Donald Frush Official Transcript

Intro/Outro – 00:00:02:

Welcome to Frame by Frame: Rethink Imaging, a podcast by Imalogix. Here, we explore the intricate world of medical imaging, aiming to dissect the field and inspire both professionals and curious minds alike. I’m your host, Chris St. John.

Chris St John – 00:00:19:

Hello, everyone, and welcome to another episode of Frame by Frame: Rethink Imaging. We have been covering a wide variety of radiology and medical imaging subjects over the last few weeks. We’ve covered a little bit of history. We’ve talked about workflows. We’ve talked about AI. And, you know, I was thinking about it, and as I was talking to our guest, it really stood out to me that we do need to start talking about the hot topic on everyone’s mind, dose safety. And so today on Frame by Frame Rethink Imaging, we are excited to welcome Dr. Donald Frush, a leading expert in radiation safety, dose optimization, and the John Strohbehn Professor of Radiology at Duke University Medical Center. With over 25 years on the faculty at Duke and significant contributions to medical imaging, Dr. Frush’s work has advanced our understanding of radiation dosimetry, image quality, and the critical importance of minimizing radiation exposure in clinical practice. I can’t wait to explore Dr. Frush’s extensive experience and gain some insights into his vision for the future of dose management and radiation safety in radiology. Welcome, Dr. Frush.

Donald Frush – 00:01:32:

Well, thank you, Chris, for that kind introduction and also the opportunity to be here today. I look forward to the conversation. And I would say, too, that your introduction of a hot topic is perfectly appropriate when we’re talking about radiation.

Chris St John – 00:01:46:

Both literally and metaphorically?

Donald Frush – 00:01:48:

Absolutely.

Chris St John – 00:01:50:

Well, okay, let’s just start. I’d love to learn a little bit about you before we really dive into the subject. So I’ve been having all of our guests actually, just give me a little bit of a window into your story and how you initially ended up in this field. More specifically, was there a particular moment when you felt called by imaging and radiology?

Donald Frush – 00:02:11:

There was. And I will say that I started out as a pediatric resident when I finished medical school and was in training. And I really got a lot out of the time we went down to round with the radiologists at the university I was training at and was taken by the fact that oftentimes the radiologists had the answer that we were looking for and at least led US in a direction to take better care of the patient. And I carried on with that idea through pediatrics because as a resident, I was a pediatric resident, I appreciate the difference between adults and children. The children are really victims of whatever disorder they have. It’s not related to self-induced dietary indiscretions or certain habits that lead to bad health. They’re really truly victims. And so from a pure sense, that part of medicine and taking care of children was one that was very fulfilling. So radiology allows one to see inside the body, allows one to help in the diagnostic management. And really radiology is a subspecialty or specialty that almost all the other specialties depend on in some form or fashion. So to me, it seemed that it was a nicer network to be able to deal with a variety of clinical colleagues.

Chris St John – 00:03:29:

Cool. Yeah, that makes sense to me. So getting into it, can you just explain the foundation for me? Let’s talk about radiation, radiation dose safety, and why it is such a critical issue to talk about.

Donald Frush – 00:03:43:

Well, much of what we do in radiology involves a kind of radiation called ionizing radiation. Other forms of imaging do use radiation, but it’s not the ionizing type, the one that we attribute to potential biological effects, which we can get into in this conversation. But those modalities, what we use modality as an equivalent for examination type are radiography, regular x-rays, fluoroscopy, like an enema examination or a barium swallow, CT or computed tomography, and nuclear medicine or nuclear imaging. Those all depend on ionizing radiation.

Chris St John – 00:04:22:

So I’m just curious, like about the basics of like the potential dangers of radiation. Yeah. And then general theories and approaches to safety around it. We can go bit by bit.

Donald Frush – 00:04:34:

Okay, okay, that’s fine. So those four modalities, radiography, fluoroscopy, and fluoroscopically guided procedures, computed tomography, and nuclear medicine, all use ionizing radiation. And generally, when we talk about radiation use in medical imaging, we have this idea of radiation protection, right? Because there is a potential detriment to the use of radiation in any dose. And so radiation protection comes down to using only as much radiation during an examination as we need, and also only performing an examination that is indicated. And that goes for all of those modalities. So really, when we’re talking about the customary or the standard approach to radiation protection, we’re talking about optimization, making sure that the exam is done correctly, correct patient, correct exam done correctly, as well as justification, which is to make sure that the examination is appropriate. But I would like to expand that a little bit, and it’s a little different than people’s understanding of radiation protection. And it will be important as a thread throughout this conversation, because we need to understand that medical imaging is really important in terms of diagnosis and management of patients, follow-up in cancer patients, et cetera. It’s an incredibly helpful part of medical care. And that examination, essentially, protects patients’ health, right? It helps in the decision-making process, whether it’s a single exam or multiple examinations. So there’s another element of protection, and that is the protection of health. And because we use those modalities that have ionizing radiation, there’s also this perspective that people need to have is that radiation from medical imaging is important to protect health. We also need to protect from the detriments of that, again, using only the appropriate examination and appropriate technique, and also the appropriate examination. But people, you know, listeners need to understand that we are also protecting the health of that patient by using these various modalities. That is, there’s a value to what we do.

Chris St John – 00:06:40:

Right. And so that, I believe, I still know to this world, but I’ve heard the acronym, right? It’s ALARA, right? As Low as Reasonably Acceptable? Is that achievable?

Donald Frush – 00:06:50:

Right. Achievable. As Low as Reasonably Achievable.

Chris St John – 00:06:53:

Right. Gotcha. That is in reference to dose safety, lowering dose.

Donald Frush – 00:06:57:

Yeah. That is right. That is in the construct of the typical understanding of radiation protection, which is only use what you need to use and only do what you need to do in terms of examinations. But again, I want everyone to understand that while we talk about risk and radiation use, because those modalities are so important and because they depend on radiation, there’s also a protection of that patient’s health, the care of that patient too. So we do tend to deal more and we’ll deal more in this conversation if you want with the typical understanding of radiation protection.

