaging. We did not assign a control group as it would be unethical to withhold potentially valuable training from some residents. We did not link preintervention and postintervention questionnaires, precluding a statistical comparison of the groups. However, postintervention results suggest overall improvement in scores for all PGY classes. This study focused largely on learning, a level 2 impact on Kirkpatrick’s37 Model of Training Evaluation. Long-term retention was not measured. Our attempts at measuring behavior change, a Kirkpatrick level 3 impact, is limited to assessment of selfreported ordering practices in “indeterminate” patient imaging scenarios in a questionnaire setting. As ordering decisions of residents are often highly influenced by attending oversight, we did not measure actual imaging ordering practices in the ED. Therefore, it is difficult to predict how our results reflect real clinical practice.

Conclusion The SIEVERT learning module was an effective tool for increasing residents’ knowledge regarding risks of ionizing radiation exposure from medical imaging. Participation in the educational session increased resident self-reported comfort levels in the discussion of these risks with patients. Considering the significant void in radiology, EM, and medical education literature on educational interventions targeting this important domain, this pilot study serves as an important foundation upon which future education and research can be built. Specifically, further studies evaluating the efficacy of this learning module, compared with conventional learning methods, as well as the impact of SIEVERT on long-term knowledge retention and imaging ordering practices, is warranted.

Acknowledgments The authors gratefully acknowledge the American College of Emergency Physicians Teaching Fellowship for providing the opportunity to meet distinguished colleagues who provided invaluable feedback during project development; especially Dr. Vi Dinh, assistant professor of emergency medicine at Loma Linda University, for devising the name of our learning module.

Appendix A. Interactive Discussion of “Indeterminate” Patient Imaging Scenarios. Assuming you have all imaging modalities readily available, please consider the following when discussing each of the cases

Scenario 1 A 24-year-old male presents with 1 day of colicky left flank pain for the first time. No fevers, urinary symptoms, or abdominal pain. His father has history of recurrent kidney stones. Scenario 2 A 37-year-old male previously healthy brought in by ambulance after a witnessed first time 3-minute general tonic-clonic seizure while in bed. He did not sustain any injuries. He is back to baseline, with normal neurological exam. He denies illicit drug use. His electrolytes are normal. Scenario 3 A 59-year-old female previously healthy presents with 1 month of atraumatic headache. It is diffuse, worse in the morning, and occasionally wakes her up at night. She is neurologically intact without fever or neck stiffness. Scenario 4 A 45-year-old male presents with 2 days of left lower quadrant abdominal pain. He denies nausea, vomiting, fever, diarrhea, or changes in bowel movements. On exam, he is well-appearing with a soft abdomen with mild to moderate left lower quadrant tenderness to palpation without rebound. Labs and urinalysis are unremarkable except white blood cell count of 13 109 per liter (L). Appendix B. Role-Playing Information Cards. Case 1 Learner role-playing as the patient: You are a 27-year-old woman. You developed left sided, sharp chest pain that increases when taking a deep breath since yesterday. You feel somewhat short of breath and recently returned from a 6 hour flight from the opposite coast 1 week ago. You have never had this before and you have worried. You had an EKG, blood work, and chest x-ray already and are eagerly awaiting the results. You have read in the New York Times that CT scans cause cancer. You would like to know whether you really need this CT. And if so, what are the risks of radiation. You would also like to know what the alternatives are to getting a CT and what the consequences are if you do not undergo CT imaging. Learner role-playing as the physician: A 27-year-old female patient presents with left sided sharp, pleuritic chest pain with shortness of breath that started yesterday. She recently returned from a 6 hour flight across the country 1 week ago. She is on oral contraceptive pills. Her vitals are


normal. She is in no acute distress and her exam, and chest x-ray is unremarkable. Her d-dimer is elevated at 694 ng/mL. Considering the patient’s overall clinical picture, you would like to obtain a CT angiography of the chest as your next step for the workup of pulmonary embolism. You will start the conversation by informing the patient of the next step in her evaluation.

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blood count, comprehensive metabolic panel, lipase, urinalysis and pregnancy test is unremarkable except for a white blood cell count 14 109 per liter (L). Considering the patient’s overall clinical picture, you would like to obtain a CT abdomen and pelvis as the next step in the workup of suspected appendicitis. You will start the conversation by informing the patient of the next step in her evaluation.

