TERRY GROSS, host:
This is FRESH AIR. I'm Terry Gross.
Most of us have been exposed to medical radiation, through dental X-rays, CT scans or cancer therapy. By my guest, Walt Bogdanich, has found that while this new technology saves countless lives, its complexity has created new avenues for error: through software flaws, faulty programming, poor safety procedures or inadequate staffing and training. And he says, when those errors occur, they can be crippling.
He's been writing a series of investigative articles on medical radiation for the New York Times. His series, "The Radiation Boom," was a Pulitzer Prize finalist. He's won three Pulitzers.
Walt Bogdanich, welcome to FRESH AIR. Why did you start looking into radiation medicine and instances of over-radiation?
Mr. WALT BOGDANICH (Journalist): Well, about two years ago, I got a tip from a major New York hospital that babies were being seriously over-radiated.
And I think what really caught my interest, other than the obvious fact that babies shouldn't be over-radiated - nor anyone else for that matter - but that it had been going on for some time.
And that told me that there was not proper oversight within the hospital and, you know, not proper oversight by the state government, which was tasked with making sure that radiation is safe.
So that indicated to be that there was, perhaps, a systemic problem and that if it was in fact happening at this New York hospital, it probably was happening elsewhere.
GROSS: And it was not only happening with babies, it was happening with adults and children.
Mr. BOGDANICH: Yes, correct.
GROSS: And the babies you found, a lot of these babies that were getting full-body X-ray scans, were supposed to just be getting chest X-rays.
Mr. BOGDANICH: They were premature babies, and because of that fact, their lungs were undeveloped. And they had routinely been assigned to go get chest X-rays.
And what I had discovered is that rather than protect the parts of the body that were not being examined, I guess because it was quicker, these babies were just being shoved in, and their entire bodies were being irradiated, including their reproductive organs, which is a very, very radiosensitive part of the body.
In fact, children are far more sensitive to radiation than adults. So there were several problems here.
GROSS: What happened with the babies? Do you know if they got sick?
Mr. BOGDANICH: Well, we couldn't identify them, and they wouldn't disclose it, but we - our stories did prompt the state to do an investigation. And the state found that the problems had continued, even after we had reported them, and that's where it stands right now.
At some point, I suppose there will be some discipline imposed, but it was quite surprising to us, and frankly to the state, that after these serious issues were laid out on the front page of The New York Times that the people involved the radiology department were continuing to make mistakes.
GROSS: Let's just rule out some procedures that aren't radiation: ultrasound.
Mr. BOGDANICH: Ultrasound and MRI are procedures that you really don't have to worry about in terms of radiation. MRIs, I thought for a while, involved radiation quite a few years ago, but they don't. And those are alternatives to CT scans.
So, I mean, there are issues with sonograms, but not from a radiation perspective.
GROSS: PET scans?
Mr. BOGDANICH: Well, PET scan involves radiation. I mean, that's - PET scan involves actually injecting radioactive materials into your body so you can more clearly get internal pictures. So that does involve quite a bit of radiation, as a matter of fact.
GROSS: Before we talk more about what you found and what you think the implications are, I don't want to terrify people because as you point out in the series, serious accidents are rare, and radiation saves countless lives. So just put this in perspective for us before we go any further.
Mr. BOGDANICH: Well, that's really important. And I was aware of that as I prepared these stories. I was very concerned because I did not want people to forego getting treatment or diagnostic imaging that they needed to make their lives safer.
So I tried to put it in perspective. I mean, these - this new medical technology is wonderful. It diagnoses internal problems, where in the past it would have required exploratory surgery. Now it doesn't need -you don't need to open up the body.
And because of the increased power and precision of radiation therapy, doctors are able to treat disease in completely new ways, more effective ways, and shorter periods of time, without having to go in necessarily and cut out that cancer that they're attacking.
So I think we made it clear that these are wonderful gadgets, devices that save countless lives, and people need to get them when they need them. But they need to ask questions.
And that was a big part of our series, that people were not asking questions. And frankly, doctors who were treating the patients were not giving patients the kind of information they needed when they were offering their bodies up to be tested or treated.
GROSS: We'll get back to that a little bit later. But let's talk about some of the things that you've found so far in your series.