Chris St John – 00:07:32:

Yeah. And honestly, I’d love to follow up with just one more question. Sure. And maybe this is too basic, but what is the difference between ionized and non-ionized radiation? Like what’s going on there that makes them different? I don’t know.

Donald Frush – 00:07:45:

Well, radiation is along the electromagnetic spectrum. And just to simply put that, that includes visible light and other forms of radiation. What ionizing radiation does is it has an energy that causes ionization and that can disrupt the atomic nature of tissue. And with that disruption, the ionization then can affect DNA. And if DNA is repaired, it’s no problem. If it’s not repaired, it may not be an issue, but sometimes the repair is either incorrect or not able to be done at all. And this could lead to potential health effects. So it’s the idea that there is an ionization involved in that atomic domain there that other forms of radiation, other energy levels don’t do.

Chris St John – 00:08:36:

Right. And so how has our understanding of radiation dose evolved over the years? You know, like, have we always had the ALARA approach at, you know?

Donald Frush – 00:08:48:

Well, I would say from a medical imaging standpoint, no. 1895 was when Röntgen discovered x-rays, and now we’re talking about more than 125 years later. And it was a brilliant discovery, but was often used as a hobby or a folly or whatever in terms of use. And there wasn’t at least immediately known within the first few months or years that it could have detrimental effects. And of course, the radiation generated then was very high compared to what we do now. Over the course of a few years and certainly subsequent decades after that, the idea that there can be health effects, particularly from very high levels of radiation that were typical of the earliest uses, we have developed this concept of radiation protection and the need to only do the correct types of examinations and do them correctly. And the technology has continued to evolve. Over the years, so that we’re doing things, as I said, with much lower doses than was typically possible a few years after the discovery.

Chris St John – 00:09:53:

Yeah. Of those technologies, are there any specific that come to mind that you see as a turning point in dose management?

Donald Frush – 00:10:02:

Well, early on, the only modality, the only technique was an x-ray, right? And there was some fluoroscopy. That fluoroscopy is continuous x-ray. So the machine is essentially always on providing x-ray images. Those were the two until nuclear medicine came around a number of decades later. And then CT wasn’t really on the radar screen until the early 1970s. So with each modality, there were lessons learned in terms of radiation protection and so on. But I don’t think there was any single seminal moment. That someone said, oh, what we do is potentially harmful. Let’s be sure that we always treat everything that might be developed in the future the same.

Chris St John – 00:10:49:

Right.

Donald Frush – 00:10:49:

Sort of rolled around as each technology came to apply what had been learned previously to what was currently being developed.

Chris St John – 00:10:57:

Right. The slow progression of medicine. Right. I can’t help but think about, you know, like old vintage early 1900s prescriptions for heroin and cocaine and giving people cigarettes for their asthma.

Donald Frush – 00:11:08:

Right.

Chris St John – 00:11:09:

And just, you know, thinking about things like that in the context of radiation exposure.

Donald Frush – 00:11:14:

Well, to that end, and it’s interesting, someone of my age will remember that they used to have radiation sources in shoe stores that would measure your foot for the ideal shoe size. That was something that existed up until the 1960s. And I have no idea what the dose was, but obviously there are still remnants of less than ideal understanding of pure radiation protection. Right. And I will say, too, that in children, there’s a gland in the chest called the thymus gland, and it’s very important for the immune system. And it tends to be relatively larger in very young children. You see it well. You don’t see it as much in adults because it just sort of changes its cellular constituency. But it’s very prominent in children, can be as wide as the heart, actually, and occupy the upper chest. And the early thinking when chest x-rays came around in children is, wow, these look very different than adults. And, you know, if children that commonly have respiratory symptoms, colds, asthma, bronchiolitis, etc., any respiratory symptoms was, wow, maybe this thymus is causing that. And so they actually used to radiate children in the early 1900s to shrink the thymus because it is radiation sensitive. And so that took place until, I think, the 1950s. There are probably people, you know, that are alive that had that thymic radiation. And certainly they’re going to be at increased risk for breast cancer, thyroid cancer, etc. And so, again, we talk about 125 years of history. We talk about… But that there are people still alive that are living history of how our education has needed to evolve over time. Very interesting.

Chris St John – 00:12:52:

Yeah, I mean, those examples are exactly what I was wondering about.

Donald Frush – 00:12:56:

Yeah.

Chris St John – 00:12:57:

Thank you for that. And so, you know, I understand the basic principle, right, that the higher the radiation dose is, you know, the more, I guess, light passing through, the better image quality you’re going to have. I’m right on with that.

Donald Frush – 00:13:09:

Yeah. Yeah, I think that’s a good way to think of it. And to take it one step further, children versus adults, if we talk about the kinds of radiation exposure that they need to have. If you think about your hand in a flashlight, I think it’s well illustrated. If you think about the palm of your hand as an adult. And the web of your fingers, as a child, you don’t see the light in your palm, but through the web, you see the light. So the web are children, and that way you need to turn down the light. You need to use less radiation to go through smaller tissues. They’re also more radiosensitive than adults are because their tissues are growing, and growing tissues are more affected by ionizing radiation than those that are already developed. So it’s really important to understand, first of all, that you’re right, that the quality tends to be higher with higher doses, but we have to balance that against the exposure part of it and say that you can’t just use as much radiation as you want to to get beautiful images because that detrimental potential, that potential health effect does increase in that setting.

Chris St John – 00:14:14:

Yeah. And would you say, like, how do we approach balancing those? Is there a generally accepted approach to that balance? Does everybody have their own recipes and thoughts on it? I’m curious how we try and reconcile the balance.

