KNOWLEDGE OF RADIATION EXPOSURE IN COMMON RADIOLOGICAL INVESTIGATIONS: A COMPARISON BETWEEN NON RADIOLOGIST AND RADIOLOGIST

Criteria: Undergraduate medical trainees. Doctors working in al 38 (2020) found that the purpose of this study was to examine the degree to which nonradiologist physicians provide formal interpretations for advanced imaging and to consider whether adequate training can be achieved for those physicians. This investigation supposed that hospitals are the only places where formal imaging training occurs. The CMS Physician/Supplier Procedure Summary Master Files (PSPSMFs) of the Medicare Part B data sets for 2015 were reviewed. They selected the Current Procedural Terminology (CPT) codes for four categories of non-invasive diagnostic imaging: CT, MRI, PET, and general nuclear imaging. Medicare place-of-service codes allowed us to ascertain the location of each study interpretation. They narrowed this analysis to data from the three major hospital places of service: inpatient facilities, hospital outpatient departments, and emergency departments. poor understanding of different imaging methods, with 26% of partakers not able to correctly point-out which procedure expose patients to ionizing radiation. Test scores significantly increased after the educational presentation. Radiologists had higher pre-presentation test scores than other specialties, and therefore less chance for improvement, but also showed improvement in radiation safety knowledge after education. Apart from radiology, there was no noteworthy difference in initial knowledge of radiation exposure and risk among the other specialties. patients to radiation hazards. To assess the knowledge of radiation protection practices, radiation hazards and clinical profile of health workers in UDUTH, Sokoto, Nigeria a cross-sectional study was conducted among 110 Dentistry staff, Radiotherapy, Radiology picked by universal sampling technique. The study comprised of administration of standardized pre-tested semi-structured questionnaire (to obtain information on knowledge of radiation hazards, socio-demographic characteristics, and radiation protection practices of participants), clinical assessment (comprising of abdominal ultrasound, chest X-ray and laboratory investigation on haematological parameters) and evaluation of radiation exposure of participants (extracted from existing hospital records on their radiation exposure status).The participants were aged 20 to 65 years (mean = 34.04 ± 8.83), most of them were married (65.7%) and males (67.3%). 58 (52.7%) had better knowledge of Personal Protective Devices (PPDs), Sixty five (59.1%) had better knowledge of radiation hazards, less than a third, 30 (27.3%) consistently wore dosimeter, and very few (10.9% and below) consistently wore the various PPDs at work. The average annual radiation exposure over a 4 year period ranged from 0.0475mSv to 1.8725mSv. 8 (9.4%) of 85 participants had abnormal abdominal ultrasound findings only 1 (1.2%) of 86 participants had abnormal chest X-ray findings, while 11 (10.0%) and 17 (15.5%) of 110 participants had leucopoenia and anaemia respectively. This study shows not so good radiation protection practices despite better knowledge of radiation hazards among the participants, but prevalence of abnormal clinical conditions and radiation exposure were found to be low. Periodical in-service training and monitoring on radiation safety was suggested. x-ray


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1. High-energy electromagnetic waves (x-rays, gamma rays) 2. Particles (alpha particles, beta particles, neutrons) Alpha particles are energetic helium nuclei emitted by some radionuclides they cannot penetrate skin beyond a shallow depth (< 0.1 mm).
Beta particles are high-energy electrons that are emitted from the nuclei of unstable atoms. These particles can penetrate more deeply into skin (1 to 2 cm) and cause both epithelial and sub-epithelial damage.
Neutrons are electrically neutral particles emitted by a few radionuclides. Their depth of tissue penetration varies from a few millimetres to tens of centimetres, depending on their energy. X-rays and Gamma radiation are electromagnetic radiation (ie, photons) of very short wavelength and can penetrate deeply into tissue (many centimetres)..
Because of these properties, beta and alpha particles cause the most damage when the radioactive atoms that emit them are within the body (internal contamination) or, in the case of beta-emitters, directly on the body. X-rays and Gamma rays can cause damage distant from their source and are typically responsible for acute radiation syndromes.

