The 2014 initiative can have potentially unintended negative consequences for medical physics in diagnostic imaging and nuclear medicine
Year: 2012
Type: article
Abstract: Arguing against the Proposition is Terry M. Button, Ph.D. Dr. Button started in Medical Physics as a Masters level physicist in Radiation Safety and Radiation Oncology in the late 1970s. He obtained his Ph.D. in Biophysics from the State University of New York at Buffalo (Roswell Park) in 1989, with his research focused on magnetic resonance. Upon graduation, he worked as an Imaging Physicist at Columbia Presbyterian until he moved to Stony Brook University in 1991. He established a graduate Medical Physics Program at Stony Brook with Dr. Lawrence Reinstein in 2002, which recently obtained CAMPEP accreditation. He also established an Imaging Physics Residency Program at Stony Brook, which has been accredited since 2009. He is an Associate Professor of Radiology, Biomedical Engineering, and Health Sciences. He oversees the undergraduate Radiological Sciences Program at Stony Brook and is the Chair of the University Radiation Protection Committee (URPC). He has served the ABMP for the past decade as a member of the Board, Panel Chair for Part I and, currently, as Panel Co-Chair of the MR Examinations. He is certified by the ABR in Diagnostic Radiologic Physics and by the ABMP in Diagnostic Physics and Magnetic Resonance. Diagnostic imaging (DI) and nuclear medicine (NM) have been intertwined with medical physics dating back to the discovery of x-rays and radioactivity. As imaging technologies continue to advance and expand into new applications, they increasingly require skilled expertise to understand the delicacy of their operation, monitor their performance, design their effective use, and ensure their overall quality and safety. Even though the ACR accreditation process has highlighted the clinical role of physicists in imaging operations, that role has largely remained a severely untapped resource. Most imaging centers fail to appreciate this potential, with medical physics groups either nonexistent or highly understaffed and their services poorly integrated into the patient care process. As a field, we have yet to define how these clinical physicists can engage as active, effective, and indispensible members of the clinical team, and how the services that they provide can be financially supported. Physicists do, and always will, contribute to research and development. However, their contributions to clinical operations in DI/NM have not been adequately established. In the face of the challenge of unleashing the real potential of clinical physics in DI and NM operations, we now further face the challenge of the new ABR requirement for the completion of an accredited residency to become eligible for board certification. The basis of this requirement is a well-justified desire to enhance and standardize the clinical competencies of physicists. However, the number of accredited residencies in the US, six in DI and none in NM at the time of this writing, is well below what can be considered adequate to meet the demand. Whilst we wish to expand the role of clinical physicists in DI/NM, the enactment of the ABR requirement by 2014 would bring about a move in the opposite direction. This is because ABR-certified physicists will not be available in adequate numbers to meet the demand in DI/NM and, as a result, even the subpar role that medical physicists currently play in the clinic will be outsourced to other specialists without sufficient physics training, clinical or not. Hence, the objective of enhancing clinical skills will not be served and ABR certification will no longer be considered essential. The result will be a further weakening of the clinical role of physicists in DI/NM and a reduction in their numbers. What we are facing is no simple challenge. On the one hand, we indeed wish to enhance the standard of practice in clinical medical physics through accredited residencies. On the other hand, however, a premature mandate might actually undermine this very objective. Recognizing that physicists are skilled at finding solutions to hard problems, I believe a solution can be found if we allow our inspiring idealism to meet practical realities. An initiative is an introductory step leading to action. The 2014 initiative leads all Medical Physics clinical training program directors to act to conform to the CAMPEP approved format. The guidelines that are available to do this are clear and easy to implement.1,2 It is also essential for program directors to act now if there is hope for their candidates to sit for the Boards in 2014! The first mission of the AAPM (Ref. 3) is to promote the highest quality medical physics services for patients. From this, follows the fourth mission:3 to foster the education and professional development of medical physicists. So what is the best training available for medical physicists? An excellent indicator of performance is the “pass rate” of candidates on their Board examinations. For example, to 2005, 95% of candidates who had completed a CAMPEP accredited residency program passed the full board examination on their first attempt compared to the average pass rate of 53% over the same period.4 More recent data for the oral examination, though not quite so impressive for CAMPEP residency program graduates, still showed a significant advantage for residents: over the period 