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Priscilla F. Butler, MS – Pioneer in radiation dose assessment and image quality

  • Debra L. Monticciolo
    Correspondence
    Department of Radiology, Baylor Scott & White Healthcare – Central Texas, 2401 South 31st Street, Temple, TX 76508, United States of America.
    Affiliations
    Department of Radiology, Baylor Scott & White Healthcare – Central Texas, 2401 South 31st Street, Temple, TX 76508, United States of America
    Radiology, Texas A&M University Health Sciences, Temple, TX, United States of America
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      1. Introduction

      Few people have had the impact that Priscilla “Penny” Butler, MS, has had on radiological technique in the United States. Being a woman leader in medical physics is equally rare. Penny forged both new avenues for women and new ideas for all during her long and productive career in the radiological sciences. She has done so with such grace and humility as to always remain accessible to those with whom she worked and served. This year, Ms. Butler was awarded the American College of Radiology Gold Medal, the College's highest honor. She is only the 10th woman to receive this recognition, the first being Madame Marie Curie in 1931. In this editorial, we celebrate Ms. Butler for her ground breaking roles in radiological dose assessment and image quality.

      2. Early life and education

      Penny was born in Rhode Island and raised in Massachusetts. She always loved science in school, especially physics. In spite of her obvious aptitude, her high school teachers were not supportive. “Girls don't go into physics”, Penny remembers being told. This only solidified her resolve. Originally, Penny wanted to be a meteorologist. She enjoyed building her own weather devices and was fascinated by the science. Penny entered Lowell Technological Institute (now part of University of Massachusetts) in their meteorology program. Of approximately 4000 undergraduates at the time, there were about 100 women on campus. Early into the program, she was warned about her job prospects. This was the 1970's, so large numbers of military men would be returning from war with similar training and would be favored for most of the jobs in her chosen field. Penny took this to be a realistic assessment. An early supporter and mentor, Dr. Ken Skrable, had acquired funds to train radiation safety technicians and offered to pay the tuition for those who advanced into the Radiological Sciences Health Physics program. Thirty applied, with Ms. Butler being one of two women to complete the program.
      While still in her new undergraduate program, she went to find work as a radiation safety technician. In her first interview, she was questioned about her physical capabilities – in a way that very few men would be. Penny assured them that she could lift the items needed for the job, knowing that she lifted much more weight when she worked in a nursing home in high school. She secured the job and worked 3 summers as a Health Physics Technician.
      Most of her colleagues who earned their Bachelor of Science in Radiological Health Physics tended toward the nuclear power industry. But Penny was more interested in radiation related to medicine. Ms. Butler applied for and was accepted to several graduate programs. But one – University of Florida Department of Nuclear Engineering Sciences – had a special pull. This was the only school from which a female faculty member personally phoned her to entice her to come. That was unique and sealed the deal. Penny earned her Master of Science in Medical Physics in 1976.

      3. Early career in medical physics

      Penny's first job as a Medical Physicist was with the FDA. She was drawn to this position because of her interest in radiation doses to the population. From 1976 to 1980, Ms. Butler worked on the BENT program: Breast Exposure: Nationwide Trends, the first FDA program directed at mammography image quality and dose. The BENT team developed phantoms and methodology for measuring radiation dose. Their work laid the foundation for the development of the ACR Mammography Accreditation Program years later. Penny wanted more connection with what was actually happening in hospitals, so she offered to consult at the National Naval Medical Center in Bethesda. There she worked with engineers to expand her knowledge of shielding and equipment installation. Ultimately, Penny was recruited by George Washington University, where she served as medical physicist, educator of residents and technology students, and dissertation committee member for the PhD medical physics program.