Measurement of radiation:
Conventional units of measurement include the roentgen, rem and rad. The roentgen (R) is a unit of exposure measuring the ionizing ability of gamma radiation or x-rays in air. The radiation absorbed dose (rad) is the amount of that radiation energy absorbed per unit of mass. Because biologic damage per rad varies with radiation type ( e.g. it is higher for neutrons than for or gamma radiation or x-rays ), the dose in rad is corrected by a quality factor; the resulting equivalent dose unit is the roentgen equivalent in man ( rem )., SI (International System) units are used outside the US and in the scientific literature, in which the rem by the sievert (Sv) and rad is replaced by the gray (Gy); 1 Sv = 100 rem and 1 Gy = 100 rad.

Types of exposure:
Radiation exposure may involve 1. Contamination

Irradiation
Radioactive contamination is the unintended contact with and retention of radioactive material, usually as a liquid or dust. Contamination may be 1. External 2. Internal External contamination is that on clothing or skin, from which some can be rubbed off of or fall, contaminating objects other people. Internal contamination is unintended radioactive material within the body, which it may enter by inhalation, ingestion or through breaks in the skin.
Irradiation is exposure to radiation but not radioactive material (i.e. no contamination is involved). Radiation exposure can occur without the source of radiation (e.g., radioactive material, x-ray machine) being in contact with the person.

Sources of exposure:
Sources may be naturally occurring or artificial.
People are persistently exposed to low levels of naturally occurring radiation called background radiation.
In the US, people receive on the average about 3 mSv/year from man-made sources, the vast majority of which involve medical imaging. On a per person basis, the contribution of exposure from medical imaging is highest for CT and nuclear cardiology procedures. However, medical diagnostic procedures hardly impart doses enough to cause radiation injury, although there is a small theoretical increase in the risk of cancer. Exceptions may include certain prolonged fluoroscopically guided interventional procedures (e.g., endovascular reconstruction, vascular 309 During imaging procedures that involve ionizing radiation and especially during radiation therapy for cancer, the most susceptible parts of the body (e.g., gonads, thyroid and female breasts) that are not being treated or imaged are shielded by lead aprons or blocks.
Although shielding of personnel with lead aprons or commercially available transparent shields effectively reduces exposure to low-energy scattered x-rays from diagnostic and interventional imaging studies, these aprons and shields are almost useless in decreasing exposure to the high-energy gamma rays produced by radionuclides.
Lee RK et al 37 (2012) found that radiological examinations are commonly advised for patients to aid clinical diagnosis. However, many doctors do not realise that during radiological investigations how much radiation dosage their patients are exposed to. This study aims to compare the knowledge of radiologists and non-radiologists about radiation doses of common radiological investigations. A prospective questionnaire study of doctors about the dosage of commonly done radiological investigations in a university teaching hospital in Hong Kong. For a standard chest x-ray exposure participants were asked to specify the average dose of radiation (in mSv). Doctors were then asked to give estimation of the doses of radiation (measured in chest x-ray equivalents) for radiological procedures. The results of non-radiologists and radiologists were compared. 158 doctors (133 non-radiologists and 25 radiologists) completed the questionnaire. The overall accuracy was 16% for non-radiologists and 40% for radiologists. One-third of non-radiologists could not distinguish radiological investigation with or without ionising radiation. No non-radiologists correctly stated the radiation dose (in mSv) of a normal chest x-ray, and 77% underestimated the dose of radiological examinations. For radiologists, only 32% were correct for the radiation dose of a normal chest x-ray while 7% underrated the radiation doses. Knowledge of radiation doses of investigation is overall inadequate among radiologists, and in particular poor in non-radiologists. Underestimation of radiation doses may expose patients to increasing radiological investigation and exposure to radiation hazards. Awareness of the radiation hazard of radiological investigations should be raised among medical professionals.
Atsina KB et al 38 (2020) found that the purpose of this study was to examine the degree to which nonradiologist physicians provide formal interpretations for advanced imaging and to consider whether adequate training can be achieved for those physicians. This investigation supposed that hospitals are the only places where formal imaging training occurs. The CMS Physician/Supplier Procedure Summary Master Files (PSPSMFs) of the Medicare Part B data sets for 2015 were reviewed. They selected the Current Procedural Terminology (CPT) codes for four categories of non-invasive diagnostic imaging: CT, MRI, PET, and general nuclear imaging. Medicare place-ofservice codes allowed us to ascertain the location of each study interpretation. They narrowed this analysis to data from the three major hospital places of service: inpatient facilities, hospital outpatient departments, and emergency departments.
