AAPM Newsletter September/October 1999 Vol. 24 No. 5

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Newsletter AMERICAN ASSOCIATION

OF

PHYSICISTS

IN

VOLUME 24 NO. 5

MEDICINE SEPTEMBER/OCTOBER 1999

AAPM President’s Column Our Relationships With Other Organizations

by Geoffrey Ibbott Lexington, KY In my March column, I discussed some of the important issues facing the AAPM. This column looks again at some of these issues, in particular, our relationships with other organizations. The AAPM interacts with a number of other professional and scientific organizations, including physics societies such as the ACMP and the Commission on Medical Physics of the ACR, as well as organizations of physicians and technologists. These interactions ensure good communication and collegial relations with our professional colleagues. Healthy relationships with other professions often help us to develop positions of strength when we need to voice our opinion, for example, on proposed legislation. Developing and nurturing such relationships has been an issue of high priority during this year, and has occupied AAPM officers, liaisons, and committee chairs to a significant extent.

Intersociety Commission The Intersociety Commission is a collection of radiology organizations through which participants have many opportunities to meet and make new acquaintances, develop new contacts,

the legislation in front of Congress was discussed. Some discussion was held on a proposal for a new institute at NIH (more on this later in this column.) The ACR is particularly concerned about a bill introduced in the House that would weaken the Stark self-referral law. Radiologists oppose weakening the restrictions against self-referral, but hospitals, insurance companies, and other physicians support the bill. and share ideas. Each year, the Commission holds a Summer C o n f e rence (formerly the Radiology Summit) at which the profession of Radiology, its relationships to other professions and its responses to external influ ences are examined.

Chairman of the Board Larry Rothenberg and I attended this year’s conference in Montreal.

The topic this year was “Survival of Excellence.” The focus was on maintaining the quality of patient care as societies respond to changing needs, departmental decentralization, and the development of product lines and centers of excellence. Sessions were held on the restructuring of radiology departments, the reorganization of radiology societies, and the impact of such reorganization on patient care. A session was held on government relations, at which some of

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INSIDE TABLE OF CONTENTS President’s Column………………p. 1 Coolidge Award............................p. 4 2000 Officers/Board.....................p. 6 Award Winners/Fellows...............p. 7 Executive Director Column..........p.8 Residency Training Programs......p. 9 ABR Recertification.....................p. 11 NCRP Report...............................p. 13 HCFA Visit...................................p. 16 CAMPEP.......................................p. 17 Letters to Editor...........................p. 18 Glasser Memorial Fund............. .p.21 CRCPD Report.............................p. 23

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Medical physicists may want to express their opposition to the bill, and show their support of our colleagues, the radiologists.

A Proposed New National Institute Recently, I asked Gary Fullerton to chair an ad hoc committee to develop mechanisms for the AAPM to indicate its suppo rt f or development of a National Institute o f Biomedica l Imaging and Engineering at the National Institutes of Health. The proposal is supported by several other organizations, including the Academy of Radiology Research (ARR), the American Institute for Medical and Biological Engineering (AIMBE) and the American Institute of Physics (AIP). Phil Judy represents the AAPM at the ARR, while Gary Fullerton and Bill Hendee are our delegates to AIMBE. Dr. Hendee also served as President of AIMBE for the last year. Chris Marshall, one of our liaisons to the AIP, and John Boone are also serving on the ad hoc committee. The AAPM decided earlier to support this proposal because imaging and bioengineering are not specific to particular diseases or org a n systems, and consequently do not fit well into the structure of NIH. According to the committee, research in imaging and bioengineering is dispersed throughout NIH and other federal agencies, without proper direction and coordination. This has led to duplication, inefficiency and lost opportunities.

There is a need for a central focus for research in both of these disciplines.

The AAPM has previously

indicated its support of two bills presently before Congress, H.R. 1795 and S. 1110, that would create this National Institute. Our position was reaffirmed by the AAPM Board of Directors in Nashville, and I was instructed to write to the presidents of the American Institute of Physics, AIMBE, ARR, and other appropriate organizations to notify them of our position.

The ad hoc committee has further recommended that AAPM members be asked to contact their members of Congress to encourage them to support the proposals, or, if they are already sponsors, to thank them for their support. I have written to Board members and chapter representatives to ask them to contact AAPM members in their regions to coordinate a letter-writing campaign. You may already have heard from someone in your chapter, but if necessary, m o re informatio n can be obtained from the ARR at http://www.acadrad.org.

ABR Last year, the American Board of Radiology announced that one of the physics trustees, Ed Chaney, would complete his term and would need to be replaced. Through a series of events described in previous Newsletters, a mechanism was developed through which the AAPM Board of Directors submitted a list of four nominees for the physics trustee position.

The ABR announced shortly before the AAPM annual meeting in Nashville that it had selected past AAPM President Bhudatt Paliwal to fill the physics trustee position. Dr. Paliwal will serve a term of four

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years starting in July 1999.

Trustees may be reappointed for a second term.

Alliance for Quality Medical Imaging and Radiation Therapy Following a decision by the AAPM Board of Directors in Nash ville, the AAPM has become an active member of the Alliance for Quality Medical Imaging and Radiation Therapy.

The goal of the Alliance is to work with Congress to enact the Medical Imaging and Radiation Therapy Quality Assurance Act of 1999. The proposed legislation would improve the quality of medical imaging and radiation therapy procedures by establishing minimum levels of education and credentialing for the technologists performing the procedures. It also adds an enforcement mechanism to the 1981 federal law that established licensure standards for radiologic personnel. Because compliance with the existing law is voluntary, only 35 states have enacted licensure laws for radiographers, and fewer states license radiation therapists and nuclear medicine technologists.

NRC At the recommendation of the Science Council, I have written to the NRC to request a new comment period for review of the revised proposed changes to 10 CFR Part 35. While it appears unlikely that the NRC will grant another comment period, we feel that the changes in the current version are sufficient to warrant our making the request.

ASTRO Earlier this year, Excom had discussions with the American

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College of Cardiology regarding the education and training of cardiologists who use radiation in medical procedures. Excom is very aware of the concern expressed by radiologists and radiation oncologists regarding the use of radiation by other specialists. Since our meeting with the ACC, other members of Excom and I have had a number of conversations with radiologists, radiation oncologists and cardiologists regarding these procedures and the role of the medical physicist.

Many of you attended the P resident’s Symposium in Nashville, at which several physicists, a cardiologist and a radiation oncologist spoke about intravascular brachytherapy. Each speaker, in addition to discussing the scientific and medical aspects of the procedure, spoke about his role and that of the other professionals.

Each was clear that the cardiologist, the interventional radiologist, the radiation oncologist (or interventional radiotherapist) and the medical physicist can and should contribute their scientific and medical expertise to assure both the best patient care and the highest quality research.

During the summer meeting of the AAPM Board of Directors I received strong support for the approach that the AAPM has taken. We will continue to hold discussions with the ACC regarding the training of cardiologists because we feel that it is important that people who perform procedures involving radiation and radioactive materials understand the physics and radiation safety issues. Our focus is on the quality of medical procedures, and the safety of the patient and staff. We will contin-

ue to stay in close contact with the radiology and radiation oncology community, and involve them in our discussions with the cardiologists.

As part of our involvement, we have contributed to the Vascular Brachytherapy Roundtable, established by ASTRO. Ravi Nath and Steve Balter have been the AAPM representatives to this effort, which has resulted in the preparation of a document called “Roles of Various Specialists in Intravascular Brachytherapy.”

During the Nashville meeting, several AAPM committees reviewed the draft, following which I returned it to ASTRO with our suggestions for minor revisions, and a statement that the AAPM is willing to sign the document with the proposed changes.

RSNA In the last Newsletter, I described a project being conducted by the RSNA in collaboration with the Disney Corporation at their Epcot Center. The exhibit will be entitled “Radiology-Exploring New Horizons” and will be part of Epcot’s Millennium Celebration.

The Education Council, chaired

by Don Frey, is in contact with the RSNA on this project, and Rick Morin represented the AAPM at a recent meeting to discuss progress on the project.

During the Nashville Board meeting, it was agreed that AAPM would officially endorse the project, and I have informed the RSNA of this decision.

Further Interactions with Government: Medicare

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In early July, I received a call from a staff member at the Health Care Financing Administration (HCFA) who requested information about medical physics services. The call was apparently prompted by an AAPM member who had written regarding the Hospital Outpatient P ro s p e c t i v e Payment System (HOPPS) proposal. I offered to provide data, but as most of you know, the comment period for this proposal ended July 30. I used the opportunity of a Tr i l a t e r a l Committee meeting to seek the advice of colleagues, but ultimately it became apparent that a personal visit was appropriate and necessary. Professional Council chair Mike Gillin and I left the meeting in Nashville briefly to visit HCFA. Mike’s report appears elsewhere in this issue of the Newsletter.

