Educational Perspective
Public Health Education Using Radiology Colin H. Murphy, BS, Richard Gunderman, MD, PhD, MPH Key Words: Public health; disease prevention; education; radiology; substance abuse. ªAUR, 2014
I
t is estimated that more than 3 billion medical and dental radiologic studies are performed each year around the world (1). In most of the cases, the images are used for only one purpose: to assess the health status of the patient on whom the study is being performed. In the case of a patient who presents with cough and fever, a chest radiograph is obtained to assess for pneumonia; a patient who has pain after a fall receives wrist radiographs; and a patient with symptoms and signs of appendicitis undergoes an abdomen/pelvis computed tomography (CT) examination. In nearly all such cases, the images are interpreted and then archived, usually never to be seen again. In some cases, this pattern of image utilization entails a substantial degree of waste. Specifically, we are missing out on huge opportunities to reuse such an image for educational purposes. To be sure, in many teaching programs, such images are captured for the education of medical students, residents, and other health professionals. For example, we use particularly illustrative clinical images to help learners to recognize pneumonias, fractures, and appendicitis. But, there is another largely unrecognized educational purpose to which radiologic images can be put—public health education. Specifically, radiologic images can be used to discourage health behaviors that lead to disease and injury. Major threats to the health of Americans include cancer, heart disease, stroke, trauma, and a host of conditions associated with substance abuse, including alcoholism, prescription drug abuse, and the use of illicit substances. In each of these cases, personal conduct plays a substantial role in determining risk. Patients who avoid smoking, maintain appropriate weight, exercise, keep blood pressure under control, drive safely and use seat belts, avoid overindulgence with alcohol, and avoid the use of controlled substances can substantially lower their risk of a variety of diseases and injuries that lead to premature disability and death.
Acad Radiol 2014; 21:554–558 From the Indiana University School of Medicine, 702 N Barnhill Drive Room 1053, Indianapolis, IN 46202 (C.H.M., R.G.). Received August 16, 2013; accepted August 20, 2013. Address correspondence to: R.G. e-mail: [email protected] ªAUR, 2014 http://dx.doi.org/10.1016/j.acra.2013.08.026
554
By providing real-life illustrations of the sorts of harms that can befall people who engage in hazardous behaviors, radiologists can help to discourage such patterns of conduct. For example, comparing CT images of the lungs of nonsmokers and long-term smokers, including patients with diseases such as lung cancer, can help to convince patients to give up smoking or never to adopt the habit in the first place. Likewise, skeletal radiographs of motorists who were ejected from their vehicles during collisions because they were not wearing safety belts can help convince people of the importance of always buckling up when traveling by car. We can bombard people with statistics, show them innumerable tables and graphs, and quote public health advocates until we are blue in the face, but as radiologists know well, sometimes a picture can be worth a thousand words. We believe this to be the case no less in public health education than in clinical medicine; specifically, we believe that wellselected radiologic images can help general public better appreciate the magnitude of certain health risks. We are not suggesting that radiologic images should supplant other educational approaches but only that they represent an important and underutilized educational resource. To illustrate the role radiologic images can play in public health education, we focus on their use in educating middleschool and high-school students about the risks associated with substance abuse. This is a major public health problem. For example, a 2012 National Institute on Drug Abuse survey found that 69% of 12th graders report having tried alcohol, 24% report having had five or more drinks in one occasion in just the last 2 weeks, 17% report smoking at least one cigarette in the past 30 days, 49% report using illicit drugs in their lifetime, and 39% having done so in the past year (2). Public health education needs to be tailored to its audience, and in the case of middle- and high-school students, it is generally best to adopt a relatively short-term perspective on risks. A 12-year-old or 17-year-old is unlikely to be as impressed by elevated risks for conditions that will not appear for several decades (such as in increased risk of lung cancer) as by more near-term consequences such as injuries that can occur the very same day (3). Also, adolescents are often particularly impressed by socially deleterious consequences such as the loss of use of a limb or a disfiguring injury. Educators can
Academic Radiology, Vol 21, No 4, April 2014
PUBLIC HEALTH EDUCATION USING RADIOLOGY
Figure 1. A 15-year-old male involved in a motor vehicle collision, after consumption of alcohol, with femur, humerus, and wrist fractures.