      4. Later career and major accomplishments

      In 1998, Penny was recruited to join the ACR. She had been assisting on ACR committees since 1993, while still serving at GWU (she would become Adjunct Professor of Radiology at GWU in 2008). Ms. Butler was also known to ACR from her excellent work at the FDA. Within a year at ACR, Penny was Director of Breast Imaging Accreditation Programs and became a Senior Director in 2001. Ms. Butler's work in the National Mammography Accreditation Program (MAP) had an outsized impact on mammography in the United States. She helped standardize the policies and procedures of the program, working with facilities and staff to create better ease of use and addressing common issues. Her work clarified the image quality and quality assurance/quality control needed for excellent mammography across facilities. Penny regularly interfaced with the FDA, including attending the National Mammography Quality Assurance Advisory Committee meetings. These meetings, which are utilized by the FDA to inform the U.S. Congress on mammography quality issues in the United States, often found Ms. Butler being requested by FDA to comment at the microphone to sort out difficult decisions on image quality and dose. Her widely respected expertise help shape and improve breast imaging at the highest level.
      Ms. Butler worked tirelessly to ensure that quality parameters were understood, especially taking into account radiation dose. She authored or co-authored many key early publications on image quality and dose, including the 1999 ACR Mammography Quality Control Manual, a seminal work in breast imaging [
      • Hendrick R.E.
      • Bassett L.
      • Botsco M.A.
      • et al.
      Mammography quality control manual.
      ,
      • Butler P.F.
      Changes to the 1999 ACR mammography quality control manual.
      ]. This was later followed with the 2016 and 2018 ACR Digital Mammography Quality Control Manuals, the first to align the various digital platforms under one QC evaluation program [
      • Berns E.A.
      • Baker J.A.
      • Barke L.
      • et al.
      Digital mammography quality control manual.
      ,
      • Berns E.A.
      • Pfeiffer D.E.
      • Butler P.F.
      • et al.
      Digital mammography quality control manual.
      ]. Ms. Butler's work with Stephen Amis, MD, produced the ACR's White Paper on Radiation Dose in Medicine in 2007, which for several years was the #1 cited article of the Journal of the American College of Radiology (JACR) [
      • Amis Jr., E.S.
      • Butler P.F.
      • Applegate K.E.
      • et al.
      American College of Radiology white paper on radiation dose in medicine.
      ]. Penny's direct involvement resulted in the ACR's support and expansion of the Image Gently and Image Wisely programs, which called attention to the need for dose reduction nationwide. The CEO of the ACR, Bill Thorwarth, MD, FACR, who is an ACR Gold Medal recipient himself, has known Penny for years and remarked, “Whether it was at an Image Wisely Board meeting or at the International Atomic Energy Agency, when Penny spoke everyone sat up and listened. Patient safety and quality care delivery have always been her true North.”
      Ms. Butler's influence also improved and supported the more wide-spread adoption of BI-RADS, the Breast Imaging Reporting and Data System. Although BI-RADS had already been created, inconsistencies in the different sections made it difficult for end-users, particularly vendors developing software that would implement BI-RADS in the field. Penny made it her mission to reconcile those differences across sections to create a more consistent overall program, opening the way for the expansion of BI-RADS utilization. The impact of this, and her creation (with Barbara Monsees, MD, FACR) of the single card BI-RADS summary, cannot be overstated. Edward Sickles, MD, a founding member of the Society of Breast Imaging and major author of BI-RADS, stated, “Penny's contributions to breast imaging in general, especially to BI-RADS, are invaluable. Neither would be the same without her.” Discussing Penny in the nominating letter for the ACR Gold Medal, Dr. Monsees wrote, “Her personal mission has always been about quality and safety, and the most lasting effect of her work is surely on the lives of the children and adults that we care for as a profession.”

      5. Closing

      In addition to being recognized with the ACR's highest honor, the 2020 Gold Medal, Ms. Butler received the American Association of Physicists in Medicine (AAPM) Marvin M.D. Williams Profession Achievement Award in 2020. She was named an Honorary Fellow of the Society of Breast Imaging in 2013 and received the Image Gently Butterfly Award in 2018. She is a fellow of the ACR and AAPM. Penny remains Adjunct Professor of Radiology at George Washington University School of Medicine and Health Care Sciences.
      Penny's quest for knowledge and excitement for life remain unchanged. Although she earned her pilot's license and instrument rating in 1978–80, these days she buzzes around in a yellow Corvette, her third. Dr. Sickles said, “I recall with great fondness her willingness to ride me around in her Corvette.” True to form, she attended driving school to master the nuances of the car. Dr. Thorwarth, remarked, “Penny is always herself, whether driving her Corvette or explaining radiation dose reduction at the International Atomic Energy Agency. She is truly one of a kind”.
      Penny was scrutinized in her field in many ways that men would not be – often in ways that had nothing to do with her skill set in science. Still, she persevered. Her aversion to being told what a woman could and could not do propelled her forward; her extensive knowledge and acquired expertise put her at the forefront of her field. Ms. Butler is an inspiration for women, as well as men, in science that hard work, dedication, and focus will bring great results. We are all better for the lifetime of work Ms. Butler has produced, especially the patients we all serve.

      Funding

      None.

      Declaration of competing interest

      None.

      Acknowledgements

      Thanks to Barbara Monsees, MD, Edward A. Sickles, MD, and William Thorwarth, MD for contributing quotes for this article.

      References

        • Hendrick R.E.
        • Bassett L.
        • Botsco M.A.
        • et al.
        Mammography quality control manual.
        Reston, ACR, 1999
        • Butler P.F.
        Changes to the 1999 ACR mammography quality control manual.
        in: Haus A.G. Yaffe M.J. Categorical courses in diagnostic radiology physics: physical aspects of breast imaging – current and future consideration. Oak Brook, RSNA, 1999
        • Berns E.A.
        • Baker J.A.
        • Barke L.
        • et al.
        Digital mammography quality control manual.
        American College of Radiology, Reston, VA2016
        • Berns E.A.
        • Pfeiffer D.E.
        • Butler P.F.
        • et al.
        Digital mammography quality control manual.
        American College of Radiology, Reston, VA2018
        • Amis Jr., E.S.
        • Butler P.F.
        • Applegate K.E.
        • et al.
        American College of Radiology white paper on radiation dose in medicine.
        J Am Coll Radiol. May 2007; 4: 272-284https://doi.org/10.1016/j.jacr.2007.03.002