Congress In the last Newsletter, I reported to you that I had written to the sponsors of a bill that would expand Medicaid coverage for certain women with breast or cervix cancer. My letter indicated the support of the medical physics community for the proposal. With the assistance of several members of the Professional Council, particularly Mike Gillin and Ivan Brezovich, I have written to the sponsors of HR 1090, a bill to exempt cancer treatment services from HCFA’s HOPPS proposal. Again, I indicated AAPM’s support for the proposal, and asked that radiation therapy be specifically listed as one of the services to be excluded from the prospective payment system.

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1999 William D. Coolidge Award - Faiz Khan This award is the AAPM’s highest honor, presented to a member wh o h as e x hib ite d a di st in g ui sh ed c a r e er i n medical physics, and who has exerted a significant impact on the practice of medical physics.

Biography Faiz Khan was born in Pakistan where he received much of his education. He moved to the United States in 1963 to accept a Fulbright Scholarship Award for furthering graduate studies and r e ce i v e d h is P h. D. i n B io ph ys i cs f r om the University of Minnesota in 1969. He joined that faculty in 1968, and is currently professor and head of the Physics Section at the University of M in n e so ta , R ad ia t i o n Oncology Department.

D r. Khan has served the AAPM as a member of the Board of Directors, Chairman of the Radiation Therapy Committee, President of AAPM and Chair and Member of serveral committees and task groups. He is Fellow of the AAPM, Fellow of the ACMP, and recipient of the 1998 Marvin M.D. Williams Award by the American College of Medical Physics. His career in medical physics spans over 30 years, and includes authoring the textbook “The Physics of Radiation Therapy,” and coediting three other books in radiation oncology, as well as 80 papers in peer-reviewed journals, and 16 chapters in books and proceedings. In the

research area he beautiful has contributed daughters, papers on clinical is here to dosimetry, treatshare this ment techniques, honor. an d tr e a t m e n t Since planning. my inducHe has taught tion 39 or advised over years ago, 1 70 stud e nt s I have including medical found residents, medmedical ical physics resiphysics to d e nts, an d be an Faiz Khan graduate students exciting in me di ca l field to Minneapolis, MN physics. His curwork in . rent interests are in the area of What I like most about this field treatment planning algorithms is the opportunity to combine f or p hot on a nd el e ctro n clinical work with teaching and beams. research. The most enjoyable project of my career was to write my first book: “The Remarks by Faiz Khan Physics of Radiation Therapy”. It took a lot of desire and deterI feel greatly honored by this mination to write a text book in award. I am also honored by the the face of the pioneering work presence of Dr. Seymour Levitt

by Johns and Cunningham. I who had a lot to do with my frequently tell my students to career as medical physicist. I read my book, especially if they thank Suntha and Bhudatt want to pass the boards. But for Paliwal for nominating me and myself, I still read and enjoy those friends and collegues who Johns and Cunningham. wrote letters in support of my I consider it a great honor to nomination. I thank the Awards be included in the list of and Honors Committee who has Coolidge Awardees that cona difficult task of selecting one tains the name of Harold Johns individual out of many deserving and John Cunningham. candidates every year. I truly Besides research, teaching share this honor with my family, and clinical practice, I have some of whom are here today. immensely enjoyed my involveMy parents, who had a lot to do ment with professional organiwith my development as a zations like the AAPM, the human being, would certainly be ACMP and the certification very proud if they were alive Boards. As you know, medical today. My wife, Kathy, who has physicists are blessed with two been a great companion for the Boards: one is a peer-Board, the last 33 years and gave me three other claims to be one. Both

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Boards deserve the credit of providing one of the most important functions of a profession, namely, the certification of its members. However, I strongly believe that a profession should not give away the right or the control of credentialing and certification to another profession. It doesn’t make sense to me that the AAPM continues to sponsor a board of radiologists and not sponsor the board of medical physicists which is well established and has been in existence for over ten years. I have nothing against the ABR - I worked with that Board for many years.

It is just that I have the same sentiment about this issue as patriotism. You want America to be governed by Americans, not by some foreign body, not even the British, no matter what the arrangement is. In any case, I feel strongly that the certification Board should be a physicists’ Board, governed not by ABR, not by ABMS, but by medical physicists.

Along the same lines, if I may criticize the AAPM one more time, let me say that unfortunately the AAPM continues to ignore the importance of ACMP as the professional College for medical physicists. Remember, ACMP was created with the blessings of the AAPM. Then why are we not delegating professional matters to ACMP and giving it more clout with a strong show of support? Indeed, we should join and work with other professions and have close working relationships. But not at the expense of our own organizations!

Of course the AAPM is the gr and d a ddy o f medic al physics organizations. We are proud to be its members. It

gives us professional status and identity. But let us be clear about this. It is a scientific and educational society, not a professional college. It should delegate professional matters to the ACMP like ASTRO and RSNA do in relation to their college, the ACR. The two societies, the AAPM and the A C M P, should compliment each other rather than compete.

Professional Issues While I am on a roll discussing professional matters, let me talk about a few other issues facing medical physics today. First a bit of good news.

I recently learned that the Department of Health and Human Services is considering having Medicare pay for medical physics residency programs. This is a significant step toward recognition of medical physics as an allied health profession. There are two remaining major issues, however: independent billing and licensure. Currently CPT codes are written so that only physicians can collect their professional f ee s . P hysi c is ts ’ w ork is lumped into technical codes which they cannot bill or collect for. This is true whether we are working in radiology, radiation oncology, neuros u rgery, cardiology or any other medical specialty. What kind of professional status is that? You can say: we are nothing more than hi re d hands, laborers or so. Well, it is not the title that is important.

The problem is that we are letting other professions define our status and collect for our services. Analysis of billing

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codes and revenues invariably shows that physicists’ staffing, employment or pay scales bear little relationship to the revenues they generate under these codes. Let us face it that, as a profession, we are and have been abused by other, more powerful groups in the health industry. Let us establish a task force to look into the issue of independent billing. I hope that we will support this effort with all our hearts, minds and pocketbooks, if needed. A strong effort by the ACMP, AAPM and hopefully, the ACR, along with congressional lobbying, will be required to make any headway on this issue. And finally, let us agree on this obvious fact that without independent billing and licensure, medical physicists will never achieve p rofessional status like the physicians, lawyers and engineers have. My career is fast approaching the finish line. It is the younger generation that I care about.

God bless the AAPM. ■

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2000 Officers and Board Members - Election Results

Charles Coffey

Jerry White

Nashville, TN

Sarasota, FL

President-Elect

Secretary

Melissa Martin Belleview, CA

Treasurer

Howard Amols

Maryellen Giger

New York, NY

Chicago, IL

Board

Board

Mary Ellen MastersonMcGary

Michael Gillan Milwaukee, WI

Board

Melbourne, FL

Board 6

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SEPTEMBER/OCTOBER 1999

Medical Physics Achievement Awards

Joe Windham Detroit, MI (given posthumously died December 1998)

The Medical Physics Achievement Award denotes outstanding achievement in medical physics practice, eduction, or organizational affairs and professional activities.

Perry Sprawls Atlanta, GA

Farrington Daniels Award - for best paper on Radiation Dosimetry in “Medical Physics� in 1998: David Rogers Sylvia Sorkin Greenfield Award - for best paper (other than Radiation Dosimerty): Willi Kalender and Marc Kachelriess AAPM Medical Physics Travel Grant - for career development and to promote medical physics communication between countries

John Antolak John Cameron Young Investigators Award - for career and diplomatic development - Rebecca Fahrig, S. Lownie, A.J. Fox and David Holdsworth

AAPM Fellows Wally Ahluwalia Howard Amols Lowell Anderson Krishnadas Banerjee Robert Barish Peter Biggs John Boone Charles Coffey Karen Doppke James Galvin Robert Gould Douglas Jones

James Havezi John Kent IV Dale Kubo Pei-Jan Paul Lin Wendell Lutz Thomas Mackie Melissa Martin Daniel McShan Charles Mistretta Stephen Nagy Amos Norman George Oliver, Jr. 7

Satish Prasad Isaac Rosen Steve Rudin Anthony Seibert Melvin Seidband Thomas Stinchcomb Keith Strauss Orhan Suleiman David Vassy Carl Vyborny Charles Wilson Ellen Yorke

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SEPTEMBER/OCTOBER 1999

Executive Director’s Column

By Sal Trofi College Park, MD Annual Meetings Attendance at the annual meeting in Nashville was greater than any previous annual meeting. There were 2,835 in attendance, which is 157 more than the previous high. Science attendees were up by 37, exhibitor attendees by 45 and guest attendees by 75.

