Evaluating a Low-Cost Radiation-Risk Educational Leaflet for Foundation Doctors: A Two-Cycle Quality Improvement Study

Background and aim: Justification of medical exposure to ionizing radiation involves weighing the anticipated clinical benefit against potential radiation detriment.The referring clinician contributes by supplying the clinical information on which that judgment rests.Referrers' knowledge of dose and malignancy risk has repeatedly been shown to be limited, and was neither taught nor assessed within one National Health Service (NHS) Foundation Programme.Reported interventions typically require protected teaching time and coordinated attendance.This project aimed to assess baseline radiation-risk knowledge, develop and distribute a low-cost educational leaflet through existing channels, and compare assessment performance before and after the intervention using anonymous, unlinked responses.Methods: This anonymous two-cycle repeated cross-sectional clinical audit and quality improvement study assessed doctors in the first two postgraduate years of the United Kingdom Foundation Programme at one NHS Trust (48 planned eligible posts per cycle).Performance was assessed using the Royal College of Radiologists AuditLive 12-item radiation-awareness instrument, covering chest radiograph dose equivalents and fatal malignancy risk.After baseline measurement, we distributed an author-written three-page leaflet targeting the weakest domains via email, messaging, and print, without a dedicated budget, additional staffing, or a teaching session.Reassessment followed two to five days later.Missing responses were scored as incorrect.Scores were compared using a Welch t-test with Hedges' g, alongside seven robustness and sensitivity analyses.Responses were anonymous and unlinked, so respondent overlap is unknown.Results: Cycle 1 yielded 18 responses from 48 planned eligible posts (37.5%), and cycle 2 yielded 16 responses (response rate: 33.3%).Mean assessment scores were 42.6% (SD: 16.6 percentage points) in cycle 1 and 80.2% (SD: 20.6 percentage points) in cycle 2. Median scores were 41.7% (Q1-Q3: 35.4%-50.0%)and 83.3% (Q1-Q3: 75.0%-91.7%),respectively.The mean difference was +37.6 percentage points (95% CI: +24.4 to +50.9 percentage points; Welch t=5.81, df=28.87;p<0.001), with Hedges' g +1.97 (approximate 95% CI: +1.14 to +2.81).Six sensitivity and adjusted analyses yielded mean differences of +34.8 to +39.8 percentage points, with all lower 95% confidence limits above +20 percentage points; the Mann-Whitney comparison was concordant.The two items addressed most directly by the leaflet showed the largest increases, each rising by 53.5 percentage points.Deficits persisted, with four items answered correctly by only 68.8% of respondents.Conclusions: Radiation-risk assessment scores were substantially higher in the cycle following leaflet distribution.The design was not randomized, responses were unlinked, and reassessment was announced, conducted open-book, and completed two to five days later; no causal or durability inference is possible.The intervention is reproducible without a dedicated budget or teaching session.Persistent deficits support delayed reassessment in a broader staff group.