European Journal of Radiology 86 (2017) 135–142

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Awareness of radiation protection and dose levels of imaging

procedures among medical students, radiography students, and
radiology residents at an academic hospital: Results of a
comprehensive survey
Lorenzo Faggioni (MD PhD) a,∗ , Fabio Paolicchi (RT PhD) a , Luca Bastiani (PhD) b ,
Davide Guido (PhD) c , Davide Caramella (MD) a
a
Department of Diagnostic and Interventional Radiology, University of Pisa, Via Roma 67, 56100, Pisa, Italy
b
Institute of Clinical Physiology, National Research Council, Via Moruzzi 1, 56124, Pisa, Italy
c
Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Via Forlanini 2,
27100, Pavia, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: To evaluate the awareness of radiation protection issues and the knowledge of dose levels
Received 7 June 2016 of imaging procedures among medical students, radiology residents, and radiography students at an
Received in revised form 14 August 2016 academic hospital.
Accepted 29 October 2016
Material and methods: A total of 159 young doctors and students (including 60 radiology residents, 56
medical students, and 43 radiography students) were issued a questionnaire consisting of 16 multiple
Keywords:
choice questions divided into three separated sections (i.e., demographic data, awareness about radiation
Radiation protection
protection issues, and knowledge about radiation dose levels of common radiological examinations).
Medical students
Radiology residents
Results: Medical students claimed to have at least a good knowledge of radiation protection issues more
Radiography students frequently than radiology residents and radiography students (94.4% vs 55% and 35.7%, respectively;
Education and training P < 0.05), with no cases of perceived excellent knowledge among radiography students. However, the
Academic hospital actual knowledge of essential radiation protection topics such as regulations, patient and tissue suscep-
tibility to radiation damage, professional radiation risk and dose optimisation, as well as of radiation
doses delivered by common radiological procedures was significantly worse among medical students
than radiology residents and radiography students (P < 0.05). Those latter significantly outperformed
radiology residents as to knowledge of radiation protection issues (P < 0.01). Overall, less than 50% of
survey respondents correctly answered all questions of the survey.
Conclusions: Radiology residents, radiography students and medical students have a limited aware-
ness about radiation protection, with a specific gap of knowledge concerning real radiation doses of
daily radiological examinations. Both undergraduate and postgraduate teaching needs to be effectively
implemented with radiation safety courses.
© 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
The recent dramatic evolution and increased use of ionising
radiation-based diagnostic modalities such as multidetector com-
puted tomography (CT) has led to a multiplication of the number
of examinations and hence of the overall radiation exposure to
∗ Corresponding author.
E-mail addresses: lfaggioni@sirm.org, lorenzofaggioni79@gmail.com
(L. Faggioni).
the population, with CT currently accounting for about 50% of the
total radiation burden for medical purposes [1,2]. This situation has
raised concerns in the scientific community about the potential side
effects on patients, with particular reference to radiation-related
cancer and death [2,3]. Moreover, several papers have recently
shown a small, but significant increase of cancer risk in children and
young patients with previous exposure to CT scans [3–5], paralleled
by a measurable increase in radiation-induced DNA damage follow-
ing several radiologic examinations that correlates with radiation
dose [6,7]. In this setting, a full awareness of radiation protection
issues and a proper knowledge of the radiation doses delivered by

