Representative HOSMER. In the last 10 years, since 1950, has there been a change in the amount of emphasis which the medical school has given to matters concerning radiation therapy and diagnosis? Dr. CHAMBERLAIN. Definitely. It has increased approximately three or four fold in either hours or emphasis or whatever other way you want to look at it. Representative HOSMER. How many of the Nation's doctors are graduates within the last 10 years from medical schools? Dr. CHAMBERLAIN. I cannot give you that figure. Representative HOSMER. It would be a minority, would it not? Representative HOSMER. The majority of the Nation's doctors graduated from medical school before this matter was given 25 percent of the attention it is today, if that much, is that right? Dr. CHAMBERLAIN. Yes. Representative HOSMER. They have had to depend for education in this field upon the medical journals and meetings? Dr. CHAMBERLAIN. Postgraduate courses and meetings. If my own calendar of speechmaking and movie appearances and television encounters and such things are any criterion, I would say that there is a tremendously greater amount of postgraduate education going on than there is under graduate medical education. The field of radiation has been in for a very large share of this in these past 10 years. As a matter of fact, for longer. Representative HOSMER. I don't want to get into the retention factor from each of your lectures, because I imagine in your case it is about 99.9 percent. I suppose it is with all these graduate schools. The only reason I questioned you like this is not in derogation of the profession, but I do believe that on occasion we get a poor perspective as to just what the competence is from hearing persons so well up to date in the field like yourself. If we went out within a radius of a thousand miles from here and picked up a physician from the average American city or town and asked him to come in here, it might be different. Dr. CHAMBERLAIN. Yes. You might be surprised at his competency or lack of competency in any particular detail. I think that the process of education in doctors is a continuous process. Obviously some of them do better than others. Doctors, too, are human, you know. Representative HOSMER. We like to think the same of Congress men. Dr. CHAMBERLAIN. They have their varying degrees of information and expertise. There is no such thing as a uniform familiarity with everything in medicine. Representative HOSMER. I would like to point out that in relation to an overexposure case, it would certainly be a great deal more difficult to make a case against the doctor for overexposing a patient than it would be against an employer for overexposing an employee. That again relates to this judgment factor. Dr. CHAMBERLAIN. That is right. Representative HOSMER. Which in turn, if it is to be claimed as a privilege of the medical profession, likewise imposes a responsibility on the medical profession that is much heavier than it would ordinarily be. Dr. CHAMBERLAIN. You have a right to expect, if you are going to put your trust in the medical profession in this field as well as in other things, that they would live up to these expectations of having put proper thought and proper internal controls on this of their own. Representative HOSMER. But having read the "Last Angry Man,” about the old physician who finally got an X-ray machine and made a career out of it, there are probably exceptions to the rule. Dr. CHAMBERLAIN. You can always find a bad example or some bad examples, but I don't think they should becloud the total picture. Representative HOSMER. What I was attempting to do was to evaluate your testimony a little bit. Thank you, Mr. Chairman. Representative HOLIFIELD. The chairman may say at this point that we have comunications from the American College of Radiology in which they refer to various of our witnesses and say that they will present the case adequately, in their opinion, including Dr. Chamberlain. You are listed among the group. Dr. Morgan, Dr. Failla, Mr. Parker and others that have appeared. We have a communication from the American Medical Association in which they decline to testify at this time. They point out that they have not formulated a policy relative to radiation protection criteria and standards. They have an ad hoc committee on atomic medicine and ionizing radiation which is studying the matter, and cataloging the major problems in the field. The Board will then, after this is done, determine which problems might be pursued most effectively by the association. The American Roentgen Ray Society declined also, but they pointed out that several of their members are appearing here, such as Dr. Morgan and Dr. Chamberlain and Dr. Failla. These will be included in the record after your testimony in full. (The statements referred to follow :) Representative CHET HOLIFIELD, THE AMERICAN COLLEGE OF RADIOLOGY, Chairman, Special Subcommittee on Radiation, Joint Committee on Atomic Energy, Washington, D.C. Chicago, Ill., May 24, 1960. DEAR REPRESENTATIVE