Rethinking Risk and Benefit in Medical Imaging: A More Patient-Centric Approach

Medical imaging has long been defined by its ability to provide critical diagnostic information while carefully managing patient risk. Yet for decades, discussions around risk and benefit have often been weighted heavily toward radiation exposure, with far less emphasis on the clinical value imaging provides to individual patients.

Recently, Applied Radiology sat down with two leaders in medical physics to explore a different way of thinking, one that evaluates radiation risk and clinical benefit together, on a common scale, and in a way that is more directly centered on the patient.

Hosted by Applied Radiology Group Publisher Kieran Anderson, the conversation featured Ehsan Samei, PhD, Distinguished Professor of Radiology and Medical Physics and Chief Imaging Physicist at Duke University Health System, and Francesco Ria, PhD, a medical physicist, and Assistant Professor of Radiology, also at Duke University Health System. Together, they discussed a novel approach to evaluating imaging decisions, one that challenges longstanding assumptions and has meaningful implications for daily radiology practice.

Why Risk and Benefit Have Been So Hard to Balance

As Dr. Samei explained, radiology has always acknowledged the need to balance risk and benefit, but historically lacked a formal way to do so. “We’ve been talking about risk and benefit for as long as I can remember,” he said. “But when you really think deeply about this, you cannot balance benefit and risk in a systematic way because they are measured differently, it’s like balancing apples and oranges.”

Compounding the challenge, radiation risk estimates are largely derived from population-level data, while imaging decisions are made for individual patients sitting in front of the radiologist. “That balancing needs to be done in the context of the individual patient,” Dr. Samei emphasized, rather than relying solely on generalized population statistics.

Putting Risk and Benefit on the Same Scale

Dr. Ria described how recent research attempts to close that gap by placing radiation risk and clinical benefit into comparable, quantitative terms. While the approach involves mathematical modeling, the goal is practical: enabling radiologists to evaluate total risk more realistically.

For a long time, radiation risk was treated as a number,” he said, while benefit was often reduced to a binary judgment, whether an image was diagnostically acceptable or not. “But behind that decision is the diagnosis itself and the improvement we bring to a patient’s life.

By expressing both radiation risk and clinical benefit in numerical terms, the model allows for direct comparison and helps identify an optimal balance. Importantly, findings from this work showed that, on average, clinical risk from missed or delayed diagnosis outweighed radiation risk by approximately 400 percent. In other words, reducing dose too aggressively may actually increase overall patient risk.

What This Means for Practicing Radiologists

For radiologists, the takeaway is not that radiation risk should be ignored, but that it must be considered in context. Dr. Ria noted that surprise at these findings reflects how deeply radiation-focused the culture has become. “We do imaging because we know we are bringing benefit to patients,” he said. “Seeing that in numbers should not be surprising.” Both physicists stressed that optimization should be task-specific and patient-specific. The diagnostic goal, such as evaluating a suspected malignancy versus a simple fracture, matters, as do patient characteristics like age, sex, and clinical history. A one-size-fits-all approach to dose optimization may not serve patients well.

Dr. Samei framed radiation as a resource rather than a liability. “Radiation is here to benefit the patient,” he said. “Our approach should not be one of fear, but one of respect.” He likened radiation to a sharp instrument, capable of harm if misused, but enormously beneficial when applied thoughtfully.

Centering the Patient in Optimization Decisions

Both speakers emphasized the importance of incorporating patient preferences into imaging decisions. Dr. Samei noted that radiology already considers multiple risks, such as those associated with contrast agents or medications, yet radiation is often singled out. Including patient values and expectations, he argued, is essential to truly patient-centered care.

Dr. Ria echoed this point, referencing prior work showing that patients are often divided between prioritizing lower dose and higher image quality. “Patients come to imaging because they want answers,” he said. “They want the best we can offer to help determine what’s wrong.”

Accounting for Diversity and Individual Risk

Another key finding from the research involved differences in both radiation risk and clinical benefit across demographic groups. Age, sex, and race can all influence disease prevalence and sensitivity to radiation, underscoring the need for tailored protocols.

“One size does not fit all,” Dr. Ria said. Advances in computing and data analysis now make it possible to account for these variables. Importantly, personalization does not always mean increasing dose; in some cases, the research identified exams where dose was higher than necessary to achieve the optimal balance.

Shifting Culture and Looking Ahead

As this approach evolves, both speakers agreed that broader adoption will require more than additional research. It will require a cultural shift in how radiology talks about risk. Dr. Samei suggested moving away from fear-based language toward a focus on safety and appropriateness. “We don’t apologize for using tools that benefit patients,” he said. “We just need to use them wisely.”

Ultimately, reframing risk and benefit in this way reinforces a core truth of radiology: imaging matters because it changes patient care. By evaluating radiation risk and clinical benefit together, radiologists can move toward a more balanced, patient-centered approach, one that reflects both the science and the purpose of medical imaging.