Rom Hendler is CEO & cofounder of Trustifi, a provider of SaaS-based security and email encryption.
Artificial intelligence (AI) and machine learning (ML) continue to gain headlines and impact the high-tech landscape at the boardroom level. Yet this technology is also rapidly becoming a destructive force causing considerable security risks in the highly regulated healthcare space.
Nefarious cyberattacks, including synthetic fraud and phishing attempts, continue to increase in scale and effectiveness thanks to AI-based tools now available to hackers. A synthetic fraud attack uses portions of a victim’s identity garnered from the internet to compile a false but convincing profile with which to commit fraud. This includes crimes like applying for patient financing under false pretenses, requesting medical services, or submitting fraudulent insurance claims.
This article highlights the rapid advancement of AI-assisted synthetic fraud attacks and medical identity theft as they affect healthcare providers and patients, along with updated recommendations for patient data privacy, AI-powered email security solutions, and data protection policies.
AI bots have long been a hacker favorite for collecting stolen credentials, accelerated by the rise of natural language generators like ChatGPT. Bots mine the internet for accurate information on a victim’s identity and use that in crafting their attacks, making it challenging for the victim to recognize these attempts as fraudulent. These emails typically include a link to a convincing imposter website that tricks recipients into providing usernames and passwords. When these breaches occur, identity theft can also result in reputational damage for the healthcare provider.
In the past, phishing attacks were easy to detect because of spelling mistakes and vague information requests. Present-day attacks incorporate persuasive personal details such as the user’s bank or healthcare provider’s name, and references to the user’s home city or local pharmacy. This is known as “geo-phishing.”
In the case of synthetic fraud that compiles information from different victims, it’s harder to determine that the resulting profile is fake since much of the data used to assemble it belongs to actual individuals. The cybercriminal uses the synthetic profile to apply for patient financing or otherwise scam large amounts of money and services. Material used to create synthetic fraud profiles is often acquired through compromised email data.
In addition, hackers can now leverage AI-based technology to rapidly create near-perfect scripts for phishing schemes using ChatGPT. Hackers will use the patient’s public email address and password from a successful phishing attack to log in to a medical provider/patient portal with these stolen credentials. If two-factor protection is not enabled on the EMR portal, the hacker can access patient records and correspondences with practitioners.
Once hackers can access a practitioner, they can request medication refills and submit false insurance claims to the provider or Medicare carriers. All this shows how critical it is for healthcare organizations to secure their patient data and infrastructures with the most up-to-date cybersecurity solutions, including AI-based tools to combat these very sophisticated (and similarly AI-powered) attacks. Traditional, legacy security capabilities in firewalls, secure email gateway applications, and first-generation multifactor authentication often fail to stop the advanced AI-powered threats hackers continue to develop.
Hackers can alter their attack methods, extend their attacks across several countries in mere seconds, and shut down their operations globally to avoid detection. Most healthcare providers’ current security adaptive controls still rely on reporting events into a Syslog file or an early generation security information and event management (SIEM) tool lacking AI capabilities. And too many solutions simply utilize blacklisting of known malicious IP addresses, which don’t detect sophisticated, contextually based threats.
So what strategies can healthcare organizations put into action to guard against increased AI-driven attacks? These guidelines can help companies remain HIPAA compliant and protect their patients against victimization.
• Abandon outdated technology and strategies: Medical providers can increase their protection by phasing out antiquated, legacy techniques. A surprising amount of healthcare organizations still use fax technology to transmit sensitive information. Companies are far better off implementing a modern protocol such as AES 256-bit encryption for the transfer of sensitive material like patient records. In addition, outdated operating systems like Windows XP (still in too many office environments) are often no longer supported by security updates and create vulnerabilities.
• Use AI to combat AI: The bright side of artificial intelligence is it can deliver as many effective capabilities to cybersecurity solutions as it does to criminals. Software should leverage sophisticated AI-based tools, including optical character recognition and algorithms that recognize “red flag” keywords that could indicate a breach.
• Deploy automation: Administrators can automate HIPAA compliance. Effective solutions allow admins to set their systems to automatically encrypt or flag sensitive email messages that fall under HIPAA statutes. This takes the burden of deciding what material needs to be encrypted out of the hands of employees, reducing human error.
