Newsletter
AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE VOLUME 26 NO. 4
JULY/AUGUST 2001
AAPM President’s Column Coffey Break Charles W. Coffey, II Nashville, TN
Panama Incident It was with sadness that we received the news of the recent radiation incident at the National Oncology Institute in Panama. The AAPM was a cosigner of a response letter written by the American College of Radiology and the American Society of Therapeutic Radiation Oncology that presented this matter to the United States radiology, radiation oncology, and medical physics communities. (This letter is posted on the AAPM Web site.) The incident centered around a misinterpretation of procedures for the proper use of a treatment plan-
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ning computer in the cobalt-60 irradiation of approximately 28 radiotherapy patients. This incident is a tragic reminder of the need for a viable quality assurance program under the leadership of a qualified medical physicist. A QA program “on paper” and for inspection purposes only is not enough. Maintaining a QA program that requires continuing quality assurance measurements throughout the entire radiotherapy process including radiotherapy simulation, treatment planning, and patient irradiation procedures is a necessity. As the news of this incident reaches the American press and our own radiotherapy patients, you may have the opportunity to emphasize the important role that medical physicists and the AAPM play in the writing, implementation, and continuing data assessment of quality assurance guidelines and procedures in radiology and radiation therapy. Additionally this would be an excellent opportunity to become proactive and write your members of Congress and let them know of the important role(s) of medical
JCAHO Liaison Network Conference Report Geoff Ibbott Houston, TX For a number of years, it was my pleasure to represent the AAPM at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). During my term as chair of the AAPM’s Professional Council, I followed the lead of the previous chair, Don Tolbert, as well as several other (See JCAHO - p. 5)
TABLE OF CONTENTS President’s Column p. 1 JCAHO p. 1 Undergrad. Fellows p. 3 Baily Awards p. 5 Members in News p. 8 Exec. Dir’s. Col. p. 9 Gov’t Rel. Col. p. 11 WIPHYS p. 12 Financials - 2000 p. 13 CRCPD p. 14 Letters to the Editor pp. 17, 18, & 19
(See Coffey - p. 2)
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Coffey (from p. 1) physicists in radiology procedures and radiation therapy treatment delivery.
National Institute of Biomedical Imaging and Bioengineering The National Institute of Biomedical Imaging and Bioengineering Task Group of the AAPM Research Committee has recently been restructured under the leadership of CoChairs Paul Carson and Phil Judy. This restructuring has included an increased task group membership and the assignment of new objectives and charges. The NIBIB Task Group sponsored two informative sessions at the Annual Meeting that provided information on the status of the NIBIB, suggestions for submitting and directing NIH research proposals to the NIBIB, and future medical physics imaging opportunities within the NIBIB. Additionally, the NIBIB Task Group is active in the submission of AAPM nominees for positions of leadership including administrative and institute research study-section leaders within the NIBIB organizational structure.
Ad Hoc Committee on Imaging with the AAPM One of the issues discussed at the recent Long Range Planning Committee Meeting in
April of this year was the decreasing presence of diagnostic and imaging physics within the AAPM organizational structure and its sponsored meetings and symposia. As president, I was petitioned to name an ad hoc committee to investigate this issue and suggest methods and organizational structure to better emphasize diagnostic and imaging physics within the AAPM medical physics community. I have named Richard Morin as chair of this ad hoc committee.
Joining Rick on the committee are a number of imaging scientists representing the major clinical and research modalities in imaging physics. Additionally, I have appointed to this committee several members of the Association who will represent the concerns of the Education Council, the Science Council, and the Program Committee during discussions of any suggested changes within the present organizational structure. This ad hoc committee will report to EXCOM and the AAPM Governing Board with appropriate objectives and suggested rec-
ommendations for the implementation of a more autonomous medical physics imaging entity within the AAPM. The projected timeline for the completion of this activity is estimated at 12-18 months.