Donald Frush – 00:14:30:

Well, we would need, Chris, probably a dozen podcasts to… To get at that issue. And I think, you know, it’s fundamentally what people want to know is how do you balance, how do you take this risk part of it and take the benefit part of it and be sure that what you’re doing is right. And that I would say just from a population standpoint is the responsibility of the imaging community, of technologists, of medical physicists, of health physicists, of radiologists, of other people who use radiation. You know, we need to understand too that it’s not just radiologists. Cardiologists in the care of their patients use angiography or maybe nuclear medicine studies. There’s fluoroscopic machines in the operating room that surgeons use or up in the intensive care units. So while we’re short of talking about the radiology domain and radiation protection, it is wider than that. There’s the medical community, the dental community. Everybody in the United States virtually has had dental x-rays. And so what we talk about and the lessons, that we’ve learned and where we need to go certainly applies to many different populations here. And so when I talk about radiologists, medical physicists, et cetera, it’s really those that use and are responsible for medical imaging have the responsibility to be sure that, again, those two principles of, is it the right exam? Do we need to do this? Yes or no? And how do we make sure that it’s done correctly? That deals with the size of the patient, the specific question, because different techniques might be used for different questions, say in computed tomography. And something as simple as, has the individual had another examination that we already know certain things so that we don’t have to perform it in a certain way? We might use a lower dose examination. So all of those things come into play. But I will step back and say that it’s a team effort and equally important voices from the technologists, from the medical physicists as the imaging professionals who actually interpret and dictate those studies all are very important and being sure that we subscribe to all those tenants of radiation protection.

Chris St John – 00:16:44:

So how do healthcare providers educate themselves on radiation safety and what resources are available and out there so they can stay up to date on best practices?

Donald Frush – 00:16:56:

That’s a complicated answer in that if you talk about healthcare providers, if we’re talking about non-imaging experts, those that refer patients and take care of patients who have a direct relationship with the patient and actually order or request the studies, that’s different than if we talk about imaging experts and how do they educate themselves. So if we take, say, the pediatrician or the family practitioner or the internist, they’re often going to get the questions from the patients about radiation use and is it safe and so on. There are innumerable resources that those individuals have and some from the U.S.. Standpoint, because there are international resources too, are the Image Gently website, which talks about safe and effective use of ionizing radiation children. The Image Wisely website, which is a sister alliance to Image Gently, radiologyinfo.org, which is RSNA. But if individuals also wanted to go to various subspecialty websites, if internal medicine or cardiology or whatever, there are… Even obstetrics and gynecology all have information related to ionizing radiation use. The patient and parent population is a little bit… Different. And we can talk about that as this dialogue goes on. Imaging professionals, those radiologists, cardiologists, orthopedic surgeons, et cetera, that use radiation, the same sorts of things. Those sites are equally usable. The American College of Radiology has information on it. The American Association of Physicists in Medicine, ASRT, the American Society of Radiologic Technologists, has information on it. And I think anyone that’s in the imaging domain is familiar with those sites and the various subspecialty sites within each organ system. There’s a plethora of information out there. I will say, Chris, though, that part of the issue, too, is that, as you know, with web-based information sources, the accurate and distilled information does not always come up first and foremost. And so from a standpoint of someone beginning explorations there, whatever their health knowledge is, whether it’s a patient, a parent, or an imaging professional, oftentimes, some of those sources are not quite as well-informed by some of those other sources that I said. But there is a wide variety, deep, deep information available, widely available.

Chris St John – 00:19:24:

Yeah. And not to answer my own question, but another great source for information is this podcast, Frame by Frame: Rethink Imaging.

Donald Frush – 00:19:30:

Yeah, absolutely.

Chris St John – 00:19:31:

And so you kind of brought up the dreaded subject of cumulative dose in some capacity a minute ago, right? You said, you know, patients who are having multiple exams. Can we just start off by defining cumulative radiation dose and discuss why it’s important to monitor patients who are undergoing repeated imaging studies?

Donald Frush – 00:19:55:

Sure, the definition is important and the significance of that is equally important, Chris. And when we talk about cumulative dose, I think probably a better way to understand this is recurrent imaging. Okay. Because there are patient populations that require multiple imaging examinations. Those populations are kind of two different. The acute setting, like someone’s in a car accident and needs a head CT and a cervical spine CT. Maybe they need an operation, then they have problems a week down the line and need another CT examination. The sort of those recurrent imaging in the setting of a singular sort of acute situation versus patients that require recurrent imaging for certain disorders. You know, cancer is the one that is probably most evident in people’s minds, but there are other conditions, inflammatory bowel disease, Crohn’s disease, ulcerative colitis. There are certain neurologic conditions that require recurrent imaging with ionizing radiation and a variety of other immune disorders that might result in that. So those are the settings of recurrent imaging. And I will say with respect to, you know, what is cumulative dose, we say that the dose and dose risk is cumulative. That is, if you have one CT scan when you’re 10 years old and another CT scan when you’re 20 and another when you’re 40, that’s three CT scans. It’s sort of the same cumulative risk. If, you know, the age, just say we’re ignoring the age. If you have those three CT scans one after the other. So there’s not, we don’t separate that time period. It probably is not entirely true. There’s probably some repair that goes on for the protracted time. But I think fundamentally, we just assume once you have a CT scan, irrespective of the length of time between the next, that that risk accumulates with subsequent risks. It’s not entirely clear. And I will say too. It’s important for all of US to understand that we talk about risks from diagnostic imaging, radiation risks. These are very, very low dose studies. And there’s a great deal of uncertainty. We do not know for sure whether a single examination, the vast majority of examinations from diagnostic imaging does result in an increased risk of cancer. There’s some strengthening evidence that’s improving our understanding, but there’s still uncertainty there. So when we talk about cumulative doses, cumulative risk. There’s still a cumulative uncertainty that goes with that exam to exam. And it’s, I guess, one way to look at this. One of the main issues and questions that come up, which is, I think something you’re angling at is how should that imaging history be used in terms of making decisions? You know, if someone’s getting five CT scans, when that next CT scan comes, is it a different pathway? Is it a different decision there than it would be if that patient didn’t have that CT scan? And. The way I look at this is in the situation where it’s an acute question that needs to be answered and that CT is warranted. I think most providers would agree that needs to be done. It doesn’t matter whether you’ve had four or five or one or none beforehand. If you need that examination, the past dose history and whatever accumulation dose there should not make that much of a difference. The situation is different when we talk about disorders that might need multiple imaging things. And in that way sort of planning the protocols and the management of these patients. I think how often they’re done, how many are done, being attendant to what the potential accumulated dose and accumulated risks there is important. So those are the two different scenarios. It’s sort of the planning of the patient that might need recurrent imaging versus the acute setting. But I think most providers, again, in the acute setting, if someone needed an examination, the conversation may come up. Well, I’ve had something before. If you need it, you need it. There’s one situation, too, where it’s sort of in between those, which is say a patient is having lung cancer screening, right? Getting CT examinations, a smoker and has some chest pain. And their doctor says, well, we’d like to get a cardiac CT just to make sure your heart is OK, your coronary artery is OK. Let’s do that. And let’s say they’re scheduled for their low dose screening examination a month from now. And the doc wants to get that exam right now. They don’t may negotiate and say, let’s do those together. OK, let’s do a single exam. You don’t need to have two because we realize there is an accumulation of dose from your recurrent imaging, even though it’s low dose. And we can just blend those together. So it’s sort of in between the acute setting and that expected recurrent imaging setting. But it’s a great question. And that’s the way I separate them out. It’s sort of immediate decision and necessity versus planning on a recurrent. Yeah.