• Implement security awareness policies: Since a majority of breaches start with a phishing attempt, make sure your staff is aware of the latest schemes and imposter email strategies. Create policies around vulnerable activities (e.g., establish a protocol where requests for wire transfers or financial login credentials are confirmed verbally).
• Focus on ease of use: Your security should be simple for employees to use. If measures are convoluted and laborious, users will abandon them, and your security investments will go by the wayside.
Preventing synthetic fraud and medical identity theft does not start with merely detecting threat vectors. Prevention begins by protecting patient information and network email data with advanced cybersecurity solutions powered by AI technology, which will help deter imposter attacks and compromised credentials, and will identity theft from the outset. It’s essential to deprive hackers and fraudsters of the key components that facilitate their attacks by protecting user attributes such as login information, Social Security numbers, and passwords, especially via email data.
Email security platforms continue to deliver integrated features, including mature AI-enabled engines that enable threat detection, email encryption, and data loss prevention. Organizations that want to enhance their email security while reducing complexity should continue to research these solutions, employing AI-driven, easy-to-use, next-generation technologies as strategies to combat the forthcoming level of AI-powered attacks.
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Nurse practitioner (NP)
Assess patients; order and interpret diagnostic tests; diagnose and treat illness; prescribe medications, in
some states with doctor supervision.
RN plus master's or doctoral degree
and advanced clinical training. National certification exam and state license.
Certified nurse midwife (CNM), certified midwife (CM)
Deliver prenatal, delivery,
and postpartum care, family-planning services, and gynecological care; prescribe medications.
Nursing or bachelor's degree plus completion of an accredited graduate nurse-midwifery course. National certification exam and state license.
Physician assistant (PA)
Examine patients, diagnose and treat illness, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling, make rounds in hospitals and nursing homes, prescribe medications.
Bachelor's degree, followed by completion of an accredited P.A. program modeled on the medical-school curriculum (average length of program is 27 months, and
most grant master's degrees). National certification exam and state license.
Podiatrist (DPM), also known as podiatric physician or podiatric surgeon
Diagnose and treat conditions of the foot, ankle, and related structures of the leg; prescribe medications. May specialize
in surgery, sports medicine, wound care, pediatrics, or diabetic care.
Four years of podiatric medical school plus three years of hospital residency training. With advanced training and experience, can obtain board certification from the American Board of Podiatric Medicine or the American Board of Podiatric Surgery. State license.
Clinical psychologist (Ph.D., Psy.D.), licensed clinical social worker, licensed professional counselor (LPC)
Diagnose and treat mental illness and emotional and behavioral problems in individuals, couples, groups, and families.
Ph.D. and Psy.D.: doctoral degree.
Licensed clinical social worker and LPC: master's or doctoral degree plus two or more years of supervised post-graduate experience. State licenses. Counselors
can also be certified by National Board
of Certified Counselors.
Food and nutrition counseling for general health, nutritional deficiencies, or disease management.
Bachelor's degree with courses approved by professional organization, plus completion of an internship. National examination.
Dispense medication and immunizations, check for potential drug interactions, provide counseling on how
to take medication and limit side effects.
Doctor of pharmacy degree from an accredited school, plus internship. Two licensing exams, one covering pharmacy skills and knowledge and the other covering pharmacy law.
M.D. (medical doctor)
Diagnose and treat illness
and injury, including surgery, examinations, testing, and prescribing medication.
Four years of medical school plus up to six years of residency training. Optional clinical fellowships and specialty certification. National licensing exams. State license.
DO (doctor of osteopathic medicine)
Practice as medical doctors
do in any specialty area. Some osteopaths also perform musculoskeletal manipulation.
Four years of osteopathic medical school, followed by medical or osteopathic residency training. Optional specialty certification. National licensing exam. State license.
Registered nurse (RN)
Provide patient care and education, care coordination, physical exams, and health histories.
Diploma or associate or bachelor's
degree from an approved nursing program. National licensing exam.