Ad Hoc Committee on Recruitment of Young Physicists into Medical Physics I have named Bruce Thomadsen as chair of an ad hoc committee to investigate the need and associated timelines for the recruitment of qualified young students into medical physics. This committee’s charge includes recommendations for increased interaction between the AAPM and members of the Society of Physics Students (SPS) through involvement of a mentor program coordinated by the Regional Organization Committee, investigation and review of the concept of a 3 + 2 (bridge) Education Program in medical physics, and promotion of medical physics education and careers within our sister societies, the American Institute of Physics (AIP), the American Physics Society (APS), and the American Association of Physics Teachers (AAPT). Committee member appointees include individuals from the Training of Medical Physicists Committee, a representative from the Manpower Assessment Subcommittee, a representative from the Regional Organization Committee,
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medical physics educators, and consultant members from the AIP, APS, and AAPT. In view of this committee’s assignments, I want to commend the efforts of the Summer Fellowship Program Subcommittee in the initiation of its summer undergraduate fellowship program this year (see report elsewhere in the newsletter).
Ad Hoc Committee on Government Relations Coordination Upon recommendation from both the Headquarters Site Review Committee and the Long Range Planning Committee, I have appointed an ad hoc committee to examine and, where possible, initiate the following tasks: provide oversight, direction, and accountability to the AAPM Government Relations effort, coordinate Government Relations efforts within the Association to help establish a united AAPM voice, assist in the coordination of Government Relations efforts between sister organizations to help establish a united medical physics voice, and establish an educational/informational program(s) that will inform and enlist AAPM members’ responses to Government Relations issues. This ad hoc committee will report to EXCOM and the Board and will present recommendations at the 2002 Annual Board Meeting for continuing these tasks through the forma-
Announcement 2001 Summer Undergraduate Fellows The AAPM Summer Undergraduate Fellowship Subcommittee is pleased to announce the following recipients of its 2001 Fellowships. Each fellow is mentored by a full member of the AAPM. Joshua Aaron James Junior, Physics Western Kentucky University Mentor: Darryl Kaurin, Ph.D., Vanderbilt University Medical Center Matthew Anderson Jessee Junior, Nuclear Engineering University of Tennessee, Knoxville Mentor: Jatinder Palta, Ph.D., University of Florida Jeananne Miller Senior, Physics University of Kentucky Mentor: Ali Meigooni, Ph.D., University of Kentucky Medical Center Nathaniel Johnathan Nelms Senior, Physics University of Iowa Mentor: Russell Hamilton, Ph.D., University of Chicago Anne Sakdinawat Senior, Electrical Engineering/ Computer Science/ Bioengineering University of California, Berkeley Mentor: Bruce Hasegawa, Ph.D., University of California, San Francisco Shannon Treis Junior, Physics University of Puget Sound Mentor: Ray Luse, M.S., Sacred Heart Medical Center, Spokane, WA
(See Coffey - p. 4)
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Coffey (from p. 3) tion of a standing committee with appropriate representation and charges. Mike Gillin is the chair of the ad hoc committee; committee membership includes representatives from the Legislation and Regulation Committee, Radiation Protection Committee, Radiation Therapy Committee, Diagnostic X-ray Imaging Committee, Nuclear Medicine Committee, the Education Council, EXCOM, HQ staff, and a consultant member from the AIP Government Relations group.
IMRT In recent months, much attention has been given to IMRT radiotherapy techniques. The increasing momentum given to IMRT within the radiotherapy community is related directly to the now widespread availability of IMRT technology and clinically proven patient treatment procedures. The AAPM addresses IMRT issues through its IMRT Subcommittee under the direction of the Radiation Therapy Committee. To date, no AAPM documents have been published that discuss and describe technologies and techniques used in IMRT radiotherapy procedures. However, a number of AAPM members have participated in the preparation of an IMRT consensus paper developed under the auspices of the National Cancer Institute. This group, the Intensity Modulated
Radiation Therapy Collaborative Working Group, chaired by Jim Purdy, has recently completed and submitted a consensus manuscript entitled, “Intensity Modulated Radiation Therapy: The State of the Art Current Status and Issues of Interest,” for publication in the International Journal of Radiation Oncology, Biology, and Physics. The Radiation Therapy Committee and the IMRT Subcommittee of the AAPM, and the Physics Committee of ASTRO have agreed to aggressively proceed with deliberations and investigations and subsequent publications of task group reports and guidance documents of IMRT issues on behalf of the medical physics community.