http://dx.doi.org/10.1016/j.ejrad.2016.10.033
0720-048X/© 2016 Elsevier Ireland Ltd. All rights reserved.
136 L. Faggioni et al. / European Journal of Radiology 86 (2017) 135–142
the various imaging modalities are essential to make sure that all
involved professionals adhere to up-to-date appropriateness and
optimisation criteria [8].
General training about radiation protection should be pro-
vided starting from undergraduate courses and followed by specific
update courses, as requested by the Guidelines on radiation pro-
tection education and training of medical professionals in the
European Union no. 175 (2014), which has set the standard of
minimum knowledge expected from each and every practitioner
involved in radiation protection [9]. In the past decade, several
studies conducted on selected cohorts of referring physicians and
staff radiologists and technologists unveiled an alarming lack of
radiation protection knowledge among them. In particular, a sub-
stantial amount of professionals resulted to be underestimating the
overall radiation doses associated with various imaging modalities,
and in some cases, they were even unable to correctly differen-
tiate between ionising and non-ionising radiation-based imaging
techniques [10–12]. Such disappointing findings warrant a system-
atic, comprehensive evaluation of the knowledge of basic radiation
protection issues needed for daily practice by students in train-
ing (such as medical students, radiography students, and radiology
residents), in an attempt to gain insight about the current status of
radiation protection education among those who will order, per-
form or interpret medical imaging examinations in their future
professional life. In this perspective, the advantages of creating
a positive radiation safety culture in the higher education and
research sectors have been outlined, with continuous education
and testing for all people involved (including students during
their training period) being key to optimise performance, minimise
errors, and protect the entire workforce as well as the general public
and the environment [13–15].
The aim of our work is to assess the degree of subjectively per-
ceived knowledge and effective knowledge of essential radiation
protection and dose assessment topics across a population of med-
ical students, radiography students and radiology residents.
2. Material and methods
2.1. Data collection
Data were obtained from a survey conducted in a group of
Radiology residents and undergraduate students by a multidisci-
plinary “dose team” between January 1 and December 31, 2015.
The survey was designed to assess the knowledge of dose exposure
levels and awareness of radiation protection among radiology resi-
dents, medical students, and radiography students. Questionnaires
were distributed on the occasion of university classes that medical
students attend during the 5th year of their six-year course, radio-
graphy students during the 2nd year of their three-year course,
and radiology residents during their five-year course, respectively.
Prior to the survey, participants had been informed that the results
of the questionnaire would be stored in a database and used for
research purposes only. Participation to the survey was voluntary
and completely anonymous.
A total of 159 young doctors and students (radiology residents
37.74%, medical students 35.22%, radiography students 27.04%)
joined the survey. This latter was divided into three sections, of
which:
• Section 1 (Demographics and Perceived radiation protection
skills) contained the demographic data of each survey partici-
pant, as well as including their degree of training and perceived
radiation protection knowledge;
• Section 2 (Radiation protection awareness) was focused on
assessing: (1) radiation standards (2) susceptibility to radiation
damage, (3) regulations, (4) knowledge about professionals with
a higher exposure risk, (5) tissues more susceptible to injury from
ionising radiation, (6) diseases caused by radiation damage, and
(7) knowledge about dose optimisation;
• Section 3 (Knowledge about radiation dose levels) investigated
specific topics, such as: (1) average dose of a postero-anterior
chest X-ray (considered as a common reference unit to compare
radiation exposure from different radiological examinations); (2)
background radiation dose absorbed by the general population;
(3) lumbar spine X-ray dose; (4) mammography dose (bilateral,
two projections per side); (5) chest CT dose; (6) pelvic mag-
netic resonance imaging (MRI) dose; (7) 18-fluorodeoxiglucose
positron emission tomography-computed tomography (18 F-FDG
PET-CT) dose; (8) abdominal ultrasound (US) dose; (9) myocardial
scintigraphy dose (2-day protocol with 99m TC-sestamibi) [16].
All questions of Sections 2 and 3 were formulated in a multiple
choice format with five to six options and one only correct answer.
One mark was assigned for each correct answer and zero marks for
each wrong or missing answer, respectively (Appendix).
2.2. Statistical analysis
A descriptive analysis of the sample was performed. Categorical
variables were expressed as percentages, and continuous variables
as mean and standard deviation, respectively. The total question-
naire score and the two subscales (Radiation Protection and Dose
Assessment) were expressed as median and interquartile ranges
(IQR) and displayed on box-plot diagrams.
The score differences related to three questionnaire sec-
tions among the three groups (radiology residents, medical
students, radiography students) were evaluated using the Kruskal-
Wallis test. Post-hoc analysis was performed using pairwise
Mann–Whitney tests with Bonferroni correction. The questionnaire
reliability was assessed in terms of internal consistency by means
of the Cronbach’s alpha (␣) coefficient [mean and 95% confidence
intervals (CI95 )].
A P-value less than 0.05 was set as threshold for statistical sig-
nificance. Statistical analysis was carried out using software (SPSS
version 23.0, http://www-01.ibm.com/software/analytics/spss).
3. Results
The demographics of the survey participants in terms of age and
gender distribution, perceived radiation protection knowledge, and
previously performed training are reported in Table 1. All 159 par-
ticipants completed the questionnaire. Mean age was 29.4, 23.8,
and 22.5 years old for radiology residents, medical students and
radiography students, respectively. Gender distribution was com-
parable across the three categories (43.1%, 48.2%, and 44.2% of male
percentage, respectively; Chi-square test, P > 0.05).
As reported in a previous paper of ours [16], the questionnaire
was found to have acceptable internal reliability (␣ = 0.780; CI95
0.762 ÷ 0.852) as a measure of knowledge of essential radiation
protection topics. The internal consistency of the questionnaire was
also assessed separately among the radiology residents, medical
students, and radiography students. Cronbach’s ␣ coefficients were