Let's start with one woman, a 32-year-old breast cancer patient. Radiation burned a hole in her chest. I mean, she could see her ribs. She ended up dying. What happened? What was the radiation problem?
Mr. BOGDANICH: Well, surprisingly, she began her treatment regimen on the day that the state of New York had issued a reminder to hospitals to be very, very careful with this particular type of radiation therapy, that there had been mistakes in the past and to make sure you double-checked everything.
On the very day that that warning arrived, this hospital began to administer 27 straight radiation treatments, each of which was three times what it should have been.
And even more striking was the fact that on the console it was - the mistake should have been obvious to the operators, that the proper radiation was not being delivered, and yet that was ignored 27 days in a row.
GROSS: And what kind of radiation was this?
Mr. BOGDANICH: Well, it's radiation therapy. It was - it's a type of device where you generate machine-generated radiation, very high-powered, that is delivered very precisely to a small area. That's a different kind of radiation than radioactive isotopes, which are not generated by machines, obviously, and in fact are regulated by two different agencies.
So this is a - one of the high-tech devices that has, in fact, saved many people, but when it's used improperly and in a hurry, without proper training, bad things happen.
GROSS: So I imagine that the woman who had the hole burned in her chest from radiation had repeated exposure to - you know, had repeated radiation therapy. How could it be that nobody noticed, even as her skin was getting more and more burned and the wound getting deeper?
Mr. BOGDANICH: Well, that's a good question. I think it goes to the heart of why I was doing these stories, because there wasn't an awareness not only among patients but among physicians as to the harm that can result from radiation.
When there's a botched surgery, you notice it right away. When there are bad drugs that are causing serious harm, you pretty much know it. But with radiation, there wasn't that ability to quickly identify the reason that perhaps skin was reddening.
There was a belief, as I discovered in my investigation, that a lot of these adverse results were pretty much written off as just, you know, part of what happens when you administer radiation.
And no one looked at it as though we had made a mistake, or no one looked at it asking could we have done better. Too often it was just dismissed as, well, you know, nothing is without risk. And surgery is not without risk, and drug therapy is not without risk.
So there weren't the kinds of questions that were being asked in the aftermath of - in this case with this poor woman, when she was suffering very serious skin damage. The questions weren't being asked why.
GROSS: So is this a one-off, or did you find that this was a pattern?
Mr. BOGDANICH: Unfortunately, it was going on all around the country, and one of the great difficulties in trying to establish scope, which is important for investigative reporters to do because we don't want to be accused of just cherry-picking a couple of bad cases - we have to convince ourselves and convince our readers that this is some kind of systemic problem and that it's just not a collection of anecdotes.
And that was very difficult to do for a number of reasons, mostly because many states do not require that accidents be reported. And there is no central place where, you know, different kinds of irradiation accidents are reported. And as a result, we really don't know when they happen.
And again, radiation harm manifests itself in a different way than medication errors or surgery errors. I mean the harm that can result from radiation obviously is cancer. And that might take a couple decades to manifest itself.
Now, in radiation therapy, where there is intense radiation being applied, there are skin problems and in some cases wounds that will not heal because the radiation literally kills the cells and they can't grow back.
And that happens sometimes several weeks afterwards, and general practitioners don't recognize that as being a radiation injury, and people are not trained really to identify them. So a lot of these accidents go unreported, undetected, and when that happens, mistakes continue.
GROSS: If you're joining us, my guest is Walt Bogdanich, and he's an investigative reporter for the New York Times. We're talking about his series "The Radiation Boom," which is investigating how new radiation medical therapies have not only created new cures but they've also created new ways to do harm.
Let's take a short break here and then we'll talk some more. This is FRESH AIR.
(Soundbite of music)
GROSS: If you're just joining us, my guest is Walt Bogdanich. He's an investigative reporter for the New York Times. We're talking about his series "The Radiation Boom," which has investigated how new radiation medical therapies have not only created new cures, they've created new problems, new ways of doing harm.
There was another example of a mistake that you found that had dire consequences, and there were several patients who had had CT scans, and this is a form of radiation scan for strokes.