Chris St John – 00:24:52:

Given your extensive experience with pediatrics and just talking about the need to lower dose for smaller bodies, I’m just curious, what is your approach where you say you have a pediatric patient who has some sort of chronic condition? Like, how do you approach that from the beginning?

Donald Frush – 00:25:09:

Right. Yeah, it’s very good to understand what that is. And I would say just in general, those conditions that are going to require some recurrent imaging in terms of follow-up, as with many things, getting all the stakeholders together. So if it’s a GI condition, having the gastrointestinal doctors, the surgeons, the emergency medicine providers that may see that patient in the acute setting, and the radiologists together and say, okay, what is the pathway we want? When do we need to do MR? When do we need to do CT? Is ultrasound going to be appropriate, et cetera? And I’m just giving that one scenario. But I think in developing the guidelines, there are practice parameters through the American College of Radiology to say, okay, in this setting of, say, urinary tract infection, this is what we recommend for imaging evaluation. In this setting of cancer, this is what we recommend. And some of those cancer pathways come through close work with the oncologist too. And generally all of the stakeholders are involved in determining those pathways, whether it’s for children or adults. Now, there can be modifications. Something changes in the status of a patient. They become ill for some reason, develop a fever, need imaging. Then we go back to the acute setting, and is a CT the right thing to do? And if so, it doesn’t matter that they’ve had several CTs for monitoring their cancer because their immune system may be compromised. We need to be sure that there’s not something going on here. So you sort of change the pathway there based on how the patient’s doing. But I think, again, developing those imaging pathways in the setting of those patients who are going to require recurrent imaging is very helpful.

Chris St John – 00:26:54:

Yeah. And feel free not to answer this question, but I just have to ask, do you have any stories or firsthand experience where recurrent imaging ended up creating like too large of a barrier? Or like, on the other hand, if it ended up being like, thank God we kept running those CTs. Like, I’m wondering if you have any specific instances that you can refer back to where this came up.

Donald Frush – 00:27:21:

Yeah, thinking about it, it does come up in general conversations. I don’t have a particular patient scenario because in the environment I work in with very capable pediatric healthcare providers, whether they’re surgeons or emergency medicine physicians or oncologists or any specialty, there is, I think, an understanding that when they feel something is warranted. They will order this or ask for this. And we review all the examinations before, as many radiologists do, before they’re officially protocoled. And we can have a conversation with them and say, hey, you know, they had a CT a week ago. I think, you know, we could probably get by with an ultrasound there. And that’s an individual radiation dose assessment. But the same thing applies to recurrent imaging. Again, I can’t recall a specific conversation where we said, boy, they’ve had this many CT examinations, so you really ought to do something else. It gets at collegiality and respect for what the providers do. A difficult situation will be, you know, a child that goes to, say, several institutions or an adult that goes to several institutions and has imaging at other places. And maybe they’ve had a CT a week ago or 10 days ago. If we don’t have access to that, we can’t say what might be answered and what might determine that they need or show that another study like an ultrasound might be indicated. So when we don’t have those outside, what we call outside imaging examinations, we’re a little bit less able to sort of have the overall radiation picture. And it may be that we get a CT that might not have been one that would have been done had we had those outside imaging studies. And it’s not pervasive that that happens, but it does happen on occasion. We just don’t have that information available at the time that the decision needs to be made.

Chris St John – 00:29:10:

Yeah. And so you touched very briefly on protocols in that answer. And I’m just kind of curious, are there specific techniques or protocols that radiologists can adopt to ensure optimal image quality while, you know, either for an acute patient or a chronic patient, honestly?