0.760 (CI95 0.746 ÷ 0.796), 0.727 (CI95 0.688 ÷ 0.744) and 0.797
(CI95 0.696 ÷ 0.835), respectively.
As to the perceived knowledge of radiation protection issues,
medical students claimed to have at least a good knowledge
in 94.4% of cases (22.2% excellent, 72.2% good), resulting in
the highest value among the other categories of survey par-
ticipants. In fact, radiology residents claimed to have at least
a good knowledge in 55% of cases (5% excellent, 50% good),
 L. Faggioni et al. / European Journal of Radiology 86 (2017) 135–142
Table 1
Sample demographics (age, gender, and level of radiation protection awareness and training). SD = standard deviation. *F-test statistic by Anova, **Chi-square test, ***Fisher’s
exact test. P < 0.05 indicates statistical significance.
Radiology residents (N = 60)
Age (mean; SD) 29.4 (3.3)
Gender (% Male) 43.1
Perceived knowledge (%)
Excellent 5.0
Good 50.0
Sufficient 43.3
Insufficient 1.7
Training (%)
Frequently 45.0
Rarely 38.3
Never 16.7
whereas radiography students got the lowest rating with a per-
ceived good level of knowledge in 35.7% of cases and no cases
of perceived excellent knowledge (Fisher’s exact test, P < 0.05)
(Table 1).
Total questionnaire scores are reported in Fig. 1. Given a score
of 1 for each correct answer, the total mean score was 10.3 out of
16 for both radiology residents and radiography students, and 8.5
out of 16 for medical students, respectively (Kruskal-Wallis test,
P < 0.001). Questionnaire results concerning radiation protection
issues were much better, with a score of 5.8 out of 7 for both radi-
ology residents and radiography students and a score of 4.8 out of 7
for medical students, respectively (Kruskal-Wallis test, P < 0.001).
Conversely, the scores related to the knowledge about radiation
doses of radiological procedures were lower, with a score of 4.5
out of 9 for both radiology residents and radiography students and
3.7 out of 9 for medical students, respectively (Kruskal-Wallis test,
P < 0.001).
3.1. Radiation protection awareness
As to the questionnaire section related to main radiation protec-
tion issues (Fig. 2), all radiology residents and radiography students
(96.7% and 100%) and the majority of medical students (89.1%) were
aware of the need to inform patients about the risks of radiation
exposure. The question about which patients are most sensitive
to ionising radiation was correctly answered by 82.1% of radio-
graphy students, 76.3% of radiology residents, and only 54.5% of
medical students, respectively. The majority of radiology residents
and radiography students (83.3% and 83.6%) correctly answered
that referring physicians, radiologists and radiographers are all
responsible for unnecessary patient exposure and lack of optimi-
sation, whereas medical students’ performance was significantly
worse (73.2%) (Chi-square test, P < 0.05). Interventional radiologists
and cardiologists were properly considered as the most exposed
category by 88.3% of radiology residents and 76.2% of radiogra-
phy students, while less than half of medical students gave the
correct answer (43.6%). Breast was correctly deemed to be the
most radiation-sensitive tissue by almost all radiology residents
(97.7%), the majority of radiography students (87.5%), and about
three quarters of medical students (75.5%), respectively. Only 69.8%
of radiography students, 62.7% of radiology residents, and 57.1% of
medical students gave the correct answer to the question about
stochastic radiation damage. Overall, the majority of respondents
from all groups knew the concept of dose optimisation, yet the rate
of correct answers by medical students was slightly, but signifi-
cantly worse compared with the other groups (medical students
87.3% vs radiography students 95.0% and radiology residents 95.3%;
Fisher’s exact test, P < 0.05).
137
Medical students (N = 56) Radiography students (N = 43) P-value
23.8 (1.6) 22.5 (3.7) <0.05*
48.2 44.2 >0.05**
22.2 0 <0.05***
72.2 35.7
5.6 54.8
0 9.5
88.7 26.8 <0.05***
9.4 46.3
1.9 26.8
3.2. Knowledge of recommended radiation dose levels for the
main imaging procedures
The percentages of survey respondents who correctly identified,
underestimated and overestimated doses for natural background
exposure and common radiological investigations are shown in
Table 2.
The radiation dose from a standard chest X-ray examination was
correctly estimated by about three quarters of radiography stu-
dents (77.6%) and about half of radiology residents and medical
students (57.6 and 56.0%, respectively) (Fisher’s exact test, P < 0.05).
The radiation dose due to natural background was poorly estimated
by all categories, as only 24.6% of radiology residents, 18.9% of med-
ical students and 14.0% of radiography students gave the correct
answer. The knowledge of the radiation dose delivered by a lum-
bar X-ray examination was even worse, as the correct dose value
was given by only 10.3% of radiology residents, 14.8% of medi-
cal students, and 7.0% of radiography students, respectively. The
dose delivered by a mammography examination was known by
37.9% of radiology residents, 22.2% of medical students and 27.9%
of radiography students, but the fact that as many as 3.4% of radi-
ology residents, 1.9% of medical students, and 4.7% of radiography
students considered mammography as a radiation-free procedure
should be a matter of concern.
The dose figure best known by all categories was that of a chest
CT examination, yet it was correctly estimated by only about half
of respondents (radiology residents 54.4%, medical students 46.4%,
radiography students 44.2%). Surprisingly, 1.8% of both radiogra-
phy students and medical students answered that CT involves no
radiation exposure. Moreover, MRI and US were correctly identi-
fied as radiation-free by all radiology residents (100%) and almost
all radiography students (97.7%), while 9.1% and 32.7% of medical
students, respectively did not know that US and MRI do not involve
the use of ionising radiation.
As for nuclear medicine procedures, radiography students cor-
rectly estimated the radiation dose of 18 F FDG PET-CT examinations
significantly more frequently than radiology residents and medi-
cal students (66.7% vs 37.9% and 34.5%, respectively; Fisher’s exact
test, P < 0.05), whereas the radiation dose delivered by a myocar-
dial scintigraphy was more familiar to radiology residents (40.4%)
than to medical students (31.5%) and radiography students (16.7%)
(Fisher’s exact test, P < 0.05). As already observed for chest CT, a
small, but significantly higher percentage of radiology residents
and medical students thought that either PET-CT (3.4% and 5.5%,
respectively) or myocardial scintigraphy (9% and 3.7%, respectively)
are not associated with radiation exposure, compared with radiog-
raphy students (0% for both procedures; Fisher’s exact test, P < 0.05).
138 L. Faggioni et al. / European Journal of Radiology 86 (2017) 135–142