HOLIFIELD: Thank you very much for your letter of May 14 inviting the American College of Radiology to present testimony on Friday, June 3, 1960, in connection with your hearings on "Radiation Protection Criteria and Standards: Their Basis and Use." I have consulted with the officers of the American College of Radiology, and they feel that the likelihood that the college could make a contribution through such testimony is rather slight at the moment because you have scheduled as witnesses so many of the people who are directing the activities of the college in the area of radiation protection. We refer specifically to Dr. Russell H. Morgan, Dr. Richard H. Chamberlain, Mr. Lauriston S. Taylor, Dr. G. Failla, Dr. H. M. Parker, and Dr. Clinton C. Powell, all of whom are members of the college's commission on radiologic units, standards, and protection. If, however, during the course of the hearings which we will follow carefully, it develops that such testimony might be helpful and useful to the subcommittee, we will request permission to be heard. We very much hope that your protocol permits us to defer final decision. Sincerely yours, WILLIAM C. STRONACH, Executive Director. Hon. CHET HOLIFIELD, AMERICAN MEDICAL ASSOCIATION, Chairman, Special Subcommittee on Radiation, U.S. House of Representatives, Washington, D.C. DEAR CONGRESSMAN HOLIFIELD: At the present time, the American Medical Association has not formulated a policy relative to radiation protection criteria and standards which will be the subject of hearings by your subcommittee on May 24 through June 3, 1960. The American Medical Association has an ad hoc committee on atomic medicine and ionizing radiation which is to study this matter and catalog the major problems in this field for our board of trustees. The board will then determine which problems might be pursued most effectively by the association. Thank you very much for inviting us to testify on this important issue. However, we must decline to testify at this time although I sincerely hope that in the future we may take an active part in hearings on this subject. Sincerely yours, Mr. CHET HOLIFIELD, F. J. L. BLASINGAME, M.D. MAYO CLINIC, Rochester, Minn., May 17, 1960. Chairman, Special Subcommittee on Radiation, DEAR ME. HOLIFIELD: In reply to your communication of May 14, let me say that the American Roentgen Ray Society does not wish to send a special representative to give testimony to the Joint Committee on Atomic Energy. Several prominent members of the society are to appear before the committee as officers of other organizations or as experts. It will not be necessary, therefore, for the American Roentgen Ray Society to assume an official position. We will hope to be properly represented by our members, among whom are Dr. G. Failla, Dr. Russell Morgan, Dr. Richard Chamberlain, and others. Sincerely yours, C. ALLEN GOOD, M.D. Representative HOLIFIELD. The American Dental Society will have witnesses here later on. Dr. Chamberlain, what types of radiation exposure in medical practice involve the greatest amount of radiation to the patient? Dr. CHAMBERLAIN. Certainly the therapeutic exposures are generally larger amounts. Did you mean this or in diagnosis? Representative HOLIFIELD. I really meant the total field which would include diagnosis. Dr. CHAMBERLAIN. I was rather interested in looking at this spectrum of fractions of a milliroentgen up to, as I say, the order of 50 million milliroentgens to a localized area. That particular example is a treatment and is a treatment with radioactive substances. It happens also incidentally to the treatment of a nonmalignant disease in the sense that is not a cancerous disease. This is about as high an exposure as is given, even locally. In whole body exposures it is not possible to go to this kind of level, but ones approaching lethality have been attempted in the treatment of leukemia on an experimental basis, and then trying to save the patient with bone marrow transplantation in the fashion that has been used for nuclear accident victims. These, however, are the exceptional situation. The average range of exposures in diagnostic procedures is on the order of 1 to 5 rads to the part of the body that is most exposed, and smaller scatter components to other parts of the body. This constitutes the great bulk of individual procedures. Representative HOLIFIELD. To what extent are fluoroscopic devices used now? Dr. CHAMBERLAIN. I would say that the use of the fluoroscope is decreasing a lot and almost completely from this educational program that has been going on in the medical profession, because the exposures are greater. However, the fluoroscope gives unusual types of information, and when it is critically needed for internal motions of the body, particularly in study of such parts as the gastrointestinal tract, it cannot be replaced with a series of films. Representative HOLIFIELD. Is there any formal position on the part of the American Medical Association in regard to the discouragement of fluoroscopic