Provider specialties were determined using Medicare's 108 specialty codes. Procedure volumes among radiologist physicians were compared with those among non-radiologists. Of the 17,824,297 hospital-based CT examinations performed in the Medicare fee-for-service population, non-radiologists interpreted 125,937 (0.71%) and radiologists interpreted 17,698,360 (99.29%). Of the 4,512,627 MRI examinations performed, non-radiologists interpreted 43,352 (0.96%) and radiologist physicians interpreted 4,469,275 (99.04%) . Of 391,688 PET studies performed, non-radiologists interpreted 22,775 (5.81%) and radiologist physicians interpreted 368,913 (94.19%). Of the 2,070,861 general nuclear medicine studies performed, non-radiologists interpreted 763,318 (36.86%) and radiologist physicians interpreted 1,307,543 (63.14%). The largest involvement of non-radiologist physicians was of cardiologists, contributing approximately 3% of all advanced imaging interpretations. All other non-radiologist physicians interpreted a tiny fraction of advanced imaging studies. Besides radiologists and cardiologists, no other medical specialty provides adequate education for their trainees and practitioners in advanced imaging interpretation to justify letting them to interpret these studies in practice, except under carefully controlled circumstances.
Hobbs JB et al 39 (2018) found that medical imaging is an increasingly important source of radiation exposure for the general population, and there are risks associated with such exposure; however, recent studies have showed poor understanding of medical radiation among various groups of health care providers. This study had two aims: (1) examine physicians' knowledge of radiation exposure and risk in diagnostic imaging across multiple specialties and levels of training, and (2) assess the benefit of a short educational presentation on enhancing physicians' knowledge. From 2014 to 2016, 232 health care providers from a number of departments took part in an educational sessions and pre-and post-presentation tests assessing knowledge of radiation exposure and risk at a big academic institution. Knowledge of radiation exposure and risk was relatively less on the pre-presentation test, including in particular 310 poor understanding of different imaging methods, with 26% of partakers not able to correctly point-out which procedure expose patients to ionizing radiation. Test scores significantly increased after the educational presentation. Radiologists had higher pre-presentation test scores than other specialties, and therefore less chance for improvement, but also showed improvement in radiation safety knowledge after education. Apart from radiology, there was no noteworthy difference in initial knowledge of radiation exposure and risk among the other specialties. Providers' knowledge of radiation exposure and risk was low at baseline but remarkably increased after a brief educational presentation. Efforts to educate ordering providers about radiation exposure and risk are needed to ensure that providers are appropriately weighing the benefits and risks of medical imaging and to ensure highquality, patient-cantered care.
Krille L et al 40 (2010) found that the frequent use of computed tomography is a major cause of the increasing medical radiation exposure of the general population. Therefore, radiation protection and dose reduction is a topic of scientific and public concern. They evaluated the available literature on physicians' knowledge regarding radiation dosages and risks due to computed tomography. A systematic assessment in accordance with the Cochrane and PRISMA statements was carried out using eight databases. 3091 references were found. Only primary studies assessing knowledge of physicians about computed tomography were included. 14 appropriate articles were identified, all focussing on dose estimations for CT. On the whole, the surveys showed average to low knowledge among physicians concerning radiation doses and the involved health risks. However, the surveys varied significantly in quality and conduct. More than one survey was available for some countries. There was no general trend in knowledge in any country except a slight betterment of knowledge on health risks and radiation doses in two back to back local German surveys. Knowledge gaps concerning associated health risks and radiation doses among physicians are apparent from published research. However, knowledge on radiation doses cannot be interpreted as authentic indicator for good medical practice.
Singh P et al 41 (2015) found that exposure to radiation during radiological investigations is of health concern, which referring physicians should rationalize. Hence, they assessed the clinician's awareness and concern of radiation exposure to patients, in relation to their referral practice. A prospective study was conducted involving specialists from Punjab (India), who were handed a standard set of questionnaire about knowledge of doses and radiation hazards from imaging procedures, consideration of age and radiation dose when referring, referrals not likely to influence treatment, and use of referral guidelines were included. Of the 150 medical doctors given the questionnaire, 106 returned it. While a few overestimated it, Majority of the clinicians underestimated radiation doses. Almost half of the clinicians (55.5%) favoured to select the rationale of asking about earlier radiological examinations as clinical need only, which was surprising. Rates of referrals not likely to affect treatment were more (66%) than reported rates in previous studies. Worryingly, only 30.1% of the clinicians had knowledge of referral guidelines and surprisingly only 10.5% had made use of it. Their study although in a small population size identifies insufficient knowledge on radiation and its guidelines among referral physicians, which justifies the immediate need for training Programs to decrease this knowledge gap.