Twenty-five Years of AAPM Membership Within the last few months, approximately 750 of our members have received a 25-year commemorative lapel pin representing their association with the AAPM as a member for twenty-five years. My congratulations to each of you and my personal thanks for your commitment and service to the AAPM through the years. This project, an idea from the Planned Giving Subcommittee, will serve as the kickoff effort for the 2001-2002 Planned Giving Campaign for the Education Development Fund. This commemorative pin project is not a one-time special offer associated with the Planned Giv-
ing Campaign; each AAPM member will receive this pin when he/she completes twentyfive years of membership.
Thanks My year as president is now one-half complete. I want to take this opportunity to thank each one of you who has “answered the call” on my behalf. I am constantly reminded that leadership is a team concept as I continue to enlist the efforts of countless AAPM members to perform tasks and serve on committees. Our Association is growing and experiencing change as we face increasingly difficult financial, technological, regulatory, and professional issues. Thanks for your commitment and willingness to serve as we face these challenges together. If you are still looking for a place to serve, let President-Elect Bob Gould, a committee chair, or myself know. I extend my thanks and appreciation also to HQ executives and staff who continually make the AAPM a better and more efficient administrative organization. My “hat is off” to them as they have made preparations and coordinated the planning necessary for another successful Annual Meeting. ■
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Announcement 7th Annual Norm Baily Awards Presented Steve Goetsch, Education Chair La Jolla, CA The Southern California Chapter of the AAPM has announced the winners of the 7th Annual Norm Baily Student Awards. The winners for this year are all graduate students in the UCLA Biomedical Physics Program. Each student submitted a paper and the winners made 15 minute oral presentations at the chapter meeting in Carlsbad, California on May 17. Randi Aaronson (Academic Advisors John DeMarco and Tim Solberg) spoke on “A Monte Carlo Model for Qual-
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ity Assurance of IMRT Incorporating Leaf Specific Characteristics.” Nzhde Agazaryan (Academic Advisor Tim Solberg) spoke on “Deliverability Scoring and Dosimetric Investigation of Leaf Sequencing in IMRT.” David McElroy (Academic Advisor Ed Hoffman) spoke on “Ultra-High Resolution in vivo I-125 and Tc-99m Small Animal Pinhole SPECT Imaging.” Each student received a certificate and a $500.00 award from the chapter. The award is given each year in memory of Professor Norman Baily of the University of California, San Diego. ■
Baily Award Winners: (l to r) Randi Aaronson, David McElroy, & Nzhde Agazaryan
p. 1)
senior AAPM members, and made relations with the JCAHO a high priority. When I resigned my position as chair to become an AAPM officer, I reluctantly put this responsibility into the capable hands of the current Professional Council chair, Mike Gillin. So it was a welcome surprise when, due to Mike’s busy schedule, I was presented with the opportunity to visit the JCAHO again June 7-8. In part, I welcomed the opportunity because I would be speaking at the AAPM Summer School on the topic of JCAHO Accreditation. This opportunity was to attend the 9th Annual Liaison Network Conference, a yearly event to which representatives of organizations with an interest in JCAHO standards are invited. The conference, as in the past, was held at JCAHO headquarters in Oakbrook Terrace, a suburb of Chicago, and spanned most of two days. Several plenary sessions were held, as well as “breakout” workshops that allowed for smaller groups to meet with senior JCAHO staff. About 60 representatives of interested organizations attended. Mark Bruels attended on behalf of the ACMP. The conference began with a talk by Dr. Dennis O’Leary, who has been president and CEO of the JCAHO since 1986. (He came to the attention of the JCAHO, as well as the nation, when he appeared (See JCAHO - p. 6)