Donald Frush – 00:29:30:

Yeah. And the protocols, depending on the modality, are… In general, available on a variety of sites. Like I said, the ImageGently website has protocols, AAPM has great CT protocols, other information on how to do those in a general sense is widely available. And what should happen at a practice or an institution is that there is a champion, a lead that’s tasked with making sure that the protocols are in line with what is generally recommended and should work in conjunction with all relevant stakeholders. Again, if it’s a technologist, it should involve medical physics, health physicists, or radiologists, or other imaging experts in terms of fine-tuning that protocol. Because it may be at, say, a cancer center that additional detail is needed, higher detail, higher dose examinations, more phases with CT. We do different time points that we do CTs with contrast administration. And it may be that a general CT for appendicitis is quite different than looking at a very small lesion in the pancreas in a children where you might need a higher dose or more phases. So it would be going back to the idea that a practice or institution should fundamentally start with the available general protocols and then go and make modifications that are necessary. And this gets at the idea, too, of once that has been done, you need to continue to audit your practice, right? You need to be sure that what you’re doing is still in line. And that means periodically revisiting these things. For example, CT examinations, there are benchmarks that are available through the American College of Radiology, the Dose Index Registry, that subscribing to this, you get the doses that are for a number of examinations done across the country. And it can be divided into region. It can be divided into type of practice. And so you can say, hey, where are we? Are we within the range of what is done other places or not? And it may be that there’s been some drift and you need to revise your protocols, et cetera. So it’s, again, getting back to that question, it’s, I think, first of all, deciding that it’s important. Second of all, recruiting the appropriate resources because this kind of thing takes money. It takes time, et cetera. So it’s getting the administration, the department, the practice leaders on board with this. It’s getting the right people in place with multiple stakeholders, looking at what’s available and pretty widely available on free sites for protocol guidance. And then once you institute that, audit that and make sure that over time, you’re able to maintain that level of radiation protection.

Chris St John – 00:32:12:

Yeah, for sure. I mean, and thinking about all of that, right up to this point, that’s been the approach that’s been what’s necessary. But we’re just approaching this point in technology where we have so much more at our fingertips. I was just talking with Dr. Siegel about AI and radiology, you know, talking about various things. But specifically, I’m curious about AI and modern technologies kind of approach and handle on dose management specifically. And I’m curious how you see this path moving forward.

Donald Frush – 00:32:47:

Yeah, and everybody wants to know about AI.

Chris St John – 00:32:50:

Yeah, who doesn’t?

Donald Frush – 00:32:53:

About how it’s going to affect the world and how it’s going to affect you personally. And those that are dependent or required to institute it are also wondering about where it goes and how we get there.

Chris St John – 00:33:07:

Yeah.

Donald Frush – 00:33:08:

I would say that’s probably one of the major challenges facing radiology today. There are other ones like workforce shortages, the separation of radiologists sort of from the virtual world, you know, being able to read from home. And I think that has some downsides. Right. But AI is certainly on that list, probably, you know, within the top three, whether you make it number one or not is up to one’s own decision. But, you know, there are multiple ways that AI can be used in the radiology domain. With respect to radiation protection, probably the summary part of that is, can AI help with dose reduction in providing some increase in image quality with lower doses that still provide diagnostic capability? There are some things with, you know, assists and diagnosis too that might be sort of a subscript there. But it’s. Phenomenally, I think mostly in CT and in nuclear medicine and PET-CT, how can we decrease the dose and yet reconstitute that image to be sure we have diagnostic accuracy? I think there’s also some work in sort of looking at multimodality, individual patient multimodality, taking an MR, perhaps taking an ultrasound, taking prior CTs and saying from a standpoint of another imaging modality, like getting MR. How would this appear on CT and can we compare it without that patient having a CT? It’s sort of an innovative approach. We’re not there yet, but we are at the point of dose reduction and increase in image quality using artificial intelligence. It’s really important to understand, I think, the landscape of that in children. You know, the testing, the data sets, the diversity of children’s individual physical characteristics. The authentication of AI that may be used in adults is something that needs a lot more work. Much of what’s done is in the adult population and simply apply that to children. Say, you know, we have this technology that makes a CT scan look really good, even though we’ve used low dose, but it’s not been tested and validated in children is problematic because it may lead to things that aren’t really there that generate some additional concern or imaging or it may obscure things that are there. So it is a problem in pediatric imaging that AI, it has traditionally been developed for the adult population. There’s currently a paper being prepared by various international pediatric radiology societies, Society for Pediatric Radiology, European Society for Pediatric Radiology, Latin American Society, and some Asian societies, which is going to get at this global issue of AI use in pediatric imaging, which sort of touches on these issues, ethical issues, appropriate testing, data sets, validation, et cetera. So it’s sort of a caveat or a takeoff of the question you ask is it does have, AI does, have some application and will be, I think, something that’s very helpful in terms of radiation protection. But we do have to be careful and cautious about the application in the pediatric population for some of the issues that I discussed.

Chris St John – 00:36:24:

So this is the first moment where I don’t just immediately have a natural follow-up. So just give me a moment.

Donald Frush – 00:36:31:

No problem.

Chris St John – 00:36:31:

I mean, so far this has all been, this is A-plus stuff, Dr. Frush.

Donald Frush – 00:36:35:

Is it what you want? Yes. Oh, okay. All right.

Chris St John – 00:36:38:

Oh my gosh, yes. I mean, it’s ideal in a word. And you’re very natural on a microphone, might I say. Oh, well.

Donald Frush – 00:36:46:

You know, and I think as our conversation goes on, you know, first of all, thank you for doing this. You know, any way that we can talk. Yeah. About radiation in a non-stressful way, because oftentimes these conversations and questions come up when someone is getting imaged or an exam is ordered and so on. And it’s just the tone and emotion involved in that is quite different. So to have something like this that is a more relaxed, non-stressful environment is really helpful. So thank you for this. And it’s also important as much your population, I think, you know, well, the majority are going to be imaging experts. The technologists, I think, are such a strong voice in the need for radiation protection and to be able to understand sort of where we are, what the sort of summary levels of radiation are, what we’re doing to advance imaging and potentially answer questions for the patients they take care of, because they’re frontline. They’re the face of radiology. It’s not me. They don’t want to see me. They see the technologists. That’s the experience they get. And that specialty is so integral in terms of the professionalism that we do. So for all those technologists who are part of this session, thank you for doing what you do.