Exhibit space sales exceeded last year’s sales by about $61,000. We had 24 new exhibitors this year, but lost 14 to mergers or no response to our solicitation to exhibit, for a net increase of 10 exhibitors.

Since Lisa Rose Sullivan took over the exhibits in 1994, she has increased the sale of booth equivalents by 86%. Each year the percentage increase has been in the double digits except this year where the increase was 5%.

The number of abstracts processed this year were four s ho r t o f t h e ab st r ac ts processed in 1998 (522 vs.

526). The electronic abstract submission system performed with no difficulty this year.

This submission system, with some modifications, will be used again next year for the World Congress meeting in Chicago.

Medical Physics Journal Online As of mid August, about 30% of eligible members have signed the online subscription agreement. This is a doubling of the number signed up in mid July.

Signing up is easy, but you must first have a valid email address listed with AAPM. If headquarters does not have your email address, simply email the i nfor mat ion to aapm@aapm.org. To sign up for the free online journal, follow these steps: 1: Log in to the subscriber a g reement page at http://www.medphys.org/agree ment-login.html using your AAPM username and password.

2: Read and agree to the online subscriber Agreement by pressing the Accept button.

Write down your Member ID from the page that is displayed.

You will need it for step 4.

3: Within an hour, AIP will email you instructions for obtaining a username and passw o rd for Medical Physics Online. NOTE: AIP only sends notices Monday through Friday.

4: Follow AIP’s instructions to cho ose yo ur M edic al Phy si cs on line user n am e and password.

Membership The total predicted membership for 1999 will increase by 100% over the 1998 year, but the full member category will increase by 3%. This is significant because in the majority of other membership organizations the membership is either stable or decreasing. Of concern is that the student membership has been decreasing for the last few years. The membership committee is focusing on this situation and is considering giving qualified students a free membership for the first year.

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Other News The 2006 Annual Meeting will be in Orlando, Florida.

Membership dues re n e w a l notices for the 2000-year will be mailed during the first week of October. The transitio n of the AAPM books and reports pro g r a m to Medical Physics Publishing is now complete and the new arrangement is running very smoothly.

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Medical Physics Residency Training Programs To Be or Not to Be?

by Kenneth Hogstrom AAPM President-Elect Houston, TX More and more sophisticated technology is being used for medical diagnosis and treatment that requires competent medical phys ics support.

Physicians of many types - diagnostic radiologists, radiation oncologists, medical oncologists, cardiologists, neurosurgeons, etc. - depend on the qualified medical physicist.

As our professi on has m a t u red, our leaders have establ ished path ways for becoming qualified through training programs and for demonstration of competency through certification. Medical physics training has traditionally encompassed graduate and postdoctoral education, both of which emphasize didactic curriculum and re s e a rc h .

Competency as a qualified medical physicist is demonstrated by the completion of board certification by the American Board of Radiology (ABR) or the American Board of Medical Physics (ABMP). To be capable of becoming board certified, clinical training is required. To date, the bulk of clinical training has been on-the-job training, usually, but not always under the supervision of a qualified medical physicist.

Some of our current and previous leaders have set the stage for an improved mechanism for clinical training, the medical physics residency, a pathway that more closely follows clini-

cal specialty training in other areas of medicine. In 1990, the AAPM published Report No. 36, entitled “Essentials and Guidelines for Hospital Based Medical Physics Residency Training Programs.� Then, to p rovide incentives for the development of medical physics residency training programs, the AAPM has utilized its development funds, funds from vendors (Varian Oncology Systems and Elekta Oncology Systems), and funds from sister p rofessional org a n i z a t i o n s (Radiological Society of North America - RSNA and American Society for Therapeutic Radiology and Oncology ASTRO) to establish 5 radiation oncology physics and 3 diagnostic imaging physics 2-year residency fellowships.

In 1995, the Commission on A c c red itation of Medical Physics Education Programs, Inc. (CAMPEP), sponsored by the American Association of Medical Physicists (AAPM), American College of Radiology (ACR), and American College of Medical Physics (ACMP), was established. CAMPEP formed a Residency Education Program Review Committee, which developed guid elines fo r accreditation of medical physics residency training programs, which were approved in 1996.

Once the accreditation mechanism was established, CAMPEP focused on attaining approval

by HCFA for reimbursement of p rogram costs. HCFA has recently responded that a CAMPEP-accredited, hospitalbased, medical physics residen-

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cy program may qualify for reimbursement as a qualified allied health education program. Though not permanently adopted, HCFA implied that it would look favorably on reimbursement for qualified medical physics residency training programs, a practice already established at the local level by the one accredited medical physics residency program (for more details, see accompanying article by Eric Klein).

To date, there exists one accredited residency training program, one in radiation oncology physics at Barnes-Jewish Hospital/Washington University School of Medicine under the direction of James Purdy. To date CAMPEP has received one other application, which is currently in the evaluation process.

Currently, CAMPEP believes there to be as many as 20 medical physics residency training programs in the United States and Canada. However, most are in their infancy, have only 1 to 2 students, and have funding challenges. Since 1996, when accreditation guidelines were approved, the AAPM has awarded medical physics residency fel-

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lowships to 8 institutions, of which only one is accredited, even though the criteria for application clearly state that the program must be accredited or apply for CAMPEP accreditation by the end of its second year of funding.

To summarize, our leaders have provided training guidelines, guidelines for program accreditation, fellowships, and potential permanent external mechanisms for program funding. All of the tools seem in place for our profession to make residency training happen, so why aren’t we making more progress? Medical physics residency training programs: are they to be or not be?

For medical physics residency training programs to develop, I see two remaining hurdles: (1) graduates of medical physics graduate education programs must have clear incentives to select residency over on-the-job training, and (2) our physician colleagues must be strong supporters of our efforts to establish residency pro g r a m s .

Regarding the first hurdle, the challenge is how to steer graduates of M.S. or Ph.D. medical physics programs to the residency training programs, foreg oi ng app ro x i m a t e l y $30,000/year of income should they elect on-the-job training.

Although the premise is that residency training would be a more efficient method of training, most graduates have difficulty ap preciating that residency training will offer better training and the ability to become board certified sooner, both likely to result in longterm benefits to the medical physicist.

Presently, even if graduates

sought residency training programs, there are insufficient p rograms to accommodate them. In fact, most medical physics residents are presently coming from graduate programs in physics or related fields, not from medical physics. The lack of demand for programs leads to the chicken or egg problem. To help obviate this perception, CAMPEP has temporarily allowed accredited programs to offer one-year training programs in lieu of two years for graduates of CAMPEPa c c redited medical physics graduate education programs.

Regarding the second hurdle, we need physician support not only through fellows hip sup por t from their professional organizations, but more importantly, through collegial support at our respective institutions. The mechanism to achieve this will be through education of physicians and through peer pressure of their colleagues having successful medical physics residency programs. Therefore, individually we need to pursue formation of residency medical physics programs, and as an Association, we must find ways to obtain the full support of our physician colleagues.

In summary, the time to establish medical physics residency training programs is now. For further information on CAMPEP accreditation, please contact: Richard Lane, Chair CAMPEP Residency Educ.

Program Review Committee M. D. Anderson Cancer Center 1515 Holcombe Blvd., Box 94 Houston, TX 77030 phone: (713) 792-3230

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fax: (713) 745-0683 Forms and instructions for applications also may be obtained by visiting the CAMPEP web site at www.campep.org or from: Lisa Rose Sullivan Manager, Continuing Education Credits One Physics Ellipse College Park, MD 20740-3846 phone: (301) 209-3387 fax: (301) 209-0862 ■ References “Essentials and Guidelines for Hospital Based Medical Physics Residency Training Programs,” AAPM Report 36, (American Institute of Physics, Woodbury, NY, 1995), pp.

147.

“Guidelines for Accreditation of Medical Physics Residency Education Programs, Revision 1.0 – August 9, 1998,” Commission on Accreditation of Medical Physics Education Programs, Inc. (1998), pp. 28.

Steven Goetsch and Jean St .

Germaine, “AAPM Residencies and Fellowships - A Brief History,” AAPM Newsletter 23(6), 7-9 (1998).