Parikh JR et al 42 (2017) found that the risk of injury associated with long-term occupational exposure to ionizing radiation is low for radiologists. The motive of this article is to systematically review and inform radiologists about radiation-related effects to which they are possibly susceptible. Formal training and education on radiation safety and management, careful attention to better radiation protection habits, and continued attention on radiation management and as low as reasonably achievable principle are recommended for all radiologists.
Paolicchi F et al 43 (2016) found that to evaluate radiation protection basic knowledge and dose assessment for radiological procedures among Italian radiographers. A validated questionnaire was distributed to 780 participants with balanced geographic distribution and demographic characteristics. Only 12.1 % of candidates attended radiation protection courses on a regular basis. Despite 90 % of radiographers saying to have adequate awareness of radiation protection issues, a lot of them underestimated the radiation dose of nearly all radiological procedures. About 4 % and 5 % of the participants, respectively, claimed that abdominal ultrasound and pelvis magnetic resonance imaging exposed patients to radiation. On the other hand, 7.0 % of the radiographers said that mammography does not use ionising radiation. About half of participants believed that radiation-induced cancer is not dependent on age or gender and were not able to differentiate between stochastic and deterministic effects. Young radiographers (with less than 3 years of experience) showed a better level of knowledge compared with the more experienced radiographers. There is a considerable need for radiographers to improve their knowledge of radiological procedures and awareness of radiation protection issues. Specific actions such as regular training 311 courses for both undergraduate and postgraduate students as well as for working radiographers should be considered in order to assure patient safety during radiological examinations.
Azmoonfar R et al 44 (2016) found that although ionizing radiation is very important in diagnostic and treatment of many diseases, the hazards of this radiation are considerable and irrefutable. Knowledge about radiation dose in radiological investigation is one of the main stages in radiation protection. The aim of this study was to determine the physicians' knowledge in radiological examinations. The data collected by questionnaire were designed and the most commonly requested radiological investigations were listed. The questionnaire was distributed among 106 consultant physicians. The survey was conducted on the awareness about the risks and radiation dose among health professionals in Iran. The results showed that the most of physicians did not know about ionizing radiation and evaluation of absorbed dose in patients. Many of these physicians were not familiar with radiations risks and the most important aspects of radiation protection; although, they have passed some courses in medical physics and radiobiology. Since radiological examinations play an important role in medicine, knowledge about hazards and radiation doses is very important. On the whole, this study showed that knowledge of radiation doses is inadequate among physicians.
Khan MO et al 45 (2018) found that junior doctors routinely request radiological investigations for patients. Earlier studies have noted that among this group there is a lack of knowledge on radiation exposure and radiation legislation in common radiological investigations. However, no studies have compared this with radiology trainees and radiographers. They compared knowledge of radiation exposure and radiation legislation in common radiological investigations among foundation year doctors (FY1, FY2) final year medical students (FYMS), against specialist radiology trainees (SRT) and radiographers (RG). A 12-question multiple choice questionnaire (MCQ) was distributed to FY1, FYMS, FY2, SRT and RG at a UK teaching hospital. Questions assessed knowledge of radiation-dose estimates legislation and radiation-dose legislation of common radiological investigations. Mean MCQ scores were compared using one-way ANOVA and Tukey post-test to determine statistical significance (pvalue < 0.05). In the study 127 participants were included. Mean scores (%) for FYMS (49.3%), FY2 (51.1%) and FY1 (52.6%) were significantly lower compared to RG (66.3%) and SRT (64.4%) (p-value < 0.05). Mean test scores between FYMS, FY1 and FY2 did not remarkably differ (p-value > 0.05). FYMS, FY1 and FY2 knowledge of radiation exposure and radiation legislation in common radiological investigations was not so good compared to SRT and RG. Patients need knowledge of radiation risk to provide informed consent as per IRMER regulations, thus they suggest formal teaching on the subject matter to promote radiation safety culture among medical undergraduates and postgraduates.