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JCAHO (from p. 5) frequently on television in 1981 following the attempted assassination of former President Ronald Reagan. He was then spokesman for George Washington University Hospital.) Other talks were given by senior JCAHO staff, including Dr. Richard Croteau, who is quite well-known to medical physicists having made presentations at several of our meetings. The attendees were reminded that the JCAHO had its origins in the hospital standardization program founded by the American College of Surgeons (ACS) in 1912. In 1946, the Hill-Burton Act made certification by the ACS a requirement for hospitals to receive federal funding for health care. The JCAHO itself was formed (as the Joint Commission on Hospital Accreditation – the term “standardization” was dropped just before incorporation) in 1951, making this their 50th anniversary. Further, the JCAHO remains the only private organization that oversees life-threatening facets of human existence. The JCAHO presently accredits about 5,000 hospitals, and nearly three times that number of other types of healthcare organizations. The number of accredited hospitals has been decreasing at the rate of 2-3% per year due to hospital closings and mergers. Most medical physicists are familiar with the JCAHO’s pro-
gram of visits made by surveyors on a triennial schedule, and the extensive preparations that precede such a visit. Perhaps fewer physicists are familiar with the JCAHO standards, and the manner in which they are developed. There is not room here to do more than mention a couple of the standards and some changes in JCAHO activities most important to medical physicists.
The JCAHO has for the last year been conducting random, unannounced surveys in an effort to catch hospitals unprepared, when their practices are more representative. These surveys have received mixed reviews, with some hospitals welcoming the encouragement to be continually prepared rather than mounting an extensive preparation process in the weeks and months before a visit. The JCAHO is also fieldtesting a program in which hospitals are visited once between the triennial survey, with an emphasis on education and support, rather than scoring. Several trends that might threaten the accreditation process have caused the JCAHO to take a close look at their standards and procedures. In early June, the Health Care Finance Administration (HCFA)
published their intention to publish “score cards” on hospitals on a quarterly basis. At the same time, the Institute of Medicine (IOM) study, “Crossing the Quality Chasm,” emphasizes the observation that several goals of the health care industry, particularly performance measurement and evidence-based practice, suffer from a lag in the implementation of information technology. The IOM also has highlighted the need to foster an environment that encourages the reporting of errors without the risk of punishment. New legislation (sponsored by Sens. Kennedy and Jeffords) that is intended to improve patient safety is anticipated. As well, several recent events of terrorism, particularly bioterrorism, further focus efforts on preparedness. This review has led to an emphasis on making accreditation more valuable to hospitals, and to an increased focus on improving patient safety. Consequently, the JCAHO has written several new standards, and revised a number of others, in an effort to better address today’s healthcare climate. One of these, EC.2.10.3, previously required hospitals to perform preventive maintenance procedures on equipment on a yearly basis. This minimum frequency has been removed because the JCAHO now expects hospitals to develop programs of inspection that assign frequencies appropriate to each piece of equip-
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ment. For radiological equipment, hospitals should refer to publications such as those of the AAPM to ensure that their own programs comply with these recommendations. Hospitals are expected to review the Sentinel Event Reports disseminated by the JCAHO and take actions to reduce the likelihood that such an event can occur in their institutions. Also, new terminology has been introduced to encourage the prospective examination of critical systems to prevent accidents. As Dr. Croteau explained, present methods of root cause analysis are helpful in determining the causes of an error after the fact, but don’t
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experiencing difficulties finding sufficient numbers of other professionals and staff. A proposed new standard for the chapter on human resources will encourage hospitals to find ways to ensure proper staffing. As mentioned above, changes are also being made to the survey process. In addition to altering the frequency of visits, the JCAHO has introduced methods of better educating their surveyors to conditions at the hospitals they’re about to visit. These include electronically communicating hospitalreported data to the surveyors and providing other sources of information that might alert the