use? Dr. CHAMBERLAIN. Yes. Representative HOLIFIELD. You say there is? Dr. CHAMBERLAIN. I think the educational program that we have been conducting has been directed to two things. One is to have the fluoroscopes in as good operating condition as possible, and secondly, to have their use largely retained only for the specific situations where you need the motion type study. Representative HOLIFIELD. Are special precautions taken in the instance of the gonads? Dr. CHAMBERLAIN. The gonad protection comes from a variety of things that are done. Actually it starts back at the machine, the choice of kilovoltage and filter. Then it has to do with how wide an area of the body is included. Then how big a portal or area is irradiated. Representative HOLIFIELD. There is lead plate protection? Dr. CHAMBERLAIN. This does not help very much. The most important thing is to confine the beam and to stay away from putting the direct beam on the gonads. The local shielding or wearing aprons and putting up little lead shields is sometimes of importance, particularly in children, but usually the confining of the beam is done directly. Representative HOLIFIELD. Has there been any formal interest on the part of the American Medical Association in the scrutiny of obsolete old-type machines? Dr. CHAMBERLAIN. In the last meeting of the American Medical Association in Texas, a formal resolution was passed urging county and State medical societies to promote programs for the inspection of apparatus. I think this is largely because of the good experience we have had in this being worthwhile in local programs such as the one in the city of Philadelphia which was sponsored by the county medical society, and urging of our own membership in a voluntary program to be sure that their machines were inspected and up to the best of modern criteria. Representative HOLIFIELD. Upon whom does the responsibility for inspection rest? Dr. CHAMBERLAIN. In New York City this has been done by the city health department. Representative HOLIFIELD. Are these people lay appointees or are they professionals? Dr. CHAMBERLAIN. Usually there is some well-trained person, a radiological physicist or a radiological health physicist, in charge of such programs. Representative HOLIFIELD. So often in local appointments it depends more sometimes on political patronage, than it does on professional competence. Dr. CHAMBERLAIN. There are unfortunately such a small number of people who are well trained in this. We have been greatly concerned about the educational program for these people who will in turn be directors of radiation health programs. Representative HOLIFIELD. Why shouldn't the manufacturers of these devices offer a calibrated service? Dr. CHAMBERLAIN. Most of them will do as much as they can, but they also have limitations on personnel. I think actually it is better usually to have the apparatus inspected by someone other than the manufacturer as a feeling of assurance to him that he has had a totally impartial opinion. Representative HOSMER. You mentioned this survey in Philadelphia. When did it occur? Dr. CHAMBERLAIN. The city health department did a study of a smaller group of dentists and physicians in the Philadelphia area to try to define our own problems, and on the basis of this study felt that it was worth while to encourage a citywide program. Representative HOSMER. When did you do it? Dr. CHAMBERLAIN. The original study was done about 412 years ago. This latest campaign was done approximately a year and a half ago. Representative HOSMER. It was probably considered worthwhile to expand the study from the results of the original study. You apparently found some quantity of equipment that was inadequate and bordering on the unsafe. Dr. CHAMBERLAIN. That is correct. Representative HOSMER. What was that percentage? Dr. CHAMBERLAIN. Approximately two-thirds of the equipment needed something done to it, but 90 percent of those machines could be brought up to acceptable latest NCRP standards with relatively minor modifications. Representative HOSMER. But two-thirds of them were not at the time functioning as they should be. Dr. CHAMBERLAIN. Two-thirds were lacking in some ways; yes. Representative HOSMER. Of that many, what were actually in the dangerous category? Dr. CHAMBERLAIN. Less than 10 percent. Representative HOSMER. Less than 10 percent? Dr. CHAMBERLAIN. Yes. Representative HOSMER. Of that 10 percent, was danger posed chiefly to the machine operator or the patient, or both? Dr. CHAMBERLAIN. Usually they go along together. When a piece of apparatus has too high an output, which is the usual thing, or inadequate filtration, or stray radiation, they usually affect both the operator and the patient. Representative HOSMER. The control study was made 42 years ago. When was the followup overall campaign inaugurated? Dr. CHAMBERLAIN. About a year and a half ago. Representative HOSMER. Has this been completed yet? Dr. CHAMBERLAIN. The formal arrangement with the county medical society has, but the followup now we have returned to the |