Rank Specialties by Level of Radiation Exposure

[wheatbar]

I have read some disturbing research on cancer rates among physicians, particularly those in specialties doing lots of fluoroscopy. For those of you with the most knowledge of this, can you please rank specialties by amount of radiation exposure with a numbered list? I've found that though many medical students and pre-meds are interested in certain fields because of potential pay (though they may not admit it) like interventional radiology, cardiology, pain management, urology, or even orthopedics etc. I was surprised to discover that there are several specialties where physicians get very significant exposure to radiation on a regular basis (all of those being some). I kind of have a small radiation quasi-phobia and though all of the official information from the corporations that produce the medical equipment say it is generally safe if you take the appropriate precautions, I have found that there have been few studies on incidence of cancer or leukemia among physicians relative to the general population involved in procedures like fluoroscopy or others that expose physicians to radiation in significant doses.

Here are some articles which deal with this issue:

http://radiology.rsna.org/content/235/2/709.1.full

http://linkinghub.elsevier.com/retrieve/pii/S0720048X0300007X

From cancer.gov "Health care providers are also at risk of radiation damage from chronic exposure to radiation from these procedures. There are an increasing number of case reports of skin changes on the hands and injuries to the lens of the eye in operators."

I'm curious about other specialties like general surgery, plastics, emergency medicine, anesthesiologists, general internal medicine, neurosurgery etc. -- how much radiation exposure do they get? Any help/information or a rank list would be greatly appreciated. It seems that all of the highest paying specialties are those that involve lots of procedures involving radiation or cosmetic procedures? Are there exceptions to this like certain surgery fields where there is little to no radiation exposure? I have read that even bariactric surgeons get a lot of exposure.

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[docB]

I'm curious about other specialties like general surgery, plastics, emergency medicine, anesthesiologists, general internal medicine, neurosurgery etc. -- how much radiation exposure do they get?

I would think EM is in the middle low area. Almost none of us do any fluro. We are standing around when they shoot a lot of portables though and we do occassionally gown up to hold Cspine on traumas and other critical stuff.

 

[Law2Doc]

If I had to guess, I would rank them as follows:
(1) interventional radiology
(2) diagnostic radiology
(3) nuclear medicine
(4) vascular surgery
(5) orthopedics
(6) anesthesia (from being in the room for the prior two)
(7) everything else

 

[wheatbar]

I think there are several others that were not included on that list. Was that because you are well-versed on this topic and believe that there are no others that are exposed to significant amounts of radiation or because you were just listing off the top of your head? For example, I think urologists, orthopedic surgeons, bariactric surgeons, etc. get significant exposure as well. Read this quote from and article below:

"Endourology is established in urology practice with routine use of fluoroscopic guidance. Medical personnel are rarely exposed to direct radiation exposure but secondary exposure occurs via radiation scatter. There are few reports on scatter radiation exposure and the subsequent risk to medical personnel involved in urological fluoroscopic procedures."

http://linkinghub.elsevier.com/retrieve/pii/S0022534701684623

Also, what about general surgeons?

 

[medicinesux]

Good grief, with my luck this is how medicine may just come back and bite me in the arse after i thought i finally got away . Either that or I find out that I contracted some horrible bloodborne disease. I hope I can make it out alive!

 

[dnslay]

I would put Urology up there too...

 

[wheatbar]

I guess I was looking for people with more experience in the field (i.e. not just based on the name of the specialty or an assumption about procedures but people that have rotated in many specialties and had extensive exposure to a specialty or those who are in practice) because cardiology was not listed and from the academic work I have read they have the MOST exposure to radiation -- even more than interventional radiologists.

 

[Guile]

If I had to guess, I would rank them as follows:
(1) interventional radiology
(2) diagnostic radiology
(3) nuclear medicine
(4) vascular surgery
(5) orthopedics
(6) anesthesia (from being in the room for the prior two)
(7) everything else

I would put PM&R high up there, too. The one I rotated with did epidural steroid injections, facet injections, etc. under fluoro several times a week. Lots of radiation exposure. Also, where does diagnostic radiology get its radiation exposure?

 

[docB]

This may be an ignorant question but do non-interventional radiologists get very much exposure? The non-IR guys I know spend their whole shift sitting in a bunker reading films on PACS. There isn't even any imaging equipment in the building they're in. I suppose the monitors emit some rads.

 

[Law2Doc]

I would put PM&R high up there, too. The one I rotated with did epidural steroid injections, facet injections, etc. under fluoro several times a week. Lots of radiation exposure. Also, where does diagnostic radiology get its radiation exposure?

The diagnostic radiologists I know all do fluoro and also spend substantial time adjacent to CT scanners and the like. Most of the studies on exposure of physicians were done on diagnostic radiologists and the radiation badges worn historically existed because of this field. I have limited exposure to PM&R.