2003–2008, the oral examination pass rate for first time takers ranged from 47 to 59% while the pass rate for those from CAMPEP accredited residencies ranged from 80 to 90%!5 The primary reason for improved performance is obvious. A CAMPEP accredited residency is required to be carefully structured to cover the entire spectrum of the appropriate Medical Physics disciplines. To be accredited, the program must be complete; there can be no missing components. Unfortunately, as recently as 2008, AAPM Task Group #133 reported that more than half of all clinical medical physics training (54%) is done on the job, while only 14% of clinical training takes place in a CAMPEP-accredited residency program.2 Current Imaging Physics statistics are probably similar given that there are only six CAMPEP approved residency programs.6 The financial implementation of a residency program is challenging. Who is going to pay for this training? Program directors need to be creative to get funding for residency slots. In my program, for example, I have added a clinical affiliate and catered to the needs of my Department by planning to focus on strong MR candidates for an additional MR fellowship component. Clearly there are obstacles in the path of the goal of excellence that is the 2014 initiative but we must find solutions. Since the largest benefactors of clinical training are the candidates, the cost of this training may, in the future, increasingly be the responsibility of the candidates themselves. We physicists have generally been spoiled by the availability of graduate student support. Maybe those days are gone for medical physics. I agree with my respected colleague that, in an ideal world, completion of a residency can ensure a consistent level of competency for practicing clinical medical physicists. However, with only a handful of residencies in DI/NM, enforcement of the new eligibility requirement in less than two years from now would lead to an insufficient number of board-certified physicists, at a time when we need such individuals more than ever to support clinical practice. Hospitals need technical support to maintain image quality and manage radiation dose, but regulations do not require them to employ ABR-certified medical physicists for this purpose. An alternative workforce of engineers or specialized technologists is used around the world to answer this need. If insufficient ABR-certified physicists are available, hospital administrators will resort to the next available (and less expensive) alternative. This trend, once initiated, may become a permanent and irreversible fixture of American medicine. A critical fact is that our profession currently does not have the financial means to bring the needed number of residencies into existence. The curricular expectations of a CAMPEP-accredited program are too extensive to enable a level of clinical productivity on the part of residents sufficient to claim much compensation from clinical sources; at the same time, the responsibilities of current physicists are too extensive to allow the significant donation of time and attention needed for quality training. Meanwhile, healthcare reform intends to reduce the so-called “overuse” of expensive diagnostic imaging procedures, and to curtail associated charges and fees. Simultaneously, NIH extramural research funding is falling. Who can or will cover the burden prescribed by our professional idealism? As much as I value and support accredited residencies, enforcing a premature deadline of 2014 without strategic actions years in advance, and without considering the particularities of DI/NM physics, will not produce the desired outcome. We need to go after the crux of the problem (i.e., inadequate funding). Requirements and regulations can only do so much without addressing the fundamental limitation at hand. Since the discovery of x-rays by Roentgen, physical scientists have played an essential role in clinical Radiology and have been the backbone of growth and proliferation of new imaging technologies. While it is true that the revenue sources to support imaging medical physicists are not as clearly defined at it is for our oncology medical physics colleagues, the services required of imaging medical physicists have never been more clearly defined. Moreover, these services are mandated by virtue of the reimbursement implications of accreditation and compliance. It is true that only a handful of CAMPEP accredited Imaging Medical Physics residency programs exist. However, until now there has been little incentive to formalize existing imaging post doctoral programs to meet CAMPEP requirements. With the 2014 initiative looming, however, there is plenty of incentive! Residency program accreditation is relatively easy to obtain and having it should provide the best students available. I feel that the number of accredited programs will greatly increase over the next few years. It is important to remember that at the beginning of World War II biplanes were still in use. By the end of the war, jet planes were being placed into service. Necessity can force remarkable advances. I feel that the 2014 initiative will greatly enhance the standard of imaging medical physics practice.
Source: Medical Physics
DOI: 10.1118/1.3658741
Authors: Ehsan Samei, Terry M. Button, Colin G. Orton
Language: English
Subfield: Radiology, Nuclear Medicine and Imaging
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2042010351