Figure 3. A 56-year-old female with a 24-year history of consuming one pint of alcohol per day, now presenting with ascites and hepatocellular carcinoma. Figure 2. A 27-year-old male involved in an assault, while intoxicated, with a left inferior orbital blowout fracture.
take this into account in crafting a responsible yet persuasive educational program. Underage alcohol use is a major public health problem. It is associated with a variety of adverse consequences, including an increased risk of developing alcoholism and its many adverse health effects, as well as with increased risk of injury, adverse sexual experiences, absenteeism in school and work, and a variety of legal consequences, up to and including incar-
ceration (4). Motor vehicle accidents are the number one cause of death of teenagers, and alcohol use substantially increases the risk (5). It is also associated with intentional trauma, including assault, homicide, and suicide. By allowing students to hear such stories and view corresponding radiologic images, we can help such risks seem more real and immediate. Consider the following three cases. In the first, a 15-yearold patient suffered multiple long-bone fractures as a result 555
MURPHY AND GUNDERMAN
Figure 4. A 53-year-old female with a 30 pack–year history of smoking with loss of the second digit secondary to thromboangiitis obliterans.
Academic Radiology, Vol 21, No 4, April 2014
Figure 5. A 50-year-old female with a history of smoking and loss of right lower extremity secondary to thromboangiitis obliterans.
Figure 6. A 39-year-old female with a 20 pack–year history of smoking, now presenting with lung cancer and multiple brain metastases.
of a motor vehicle collision that occurred when the patient was driving while intoxicated (Fig 1). A second case shows an orbital blowout fracture in an 18-year-old patient who became involved in a fight while under the influence of alcohol (Fig 2). And while longer term risks may not be as salient with teenagers, it is important not to neglect them completely. So our third case features an abdominal CT image 556
showing both cirrhosis and hepatocellular carcinoma in a 57year-old patient (Fig 3). Particularly when learners are looking at unfamiliar anatomy, it can be helpful to juxtapose a normal image for comparison. Although cigarette smoking has been declining in the United States, the teenage years still represent the time during which most new smokers take up the habit. Hence efforts to
Academic Radiology, Vol 21, No 4, April 2014
Figure 7. A 45-year-old male with hemorrhagic stroke after cocaine use.
PUBLIC HEALTH EDUCATION USING RADIOLOGY
Figure 9. A 23-year-old female with a retained needle from intravenous drug abuse.
Figure 8. A 20-year-old male with multiple ischemic strokes after methamphetamine use.
discourage teen smoking offer particularly important public health benefits. Disfigurement due to vascular effects of smoking can be a psychologically effective consequence to stress in reaching teenagers. In the first two cases, we see a patient who lost a digit and a second who lost a lower leg because of smoking-related thromboangiitis obliterans (Figs 4 and 5). Again, however, long-term risks should not be overlooked,
so we also include a chest CT image of a smoker with lung cancer who presented with several brain metastases on magnetic resonance imaging (Fig 6). Illicit drugs also warrant consideration. For example, nearly 5% of 12th graders report having used cocaine (2). A head CT image shows a relatively younger man who suffered intracerebral hemorrhage after cocaine use (Fig 7). Nearly 8% of 12th 557
MURPHY AND GUNDERMAN
Academic Radiology, Vol 21, No 4, April 2014
Figure 10. A 30-year-old male with a history of polysubstance abuse, who attempted to self-harm after ingestion of bath salts.