necessarily institute procedures to prevent the error in the future. Instead, processes used in engineering will be applied to healthcare, requiring hospitals to conduct failure mode and effects analysis for critical processes. New standards will require a pilot test of any new process, and will require management to be accountable for assuring that hospital procedures are followed. The JCAHO has also acknowledged the chronic shortage of hospital staff that has developed over the past several years. While the nursing shortage is most apparent and receives the most publicity, it is recognized that hospitals are
(See JCAHO - p. 8)
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JCAHO (from p. 7) surveyors to conditions of concern. We learned that not all states recognize JCAHO hospital accreditation. NJ, KY, HI and PR require that their health departments conduct accreditation visits for payment of Medicaid funds. NY and PA allow the JCAHO to report accreditation information to the state simultaneously with reporting to hospitals. HCFA now surveys 5% of all JCAHO-accredited hospitals to validate the results. Issues of concern to medical physicists arose, raising discussion with several senior JCAHO staff. For example, Dr. Croteau described new standards requiring the hospital to inform patients of unanticipated outcomes. The standard clearly was written to apply to procedures, such as surgery, that have immediate consequences. He was asked how he would advise a radiation therapy department that recognizes that a treatment delivery error had been made. The point of the question was that it may cause a patient great anxiety to reveal a significant error which might not result in an adverse outcome during the patient’s lifetime. Dr. Croteau admitted that this was a difficult situation and that the JCAHO may have to consider the circumstances when applying the rule. Concern was indicated that relaxing the requirement for annual performance evaluations of equipment such as x-
ray units might encourage hospitals to postpone or forgo such inspections. It was observed that some new equipment was being described by the manufacturer as requiring little maintenance, and that the certain major maintenance procedures could be performed by relatively unskilled technologists. This was viewed by some physicists as an inappropriate stance and one that might lead to inadequate performance. The JCAHO staff felt that the standards adequately referred hospitals to existing standards and recommendations produced by organizations such as the AAPM. It should be our goal to maintain our relations with the JCAHO in order to ensure that they are aware of our recommendations for such procedures. Medical physicists should know that a great deal of information is available on the JCAHO Web page (http:// www.jcaho.org). In addition, members might find the report in the AAPM 2001 Summer School publication useful for learning about other changes at the JCAHO. I wish to close by thanking the AAPM and Mike Gillin for this opportunity to renew my acquaintance with the JCAHO. Both Mark Bruels and I felt our attendance at the meeting was worthwhile. We were able to renew existing acquaintances and develop several new ones that we hope will be of benefit to our profession. ■
Members in the News Niroomand-Rad Honored The following is an excerpt of a news release from Cazenovia College in New York: An honorary doctor of science degree was conferred on alumna Azam Niroomand-Rad during Cazenovia College’s commencement ceremonies on May 12, 2001. Dr. NiroomandRad received an associate degree in mathematics from Cazenovia Junior College in 1968. After graduating from Cazenovia, Dr. NiroomandRad received a bachelor’s degree in mathematics at the State University of New York at Albany in 1970. She was granted a master’s degree and a doctoral degree in physics from Michigan State University, and a post-doctoral degree in medical physics at the University of Wisconsin at Madison. She is now a professor and director of clinical physics at Georgetown University’s Department of Radiation Medicine. It may be noted at this time that Azam Niroomand-Rad was elected vice president of the International Organization for Medical Physics (IOMP) in May of 2000 and will serve as president in 2003. ■ Editor’s Note: Any member wishing to share his/her or another member’s spotlight in the news may forward such to the editor for consideration in an upcoming issue.
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Executive Director’s Column Sal Trofi College Park, MD
for 2002. At the last AAPM Long Range Planning Committee Meeting, councils and committees agreed to support budget requests by stating the objective to be accomplished with the budget money. The budget information entered by council and committee chairs can be reviewed by the AAPM treasurer in real time.