Kennet h Ho gstrom, “ Medical Physics Residency Training Program Accredit atio n Update ,” AC MP Newsletter December, 3 (1998).

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ABR Physics Recertification Committee

by Bill Hendee Milwaukee, WI The Restructuring Committee for the American Board of Radiology Physics Ce rti ficat ion Ex a mina ti on held its third meeting in Louisville, KY on May 19, 1999. The meeting yielded the following conclusions and assignments:

Compressed Oral Examinations Dr. Chaney reported that the examination concluded on the previous day was the last date that individuals could take a compressed oral examination in more than one certification specialty. In the future, only individuals who have failed or conditioned a previous compressed examination would be examined in a compressed format. The number of such individuals is very small.

Graduate Degree Requirements for Candidacy Dr. Simmons reported that his committee (Drs. Simmons, C o ffey, Morin, Barish and Hubbard) had considered the graduate education requirements for admission to candida cy fo r t he ph ysi cs certification examination. Part 1 of the written examination may be taken any time after an individual is enrolled in an appropriate graduate education program. For admission into the Part II examination, an individual must have acquired a graduate degree from an

accredited institution in a discipline such as engineering, medical physics, physics, or a r elat ed phy s ica l scie n ce .

Persons graduated from a CAMPEP-approved or -eligible graduate program will be admitted to the examination provided they meet the experience requirements. Other individ ua l s w il l b e adm itt e d pending approval of their gr ad ua te tra i ni ng, w hi ch should include appro p r i a t e courses in biology or medical science. Graduates of nonaccredited foreign institutions will be considered on a caseby-case basis.

Psychometrics Verification of Examination D r. Gerdeman pre s e n t e d the findings of a study to examine the correlation of candidates’ scores on various parts of the written and oral examinations. The corre l ation is as expected. There is excellent agreement among the various parts of the written examination, as well as between these parts and performance on the oral examin a t io n . Th e r e s u l t s a l s o demonstrate that the written and oral examinations test d i ff e rent attributes of the candidates’ performance, and both examinations are important to assessing the ability of can didates to meet the minimum essentials required for certification.

Letters from Candidate’s References

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At the last meeting of the committee, Dr. Chaney agreed to revise the instructions to a candidate’s references to elicit more specific information about the candidate. This revision has been accomplished, and the new instructions were implemented several months ago.

Computerizing the Oral Examination Last year a committee of Drs. Frey, Biggs and Madsen was empowered to develop oral questions that could be migrated easily into a workstation environment for oral examination by computer.

Several such questions were used this year in the oral examinations in Therapeutic Ra di o l og i ca l, Di a gno st ic Radiological, and Medical Nuclear Physics. The committee agreed that some oral questions in each of the three specialty areas should be asked next year within a computer workstation enviro nm e nt .

The co m mi tt e e concluded that next year one examiner in each examination panel would ask computerbased questions in each of the areas. The goal would then be to migrate the entire oral examination into a computer work-station enviro n m e n t over the succeeding two years. At Dr. Capp’s suggestion, the committee agreed to meet with ABR inform a t i c s staff over the noon hour to discuss the preparation and submission of questions for computer presentation during t he o ra l ex a mi n at io n i n

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Recertification Committee physics next year. This meeting was subsequently held, and yielded a blueprint for f o rmatting and submitting questions for the computerized oral examination.

New Business Dr. Hendee announced that Dr. Morin is retiring from his chairmanship of the written examination committee in D i a g no s t i c R a d i o lo g ic a l Physics, and that Dr. Seibert is taking his place, with Dr. R i t e n ou r ( U n iv e r s i t y o f Minnesota) joining the committee. Dr. Morin is moving to the Ge n e r a l Physics C om m i t t e e t o h e lp D r.

Hubbard.

Dr. S i m m o n s announced that Dr. Graham is retiring from his chairmanship of the written examination committee in Medical Nuclear Physics, and that Dr. Madsden is taking his place, with Ms. Harkness (Wake Forest) joining the committee.

Dr. Banerjee indicated that Dr. Barnes has assumed primary responsibility for the Clinical Examination.

Physics Restructuring Committee Edward Chaney Guy Simmons Lincoln Hubbard Robert Barish Charles Coffey Donald Frey Peter Biggs Stephen Graham Richard Morin Thomas Payne Donald Frey Russell Ritenour Kris Banerjee William R. Hendee, Chair

ABR Physics

Th e Rec e rt if i ca ti on Committee for the American Board of Radiology, held its second meeting in Louisville, KY on May 19, 1999. All of the committee members listed below were present. The meeting yielded the following conclusions and assignments.

• Implementation of Physics Recertification • 10-year time-limited certificates to be issued in physics beginning in 2002 • Recertification to be an ongoing process following certification consisting of: Ongoing continuing education Periodic (every 4 years) examination O bje ct ive s of Ph ysi c s Recertification • To provide assurance of: Competency in the clinical pract ice of radiologic al physics • Maintenance of up-to-date knowledge of radiological physics and its applications • Public accountability of the specialty of radiological physics

Components of The Physics Recertification Process A. Continuing Education C on ti nu in g e du ca t i on category 1 credit for: • C AM PEP app r ove d programs • ACC ME ap pr o ve d programs • ACR approved programs

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Continuing education category 2 credit for • Graduate course enrolled fo r c re di t – 3 c re di ts maximum/year • Graduate course taught – 3 credits maximum once/ 10 years • Meetings, symposia, courses approved for CE credit by organizations other than 1 – 3 above C redit for other activities by petition • 20 credits/year, of which at least 10 must be category 1 • No credit for publications, presentations, reading, committee service, etc

B. Examination Examination is part of the continuing education process • Body of material to be used for testing • Material identified for candidate study • Material to cover new i n f o r ma tio n si nce l as t certification/recertification examination • Material to include items such as:

AAPM Task Group reports • NCRP reports • ICRP reports • ICRU reports

Standards of Practice • F e dera l rul e s and regulations • F ac ili ty a cc re di ta t ion standards • Other relevant documents defin in g stat e-of -th e-art practice

Process of testing

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• Open book • Computerized format (disk or internet) • Exam available every 4 years beginning in 2004 • May take exam as often as desired, with 60 day wait between attempts • Approximate time to take exam = 2 hours, but no time limit • Approximately 50 multiple c ho ice qu e st io ns (Radiographics format) • Two exams “alive” at any time – each exam available for 4 years • Independent verification of identity not required • Immediate histogram feedb a ck of re su lts to candidate

Physics Recertification Committee Edward Chaney Guy Simmons Dan Bourland Tom Payne Don Frey Rod Wimmer Russell Ritenour Jon Trueblood William Hendee, Chair

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NCRP Annual Meeting

by Edward Webster AAPM Liaison Boston, MA Radiation Protection in Medicine: Contemporary Issues Topics covered at the 35th annual meeting involved medical radiation exposure, effects, risks and control. For the first time the NCRP published in advance a Proceedings (#21) of the meeting. These topics are a recurring theme in NCRP history, most recently addressed in the annual meeting of 1992.

The significance of medical exposure was emphasized by Henry Royal, MD the program chairman, showing in a “pic” diagram that in 1987, 88% of the annual per capita manmade exposure was from diagnostic radiation.

The risks from diagnostic exposure depend of the cont roversial issue of whether there is a dose threshold for risk. This was appropriately discussed in the first paper by Arthur Upton who summarized the recend draft report of NCRP Scientific Committee 1.6 which re-appraised the linear nonthreshold (LNT) dose-response model. The experimental finding that a single radiation track can cause a double-strand b reak in th e DNA of an exposed cell for which repair is error-prone, and can therefore result in a mutation or chromosome aberration, provides biophys ical s upport for a n o n - t h reshold hypothesis.

Several experimental linear

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d o s e - response relations for malignancies induced in animal and some human populations lend further support for the conclusion that the LNT model is the most plausible, although other models cannot be excluded. In this session, a more speci alized paper on D evel opmental a nd Reproductive Risks from irradiation during pregnancy was presented by Robert Brent.

Several kinds of risk were discussed: teratogenesis and mental retardation which have a threshold dose above 0.2 Sv, childhood cancer especially leukemia, the risk for which may be smaller than that published by A. Stewart and recently defended by Doll and Wakeford, and the fetal thyroid risk from I-131. A use section on counseling patients exposed to ionizing r adiati on was included.