graders report amphetamine use, and another CT image shows multiple ischemic strokes in a young adult after taking methamphetamines (Fig 8). Heroin use is rarer, but its intravenous administration is associated with a number of blood-borne diseases such as AIDS. This radiograph shows a retained needle in a young addict’s hand (Fig 9). Finally, a variety of synthetic stimulants, such as ‘‘bath salts,’’ have come into wide use. A radiograph shows a knife in the leg of a young adult after an attempt at self-harm after ingesting bath salts (Fig 10). Of course, the use of harmful substances by teenagers is just one example of the potential roles for radiologic images in public health education. Numerous other opportunities come readily to mind. For example, images from mammography, CT chest imaging, and CT colonography can play an important role in encouraging patients to undergo cancer screening, helping to illustrate how many cancer deaths can be prevented. Trauma images can be used to discourage habits associated with an increased risk of motor vehicle accidents and falls. And images from patients with heart disease and stroke can be used to encourage appropriate management of diabetes and hypertension. The bottom line is that radiologic images can make the consequences of poor health choices seem both more real and more relevant to the people who face them. By choosing
558
cases of patients who resemble the intended audience in important respects, public health educators can ensure that such lessons hit close to home with the target audience. The goal is not simply to scare audiences but to let them see firsthand the otherwise often hidden consequences of the choices before them. In this respect, radiologists have an opportunity to focus less attention on diagnosing serious diseases and injuries and use the fruits of their labors to help prevent them in the first place.
REFERENCES 1. Mettler FA, 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 2009; 253:520–531. 2. Johnston LD, O’Malley PM, Bachman JG, et al. Monitoring the future national survey results on drug use, 1975-2012. Volume I: Secondary school students. Ann Arbor, MI: Institute for Social Research, The University of Michigan, 2013. 3. Dusenbury L, Falco M. Eleven components of effective drug abuse prevention curricula. J Sch Health 1995; 65:420–425. 4. Bouchery EE, Harwood HJ, Sacks JJ, et al. Economic costs of excessive alcohol consumption in the US, 2006. Am J Prev Med 2011; 41:516–524. 5. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2012. Rockville, MD: U.S. Department of Health and Human Services, 2013.
Public Health Education Using Radiology Colin H. Murphy, BS, Richard Gunderman, MD, PhD, MPH Key Words: Public health; disease prevention; education; radiology; substance abuse. ªAUR, 2014
I
t is estimated that more than 3 billion medical and dental radiologic studies are performed each year around the world (1). In most of the cases, the images are used for only one purpose: to assess the health status of the patient on whom the study is being performed. In the case of a patient who presents with cough and fever, a chest radiograph is obtained to assess for pneumonia; a patient who has pain after a fall receives wrist radiographs; and a patient with symptoms and signs of appendicitis undergoes an abdomen/pelvis computed tomography (CT) examination. In nearly all such cases, the images are interpreted and then archived, usually never to be seen again. In some cases, this pattern of image utilization entails a substantial degree of waste. Specifically, we are missing out on huge opportunities to reuse such an image for educational purposes. To be sure, in many teaching programs, such images are captured for the education of medical students, residents, and other health professionals. For example, we use particularly illustrative clinical images to help learners to recognize pneumonias, fractures, and appendicitis. But, there is another largely unrecognized educational purpose to which radiologic images can be put—public health education. Specifically, radiologic images can be used to discourage health behaviors that lead to disease and injury. Major threats to the health of Americans include cancer, heart disease, stroke, trauma, and a host of conditions associated with substance abuse, including alcoholism, prescription drug abuse, and the use of illicit substances. In each of these cases, personal conduct plays a substantial role in determining risk. Patients who avoid smoking, maintain appropriate weight, exercise, keep blood pressure under control, drive safely and use seat belts, avoid overindulgence with alcohol, and avoid the use of controlled substances can substantially lower their risk of a variety of diseases and injuries that lead to premature disability and death.