Fig. 1. Distribution of scores related to knowledge of radiation protection (a), dose level assessment (b), and overall knowledge (i.e. radiation protection and dose level
assessment) among radiology residents, medical students, and radiography students (c). Box plot diagrams show the distribution of median, interquartile range, minimum
and maximum values. P-values indicate statistical significance.

4. Discussion
Over the last years, the evolution of medical imaging has led to
a broadening of the clinical indications to several imaging proce-
dures, and consequently to a multiplication of imaging requests
by referring clinicians. This is especially true for CT, due to its
widespread availability even in peripheral centres, fast image
acquisition time, and excellent spatial and contrast resolution,
which allows to obtain a wealth of morphological and even func-
tional information from a single one-stop shop study. On the
other hand, such progress has spawned concern on the related
increase in radiation exposure to patients and the overall popula-
tion, prompting efforts towards a systematic reduction of radiation
doses through the development of dose-saving tools [17] and the
optimisation of radiological resources, including dose auditing and
initiatives aimed to improve radiation protection culture among
healthcare operators [18–20].
To the best of our knowledge, this is the first report of a survey
on the basic aspects of radiation protection (both subjectively per-
ceived and objectively tested through a structured questionnaire)
simultaneously involving medical students, radiology residents
and radiography students all studying or working in the same aca-
demic hospital. Strikingly, medical students resulted to have the
highest perceived knowledge on radiation protection issues (100%,
with 22.2% of them self-rating as excellent), but reported the worst
scores in objective tests (12.5% of 100% correct answers for gen-
eral radiation protection questions, and 0% for average dose levels
of common imaging techniques, respectively). It should be noted
that all medical students involved were attending the fifth year of
their 6-year undergraduate programme (including both theoretical
education and practical training in medical wards since the second
half of the third year) at the time of the survey, so that a basic
preparation on the main radiation protection issues as presented
in the questionnaire would have been expected. Yet, such a lack
of knowledge was paralleled by a high degree of self-confidence,
likely due to a simplistic view about radiation protection topics
that ultimately led to an overestimation of their own knowledge.
A potential explanation for this may be a general understatement
of radiation protection culture, which may have been engendered
by a poor knowledge itself as well as by a lack of familiarisation
with such topics during academic training. Such findings are sub-
stantially in line with the literature [10,12,21,22], and in particular,
Zhou et al. showed that the awareness of ionising radiation from
diagnostic imaging was lacking among senior medical students and
interns, with as high as 11.3% and 25.5% of respondents believing
that US and MRI involve the use of ionising radiation, respectively
[12]. It is worth noting that in this latter paper, interns from three
teaching hospital performed significantly better than fourth to sixth
year medical students, underscoring the importance of systematic
exposure to real-life training. Moreover, O’Sullivan et al. showed
 L. Faggioni et al. / European Journal of Radiology 86 (2017) 135–142 139

Fig. 2. Descriptive statistics of radiology residents’, medical students’, and radiography students’ answers to survey questions about general radiation protection issues (a,
questions from 1 to 4; b, questions from 5 to 7 of Section 2 of the survey questionnaire). Correct answers are boxed. IR = ionising radiation.

that medical students attending yearly modules of clinical radi-
ology education over their 5-year undergraduate programme had
a significantly greater awareness of radiation exposures associ-
ated with diagnostic imaging examinations than students following
the regular programme [23], suggesting that continuous radiation
protection education may be more effective at providing medi-
cal students with adequate radiation protection skills. Anyway, it
is clear that such understatement of radiation protection educa-
tion might have dangerous consequences, potentially resulting in
an increased number of inappropriate requests for imaging tests,
unnecessary higher radiation exposure to patients (as well as to
operators, in case of interventional procedures), and extra health-
care costs [13,23–25].
On the other hand, radiology residents and radiography students
possessed a significantly better knowledge of radiation protec-
tion issues, yet their perceived degree of knowledge was lower
140 L. Faggioni et al. / European Journal of Radiology 86 (2017) 135–142

Table 2
Overall distribution of answers to questions about the dose of natural background radiation and commonly performed imaging examinations given by radiology residents,
medical students, and radiography students. Values are expressed in terms of equivalent number of postero-anterior (PA) chest radiographs. Correct answers are highlighted
in shaded bold.