And they were having problems, and they - several of them showed up with the exact same pattern of hair loss, like a circle around their head, around the centers of their head that were like a strip around the head that was bald. And so there was hair above it and hair below it, and it's as if somebody just put a band around the center of their heads and stripped all the hair off of it.
Mr. BOGDANICH: What is amazing about that case is that there were hundreds and hundreds of instances where that occurred. And they continued for more than a year in more than one location.
And these kinds of bald patterns, where it's as though you took a razor and a ruler and a perfectly straight line, shaved the head - well, that doesn't occur in nature. I mean, that's not how one loses their hair.
And what was amazing to me, and frankly spoke volumes about our inability to recognize radiation injuries, is that this went on over and over and over again and doctors saw this, and for some reason never thought to ask or didn't pursue it, didn't ask the patient: Well, recently, did you have some kind of medical procedure on your head?
That would seem to be a very obvious question. And when the person obviously answered yes - well, it would seem that that ought to be pursued, and for some reason it wasn't. And as a result, hundreds and hundreds of patients around the country were seriously over-radiated, and they're suffering ill effects to this day.
GROSS: So is there, like, a band that's put on the head for this kind of CT scan that matches the pattern of baldness?
Mr. BOGDANICH: Pretty much, exactly. It's where the radiation went in, and when it's high enough, it kills the hair cells and follicles. And it did it in straight lines around the head. And understandably, people who were subjected to this were quite worried.
They would go take a shower and all of a sudden there would be huge gobs of hair in the bathtub, and they would, in a panic, go talk to the doctor and say what's going on. And most frequently they were told: Well, you must have some alopecia or some kind of skin ailment that will come and go, and we'll give you some cream.
I mean, one person who had it was given some kind of other therapy to try and make the hair grow again, when in fact what had caused it was serious cases of over-radiation.
GROSS: So what went wrong in this instance?
Mr. BOGDANICH: Well, the operators, quite honestly, did not understand how to use these very high-tech radiation devices. Hospitals are in -they want more patients, understandably.
And as soon as a new gee-whiz medical device comes out that is some life-saving device - and there are many of them, and praise to the people who are producing them - but every hospital wants to get them as quickly as possible, and sometimes they move too quickly.
They buy them, they install them, they don't spend the kind of money necessary to properly train the staff in its use and to develop the kind of protocols necessary to ensure that mistakes don't happen.
Now, mistakes will always happen. I mean, they happen in journalism. They happen in every profession. The idea is: How can we devise a system where we will minimize the possibility of that? And that wasn't happening. And that was a part of the issue that we were looking into.
GROSS: There's another type of radiation medicine problem I want to ask you about, and that's dental X-rays, particularly children's dental X-rays. What's the problem you found?
Mr. BOGDANICH: What I found is that people do not realize the levels of radiation being administered to their children. And they don't realize the children are - their children are more vulnerable to the harmful effects of radiation.
And like most parents - and I'm one of them - it had never occurred to me that there might be excess radiation being administered in a dental office. I was always under the impression that - under the impression because dentists told me this - don't worry about it.
Every time you came in to have your teeth checked, you were given X-rays, and everyone told me it was the lowest amount of any medical procedure. And I believed them.
And in some cases that's true, but what I discovered in other cases, it's not. And that is because of new technology that had been administered, that had been developed, and was increasingly being used on young adults who are getting braces, orthodontic care.
And there's this device called a cone-beam CT scan. It's not as powerful as the CT scans that are in hospitals or clinics, that, you know, may be looking inside one's body. But they are more powerful than the typical X-rays that you would get in a dentist's office.
And what struck me, and merited further investigation, is that when sources told me that - parents are given the option of having pictures of their child's mouth before they get braces, of having a cone-beam CT scan, which administers a significant amount of radiation, or having their child merely have pictures taken of their mouth, regular pictures that don't use radiation.
So you have an option of radiation on one hand or no radiation on the other hand. Now, the radiation produces these incredible, brilliant 3-D pictures, but dentists tell me that that's not always necessary. There are also adequate images that can be put together in 3-D form by simply taking pictures within the mouth.
Well, you know, that - here was a clear-cut case of, I thought - and many of the experts that I interviewed thought as well - there was no need to subject young adults to these levels of radiation. And it was an interesting question to try and figure out why.