Licensed practical nurse (LPN), licensed vocational nurse (LVN)
Provide basic nursing care under the direction of registered nurses and doctors.
Completion of a state-approved educational program (usually one year) and passage of a licensing exam.
We owe our eyes a lot, and it is often easy to take them for granted. However, vision problems can seriously affect your life over time -- beyond having to wear glasses or contacts. In fact, vision loss can lower your quality of life and raise your risk of depression, diabetes and other health issues, according to the US Centers for Disease Control and Prevention.
Practicing simple, daily habits can help you Excellerate your eye health and reduce your risk of problems in the future.
Read more: Omega-3 Rich Foods Offer Many Benefits for Heart, Hearing and Overall Health
Exposing your eyes to ultraviolet rays may cause damage over time. Wearing sunglasses can block harmful UV light, lowering your risk of eye diseases like cataracts, sunburn, eye cancer and growths around the eye, per the American Academy of Ophthalmology. Polarized glasses with smoke or gray lenses may offer the best protection against the sun's rays and reduce glare.
Prolonged screen time can cause dry eyes, pain in the neck and shoulders, blurred vision, headaches and digital eye strain, or computer vision syndrome. The American Optometric Association recommends using the 20-20-20 rule to prevent CVS. Every 20 minutes, look at something at least 20 feet away for 20 seconds.
Screen time isn't the only way to strain your eyes. When you read a book, you probably hold it up close for long periods, too. Both activities can lead to nearsightedness, or myopia, which means far-away objects are blurry while up-close things are clear. Just like you should use the 20-20-20 rule to take screen breaks, you should also use this rule for book breaks. If you find yourself engrossed in what you're memorizing or doing on the computer, set an alarm so you don't miss your 20-minute break.
Regular exercise can provide eye health benefits, such as promoting healthy blood vessels and lowering your risk of developing glaucoma and diabetic retinopathy, the AAO reports. The CDC recommends at least 150 minutes of moderate aerobic activity every week, plus two days of strength training for your muscles. You can also practice eye exercises to reduce tension and eye strain while sitting at your desk.
Read more: Sneak More Exercise Into Your Daily Routine: 7 Steps That Actually Work
Children and adults need to get outside often, even if you get your recommended exercise indoors. Research shows that children who spend time outdoors have a lower risk of developing nearsightedness in adolescence and as adults. Playing with your kids at the local playground, walking through the woods or even playing in the backyard can help the whole family stay healthy and active. Don't forget your sunglasses!
It's well known that smoking is bad for your health. It can also increase your risk of developing eye diseases like cataracts or age-related macular degeneration, according to the Food and Drug Administration. Smokers have a two or three times higher chance of developing cataracts and up to four times higher risk for AMD. Future research may determine if smoking cigarettes can also cause glaucoma, Graves' eye disease, thyroid eye disease and encourage diabetic retinopathy onset or progression. To Excellerate your health, build a quit plan.
The foods you eat every day can improve your eye health. Eating foods rich in vitamins A, C and E, beta-carotene, omega-3 fatty acids, lutein, zeaxanthin and zinc can help cellular growth, lower eye tissue inflammation and limit free radicals that can damage your eyes.
To get the right nutrients for your eyes, eat balanced meals by including some of these foods in your regular diet, recommended by the AAO:
If you habitually rub your eyes, it could cause eye damage or infections. Dry eyes and eye strain can make you want to rub your eyes, and some may rub them too much or too hard. This can lead to issues such as reduced or blurry vision, headaches, inflammation, eye and light sensitivity. Another reason to avoid eye rubbing is that bacteria or viruses on your fingers or hands could lead to conjunctivitis, commonly called pink eye. Instead of rubbing your eyes, use eye drops or saline to clean your eyes and keep them moist. Resist the urge and find something else to keep your hands busy until you undo the habit.
Read more: 7 Home Remedies for Dry, Itchy Eyes
You should always wash your hands before touching your face or eyes and handling contact lenses. Almost 45 million Americans wear contact lenses, and around 1 in 3 wearers develop complications, with 1 in 5 infections from contact lenses causing corneal damage.
