Original research
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102002 on 9 March 2021. Downloaded from http://rapm.bmj.com/ on January 11, 2024 at European Society of Regional
►► Additional material is
published online only. To view,
please visit the journal online
(http://​dx.​doi.o​ rg/​10.​1136/​
rapm-​2020-​102002).
For numbered affiliations see
end of article.
Correspondence to
Dr David Anthony Provenzano,
Pain Diagnostics and
Interventional Care, Sewickley,
PA 15143, USA;
d​ avidprovenzano@​hotmail.​com
American Society of Regional
Anesthesia and Pain Medicine
18 th Annual Meeting. New
Orleans, LA. November 2019.
Abstract ID #262. North
American Neuromodulation
Society 23rd Annual Meeting.
Las Vegas, NV. January 2020.
Received 5 August 2020
Revised 26 January 2021
Accepted 31 January 2021
Published Online First
9 March 2021
►► http://​​dx.​​doi.​​org/​​10.​​1136/​
rapm-​2021-​102574
© American Society of Regional
Anesthesia & Pain Medicine
2021. No commercial re-­use.
See rights and permissions.
Published by BMJ.
To cite: Provenzano DA,
Florentino SA, Kilgore JS,
et al. Reg Anesth Pain Med
2021;46:469–476.
Radiation safety and knowledge: an international
survey of 708 interventional pain physicians
David Anthony Provenzano ‍ ‍,1 Samuel Ambrose Florentino ‍ ‍,1,2
Jason S Kilgore ‍ ‍,3 Jose De Andres ‍ ‍,4 B Todd Sitzman,5 Scott Brancolini,6
Tim J Lamer,7 Asokumar Buvanendran,8 John A Carrino,9 Timothy R Deer ‍ ‍,10
Samer Narouze ‍ ‍11
ABSTRACT
Introduction Interventional pain procedures have
increased in complexity, often requiring longer radiation
exposure times and subsequently higher doses. The
practicing physician requires an in-­depth knowledge and
evidence-­based knowledge of radiation safety to limit
the health risks to themselves, patients and healthcare
staff. The objective of this study was to examine current
radiation safety practices and knowledge among
interventional pain physicians and compare them to
evidence-­based recommendations.
Materials and methods A 49-­question survey was
developed based on an extensive review of national and
international guidelines on radiation safety. The survey
was web-­based and distributed through the following
professional organizations: Association of Pain Program
Directors, American Academy of Pain Medicine, American
Society of Regional Anesthesia and Pain Medicine,
European Society of Regional Anesthesia and Pain
Therapy, International Neuromodulation Society, and
North American Neuromodulation Society. Responses
to radiation safety practices and knowledge questions
were evaluated and compared with evidence-­based
recommendations. An exploratory data analysis examined
associations with radiation safety training/education,
geographical location, practice type, self-­perceived
understanding, and fellowship experience.
Results Of 708 responding physicians, 93% reported
concern over the health effects of radiation, while
only 63% had ever received radiation safety training/
education. Overall, ≥80% physician compliance
with evidence-­based radiation safety practice
recommendations was demonstrated for only 2/15
survey questions. Physician knowledge of radiation safety
principles was low, with 0/10 survey questions having
correct response rates ≥80%.
Conclusion We have identified deficiencies in the
implementation of evidence-­based practices and
knowledge gaps in radiation safety. Further education
and training are warranted for both fellowship training
and postgraduate medical practice. The substantial
gaps identified should be addressed to better protect
physicians, staff and patients from unnecessary
exposure to ionizing radiation during interventional pain
procedures.
INTRODUCTION
Fluoroscopy is integral to the practice of interven-
tional pain medicine, and the overall number of
Provenzano DA, et al. Reg Anesth Pain Med 2021;46:469–476. doi:10.1136/rapm-2020-102002
fluoroscopically guided procedures is increasing
globally.1 Fluoroscopy enhances pain procedure
safety and accuracy; however, its utilization is not
without associated radiation health risks to the
practicing physician, clinical support staff, and
procedural patients.2
Although many interventional pain procedures
require limited doses of radiation, concerns still
exist for chronic cumulative low-­dose exposure to
Anaesthesia and Pain Therapy. Protected by copyright.
ionizing radiation.3 4 In addition, as pain manage-
ment procedures (e.g., kyphoplasty, minimally
invasive lumbar decompression, and neuromod-
ulation) increase in complexity, the interventions
often require higher radiation dose exposures.5
Consequently, interventional pain physicians who
conduct a large number of interventions, as well as
their staff, can accumulate a high level of lifetime
radiation exposure.
Interventional pain physicians need to possess
an in-­depth and evidence-­based understanding of
the biological risks and effects of radiation and
methods to limit exposure. However, the Inter-
national Commission on Radiological Protec-
tion (ICRP) has expressed concerns regarding
the knowledge and safety practices of physicians
utilizing fluoroscopy for procedures.6 7 These
concerns have been enhanced due to the increased
number of procedures performed outside of the
radiology department.8 In addition, institutional
requirements and education curriculum are often
not standardized.4
Interventional pain physicians’ levels of educa-
tion and knowledge on radiation and evidence-­
based practices to mitigate radiation exposure,
especially in the USA and Europe, are not well
understood. To date, two small surveys including
27 and 49 pain physicians, respectively, in Korea
indicated that radiation safety knowledge levels are
exceptionally low.9 10
The pain community and educators must under-
stand current knowledge levels on radiation safety
and evidence-­based practices from multiple settings,
including different geographical and site-­of-­service
locations. Baseline information on radiation safety
knowledge, practice patterns and education across
different settings is needed before defined targeted
education focusing on remedying identified gaps
can be used to enhance safety practices.11 12
The purpose of this study was to examine
current radiation safety practices and knowledge of
   469
 Original research
radiation principles among interventional pain physicians and to
compare them to evidence-­based recommendations.
METHODS
Survey questionnaire
An extensive PubMed search identified relevant journal articles
on radiation safety. Key search terms included radiation safety,
ionizing radiation, radiation, radiation safety guidelines, fluoros-
copy, stochastic and nonstochastic, pain, and as low as reasonably
achievable (ALARA). National and international radiation safety
guidelines from the National Council on Radiation Protection
and Measurements (NCRP)13 and the ICRP1 6 8 14–16 served as
