Courtesy: Imagegently.org
The Image Gently Alliance 10 years later: challenges met and the future direction
March 14, 2018
By Dr. Marta Hernanz-Schulman
The Image Gently Alliance, conceived to educate about the informed use of radiation as well as decrease and manage radiation exposure in pediatric patients, was launched in January 2008, originally named The Alliance for Radiation Safety in Pediatric Imaging.
The Alliance was initially envisioned by the Society for Pediatric Radiology (SPR) through the inspiration and leadership of its then- President Marilyn Goske, and was founded by four pillar societies, the SPR, the American Association of Physicists in Medicine (AAPM), the American College of Radiology (ACR) and the American Society of Radiologic Technologists (ASRT). Since that time, the influence of this campaign has reached the global stage with links to the International Atomic Energy Agency (IAEA), the World Health Organization (WHO) and connections with multiple regulatory agencies including the Food and Drug Administration and The Joint Commission. The 101 allied organizations represent more than 1 million members.
The beginning
The impetus for the creation of this new Alliance was increasing awareness of potential stochastic (cancer-causing) effects of radiation exposure that was brought to medical, and later lay, attention at the beginning of the 21st century. This included articles by Brenner and Hall in 2001, echoed by the BEIR VII publication in 2006, and data from the National Council on Radiation Protection and Measurements indicating that between 1987 and 2006 man-made radiation had increased from 18 percent to 48 percent of the total population burden while CT alone accounted for nearly half of that fraction.
To add to the growing scrutiny of medical radiation, CT settings were not being adjusted for children. The founding working group of pediatric radiologists, ACR , ASRT and AAPM representatives, working on what they conceived as a National Radiation Safety Initiative during the planning meetings through 2007, outlined a goal of educating target populations with the intent of changing practice via social marketing. The target populations were defined as radiologists, technologists, referring health care providers and parents and caregivers.
The task of educating these large segments of the population on radiation issues relative to all imaging modalities was correctly perceived as monumental, and was therefore subdivided into discrete campaigns, prioritizing areas of greatest impact. The message was to be simple, resonant, powerful and memorable. The stated mission of this Alliance was to change practice at the local, national and international levels, by using the right amount of radiation, or child-sizing the dose when imaging children. This was to be accomplished through education and with the cooperation of the allied societies.
In January 2008, when the Alliance for Radiation Safety in Pediatric Imaging and the first Image Gently Campaign were officially launched, many of us hoped that they would have the desired effect of promoting a thoughtful and insightful approach to the imaging of children, maximizing diagnostic information while minimizing radiation. However, I think the most sanguine among us would have been surprised had we glimpsed at that time the tremendous influence that this campaign would have, not just in changing practice, but in putting the radiologists in the command center of managing the contemporaneous radiation issues that had come to dominate the conversation in the medical/scientific and lay communities.
10 years of education and outreach
The first campaign targeted CT, at that time responsible for a large portion of patient exposure, and growing at a rapid pace that at times seemed difficult to defend. The ability of the Image Gently logo, a child’s hand holding a butterfly, to capture the minds and hearts of the public, and to convey at a glance the message of the Alliance, was obvious from the first. The Alliance did not say, “Don’t Image.” Instead the message was to “Image Gently.” Similarly, who could forget the image of the poster child at the edge of the beach with too large a life jacket, and the simple mantra, “Be wise, adjust for size?”
The Alliance has had additional campaigns addressing fluoroscopy in interventional radiology (Step Lightly), in diagnostic radiology (Pause and Pulse), which was granted the Aunt Minnie award for best marketing campaign in 2011, and in conventional radiography (Back to Basics), which generated a consensus committee of ACR, SPR and AAPM members partnering with industry to create optimal exposure parameters for digital radiography in children.
The Alliance has worked with dentists and national and international dental organizations to shed light on the practice of dental radiography, and through the Dose Optimization Task Force has also reviewed nuclear medicine doses, publishing North American Consensus Guidelines for pediatric radiopharmaceuticals. Five years after its founding, the Steering Committee of the Alliance published a self-analysis, reviewing the goals that the Alliance had set for itself and to analyze the level of success attained. Among the goals within each of those campaigns was the provision of information to parents, referring physicians, radiologists and technologists, which is accomplished through the rich content on its website and multiple external links.
Another goal of the Alliance has been to enhance education and user support for imaging equipment in the pediatric population and to tailor equipment to pediatric patients. In these important areas its success has been far-reaching: through the FDA’s Initiative to Reduce Unnecessary Radiation Exposure for Medical Imaging in 2009, the Pediatric Information for Xray Imaging Device Premarket Notifications in 2012 and the FDA publication Guidance Document for Industry for Pediatric Information for Xray Imaging Device Premarket Notifications in 2017.