Plus, there's no telling what kind of germs are on objects you touch after someone unknowingly contaminated them. Washing your hands regularly can lower your risk of respiratory illness by up to 21% and diarrheal illness by up to 40%, the CDC reports.
After a long day, the last thing you might think about is removing your eye makeup before you get into bed. But doing so benefits your eye health and can lower your risk of blepharitis or eyelid inflammation, according to the Optometrists Network.
You should also adopt good makeup practices that can save your skin and eyes, such as only using products made for eyes, replacing your makeup often (especially after an eye infection), not applying eye makeup in the inner lids and never sharing eye makeup with someone else. If you use brushes or sponges to apply eye makeup, wash them regularly.
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Vitiligo is a skin condition that causes white patches to appear on the skin due to loss of pigmentation and has a significant impact on the mental well-being of an affected individual because coming to terms with the changes in appearance, daily social ostracization, non-inclusion and the resulting sense of isolation can be emotionally draining for vitiligo patients. It is essential to acknowledge that these challenges stem from ignorance and stigma and that collective action is essential to remedy the situation.
In an interview with HT Lifestyle, Dr Vikram Vora, Medical Director at Indian Subcontinent – International SOS, shared, “There are numerous strategies to help promote self-acceptance and foster resilience in those impacted by this condition. However, these need to be credible, comprehensive and coordinated. Due to prior experiences, vitiligo sufferers may have a lesser degree of faith in people. Building trust and empathy with the affected individuals, demonstrating a genuine understanding of their experiences and acknowledging the emotional impact of living with vitiligo is a good start. Many vitiligo sufferers may have developed self-stigma about their condition and educating them is crucial to help manage their mental well-being effectively. Accurate information about causes, symptoms and available management options, along with clearing any misconceptions about the condition can alleviate their anxiety. With increased awareness and knowledge, these individuals can develop a better understanding of their condition and feel more in control.”
He highlighted, “As vitiligo impacts one’s self-esteem and body image, the development of a positive self-image can be achieved by helping them focus on their strengths and talents rather than solely their appearance. Psychologists suggest that self-compassion and reducing negative self-talk can assist in building a more realistic and positive self-perception. Acceptance of the condition can be achieved by encouraging overall well-being rather than a singular focus on physical appearance. Regular exercise, healthy eating, and engaging in hobbies or creative pursuits are self-care strategies that definitely help. Encouraging adoption of relaxation techniques and the practice of mindfulness reduces stress and anxiety and helps to challenge and counter negative thought patterns.”
According to him, having a robust support network comprising of family, friends, colleagues and managers provides a sense of belonging and support, through experience-sharing. Dr Vikram Vora revealed, “This support can be in-person or even online via multiple available forums. Local support groups, counselling services in the community and EAPs at the workplace can also offer ways for patients to share their stories, gain insights, develop adaptive coping mechanisms and receive validation of their efforts. Empathy can create a safe space for expressing emotions and begin the healing process. Addressing the mental well-being challenges of those who have vitiligo requires an honest and empathetic approach. Keeping them away from normal social discourse and interactions is something that should not and cannot be accepted in today’s world. All sections of society need to work together, towards promoting a society that embraces diversity and inclusion. For those impacted, self-acceptance, resilience, and a positive self-image that ensures a fulfilling life, can only happen when we make this effort.”
Adding to the list of few simple methods to motivate patients with vitiligo, Dr Sushil Tahiliani, Consultant Dermatologist at PD Hinduja Hospital and Medical Research Centre in Mumbai, suggested, “Post-diagnosis, it is extremely important to normalise the disease as only the loss of colour from the body. It is crucial to establish that their bodies are healthy and because it does not affect their health, if they don't get bogged down psychologically, they can achieve goals which a lot of vitiligo patients have achieved in their life because they did not look at vitiligo as a very serious disease which should finish their aspersions and aspirations in life but rather continues to follow and achieve them. The second most important thing that I have definitely incorporated in my practice is examining the patients without gloves if not required. By touching the lesions and trying to win their confidence and reassure them about the non-contagious nature of this condition.”
