MEDICAL PHYSICS PROFESSION

Presented at the 2003 Annual ACMP Meeting,

Lake George, NY,

May 10-15, 2003.

Ivan A. Brezovich, Ph.D.,

Dept. of Rad. Onc.

University of Alabama at Birmingham

Birmingham, AL 35294

Apparent Paradox

• 80 Positions for medical physicists unfilled.

High-quality applicants for residency

programs scarce. Shortage?

• Board certified medical physicists working as

sales reps., leaving the field. Oversupply?

Reality

• Patients don’t receive optimal treatment

• Cancer centers lose revenue

• Medical physicists not working in the profession of their choice

Purpose of Talk

• Identify causes of paradox

• Suggest Solution

Medical Physicists are Medical Specialists - in Addition to Being Physicists

• Medical specialists listed by ABMS. Credential can be checked 1-866-ASK-ABMS

• Certified by ABR or have Letter of EquivalenceSame specialty board that certifies Diagnostic and Therapeutic Radiologists

• Guide To Radiological Physics Practice, American College of Radiology (ACR), p. 1, 1990.

Medical Physicists are Medical Specialists - in Addition to Being Physicists (cont’d)

These individuals (medical physicists) are “Professionals” in every sense of the word and they deserve the respect, support, and compensation relative to their positions.

John D. Watson, JR., MD., one of the founding members of radiation oncology as a medical specialty

Responsibility

• Accurate delivery of prescribed radiation dose (quantity and geography)

• “ ….. physicists orchestrate the entire treatment process …” Chairman of ASTRO (American Society for Therapeutic Radiology and Oncology) in letter to HCFA (now CMS)

Direct Effect on Cancer Patients

• Cancer death 0.9% higher in Florida where medical physicists in many centers spend 18% less time per patient than national average [~ 360 avoidable deaths/year]

• Charges 42% higher in centers with low medical physicist time per patientMitchell and Sunshine, New England Journal of Medicine 327:1497-1501, 1992

Tumor Control/Normal Tissue Complication:Effect of a 3% Error in Delivered Dose

0 20 40 60 80 100 1200

20

40

60

80

100

Dose (Gy)

Pro

bab

ility

(%

)

32.9% reduction

3.3% increase

H&N SCC control probabilityXerostomia probability

Small Error-Tragic Consequences

• Qualified medical physicist replaced by unqualified

• Inappropriate calculation method

• Too many duties, not enough time in clinic

• Patients get too much radiation

• ~ 1,000 patients are injured, many die

• Medical physicist mentally destroyed

• Radiation oncologist dies the night before court trial

Critical Tasks of Medical Physicists

• Design and verification of tx plans for individual patients, special treatment devices ~ 80% of time

• Design of facility, especially shielding• Acceptance testing• Calibration• Commissioning• Beam data entry into treatment planning system• System checkout (CT data transfer, etc)• Quality Assurance (QA) of dose and alignment• Continued vigilance for software and hardware

changes• Special procedures (seeds for prostate cancer, HDR,

whole-body tx, intravascular tx, brain irradiation, etc.)

Responsibility for Treatment Planning

• “…It is the responsibility of the Qualified Expert to verify the results of each specific calculation”

Acceptable Tolerances

• NIST Calibration 0.5%• Temperature/Pressure 0.5%• Field size dependence 2.0%• Depth dependence (TMR) 2.0%• Wedge factor 3.0%• Variation of accelerator 2.0%

TOTAL 10.0%

Historical Background

• 1895 Roentgen discovers x-ray – Takes image of wife’s hand. – First medical physicist in radiology

• 1896 Becquerel discovers radioactivity

• Therapeutic benefits soon recognized

• Evolution of equipment and procedures

Historical Background cont’d

• Physicists provide equipment– radiologists operate and maintain equipment – radiologists do treatment planning

• Obstacles: – Radioisotopes scarce – x-rays have poor penetration (“skin burns”)

• 1940: Betatron (Donald Kerst, Ph.D.)

– 1948: Kerst and Henry Quastler, MD, treat brain tumor (radiosurgery)

• 1950’s: Reactor made Isotopes (137Cs, 60Co)

Historical Background cont’d

• 1960s - 1980s Close collaboration between radiologists and medical physicists

– Linear Accelerators

– Treatment planning computers

– Custom blocks (Cerrobend)

– Treatments become complex

– Medical physicists become part of the the clinic

– Payment for services in lump sum to hospital, based on “reasonable and customary” fees

Historical Background - Uncertainty During 1980s (cont’d0

• HCFA widens use of CPTCPT codes

• Recognition of medical physicists as professionals, but only in few areas

• Inadequate reimbursements • HCFA proposes RAPS RAPS

Radiology, Anesthesiology and Pathology Services to be paid as hospital expenses

• Shortage of residents

• Radiologists ask medical physicists for help

Medical Physicists Join Radiologists in Opposition to RAPS

Letter Campaign Succeeds

• RAPSRAPS no threat for radiation oncologists after 1990s• Radiation oncology becomes attractive• Residents plentiful

• RAPS RAPS conditions continue for medical physicists

Hope for Physicists

• HCFA asks for public comments to clarify CPT 77300 Physics Codes

(Attn: BPDD770DP, published in Federal Register)

User’s Guide, American College of Radiol., p.21, 1990

Tragedy Strikes Medical Physicists - and Cancer Patients

• No dialogue. No consideration of 77336 and 77370 codes

Letters to Radiation Oncology Societies unanswered

“…Pseudo doctors ….”