Lee WJ et al 46 (2016) found that imaging methods that use ionizing radiation in emergency departments (EDs) have increased with advances in radiological diagnostic methods. Physician and nurse awareness of the radiation dose in the ED and the associated cancer risks to which the patients are exposed were surveyed with a questionnaire. A total of 191 subjects in six EDs participated in this study. ED physicians and ED nurses were asked about the radiation doses and the risks of imaging methods ordered in the ED. The variance between the two groups was compared using Student's t-test for continuous variables. A Fisher's exact and Chi-squared tests were used for categorical variables. A total of 109 ED nurses and 82 ED physicians finish the questionnaire; 8 (7.3%) nurses' 38 and (46.3%) physicians correctly gave answer to the question about the chest X-ray radiation dose. A question about the number of pelvic X-rays that is equivalent to the dose of a chest X-ray was answered correctly by 9 (8.3%) nurses and 5 (6.1%) physicians (P = 0.571). Questions regarding magnetic resonance imaging, abdominal ultrasonography, abdominal computed tomography (CT), chest CT and brain CT were answered correctly more frequently by the physician group than the nurse group (P < 0.05). The risk of developing cancer over a lifetime due to a brain CT was correctly answered by 30 (27.5%) nurses and 21 (25.6%) physicians (P = 0.170). A similar question about abdominal CT was correctly answered by 42 (38.5%) nurses and 21 (25.6%) physicians (P = 0.127). Knowledge of the radiation exposure of radiology examinations was less in nurses than physicians, but overall knowledge was poor in both groups. ED physicians and nurses should be educated about cancer risks and radiation exposure associated with various diagnostic radiological methods.
Maharjan S et al 47 (2017) found that the usage of radiation has become an inevitable part of human life. From medical usage they receive 19.7% (0.6mSv) of radiation. Radiation technology not only helps medical management, but also causes severe adverse effects. So the knowledge and practice of radiology professionals regarding radiation safety and harmful biological effects of ionizing radiation is an utmost important topic to be addressed. Awareness 312 of measures of precautions and radiation protection is the biggest hurdle in order to manage radiation hazards promptly and properly. To accomplish this difficult task and to set standard guidelines, various international organizations have been established. The importance of safe operation and knowledge and of radiation has been drawing special attention, from the era of Roentgen's discovery of x-rays. Medical exposure is closely associated with many times increase in lifetime cancer risk. To avoid unnecessary exposure and facilitate better patient care, radiology professionals should be well aware of these issues. Many radiology professionals still disregard as x-rays do not cause immediate severe adverse effects. Till today, x-ray imaging technology have glanced many advancement. Still, they are reluctant and neglect to practice radiation using safety precautions. This shows the lack of inadequate knowledge of radiation protection principles and they are still not sensitive about their daily working ethics. To the best of their knowledge, this is the first study in Nepal that identifies the perception of radiation protection and its safe usage. To date, only a few of studies have been done to assess awareness and knowledge of radiation protection elsewhere as well. When the title of this manuscript was typed in the Pub Med Central (PMC) database, only 129 articles were shown and a sufficient of relevant literatures was accessed in this article. This also shows the importance of this study in international context as well. The main goal behind this survey-based study was to obtain a better understanding of the current status, awareness and knowledge of radiation protection, the need for safe practices among radiology professionals and to compare the data with international literatures.
Algohani KA et al 49 (2018) found that more than 3,600 million radiology examinations are carried out every year worldwide. In spite of the great benefits of diagnostic and therapeutic radiations, they may result in some hazards if used inappropriately. However, these hazards can be prevented through raising the awareness of health care professionals about these hazards and the protective measures to be considered. Several regulations and guidelines were issued for this purpose including; the ALARA principle and POPUMET regulations and the WHO global initiative on radiation safety in health care settings. The current study aimed at assessing the level of radiation protection awareness among clinicians and radiologists in addition to exploring if radiation protection courses have a beneficial effect on the awareness level or not. Methods: This was a cross-sectional study where the level of radiation protection awareness was assessed using an anonymous questionnaire. A total of 101 (100%) participants responded to the questionnaire. Of which; 49 (48.5%) were residents, 30 (29.7%) were specialists and 22 participants (21.8%) were consultants. A little less than half of the participants (48, 47.5%) have taken part in a radiation protection course before. The majority of participants who attended a course (68.8%) have heard about the POPUMET regulations (p<0.001). Attendants were asked about the procedures with risk equivalent to 0.25 mSy of radiation estimated dose equivalent. And it was found that course attendance improved the knowledge about the risk of 3 (out of 4) procedures (p<0.05). On the other hand, course attendance didn't improve the knowledge about the approximated radiation doses of some procedures (p>0.05) or the degree of radio-sensitivity of different organs (p>0.05). Most of the participants (96%) were not aware that there is no annual limit of radiation dose for patients. More than half of the participants (56.4%) were aware about what the word -ALARA‖ stands for. Results of the current study suggested that the level of radiation protection awareness among healthcare professionals is not adequate to ensure workers and patients' safety. And accordingly, they suggested that more efficient awareness programs for health care professionals are conducted on regular basis with regular monitoring of awareness level to explore areas for improvement.