GROSS: So you say that children are more vulnerable to radiation than adults. Why is that?
Mr. BOGDANICH: A couple of reasons why it's more dangerous for children. One, their cells are dividing and they're more vulnerable. Second of all, children face a lifetime of radiation procedures, some of which haven't even been developed yet, but as technology marches forward, we know they will be.
And there's a strong belief, consensus in the medical community, that the harmful effects of radiation are cumulative. And what that means is the more radiation you receive in your lifetime, the greater the likelihood that you'll develop cancer.
So particularly with children, you don't want to get them started on a path where you're over-radiating them, particularly when it's not necessary.
GROSS: Walt Bogdanich will be back in the second half of the show. He's an investigative reporter for the New York Times. You'll find links to the articles in his series "The Radiation Boom" on our website, freshair.npr.org. I'm Terry Gross and this is FRESH AIR.
(Soundbite of music)
GROSS: This is FRESH AIR. Im Terry Gross.
We're talking about medical radiation with Walt Bogdanich, an investigative reporter for The New York Times. His series the "Radiation Boom" was a Pulitzer Prize finalist. He's won three Pulitzers.
He says medical radiation has saved countless lives and serious accidents are rare. But medical radiation's complexity has created new avenues for error through software flaws, faulty programming, poor safety procedures or inadequate staffing and training. When we left off, we were talking about dental X-rays.
Now, children and adults get regular dental X-rays and a lot of dentists have new digital X-ray machines. Are the digital X-rays, do they have less - do they emit less radiation than the old films do?
Mr. BOGDANICH: Digital imaging does produce less radiation. But as I learned in investigating dental X-rays, I found that there is even a wide difference in the more traditional film imaging of your dental structure; the kind we're all familiar with when we go in and we have our teeth examined and they take these quick pictures.
Most doctors, according to the FDA, doctors should be using digital imaging. But instead, they're sticking with the old film. And there are two different speeds of film developing, and a lot of doctors are using the slower film. Which means that you are exposed for a greater period of time to the radiation. If they were using faster speed film it would be a shorter period.
I also found that doctors were using improper development techniques for that film once the images were taken, which required them to expose the patient longer, for longer periods of time in order to get a clearer image. Because you couldn't get a clear image with a bad developing techniques that were being used.
So there were a whole host of problems that existed in dental radiation that were rarely written about.
GROSS: So what are some of the questions do you think people should ask their dentist about themselves or their children?
Mr. BOGDANICH: Well, is this imaging exam that you're talking about necessary? Is it necessary for me every six months when I come in to have my teeth cleaned to have X-rays? I think everyone should ask what speed film the dentist is using. And every patient should ask why are you not using digital? And particularly for young adults, who are about to have braces put on, is it really necessary for me to have this Cone Beam CT scan? Or is there a way for you to get the images you need, to make sure that I get the proper braces put on, without using as much radiation?
Those are the kinds of questions really that we should be asking for any kind of radiological procedure.
GROSS: So when you ask your dentist if you really need the six month X-rays, doesnt your dentist say, yes, you do?
Mr. BOGDANICH: In fact, that's what I was told...
(Soundbite of laughter)
Mr. BOGDANICH: ...about that five months ago. And I said, well, actually I don't think I need it because I don't have a history of cavities and I have good dental hygiene. Now, that may be required for people with poor dental hygiene and are more prone to cavities. But I hadn't had a cavity in years, despite all of these exams that I have been having.
You know, please tell me why I need this procedure; be it a dental X-ray, be it in CT scan, be it a chest X-ray. They - every bit of it, and there has to be a need for it otherwise you have no benefit and only risk.
GROSS: But I feel it's our responsibility to say here there often is a really good reason why you need it. And if you need it, get it.
(Soundbite of laughter)
Mr. BOGDANICH: Oh, absolutely. Absolutely.
GROSS: I feel like we need to keep repeating that.
(Soundbite of laughter)
Mr. BOGDANICH: And we should. And I went to great pains in my stories, at the top of the story to talk about how valuable this is. I mean it is amazing technology. To see these 3D the images of the mouth or 3D images of the body, and to realize how much medicine has advanced, and how you no longer have to cut the body open to find out what's going on inside -that's fabulous. And also the ability to treat cancer and to kill cancer cells without having to cut it out, and to do so with incredible precision and accuracy in fewer treatments. So that's great information and hats off to all the people responsible for that.