He explained, “By also sharing statistics and success stories of patients being affected by vitiligo would create a sense of confidence in the patients. Translating that into figures to tell them that at least 28 million Indians must be having vitiligo - would help in reducing the feeling of being the odd one out. Additionally, inform them about the modern ways of treating vitiligo and provide them guarded optimism because in good 60% odd cases, you can re-pigment them. While they are being re-pigmented, they are also given options of using camouflage creams on the open areas of the body, because it goes a long way in building confidence because when they look at the world, they can discuss what they've gone to discuss, they can study what they're going to study and the course doesn't get diverted to vitiligo, which can be an irritant and harm the self-confidence.”
He concluded, “While also highlighting to them that in case the medicines don't work in some of the stable vitiligo cases, especially the segmental vitiligo cases, we have surgical options which work very well. And in those cases where everything fails, and they got two colours, and about 40, or 50% of the body turns white, I provide them the option of removing the balance pigmentation to provide them a uniform colour. Added-on tips would include protecting their skin against excessive sun exposure because they don't have melanin to protect their skin, and thus will be at a higher risk of skin ageing. The challenge is bigger if we have a child as a patient because we had to do hand holding and counselling for the parents first so that they don't cry in front of the child and they don't have drop jaws and sad faces. It's very important for the child to have encouragement and support from the parents and for the parents to keep the child happy and provide the child a lot of confidence that does half the job done. The more you normalise the disease, the better it would be for those affected.”
AGE is just a number, and you're only ever as old as you feel - so maturing shouldn't always be seen as a negative.
However, we all want to feel confident and radiant in our own skin - and for some, that means trying to maintain as youthful complexion as possible.
But with so many anti-ageing tips and tricks out there, it can be hard to know which ones to follow.
Skincare pro and NHS surgical and aesthetic doctor, Dr Deepa Panch, says: "Ageing is a natural process and one that we cannot stop, however our understanding of ageing has progressed significantly over the years to allow us to look at how ageing can be slowed down biologically.
"There are numerous factors that can accelerate the physical signs of ageing as they appear on our skin, and some key concerns of my patients are the development of deep lines, loss of elasticity and plumpness and a sallowness to the skin.
"Healthy and consistent habits can promote skin longevity and create a more youthful appearance, and I encourage all my patients to incorporate the tips below into their routine."
Here, Dr Deepa shares her six hacks to maintaining your natural, baby-faced beauty and fighting off any unwanted signs of ageing..
Whatever age you are, daily sun protection is crucial.
Dr Deepa says: "Collagen and elastin are two key proteins that act as 'scaffolding' for our skin.
"When they deplete, we start to notice wrinkles forming as the underlying structural support disintegrates.
"This happens naturally with age, however is significantly increased with UV exposure, which can also add to additional signs of ageing on the skin such as sun spots, as well as the development of skin cancer.
"This is why I advise everyone to wear a daily SPF with a high UVA rating, every single day of the year.
"One of my favourites is Heliocare which has a light tint in it and is non-comedogenic (which means it won't clog your pores) so great for those who are prone to breakouts."
Make sure you incorporate skincare with active ingredients into your routine.
Deepa says: "Make sure you use skincare that has ingredients that will actually create biological changes to the cells.
"Some of my favourite actives are vitamin C, which is fantastic as an antioxidant as it helps to minimise pigmentation and helps with brightening the complexion, and retinol - which is the most powerful anti-ageing ingredient there is.
"Retinol aids with skin rejuvenation by accelerating cell turnover, as well as boosting our production of collagen and should be a key part of your skincare routine from your thirties onwards.
"Brands like CeraVe and Neostrata do great, affordable products."
The Ordinary also do a retinol serum, from just £6.90, to target general signs of skin ageing.
Deepa says: "A good nights sleep is vital to keep the immune system functioning at its optimum and studies have shown elevated levels of inflammatory molecules are associated with sleep deprivation.
"This can lead to the development of inflammation which can impact the skin and worsen conditions such as acne and eczema.
"I also think it's worth investing in a silk pillowcase which can help to reduce the friction between your skin and the pillow surface, thus minimising those pesky sleep lines.
"Silk also absorbs less moisture than cotton so you can be certain your night time products are more likely to stay on your skin."