Fellow Nomination Process for 2002 Fellow nominations are now accepted through an online nomination system. Fellow nomination applications will no longer be accepted by paper copy submissions. Nominations may be made by either an AAPM chapter, with supporting letters by two fellows, or by two AAPM Fellows. The nominated fellow must be a full member of AAPM for a minimum of ten years. When a nomination is submitted online, the new system will automatically check your eligibility to nominate someone and the nominee’s membership eligibility. In addition, the system will notify the nominee via e-mail that the nomination has been made and that they need to complete the application. If you have any questions regarding the new system, please contact Nancy Vazquez at nvazquez@aapm.org
Information Services (IS) News Recently, two new improvements were added to the AAPM Online Membership Directory; an ID style photograph that will be shown in the
online directory, and the addition of “Member Since” dates. Photos - A digital photo booth was set up at the Annual Meeting to promote this new service. If you weren’t able to stop by the AAPM booth to have your photo taken, visit the member profile section of the AAPM home page. You are now given the option to upload an ID style photo. Member Since Dates - Now that the fellow nomination process is automated, we are relying more heavily on the “Member Since” date records that we have in the AAPM database. These dates are now published so that a member may review them for accuracy, and so that any potential nominators may view how long a member has been both a member, and the current member type. An online budget system was developed in order to streamline the budget request process. Councils and committees were asked to provide information online about their budget needs
AAPM Publications Four new task group reports will be printed and distributed before the end of this year. The following reports will be inserted in the AAPM monthly mailings: •Report 71, A Primer for Radioimmunotherapy and Radionuclide Therapy, written by the Nuclear Medicine Committee’s Task Group 7, is published and will be inserted in the July monthly mailing. •Report 72, Basic Applications of Multileaf Collimators, written by the Radiation Therapy Committee’s Task Group 50, will be published and distributed early this fall. •Report 73, Medical Lasers – Quality Control, Safety, Standards and Regulations, is a jointly published report from the AAPM General Medical Physics Committee’s Task Group 6 and the American College of Medical Physics. It will be published and distrib(See Trofi - p. 10)
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uted before the end of the year. •Report 74, Reference Values for Patient Doses in Diagnostic Radiology, written by the Diagnostic X-ray Imaging Committee’s Task Group 19, will be published and distributed to the AAPM membership before the end of the year. Two other publications will soon be available and can be purchased by AAPM members at a 20% discount: •Monograph 27, the 2001 Summer School Proceedings entitled Accreditation Programs and the Medical Physicist, will be available for purchase in July 2001. Discounted price to AAPM members is $65. •Miscellaneous Publication, Ultrasound Physics Workbook, written by the Ultrasound Committee and published in June 2001, is scheduled to be available for purchase in August. Discounted price to AAPM members is $40. For the most up-to-date listing of AAPM publications, please visit Medical Physics Publishing’s Web site at www.medicalphysics.org.
Summer Fellowship Program The AAPM has awarded six Summer Undergraduate Fellowships for 2001. These junior- and senior-ranking under-
graduates will each receive a $4,000 stipend from the AAPM. Student fellows were selected based on a combination of the quality of their personal statement, their GPA and their potential future in medical physics. Each student fellow chose his or her mentor based on location and the student’s interest in the mentor’s proposed project. A list of student fellows, mentors, and institutions can be found elsewhere in this issue of the newsletter.
dent expert in plants and flowers to help beautify the office and our homes. ■
Staff News Falaq Moore-Pimienta was hired as our accounting assistant in May. She replaces Kysha Marshall who resigned in March. Falaq worked with us as temporary help for two months and decided to apply for the open position. Falaq recently relocated to the Washington, DC area from Massachusetts with her husband and daughter. Falaq has about ten years experience working in various accounting departments. Jennifer Davis replaced Magda Renaud-Durham as our receptionist in May. While attending high school, she took extra training in a nursing program. After completing high school, she worked in several medical centers and medical offices in a variety of positions. Jennifer grew up working on her family’s farm which produced vegetables and nursery products. We now have a resi10 1
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Government Relations Column Angela L. Furcron College Park, MD
members were crossing party lines during important votes. In my last column, I mentioned the Bush Administration Budget that was released on April 9th. A breakdown of how agencies of importance to the AAPM fared appears below.