Acad Radiol 2014; 21:554–558 From the Indiana University School of Medicine, 702 N Barnhill Drive Room 1053, Indianapolis, IN 46202 (C.H.M., R.G.). Received August 16, 2013; accepted August 20, 2013. Address correspondence to: R.G. e-mail: [email protected] ªAUR, 2014 http://dx.doi.org/10.1016/j.acra.2013.08.026
554
By providing real-life illustrations of the sorts of harms that can befall people who engage in hazardous behaviors, radiologists can help to discourage such patterns of conduct. For example, comparing CT images of the lungs of nonsmokers and long-term smokers, including patients with diseases such as lung cancer, can help to convince patients to give up smoking or never to adopt the habit in the first place. Likewise, skeletal radiographs of motorists who were ejected from their vehicles during collisions because they were not wearing safety belts can help convince people of the importance of always buckling up when traveling by car. We can bombard people with statistics, show them innumerable tables and graphs, and quote public health advocates until we are blue in the face, but as radiologists know well, sometimes a picture can be worth a thousand words. We believe this to be the case no less in public health education than in clinical medicine; specifically, we believe that wellselected radiologic images can help general public better appreciate the magnitude of certain health risks. We are not suggesting that radiologic images should supplant other educational approaches but only that they represent an important and underutilized educational resource. To illustrate the role radiologic images can play in public health education, we focus on their use in educating middleschool and high-school students about the risks associated with substance abuse. This is a major public health problem. For example, a 2012 National Institute on Drug Abuse survey found that 69% of 12th graders report having tried alcohol, 24% report having had five or more drinks in one occasion in just the last 2 weeks, 17% report smoking at least one cigarette in the past 30 days, 49% report using illicit drugs in their lifetime, and 39% having done so in the past year (2). Public health education needs to be tailored to its audience, and in the case of middle- and high-school students, it is generally best to adopt a relatively short-term perspective on risks. A 12-year-old or 17-year-old is unlikely to be as impressed by elevated risks for conditions that will not appear for several decades (such as in increased risk of lung cancer) as by more near-term consequences such as injuries that can occur the very same day (3). Also, adolescents are often particularly impressed by socially deleterious consequences such as the loss of use of a limb or a disfiguring injury. Educators can
Academic Radiology, Vol 21, No 4, April 2014
PUBLIC HEALTH EDUCATION USING RADIOLOGY
Figure 1. A 15-year-old male involved in a motor vehicle collision, after consumption of alcohol, with femur, humerus, and wrist fractures.
Figure 3. A 56-year-old female with a 24-year history of consuming one pint of alcohol per day, now presenting with ascites and hepatocellular carcinoma. Figure 2. A 27-year-old male involved in an assault, while intoxicated, with a left inferior orbital blowout fracture.
take this into account in crafting a responsible yet persuasive educational program. Underage alcohol use is a major public health problem. It is associated with a variety of adverse consequences, including an increased risk of developing alcoholism and its many adverse health effects, as well as with increased risk of injury, adverse sexual experiences, absenteeism in school and work, and a variety of legal consequences, up to and including incar-
ceration (4). Motor vehicle accidents are the number one cause of death of teenagers, and alcohol use substantially increases the risk (5). It is also associated with intentional trauma, including assault, homicide, and suicide. By allowing students to hear such stories and view corresponding radiologic images, we can help such risks seem more real and immediate. Consider the following three cases. In the first, a 15-yearold patient suffered multiple long-bone fractures as a result 555
MURPHY AND GUNDERMAN
Figure 4. A 53-year-old female with a 30 pack–year history of smoking with loss of the second digit secondary to thromboangiitis obliterans.
Academic Radiology, Vol 21, No 4, April 2014
Figure 5. A 50-year-old female with a history of smoking and loss of right lower extremity secondary to thromboangiitis obliterans.