Case 2 Case 4 Learner role-playing as the patient’s wife: Your 61-year-old husband tripped and fell, hitting his forehead 4 hours ago. He did not want to see a doctor and you had to drag him to the ED as he is on a blood thinner. He did not lose consciousness. He looks ok to you except for a big bruise on his forehead where he says he has a headache. He is an easy-going guy and is always happy to do whatever others ask of him. You feel that you sometimes need to advocate for him, especially when it comes to your husband’s health. He has deferred all decisionmaking to you. Your brother had hydrocephalus as a child and was subjected to repeated CT scans of his head. He later died of brain cancer in his 30’s. You would like to know whether your husband really needs this CT. And if so, what are the risks of radiation. You would also like to know what the alternatives are to getting a CT and what the consequences are if your husband does not undergo CT imaging. Learner role-playing as the physician: A 61-year-old male with atrial fibrillation on warfarin brought in by his wife after tripping on uneven brick and hitting his forehead on the ground 4 hours before arrival. He did not lose consciousness. His vitals are normal. He has an abrasion with mild ecchymosis over his forehead. He has a mild frontal headache without vomiting. He appears well and is neurologically normal with nontender c-spine. INR is 2.3. Considering the patient’s overall clinical picture, you would like to obtain a head CT as your next step in the workup of intracranial bleeding. You will start the conversation by informing the patient and his wife of the next step in the evaluation.

Learner role-playing as the patient’s father: You are the father of a 19-year-old teenage boy accidentally struck by another player during soccer 4 hours ago. Their heads collided and your son fell to the ground. It is unclear if he lost consciousness but he was disoriented for about 2 minutes afterwards but quickly returned to baseline. He has mild nausea, headache, and dizziness but otherwise looks fine to you. You are concerned your son has bleeding in his brain. You are adamant about wanting a “CAT” scan done on your son’s head. After all, it is just a “CAT” scan, which has no risks that you are aware of. Your son looks to you to help him make any healthcare related decisions. Learner role-playing as the physician: A 19-year-old male brought in by his father for minor head injury. The patient’s head collided with another player’s head during soccer. It is unclear if the patient lost consciousness for a second or two, but he was disoriented for 2 minutes afterwards. He is now back to baseline, acting normally, complaining of a mild headache, nausea and dizziness. He remembers preceding events including the game score accurately. He has a normal neurological examination and has no neck pain. He easily clears the Canadian Head CT rules. Considering the patient’s overall clinical picture, you are concerned that he has a concussion, and would like to avoid obtaining a CT scan at this time. You plan to refer the patient to outpatient concussion clinic. You will start the conversation by informing the patient and his father of your plan.

Case 3 Appendix C. Preintervention and Postintervention Survey. Learner role-playing as the patient: You are a 43-year-old woman with 2 days of right lower abdominal pain. You feel feverish, nauseated and have no desire to eat. Other than history of lymphoma as a child, you are otherwise healthy. You already had blood work and urine testing done and you are eager to hear about the results. You have had multiple CT scans of your chest and abdomen for lymphoma in the past and would prefer to avoid further CTs. You would like to know whether you really need this CT. And if so, what are the risks of radiation. You would also like to know what the alternatives are to getting a CT and what the consequences are if you do not undergo CT imaging. Learner role-playing as the physician: A 43-year-old female with history of lymphoma in her 20s in remission presents with right lower quadrant abdominal pain for 2 days. It is associated with subjective fevers, nausea, and anorexia. She denies any vomiting, vaginal, urinary symptoms or changes in her bowel movements. Her last menstrual period was 3 weeks ago. Her vitals are only remarkable for temperature of 100.7F. Her examination shows a soft but tender abdomen in the right lower quadrant. There is no guarding, rebound, or masses. Her pelvic examination was unremarkable. Her workup including complete

Part 1: Survey Demographics and Background Knowledge 1. What is your level of training? A) PGY-1 B) PGY-2 C) PGY-3 D) PGY-4 2. How familiar are you with the American College of Radiology Appropriateness Criteria as regards to imaging utilization? A) Not at all familiar B) Slightly familiar C) Somewhat familiar D) Moderately familiar E) Extremely familiar 3. How frequently do you discuss the risks of ionizing radiation from imaging with patients in your clinical practice? A) Never B) Rarely C) Sometimes D) Often E) Always