What you eat can also have a significant impact on your skin.
Deepa says: "A diet rich in nutrients, anti-oxidants and omega-3 can help protect our cells from the signs of ageing and Excellerate skin health.
"Minimising sugar intake is also a key part of this.
"High sugar levels in the body can put it into a state of oxidative stress which can lead to a dull complexion."
There are some lifestyle choices that can be especially detrimental to our skin.
Deepa says: "Alcohol can heavily dehydrate the skin.
"Additionally, smoking speeds up the breakdown of collagen, so these are both lifestyle factors I would encourage patients to look at."
If you're still unhappy with any fine lines, you can explore non-surgical treatments, also known as 'tweakments'.
Deepa says: "Lastly, there have been huge advancements in the arena of regenerative medicine in the last decade.
"As well as the usual anti-wrinkle and filler treatments, there are a host of other excellent options available such as platelet rich plasma, collagen stimulators and skin boosters that will work to boost your production of collagen, repair damaged cells and generate healthy skin cells.
"A good aesthetic practitioner will be able to talk you through all your options and make suggestions for what is right for you."
Holistic health practitioners consider contributing factors and non-medical aspects of a patient's health when determining a course of treatment. They are most often a doctor of osteopathic medicine, which emphasizes preventative care more than a doctor of medicine does. Holistic health practitioners typically practice general medicine as the patient's primary care provider.
The average salary for a holistic health practitioner in 2010 was $173,860 per year, or $83.59 per hour, according to the Bureau of Labor Statistics. Holistic health practitioners In the 10th percentile earned an average of $86,600 per year, or $41.64 an hour. The salary for holistic health practitioners in the 25th percentile was $125,800 per year, or $60.40 an hour. The median salary for this occupation was $163,510 a year, or $78.61 an hour.
The largest numbers of holistic health practitioners were in physicians' offices as of 2010, with salaries averaging $179,060 per year. Hospitals paid their holistic health practitioners an average of $169,110 per year, and those in outpatient care centers earned an average of $167,870 per year. The annual salaries of holistic health practitioners in local governments was $148,910 on average, and holistic health care practitioners in state government earned an average of $138,710 per year.
The highest level of employment for holistic health practitioners was in California during 2010, where the average annual income was $168,010. Pennsylvania's holistic health practitioners earned an average of $163,310 per year, and those in Texas had average salaries of $186,090 per year. The holistic health practitioners in Illinois had salaries averaging $171,680 per year, and the average annual income for holistic health practitioners in Florida was $163,030 per year.
The employment of holistic health practitioners should increase by 22 percent between 2008 and 2018, according to the BLS. The expansion of the healthcare industry will continue to drive the need for more holistic health practitioners. The growing elderly population will also generate a demand for holistic health practitioners, especially in low income areas. Holistic health practitioners who perform the more routine aspects of health care will find the greatest opportunities for employment.
Physicians and surgeons earned a median annual salary of $204,950 in 2016, according to the U.S. Bureau of Labor Statistics. On the low end, physicians and surgeons earned a 25th percentile salary of $131,980, meaning 75 percent earned more than this amount. The 75th percentile salary is $261,170, meaning 25 percent earn more. In 2016, 713,800 people were employed in the U.S. as physicians and surgeons.
Radiological imaging is a major and increasing source of radiation exposure worldwide. Computed tomography (CT) is the largest contributor to medical radiation dose patients receive. Typically, CT scans impart doses to organs that are 100 times higher than doses imparted by other lower dose modalities such as chest X-rays. In general, CT examinations may involve doses (typically an average of 8 mSv) which may be equal to the dose received by several hundreds of chest X-rays (about 0.02 mSv/chest X-ray).
During an IAEA consultation on justification in 2007, it was estimated that up to 50% of examinations may not be necessary. It should be anticipated that part of the increase in global annual mean dose that has been observed recently is due to unjustified radiological procedures. Direct epidemiological data suggest that medical exposure to low doses of radiation even as low as 10-50 mSv might be associated with a small risk of cancer induction in the long term. The fact that a considerable percentage of people may undergo repeated high dose examinations , such as CT (sometimes exceeding 10 mSv per examination) dictates that caution should be used when referring a patient for radiological procedures. Health professionals need to make sure the patient benefits from the procedure and risk is kept minimal.