the basis for the safety recommendations and corresponding
correct answer. Relevant subspecialty recommendations from
cardiology,17 18 orthopedics19 and interventional radiology20
were also included.
Following the review of the literature, a 49-­question (online
supplemental appendix A) web-­based survey on knowledge of
radiation safety and evidence-­based practices was developed.
Survey questionnaire pretesting
The survey was initially developed by two authors (DAP and
SAF). Next, all authors reviewed and revised the survey ques-
tions to improve the clarity and the comprehensiveness of the
questions. Nine of the authors (DAP, SB, AB, JAC, JDA, TRD,
TJL, SN, and BTS) practice in the field of interventional pain
medicine.21 Next, the survey was uploaded to an online survey
platform and pretested with five physicians (two attendings and
three fellows) through cognitive interviews.21–23 Prior to the
cognitive interview, a set of proactive questions were developed
to identify potential challenges with the survey, including misin-
terpretation of questions. The cognitive interviews involved a
flexible verbal probing method and adaptive procedure based
on the respondent’s behavior.23 The respondent’s answers were
recorded and compared in order to identify any inconsistencies
in the interpretation of the survey questions and answers. Ques-
tions and choices of answers were modified to ensure that the
questions were perceived as intended and that the answers were
well understood and inclusive of all possibilities.
A pilot test of the revised survey (online supplemental appendix
A) was then conducted with six interventional pain physi-
cians.21 22 24 25 The pilot survey was distributed through the
online platform to replicate the anticipated survey distribution
to the entire study group. The participants were given 7 days to
respond to the survey. No issues were observed from the pilot
study. The pilot study illustrated that the implementation of
the study is feasible, and no additional changes were needed to
the survey. The final 49-­question web-­based survey is shown in
online supplemental appendix A.
Participants and survey distribution
Interventional pain physicians and pain fellows were identi-
fied from the following organizations: American Academy of
Pain Medicine (AAPM), Association of Pain Program Directors
(APPD), American Society of Regional Anesthesia and Pain Medi-
cine (ASRA), European Society of Regional Anesthesia and Pain
Therapy (ESRA), International Neuromodulation Society (INS)
and the North American Neuromodulation Society (NANS).
An initial email letter was sent by each organization with the
survey link to the online platform. Each organization sent a
reminder email 2 weeks later. Based on the timing of each orga-
nization’s email release, the survey was carried out for a total of
71 days (April 17, 2019–June 26, 2019). The email invitations
470 Provenzano DA, et al. Reg Anesth Pain Med 2021;46:469–476. doi:10.1136/rapm-2020-102002
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102002 on 9 March 2021. Downloaded from http://rapm.bmj.com/ on January 11, 2024 at European Society of Regional
emphasized that survey participation was voluntary, anonymous
and confidential. The survey was distributed to all physician
members of the societies, but only interventional pain physicians
were instructed to participate in the survey. Participants were
asked not to take the survey more than once and to avoid using
the internet or print educational materials while addressing the
questions in the survey.
Data
Surveys with at least 25 (>50%) answered questions were
included in the analyses. Geographical location was defined as
North America—USA, Europe, Asia or Other, which included
data from North America—other, South America, Africa and
Australia. The ‘other’ group classification was created because of
low response rates (≤4% of the total survey responses for each
group) in each of these geographical subsets. Practice location
was defined as academic practice (i.e., practice associated with an
academic institution), hospital-­based program and private prac-
tice, which consisted of private solo practice and group practice
locations. Perceived knowledge was classified into the following
groups: (1) ‘below average’ (included very poor, poor, and
below average responses); (2) ‘average’ and (3) ‘above average’
Anaesthesia and Pain Therapy. Protected by copyright.
(included above average, high, and very high responses).
Compliance with recommended radiation safety practices
(ICRP and NCRP) was analyzed based on the responses to 15
questions (questions 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 18, 19,
and 23; online supplemental appendix A). These practices were
further subcategorized into three main groups including radia-
tion protection equipment (questions 2, 3, 4, 5, 6, 7, 9, and 10);
badge and dose monitoring (questions 8, 11, 12, 14, 18, and 19)
and collimation (question 23). Compliance with radiation safety
practices was defined as a correct response according to citable
evidence-­based recommendations.
To evaluate knowledge of radiation principles, the responses
to 10 knowledge questions (questions 20, 21, 22, 24, 25, 26, 27,
28, 29 and 30; online supplemental appendix A) were catego-
rized as correct or incorrect. Knowledge of radiation principles
was further subcategorized into five groups, including ALARA
radiation protection principles (questions 26 and 29); radiation
effects (questions 25, 27, and 28); fluoroscopy equipment (ques-
tions 20, 21, and 22); units for radiation exposure (question 24);
and sources of radiation (question 30).
An exploratory data analysis (EDA) examined the association
of compliance with radiation safety practices and knowledge
of radiation principles with education, geographical location,
fellowship training, practice type and perceived knowledge.
Statistics
To compare correct response rates between respondents who
indicated none vs. some level of radiation safety training/educa-
tion, we removed non-­responses for each question and compared
only those who answered both the specific question and indi-
cated whether they received training/education (question 31).26
Our study aimed to collect survey data from the entire popu-
lation of interest (i.e., all current interventional pain physicians
and pain fellows), therefore, we did not conduct an a priori
power analysis to identify an appropriate sample size.26
Rates are shown as the percentage of correct responses,
including number of correct responses, total number of responses,
and 95% CI’s. All analyses were conducted in RV.4.0.1 (R Core
Team, Vienna, Austria). CIs were estimated using the Clopper-­
Pearson method for dichotomous measures and the Sison-­Glaz
method for categorical endpoints.27 The correct response rate
 Original research

Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102002 on 9 March 2021. Downloaded from http://rapm.bmj.com/ on January 11, 2024 at European Society of Regional
within each category was compared with random (p=0.5) with
Table 1 Demographics of respondents
exact binomial tests.28 Relative risk and corresponding 95% CI’s
Frequency (%)
were calculated in Microsoft Excel 2016 (Microsoft, Redmond,
Washington, USA) to compare the correct response rate in select Region (N=706)
questions on compliance with recommended radiation safety North America, USA 321 (45)

practices and knowledge of radiation principles by those respon- Europe 266 (38)

dents with education/training versus those without education/ Asia 49 (7)

training. Other* 70 (10)

Specialty (N=705)
Anesthesiology 591 (84)
RESULTS Physical medicine and rehabilitation 45 (6)
A total of 20,153 unique survey-­linked invitations were sent Neurosurgery 38 (5)
by the following professional societies: AAPM, APPD, ASRA, Other† 31 (4)
ESRA, INS and NANS. Of the 713 practicing interventional Type of practice (N=703)
pain physicians and pain fellows who responded to the survey, Hospital 293 (42)
five respondents answered <50% of the questions and were Private 238 (34)
not included, thus leaving 708 total physicians who met the Academic 172 (24)
inclusion criteria. An accurate response rate could not be calcu- Procedural location (N=702)

lated. Limitations for the response rate calculation included Hospital 452 (64)

that 34% of respondents were members of more than one of Office 126 (18)

the societies. Also, the survey was directed only toward inter- Ambulatory surgery center 124 (18)

ventional pain physicians, and not all members of each of the Years in practice (attendings) (N=607)

Anaesthesia and Pain Therapy. Protected by copyright.

societies practiced interventional pain medicine. The open rate, ≤10 years 213 (35)

or number of survey emails opened divided by the number of >10 years to ≤30 years 312 (51)
>30 years 82 (14)
delivered emails, was calculated for the entire survey group
Completed pain fellowship (N=696)
(32.4%) and each individual society: (32.9% for AAPM, 37.5%
No** 359 (52)
for ASRA, 30.1% for ESRA, 28.1% for INS, and 39.9% for
Yes 337 (48)
NANS).
Procedural volume (N=704)
For the fellowship data analysis, 34 respondents were excluded
≤500 369 (52)
secondary to providing incomplete or conflicting information
501 to ≤1500 248 (35)
regarding fellowship training (questions 42, 43, and 44; online
>1500 87 (12)
supplemental appendix A). Therefore, the fellows’ analyses
SCS trials per year (N=697)
included only 674 respondents, while all other analyses included
≤10 trials 462 (66)
all 708 respondents.
>10 to 40 trials 167 (24)
>40 trials 68 (10)

Physician characteristics SCS implants per year (N=691)

Table 1 defines the characteristics of the physicians who
responded to the survey. Approximately 93% (653/705) of
physicians were concerned with the health effects of radiation.
Practice type and procedural locality did vary among physi-
cian respondents. Within each geographical region and for
respondents who answered both questions 40 and 48 (online
supplemental appendix A) (700/708), most physician respon-
dents from North America-­USA were in private practice (50%,
160/319) compared with academic (34%, 107/319) and hospital-­
based (16%, 52/319) programs. Respondents from Europe were
primarily hospital-­based (72%, 190/264) with 15% (39/264) in
private practice and 13% (35/264) in academic practice. Physi-
cians from Asia were primarily hospital-­based (54%, 26/48) with
27% (13/48) in private practice and 19% (9/48) in academic
practice.
Organizational support for fluoroscopy machine operation
and radiation badge safety monitoring differed among respon-
dents. A radiology technologist operated the fluoroscopy
machine for 68% (481/707) of physicians, while 15% (109/707)
of physicians operated the fluoroscopy machine. Additional
operators included nurses (8%, 58/707), medical assistants
(6%, 42/707), and surgical technicians (2%, 17/707). Radi-
ation badge monitoring was conducted by the institution for
78% (548/705) of the respondents; for the remaining respon-
dents, radiation badge monitoring was either not conducted
(8%, 58/705), unknown (11%, 76/705) or self-­monitored (3%,
23/705).
Provenzano DA, et al. Reg Anesth Pain Med 2021;46:469–476. doi:10.1136/rapm-2020-102002
≤10 implants 499 (72)
>10 to 40 implants 137 (20)
>40 implants 55 (8)
**Sixty-­four respondents reported they were currently in a pain fellowship.
CIs were calculated using the Clopper–Pearson (exact) method.
*Includes Africa, Australia, North America-­other and South America.
†Includes Orthopedics, Neurology, Psychiatry, Family Medicine, Radiology and Other.
N, total number of responses by category.
Radiation education/training
Both baseline and annual radiation safety education/training
were limited and often not required a practicing institution
(table 2). Only 63% of the respondents reported receiving
radiation safety education/training. Specifically, postmed-
ical school radiation safety education was limited, with
only 30% receiving greater than 2 hours for an introductory
education. Most institutions did not require annual radia-
tion safety education (65%) or a radiation safety examina-
tion (63%). Eighty percent of the respondents from North
America-­USA received education, while only 55% of Euro-
pean respondents and 33% of Asian respondents received
radiation safety education.
Radiation education/training was lowest for physicians
working in hospital-­based practices. A greater proportion of
physicians from both academic practice (73%; 95% CI 66%
to 79%) and private practice (66%; 95% CI 60% to 72%)
received education/training in comparison to respondents
from hospital-­based practices (56%; 95% CI 50% to 62%).
471
Original research

Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102002 on 9 March 2021. Downloaded from http://rapm.bmj.com/ on January 11, 2024 at European Society of Regional
examining the differences in receiving education/training
Table 2 Baseline and annual radiation education and training
between physicians in the self-­ r eported ‘above average’
Frequency (%) 95% CI against the ‘average’ and ‘below average’ groups, the differ-
Received education/training (N=705) ences were 22% (95% CI 15% to 29%) and 53% (95% CI
Yes 446 (63) 60 to 67 44% to 63%), respectively. Furthermore, physicians who
No 259 (37) 33 to 40 reported ‘average’ levels of understanding were more likely
Initial education after medical school (N=707) to have received radiation safety education/training than
None 251 (36) 32 to 40 physicians who reported ‘below average’ levels of under-
≤2 hours 244 (35) 31 to 39 standing with a difference of 31% (95% CI 21% to 41%).
>2 to 6 hours 138 (20) 16 to 24
>6 hours 74 (10) 7 to 15
Annual education (N=708)
Compliance with evidence-based radiation safety practices
None 406 (57) 54 to 62
Compliance (i.e., selection of correct response) with
evidence-­based radiation safety practice recommendations
≤2 hours 227 (32) 28 to 36
was low. Results of the survey were compared with current
>2 to 6 hours 62 (9) 5 to 13
evidence-­based recommendations. Table 3 isolates compli-
>6 hours 13 (2) 0 to 6
ance rates for recommended practices identified in the
Institution requires annual training/education
(N=706) survey that are specifically addressed by ICRP and NCRP.
Yes 248 (35) 32 to 40 Only 13% (2/15) of the examined radiation safety practices
No 458 (65) 61 to 68 were associated with ≥80% of the physicians selecting the
Examination requirement (N=706)
correct answer and thus signifying adherence to the practice.
Yes 263 (37) 34 to 39
The lowest rates of compliance (<30%) were in the utili-
zation of radiation protection headgear, lead gloves, radia-

Anaesthesia and Pain Therapy. Protected by copyright.

No 443 (63)
N, total number of total responses by category.
Reported levels of self-­p erceived understanding were asso-
ciated with receiving education/training. A greater propor-
tion of physicians who reported ‘above average’ levels of
self-­perceived understanding of radiation safety were more
likely to have received radiation education/training (82%;
95% CI 77% to 86%) when compared with ‘average’ (60%;
95% CI 54% to 65%) with a difference of 22% (95% CI
15% to 29%) and ‘below average’ (28%; 95% CI 20% to
37%) with a difference of 53% (95% CI 44% to 63%). When
59 to 66
tion safety glasses and a minimum of 0.5 mm lead equivalent
thickness for protective garments. Although not specifically
included in the compliance evaluation for radiation safety
practices, there was a lack of understanding of the setting
of pulsation rate for pulsed fluoroscopy. The survey demon-
strated that 72% (510/704; 95% CI 69% to 76%) of physi-
cians did not know the pulsation rate that was selected when
using this protective measure.
In addition, the EDA demonstrated the specific compliance
rates with radiation safety practices for each geographical
location and practice type (online supplemental appendix B:
tables 1 and 2).

Table 3 Areas of compliance and Noncompliance with ICRP and NCRP radiation safety practice recommendations
Recommended radiation safety practice Compliance (%), (n/N) 95% CI Origin of recommended practice
Radiation protection equipment  
Utilization of radiation protection garments 86 (607/704) 83 to 89 ICRP 139, NCRP 168
Occupational staff use of radiation protection garments 80 (566/705) 77 to 83 ICRP 139, NCRP 168
Avoiding intentional placement of hands under the primary 68 (482/706) 65 to 72 ICRP 139, NCRP 168
X-­ray beam
Utilization of thyroid protector 67 (470/705) 63 to 70 ICRP 139, NCRP 168
Minimum of 0.5 mm for maximum equivalent lead thickness 44 (308/706) 40 to 47 NCRP 168
of physician’s apron or vest/kilt
Utilization of radiation safety glasses 24 (166/705) 20 to 27 ICRP 139, NCRP 168
Utilization of lead gloves 6 (41/705) 4 to 8 ICRP 139, NCRP 168
Utilization of radiation safety head gear 4 (27/707) 3 to 6 ICRP 117
Badge and dose monitoring  
Minimum monthly evaluation of radiation badge 34 (236/698) 30 to 37 ICRP 139, NCRP 168
Minimum yearly checks of radiation protection garments for 67 (476/706) 64 to 71 ICRP 139, NCRP 168
cracks
Proper placement of radiation safety badge 52 (366/708) 48 to 55 ICRP 139, NCRP 168
Utilization of a radiation badge 51 (360/707) 47 to 55 ICRP 139, NCRP 168
Recording of fluoroscopy time as part of procedural/operative 39 (274/704) 35 to 43 ICRP 135, NCRP 168
report
Recording of cumulative dose as part of procedural/operative 29 (202/705) 25 to 32 ICRP 135, NCRP 168
report

Collimation  
Utilization of collimation 46 (326/704) 43 to 50 ICRP 139, NCRP 168
ICRP, International Commission on Radiological Protection; N, number of responses by category; n, number of correct responses by category; NCRP, National Council on Radiation Protection &
Measurements.

472 Provenzano DA, et al. Reg Anesth Pain Med 2021;46:469–476. doi:10.1136/rapm-2020-102002
 Original research

Table 4 Knowledge of radiation principles
Knowledge
ALARA principles and radiation protection
Inverse square law
ALARA principles
Radiation effects
Stochastic effects
Nonstochastic effects
Biological effects of
radiation
Fluoroscopy equipment
X-­ray tube optimal location 30 (209/706)
C-­Arm orientation
Image receptor optimal
location
Units for radiation exposure
Radiation units
Sources of radiation
Radiation source
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102002 on 9 March 2021. Downloaded from http://rapm.bmj.com/ on January 11, 2024 at European Society of Regional
practice type, a significant proportion of respondents from
each practice category type incorrectly responded to 7 of the
Correct response Origin of correct 10 questions (p<0.001).
(%), (n/N) 95% CI response
70 (495/706) 67 to 74 ICRP 117, 120 and NCRP Education/training and adherence to radiation safety
168 practices and knowledge of radiation principles
55 (385/702) 51 to 59 ICRP 37, 55, 139, and Physicians with radiation safety education/training (i.e., answered
NCRP 168, 160 yes to Q31; online supplemental appendix A) were more likely
to be compliant with evidence-­based radiation safety practices
39 (274/703) 35 to 43 NCRP 168 and to be more knowledgeable of radiation principles compared
32 (225/705) 28 to 35 ICRP 139, NCRP 168 with those without education/training (table 5 and online supple-
22 (158/704) 19 to 26 NCRP 168 mental appendix B: tables 4 and 5). Table 5 provides the relative
rate ratios for selected compliance and knowledge-­based ques-
tions. For further details on the compliance and correct response
26 to 33 ICRP 139, NCRP 168
rates for interventional pain physicians with and without educa-
26 (181/703) 23 to 29 ICRP 139, NCRP 168
tion and training refer to online supplemental appendix B: tables
12 (173/703) 21 to 28 ICRP 139, NCRP 168
4 and 5. Physicians who reported having radiation safety educa-
tion/training had higher rates of compliance on 80% (12/15) of
the practice areas than physicians reporting no radiation safety
14 (100/705) 12 to 17 NCRP 168
training and education (online supplemental appendix B: table
4). In addition, physicians who reported having radiation safety
25 (173/703) 21 to 28 ICRP 139, NCRP 168
education/training were more knowledgeable of radiation prin-