• Radiology societies make statements to the effect that medical physicists are not involved in professional physics services

• Radiology societies encourage their members to write similar letters to HCFA

• Radiology societies oppose neutral evaluation

Tragedy Strikes ……. (cont’d)

Example of letters to HCFA

“…. The technical work performed by the physicist is not immediately translated into direct care of a patient.”

Example of Letters to HCFA cont’d

Tragedy Strikes ……. (cont’d) Political lobbying against neutral evaluation

Tragedy Strikes ……. (cont’d) Physicists turned against each other

Medical physicists’ societies fail to take stand: Opportunity Missed

• Loss of Provider Status, only medical specialists not recognized as providers (Unlike social workers, nurse anesthetists, MDs, etc.)

• Loss of financial recognition “The ‘professional’ component was clearly intended to be reimbursed for the

non- physician professional physicist. Unfortunately over the years …. This revenue stream was lost in the system …”

(Administrative Radiology 1992)

• Continuing erosion of recognition (Physics codes become “delivery codes”)

Profession Becomes Less Desirable

• Limited control over profession• Low professional standing• Outdated QA equipment, tx planning systems• Insufficient time for quality treatment planning and

verification• Error prone (Riverside, Florida)• Limited input in equipment purchase and facility

design - full responsibility • Insufficient secretarial and other help• Low pay, even when clinic profitable

The Industrial Physicist (American Institute of Physics, April/May 2003, p.13)

Difficult Working Conditions

• Medical physicists work under these brute conditions, even in areas with low HMO penetration

“HMO’s can brutalize medical care if their

goal is to make money from the sick” Robert Kagan, MD and Oliver Goldsmith, MD The Journal

of Oncology Management, p. 18, July/August 2002

Effects on Patient Care

• Impact at first masked by long pipeline and oversupply due to end of space program

• Cumulative effect: Fewer physicists willing to work under the given conditions

• Board certified physicists leaving profession (work as manufacturer’s reps, retire early )

• Parents discouraging children• Disproportionate reliance on immigrants (> 50%

of physics graduate students foreign born)• Language barriers• Selection decreasing (quality?)• Training programs suffering

The Industrial Physicist (American Institute of Physics, April/May 2003, p.13)

Oversupply Ends

One common denominator: Lack of proper recognition

• Solution: Provider Recognition by

CMS

Provider Status is Realistic Goal(50 Provider Categories on Medicare Website)

Ambulance Service Supplier

Ambulatory Surgical Center

Audiologist

Certified Clinical Nurse Specialist

Certified Nurse Midwife

Certified Registered Nurse Anesthetist

Clinic/Group Practice

Clinical Psychologist

Community Mental Health Center

Comprehensive Outpatient Rehabilitation Facility

Durable Medical Equipment, Prosthetics, Orthotics, or Supplies

……etc ….

Provider Status is Desirable

• Higher professional standing– billing could be done by clerks as now

– office space, secretarial help, parking, lunch room

– signing billing rights to clinic would maintain status quo

• More job security

• More control over profession, allotment of time, working hours– quality of work

– better QA equipment and Treatment Planning Systems

– higher income

• Easier recruitment of new medical physicists

Steps to Achieve Provider Status

• Professional Oath

• Closer ties with Radiological Societies– awards for distinguished radiation oncologists

– discounts at physics workshops for radiologists

• Letters of Support from Well-known Radiation Oncologists and Radiological Societies

• Obtain Legal Counsel

• Political Lobbying - start PAC– necessary in today’s environment

– returns out of proportion with investment

– is done by majority of radiological societies

Form Political Action Committee (PAC)

• Physicists are good politicians - 2 Congressmen• Lobbying has high returns • Recent limits are leveling playing field• All contributions voluntary - less disagreement • Provider status is reasonable request

– helps cancer patients– financial impact small - easier to get through Congress

• Timing is excellent– physicists in demand, supply will get worse– current pay scale makes lobbying affordable

CONCLUSION

• Medical physics has all the features of a medical specialty, except Medicare recognition as Providers

• Provider status will eliminate the root causes of the majority of problems in our profession

• Obtaining Provider status has been the primary reason for the formation of ACMP

• Obtaining Provider status has to become again the primary goal of all professional activities of ACMP