Five papers concerned radiation protection in diagnostic radiology The first by A. Poznanski noted a higher cancer ris k in chi ldr en a nd teenagers compared with adults by about a factor of 3, but this was compensated to some extent by smaller radiation exposures. An exception to this trend is the use of CT examinations in children where frequently the same kV and mAs are employed, leading to a higher effective dose in the child. Reduction of mAs by a factor of 2 or more would reduce the dose without loss of image quality. The reduction of dose in childhood fluoroscopy is automatically accomplished

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if an automatic brightness control system is available. The use of pulsed fluoroscopy can also reduce fluoroscopic dose: operation at 7.5 frames/sec will require 4 times less dose than 30 frames/sec.

L. Rothenberg discussed the improvements in image quality i n mam mog r aphy ma inl y attributable to the thorough QA programs now mandatory under the MQSA government (federal and state) regulations, and the availability of special training programs for personnel. Particular attention was directed to the calculation of mean glandular dose as related to x-ray tube kV, tube target metal, filter, breast thickness and compostion, now available in published tables (Wu et al, Radiology 193, 83, 1994).

The data available on the radiation risks of breast cancers and the benefits of mammography screening were also concisely reviewed.

The next pap er by E. Fishman was an elegant and exciting discussion of recent technical developments in CT equipment, including spiral CT, angiography with CT and multi-detector scanners, illustrated with excellent images. A. Siebert discussed the digital acquision of x-ray projection images formed on photostimulable storage phosphor detectors, commonly known as “computed radiography” (CR).

The wider latitude, ability to amplify the CR iamge after acquisition, and its compatibility with digital picture archiving systems (PACS) were comprehensively presented with an emphasis on the need for thorough QC. The final paper in this session was presented by

O. Suleiman from the FDA on radiographic doses and their variation through the years with particular reference to the national surveys (NEXT programs) conducted in 1992 and 1995. Of interest was the increase in dental film speed from Type C to the new Type E by a factor of 10 between the years of 1964 and 1995, and the reduction in mean glandular dose for mammography from 14 mGy in 1974 to 2 mGy in the present decade.

The third session contained 3 nuclear medicine papers. The first by R. Wahl discussed cancer treatment with radiolabeled monoclonal antibodies noting promising results from an antiCD20 antibody labeled with I131 for treating non-Hodgkin’s lymphoma. The whole body dose is typically 0.75 Gy and the tumor dose 10 to 15 times higher. A response rate of 65% was reported in patients who failed chemotherapy. J. Siegal discussed a revised NRC regulation (May 1977) for release of patients who have received radionuclide therapy. The new rule is based on a dose limit of 5 mSv to persons near the patient. Elaine Ron (NCI) discussed radiation effects on the thyroid gland, particularly from I-131 for medical use from environmental releases from several sources including the Nevada Test Site, Hanford Nuclear Site and Chernobyl.

According to a 1997 NCI report

by C. Land, the Nevada releases caused an estimated lifetime excess of 49,000 excess thyroid cancers (with a wide uncertainty range) based on an RBE of 0.66 for I-131 vs. x-ray exposure. E. Gilbert in 1998 (JNCI) in another study estimated

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about 12,000 incident thyroid cancers and 4,600 thyroid cancer deaths and a suggestion of dose association with ERR of 10.6 per Gy (95% confidence interval 1.1 - 29) for exposure before age 1.

Between 1944 and 1957 an estimated 600,000 curies of I131 was released from Hanford into the atmosphere. The mean thyroid dose of 3,000 persons who lived near Hanford at that time has been estimated at 186 mGy and the results to date provide no evidence of thyroid neoplasia. The large excess of childhood thyroid cancer due to I-131 fallo ut after the Chernobyl accident (e.g. in Belarus 7 childhhod cancers in the 10 years before Chernobyl vs. 507 cancers in the 10 postaccident years) has suggested a relative risk of about 2.3 per Gy of thyroid dose. [Astakhova, Rad.Res. 150: 349, 1998)] Three diverse papers relating to Radiation Oncology comprised the fourth session. S. Leibel discussed the origin and advantages of three-dimentional conformal radiation therapy.

In this system a prescribed dose is targeted to the specific volume of the tumor conforming to its spatial configuration.

This pro c e d u re allows an increase in tumor dose while minimizing the dose to the surrounding normal organs. The importance in 3D treatment planning of defining the tumor volume and the local critical normal tissue was emphasized.

Examples of these refined techniques as applied to prostate cancer treatment and utilizing doses exceeding the conventional 60 Gy up to 81 Gy or even 86 Gy were described. D. Brenner (for E. Hall) reviewed

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the origin and increasing number of second cancers now presenting for radiotherapy, some due to inherited genetic susceptibility in the host and some induced by previous cancer therapy. A good example of the former is the Li-Fraumeni syndrome which is characterized by early-onset breast cancer and sarcomas followed by a second, third or even a fourth cancer. Second cancers appear several years after the first cancer has been treated by radiotherapy. For example after radiotherapy for prostate cancer, the risk of a second cancer was 35% ten or more years later, particularly for bladder and rectal cancer. Fred Mettler discussed the consequences of continuing radiotherapy calibration error which occured in Costa Rica in 1996. Ther error was the assumption that the radiotherapy timer units were 0.01 minute instead of seconds.

Thus, a time of 60 units was actually 60 seconds and not 60/100 minute or 36 seconds, cause a 60% overdose in 114 patients before the error was discovered. At least 17 patients have died from radiation injury.

The fifth session comprised 5 papers related to the use and hazard of fluoroscopy in interventional radiological and cardiac procedures and a paper on the recent use of high dose-rate radioactive sources to prevent restenosis in cardiac arteries.

This session highlighted some of the procedures in which fluo roscoic skin doses have reached or exceeded erythema levels and have induced warnings regarding dose control from the FDA. Richard Latchaw reviewed radiation doses during neuroradiological procedures

such as carotid stenosis proced u res and embolizations.

Instrumentation to facilitate skin dose measurement was briefly discussed, including a Dose Arca Product ionization chamber attached to the x-ray collimator from which the energy input can be assessed. An alternative method to assess skin dose utilizes a record of the kVp, mA, procedure time and target-skin entrance. One table lists the integrated skin doses for a series of carotid stenosis procedures with 15 cases of transient erythema and 4 cases of epilation from 3 Gy. A similar table for embolization lists 16 cases of permanent epilation with doses of 7 Gy or more.

Helen Redman recommended the use of pulsed fluoroscopy at 7.5 or 15 pulses per second to reduce dose. A paper by Bruce Lindsay contains a table of entrance skin dose for patients undergoing arrhythmia ablation: of 55 patients, 4% received between 2 and 3 Gy while 2% received more than 3 Gy. L. Wagner reviewed in detail the dose, onset time and peak effect time for 8 major effects ranging from transient crythema at 2 Gy to telangiectasia at 12 Gy. A photographic series of fluoroscopic high dose effects included one patient after 3 angioplasty procedures showing serious skin in jury 22 months later.

In the final paper of this series B. Archer discussed the problem of under-trained fluoroscopists in these special procedures and exhibited a list of basic rules for fluoroscopic use to minimize the skin dose, which he named the “10 commandments�.

The final session of the meeting was devoted to Policy

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ing was devoted to Policy Issues and was essentially a single paper on the need for education, credentialling and privileging for the use of x-rays by physicians, primarily with reference to the special procedures employing fluoroscopy which can injure patients as discussed in the previous session. Joel Gray presented this paper and plea, noting 3 other areas of concern in addition to fluoroscopy: CT examination doses, potential for unlimited doses in digital imaging (such as CR systems) which tolerate large over-exposures, and the wide disparity of doses for conventional radiographic examinations. The often forgotten fact that CT examination is a high dose pro c e d u re was emphasized with proposals to reduce the CT dose for chest examinations by a factor of 10 and to reduce the CT operating factors (such as mAs/slice) for pediatric CT which now often employ the adult factors. A draft training curriculum proposed in 1992 by a working group of the ACR was presented with relative weights for 10 different topics. It was noted that some of the Specialty Boards do not require evidence of special training in radiological practice (e.g. American Board of Internal Medicine an d American Boar d of Orthopedic Surgery).

A special plea for mandatory credentialling in fluoroscopy was made, proposing action by hospitals, state regulations, the JCAHO and the NCRP. It is dubious whether the NCRP has the authority or power to re q u i r e thi s c hang e in training programs. â–

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AAPM Visit to HCFA

by Mike Gillin, Chairman AAPM Prof. Council Milwaukee, WI As a direct result of a letter written by an AAPM member on the proposed APC rules, a representative of HCFA contacted the AAPM and requested information on the cost of providing medical physics services in radiation oncology. A response was pre p a red for HCFA and reviewed at various meetings in Nashville. On July 28, 1999 Geoff Ibbott and I w ent t o B alt i mor e a nd explained our response to a representative of HCFA. HCFA was interested in medical physics services in radiation oncology because a number of letters suggested that the proposed APC re-embursement rates were not sufficient to support medical physics activities. All physicists who wrote to HCFA should understand that there has been a response t o t hei r le t te rs.