 

[Coastie]

anesthesiologists...

wish we were given radiation badges.

 

[Superfrost]

why don't we throw needle sticks into this while we're at it?

 

[Guile]

Also would add pulmonologists to the list. They spend a lot of time doing bronchs and getting exposure there.

 

[gutonc]

Also would add pulmonologists to the list. They spend a lot of time doing bronchs and getting exposure there.

Exposure to what? I've only seen a dozen or so bronchs but not a single one of them used fluoro.

 

[gutonc]

I would put PM&R high up there, too. The one I rotated with did epidural steroid injections, facet injections, etc. under fluoro several times a week. Lots of radiation exposure. Also, where does diagnostic radiology get its radiation exposure?

Not PM&R necessarily but anybody who does interventional pain (Gas, neuro, PMR) will have plenty of fluoro exposure.

To the OP. In no particular order, the specialties with the most radiation exposure would include (but are not limited to):
Interventional (and diagnostic, but less so) rads - In most places, diagnostic rads does CT-guided bx and other fluoro procedures
Cards
Surgery - All subspecialties use fluoro in the OR to some extent but ortho, vascular, neurosurg and urology probably use the most
Interventional Pain - It's basically all done under fluoro
Gas - From being in the OR and monitoring imaging procedures requiring sedation
Rad Onc - Strangely enough, they don't seem to get that much exposure but since they basically spend their entire day around very high energy radiation, they'll get a certain amount over the course of a career

The rest of the IM and Peds sub-specialties have little to no regular radiation exposure other than being around portable XRays in the ICU.

If you want to avoid radiation, go with Path, Derm or Psych.

Finally (and somewhat OT), Law2Doc is always including Nuc Med in his various posts about different specialties. Not sure if this is just a quirk of where we did our training, but I have rotated at about a dozen different hospitals (med school, residency and fellowship) and have yet to meet a "Nuclear Medicine" physician. Radiology reads nuke studies (PETs and thyroid studies), Cards reads MUGAs, Endo and ENT direct radioactive iodine treatment and Radiation Biology (usually a PhD) does all the actual dose determination while techs/RNs do the administrating.

 

[wheatbar]

Thank you for the excellent post gutonc! It looks like there is a correlation between high $$$ and radiation exposure/fluoroscopy. There has not been a lot of data on cancer rates of doctors performing fluoroscopy but it seems like from the research I have seen it does seem to be higher if you look at the actual data and read between the lines as opposed to just considering the overall findings. I'm surprised more pre-meds or medical students don't take this issue more seriously. It seems that the more studies they do the more they find out that the radiation exposure from the machines the medical equipment corporations and mainstream articles say are safe were not as safe as they thought even if every precaution and every direction is followed. It's not like other professionals (like say JD's and MBA's) have to deal with this kind of thing.

Just found this article (cached from Google -- linkinghub.elsevier.com/retrieve/pii/S002234765480196X) that states the following "recent reports claim the inci- dence of leukemia in physicians as a ,group is three times that of acom- parable age group of laymen." It requires a paid subscription for the whole thing but that is disturbing to me and strange that more people (especially pre-meds or medical students interested in residencies/specialties with high exposure) don't think about this too much.

Does anyone know about exposure for plastics, neurologists, hospitalists? That's pretty surprising that radiation oncologists don't get a lot of exposure...

 

[Law2Doc]

...
Finally (and somewhat OT), Law2Doc is always including Nuc Med in his various posts about different specialties. Not sure if this is just a quirk of where we did our training, but I have rotated at about a dozen different hospitals (med school, residency and fellowship) and have yet to meet a "Nuclear Medicine" physician. Radiology reads nuke studies (PETs and thyroid studies), Cards reads MUGAs, Endo and ENT direct radioactive iodine treatment and Radiation Biology (usually a PhD) does all the actual dose determination while techs/RNs do the administrating.

At the bigger academic centers, nuclear medicine is its own distinct specialty. It has its own residents (you can apply on ERAS to match into nuclear medicine -- if you do a google search you will find multiple programs, usually 3 years plus a prelim year), they go to their own national meetings, and in many hospitals have their own distinct department and reading rooms. The interest amongst US grads is limited these days because (1) it is a dying field, as it is being usurped by radiology (especially now that the major studies are soon going to all be combined modalities (PET-CT, PET-MRI)), and (2) it is very research intensive (probably due to seeing the writing on the wall that folks need to justify their existence independent of radio). But as of this date it is a separate and distinct specialty, and you certainly can meet nuclear medicine physicians if you look hard enough, usually deep in the basements of the hospital next to the pathologists. It's very noncompetitive (unlike radiology) due to its questionable longterm future, so it tends to fill up with foreign educated folks and folks hoping for a longshot backdoor into radiology.