And, you know, I guess, you know, one question that has been asked of me: Why are you just reporting on the negative side of things. And, you know, first of all, I tried to point out the positive side of it. But I felt that hospitals and manufacturers of this equipment were doing quite a good job of promoting it and selling it to patients. All you have to do is turn on the radio and listen to this hospital or that hospital talking about the new radiation therapy equipment that it's got.
So I felt it was time for people to stop and have a time out, and realize that this is nothing to be taken lightly. It is a time to ask questions and not be afraid to ask those questions.
GROSS: If you're just joining us, my guess is Walt Bogdanich. He's a New York Times investigative reporter who's been writing the series the "Radiation Boom," which is investigating how you radiation medical therapies are not only creating new cures, they're also creating new ways to do harm.
So let's take a short break here, then we'll talk some more.
This is FRESH AIR.
(Soundbite of music)
GROSS: If you're just joining us, my guest is Walt Bogdanich. He's an investigative reporter for The New York Times. We're talking about his series "The Radiation Boom", which has been investigating how new radiation medical therapies have not only created new cures, but they've also created new ways to do harm.
So what is the regulatory environment for radiation medicine?
Mr. BOGDANICH: Well, it's very spotty and that is one of the problems. Their responsibility for ensuring the safe delivery of radiation therapy or diagnostic radiation, lies in many different agencies. And each of those agencies have different requirements, have different standards. One state, Texas, requires that errors to be reported but it doesn't have the authority to punish or to discipline the people who make those errors. Other states don't require that errors be reported at all.
Then you have the Food and Drug Administration. Its responsibility is on the devices themselves but not how they are used. And what I discovered is that the operators, for instance, don't - who are in some states not credentialed. They don't have to meet any kind of educational standards. They don't have to be licensed. They don't know how to use the machines properly. And when that happens, people are harmed.
GROSS: And you also found that licensing of radiation technologist is a state-by-state affair. And some states have no licensing requirements at all.
Mr. BOGDANICH: That's correct. And for 10 years now there has been movement in Congress to try and pass a bill. The acronym is the CARE Bill, which would require some kind of uniform licensing of key medical personnel involved in administering radiation. And there are quite a few professions involved, many of whom are not licensed at all. And yet, after 10 years of debate and bipartisan support, it has not become law much to the amazement of leadership in the field because I did a report on that and I frankly couldn't find anyone who didn't want that bill to pass. I guess it just came down to the fact that members of Congress felt that there were more important issues to deal with.
And as a result, that bill is still languishing, as they say, in the halls of Congress. And operators continue to perform these very complex procedures without having to meet any specific requirements.
GROSS: So if you're having radiation treatment for cancer, for instance, the person who's actually aiming the radiation beam and, you know, turning it off and on, and setting up the controls for the equipment, is that a technologist who may or may not be licensed?
Mr. BOGDANICH: That's correct. That's correct. But as I said earlier, there are a number of different professions involved in the actual administration of radiation therapy. I think one of the most critical professions is a group of people called medical physicists, and it's their job to calculate, and to come up with the algorithms and plug in a ton of numbers, and figure out how to most safely deliver this radiation in a precise manner, in the way that oncologist has prescribed. And that's no easy matter.
So you start with the oncologist, who comes up with a recommendation for what he or she wants done. Then you have a medical physicist who, in conjunction with the oncologist, devises some complicated medical plan with the help of computers. Which can take hours sometimes for even these very fast computers to come up with the proper treatment plan. And then it's passed on to the operators who are actually responsible for, you know, pressing the buttons and turning the dials.
GROSS: So what are you supposed to do, say, to the radiation therapist or radiation technologist who's working with you: Excuse me, are you licensed? Excuse me, do you actually know what you're doing? I mean how do you know if a person is adequately trained, if they're really paying attention, if they're know what they're doing, if you're getting what you are supposed to get?