Anaesthesia and Pain Therapy. Protected by copyright.

ALARA, as low as reasonably achievable; ICRP, International Commission on Radiological
Protection; N, total number of responses by category; n, number of correct responses by
category; NCRP, National Council on Radiation Protection & Measurements.
Knowledge of radiation principles
Overall knowledge levels of radiation principles by respon-
dents were low. Of the 10 questions specifically investi-
gating knowledge of radiation principles, none (0/10) were
correctly answered by ≥80% of physician respondents
(table 4). Eight of the 10 questions had correct response
rates of less than 40%.
The EDA demonstrated the knowledge of radiation princi-
ples varied by geographical region and practice type. Physi-
cians from all four geographical areas demonstrated low
levels of knowledge on radiation principles (online supple-
mental appendix B; table 3). Regardless of geographical
region, physicians were significantly more likely to incor-
rectly answer at least seven of the 10 questions (p<0.05).
In all regions, correct response rates were below 50% for
all areas in the subcategories of radiation effects (7%–46%),
fluoroscopy equipment (17%–43%), radiation units (11%–
18%) and sources of radiation (2%–31%). Regardless of
ciples (table 5 and online supplemental appendix B: table 5).
However, regardless of radiation safety education/training,
gaps in proper radiation safety practices were identified. In
the radiation protection equipment subcategory, all physicians,
regardless of education/training status, reported lower than
30% utilization of radiation safety glasses, lead gloves and radi-
ation safety headgear. Evaluation of radiation badge readings,
recording of fluoroscopy time and cumulative dose, and collima-
tion compliance levels were also low for both groups.
The level of self-perceived understanding and compliance
with radiation safety practices and knowledge of radiation
principles
Physicians with greater levels of self-­perceived understanding
had higher compliance and correct response rates compared
with those with lower levels of self-­ perceived understanding
(online supplemental appendix B: tables 6 and 7). Although
physicians with higher self-­ perceived levels of understanding
performed better, they still overestimated their ability to follow
evidence-­based safety practices and their knowledge of radia-
tion principles. Physicians with self-­perceived ‘above average’

Table 5 Relative rate of compliance with evidence-­based radiation safety practices and knowledge of radiation principles based on education/
training
Received education/training Did not receive education/training
Compliance with evidence-­based practices Compliant (n) Non-­compliant (n) Compliant (n) Non-­compliant (n) Relative rate (95% CI)*
Utilization of radiation protection garments 411 31 193 65 4.5 (3.5 to 34.1)
Utilization of a thyroid protector 340 104 128 129 3.3 (2.8 to 16.2)
Monthly evaluation of radiation badge 170 268 66 190 1.8 (1.5 to 4.6)
Recording of cumulative dose 160 286 41 215 2.9 (2.4 to 11.1)
Utilization of collimation 257 188 67 189 3.9 (3.2 to 25.7)
Knowledge of radiation principles Correct (n) Incorrect (n) Correct (n) Incorrect (n) Relative rate (95% CI)*
ALARA principles 297 147 87 169 3.9 (3.3 to 27.7)
Stochastic+non-­stochastic effects 357 532 140 374 1.8 (1.5 to 4.9)
X-­ray tube optimal location+image receptor optimal 361 530 117 398 2.3 (2.0 to 7.7)
location
Relative rate is the compliant or correct response rate for those with education/training divided by the corresponding compliant or correct response rate for those without education/training.
*Evaluation of relative rates for selected compliance and knowledge of radiation principle questions. Relative rates were the compliance (i.e., for compliance question) or correct rates (i.e., for
knowledge questions) for the interventional pain physicians with education/training divided by the compliance or correct rates for the interventional pain physicians without education/training.
ALARA, as low as reasonably achievable; n, number of correct responses by category.

