Re: MDL and Dose Effects - Medical "ALARA"

["Michael P. Grissom" <mikeg@SLAC.Stanford.EDU>]

Radsafers,

I believe a medical "ALARA" program in the fashion of an
industrial ALARA program, e.g., pre-planning a specific
activity within job specific accumulated dose limits, has
not been done routinely in the medical arena, at least from
the patient's perspective.  Efforts have been made from the
worker's perspective, particularly for radiology and cardio-
logy residents.

That said, NCRP Report No. 70, "Nuclear Medicine-Factors
Influencing the Choice and Use of Radionuclides in Diagnosis
and Therapy" (1982), at least did grapple with the concept
of patient referral criteria (which in some respects does
resemble the cost-benefit analysis expected for industrial
ALARA work planning).  Also, dose guidelines established by
the FDA, including feedback (again, an industrial ALARA program
is expected to have a "lessons learned" database to ensure
work experience is incorporated into work planning and training)
from demonstrated machine performance and recommendations from 
programs such as DENT (Dental X-ray), BENT (Mammography), and 
NEXT (general medical radiography) which all diagnostic medical 
physicists at least consider when reviewing the performance of 
the machines in their facilities.

The combination of patient referral criteria (usually physician
based) and nuclear medicine/radiographic equipment performance
(usually medical physicist/medical HP based) jointly affect who 
receives a dose and how much dose for a given medical benefit.

There is concern building that this process (never terribly
well formalized at many medical facilities) may be weakening
for hospitals due to the "relaxation" of JCAHO, the organization
concerned with the accreditation of hospitals in the US, on
radiological criteria which included the evaluation of radiographic
facilities, such as the use of phantoms to "optimize" performance
(read most diagnostically useful with least dose practicable).  The
exception, of course, is the MQSA requirements for mammography.
This has been linked to the managed care situation and the declining
resources issue in the US health care system.

So, Dave is right that some ALARA-like activity has occurred and
Wade is right that it has never been as formalized (and may be
declining) in the medical community.

Ciao,

MikeG.


At 10:17 AM 11/5/96 -0600, you wrote:
>David Scherer wrote:
>> I beg to differ.  A great deal of time, money, and 
>>effort are spent on keeping medical exposures ALARA, ...
>
>Dave:
>You're citing the exception that proves the rule.
>Not one dentist or internist in a 1000 with an xray 
>machine knows what ALARA means...
>Perhaps an ALARA discussion and justification takes 
>place on a case-by-case basis somewhere, sometimes, 
>but surely not in 90%+ of all the medical/dental xray 
>scenarios.
>
>Best wishes,
>Wade

-----------------------
Michael P. Grissom
Special Assistant, SLAC
mikeg@slac.stanford.edu
Phone:  (415) 926-2346
Fax:    (415) 926-3030