And since they all administer their own isotopes to patients, they tend to have decent exposure to radioactive materials.

 

[Law2Doc]

...
Surgery - All subspecialties use fluoro in the OR to some extent but ortho, vascular, neurosurg and urology probably use the most...

I would put ortho toward the top of this list simply because in many cases those dudes have to hold limbs in certain rotational positions when shooting an image, and you frequently see hands/fingers on the film (ie direct exposure). Vascular/uro isn't quite as bad, but someone still has to be advancing a catheter near the radiation source, but not necessarily "in" the radiation source (also unlike ortho, they usually haven't just implanted metal plates/screws, which do a good job of sometimes reflecting radiation in multiple undesirable directions. Most of the other surgical fields get to step back a foot from the C-arm/fluoro, at least from the procedures I have seen.

Since radiation drops off exponentially with distance, being a few feet away from the image is hugely different exposure than someone with their body immediately adjacent to the area being imaged. (And for this reason the gas folks probably aren't as badly exposed even though they work in all of these cases). With radiation, distance is your friend, and a few feet is a big difference. And of course lead vests/shields make a huge difference.

 

[Law2Doc]

why don't we throw needle sticks into this while we're at it?

I would put EM at the top of needle sticks, with surgical fields and IR second. IM somewhere after that, particularly at teaching hospitals with med students and new residents wielding sharps. Psych would be dead last.

 

[Smurfette]

I would put EM at the top of needle sticks, with surgical fields and IR second. IM somewhere after that, particularly at teaching hospitals with med students and new residents wielding sharps. Psych would be dead last.

I would put surgical fields above ER by a long shot...between bovie injuries and splashes, perforated gloves, as well as needle sticks, scalpel injuries, etc., etc. I also know that surgical fields under-report the number of exposures as well.

 

[Ludicolo]

I would put surgical fields above ER by a long shot...between bovie injuries and splashes, perforated gloves, as well as needle sticks, scalpel injuries, etc., etc. I also know that surgical fields under-report the number of exposures as well.

Needle stick injuries are under reported across all specialties and with all health care workers in general.

Include PM&R and neurologists, especially those of us who perform EMGs regularly, under high risk needle stick groups. Throw in the fluoro procedures, and we physiatrists are nothing but glow-in-the-dark pin cushions.

 

[Guile]

Exposure to what? I've only seen a dozen or so bronchs but not a single one of them used fluoro.

Interesting. I've seen a couple and they all used fluoro. Our pulm fellows all wear radiation badges as well. We did biopsies both times, so perhaps they checked for a pneumo afterwards? Not sure why they needed it, but we definitely shot fluoro and wore lead aprons.

 

[Hernandez]

Exposure to what? I've only seen a dozen or so bronchs but not a single one of them used fluoro.

we use fluoro to confirm proper placement for some BALs/washings and for most bx, and then post bx to check for pneumo. although pulm probably doesn't use as much fluoro as some others, it would seem to me to be about the same as many gen surg docs from my experience.

 

[Giemsa]

If you want to avoid radiation, go with Path, Derm or Psych.

Definitely agreed.

But since we've thrown in needle sticks, consider that path has considerable exposure to formaldehyde (and other noxious chemicals). And then there's those patient-died-very-rapidly-of-unknown-cause-query-infectious autopsies. Potentially, derm suffers from this as well.

If you're looking for a nice safe job, go psych. Build a pleasant outpatient practice, your probability of encountering patient zero in the next SARS epidemic (or whatever) is low.

 

[doctalaughs]

Definitely agreed.

But since we've thrown in needle sticks, consider that path has considerable exposure to formaldehyde (and other noxious chemicals). And then there's those patient-died-very-rapidly-of-unknown-cause-query-infectious autopsies. Potentially, derm suffers from this as well.

If you're looking for a nice safe job, go psych. Build a pleasant outpatient practice, your probability of encountering patient zero in the next SARS epidemic (or whatever) is low.

Derm is actually towards the top of needle sticks as well. Consider we either biopsy, inject or excise something from a majority of patients. And most of it is done in a fast paced clinic environment, not a well-controlled OR under general.

 

[cartoondoc]

Needle stick injuries are under reported across all specialties and with all health care workers in general.

Include PM&R and neurologists, especially those of us who perform EMGs regularly, under high risk needle stick groups. Throw in the fluoro procedures, and we physiatrists are nothing but glow-in-the-dark pin cushions.

I would think a needle stick from EMG is pretty low risk though? Since the needle is so small, even more so than the one for suturing.

Pain medicine is probably big for radiation, but not so much general physiatry.

 

[Ludicolo]

I would think a needle stick from EMG is pretty low risk though? Since the needle is so small, even more so than the one for suturing.

Pain medicine is probably big for radiation, but not so much general physiatry.

I have no idea if size matters. Uh… I mean needle size.