However, ensuring maximum benefit to risk ratio for the patient is not a trivial task. Referring medical practitioners, in a large part of the world, lack training in radiation protection and in risk estimation. 97% of practitioners who participated in a study underestimated the dose the patient would receive from diagnostic procedures. The average mean dose was about 6 times higher than the physicians had estimated. The fundamental principles of radiation protection in medicine are justification and optimization of radiological protection. Referring medical practitioners have a major role in justification. They are responsible in terms of weighing the benefit versus the risk of a given radiological procedure.
Justification requires that the expected net benefit be positive. According to principles established by the International Commission on Radiological Protection (ICRP) and accepted by major international organizations, the principle of justification applies at three levels in the use of radiation in medicine.
Yes, jointly with the radiological practitioner. As stated above, justification at the third level is the responsibility of the referring medical practitioner, as is the awareness about appropriateness criteria for justification at level 2. According to the BSS, the radiological exposure has to be justified through consultation between the radiological medical practitioner and the referring medical practitioner, as appropriate, or be part of an approved health screening programme.
Since referring medical practitioners usually have the most complete picture of the patient’s health, they should be responsible for the guidance of the patient in undergoing only necessary procedures and benefitting from them. Particularly, this responsibility weighs more on generalists such as primary care providers. In order to facilitate justification in the case of radiological procedures, it is desirable that referring medical practitioners are knowledgeable about radiation effects in regard to the various dose ranges. The referring medical practitioners are responsible for keeping their knowledge about radiation up to date. In support of this, they should be provided education in radiation protection during their medical studies.
According to the BSS, the justification of medical exposure for an individual patient shall be carried out through consultation between the radiological medical practitioner and the referring medical practitioner, as appropriate, with account taken, in particular for patients who are pregnant or breast-feeding or paediatric, of:
Justification should be patient specific. The referring medical practitioner should take into account all clinical aspects regarding the management of every patient separately. Other possible procedures with lower or no exposure, such as ultrasound or magnetic resonance imaging, should be considered, if and when appropriate, before proceeding to radiological procedures.
According to the BSS, in order for a symptomatic or asymptomatic patient to undergo a medical procedure that involves ionizing radiation, the patient or the patient’s legally authorized representative should be informed in a timely and clear fashion, of the expected diagnostic or therapeutic benefits of the radiological procedure as well as the radiation risks. Thus, the emphasis is on provision of information.
According to the guidelines published by the Royal College of Radiologists (RCR), a useful investigation is one in which the result, either positive or negative, will alter a patient’s management or add confidence to the clinician’s diagnosis. According to the RCR guidelines, there are some reasons that lead to wasteful use of radiation. With emphasis on avoiding unjustified irradiation of patients, the RCR report has provided a check list for physicians referring patients for diagnostic radiological procedures:
There are various reasons that may lead medical practitioners to refer patients for more procedures than needed. Practitioners should be aware of that and take action to avoid such situations. Some of the reasons that lead to over-investigation are the following:
During the last 20 years international and national organizations published guidelines for proper justification of radiological procedures. The UK Royal College of Radiologists (RCR) publication "Making the best use of clinical radiology services " has been in print since 1989. The American College of Radiology (ACR) published its guidelines as Appropriateness Criteria. Similar efforts have been undertaken by the Department of Health of Western Australia in Diagnostic Imaging Pathways.
For references of publications from national societies in Europe, Oceania, and other regions please see publication from Remedios. These publications constitute guidelines and aim to guide referring medical practitioners in the selection of the optimum procedure for a certain clinical problem. In case there are alternative procedures that do not utilize radiation but yield results of similar clinical value, these guidelines encourage the avoidance of radiological procedures.
The cited publications provide very specific guidance to help practitioners perform justification properly.