(When any federal CPT Code o r sta te age ncy (MD file) requests public comments, it is important 77295 to provide reason77300 able and re l e v a n t 77305 responses, both indi77310 vidually and through 77315 our various organiza77321 tions.) The deadline 77326 for public responses 77327 to this proposal was 77328 July 30th. Both the 77331 A C R an d A STR O 77332 su b mit te d v ery 77333 detailed, important 77334 responses by this 77336 deadline.

77370

The HCFA re p re s e n t a t i v e was pleasant and attentive.

She informed us that she had been visited by a number of other interested groups. We visited for a brief period and exchanged personal information. She had had personal experience in radiation oncology and was aware of the fact that treatment units were not always functional. She agreed with our statement that medical physics services were an integral and necessary part of the treatment delivery process.

Together we reviewed the HCFA data and the AAPM data.

The two data sets were very different. She promised that she would forward the AAPM data to the consultants from 3M who were analyzing the charge and cost data for HCFA. In the Balanced Budget Act of 1997, Congress mandated that HCFA use 1996 Medicare claims data to establish an outpatient prospective payment Total OPD Claims Single Claims (Revised APC File) 10,014 395,875 18,532 13,885 126,522 18,363 1,314 1,868 12,101 104,282 21,301 15,918 314,524 937 353

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system. The goal is to reduce M e d i c a re expenditures by approximately 5%. HCFA and their consultants analyzed a portion of the 1996 Medicare charges and defined their initial APC proposal, including the payment amounts for the various APC’s. There are problems with their analysis.

One problem, which has been pointed out by ASTRO and others, invo lves multipl e claims for patient services on a si ngl e da te . Sub st ant i al amounts of data were apparently ignored by impro p e r handling of this common situation. The following data was taken from the ASTRO July 30th, 1999 response and indiNumber of Claims Used to Calculate Rate 329 540 70 211 602 115 7 7 490 170 92 164 634 5,234 712

% of Total

3.3% 0.1% 0.4% 1.4% 0.5% 0.6% 0.5% 0.5% 4.0% 0.2% 0.4% 1.0% 0.2% 558.6% 201.7%

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cates some of the deficiencies of the initial HCFA analysis.

HCFA has minimum, maximum, mean, and median cost data for each CPT code in their revised APC file, as well as median charge data. It was from that data that HCFA constructed the APC re-embursement rate.

T he AA PM resp onse to HCFA for the costs of providing medical physics services a d d ressed only the 773XX codes, although it noted that physicists made important contributions to other codes as well, e.g. 77295. The cost of providing these services was based upon the time required, the cost of equipment, and the cost of the annual support for that equipment. The time estimates for a qualified medical physicist to provide an individual patien t wi th services

described by each 773XX code was taken from the 1995 study performed by Abt Associates, “The Abt Study of Medical Phys ic s Wo r k Va lu es fo r Radiation Oncology Physics Services”. In addition to physics time, the time for the medical dosimetrist and the mo ld lab tech were also included. The inform a t i o n was presented to HCFA in the same format that HCFA had re qu est ed w he n pra cti ce expense data was being submitted to them. A conscious decision was made to provide a reasonable estimate of medical physics services. The cost of physics services is not a simple question, however.

Individual practices will differ from the AAPM estimates.

What happens next? HCFA is under a congressional mandate to act. The expected course of events will most like-

CAMPEP

by Eric Klein St. Louis, MO On March 30th 1999, the H ealth C are Fi nance Administration confirmed that formal medical physics residency programs are considered to be an approved educational activity. This confirm a t i o n strengthens a provider’s (hospital) request to have training costs associated with physics residents reimbursed. In the regulatory guide 42 CFR 413.85, m e d i c a re supports hospital costs associated with, specific and other, appropriate training p rograms. Though medical

physics is not a specific listed program, the March 30th letter confirms that it is an appropriate training program for and allowable for reimbursement, as long as certain are met. They are as follows; T he p rogr am mus t be accredited by CAMPEP. If state licensure for the program is re q u i red, and licensure is granted to the program, this may serve in lieu of CAMPEP accreditation. CAMPEP has a specific methodology and set of requirements for accreditation. No state licensure program includes medical physics to date.

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ly include a review of all of the public comments, followed by the development of a revised APC proposal, and its internal review and publication. The likelihood of HCFA publishing their final rule for public comments is small. It is expected that HCFA will publish their final rule this fall to become e ffective in the year 2000.

THE FINAL RULE IS, OF COURSE, NOT FINAL. It is just the starting point. There will be mechanisms for modifying the final rule to reflect both problems with the rule and the continuing evolution of medical practice. Medical physics will have to collect detailed data on the cost of providing physics services and be prepared to continue to work with HCFA and other organizations to create a fair and equitable APC system. ■

• The provider must incur costs associated with training.

• The provider must control of the curriculum and determine graduation requirements.

• The provider must control administrative duties and the day-to-day operation.

• The provider must employ the faculty.

The provider must provide and control the classroom and clinical instruction.

1) Apply for CAMPEP accreditation. Applications can be obtained from Dr. Richard Lane, Chairman, Residency Education Program Committee of CAMPEP. 2) Once accreditation has been received, immediately alert the finance department of

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the institution, specifically someone who handles reimbursement. If CAMPEP accreditation has not been received, but is in process, a HCFA intermediary may still approve reimbursement for your program.

3) Provide the finance person with all direct costs for the individual. Direct costs include salary and benefits. The indirect costs, such as those associated with faculty, space, etc. a re very difficult to pass through due to HCFA’s distain for joint product. In other words, on-the-job-training is not a true additional cost as a technical task is being performed for the patient and nothing additional is being expedited due to the training.

If an institution attempts to pass through indirect costs, c a reful documentation with justification is re q u i red. In addition the department must c l ea rly ou t line tha t th e p rovider has fulfilled the re q u i rements listed above.

This should not be a problem for hospital based physics programs, or for clinics where the university provides the faculty and that the hospital pays the university for the physics faculty efforts and that the hospital still has administrative responsibility.

4) The finance individual then adds these costs to the department center cost. The amount reimbuirsed depends on the amount submitted and

the percentage of medicare to total generated revenue.

Typically finance will further add on costs such as global h o s p i t a l co s t s ( h u m a n resources, etc.) that formal medi cal physi cs i nit iate receiving reimbursement is as follows: A copy of the letter sent by HCFA can be obtained from .

Eric Klein.

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Letters to the Editor It Is Vital For Us To Be Medical Specialists Reply to Brezovich Letter

by Howard Amols New York, NY I feel compelled to rebut statements made b y Ivan Brezovich in his letter to the July/August issue entitled “It is vital for us to be medical specialists”. I think Ivan and I are striving for the same things.

Namely recognition of the important roles we play in patient care, and fair pay for doing it. But Ivan argues that we should get these things because we are medical specialists in ‘physics’. I on the other hand want these same things because I am a medical

physicist. And the difference between being a medical physicist and a medical specialist with special expertise in physics goes a lot deeper than semantics.

Some of the statements Ivan made in his letter, although clearly not meant to be so, could easily be misinterpreted as being self deprecating remarks about the intrinsic merits of physics relative to those of medicine. For example: 1. “We are being paid for our expertise in the medical field”’ 2. “in our subspecialty physics is just a means for becoming a medical specialist” 3. Expertise in physics is

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‘irrelevant unless we work in [medical] areas”’ 4. “If we insist on being ‘just physicists’ we will surrender the prestige, compensation, and authority associated with beingmedical specialists” 5. “We may lose some of our current fringe benefits, like the corner office or parking space.”

I’m sure he’s not really trying to saying it, but the above sounds a lot like medicine is a noble profession worthy of respect and high salaries, while physics is an interesting but useless (at least in a hospital) intellectual diversion for nerds who don’t deserve fancy offices or reserved parking spaces. But all of this can be rectified if we call ourselves medical specialists instead of physicists or scientists!

Firstly, let’s explore the very

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name of our pro f e s s i o n — ‘Medical Physics’. In this term ‘Medical’ is an adjective, and ‘Physics’ is THE NOUN. That means (see for example, the dictionary, or English-101) that we are physicists. The adjective ‘medical’ is a modifier that merely gives a little more information about what kind of physicists we are. It differentiates us from solid state physicists, low temperature physicists, etc. After all, none of us went to medical school to get degrees in ‘Physical Medicine’ hoping to be called ‘Physical Physicians’ or physicians with special expertise in physics.

