Advertisement

Dr. Marilyn Goske: Innovator in pediatric radiation safety and education

One in a series highlighting women recipients of the ACR Gold Medal

      Highlights

      • Co-created the widely successful Cleveland Clinic Web-based Curriculum for radiology residents.
      • Reached acclaimed success with 65 modules used by 25,000 registrants in 53 countries and over 400 residency programs.
      • Developed a worldwide coalition that included people from all aspects of radiology for the Image Gently campaign.
      • Established the Quality Improvement Registry in CT Scans in children in 2011.
      • Worked as the pediatric radiology representative on the American College of Radiology’s Dose Index Registry in 2013.
      • Dr. Goske was the 2018 recipient of the ACR Gold Medalist, only the ninth woman ever to do so.

      Abstract

      Committed to teaching, Dr. Goske developed an academic niche for herself focusing on educational initiatives. She co-created the widely successful Cleveland Clinic Webbased Curriculum for radiology residents, which reached acclaimed success with 65 modules used by 25,000 registrants in 53 countries and over 400 residency programs. With her natural curiosity, enthusiasm and perseverance, Dr. Goske subsequently had the vision to develop a worldwide coalition that included people from all aspects of radiology to broadcast a simple message, image gently. The influential and longstanding campaign, Image Gently, served to educate radiologists, medical physicists, radiologic technologists and most importantly, parents. Dr. Goske wanted to empower parents and the radiology community to improve pediatric patient safety and work towards decreasing radiation exposure in children. She continued her impactful work by establishing the Quality Improvement Registry in CT Scans in children in 2011 and worked as the pediatric radiology representative on the American College of Radiology's Dose Index Registry in 2013. Focused on compassionate patient care, Dr. Goske's overarching goal was to improve the patient experience throughout the many advancements in radiology. Her excellence in patient care, innovative approaches to education and safety, and collaborative ability to bring out the best in radiology led to her being the 2018 recipient of the ACR Gold Medalist, only the ninth woman ever to do so.

      Keywords

      1. Early life

      As the daughter of one of the first woman journalists for the Associated Press, Dr. Marilyn Goske was born to become a trailblazer. Raised near Cleveland, Ohio she attended an all-girls school “known for producing excellent stenographers” [
      ]. Dr. Goske understood that she could do and be more with her love for science. With the guidance of her older brother, the first physician in their family, she pursued medicine at a time when women made up less than 10% of a medical school class. During her application cycle in 1974, medical schools across the country were making intentional efforts to recruit women, recalls Dr. Goske [
      ]; with her strong application, she was accepted to every school to which she applied.
      During medical school, Dr. Goske loved the vastness of medicine and the wide range of pathologies and specialties offered. She had early success in the field of diagnostic imaging – her first research project was published in Radiology – and with the encouragement of her cardiothoracic radiologist mentor, she decided to pursue the field of radiology [
      • Westcott J.L.
      • Rudick M.J.
      Cardiopulmonary effects of intravenous fluid overload: radiologic manifestations.
      ]. As a diagnostic radiology resident at the University of Rochester's Strong Memorial Hospital, Dr. Goske found her passion in the field of pediatric radiology. Dissatisfied with the New York State Law disallowing parents (as “non-essential personnel”) into the radiology suite, she worked around this restriction by communicating with parents and children before and after the exam, in an era when radiologists were generally cloistered away in a dark back reading room. She fearlessly took initiatives to find ways to ease the often- stressful imaging experience for both children and their parents. Her clinical success during residency matched her accomplishments as an academic researcher. Praised for her natural curiosity, enthusiasm and perseverance by her mentor, Dr. Beverly Wood, she attended her first Society for Pediatric Radiology (SPR) meeting, where she received the prestigious John Caffey Award for best scientific paper for her first ever national scientific presentation in 1984 [
      ,

      Goske MJ, Morin FC, Eskin TA. Experimental neonatal intraventricular hemorrhage: clinical radiographic, and pathologic features. John Caffey Award Paper. Society for Pediatric Radiology 27th Annual Meeting. Las Vegas, NV. April 6–8.

      ].