Mr. BOGDANICH: Those are all good questions but I frankly wouldn't ask the operator. I would start with the oncologist, the doctor who has ordered his test, with whom you have a relationship or should have a relationship. And that doctor ought to be able to answer those questions. Among them: Is this facility accredited to do radiation therapy? Is there a professional organization thats accrediting it?
In the absence of any kind of effective government oversight, at least there are reputable professional groups that will accredit these units. And that should be asked. And I think it's fair to ask are the operators of this device - when I'm lying down on that machine in this powerful radiation-generating devise is aimed at my body, I want to know that that operator has been properly trained and credentialed. Can you assure me that he or she is? And that's really all you can do.
I think a lot of people are afraid to ask questions of their doctors, 'cause they feel they'll get worse treatment, that the doctor will be angry. He'll be a little snippy and - but, you know, that's unfounded. I've never met a doctor who would intentionally give bad treatment to someone who irritated them by asking questions. They might be slightly irritated, yes. But I think that that puts them on a higher state of alert.
And I certainly feel that way when I ask the questions now. And I think that's a good thing, because a higher state of alert is where they ought to be. Every procedure is serious and it should not be routine.
GROSS: If you're just joining us my guest is Walt Bogdanich. He's an investigative reporter for The New York Times. And we're talking about in series "Radiation Boom," which is about how you new radiation medical therapies have not only created new cures, they've created new ways of doing harm.
So, like what would you recommend to somebody who's listening to you now who is about to start radiation therapy for cancer?
Mr. BOGDANICH: Well, I would make sure that this is a top-flight institution that's providing it. There is no need for every hospital in the country to provide high-tech radiation therapy treatment. It simply makes no sense financially or from a safety perspective. I want to go to a hospital that does it, has done it for a considerable amount of time, has a good reputation for doing it and does it often. And I will research, 'cause I mean I may have a leg up on a typical patient, but I'll research the doctor.
Go out on Google, find out what kind of problems the doctor may have had. Maybe check lawsuits; that's no guarantee. But nonetheless, you know, I think you just have to ask questions, the kind we talked about earlier in the program: Is this a facility accredited; you know, how many of these procedures do you do; are the operators, the technicians are they credentialed, are they licensed; is it necessary. You know, that's another question because there is a great deal of evidence that some of these procedures are performed when there really isn't a necessity for it.
In one area that that commonly happens is in prostate cancer treatments, where sometimes the wise course is to watch and wait. But when you have, you know, you've just spent all this money on these high-tech devices, there is a, you know, an incentive to use it. And sometimes it's used inappropriately and in cases where it's not necessary.
GROSS: So, you know, in reading your series and in talking with you, one of the things I've been thinking about is that I have absolutely no idea how much cumulative radiation I have gotten over the years, in terms of, you know, mammograms and chest X-rays - in X-rays after falls and things like that, scans. I just have absolutely no idea.
Mr. BOGDANICH: Nobody does. You have highlighted, I think, the biggest problem right now that needs to be addressed. And people fortunately, as a result of my stories and other concerns expressed in the profession, they're now talking about ways to make sure that individual patients on their records, this radiation exposure is recorded. And so when you go from one doctor to another doctor, move from one city to another city, this type of information goes with you.
But there are problems that have to be worked out before that can work. And fortunately there are many different ways to measure radiation exposure. And there are debates in the field that go on, well, here's one way, here's another way. In fact, there are different ways to even identify doses in radiation, different terminology is used - grays or milli-sieverts. So there has to be some kind of uniformity of collecting this data and measuring it, so that it becomes meaningful.
But I think you've hit on a really important point. And, quite honestly, medical profession recognizes it, too. We need to find a way to measure the cumulative doses that we each receive as we go through life, and experience the inevitable, you know, X-ray procedures and illnesses. And it's important to know that.
GROSS: Well, I wish you good health.
(Soundbite of laughter)
Mr. BOGDANICH: Oh, thank you.
GROSS: Thank you so much for talking with us.
Mr. BOGDANICH: Thanks for having me.
GROSS: Walt Bogdanich is an investigative reporter for The New York Times. You'll find links to the articles in his series the "Radiation Boom" on our website FreshAir.NPR.org.
Coming up, rock historian Ed Ward considers Neil Diamond's early years, his earliest recordings, are collected on a recent CD.
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