It’s not just the risk of infection following a single sharps injury. There is a lifetime risk of being stuck (much like the radiation exposure risk), performing the same procedures day in and day out.

Actual risks are unknown, due to the underreporting phenomenon. However there was a recent study (Mateen FJ, et al. Needlestick injuries among electromyographers. Muscle Nerve 2008;38:1541-5) surveying approximately 800 practicing EMGers (performing EMGs at least one day per week), of which 2/3 reported at least one needle stick injury related to EMG. Average length of time practicing was 16 years. One out of eleven reported having an injury associated with a known HIV or hep B/C infected patient. Frighteningly, not everyone surveyed observed universal precautions regularly. Not everyone reported having specific EMG needle safety training during residency/fellowship.

And it’s not just EMG needles. Peripheral joint injections, Botox injections, trigger point injections, fluoro injections, etc. These are all procedures that resident physiatrists potentially are trained to do. Certainly other specialties perform them as well. Many physicians also seek training in acupuncture – physiatry or otherwise. How frequently one chooses to do these procedures once they’re out practicing is up to the individual. The variety and scope of practice patterns in physiatry (and medicine in general) never ceases to amaze me.

Any specialty that performs procedures regularly is at risk. There are precautions we can take to reduce the risk, and there are protocols to follow if an injury does occur. Medicine is dangerous. That’s why they pay us the big bucks. Personally though, I think this guy practicing prison medicine has it worse than any of us:

http://forums.studentdoctor.net/showpost.php?p=9509254&postcount=17



OP - sorry about the hijack.

 

[Law2Doc]

...
Any specialty that performs procedures regularly is at risk. ...QUOTE]


It's interesting because physiatry never even made the list when they showed us needle stick data in med school.

I would think putting in needles in a controlled environment like you describe would result in fewer sticks than in a thrashing uncooperative patient, as other fields often have to deal with. Thus something like EM suturing where the patient is often drunk or crazy or using, or a surgeon trying to sew in an emergent central line while others are doing chest compressions in a code is far more likely to result in a stick, simply because the needle isn't the only moving part you have to contend with. But I'll defer to others on this.

 

[Ludicolo]

Sadly, PM&R is frequently omitted in studies comparing multiple specialties. Pound for pound, we are the most poorly understood and least recognized field.

Yes, risks are minimized in a controlled setting. But patients are unpredictable. They have these funny habits of flinching or moving when stuck. Conversely, things are not always so chaotic in the ED or other settings. Your lifetime risk goes up with increasing frequency and duration one wields a needle. There is also an increased risk associated with inexperience, or if one is working with relatively inexperienced personnel (i.e. residents) as those of working in teaching institutions often do.

 

[Guile]

Sadly, PM&R is frequently omitted in studies comparing multiple specialties. Pound for pound, we are the most poorly understood and least recognized field.

Yes, risks are minimized in a controlled setting. But patients are unpredictable. They have these funny habits of flinching or moving when stuck. Conversely, things are not always so chaotic in the ED or other settings. Your lifetime risk goes up with increasing frequency and duration one wields a needle. There is also an increased risk associated with inexperience, or if one is working with relatively inexperienced personnel (i.e. residents) as those of working in teaching institutions often do.

I've never understood why PM&R wasn't more popular or competitive. A lot of it may be poor exposure during medical school. You guys do some really cool procedures and I imagine the reimbursement must be pretty good considering the number of procedures.

 

[nancysinatra]

Psych would be dead last.

Likely close to true, however, psych can do pain fellowships. I don't know how much of their role is interventional.

What about pathology? They wouldn't even be next to a patient getting a CXR, which happens in psych when you're in the ER.

 

[nancysinatra]

If you're looking for a nice safe job, go psych. Build a pleasant outpatient practice, your probability of encountering patient zero in the next SARS epidemic (or whatever) is low.

Yes, indeed--psych, the specialty that treats people known to cut up and eat others... ;-)

I think I read somewhere that the most assaulted doctors were plastic surgeons, and the most assaultive patients were males disappointed with their plastic surgery. (Don't quote me though, I'm not sure.) Psych is not far behind--look at the illnesses we treat. 1st week of residency we had a lecture on "what to do if your patient pulls out a gun."

 

[Guile]

Likely close to true, however, psych can do pain fellowships. I don't know how much of their role is interventional.

What about pathology? They wouldn't even be next to a patient getting a CXR, which happens in psych when you're in the ER.

As an aside, the x-rays scatter in the case of portable CXRs, KUBs, etc. No one within 5-6 feet gets any radiation.

 

[Eta Carinae]

As an aside, the x-rays scatter in the case of portable CXRs, KUBs, etc. No one within 5-6 feet gets any radiation.

Beyond

 

[Guile]

Beyond

Indeed. Thanks.