Image Gently’s message has also not been lost on industry, which has become involved in the enterprise of quality and safety, introducing dose alerts and notifications, improved detector efficiency, adaptive collimation, tube current modulation, prospective gating and iterative reconstruction, greatly reducing the dose necessary for diagnostic examinations in children and patients of all ages, promoted by the National Electrical Manufacturers Association. The ACR registries have served to determine and publish diagnostic reference ranges for both thoracic and abdominal pediatric imaging to promulgate national standards for dose optimization. The reputation of the Image Gently Alliance has also allowed it to become a source for other agencies, such as The Joint Commission, and even for watchdog publications in the lay press.
Think-A-Head: Looking toward the future
With the rollout of the Think-A-Head campaign in November 2016, the Alliance is looking forward to its next 10 years, widening its focus and scope from a primary concentration on dose reduction to “an emphasis on appropriate and informed use and on the value of the imaging findings.” This campaign focused not just on how the head CT was performed, but on evidence-based criteria on whether it should be performed at all, and was the product of collaboration with our clinical colleagues working on behalf of their respective societies. Reflective of this deeper focal length, the Alliance has officially changed its name from The Alliance for Radiation Protection in Pediatric Imaging, which orchestrated the Image Gently Campaign, to the Image Gently Alliance.
The Image Gently Alliance seeks to become even more transparent and inclusive, widening the latitude of its Steering Committee to include adult radiologists, community practitioners and patient representatives. The Have-a-Heart Campaign, released in the spring of 2017, was also the product of collaboration with our clinical colleagues and their respective societies, and included an open-source position statement, which was endorsed by 13 separate organizations, including the American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), the American Academy of Pediatrics (AAP) and the American College of Cardiology (ACC).
The Image Gently Alliance, with a focus on a future reaching across the subspecialty and specialty aisles, holding hands with organizations representing pediatricians, cardiologists, emergency medicine physicians, neurologists and neurosurgeons among others, champions the principle of justification, performing the right exam on the right patient, and of course, in the right way.
About the author: Dr. Marta Hernanz-Schulman, FAAP, FACR, is a professor, radiology and radiological sciences as well as pediatrics, radiology vice-chair for pediatrics, and medical director of diagnostic imaging at Monroe Carell Jr. Children's Hospital at Vanderbilt.
The Image Gently Alliance, conceived to educate about the informed use of radiation as well as decrease and manage radiation exposure in pediatric patients, was launched in January 2008, originally named The Alliance for Radiation Safety in Pediatric Imaging.
The Alliance was initially envisioned by the Society for Pediatric Radiology (SPR) through the inspiration and leadership of its then- President Marilyn Goske, and was founded by four pillar societies, the SPR, the American Association of Physicists in Medicine (AAPM), the American College of Radiology (ACR) and the American Society of Radiologic Technologists (ASRT). Since that time, the influence of this campaign has reached the global stage with links to the International Atomic Energy Agency (IAEA), the World Health Organization (WHO) and connections with multiple regulatory agencies including the Food and Drug Administration and The Joint Commission. The 101 allied organizations represent more than 1 million members.
The beginning
The impetus for the creation of this new Alliance was increasing awareness of potential stochastic (cancer-causing) effects of radiation exposure that was brought to medical, and later lay, attention at the beginning of the 21st century. This included articles by Brenner and Hall in 2001, echoed by the BEIR VII publication in 2006, and data from the National Council on Radiation Protection and Measurements indicating that between 1987 and 2006 man-made radiation had increased from 18 percent to 48 percent of the total population burden while CT alone accounted for nearly half of that fraction.
To add to the growing scrutiny of medical radiation, CT settings were not being adjusted for children. The founding working group of pediatric radiologists, ACR , ASRT and AAPM representatives, working on what they conceived as a National Radiation Safety Initiative during the planning meetings through 2007, outlined a goal of educating target populations with the intent of changing practice via social marketing. The target populations were defined as radiologists, technologists, referring health care providers and parents and caregivers.
The task of educating these large segments of the population on radiation issues relative to all imaging modalities was correctly perceived as monumental, and was therefore subdivided into discrete campaigns, prioritizing areas of greatest impact. The message was to be simple, resonant, powerful and memorable. The stated mission of this Alliance was to change practice at the local, national and international levels, by using the right amount of radiation, or child-sizing the dose when imaging children. This was to be accomplished through education and with the cooperation of the allied societies.