Chris St John – 00:38:03:

Yeah. And actually, that brings me to a question. You know, you’re talking about the communication with patients and emotionally stressful time, potentially while they’re under duress, while they’re stressed. Do you have any advice on either kind or effective communication in helping patients understand the risks and the benefits of radiation exposure in these moments, right?

Donald Frush – 00:38:29:

Well, I’m glad you asked, and I did not feed you that question. No! But it is something that’s very near and dear to my heart because we’ve not done a very good job of this. And to me, there’s two parts of communication. There’s content and there’s delivery. Right. Of course. And we’re pretty doggone good with content. I mean, there’s a lot out there about low-level radiation, what we do understand, what we don’t understand, what are the doses of imaging modalities. There’s a lot of factual information out there, but the delivery is incredibly important.

Chris St John – 00:39:01:

Yeah.

Donald Frush – 00:39:01:

A content delivered badly is bad. Content delivered well is good. So you need to have good content, but delivery is the fundamental requirement of effective communication. And people need to understand, at least from pediatrics, that a nuance of pediatric care versus adult care is that that decision about imaging, whether it needs to be done, when it needs to be done, how is it going to be done? Is there radiation? What is the risk? Is a parent making that decision for that child? That is a huge psychological thing that often stays with these parents that I’ve talked to for years.

Chris St John – 00:39:38:

Yeah.

Donald Frush – 00:39:38:

And they get back with me and say, five years ago, my child had this, I heard radiation caused cancer. I am really worried that they’re going to get cancer. And so it stays with them. That’s very different than the covenant between a 55-year-old who might have pneumonia and they want to get a chest CT just to make sure it’s nothing. That is a decision that’s between the provider and that patient. So this triad; patient, parent, or caregiver, and provider is really important for people to understand. And I say that, while this does apply to adults, is because if you think about your own experiences in medicine and maybe in the acute setting, if anyone’s been in the emergency room or needed acute care, is you want to know that the people who are doing this know what they’re doing, number one, and that they’re sensitive. They understand where you’re coming from, number two. And that they’re engaged, number three. So be informed, be sensitive, and be engaged. And I just go through conversation that can happen in the emergency room. Say a child needs a head CT and the parent says, I hear radiation might cause cancer. Is that true? And the provider says, I don’t know. I don’t know that. What is the radiation from the CT scan here? Well, I don’t know that. That’s the radiologist. They’ve had other imaging examinations. Do you know how much radiation they have? Well, I really don’t know that either. So you can see, the confidence level is not there. And those are all reasonable questions from someone who doesn’t deal with radiation, right?

Chris St John – 00:41:03:

Right.

Donald Frush – 00:41:03:

So the way to handle that conversation is, and I always start out with, and I think this is effective no matter who you are in medicine, particularly imaging, is to say, that’s a great question. Because people want to know that you appreciate what they ask, even if it’s not a great question, right? If it’s kind of silly, you know, you say, thank you. And what I do is I say, you know, thank you for advocating for your child. Not many parents ask that. You know, very few ask this. Right now, you’ve got them. You’ve brought them in. You said, you are a special person to me, right? You’re advocating for your child. That’s a great question. I can answer that. This is what we know about the CT scan dose. This is what we know about how we do it here. And I don’t deal with any particular numbers with radiation risk. And at the end of that, you know, I say, this is how we’re going to do it. And to say, this is an important examination. Your providers need this information to make decisions, even if it’s normal. That helps make decisions about what pathway not to go down. So it’s really important that this is done. Do you have any more questions? And if you think about that line of responses, you’re being sensitive, you’re recognizing they’re advocating, you’re informed, you know that at your practice, you do low-dose imaging, that pediatric patients are treated specially, they’re taken into consideration, that this is an important, important thing to do. It needs to be done. And you’re engaged. Do you have any more questions? And at the end of those conversations, there may be a question or two, but what you’ve done is you’ve touched someone on the shoulder, you’ve taken their hand, you’ve walked with them, and while you’re walking with them, you’ve made, you’ve stressed the fact that this is important. Do you have any other questions? It’s a done deal.

Chris St John – 00:42:49:

I love that, especially thanking someone for their question.

Donald Frush – 00:42:52:

It’s so simple.

Chris St John – 00:42:54:

It’s so easy.

Donald Frush – 00:42:56:

Right.

Chris St John – 00:42:56:

Words of affirmation are my bread and butter. I could not eat for a year. And if people just said, thank you and I appreciate you, I’d survive.

Donald Frush – 00:43:03:

Right. We’re all that. We’re all humans. Yeah, we are that way. Yeah, and it goes such a long way. And when it comes across sincerely, and while I talk about that approach from the use of ionizing radiation and medical imaging, it helps in any interaction you have with individuals. You know, thank you for asking that. It’s really good. Let me tell you what I know about it. And this is why we’re heading on that pathway, whether it’s in business or car repair or whatever, or with children. You know, you form those responses a little different with kids. And then, you know, is there anything else that I can answer for you? A nuance of this is I do avoid the word OK, because anytime you add OK to a conversation, you are saying, I’ve given you all this information. So now do you agree with what? I say. I don’t want them to have to make that decision of whether they agree or not. I’m telling them in a respectful way why we’re doing this and that I’m going to take care of them. And so I never put okay in that conversation. It’s a very frequently used word and it just conveys this idea of I’ve given you all this stuff, but maybe you don’t think that it’s important, right? Tell me if you think it’s important and which way we had and so on. So I really avoid that word.

Chris St John – 00:44:15:

Yeah. Okay. I’ve never thought about it before, but it really does have such like a subtle nuance in terms of-

Donald Frush – 00:44:22:

It’s like consent.

Chris St John – 00:44:23:

Right. Yeah. Forcing some sort of response.