Madrigano RR et al 50 (2014) found that to assess the non-radiologist physicians' knowledge on the use of ionizing radiation in imaging. Cross-sectional study using an anonymous questionnaire responded by surgical specialties and physicians in clinical, divided into two parts as follows: one including multiple choice questions approaching general knowledge about radiation, radioprotection and optimization principles and another part include questions about the physicians' characteristics, participation in professional updating events and frequency of imaging studies requests. From a total of 309 questionnaires, 120 (38.8%) were responded, 50% in clinical specialties and 50% by physicians in surgical specialties; respectively 2.5% and 45% of physicians responded that ultrasonography and magnetic resonance imaging use ionizing radiation. On the whole, the overall grade was higher for surgical specialists with no remarkable difference, except for the question about exposure in pregnant women (p = 0.047). Physicians who are professionally updated, particularly those and taking part in teaching activities (p = 0.047) and take part in clinical meetings (p = 0.050), showed statistically better knowledge about ionizing radiation as compared to others. The non-radiologist physicians' knowledge is varying and in some points needs to be improved. Multidisciplinary clinical meetings and teaching activities are important ways to spread information on the subject.
Awosan KJ et al 51 (2016) found that use of ionizing radiation in medical imaging for diagnostic and interventional purposes has risen substantially in recent years with a consequent increase in exposure of health workers and 313 patients to radiation hazards. To assess the knowledge of radiation protection practices, radiation hazards and clinical profile of health workers in UDUTH, Sokoto, Nigeria a cross-sectional study was conducted among 110 Dentistry staff, Radiotherapy, Radiology picked by universal sampling technique. The study comprised of administration of standardized pre-tested semi-structured questionnaire (to obtain information on knowledge of radiation hazards, socio-demographic characteristics, and radiation protection practices of participants), clinical assessment (comprising of abdominal ultrasound, chest X-ray and laboratory investigation on haematological parameters) and evaluation of radiation exposure of participants (extracted from existing hospital records on their radiation exposure status).The participants were aged 20 to 65 years (mean = 34.04 ± 8.83), most of them were married (65.7%) and males (67.3%). 58 (52.7%) had better knowledge of Personal Protective Devices (PPDs), Sixty five (59.1%) had better knowledge of radiation hazards, less than a third, 30 (27.3%) consistently wore dosimeter, and very few (10.9% and below) consistently wore the various PPDs at work. The average annual radiation exposure over a 4 year period ranged from 0.0475mSv to 1.8725mSv. 8 (9.4%) of 85 participants had abnormal abdominal ultrasound findings only 1 (1.2%) of 86 participants had abnormal chest X-ray findings, while 11 (10.0%) and 17 (15.5%) of 110 participants had leucopoenia and anaemia respectively. This study shows not so good radiation protection practices despite better knowledge of radiation hazards among the participants, but prevalence of abnormal clinical conditions and radiation exposure were found to be low. Periodical in-service training and monitoring on radiation safety was suggested.
Dellie ST et al 53 (2014) found that to evaluate the level of knowledge about the radiation exposure to diagnostic imaging procedures among the final-year medical students and interns and to suggest how education could be improved. From Tikur Anbessa Teaching Hospital in Addis Ababa all 355 interns and final-year medical students were included in the study. Participants were asked to complete a questionnaire consisting of their preferred method of learning and actual knowledge on ionizing radiation. All questions were in multiple choice formats ranging from 4 to 7 choices. Statistical software was used to analyse the obtained data. 343 completed questionnaires were received in total. Up to 78.9% of respondents do not know or underestimated or the radiation dose from commonly requested radiological procedures. Surprisingly, 254 (79.3%) and 245 (71.4%) students faultily believed that MRI and ultrasound, respectively, emit ionizing radiation or they have no idea if they emit radiation or not. Both medical students and interns did not have notable difference in their knowledge of ionizing radiation. A combination of tutorials or workshops (29.7%) learning modules (19.8%) combined were their first and last preferred methods of teaching for future radiation awareness, respectively. This study showed that awareness of ionizing radiation from diagnostic imaging is lacking among senior medical students and interns. The results show the need for better education to decrease unnecessary exposure of patients.
