First, I thank the ICRP for the drafting of the document, for the full transparency and the given opportunity to share comments.
This document represents an excellent support for the implementation of the optimization principle in Imaging facilities all over the world, despite the fact that not all the facilities around the world have the necessary tools, teams, nor expertise to fully embrace optimisation and take it forward to the same end-point, as well reported in paragraph 3.1, lines 1119-1123.
I completely agree with ICRP that optimization, , along with justification, is one of the two pillars of medical radiation protection and that it is necessary to invest in adequate staffing levels and providing appropriate training to all professionals as reported in EXECUTIVE SUMMARY, page 9, lines 293-295.
Optimization process is complex and it requires all staff members (radiologist, radiographer and medical physicist) working together as a team.
In my opinion a basic (“C”) level of optimization could be easily achieved in most of the countries all over the world, despite the fact that all the “actors” of imaging process act as “individual” or as a “team”.
Anyway If an intermediate (“B”) or advanced (“A”) levels of optimization would be achieved, the team approach proposed in paragraph 3.3, pages 32-34, is fundamental.
To do that Radiologists/Medical practitioners and all other healthcare professionals have to work closely together, as correctly emphasized several times in the text.
It is important to delineate unique roles and responsibilities of all healthcare professionals involved in imaging process, as well reported in table 6.1 page 74. In the document there are some inconsistencies in healthcare professionals terminology (radiologist practitioner?).
As well as it is also important to delineate figures and the non-interchangeability of their roles.
In some countries, this may seem pleonastic but in other countries, the physical presence and cooperation of all staff members may not be guaranteed due to economic or commercial reasons. We should keep in mind that justification and optimization should be patient-centered and not professional-centered.
There are some inconsistencies in terminology used particularly in relation to the descriptions of healthcare personnel involved in radiological imaging and optimisation. Some but not all of these have been highlighted in the comments. It is suggested that wherever possible generic role descriptors should be used and specific titles such as radiologist, radiographer etc avoided.
Paragraph 6.2. Professionals with a role in the optimisation process, Pages 73-74
In medical imaging optimisation is a continuous, never-ending process that should be performed at two levels 1) the design and construction of the equipment and the installation where it is used and 2) the day to-day working procedures performed by the staff involved, as correctly underlined several times in the document.
To achieve an advanced level of optimization a core team should include the medical physicist, the radiologist, and the radiographer/technologist, each using their unique sets of skills to improve imaging performance and address deficiencies.
At level 1, protocols optimization and monitoring and analysis of performance are fundamentals and requires a high level of cooperation (at least) between medical physicist, radiologist/medical practitioner and radiographers.
At level 2, Individual optimization in day-to-day work requires the physical presence of radiologist/medical practitioner and radiographers for common procedures (such as conventional x-ray, CT, diagnostic fluoroscopy). In the case of complex / uncommon procedures (such as interventional fluoroscopy) the involvement of a medical physics is recommended/mandatory.
So I agree with the following statements:
lines 2526-2528 “Key professional groups each need a specific set of knowledge, skills and
2527 competencies (KSC) to ensure their effective contribution and participation as a team in the 2528 optimisation process”.
lines 2550-2551 “....the lack of access to a Medical Physicist qualified in medical imaging is an obstacle to optimisation,...”
lines 2553-2554 “...In addition to being responsible for the technical QC and dosimetry, clinically qualified Medical Physicists have specific skills and competencies in optimization...”
Individual justification of medical exposure is a fundamental, complex, procedures that requires high level of competence and a clear definition of responsibilities and tasks among all professionals involved in medical exposure.
Individual justification of medical exposure is a medical act and the responsibility of this has to be maintained by radiologists or other medical practitioners.
A procedure considered clinically unjustified means 100% dose saving to the patient. A clinically unjustified procedure considered justified means exposure to potentially harmful ionizing radiation.
That’s why all procedures have to be performed under the clinical responsibility of a medical practitioner who act as a supervisor of the entire process: justification (and suggestion of alternative techniques and methods in non-justified procedures); provision of information and informed consent; optimization, collaboration with other health professionals involved (radiographers/imaging technologists) , interpretation / reporting / communication / discussion with the clinician ; archiving.
The Radiological Medical Act, as described by The Italian Society of Medical and Interventional Radiology in “The Radiological Medical Act, Approved by the SIRM Executive Committee on July 2, 2007” [Radiol med (2008) 113:319–328 DOI 10. 1007/s11547-008-0266-5], consists of a series of strictly interdependent and related moments.
Due to these reasons I suggest to use:
L389 “medial practitioner” instead of “radiological practitioner”
L391 “medial practitioners” instead of “radiological practitioners”
L395-396 “medical practitioner” instead of “radiological practitioner” and “other medical specialists” instead of “other healthcare professionals”
In any case, I totally agree with the statement (pages 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
Paragraph 1.2 Justification and optimisation of medical exposures
Pages 11-13
medical physicists, radiographers, and radiologists, cardiologists and other clinical radiation practitioners is key to achieving optimisation of imaging and establishing and reviewing clinical protocols”.
Chapter 5 EVALUATION OF IMAGE QUALITY
Image quality should be always evaluated by a medical physicist together with radiologist or medical practitioner. Images could have acceptable physical parameters (i.e. noise ratio or spatial resolution) but that not means that they are clinically acceptable.
Due to that I suggest to change sentence “with medical physicist, radiologist and/or medical practitioner (for instance when a previously unseen or unknown" at line 2264
For the same reasons please consider tue possibility to add “radiologist and/or medical practitioner” at the end of the sentence of L1037 in paragraph 2.4.4. Contract management and maintenance.