Such a degree would have distinguished us from other types of physicians such as Neurological Physicians who have expertise in nerves and brains; or from Pulmonary Physicians who have expertise in lungs, etc. And while all medical schools offer courses on brains and nerves and lungs, none offer any courses on physics. Why, one might ask, is this so?

It is quite simply because there is no such medical specialty known as physics!

Physics is a science- not a subfield of medicine. Physics is taught in a school of Arts and Sciences. Along with other fields of enormous importance to society such as literature, history, music, biology, chemistry, mathematics, engineering, etc.

Ok- I’m being semantic and pedantic! Let’s get to the point.

When accepting his re c e n t Coolidge Award Dr. Faiz Khan said ‘I am proud to be a physicist!’ Well dammit- so am I! The early development and success of Radiology and Radiation Oncology; the invention or dis-

covery of X-rays, radium, linear accelerators, artificial isotopes, CT, MR, etc.; were all made possible by the close cooperation between physicists (Roentgen, Becquerel, the Curies, Coolidge, Williams, etc), inventors (such as Edison), engineers (Tesla, Grubbe), physicians, and others; all working as experts in their chosen fields without any concern about who was a ‘medical specialist’ and who was not.

Why can’t we continue in this historical context and simply work together as colleagues.

Let’s continue to be proud physicists instead of being physician wannabes?

Yes, there are some physicians and administrators who consider physicists to be second class citizens. But they are the ones with the problem not us!

Let’s try to correct that situation by educating ‘those kinds of people’ about the history of Radiology and R adiation Oncology and the importance of physics; not by pretending to be ‘medical specialists’. I’ve never regretted not having an MD after my name. In my training as a physicist I was taught skills that are different from, and just as important as the skills physicians were taught in medical school. If physicists themselves question the importance of, or financial worth of someone who is ‘just a physicist’ then how can we expect nonphysicists to respect us or our profession?

Physicians need to respect us because our training and skills are different from and complementary to theirs - not because were ‘just’ another medical specialist. Physicians never ask us questions like ‘Gee, do you think that tumor is a stage 2A or

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2B?’ They ask us things like ‘Why the hell isn’t that machine working?’ The first question is medicine. The second is physics (or maybe engineering). And the patient who goes to a hospital w h e re the physicist doesn’t know why the machine isn’t working is in at least as much trouble as the patient whose doctor doesn’t know the difference between stage 2A and 2B. That is why medical physicists should be fairly paid, respected, and entitled to corner offices and parking spaces- not because we’re just another medical specialist. Let’s get those rights for the right reasons. Let’s get them because we are the ONLY people in a hospital who know physics and we provide a vital service to patients in our capacity as physicists. I would beg to disagree with any physicist who thinks that we’re all being paid fat salaries because of our ‘medical expertise’. We’re getting paid because we know what makes a linear accelerator tick, and a CT scanner tick, and a computer tick, and why x-rays interact in matter the way they do. And most importantly, we didn’t spend 4-8 years in medical school and residency memorizing things. We spent 4-8 years in graduate school learning how to think, solve problems, assess new technologies, and be all around clever people who can be relied upon when everybody else is stumped. I’d suggest that any physicist who feels like he or she is ‘just a physicist’ would be better off in another line of work. Preferably some kind of employment close to a bus route since you probably won’t be taking your assigned parking space with you to your new job.

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Letters to the Editor

ABR / ABMP

By Stewart Bushong Houston, Texas At a recent medical physics meeting I was told again that the AAPM cannot provide “tangible support” for the ABMP or the AAPM risks its sponsorship of the ABR. This was one argument at the 1998 AAPM Business Meeting in San Antonio to attempt to deny hotel facilities for the conduct of the ABMP examination. It has also been used as justification to limit space in this Newsletter for ABMP information.

In response to this action and the ongoing ABR-AMBP discussions, the ACMP (one of two sponsors of the ABMP) drafted a proposal for the unification of the ABMP into the ABR. As President Ibbott reported in the May-June, 1999 Newsletter, this effort had the full support of the AAPM yet was denied by the ABR following a vote of 4 ‘no’, 2 ‘yes’, and 2 ‘abstain’. The ‘yes’ votes were cast by AAPM and ASTRO. To me, this indicates that our radiation oncology physician colleagues appreciate and support their medical physics coll eag ues. W hat about the diagnostic radiology community? In rejecting the ACMP prop osal the ABR mad e no alternate suggestions.

I have been told many times that were the AAPM to sponsor another Board we would be automatically removed as spon-

sors of the ABR. I reviewed a copy of the Constitution and By-Laws of t he ABI and nowhere in these documents did I see any reference whatsoever to sponsorship of additional Boards by a sponsor of the ABR. Would someone please correct me on this and direct me to where this prohibition exists.

Regardless, it is time for the AAPM to sponsor the ABMP. Currently 583 AAPM members are ABMP diplomates.

It is disappointing that the AAPM cannot select its own trustees to the ABR As President Ibbott reported, the AAPM submits nominees and the ABR takes it’s pick. On the other hand, the ABMP is made up of those members appointed by its sponsoring organizations, not those chosen by the ABMP. I have no desire to interfere with the relationship between the AAPM and the ABR. I totally support AAPM’s sponsorship of the ABR, but I am concerned that the AAPM may find itself in an embarrassing situation if it is not a sponsor of the future s t r u c t u re of the ABMP. Currently the ABMP is sponsored by the ACMP and the AAHP. It is possible that in the future other organizations like the SDMS, the MRS and the ACC may become sponsoring organizations. Regardless of these possibilities, the AAPM should be a sponsoring organization of the only medical physics certification board run by, controlled by, and solely desi gned to ben efit medical physicists.

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ACMP Appoints ABMP Directors

by Eric Klein New York, NY The American College of Medical Physics (ACMP) has a p po in te d La wr e n c e Rothenberg and Michael Gillin to the American Board of Medical Physics (ABMP) Board of Directors. These appointees replace Faiz Khan and Paul Lin, whose terms of service conclude at the end of this year. Both Drs. Rothenberg and Gillin have served as C h a i rman of the Board of Chancellors of the ACMP. They have been active within the ABMP, participating in the oral exams as well as in the preparation of the written exams.

Dr. Rothenberg is immediate past-President of the AAPM and is currently the Chairman of the AAPM Board. Dr. Gillin is currently the Chair of the AAPM Professional Council.

Composition of the board effective January 1, 2000 will be: Lawrence Reinstein, Kenneth Hogstrom, Benjamin Archer, Eric Klein, Lawrence Rothenberg, Michael Gillin, Richard Vetter, and Kenneth Miller.

ABMP RECERTIFICATION The American Board of Medical Physics recognizes the importance of continuing professional development and

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awards Certification on a timelimited basis. At its inception, the ABMP Certification was structured as a time-limited one of ten years. To remain listed on the Registry of Certified Medical Physicists (published annually in the ACMP Membership Directory), Diplomats must renew their certification following expiration of initial certification.

Recertification, after the initial 10 years, is time-limited to five (5) years and renewable every five (5) years thereafter. To be eligible for renewal, Diplomats will be required to provide evidence of continuing active practice and education.

Before March 1 of the tenth year after initial certification, Diplomats must submit:

1) A statement of current medical physics practice 2) A ledger of continuing education credits indicating that at least 72 hours of approved continuing educatio n c re di ts ha ve b ee n obtained for the three years p receding the application.

Documentation of CE credits from independent organizations such as CAMPEP should be provided, and 3) A nominal recertification fee.

At this time there is no requirement for a recertification examination or practice review.

The next group of candidates eligible for recertification, will be those certified in 1990. The necessary forms and information will be sent to these individuals in the near future.