Which is the average dose for a PA chest radiograph?

<0.01 mSv 0.01–0.1 mSv 0.1–1 mSv 1–10 mSv 10–100 mSv >100 mSv

Radiology residents 8.5 57.6 28.8 1.7 3.4 0.0

Medical students 2.0 56.0 24.0 18.0 0.0 0.0
Radiography students 2.3 76.7 18.6 0 2.3 0.0

If a PA chest radiograph counts as 1 unit, how much is the average dose due to natural background radiation in Italy?
0 1–10 10–50 50–100 100–500 >500
Radiology residents 1.8 35.1 26.3 12.3 24.6 0.0
Medical students 3.8 26.4 30.2 17.0 18.9 3.8
Radiography students 0.0 7.0 34.9 44.2 14.0 0.0

If a PA chest radiograph counts as 1 unit, how much is the average dose due to a lumbar x-ray examination?
0 1–10 10–50 50–100 100–500 >500
Radiology residents 0.0 58.6 27.6 10.3 3.4 0.0
Medical students 0.0 59.3 22.2 14.8 3.7 0.0
Radiography students 0.0 39.5 44.2 7.0 9.3 0.0

If a PA chest radiograph counts as 1 unit, how much is the average dose due to mammography (bilateral, two projections each, i.e. four images in total)?
0 1–10 10–50 50–100 100–500 >500
Radiology residents 3.4 46.6 37.9 8.6 3.4 0.0
Medical students 1.9 50.0 22.2 13.0 9.3 3.7
Radiography students 4.7 51.2 27.9 16.3 0.0 0.0

If a PA chest radiograph counts as 1 unit, how much is the average dose due to a noncontrast chest CT examination?
0 1–10 10–50 50–100 100–500 >500
Radiology residents 1.8 0.0 15.8 26.3 54.4 1.8
Medical students 1.8 7.1 14.3 25.0 46.4 5.4
Radiography students 0.0 0.0 4.7 46.5 44.2 4.7

If a PA chest radiograph counts as 1 unit, how much is the average dose due to a pelvis MRI examination?
0 1–10 10–50 50–100 100–500 >500
Radiology residents 100 0.0 0.0 0.0 0.0 0.0
Medical students 67.3 3.6 5.5 12.7 7.3 3.6
Radiography students 97.7 0.0 0.0 2.3 0.0 0.0

If a PA chest radiograph counts as 1 unit, how much is the average dose due to a whole body PET-CT examination?
0 1–10 10–50 50–100 100–500 >500
Radiology residents 3.4 3.4 10.3 6.9 37.9 37.9
Medical students 5.5 3.6 10.9 16.4 29.1 34.5
Radiography students 0.0 0.0 2.4 14.3 16.7 66.7

If a PA chest radiograph counts as 1 unit, how much is the average dose due to an abdominal ultrasound examination?
0 1–10 10–50 50–100 100–500 >500
Radiology residents 100 0.0 0.0 0.0 0.0 0.0
Medical students 91.1 1.8 0.0 3.6 3.6 0.0
Radiography students 97.7 0.0 2.3 0.0 0.0 0.0

If a PA chest radiograph counts as 1 unit, how much is the average dose due to a myocardial scintigraphy (2-day protocol with 99m Tc-sestamibi)?
0 1–10 10–50 50–100 100–500 >500
Radiology residents 9 5.3 10.5 14.0 21.1 40.4
Medical students 3.7 9.3 14.8 18.5 22.2 31.5
Radiography students 0.0 2.4 9.5 14.3 57.1 16.7