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Part 2: Learning Assessment Instrument 1. From 1980-2006, the number of radiologic studies performed in the US has: A) Remained the same B) Increased 2-fold C) Increased 5-fold D) Increased 10-fold 2. From 1993-2006, the number of CT scans performed in the US has: A) Remained the same B) Increased 3-fold C) Increased 10-fold D) Decreased by 50% 3. In terms of absolute numbers, reducing current use of CTs in which of the following age group would result in the largest potential public health impact? A) Age o 18 years B) Age: 18-35 years C) Age: 35-54 D) Age: 55-70 4. The risk-benefit ratio in the use of CT in symptomatic patients has been shown to be: A) Unfavorable B) Favorable C) Equivocal D) Difficult to determine 5. Which of the following is true regarding deterministic and stochastic effects? A) Stochastic effect has a threshold at which damage can occur while deterministic does not. B) Examples of Stochastic effect include radiation burns, colitis, and hair loss. C) The severity of Stochastic effect depends on the radiation dose. D) Stochastic effect has “no threshold” and the risk of event occurring as a result is dependent on radiation dose. 6. Which of the following is true regarding absorbed dose and effective dose? A) Effective dose is measured in Gray while Absorbed dose is measured in Sievert. B) Effective dose is used for dose distributions that are nonuniform as an expression of risk equivalent to whole body exposure. C) Absorbed dose takes into account the weighting factor or the sensitivity of the organ or tissue exposed. D) Effective dose is used to measure radiation dose to individual tissue or organ. 7. The most robust source of evidence of cancer risk from ionizing radiation comes from which population? A) Nuclear industry workers B) Atomic bomb survivors C) Radiologic science healthcare workers D) Pediatric patients who have undergone radiation treatment 8. Which of the following is true regarding the linear-nothreshold model? A) It proposes that there may be a threshold dose below which radiation is harmless. B) It suggests that there may be a threshold dose below which radiation is protective. C) It hypothesizes that cancer risks seen at higher doses cannot be extended to lower dose ranges. D) It describes a linear response to radiation and that there is no threshold below which cancer may not develop. 9. The adult effective dose for a 2-view chest x-ray is estimated to be: A) 0.1 mSV

10.

11.

12.

13.

14.

B) 1 mSV C) 10 mSV D) 100 mSV The adult effective dose for a head CT is estimated to be: A) 0.2 mSV B) 2 mSV C) 20 mSV D) 200 mSV The adult effective dose for CTA of chest for pulmonary embolism is estimated to be: A) 0.15 mSV B) 1.5 mSV C) 15 mSV D) 150 mSV The adult effective dose for a CT abdomen and pelvis is estimated to be: A) 0.8 mSV B) 8 mSV C) 80 mSV D) 800 mSV The adult effective dose for a cardiac rest-stress using 99m Tc-sestamibi is estimated to be: A) 0.9 mSV B) 9 mSV C) 90 mSV D) 900 mSV Of the various methods to reduce patient radiation exposure from medical imaging, where might emergency physicians have the most impact? A) Optimization of CT or fluoro or nuclear imaging-related dose in individual patients B) Consider other reasonable imaging alternatives (Ultrasound and MRI) C) Reduce overall CT or Nuclear medicine studies D) B and C

Part 3: Survey Instrument 1. A 24-year-old male presents with 1 day of colicky left flank pain for the first time. No fevers, urinary symptoms, or abdominal pain. His father has history of recurrent kidney stones. What imaging modality, if any, would you use in your diagnostic approach? A) No imaging B) Abdominal x-ray C) Renal ultrasound D) CT abdomen and pelvis 2. A 37-year-old male previously healthy brought in by ambulance after a witnessed first time 3-minute general tonic-clonic seizure while in bed. He did not sustain any injuries. He is back to baseline, with normal neurological exam. He denies illicit drug use. His electrolytes are normal. What imaging modality, if any, would you use in your diagnostic approach? A) No imaging B) CT head C) MRI of brain D) Consult neurology for their imaging recommendation 3. A 59-year-old female previously healthy presents with 1 month of atraumatic headache. It is diffuse, worse in the morning, and occasionally wakes her up at night. She is neurologically intact without fever or neck stiffness. What imaging modality, if any, would you use in your diagnostic approach? A) No imaging B) CT head C) MRI brain D) Consult neurology for their imaging recommendation


4. A 45year-old male presents with 2 days of left lower quadrant abdominal pain. He denies nausea, vomiting, fever, diarrhea, or changes in bowel movements. On exam, he is well-appearing with a soft abdomen with mild to moderate left lower quadrant tenderness to palpation without rebound. Labs and urinalysis are unremarkable except white blood cell count of 13 109 per liter (L). What imaging modality, if any, would you use in your diagnostic approach? A) No imaging B) KUB C) Complete abdominal ultrasound D) CT abdomen and pelvis 5. How comfortable are you in discussing the benefits and risks imaging procedures with patients? A) Very uncomfortable B) Uncomfortable C) Neither comfortable nor uncomfortable D) Comfortable E) Very comfortable

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