In January 2008, when the Alliance for Radiation Safety in Pediatric Imaging and the first Image Gently Campaign were officially launched, many of us hoped that they would have the desired effect of promoting a thoughtful and insightful approach to the imaging of children, maximizing diagnostic information while minimizing radiation. However, I think the most sanguine among us would have been surprised had we glimpsed at that time the tremendous influence that this campaign would have, not just in changing practice, but in putting the radiologists in the command center of managing the contemporaneous radiation issues that had come to dominate the conversation in the medical/scientific and lay communities.
10 years of education and outreach
The first campaign targeted CT, at that time responsible for a large portion of patient exposure, and growing at a rapid pace that at times seemed difficult to defend. The ability of the Image Gently logo, a child’s hand holding a butterfly, to capture the minds and hearts of the public, and to convey at a glance the message of the Alliance, was obvious from the first. The Alliance did not say, “Don’t Image.” Instead the message was to “Image Gently.” Similarly, who could forget the image of the poster child at the edge of the beach with too large a life jacket, and the simple mantra, “Be wise, adjust for size?”
The Alliance has had additional campaigns addressing fluoroscopy in interventional radiology (Step Lightly), in diagnostic radiology (Pause and Pulse), which was granted the Aunt Minnie award for best marketing campaign in 2011, and in conventional radiography (Back to Basics), which generated a consensus committee of ACR, SPR and AAPM members partnering with industry to create optimal exposure parameters for digital radiography in children.
The Alliance has worked with dentists and national and international dental organizations to shed light on the practice of dental radiography, and through the Dose Optimization Task Force has also reviewed nuclear medicine doses, publishing North American Consensus Guidelines for pediatric radiopharmaceuticals. Five years after its founding, the Steering Committee of the Alliance published a self-analysis, reviewing the goals that the Alliance had set for itself and to analyze the level of success attained. Among the goals within each of those campaigns was the provision of information to parents, referring physicians, radiologists and technologists, which is accomplished through the rich content on its website and multiple external links.
Another goal of the Alliance has been to enhance education and user support for imaging equipment in the pediatric population and to tailor equipment to pediatric patients. In these important areas its success has been far-reaching: through the FDA’s Initiative to Reduce Unnecessary Radiation Exposure for Medical Imaging in 2009, the Pediatric Information for Xray Imaging Device Premarket Notifications in 2012 and the FDA publication Guidance Document for Industry for Pediatric Information for Xray Imaging Device Premarket Notifications in 2017.
Image Gently’s message has also not been lost on industry, which has become involved in the enterprise of quality and safety, introducing dose alerts and notifications, improved detector efficiency, adaptive collimation, tube current modulation, prospective gating and iterative reconstruction, greatly reducing the dose necessary for diagnostic examinations in children and patients of all ages, promoted by the National Electrical Manufacturers Association. The ACR registries have served to determine and publish diagnostic reference ranges for both thoracic and abdominal pediatric imaging to promulgate national standards for dose optimization. The reputation of the Image Gently Alliance has also allowed it to become a source for other agencies, such as The Joint Commission, and even for watchdog publications in the lay press.
Think-A-Head: Looking toward the future
With the rollout of the Think-A-Head campaign in November 2016, the Alliance is looking forward to its next 10 years, widening its focus and scope from a primary concentration on dose reduction to “an emphasis on appropriate and informed use and on the value of the imaging findings.” This campaign focused not just on how the head CT was performed, but on evidence-based criteria on whether it should be performed at all, and was the product of collaboration with our clinical colleagues working on behalf of their respective societies. Reflective of this deeper focal length, the Alliance has officially changed its name from The Alliance for Radiation Protection in Pediatric Imaging, which orchestrated the Image Gently Campaign, to the Image Gently Alliance.
The Image Gently Alliance seeks to become even more transparent and inclusive, widening the latitude of its Steering Committee to include adult radiologists, community practitioners and patient representatives. The Have-a-Heart Campaign, released in the spring of 2017, was also the product of collaboration with our clinical colleagues and their respective societies, and included an open-source position statement, which was endorsed by 13 separate organizations, including the American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), the American Academy of Pediatrics (AAP) and the American College of Cardiology (ACC).
Dr. Marta Hernanz-Schulman
About the author: Dr. Marta Hernanz-Schulman, FAAP, FACR, is a professor, radiology and radiological sciences as well as pediatrics, radiology vice-chair for pediatrics, and medical director of diagnostic imaging at Monroe Carell Jr. Children's Hospital at Vanderbilt.