A medical physicist with experience and expertise in radiation protection will be able to provide information and guidance on radiation doses and risks in radiological procedures. In case you do not have an access to the help of radiation protection experts, referring medical practitioners may address their questions to their colleagues who work in radiology departments. However, staff specialized in radiation protection is more likely to provide complete, responsible and up-to-date information for the specific clinical problem. Radiation protection experts are comfortable with dose measurements and quantities which come from the domain of natural sciences and are usually hard to conceive for people outside the field.
The referring medical practitioner should be aware about procedures which impart high radiation dose to patients in order to be more cautious in such cases. This does not mean that other procedures should be written without proper justification. A quantitative knowledge of doses of various procedures is useful for the referring medical practitioner. Data given below will help the practitioner in that direction. In diagnostic radiological procedures, dose depends on the modality used. Computed tomography (CT) exposes patients to relatively high doses in comparison to other diagnostic imaging modalities.
Interventional diagnostic and therapeutic procedures that utilize fluoroscopy may also be a source of high radiation doses. Such procedures carry the risk of causing erythema to patients that receive high dose in single or repeated procedures. Some nuclear medicine procedures are also responsible for high radiation doses to patients.
The responsibility to identify patients that might be pregnant and are unaware of it is shared by the patient, referring medical practitioner and the imaging service providers. Safeguards to avoid inadvertent exposures of the foetus should be observed at all times.
The “ten day rule” was postulated by ICRP for women of reproductive age. The more recent “28-day rule” allows radiological procedures throughout the complete menstrual cycle unless there is a missed period. When a woman has a missed period, she is considered pregnant unless proven otherwise.
Even if safeguards are observed, sometimes a pregnant patient may be exposed to radiation. Depending on the radiation dose and the gestation age of the foetus, radiation effects may differ. Radiation risks are most significant during organogenesis in the early foetal period, somewhat less in the second trimester, and least in the third trimester.
As a rule of thumb one can assume that properly carried out diagnostic radiological procedures to any part of the body other than the pelvic region or when the primary X-ray beam is not passing through the foetus can be performed throughout pregnancy without significant foetal risk, if clinically necessary and justified. For radiological procedures where the primary beam intercepts the foetus, advice from the medical physicist should be obtained, who will calculate radiation dose to the foetus and, based on that, the practitioner and patient should make a decision. However, doses associated with radiotherapy procedures and interventional procedures are high and they require the attention of experts (including medical or health physicists, practitioners, and sometimes engineers and epidemiologists). In the case when a practitioner is responsible for a patient who has undergone a radiological procedure inadvertently and has subsequently been found to be pregnant, advice from the individuals listed above is needed. For more information, please click here where comprehensive information is provided not only for diagnostic radiology but also for nuclear medicine and radiotherapy.
Sometimes it is imperative that pregnant women should undergo radiological procedures. The referring medical practitioner and the imaging provider have to be mindful of risk and benefit and decide whether a radiological procedure should be asked for or if the medical problem may be solved by other non-radiological procedures. Generally, it is preferable that non-radiological procedures, or at least those that do not provide exposure to ionizing radiation, are used whenever possible. However, the use of radiological procedures is not prohibited and, when properly justified, they may be optimized so that these procedures may help to achieve the desired result for the patient while keeping dose to the foetus at low levels. The patient should be made aware about the possible impact of radiation exposure to the foetus. The need for consent must be determined based on individual practice standards, guided by more global professional or regulatory/legislative requirements.
Acute injuries such as skin erythema, blistering and hair loss have been recognized as a rare side effect of procedures guided by fluoroscopy. Similar injuries have been long recognized in radiation oncology, which uses much higher doses of radiation than diagnostic imaging. While radiation therapy is administered in fractions and the radiation-inflicted cells may recover in between sessions, fluoroscopy usually imparts a high dose to the skin in a short amount of time and with no dose fractionation. Referring medical practitioners could miss recognizing acute radiation injury resulting from interventional procedures. Such injuries may appear weeks after the interventional procedure and patients may not think of the procedure as being the cause unless they have been instructed accordingly by the interventional facility. Practitioners have often tended to attribute injury to many other causes, including insect bite and allergic reactions, but not to radiation exposure. Awareness about radiation through fluoroscopy being a possible cause can avoid mis-diagnosis and patient suffering.
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