There was a radiological accident at the National Oncology Institute (ION) in Panama involving 28 people. ION representatives announced on May 18, 2001, that 28 patients (See Gov’t. Rel. - p.12)
Bush Administration Budget Details Department of Energy Office of Science: $4.4 million or 0.1% increase Nuclear Physics: Received level funding. There are changes here in Washington. There is now a Democratic majority in the Senate and a change in committee chairs, as well as a change in committee and staff ratios. This shift in power was caused by Sen. James Jeffords’ departure from the Republican Party to become an Independent on May 24th. The Senate now has 50 Democrats, 49 Republicans and one Independent. It will be interesting to see how bipartisanship works with a Democratic majority in the Senate and a Republican President. This shift in power shouldn’t change any votes. It has been shown lately that regardless of party affiliation, senators are willing to cross party lines to support bills that they personally believe in. Recently in the Washington Post there was an article about the frustration felt by the majority and minority leaders because many of their
Food and Drug Administration FDA Total: $123 million or 9.6 % increase Devices and Radiology Health: $18 million or 10% increase Health Care Financing Administration Medicare: 11 million or 5% increase National Institute of Health NIH Total: $2.7 billion or 13.5 % increase National Institute of Biomedical Imaging and Bioengineering Appropriated Total: $40 million Total Transferred from other NIH Agencies: $60 million (tentatively) Grand Total: $100 million National Institute of Standards and Technology NIST Total: $487.5 million or 18.3 % decrease NIST Laboratories: $35.2 million, or 11.7 % increase National Science Foundation NSF Total: $56 million or 1.3% increase Physics Research: $6.93 million or 5.3% decrease Nuclear Regulatory Commission NRC Total: $25.7 million or 5.3% increase 11
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Announcement
treated at the institute for colon, prostate, and cervical cancer may have received radiation doses from 20 to 100 percent above what was prescribed. Eight patients are reported to have died, and five of the deaths have been attributed to the excess radiation received during the treatments. Panamanian authorities initiated an investigation and subsequently requested International Atomic Energy Agency (IAEA) assistance. The IAEA sent an investigation team to Panama on May 26. On June 2 the IAEA issued an Advisory Information Notice on the initial findings of the investigation. The primary finding of the investigation by the IAEA was that the overexposures were caused by a change in the procedure for entering treatment data into the treatment planning software. The change, combined with the lack of a verification that the correct treatment dose was being calculated and delivered, allowed the overdoses to occur. You can obtain more information about the radiological accident in Panama from www.iaea.org/.