compared with medical students. Such data may be explained by
the fact that radiology residents and radiography students receive
a more focused and intensive radiation protection training than
medical students due to the specialised nature of their academic
courses, and are in line with the finding by Borgen et al. [26] of
radiologists and radiographers having better knowledge of radia-
tion issues and referral guidelines than clinicians. Moreover, it may
be supposed that owing to their better radiation protection back-
ground, radiology residents and radiography students are more
aware of, and even somewhat daunted at the complexity of an in-
depth radiation protection knowledge such as they will be expected
to master in their future professional life.
To this latter respect, it is worth noting that in our study, train-
ing was perceived to be less frequent by radiology residents and
radiography students than by medical students. Indeed, all sub-
jects from the three groups attended hospital wards as a part of
their training, and especially radiography students are expected to
be directly involved in technically setting the radiation dose to be
delivered to patients, yet most radiography students rated their
training on radiation protection issues to occur rarely (46.3%) or
even never (26.8%). Such figures were better for radiology resi-
dents, though even among them training was reported to occur
rarely in quite a large fraction of cases (38.3%), and never in as
many as 16.7% of cases. Though we did not ask respondents to
quantify their training time, the finding of insufficient training was
also reported in the study by Portelli et al., in which half of radi-
ology practitioners and radiographers involved in a survey had
declared receiving a maximum of 20 h of radiation protection edu-
cation and training, which is much less than the recommended
30–50 h for radiology practitioners and 100–140 h for radiogra-
phers [21].
Taking the objective performance scores of radiography
students and radiology residents separately, we found that radiog-
raphy students significantly outperformed radiology residents as to
knowledge of radiation protection issues (P < 0.01). In their future
professional life, radiology residents will be expected to be able to
 L. Faggioni et al. / European Journal of Radiology 86 (2017) 135–142
choose the best imaging technique for a given diagnostic query and
will be held legally responsible for the justification of imaging pro-
cedures along with prescribing physicians, whereas radiography
students (i.e., future technologists) should gain a comprehensive
knowledge of dose levels as they are going to be technically respon-
sible for delivering radiation dose to patients. Overall, only 44.2%
of radiography students and 31.7% of radiology residents correctly
answered all questions on general radiation protection issues in
the objective test questionnaire, respectively, while as few as 2.3%
of radiography students and 5% of radiology residents correctly
answered all questions on radiation dose levels. This was quite
disappointing given the rather low difficulty level of the ques-
tionnaire, which was aimed to assess a basic knowledge about
radiation protection even among students without specialty pro-
fessional training in radiology, such as medical students. A poor
knowledge of radiation doses among trainees was also reported
by other authors (with, for instance, only 20% of radiology prac-
titioners providing the correct dose estimate for radiation-based
paediatric examinations in a primary paediatric referral centre [21],
and as few as 7% of residents knowing the dose of a postero-anterior
chest X-ray [25]. Actually, general dosimetry information is part
of the teaching programme of radiology courses to undergraduate
medical students, as well as of the core curriculum of radiology
residents as recommended by major radiological societies and reg-
ulatory institutions [24,27,28]. Combined with the relatively high
rate of survey respondents perceiving their training as not frequent,
a potential explanation to the above findings may be a trend by
working professionals acting as tutors in their daily activity to over-
look radiation protection issues. In other terms, it may be likely
that while radiography students and radiology residents receive
better theoretical radiation protection teaching than medical stu-
dents (as confirmed by their higher scores in objective radiation
protection knowledge tests), they do not get enough educational
feedback and radiation protection skill reinforcement during their
training time because radiation protection culture within the radi-
ological staff is either lacking or undervalued. While action has
recently been taken to improve radiation protection knowledge and
its implementation through quality assessment and workflow opti-
misation initiatives in radiology departments [18–20], evidence
exists in the literature that radiation protection awareness among
referring physicians as well as performing radiologists and technol-
ogists is quite variable and hovers at definitely substandard levels
in a substantial fraction of cases, even at academic or tertiary care
centres [29,30]. In this perspective, we believe that one of the chal-
lenges for promoting the importance of radiation protection culture
among radiological and non-radiological professionals in training