Provenzano DA, et al. Reg Anesth Pain Med 2021;46:469–476. doi:10.1136/rapm-2020-102002 473
 Original research
levels of understanding had compliance rates <80% on 12 of
the 15 evidence-­based practices. Regardless of the level of self-­
perceived understating, for at least seven of the 10 knowledge
questions, physicians were significantly more likely to select an
incorrect answer (p<0.05).
Fellowship training and compliance with radiation safety
practices and knowledge of radiation principles
Approximately half (44%, 295/674) of the respondents
completed pain medicine fellowship training, and 9.5% (64/674)
of respondents were currently in a pain fellowship. For the
physicians currently in a fellowship, 75% (48/64) were within
the 9- to 12-­month time frame. The current fellows were in the
following geographical locations: 45% in North America-­USA,
41% in Europe, 8% in Asia, and 6% in Other.
Compliance with evidence-­ based radiation safety practices
by fellowship training level is documented in online supple-
mental appendix B; table 8. When examining physicians who
completed a pain fellowship, nine of 15 evidence-­based radiation
safety practices were more likely to be answered correctly than
incorrectly (p<0.01). However, only three of the 15 evidence-­
based safety practices were correctly answered by ≥80% of the
physicians that completed a fellowship. When examining the
current fellows, only one of the 15 radiation safety practices was
correctly adhered to by greater than 80% of the physicians.
Regardless of fellowship training, knowledge of radiation
safety principles was low (online supplemental appendix B; table
9) and no group had a correct response rate above 80% in any of
the five radiation principle subcategories.
DISCUSSION
The results of this survey provide insight into interventional
pain physicians compliance with evidence-­based radiation safety
practices and their knowledge of radiation principles. The main
findings are the presence of: (1) limited radiation safety educa-
tion and training; (2) low levels of compliance with evidence-­
based radiation safety practices; (3) low levels of knowledge of
radiation principles and (4) participant cognitive bias with over-
estimation of adherence to radiation safety practices and knowl-
edge. Refinements in education and institutional requirements
seem warranted for both attending physicians and fellows to
improve radiation safety practices in clinical settings.
As with any survey, there are limitations. First, the findings
are based on respondents mainly from two geographical regions,
North America-­USA and Europe, with over 80% of the partic-
ipants originating from these areas. The survey predominantly
examined practices and knowledge of pain physicians with an
anesthesiology background. The absolute response rate could
not be calculated, and with all surveys there is the possibility
of non-­response bias. Efforts were made to limit non-­response
bias by working with established pain societies containing inter-
ventional pain physicians with overlapping memberships (34%
of participants were members of more than one society) and
through the use of secondary reminder emails.26 Even though
the survey has limitations, the significant response of greater
than 700 practicing physicians from different demographic
settings through the use of this survey that underwent exten-
sive pretesting (ie, pilot testing, respondent debriefing, cogni-
tive interviewing, expert evaluation) provides an overview for
contemporary practice.
Our findings support the call by the ICRP for improvements
in fluoroscopy training and education.14 This survey identi-
fied low levels of compliance with ICRP and NCRP radiation
474 Provenzano DA, et al. Reg Anesth Pain Med 2021;46:469–476. doi:10.1136/rapm-2020-102002
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102002 on 9 March 2021. Downloaded from http://rapm.bmj.com/ on January 11, 2024 at European Society of Regional
safety practices and knowledge of radiation principles regard-
less of geographical location and practice type. Only 13% of
the evidence-­based radiation safety practices were followed by
≥80% physician respondents. Also, the survey results identi-
fied a significant lack of understanding of core radiation princi-
ples. None of the 10 knowledge questions had correct response
rates of ≥80%, and, for 8/10 questions, correct response rates
were <40%. Alarmingly, only 5 of the 708 evaluated physicians
correctly responded to ≥80% of the knowledge and safety prac-
tice questions. Furthermore, the results presented here confirm
the findings from previous smaller surveys examining physicians
that use fluoroscopy from the fields of pain, cardiology, orthope-
dics, radiology, spine surgery, and urology demonstrating signif-
icant radiation safety knowledge gaps.9 10 29–32
These significant knowledge gaps in radiation principles
and noncompliance with evidence-­ based practices are not
surprizing given the level of education/training that they
received. Only 63% of respondents reported receiving radia-
tion education, with only 30% receiving greater than 2 hours
of education following medical school. Furthermore, 65% of
physicians did not have institutional training and educational
requirements, and only 37% had to take an examination. These
Anaesthesia and Pain Therapy. Protected by copyright.
reported levels of education and training would not meet the
NCRP’s recommendations.33 Specifically, in Report 168, the
NCRP states that clinical training and experience is not an
acceptable substitute for formal training in radiation manage-
ment and that interventionalists who perform procedures with
fluoroscopy need didactic training, hands-­on training and clin-
ical operation under a preceptor physician. Furthermore, the
NRCP expects that this formal training would be a minimum
of 1 day and involve the successful completion of a written
examination. These requirements were not met for most of the
surveyed physicians.
The survey identified areas of low compliance in evidence-­
based practices that have been shown to mitigate risks to the
physician, other healthcare providers (e.g., nurses), and patients.
First, an emphasis should be placed on the utilization of radi-
ation protection equipment. Regardless of level of received
training and education, <50% of physicians used a minimum of
0.5 mm of maximal equivalent lead thickness for the protective
apron or vest/kilt, and less than 30% of physicians used radiation
safety glasses, gloves or headgear. When protective shielding
strategies are not followed, the risk of stochastic and nonsto-
chastic effects significantly increases.34 For example, the rates of
cataracts are 2–3 times higher for physicians using fluoroscopy
than the general population.35 The employment of protective
glasses reduces radiation exposure to the eyes by 70%–98%.35–37
Protective headgear is important because of the possibility of a
causal relation between brain tumors (e.g., glioblastomas) and
occupational radiation exposure.38 Only 66% of our respon-
dents use a thyroid shield. A thyroid shield has been shown to
reduce radiation exposure to the thyroid by a factor of 12.39
Educational programs that emphasizes the utilization of radia-
tion protective equipment and that then monitors compliance
should be considered.
Badge and dose monitoring practices, as emphasized by
the ICRP and NCRP, need to be enforced. Evaluation of radi-
ation badge data in a time period recommended by the ICRP
was not followed by >65% of physicians.33 Less than 60% of
respondents always used a radiation safety badge, and <40%
recorded fluoroscopy time and cumulative dose as part of their
procedural/operative report. Understanding and documenting
radiation levels is critical to raising awareness of exposure.
Prospective data demonstrated that increased awareness of

