On behalf of the European Federation of Organizations for Medical Physics (EFOMP) I thank the ICRP for the efforts dedicated to the drafting of the document and for the full transparency.
EFOMP agrees with ICRP that optimization is particularly important in medical field, as (pag. 7, lines 199-201) Medical exposures are the most significant contributor to the exposure of the population world-wide from artificial sources of radiation.
In general, EFOMP agrees with what is expressed in the document, which we think can represent an excellent support for the practical implementation of the optimization principle in medical imaging. This also from the point of view of the organization and harmonization of staffing levels.
In fact, to pursue a better practical application of the optimization principle, it is necessary to invest in adequate locally available staffing levels and providing appropriate training, as outlined in
Pag. 9, lines 293-295 Optimisation will only be achieved through facilities investing in adequate staffing levels to operate their imaging equipment, and providing the appropriate training, together with professional development opportunities for their staff.
Furthermore, EFOMP agrees that "digital is not intrinsically better and safer just because is newer ...". In fact, the effective and optimized use of novel and more complex xray systems is not automatic, as it is correctly underlined several times in the text, (for example pag. 15, lines 557-568) but requires trained healthcare professionals to get a more refined exposure/image quality optimization for patient benefit, starting with radiologists that have the clinical responsibility of medical exposure. This point is crucial: local radiology/medical imaging departments as well as medical physics departments are always too small or, in extreme cases, even not available. This document represents a great opportunity for all countries that do not have adequate local staffing levels (radiologists, radiographers, medical physicists), to ensure patients an effective, optimized and safe service, also considering that optimization is a dynamic process, which requires continuous updating, as correctly emphasized several times in the text. In particular, EFOMP fully agrees with the following statements
(pag. 30, lines 1119-1123) At the present time, the majority of facilities around the world do not have the necessary tools, teams, nor expertise to fully embrace optimisation and take it forward to the same end-point. There are particular concerns when digital imaging equipment is introduced into centres for the first time. The replacement of older equipment with digital often creates a perception that the digital is ‘intrinsically’ better and safer just because it is newer or digital.
(pag. 31, lines 1196-1198) there are many centres throughout the world that will not be able to achieve this basic level at the present time, because of limited input or skills of professional groups, particularly medical physicist availability (professional skills), limited equipment and experience in performance testing (methodology), or an inadequate organisational support network.
For an effective application in clinical practice of the optimization principle, collaboration between professionals and teamwork are fundamental, as correctly underlined several times in the document (for example, pag. 33, table 3.; pag. 34, lines 1272-1274; pag. 35, table 3.2; pag. 36, table 3.3).
EFOMP agrees that artificial model observers can help in optimization, but “they are not a substitute for the clinical validation of protocols or systems, which …needs the intervention of radiologists…” (pag. 62, lines 2217-2220).
EFOMP fully agrees with the following statements:
(pag. 32-33, lines 1243-1248) At the start of the referral process communication between the referring clinician and the radiologist is essential for appropriate justification. If radiologists do not have access to the relevant aspects of their patients’ clinical histories, they cannot determine what imaging is appropriate. Communication between medical physicists, radiographers and radiologists, … is key to achieving optimisation of imaging and establishing and reviewing clinical protocols.
Pag. 72, lines 2465-2467 Investment in an adequate staffing level, with trained healthcare staff and a commitment to their continuous professional development (CPD) are essential when considering investment in new imaging equipment and software.
Pag. 72, lines 2475-2478. Medical physicists have a key role in optimisation, ensuring a link between the equipment and its clinical users. The ICRP strongly recommends that their education and clinical training be adequate for performing this role and for educating others in radiological protection.
Pag. 73-74, lines 2547-2557. Each of the professionals shown in Table 6.1 has an important role to play in optimisation, but due to the specific education as a healthcare scientist, the Medical Physicist has a key role in ensuring a link between the equipment/software and its clinical users. In many circumstances, the lack of access to a Medical Physicist qualified in medical imaging is an obstacle to optimisation, a problem that is of special importance for rural/small facilities or low- or middle-income countries where the profession does not exist or is not recognised as a healthcare profession. In addition to being responsible for the technical QC and dosimetry, clinically qualified Medical Physicists have specific skills and competencies in optimisation. The Commission recommends that access to Medical Physicists qualified in medical imaging is ensured in all activities related to diagnostic and interventional radiology, and that their education and clinical training be adequate for performing their role in optimisation.
Pag. 7, lines 224-228. Optimisation requires the input of knowledge and skills on many different aspects of how radiological images are formed and so requires contributions from different healthcare professionals working together as a team. The radiologist can judge whether the image quality is sufficient for the diagnostic purpose, the radiographer should know the practical operation and limitations of the equipment, and the medical physicist should understand the physical principles behind image formation and can perform and interpret measurements of dose and image quality. In order to achieve optimisation, the three specialities, together with other healthcare professionals who will sometimes be involved, must have mutual respect for their individual skills and work together as a cohesive group.