- Fiona Godlee, editor, BMJ
Do you know the radiation dose from a computed tomography scan or barium enema? And do you tell your patients? H E Davies and colleagues (doi:10.1136/bmj.d947) provide a useful table of the doses from common radiological investigations. A CT scan of the abdomen delivers 400 times the dose of a chest radiograph. So does a barium enema. Given the high absolute risk of cancer (a one in three lifetime risk), the contribution from iatrogenic radiation is small: the authors estimate that in the UK it causes 800 cancers a year in men and 1300 in women. But for patients who need repeated radiological investigation, and for pregnant women and children, the risks may be substantial and are rarely discussed.
Davies and colleagues say these risks are poorly understood by clinicians and they urge us to do better. They suggest calculating the single and accumulated radiation dose for each patient before ordering an investigation—online tools and mobile apps are available for doing this. They stress the need to avoid unnecessary CT scans, which about a third of them are. They recommend using other imaging techniques such as MRI and ultrasound if possible, and making sure that procedures and technology are optimised to minimise exposure.
As to what patients should be told, information on the risks of radiation exposure might change their decisions and should be shared, say the authors. Informed consent isn’t routinely requested for radiological investigations. It should be, they say, particularly where higher doses of radiation are involved. The benefits and harms may be hard to balance in some cases. They suggest that difficult decisions are discussed in multidisciplinary meetings.
What of the difficult decisions facing general practitioners in England as a result of the proposed changes to the NHS? As they take on responsibility for commissioning most of healthcare, how will they reconcile their conflicting roles? Somehow they will have to allocate finite resources and yet be the advocate for the patient in front of them. Many have voiced this concern publicly and privately since the changes were first announced. Some of you reading this may have ideas on how to remedy or at least minimise this conflict. We would like to hear them. Meanwhile, ethicist Mark Sheehan is uncompromising (doi:10.1136/bmj.d1430). These conflicting roles cannot and should not be reconciled. “Trust and confidentiality are precisely built on the understanding that my doctor has my interests at the forefront of his or her mind. If the GP is tasked with resource allocation, there is now an additional dimension to the decision: what is best for others.” It is unethical for general practitioners to be commissioners, he says.
Health reform has gained a bad name in England, but perhaps that’s because we had a system that was largely working and improving when these latest changes were imposed. But political intervention can transform health and healthcare, and Turkey provides a shining example. Enis Barış and colleagues attribute some of the change to the Ministry of Health’s decision to do “more steering and less rowing” (doi:10.1136/bmj.c7456).
Cite this as: BMJ 2011;342:d1551