      2. Pediatric radiology

      Dr. Goske continued to nurture her passion for pediatrics by completing a fellowship in pediatric radiology. She stayed on at the University of Rochester as a faculty member but later moved to Cleveland where her family resided and worked in adult radiology at a community practice, while she and her husband, Dr. Richard Rudick, a neurologist raised their two small children. It was here that she learned that hospitals with no pediatric radiologists were thirsting for practical instructions in how best to care for children during imaging. Unbeknownst to Dr. Goske at the time, this experience was later influential as she spearheaded one of her many outstanding achievements, the internationally renowned Image Gently campaign. After four years in community practice, Dr. Goske restarted her pediatric career at the Cleveland Clinic in 1990. She was the first full-time section chief of pediatric radiology nested in the adult radiology department and worked diligently to create a robust section [
      • Baron R.L.
      • Author Affiliations from the Radiological Society of North America (RSNA)
      Congratulations to the 2012 RSNA outstanding educator: Marilyn J. Goske, MD.
      ]. Her section was one of the first known for fostering a welcoming environment for patients. She recruited artists to paint brightly colored and welcoming art murals for exam room walls and purchased toys and activities for patients while in the waiting room. She developed parent information pamphlets and gave parents her business card with an after- hours direct number. These novel methods promoted patient comfort and eased the imaging experience.
      Committed to teaching and embracing the internet as a new teaching tool, Dr. Goske was the first medical education fellow at the Cleveland Clinic Lerner College of Medicine in 2004. Her thesis project was a web-based learning module for radiology residents on professionalism and care and compassion in radiology, a portent of projects to come. She went on to develop an academic niche for herself focusing on educational initiatives. During this time, she along with a colleague Dr. Janet Reid, created the widely successful Cleveland Clinic Web-based Curriculum for radiology residents [
      • Reid J.R.
      • Goske M.J.
      • Hewson M.A.
      • Obuchowski N.
      Creating an international comprehensive web-based curriculum in pediatric radiology.
      ]. The importance of this effort was recognized by the SPR in 2000, through a Thorne Griscom Education Grant. Drs. Goske and Reid contacted sixty pediatric radiologists and asked them to develop online materials instead of book chapters. Dr. Goske and team also created a pre- and post-test that enabled residency directors to document learning for residents in pediatric radiology. The Cleveland Clinic Web Curriculum reached acclaimed success with 65 modules used by 25,000 registrants in 53 countries and over 400 residency programs [

      Learning in the digital era: Cleveland Clinic pediatric radiology curriculum. The Cleveland Clinic. Retrieved from https://www.cchs.net/onlinelearning/cometvs10/pedrad/default.htm.

      ]. The novel approach to assess pediatric learning and the web-based curriculum were early pioneering examples in Dr. Goske's career and led to her being named the Outstanding Educator at the Radiologic Society of North America's 2012 annual meeting [
      • Baron R.L.
      • Author Affiliations from the Radiological Society of North America (RSNA)
      Congratulations to the 2012 RSNA outstanding educator: Marilyn J. Goske, MD.
      ], the same year she received the SPR's Gold Medal. These experiences propelled Dr. Goske into leadership positions in the SPR serving as board member, president, and eventually, chair of the board of directors. It was during this time Dr. Goske developed her worldwide campaign, Image Gently.