Donald Frush – 00:44:26:

Right. Yeah.

Chris St John – 00:44:27:

You know, honestly, I think about my old business partner taught me one time, you know, I came in and an employee was, you know, not having a good time. I didn’t notice. And I was like, Hey, how are you? You know, and they look at me just like, I’m not good. And I was like, Oh, right. Okay. Like, let’s get into it, I guess. Or what can I do for you? All of this. But, you know, I was talking to my old business partner about it and, you know, one subtle little change. He was like, you can always just say, it’s nice to see you. You can affirm this person. You can let them know that they are bringing joy into your life in a greeting and you don’t put anything onto them. You’re not forcing them to reveal anything about themselves. You’re not forcing them to engage.

Donald Frush – 00:45:07:

Absolutely. Yeah.

Chris St John – 00:45:08:

You just get to tell them that you’re here for them. Right. And that has always stuck with me. I kind of see it as the same thing.

Donald Frush – 00:45:15:

Right. Absolutely.

Chris St John – 00:45:16:

Like this forced consent.

Donald Frush – 00:45:18:

Well put. Yeah. Right. It’s acknowledging that they’re there and that you are going to be part of that experience instead of the challenge of why, you know, why this and whatever, you know, it’s a much more welcome entree into that, whatever interaction you’re going to

Chris St John – 00:45:34:

I have. Yeah, absolutely. I mean, you’re full of these wise little moments. One thing I’m really trying to do with this show is to try and reach, you know, potentially the next wave of radiology techs, the younger folks in the US or honestly all over the world, whoever falls into our listener base. And I’m curious, you have this extensive experience. What advice would you give to a young radiology tech or someone who’s considering the field or someone who’s in residency or something? What advice would you give folks who are just starting to navigate the complexities of radiation safety?

Donald Frush – 00:46:13:

It’s a really good question, Chris. And it’s a little bit dependent on who that individual is and what their level of training is and so on. But as always, to validate that what they’re doing from a professional standpoint is appreciated. Right. Yeah. And the value of that to the patient, right? Because fundamentally, what is healthcare? What is excellence in healthcare? It’s making sure that the patient is well taken care of. Now, there are multiple levels, you know, efficiency, effectiveness, you know, marketing, professional advancement. There are many things that are metrics for what someone might consider excellence. But if we talk about what is the fundamental part of why we’re here, it’s taking care of patients. And it’s… It’s protecting them from harm. And it’s also providing them a benefit. And, you know, medical imaging that uses ionizing radiation is, it’s like the poster child of that kind of thing of do good, but do no harm there. And so it’s sort of emphasizing the importance of what they’ve done from a professional standpoint and reiterating that radiation protection is an important part of that. And whatever level they’re at, whether it’s a radiology resident or, you know, an internist or a cardiology fellow or a radiology technologist or a health physicist, is to look at the domain of what you’re supposed to understand about the use of ionizing radiation and be familiar with the types of conversations that you might need to know. You know, what are you going to be dealing with? Providers? Are you going to be dealing with patients? Are you going to be dealing with other imaging experts, et cetera? And to sort of say, okay, what do I need to know? What kind of questions come up? What is the scope of what I need to know? Because you can’t know everything. And, you know, talk to senior individuals. Say, okay, you know, that’s part of the training here is what exactly do you need to know about doses and risk and so on. And to get talking points, I think to develop the population-based talking points depends on who you’re going to be speaking with, whether it’s a patient or a colleague or an administrator or a medical physicist related to that. And there is a variety of information available for individuals to do that. And, you know, to always remember, you know, the tenets of radiation protection, which is, is it the right exam? How do I work towards making sure it’s the right exam? Technologists may say, hey, they ordered this just yesterday. What do we need to do? And technologists have said this to me. And I said, wow, maybe they made a mistake. Maybe they didn’t know. And so that conversation comes up with the provider and say, you know, we did this yesterday or something similar. I think I can answer your question. So it’s for them to always be an advocate for the radiation protection. Is it the right exam? Be sure that it’s done appropriately and that everyone, you know, needs to develop in their own regard and role, this collective radiation protection program for wherever they’re working. So it does echo a lot of what we’ve talked about before, but it’s identifying a champion, right? The group that’s really invested in this, it’s providing the proper resources and it’s supporting those individuals because radiation protection is sort of an odd bird because it doesn’t bring in revenue, right? It doesn’t. It doesn’t reduce costs. Unless you’re not going to get an exam and you don’t use it, but then you’re talking about the rest. So it doesn’t bring in revenue. It doesn’t reduce costs. And it’s actually costly because you do need to provide, you do need to put together the team to do this.

Chris St John – 00:49:44:

Of course, it takes time.

Donald Frush – 00:49:46:

And if you think about it, if you step back and say, okay, radiation protection or any safety in medicine, what is the measure of success? And the problem with radiation protection and any element of quality is no one comes home after being a champion of safety or radiation protection and say, gosh, all my patients were really protected today, right? It was 100% protection. Why? Because that’s expected, right? What do people come home with? Oh my gosh, this CT, we’ve drifted and we’re using too much dose, or this patient got a procedure and didn’t need to do it. Or, you know, the chair is calling me and saying, what happened with this procedure? This, you know, patient is complaining that it took too long and they got too much radiation. So those individuals who are invested in this just have to understand, lobby for what they do, but realize that it is somewhat of a thankless task in that, you know, those, all the measures of what we consider, you know, what do we want to do? We want to, you know, have a beneficial practice, which actually can support itself. We want to make sure costs are reduced. We want to come home and be, you know, happy about what we’ve succeeded in. And, you know, a lot of the quality people, a lot of radiation protection is, you know, the success is perfection and that’s what’s expected. So if people remember that, real respect of what you’re doing, you’re in a health physicist, medical physicist, et cetera, is to understand that domain, but also go back to some of those earlier things that I talked about in terms of defining what you need to do, developing talking points, working with the stakeholders, being a champion, and just knowing that you’re responsible for radiation protection. You know, if you think about it for yourself, you know, what would you want for you and your family? Is that what you’re doing for your patients and the colleagues that you work with?