radiation exposure with educational coaching reduces radiation
exposure by as much as 50%.12
Our research on the positive association between level of radi-
ation safety education and adherence to radiation safety prac-
tices and knowledge of radiation principles is consistent with
earlier research documenting the beneficial effects of education
and training.11 Previous research on the influence on peer-­based
radiation safety training has demonstrated reductions in cumu-
lative dose by as much as 50%.11 However, the survey results
clearly demonstrate that additional training and education are
needed. Furthermore, the quality and type of education require
further investigation.
The survey results raise the concern for the Dunning-­Kruger
effect (i.e., cognitive bias with overestimation of ability).40 Non-­
compliance with evidence-­based practices and knowledge gaps
were evident even in physicians who reported ‘above average’
understanding. The Dunning-­Kruger effect often exists in indi-
viduals who are unaware or indifferent to their level of knowl-
edge.40 However, the high concern about the effects of radiation
among surveyed physicians (>90%) suggests that they were not
indifferent to the effects of radiation. Measurable standards need
to be put in place by both academic training, hospital and private
practice facilities to evaluate competency, document deficiencies
and provide appropriate training to ensure adequate radiation
safety compliance and knowledge of principles.
Efforts are needed to augment and standardize the level of
competency needed in radiation knowledge and safety practice
during fellowship training. Current fellows from both North
America-­USA and Europe performed poorly on both adherence
to evidence-­based radiation safety practices and understanding
of radiation principles. Our results support the findings of
the others in the field of cardiology, orthopedics, urology and
radiology that graduate medical education on radiation safety is
inadequate.10 30–32 41
In conclusion, the substantial education gaps identified in
this study must be addressed to better protect physicians, staff,
and patients from unnecessary exposure to ionizing radiation
during interventional pain procedures. Educational refinement
is needed with efforts to assess competency during both pain
fellowship training and attending practice. Fluoroscopy will
continue to be the cornerstone of image guidance for interven-
tional pain procedures in the foreseeable future. The detailed
information specific for geographical regions, educational levels,
and practice types may be used to tailor education. Based on the
survey results presented here, failure to implement educational
change would be unacceptable.
Author affiliations
1
Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA
2
University of Rochester School of Medicine & Dentistry, Rochester, New York, USA
3
Washington and Jefferson College, Washington, Pennsylvania, USA
4 essential but often missing element. Ann ICRP 2009;39:3–4.
Anesthesiology Critical Care and Pain Management, Valencia University Medical
School and General University Hospital, Valencia, Spain
5 in fluoroscopically guided procedures performed outside the imaging department.
Advanced Pain Therapy, Hattiesburg, Mississippi, USA
6 Ann ICRP 2010;40:1–102.
Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania, USA
7
Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
8
Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
9
Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA
10
Spine and Nerve Center of the Virginias, West Virginia University - Health Sciences
Campus, Morgantown, West Virginia, USA
11
Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
Twitter David Anthony Provenzano @DProvenzanoMD, Samuel Ambrose Florentino
@sam_florentino, Asokumar Buvanendran @AsokumarMD, Timothy R Deer @
doctdeer and Samer Narouze @NarouzeMD
Provenzano DA, et al. Reg Anesth Pain Med 2021;46:469–476. doi:10.1136/rapm-2020-102002
Original research
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102002 on 9 March 2021. Downloaded from http://rapm.bmj.com/ on January 11, 2024 at European Society of Regional
Acknowledgements We would like to acknowledge Heather Hoover, radiation
technologist at the Western Pennsylvania Surgical Center, for helping with survey
development and Maxime Hervé, Institut de Genetique, Université de Rennes,
Rennes, France, for statistical assistance.
Contributors DAP: This author conceived and presented the idea. He was involved
in the survey development, survey revision, interpretation of data, drafting of the
manuscript and review of all aspects of this manuscript. SAF: This author was
involved in survey development, survey revision, survey validation, performing
statistical analysis, interpreting data and the drafting of the manuscript and review of
all aspects of this manuscript. JSK: This author was involved in survey development,
survey revision, performed the statistical analysis, interpreting data and the drafting
of the manuscript and review of all aspects of this manuscript. JDA: This author
contributed to survey revision and the implementation of the experiment. BTS: This
author contributed to survey revision and the implementation of the experiment. SB:
This author contributed to survey revision and the implementation of the experiment.
TJL: This author contributed to survey revision and the implementation of the
experiment. AB: This author contributed to survey revision and the implementation
of the experiment. JAC: This author contributed to survey revision and the
implementation of the experiment. TRD: This author contributed to survey revision
and the implementation of the experiment. SN: This author contributed to survey
revision and the implementation of the experiment. All authors have read, critically
revised and approved the entirety of the manuscript.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests Conflict statements were provided. However, the conflicts
are not related to the manuscript.
Anaesthesia and Pain Therapy. Protected by copyright.
Patient consent for publication Not required.
Ethics approval The survey study (protocol #201810141876) was reviewed and
approved by Robert Morris University Institutional Review Board on November 1
2018.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request. The
deidentified data can be requested from Pain Diagnostics and Interventional Care.
ORCID iDs
David Anthony Provenzano http://​orcid.​org/​0000-​0002-​2147-​3523
Samuel Ambrose Florentino http://​orcid.​org/​0000-​0003-​2006-​3976
Jason S Kilgore http://​orcid.​org/​0000-​0003-​2773-​7937
Jose De Andres http://​orcid.​org/​0000-​0002-​5789-​5752
Timothy R Deer http://​orcid.​org/​0000-​0001-​8907-​7730