Faggioni L et al 54 (2017) found that to evaluate the awareness of radiation protection issues and the knowledge of dose levels of imaging procedures among medical students, radiology residents, and radiography students at an academic hospital. A total of 159 students (including 56 medical students,60 radiology residents, and 43 radiography students) and young doctors were given a questionnaire having 16 multiple choice questions divided into three separate sections (i.e. awareness about radiation protection issues, demographic data, and knowledge about radiation dose levels of common radiological examinations). Medical students claimed to have at least a better knowledge of radiation protection issues more frequently than radiology residents and radiography students (94.4% vs. 55% and 35.7%, respectively; P < 0.05), with no cases of recognised excellent knowledge among radiography students. However, the actual knowledge of important radiation protection topics such as professional radiation risk and dose optimisation, as well as of radiation doses delivered by common radiological procedures, patient and tissue susceptibility to radiation damage, regulations, was significantly worse among medical students than radiology residents and radiography students (P < 0.05). Those later notably outperformed radiology residents as to knowledge of radiation protection issues (P< 0.01). on the whole less than 50% of survey respondents correctly answered all questions of the survey. Radiology residents, radiography students and medical students have a less knowledge about radiation protection, with a certain gap of knowledge concerning real radiation doses of daily radiological examinations. Both postgraduate and undergraduate teaching needs to be constructively implemented with radiation safety courses. Plastic Surgery Department, Surgery Department, Urology Department and Emergency department and .Questionnaires was distributed by both hard copies and by email to each doctor in these departments.

Questionnarie Format:
For the purpose of this proposal, a closed question format to collect data was used. Closed questions yield data that allow for comparison between respondents as all the response are in the same format, this additionally allows for the collection of valid and reliable data. They can be answered quickly and therefore improve response rates and can be pre coded, thereby making analysis easier (Parahoo 1997).The limitations of closed question format, is that an appropriate response may be omitted thereby obtaining an invalid response . This according to Parahoo (1997) can be offset by care and skill full construction of the questionnaire. It is proposed that the questionnaire initially asks demographics question. To determine knowledge level a multiple choice format was used. Polit et al (2001) suggest that this format is appropriate in cases where there is more or less fixed number of alternatives. Multiple -choice offers the participant a list of response, from which they select the one most appropriate.

Sample size:
For the proposal of this study sample size was one hundred and fifty

Ethical Consideration:
Ethics refers to the right and protection of subjects according to Cormack(2000) there are ethical considerations at every at every stage of a research process including the choice of topic to search .A written explanation of the nature of study was given along the questionnaire. Participants can make an informed decision whether to enter in to the study, by the informed consent form (appendix II). No name was attached to the questionnaires, which will allow participant anonymity. Confidentiality of the data gathered from participants was respected at all times .This research proposal was submitted to the Peerless Hospital's Ethics committee for scrutiny and was undertaken if approval is granted.

Statistical Analysis:
For statistical analysis data were entered into a Microsoft excel spreadsheet and then analyzed by SPSS (version 25.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism version 5. Data had been summarized as mean and standard deviation for numerical variables and count and percentages for categorical variables. Two-sample t-tests for a difference in mean involved independent samples or unpaired samples. Paired t-tests were a form of blocking and had greater power than unpaired tests. A chi-squared test (χ2 test) was any statistical hypothesis test wherein the sampling distribution of the test statistic is a chi-squared distribution when the null hypothesis is true. Without other qualification, 'chi-squared test' often is used as short for Pearson's chi-squared test. Unpaired proportions were compared by Chi-square test or Fischer's exact test, as appropriate.
Explicit expressions that can be used to carry out various t-tests are given below. In each case, the formula for a test statistic that either exactly follows or closely approximates a t-distribution under the null hypothesis is given. Also, the appropriate degrees of freedom are given in each case. Each of these statistics can be used to carry out either a one-tailed test or a two-tailed test.