Chris St John – 00:51:25:

Yeah. I feel like there’s got to be like some sort of aphorism in there.

Donald Frush – 00:51:29:

Okay. Well, let me know if you figure that out.

Chris St John – 00:51:33:

I don’t know what it is. When I come up with it thing, there’s something about doing great thankless work. I can’t quite put my finger on it yet, but yeah.

Donald Frush – 00:51:41:

Well, yeah, it is.

Chris St John – 00:51:42:

We’ll get there. Yeah. I want to be respectful of your time. Do you have time for just one more question?

Donald Frush – 00:51:48:

Yeah, I do. After I’m done here, I’m going to go out and brush hog the pasture so it can wait.

Chris St John – 00:51:54:

Amazing. So this may be too big of a question, so bear with me. But if you could change something about how we’re currently managing radiation dose and our approach in clinical practice, what would you change?

Donald Frush – 00:52:09:

Well, yeah.

Chris St John – 00:52:10:

If anything.

Donald Frush – 00:52:11:

I said. Thank you, but I can’t believe you asked me that.

Chris St John – 00:52:14:

It’s a big question. I’m just curious. I want to know.

Donald Frush – 00:52:19:

Yeah, I think when I look at this, fundamentally, all the information that we need to educate each other, educate our patients, educate our providers, do good imaging, have appropriate and justified examinations, it’s all there. It exists in some form or another. It’s just trying to figure out how to take these tools and really build a consistent practice across all different parts of the country. We still have a ways to go. There’s still doses that are probably too high. There’s still variability that doesn’t need to exist. There’s still examinations that are done that don’t need to be done. There’s still a level of concern which could be mitigated by just simple conversations. And we’re working towards that. That’s what ImageGently is available for, and ImageWisely are out there. We need to leverage social media better than we do. Some data has suggested that what’s available on social media regarding medical radiation is all about the detriment and the beware and stuff like that, instead of emphasizing the value of this and how people are working together to do this. And one thing is we, as medical professionals, have not done a consistent job in finding out exactly what the public, what patients, and what parents want to know or need to know or understand about radiation. In order to address those questions and in order to provide a comprehensive, you know, sweeping practice that is attendant to all these things, we have to listen to them. And we’ve just sort of decided what we think is important in terms of content, how to put it up, where it should be, and we can’t believe that people don’t understand it. So there is currently a grant through the Patient-Centered Organization for, let’s see, a Pecorius Patient-Centered Outcomes Research Institute that colleagues at Duke have developed. We’re just addressing those questions. So we’re going to go to the public, go to providers and say, okay, what do you understand? How do you get this information? What do you want to know? And how best can we provide it? It’s a phased approach, but I’m very excited about this because I think that will begin to tell US why some of the efforts that have been put out there, some overlapping, there are some gaps, have not been as successful in terms of radiation protection. So more to come on that. It’s a two-year grant.

Chris St John – 00:54:46:

Yeah, and just small follow-up. Given the context of our conversation right now, we are effectively creating content podcasts. We will be posting clips on social media about the dangers, safety, benefits of radiation dose. I’m just curious, do you have anything to say that we can throw up on social media that really emphasizes the value of imaging? Like, do you have anything at the top of your mind that would help deliver this message that you’re talking about? And no pressure.

Donald Frush – 00:55:15:

I guess it is. Yeah. I want to come at this idea of medical imaging that uses ionizing radiation from the standpoint of always introducing that it is incredibly valuable and that our examination program with recurrent imaging is very important to your health. To not do it may have more detriment than any potential risk of doing it. And it’s always to come at it from that standpoint, to set a tone that medical imaging is valuable. For example, there are conditions that if you don’t get an imaging examination, say someone has a head injury and they have maybe a little bit of loss of consciousness, but are okay to not get a head CT examination, they may have something significant, which with this kind of blood on the brain, an epidural hematoma may result in death rate of one in two to about one in 20 or more. Okay. So that’s pretty significant. Whereas the risk of developing cancer from that CT examination may be one in 10,000. So it is to put the perspective of the value of imaging front and center to understand that radiation protection is important, that there are health considerations that we are aware of and doing everything we can to minimize. And those health risks for a single examination are uncertain, but we are certain of the value of that examination. So it’s how you approach the conversations, whether it’s with a provider, a patient or a caregiver for that patient. Does that make sense?

Chris St John – 00:56:52:

Yeah, that’s great.

Donald Frush – 00:56:53:

Yeah.

Chris St John – 00:56:53:

That’s exactly what I was looking for.

Donald Frush – 00:56:55:

Yeah.

Chris St John – 00:56:56:

Well, Dr. Frush is the professor of radiology and an associate faculty member of the medical physics graduate program at Duke University Medical Center. Dr. Frush, thank you so much for joining us today on Brain by Frame Rethink Imaging. I had an excellent time talking with you today.

Donald Frush – 00:57:13:

Well, thank you for the invitation. It was a wonderful conversation. You asked great questions. I think these are things that people want to know, and I’m sure that this information is going to be helpful for them. Thank you again for the opportunity to talk with you today.

Intro/Outro – 00:57:27:

Dr. Frush, thank you so much. Frame by Frame: Rethink Imaging is brought to you by Imalogix. Here, you’ll find engaging interviews with thought leaders, experts, and patients, sharing stories that showcase the transformative power of medical imaging. To discover how Imalogix is rethinking imaging in healthcare, visit emologix.com. Be sure to subscribe to Frame by Frame: Rethink Imaging on Apple Podcasts, Spotify, or wherever you listen. And from all of us here at Imalogix, thanks for tuning in.