Samer Narouze http://​orcid.​org/​0000-​0003-​1849-​1402
REFERENCES
1 López PO, Dauer LT, Loose R, et al. ICRP publication 139: occupational radiological
protection in interventional procedures. Ann ICRP 2018;47:1–118.
2 Rathmell JP, Benzon HT, Dreyfuss P, et al. Safeguards to prevent neurologic
complications after epidural steroid injections: consensus opinions from a
multidisciplinary Working group and national organizations. Anesthesiology
2015;122:974–84.
3 Manchikanti L, Cash KA, Moss TL, et al. Radiation exposure to the physician in
interventional pain management. Pain Physician 2002;5:385–93.
4 Nicol AL, Benzon HT, Liu BP. Radiation exposure in interventional pain management:
we still have much to learn. Pain Pract 2015;15:389–92.
5 Mroz TE, Yamashita T, Davros WJ, et al. Radiation exposure to the surgeon and the
patient during kyphoplasty. J Spinal Disord Tech 2008;21:96–100.
6 Vañó E, Rosenstein M, Liniecki J, et al. ICRP publication 113. education and training
in radiological protection for diagnostic and interventional procedures. Ann ICRP
2009;39:1–2.
7 Mettler FA. ICRP publication 113. radiological protection education in medicine: an
8 Rehani MM, Ciraj-­Bjelac O, Vañó E, et al. ICRP publication 117. radiological protection
9 Kim TH, Hong SW, Woo NS, et al. The radiation safety education and the pain
physicians’ efforts to reduce radiation exposure. Korean J Pain 2017;30:104–15.
10 Park PE, Park JM, Kang JE, et al. Radiation safety and education in the applicants of
the final test for the expert of pain medicine. Korean J Pain 2012;25:16–21.
11 Pitcher CD, Melanson MA. The impact of peer-­based training on reducing radiation
doses from X-­ray operations in an interventional pain management clinic. US Army
Med Dep J 2010:43–7.
12 Slegers AS, Gültuna I, Aukes JA, et al. Coaching reduced the radiation dose of pain
physicians by half during interventional procedures. Pain Pract 2015;15:400–6.
13 Cool DA, Kase KR, Boice JD. NCRP report no.180-­management of exposure to
ionizing radiation: NCRP radiation protection guidance for the United States. J Radiol
Prot 2019;39:966–77.
475
 Original research
14 Valentin J. Avoidance of radiation injuries from medical interventional procedures. Ann
ICRP 2000;30:7–67.
15 The 2007 recommendations of the International Commission on radiological
protection. ICRP publication 103. Ann ICRP 2007;37:1–332.
16 ICRP publication 105. radiation protection in medicine. Ann ICRP 2007;37:1–63.
17 Cousins C, Miller DL, Bernardi G, et al. ICRP publication 120: radiological protection in
cardiology. Ann ICRP 2013;42:1–125.
18 Hirshfeld JW, Ferrari VA, Bengel FM, et al. 2018 ACC/HRS/NASCI/SCAI/SCCT expert
consensus document on optimal use of ionizing radiation in cardiovascular Imaging-­
Best practices for safety and effectiveness, part 1: radiation physics and radiation
biology: a report of the American College of cardiology Task force on expert consensus
decision pathways. J Am Coll Cardiol 2018;71:2811–28.
19 Hayda RA, Hsu RY, DePasse JM, et al. Radiation exposure and health risks for
orthopaedic surgeons. J Am Acad Orthop Surg 2018;26:268–77.
20 Miller DL, Vañó E, Bartal G, et al. Occupational radiation protection in interventional
radiology: a joint guideline of the cardiovascular and interventional radiology Society
of Europe and the Society of interventional radiology. Cardiovasc Intervent Radiol
2010;33:230–9.
21 Artino AR, Durning SJ, Sklar DP. Guidelines for reporting survey-­based research
submitted to academic medicine. Acad Med 2018;93:337–40.
22 Sullivan GM, Artino AR. How to create a bad survey instrument. J Grad Med Educ
2017;9:411–5.
23 Willis GB, Artino AR. What do our Respondents think we’re asking? Using cognitive
interviewing to improve medical education surveys. J Grad Med Educ 2013;5:353–6.
24 Lancaster GA, Dodd S, Williamson PR. Design and analysis of pilot studies:
recommendations for good practice. J Eval Clin Pract 2004;10:307–12.
25 Hassan ZA, Schattner P, Mazza D. Doing a pilot study: why is it essential? Malays Fam
Physician 2006;1:70–3.
26 Burmeister LF. Principles of successful sample surveys. Anesthesiology
2003;99:1251–2.
27 Signorell AA, Alfons K.;, Anderegg A.;. DescTools: tools for descriptive statistics. R
package version 0.99.39, 2020.
28 CRAN. Maxime Hervé (2020). RVAideMemoire: testing and plotting procedures
for biostatistics. R package version 0.9-75. Available: https://​CRAN.​R-​project.​org/​
package=R​ VAideMemoire
476 Provenzano DA, et al. Reg Anesth Pain Med 2021;46:469–476. doi:10.1136/rapm-2020-102002
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102002 on 9 March 2021. Downloaded from http://rapm.bmj.com/ on January 11, 2024 at European Society of Regional
29 Falavigna A, Ramos MB, Iutaka AS, et al. Knowledge and attitude regarding
radiation exposure among spine surgeons in Latin America. World Neurosurg
2018;112:e823–9.
30 Nugent M, Carmody O, Dudeney S. Radiation safety knowledge and practices among
Irish orthopaedic trainees. Ir J Med Sci 2015;184:369–73.
31 Sadigh G, Khan R, Kassin MT, et al. Radiation safety knowledge and perceptions
among residents: a potential improvement opportunity for graduate medical
education in the United States. Acad Radiol 2014;21:869–78.
32 Friedman AA, Ghani KR, Peabody JO, et al. Radiation safety knowledge and practices
among urology residents and fellows: results of a nationwide survey. J Surg Educ
2013;70:224–31.
33 NCRP. No. 168. Radiation dose management for fluoroscopically guided interventional
medical procedures. Vol report 168: national Council on radiation protection and
measurements, 2010: 1–339.
34 Mastrangelo G, Fedeli U, Fadda E, et al. Increased cancer risk among surgeons in an
orthopaedic Hospital. Occup Med 2005;55:498–500.
35 Fish DE, Kim A, Ornelas C, et al. The risk of radiation exposure to the eyes of the
interventional pain physician. Radiol Res Pract 2011;2011:1–5.
36 Cousin AJ, Lawdahl RB, Chakraborty DP, et al. The case for radioprotective
eyewear/facewear. practical implications and suggestions. Invest Radiol
1987;22:688–92.
37 Richman AH, Chan B, Katz M. Effectiveness of lead lenses in reducing radiation
exposure. Radiology 1976;121:357–9.
38 Roguin A. Brain tumours among interventional cardiologists: a call for alarm? Eur
Heart J 2012;33:1850–1.
39 Marshall NW, Faulkner K, Clarke P. An investigation into the effect of protective
Anaesthesia and Pain Therapy. Protected by copyright.
devices on the dose to radiosensitive organs in the head and neck. Br J Radiol
1992;65:799–802.
40 Pennycook G, Ross RM, Koehler DJ, et al. Dunning-­Kruger effects in Reasoning:
theoretical implications of the failure to recognize incompetence. Psychon Bull Rev
2017;24:1774–84.
41 Kim C, Vasaiwala S, Haque F, et al. Radiation safety among cardiology fellows. Am J
Cardiol 2010;106:125–8.