Once a t value is determined, a p-value can be found using a table of values from Student's t-distribution. If the calculated p-value is below the threshold chosen for statistical significance (usually the 0.10, the 0.05, or 0.01 level), then the null hypothesis is rejected in favor of the alternative hypothesis.
p-value ≤ 0.05 was considered for statistically significant.                                        The association of Age vs. two groups was not statistically significant (p=0.9886).  The association of category vs. two groups was not statistically significant (p=0.1059).     The association of RE during thoracic spine x-ray vs two groups was statistically significant (p<0.0001).  The association of RE during lumbar spine x-ray vs two groups was statistically significant (p<0.0001).  The association of RE during pelvis x-ray vs two groups was statistically significant (p<0.0001).  The association of RE during hip x-ray vs two groups was statistically significant (p= 0.0001).  The association of RE during CT-head vs two groups was statistically significant (p<0.0001).  The association of RE during CT abdomen vs. two groups was statistically significant (p<0.0001).  The association of Radiation dose during IVU vs. two groups was statistically significant (p<0.0001).  The association of RE during barium enema vs. two groups was statistically significant (p<0.0001).    The association of RE during ultrasound abdomen vs two groups was statistically significant (p=0.0009).  The association of RE during MRI brain vs. two groups was statistically significant (p=0.0054).             Hobbs JB et al 39 (2018) found that knowledge of risk and radiation exposure was relatively low on the prepresentation test, including specifically poor understanding of different imaging modalities, with 26% of participants not able to correctly identify which modalities expose patients to ionizing radiation. Efforts to educate ordering providers about radiation exposure and risk are needed to ensure that providers are appropriately weighing the risks and benefits of medical imaging and to ensure high-quality, patient-centred care.

Figure 23: Association between category: Group
Krille L et al 40 (2010) found that overall, the surveys showed moderate to low knowledge among physicians concerning radiation doses and the involved health risks. However, knowledge on radiation doses cannot be elucidated as reliable indicator for good medical practice.
Singh P et al 41 (2015) found that Majority of the clinicians underestimated radiation doses, while a few overestimated it. Almost half of the clinicians (55.5%) favoured to select the rationale of asking about earlier radiological examinations as clinical need only, which was surprising. Their study as such in a small population size shows inadequate knowledge on radiation and its guidelines among referral physicians, which shows the immediate need for training programs to bridge this knowledge gap.
Our study showed that in Non Radiologist group, 31 Azmoonfar R et al 44 (2016) found that the results indicated that the majority of physicians did not know about ionizing radiation and evaluation of absorbed dose in patients. Many of these physicians were not aware of the most important aspects of radiation protection and radiations risks. On the whole, this study showed that knowledge of radiation doses is not adequate among physicians.
We found that in Non Radiologist group, 88(88.0%) doctors had told a Right Answer. In Radiologist group, 50 Khan MO et al 45 (2018) found that patients require knowledge of radiation risk to provide informed consent as per IRMER regulations, thus they propose formal teaching on the subject matter to promote radiation safety culture among medical undergraduates and postgraduates.
Maharjan S et al 47 (2017) found that Medical exposure is closely associated with manifold increase in lifetime cancer risk. To avoid unnecessary exposure and facilitate better patient care, radiology professionals should be well aware of these issues. Many radiology professionals still ignore as x-rays do not cause immediate severe adverse effects.
Parikh JR et al 42 (2017) found that formal education and training on radiation safety and management, careful attention to good radiation protection habits, and continued emphasis on radiation management and the as low as reasonably achievable principle are recommended for all radiologists.

Conclusion:-
We found that the knowledge of radiation dose of investigation is significantly poor in non radiologist.
Our study also showed that knowledge of radiation dose of investigation is generally inadequate among radiologists.
It was found that young practitioners among non radiologist as well as radiologist have better knowledge of radiation dose of investigation.
Knowledge and awareness of the radiation hazards of radiological examinations can be raised among emergency physicians and other medical professionals as a part of continuous medical education programmes.
Knowledge of radiation doses of investigation is generally inadequate among radiologists, and particularly poor in non-radiologist. Underestimation of radiation doses may expose patients to increasing radiological investigation and expose to radiation hazards.
Efforts to educate medical professional about radiation exposure and hazard are needed to ensure that medicinal professional are appropriately weighing the risks and benefits of medical imaging and to ensure high-quality, patient-cantered care.

Limitations of The Study:
In spite of every sincere effort my study has lacunae.