Memorial Fund For Hy Glasser

by Steve Goetsch La Jolla, CA A memorial fund in memory of Hy Glasser has been established by the Development Committee of the AAPM. The fund was creatd by a generous and spontaneous gift fro m CIRS, Inc. in Hy’s name. Many AAPM members remember Hy Glasser, the founder of Nuclear Associates, who passed away last year. His kind, gregarious nature and loud laughter are much missed at our annual

meetings. A number of our Corporate Affiliates have indicated that they wish to keep Hy’s name and spirit alive. CIRS suggests that a scholarship, fellowship or residency by set up in the name of Hy Glasser. The Development Committee will meet at the RSNA on November 28 to review contributions to date and see how best to utilize the funds. Contributions can be made payable to AAPM Education Endowment Fund and sent to Sal Trofi at AAPM.■

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SEPTEMBER/OCTOBER 1999

ACMP 2000 TESTING SCHEDULE Part I: General Medical Physics Written Exam July 22, 2000 Chicago, IL Deadline for applications: Jan. 15, 2000

Part II: Specialty Written Exams Radiation Oncology Physics Diagnostic Imaging Physics Hyperthermia Physics Medical Health Physics Magnetic Resonance Imaging Physics July 23, 2000 Chicago, IL Deadline for applications: Jan. 15, 2000

Part III: Specialty Oral Examinations Radiation Oncology Physics Diagnostic Imaging Physics Hyperthermia Physics Medical Health Physics Magnetic Resonance Imaging Physics April 13-16, 2000 Chicago, IL Deadline for applications: December 15, 1999 For further information, contact: American Board of Medical Physics Inc. c/o Credentialing Services, Inc. P.O. Box 1502, Galesburg Illinois 61402-1502.

Tel. (309) 343-1202 FAX: (309) 344-1715 ■

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Letters to the Editor Reply to Brezovich Letter Reply to Brezovich Letter

by John Glover Plymouth, MA Ivan Brezovich and I are either playing a very silly game or we are raising some very serious questions about who we are as a profession. I do not consider myself a medical specialist which, in common parlance (1), means a specialist in medicine. I consider m yse l f a SP EC I AL IST in PHYSICS. I think the founders of the A m eric an As soc i ati on of Physicists in Medicine chose t h at nam e ca re ful ly: for instance, they did not call the o rganization “the American A ss oc i ati on o f Me d ica l Specialists (Physics)”, etc.

As Dr. Sarah Donaldson pointed out in our newsletter of Sept/Oct 1997, our eventual involvement with the ABR was not a grassroots action initiated by physicists (although physicists were involved) but rather an action initiated by a physician within the ABR. Now, by virtue of our involvement with ABR, we are involved with the American Board of Medical Specialties. But if ABR were not in ABMS while still certifying physicists, ABMS would not allow ABR to join (2). Nor would ABMS allow us to join independent of ABR. So our putative designation of “medical specialists” is not because

we ARE medical specialists but simply an accident of history.

And this is the simple answer for which Dr. Brezovich was looking. In no other context and by no other authority are we referred to as medical specialists. Pursuing this delusion just dilutes our efforts at proper professional status.

And it raises the very divisive question: Are only physicists certified by the ABR to be referred to as “medical specialists”?

Le me respond to some of Dr. Brezovich’s specific points.

Dr. Brezovich signed his letter (3) not as a private member but as C hai r m an o f t he R e imb urs e me nt Pa tter n s Subcommittee. Does this mean that his view is the official stance of the AAPM? I surely don’t remember any such action by the Board or vote of the membership.

R ad io lo g i s t s w h o t o o k undergraduate degrees in life sciences don’t refer to themselves as biologists because they went to medical school, obtained licenses to practice medicine, and took residencies in radiology. These are activities that we do not do, although we may go to graduate school for physics, get licensed to practice medical physics, and, less likely, go t h r o u g h a r e s id e nc y i n medical physics.

Dr. Brezovich correctly quoted me in his header, to wit, “just being physicists.” But twice in the body of his letter he uses the expression “being just physicists.” There is a world of difference between

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those two phrases. My phrase connotes satisfaction with my profession; his does not.

He would also imply that the Federal government may take special care of us by citing an action taken on behalf of Family Practitioners. I contend the feds have done nothing to treat us as medical specialists and aren’t likely to: through HCFA (AMA-CPT) billing rules, they don’ t even consider us professionals.

And it is our accomplishments in education, experience, certification, and our w i ll in gne s s t o d eal w ith PATIENTS (and not just lab rats and instruments) and the attendant re s p o n s i b i l i t i e s , pressures and risks that justifies our relatively good compensation and not some quirk of nomenclature.

B ut f inal l y, ye s , Dr. Brezovich, we do need broader (and deeper) recognition, but not as what we can never be but as what we are and should be: a profession that stands on its own feet.

(1) Webster’s Third New I n t e r nat io nal D ict io na ry Unabridged, 1971, p.2186 (2) Guy Simmons, AAPM newsletter, Jan/Feb 1999, p.6 (3) Ivan Brezovich, AAPM newsletter, July/Aug, 1999, p. 11■

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CRCPD Report on the AAPM Annual Meeting

by Jill Lipoti Trenton, NJ The AAPM members extended a warm welcome to me at the i r an nu a l m ee tin g in Nashville. It was a pleasure to represent the Conference of Radiation Control Pro g r a m Directors. Yes, I really mean that! The traditional friction that has existed between regulators and the medical physicis ts ha s c han g ed t o a realization that we can both help each other.

T h e re is a problem that CRCPD and AAPM can work on together. CRCPD writes regulations, but by the time they are written, they are almost instantly out of date du e t o t h e tre m e n d o u s advances in medical technology. We, as regulators, need to anticipate the technological advances and devise our regulatory strategies earlier. The AAP M S ci entifi c s ess io ns showcase what is going on in research in the Americas. The P resident’s symposium on Intravascular Brachytherapy was particularly enlightening.

The exhibit hall was also set up to help people understand the latest and greatest in diagnostic and therapy systems.

Maybe we should fund some of our SSR committees to meet in conjunction with the AAPM meeting to encourage medical physicists to get involved in the SSR committee work, and to ta ke adv ant ag e o f the exhibitors.

The AAPM committee meetings are open to anyone, and I

attended a meeting of the Reference Values Task Group (TG #7). They will be writing an article for the Newsbrief on their activities since they are using data that we collected through the NEXT surveys.

In the Leg i sla tion an d Regulation Committee, there were a number of questions about how to work with C o n g res s a nd Sta te Legislatures for more effective legislation. The Shielding Design Rewrite (TG #13) Committee has Bob Quillan as a member. They are working on a document that will be released by NCRP and will be extremely useful to standardize shielding design. It is obvious that the committees’ work will have a direct impact in improving public safety and health. As such, there is common ground between the regu la t ors and t he me d ica l physics community.

I presented a paper at the P rofessional C ounci l Symposium. The conference staff deserves a great deal of credit for making it as easy as possible for speakers to submit abstracts and papers to be posted on the web. The full text of my talk is posted on the AAPM website. The audience had a number of questions. Don Tolbert was particularly outspoken in his support for the CRCPD and AAPM partnership.

Due to my particular interest in mammography, the scientific sessions on Breast Imaging, Digital Mammography/ Digital Radiography, and ComputerAided Diagnosis/ PACS were

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very helpful. I’ll be honest some of the papers were too advanced for me to understand or too esoteric for me to see the connection to real life, but I was on a fast learning curve. Dr. B a rnes’ session on Patient Dosimetry in Radiography and F l u o roscopy, though, was understandable, practically applicable, and a refreshingly candid assessment of the stateof-the-practice, and how it could be improved.

I was bursting with pride during the awards presentation. Three of the new fellows were individuals who were instrumental in improving relations with the CRCPD. They w e re Melissa Martin, Keith Strauss, and Orhan Sulieman.

Representing CRCPD was a tremendous opportunity for me to help bridge the gap between the members of our respective organizations. I hope that as more of the CRCPD members participate in AAPM activities, and AAPM members serve on CRCPD committees, we can continue to learn from each other. It is also essential that medical physicists become “ i n t e rested parties” in their respective states. If we can learn to think globally, but act locally, we can have an even greater impact.

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AAPM NEWSLETTER MANAGING EDITOR Marsha Dixon

EDITOR-IN-RESIDENCE Robert Dixon Send information to: Marsha Dixon Broadcast News Public Relations 201 Knollwood Street Winston-Salem, North Carolina 27104 (336) 721-9171 Phone (336) 721-0833 Fax e-mail: rdixon@rad.wfubmc.edu The AAPM newsletter is printed bi-monthly. Deadline to receive material for consideration is four to six weeks before mailing date. We welcome your entries, and encourage authors of articles to supply a photo. Please send material via e-mail, disks or mail. Faxes are encouraged as back-up, and are acceptable alone.

NEXT ISSUE November/December, 1999

DEADLINE

MAIL DATE

October 15, 1999

November 15, 1999

Editorial Board Benjamin Archer Bruce Curran Marsha Dixon Don Frey John Kent Richard Morin Alfred Smith

AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE One Physics Ellipse College Park, Maryland 20740-3846 (301) 209-3350 Phone (301) 209-0862 Fax e-mail: aapm@aapm.org http://www.aapm.org

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