      3. Image gently

      On a routine call night in 2007, Dr. Goske was asked by a radiologic technologist to speak to a mother who had a question about her child's upcoming CT scan: Is a CT scan safe for my child?” [
      • Goske M.J.
      Doctor, is a CT scan safe for my child? (invited commentary).
      ] This simple question inspired Dr. Goske to create the influential and longstanding campaign which served to educate radiologists, medical physicists, radiologic technologists and most importantly, parents. She wanted to empower parents and the radiology community to improve pediatric patient safety and work towards decreasing radiation exposure in children. Forming a steering committee with representatives from the SPR, including Dr. Donald Frush (current Chair of Image Gently), the American Society of Radiologic Technologists (Gregory Morrison), American Association of Physicists in Medicine (Keith J. Strauss) and the American College of Radiology (Priscilla F. Butler). The alliance believed it of critical importance to include industry and government agencies such as the United States Food and Drug Administration [
      • Strauss K.J.
      • Goske M.J.
      • Frush D.
      • et al.
      (Invited editorial) Image gently vendor summit: working together for better estimates of pediatric radiation dose from CT scans.
      ]. From her experience in community practice, she understood the value of radiologic technologists' expertise as they performed the imaging studies and directly interacted with the patient and their parents. The notion of equal partners (radiologist, technologist, medical physicist, parent) respecting the others role in the safe care of imaging of children was revolutionary for its time. The team created the Image Gently Alliance, “a coalition of healthcare organizations to provide safe, high quality pediatric imaging” with the ultimate goal “to change practice” []. The Alliance now numbers over 100 organizations world-wide and spawned the Image Wisely campaign focused on adult radiation safety and other numerous international campaigns. The steering committee matched Dr. Goske's enthusiasm, with each member providing critical expertise to communicate the core message as well as create practical teaching materials that were all free and available on the Image Gently website (www.imagegently.com). She had the vision to develop a worldwide coalition that included people from all aspects of radiology and she diligently worked to launch a collaborative network of experts and highlighted their contributions.
      Together, they broadcast a simple and unified message utilizing social marketing [
      • Goske M.J.
      • Applegate K.E.
      • Boylan J.
      • Butler P.F.
      • et al.
      Image gently: a national education and communications campaign in radiology using the science of social marketing.
      ]. The use of logos, pamphlets, and slogans was unique, timely, and reinforced the simple message of Image Gently, which premiered its first campaign in CT in early 2008 [
      • Goske M.J.
      • (Invited editorial) and the Alliance for Radiation Safety in Pediatric Imaging Writer’s group
      The image gently campaign: increasing CT radiation dose awareness through a national education and awareness program.
      ,
      • Frush D.
      • Goske M.J.
      • Schulman M.
      Rebuttal letter to Brenner article, CT radiation risks in children.
      ]. Described by Dr. Goske as a “remarkable, perfect storm” of support from organized radiology, alliance organizations, government and international agencies, the group was able to address the frequency (“scan once”) and manner in which pediatric CT patients are imaged (“scan only the indicated area and lower the kVp and mA”) [
      • Goske M.J.
      • (Invited editorial) and the Alliance for Radiation Safety in Pediatric Imaging Writer’s group
      The image gently campaign: working together to change practice.
      ]. Dr. Goske's and the steering committee spearheaded Image Gently through six campaigns representing the imaging modalities of CT [
      • Strauss K.J.
      • Goske M.J.
      • Kaste S.C.
      • et al.
      Image gently: ten steps you can take to optimize image quality and lower CT dose for pediatric patients.
      ], parent education [
      • Bulas D.
      • Goske M.J.
      • Applegate K.E.
      • Wood B.P.
      (Invited editorial). Image gently: improving health literacy for parents about CT scans for children.
      ], interventional radiology [
      • Sidhu M.
      • Strauss K.J.
      • Connolly B.
      • Yoshizumi T.T.
      • Racadio J.
      • Coley B.D.
      • et al.
      Radiation safety in pediatric interventional radiology.
      ], fluoroscopy [
      • Hernanz-Schulman M.
      • Goske M.J.
      • Bercha I.H.
      • Strauss K.J.
      Pause and pulse: ten steps that help manage radiation dose during pediatric fluoroscopy.
      ], digital radiography [
      • Don S.
      • Goske M.J.
      • John S.
      • Whiting B.
      • Willis C.E.
      Image gently pediatric digital radiography summit: executive summary.
      ,
      • Morrison G.
      • John S.
      • Goske M.J.
      • et al.
      Pediatric digital radiography education for radiologic technologists– current state.
      ], nuclear medicine [
      • Treves S.T.
      • Parisi M.T.
      • Gelfand M.J.
      Pediatric radiopharmaceutical doses: new guidelines.
      ] and dentistry [
      • Law C. Douglass J.M.
      • Farman A.G.
      • White S.C.
      • Zeller G.G.
      • Lurie A.G.
      • Goske M.J.
      The image gently in dentistry campaign: partnering with parents to promote the responsible use of X-rays in pediatric dentistry.
      ] and developed online educational material for each campaign. Volunteers helped translate the campaigns into other languages allowing for worldwide success, enabled by the International Atomic Energy Agency and the World Health Organization [
      • Goske M.J.
      • Applegate K.E.
      • Bell C.
      • et al.
      Image gently: providing practical educational tools and advocacy to accelerate radiation protection for children worldwide. Invited commentary in Semin in ultrasound.
      ]. At the 2007 Radiologic Society of North America scientific conference, Dr. James Thrall, former Chair of Radiology at Massachusetts General Hospital received the 2007 Gold Medal. In spite of his great honor, he approached Dr. Goske in a crowded hallway to compliment Image Gently as the “best thing happening in Radiology” [
      ], illustrating the support and enthusiasm for this initiative at the highest levels.