Figure 6. A 39-year-old female with a 20 pack–year history of smoking, now presenting with lung cancer and multiple brain metastases.
of a motor vehicle collision that occurred when the patient was driving while intoxicated (Fig 1). A second case shows an orbital blowout fracture in an 18-year-old patient who became involved in a fight while under the influence of alcohol (Fig 2). And while longer term risks may not be as salient with teenagers, it is important not to neglect them completely. So our third case features an abdominal CT image 556
showing both cirrhosis and hepatocellular carcinoma in a 57year-old patient (Fig 3). Particularly when learners are looking at unfamiliar anatomy, it can be helpful to juxtapose a normal image for comparison. Although cigarette smoking has been declining in the United States, the teenage years still represent the time during which most new smokers take up the habit. Hence efforts to
Academic Radiology, Vol 21, No 4, April 2014
Figure 7. A 45-year-old male with hemorrhagic stroke after cocaine use.
PUBLIC HEALTH EDUCATION USING RADIOLOGY
Figure 9. A 23-year-old female with a retained needle from intravenous drug abuse.
Figure 8. A 20-year-old male with multiple ischemic strokes after methamphetamine use.
discourage teen smoking offer particularly important public health benefits. Disfigurement due to vascular effects of smoking can be a psychologically effective consequence to stress in reaching teenagers. In the first two cases, we see a patient who lost a digit and a second who lost a lower leg because of smoking-related thromboangiitis obliterans (Figs 4 and 5). Again, however, long-term risks should not be overlooked,
so we also include a chest CT image of a smoker with lung cancer who presented with several brain metastases on magnetic resonance imaging (Fig 6). Illicit drugs also warrant consideration. For example, nearly 5% of 12th graders report having used cocaine (2). A head CT image shows a relatively younger man who suffered intracerebral hemorrhage after cocaine use (Fig 7). Nearly 8% of 12th 557
MURPHY AND GUNDERMAN
Academic Radiology, Vol 21, No 4, April 2014
Figure 10. A 30-year-old male with a history of polysubstance abuse, who attempted to self-harm after ingestion of bath salts.
graders report amphetamine use, and another CT image shows multiple ischemic strokes in a young adult after taking methamphetamines (Fig 8). Heroin use is rarer, but its intravenous administration is associated with a number of blood-borne diseases such as AIDS. This radiograph shows a retained needle in a young addict’s hand (Fig 9). Finally, a variety of synthetic stimulants, such as ‘‘bath salts,’’ have come into wide use. A radiograph shows a knife in the leg of a young adult after an attempt at self-harm after ingesting bath salts (Fig 10). Of course, the use of harmful substances by teenagers is just one example of the potential roles for radiologic images in public health education. Numerous other opportunities come readily to mind. For example, images from mammography, CT chest imaging, and CT colonography can play an important role in encouraging patients to undergo cancer screening, helping to illustrate how many cancer deaths can be prevented. Trauma images can be used to discourage habits associated with an increased risk of motor vehicle accidents and falls. And images from patients with heart disease and stroke can be used to encourage appropriate management of diabetes and hypertension. The bottom line is that radiologic images can make the consequences of poor health choices seem both more real and more relevant to the people who face them. By choosing
558
cases of patients who resemble the intended audience in important respects, public health educators can ensure that such lessons hit close to home with the target audience. The goal is not simply to scare audiences but to let them see firsthand the otherwise often hidden consequences of the choices before them. In this respect, radiologists have an opportunity to focus less attention on diagnosing serious diseases and injuries and use the fruits of their labors to help prevent them in the first place.
REFERENCES 1. Mettler FA, 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 2009; 253:520–531. 2. Johnston LD, O’Malley PM, Bachman JG, et al. Monitoring the future national survey results on drug use, 1975-2012. Volume I: Secondary school students. Ann Arbor, MI: Institute for Social Research, The University of Michigan, 2013. 3. Dusenbury L, Falco M. Eleven components of effective drug abuse prevention curricula. J Sch Health 1995; 65:420–425. 4. Bouchery EE, Harwood HJ, Sacks JJ, et al. Economic costs of excessive alcohol consumption in the US, 2006. Am J Prev Med 2011; 41:516–524. 5. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2012. Rockville, MD: U.S. Department of Health and Human Services, 2013.