and improving their radiation protection skills is to consistently
implement their learning curricula with specific theoretical and
practical modules held by board certified radiologists and medical
physicists.
Our study has some limitations. Firstly, we performed a single
centre study, which prevented us from making comparisons and
eventually finding out any differences among medical students,
radiography students and radiology residents from different aca-
demic institutions. While this could be an interesting extension of
our present work that might warrant further investigation, teach-
ing curricula for students of the three aforementioned categories
are harmonised in agreement to national and European bylaws,
which should contribute to mitigate potential inter-institutional
discrepancies. Secondly, our survey sample was not large com-
pared with other studies [10,12,25], but can be deemed to be of
average size [21,30] and was sufficient to detect statistically signif-
icant differences among the three groups. Thirdly, unlike Portelli
et al. [21], we did not ask the survey respondents to give a quan-
titative estimation of the hours spent in their radiation protection
training, because this would have been quite complicated for med-
141
ical students (whose radiation protection training usually occurs
on various occasions other than at radiology departments and is
therefore unavoidably more dispersed in both time and space),
potentially leading to inconsistent findings. Fourthly, we did not
include a gold standard group of experts (such as radiation physi-
cists or board certified radiologists) for comparison, because we
feel that the complexity of radiation protection as a whole matter
makes it difficult to identify a single professional category as a valid
reference standard.
5. Conclusions
Our findings indicate that medical students near the end of
their undergraduate career tend to overestimate their own knowl-
edge of radiation protection issues as assessed by means of a basic
level survey, yet their radiation protection skills are significantly
worse compared with radiology residents and radiography stu-
dents participating to the same survey. On the other hand, those
latter believe that their radiation protection background and train-
ing is not enough for their future professional needs, and their
objective radiation protection knowledge still reveals significant
flaws. Despite the recently increased sensitivity of the medical
community and radiology vendors towards building a stronger
radiation protection culture, further efforts are needed to ensure
that radiation protection effectively becomes an essential part of
the professional skills of all healthcare providers involved. This is
the recommended approach to safeguard patients’ and operators’
safety and optimise resources, both inside and outside the radio-
logical environment.
Funding information
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Appendix A. Supplementary data
Supplementary data associated with this article can be found,
in the online version, at http://dx.doi.org/10.1016/j.ejrad.2016.10.
033.
References
[1] F.A. Mettler Jr., M. Bhargavan, K. Faulkner, et al., Radiologic and nuclear
medicine studies in the United States and worldwide: frequency, radiation
dose, and comparison with other radiation sources—1950–2007, Radiology
253 (2009) 520–531 http://dx.doi.org/10.1148/radiol.2532082010.
[2] R. Smith-Bindman, J. Lipson, R. Marcus, et al., Radiation dose associated with
common computed tomography examinations and the associated lifetime
attributable risk of cancer, Arch. Intern. Med. 169 (2009) 2078–2086 http://
dx.doi.org/10.1001/archinternmed.2009.427.
[3] D.L. Miglioretti, E. Johnson, A. Williams, et al., The use of computed
tomography in pediatrics and the associated radiation exposure and
estimated cancer risk, JAMA 167 (2013) 700–707 http://www.dx.doi.org/10.
1001/jamapediatrics.2013.311.
[4] H. Baysson, N. Journy, T. Roué, H. Ducou-Lepointe, C. Etard, M.O. Bernier,
Exposure to CT scans in childhood and long-term cancer risk: a review of
epidemiological studies, Bull. Cancer 103 (2016) 190–198 http://www.dx.doi.
org/10.1016/j.bulcan.2015.11.003.
[5] J.D. Mathews, A.V. Forsythe, Z. Brady, et al., Cancer risk in 680,000 people
exposed to computed tomography scans in childhood or adolescence: data
linkage study of 11 million Australians, BMJ 21 (2013), 346:f2360 http://
www.dx.doi.org/10.1136/bmj.f2360.
[6] M.A. Kuefner, M. Brand, C. Engert, S.A. Schwab, M. Uder, Radiation induced
DNA double-strand breaks in radiology, Rofo 187 (2015) 872–878 http://
www.dx.doi.org/10.1055/s-0035-1553209.
[7] K. Kanagaraj, S. Abdul Syed Basheerudeen, G. Tamizh Selvan, et al.,
Assessment of dose and DNA damages in individuals exposed to low dose and
low dose rate ionizing radiations during computed tomography imaging,
Mutat. Res. Genet. Toxicol. Environ. Mutagen. 789–790 (2015) 1–6 http://
www.dx.doi.org/10.1016/j.mrgentox.2015.05.008.
142 L. Faggioni et al. / European Journal of Radiology 86 (2017) 135–142
[8] P.V. Shaw, P. Croüail, R. Paynter, M. Coeck, Education and training in radiation
protection: improving ALARA culture, J. Radiol. Prot. 35 (2015) 223–227
http://www.dx.doi.org/10.1088/0952-4746/35/1/223.
[9] European Commission, Radiation Protection No. 175. Guidelines on radiation
protection education and training of medical professionals in the European