      4. Quality improvement

      Dr. Goske continued her impactful work by establishing the Quality Improvement Registry in CT Scans in children in 2011 funded by the Harvey and Jean Picker/Derek Harwood-Nash Education Scholar award. She subsequently worked as the pediatric radiology representative on the American College of Radiology's Dose Index Registry in 2013. She took to task another aspect of pediatric radiology she thought was lacking, the need to quantify the amount of radiation children were exposed to. Again with Dr. Don Frush and Mr. Keith Strauss, they developed a consortium of six children's hospitals to form a registry to track pediatric CT radiation dose using a new, more accurate unit of measurement, size specific dose estimates (SSDE), developed by the American Association of Physicists in Medicine (AAPM). With this group, Dr. Goske has published numerous papers on CT reference ranges including “Diagnostic Reference Ranges for Pediatric Abdominal CT” [
      • Goske M.J.
      • Strauss K.J.
      • Coombs L.P.
      • Mandel K.E.
      • Towbin A.J.
      • Larson D.B.
      • et al.
      Diagnostic reference ranges for pediatric abdominal CT.
      ] and “Pediatric Chest CT Diagnosis Reference Ranges: Development and Application” [
      • Strauss K.J.
      • Goske M.J.
      • Towbin A.J.
      • Sengupta A.
      • Callahan M.J.
      • Darge K.
      • et al.
      Pediatric chest CT diagnosis reference ranges: development and application.
      ]. Dr. Goske is considered an international expert and has worked with the World Health Organization, FDA, National Council on Radiation Protection in Medicine, and the International Atomic Energy Agency.
      Focused on compassionate patient care, Dr. Goske's overarching goal in pediatric radiology was to improve the patient experience throughout the many advancements in radiology. As a radiologist who trained before CT scans, MRI, and ultrasound, Dr. Goske has seen the remarkable transformation of radiology from “plain films” to the advanced imaging modalities of today. She watched the field of radiology develop from a primarily consultant-based specialty to being more patient-oriented and interactive. Her excellence in patient care, innovative approaches to education and safety, and collaborative ability to bring out the best in radiology led to Dr. Goske being the 2018 recipient of the ACR Gold Medalist, only the ninth woman ever to do so after Marie Curie (1931), Edith Quimby (1963), Allice Ettinger (1984), Rosalyn Yalow (1993), Kay Vydareny (2005), Sarah Donaldson (2007), Valerie Jackson (2008) and Carol Rumack (2014). She felt “incredulous” at the honor and it remains one of the highlights of her career.

      5. Looking forward

      Dr. Goske spent the six last years of her career at Cincinnati Children's Hospital, a “most remarkable institution”, as the Corning Benton Endowed Chair in Radiology Education with Dr. Janet Strife, another influential mentor. She is now Professor, Clinical Emerita in the Department of Radiology at the University of Cincinnati and is retired. She is most enthusiastic about the next generation of diverse leaders who will continue to advance the field of radiology. She recommends women and men in the field of radiology be their authentic selves and use every opportunity to learn. “See what is missing in the field,” Dr. Goske recommended in a personal interview granted to the authors, “and act on it!” [
      ] Natural curiosity will lead to places where there is a need, she says and challenging ourselves to fill those spaces will result in improvements in patient care, as well as advanced knowledge and research in diagnostic radiology.

      Acknowledgments

      The authors wish to thank Dr. Goske for granting a personal interview and reviewing the article prior to double-blinded peer review.

      References

      1. Personal interview with Dr. Marilyn Goske. Conducted by Jacqueline Koomson and Elizabeth Kagan Arleo. 31 July 2020
        • Westcott J.L.
        • Rudick M.J.
        Cardiopulmonary effects of intravenous fluid overload: radiologic manifestations.
        Radiology. 1978; 129: 577-585
      2. John Caffey Award Papers. The Society for Pediatric Radiology and the SPR Research and Education Foundation, 1969–1998 (Retrieved from)
      3. Goske MJ, Morin FC, Eskin TA. Experimental neonatal intraventricular hemorrhage: clinical radiographic, and pathologic features. John Caffey Award Paper. Society for Pediatric Radiology 27th Annual Meeting. Las Vegas, NV. April 6–8.

        • Baron R.L.
        • Author Affiliations from the Radiological Society of North America (RSNA)
        Congratulations to the 2012 RSNA outstanding educator: Marilyn J. Goske, MD.
        in: RadioGraphics. 1 Nov. 2012
        • Reid J.R.
        • Goske M.J.
        • Hewson M.A.
        • Obuchowski N.
        Creating an international comprehensive web-based curriculum in pediatric radiology.
        AJR. 2004; 182: 797-801
      4. Learning in the digital era: Cleveland Clinic pediatric radiology curriculum. The Cleveland Clinic. Retrieved from https://www.cchs.net/onlinelearning/cometvs10/pedrad/default.htm.

        • Goske M.J.
        Doctor, is a CT scan safe for my child? (invited commentary).
        Br J Radiol. 2014; 87 (Feb. [Best of BJR paper]): 1034
        • Strauss K.J.
        • Goske M.J.
        • Frush D.
        • et al.
        (Invited editorial) Image gently vendor summit: working together for better estimates of pediatric radiation dose from CT scans.
        AJR Am J Roentgenol. 2009; 192 (May): 1169-1175
        • Image Gently
        About image gently.
        • Goske M.J.
        • Applegate K.E.
        • Boylan J.
        • Butler P.F.
        • et al.
        Image gently: a national education and communications campaign in radiology using the science of social marketing.
        J Am Coll Radiol. 2008; 5: 1200-1205
        • Goske M.J.
        • (Invited editorial) and the Alliance for Radiation Safety in Pediatric Imaging Writer’s group
        The image gently campaign: increasing CT radiation dose awareness through a national education and awareness program.
        Pediatr Radiol. 2008; 38: 265-267
        • Frush D.
        • Goske M.J.
        • Schulman M.
        Rebuttal letter to Brenner article, CT radiation risks in children.
        NEJM. 2008; 358: 850-853
        • Goske M.J.
        • (Invited editorial) and the Alliance for Radiation Safety in Pediatric Imaging Writer’s group
        The image gently campaign: working together to change practice.
        AJR. 2008; 109: 273-274
        • Strauss K.J.
        • Goske M.J.
        • Kaste S.C.
        • et al.
        Image gently: ten steps you can take to optimize image quality and lower CT dose for pediatric patients.
        AJR. 2010; 194 (Apr): 868-873
        • Bulas D.
        • Goske M.J.
        • Applegate K.E.
        • Wood B.P.
        (Invited editorial). Image gently: improving health literacy for parents about CT scans for children.
        Pediatr Radiol. 2009 Feb; 39 (Epub 2008 Dec 16): 112-116
        • Sidhu M.
        • Strauss K.J.
        • Connolly B.
        • Yoshizumi T.T.
        • Racadio J.
        • Coley B.D.
        • et al.
        Radiation safety in pediatric interventional radiology.
        Tech Vasc Interventional Rad. 2010 Sep; 13: 158-166
        • Hernanz-Schulman M.
        • Goske M.J.
        • Bercha I.H.
        • Strauss K.J.
        Pause and pulse: ten steps that help manage radiation dose during pediatric fluoroscopy.
        AJR Am J Roentgenol. 2011; 197: 475-481
        • Don S.
        • Goske M.J.
        • John S.
        • Whiting B.
        • Willis C.E.
        Image gently pediatric digital radiography summit: executive summary.
        Pediatr Radiol. 2011 May; 41 ([Epub 2011 Jan 21]): 562-565
        • Morrison G.
        • John S.
        • Goske M.J.
        • et al.
        Pediatric digital radiography education for radiologic technologists– current state.
        Pediatr Radiol. 2011 May; 41 ([Epub 2011 Apr 14]): 602-610
        • Treves S.T.
        • Parisi M.T.
        • Gelfand M.J.
        Pediatric radiopharmaceutical doses: new guidelines.
        Radiology. 2011; 261: 347-349https://doi.org/10.1148/radiol.11110449
        • Law C. Douglass J.M.
        • Farman A.G.
        • White S.C.
        • Zeller G.G.
        • Lurie A.G.
        • Goske M.J.
        The image gently in dentistry campaign: partnering with parents to promote the responsible use of X-rays in pediatric dentistry.
        Pediatr Dent. Nov 2014; 36: 458-459
        • Goske M.J.
        • Applegate K.E.
        • Bell C.
        • et al.
        Image gently: providing practical educational tools and advocacy to accelerate radiation protection for children worldwide. Invited commentary in Semin in ultrasound.
        CT MRI. 2010 Jan; 31: 57-63
        • Goske M.J.
        • Strauss K.J.
        • Coombs L.P.
        • Mandel K.E.
        • Towbin A.J.
        • Larson D.B.
        • et al.
        Diagnostic reference ranges for pediatric abdominal CT.
        Radiology. 2013; 268 (July): 208-218
        • Strauss K.J.
        • Goske M.J.
        • Towbin A.J.
        • Sengupta A.
        • Callahan M.J.
        • Darge K.
        • et al.
        Pediatric chest CT diagnosis reference ranges: development and application.
        Radiology. 2017; 284 (Jul): 219-227