Union, 2016, http://ec.europa.eu/energy/sites/ener/files/documents/175.pdf,
2014 (Accessed 14 08 2016).
[10] M. Günalp, B. Gülünay, O. Polat, et al., Ionising radiation awareness among
resident doctors, interns, and radiographers in a university hospital
emergency department, Radiol. Med. 119 (2014) 440–447 http://www.dx.doi.
org/10.1007/s11547-013-0374-8.
[11] R.K. Lee, W.C. Chu, C.A. Graham, T.H. Rainer, A.T. Ahuja, Knowledge of
radiation exposure in common radiological investigations: a comparison
between radiologists and non-radiologists, Emerg. Med. J. 29 (2012) 306–308
http://www.dx.doi.org/10.1136/emermed-2011-200481.
[12] G.Z. Zhou, D.D. Wong, L.K. Nguyen, R.M. Mendelson, Student and intern
awareness of ionising radiation exposure from common diagnostic imaging
procedures, J. Med. Imaging Radiat. Oncol. 54 (2010) 17–23 http://www.dx.
doi.org/10.1111/j.1754-9485.2010.02132.x.
[13] P. Cole, R. Hallard, J. Broughton, et al., Developing the radiation protection
safety culture in the UK, J. Radiol. Prot. 34 (2014) 469–484 http://www.dx.doi.
org/10.1088/0952-4746/34/2/469.
[14] T. Coldwell, P. Cole, C. Edwards, et al., The advantages of creating a positive
radiation safety culture in the higher education and research sectors, J. Radiol.
Prot. 35 (2015) 917–933 http://www.dx.doi.org/10.1088/0952-4746/35/4/
917.
[15] R.K. Singh, P. McCoubrie, K. Burney, J.A. Miles, Teaching medical students
about radiation protection-what do they need to know? Clin. Radiol. 63
(2008) 1344–1349 http://www.dx.doi.org/10.1016/j.crad.2008.06.010.
[16] F. Paolicchi, F. Miniati, L. Bastiani, L. Faggioni, A. Ciaramella, I. Creonti, C.
Sottocornola, C. Dionisi, D. Caramella, Assessment of awareness about
radiation protection and knowledge about radiological examination doses
among Italian radiographers, Insights Imaging 7 (2016) 233–242 http://www.
dx.doi.org/10.1007/s13244-015-0445-6.
[17] S.P. Raman, P.T. Johnson, S. Deshmukh, M. Mahesh, K.L. Grant, E. Fishman, CT
dose reduction applications: available tools on the latest generation of CT
scanners, J. Am. Coll. Radiol. 10 (2013) 37–41 http://www.dx.doi.org/10.1016/
j.jacr.2012.06.025.
[18] E.P. Tamm, X.J. Rong, D.D. Cody, R.D. Ernst, N.E. Fitzgerald, V. Kundra, Quality
initiatives: CT radiation dose reduction: how to implement change without
sacrificing diagnostic quality, Radiographics 31 (2011) 1823–1832 http://
www.dx.doi.org/10.1148/rg.317115027.
[19] F. Paolicchi, L. Faggioni, L. Bastiani, S. Molinaro, D. Caramella, C. Bartolozzi,
Real practice radiation dose and dosimetric impact of radiological staff
training in body CT examinations, Insights Imaging 4 (2013) 239–244 http://
www.dx.doi.org/10.1007/s13244-013-0241-0.
[20] F. Paolicchi, L. Faggioni, L. Bastiani, S. Molinaro, M. Puglioli, D. Caramella, C.
Bartolozzi, Optimizing the balance between radiation dose and image quality
in pediatric head CT: findings before and after intensive radiologic staff
training, AJR Am. J. Roentgenol. 202 (2014) 1309–1315 http://www.dx.doi.
org/10.2214/AJR.13.11741.
[21] J.L. Portelli, J.P. McNulty, P. Bezzina, L. Rainford, Paediatric imaging radiation
dose awareness and use of referral guidelines amongst radiology
practitioners and radiographers, Insights Imaging 7 (2016) 145–153 http://
www.dx.doi.org/10.1007/s13244-015-0449-2.
[22] M.W. McCusker, C. de Blacam, M. Keogan, R. McDermott, P. Beddy, Survey of
medical students and junior house doctors on the effects of medical radiation:
is medical education deficient? Ir. J. Med. Sci. 178 (2009) 479–483 http://
www.dx.doi.org/10.1007/s11845-009-0341-5.
[23] J. O’Sullivan, O.J. O’Connor, K. O’Regan, et al., An assessment of medical
students’ awareness of radiation exposures associated with diagnostic
imaging investigations, Insights Imaging 1 (2010) 86–92 http://www.dx.doi.
org/10.1007/s13244-010-0009-8.
[24] A. Hertault, B. Maurel, M. Midulla, et al., Editor’s choice—minimizing radiation
exposure during endovascular procedures: basic knowledge, literature
review, and reporting standards, Eur. J. Vasc. Endovasc. Surg. 50 (2015) 21–36
http://www.dx.doi.org/10.1016/j.ejvs.2015.01.014.
[25] S. Divrik Gökçe, E. Gökçe, M. Coşkun, Radiology residents’ awareness about
ionizing radiation doses in imaging studies and their cancer risk during
radiological examinations, Korean J. Radiol. 13 (2012) 202–209 http://www.
dx.doi.org/10.3348/kjr.2012.13.2.202.
[26] L. Borgen, E. Stranden, Radiation knowledge and perception of referral
practice among radiologists and radiographers compared with referring
clinicians, Insights Imaging 5 (2014) 635–640 http://www.dx.doi.org/10.
1007/s13244-014-0348-y.
[27] European Training Curriculum for Radiology, http://www.myesr.org/cms/
website.php?id=/en/education training/european training curriculum for
radiology.htm, 2016 (Accessed 14 08 2016).
[28] E.S. Amis Jr., P.F. Butler, ACR white paper on radiation dose in medicine: three
years later, J. Am. Coll. Radiol. 7 (2010) 865–870 http://www.dx.doi.org/10.
1016/j.jacr.2010.04.006.
[29] N. Brown, L. Jones, Knowledge of medical imaging radiation dose and risk
among doctors, J. Med. Imaging Radiat. Oncol. 57 (2013) 8–14 http://www.dx.
doi.org/10.1111/j.1754-9485.2012.02469.x.
[30] S. Ramanathan, J. Ryan, Radiation awareness among radiology residents,
technologists, fellows and staff: where do we stand? Insights Imaging 6
(2015) 133–139 http://www.dx.doi.org/10.1007/s13244-014-0365-x.