WORDS FROM WIPHYS Azam Niroomand-Rad Washington, D.C. The Committee on the Status of Women in Physics (CSWP) welcomes you to the Women in Physics List Server, WIPHYS, which is dedicated to the discussion of issues involving women in physics. This electronic forum offers unique possibilities to assist in creating an atmosphere of cooperation, mentoring, and support. It also enhances our ability to offer services to our constituency. Examples of services available on WIPHYS include: •discussion of issues involving women in physics; •announcement of government or privately sponsored programs designed to aid in establishing the careers of women scientists; •postings of job listings; •news about women in physics; •online mentorship (issues re-
cently discussed include sexual harassment, the impact of changing one’s name on publications and research, advice on the tenure process); •information on women’s events at the American Physical Society (APS) Meetings (postings on informal and planned dinners, receptions, sessions; help for those seeking roommates); •advice on teaching (suggestions for textbooks, discussion of different learning styles). Guidelines for posting to WIPHYS are available on the APS Web site at http:// www.aps.org/educ/cswp/ index.html. In order to subscribe to WIPHYS, please send a message to: majordomo@aps.org. Leave the subject line blank. The body or text of the message should read: subscribe wiphys. ■
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2000 Year Summary of Financial Results Melissa C. Martin, Treasurer Bellflower, CA The financial audit for the 2000 year is complete and no discrepancies were noted. The AAPM in the 2000 year experienced its first financial operating loss since 1993. The loss was $112,134. This loss was not as severe as the $307,944 deficit predicted in the Boardapproved budget. The actual financial result represents a $195,810 improvement over the budget. Two major factors contributed to the deficit: the poor results of the investment equity markets and the disappointing financial results of the World Congress Meeting. The overall financial health of the AAPM continues to be very strong. Our reserves are over $4 million, which is 80% of our moving target of one year’s budget amount, which is now about $5 million. Our reserve investments are about 60% in equities and 40% in fixed income. In 2000, we had about a 5% loss on the equity portion of our investments, which compares quite favorably with leading indexes. When the fixed income portion is combined with the equity portion, the loss is less than 1%. The 2001 year may see more erosion of our invested reserves. We have a professional
financial advisor handling our investments to minimize these losses. Although the World Congress meeting was a scientific success, the financial results were disappointing. The one item most responsible for this disappointment was the penalties incurred as a result of unsold hotel sleeping rooms that were guaranteed. This attrition clause penalty is a fairly new clause in hotel contracts, which imposes a penalty, within certain tolerances, if reserved sleeping rooms are not purchased by attendees. You can help in the future by staying at the hotels designated by AAPM when attending the AAPM Annual Meeting. We should note that the sleeping rooms not picked up were not due to the lack of AAPM member attendees. The projected rooms to be occupied by our members exceeded those predicted by our headquarters staff but the
World Congress budget is a consolidated budget for all participants. The Medical Physics Journal continues to have financial success, even though more pages are being published and we have the extra expense of an electronic journal. This good news is made possible because advertising revenue has exceeded expectations and institutional subscriptions to the paper version have increased. The American Institute of Physics handles both these revenue sources as well as the production of the journal. Their efforts are very much appreciated. Council, committee and liaison expenses as a group spent less than their approved budgets. The Summer School had more revenue than expenses, the net of which was better than budget. The headquarters also spent less money than authorized. In summary, this past year offered many financial challenges. We were able to finish better than anticipated because of everyone’s dedication and hard work. I offer my thanks and appreciation to all that helped this to happen. ■
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33rd Annual Conference on Radiation Control Program Directors (CRCPD) Keith Strauss & Melissa Martin AAPM Liaisons to the CRCPD The 33rd annual meeting of the Conference of Radiation Control Program Directors (CRCPD) was held in Anchorage, Alaska April 29 - May 2, 2001. “New Frontiers” was the overall theme of the meeting. The working relationship and spirit of cooperation between state regulatory personnel, medical physicists, and other medical professionals continues to become stronger. The variety of training available at the annual meetings has been greater in recent years due to the efforts of the AAPM, ACR, and ACMP. Many issues continue to surface, however, (e.g. interventional fluoroscopic radiation injuries, intravascular brachytherapy, PET and medical cyclotrons, radiation shielding, nonionizing radiation, less leadership provided by the federal agencies due to cutbacks and staff reductions, etc.) that underscore the need for medical physicists in each state to establish a working relationship with their CRCPD members to work through concerns and issues.
Training Sessions The AAPM sponsored a day of training at no cost to the at-
tendees entitled “New Technologies in Diagnostic Imaging and Radiation Oncology.” This was very well received by the 50 state regulatory personnel in attendance. Topics covered included Interventional Radiology/Cardiology procedures, Multi-Slice/Spiral CT Scanners, CT-Fluoroscopy Combination Units, Digital and Computer Radiography, High Dose Rate Brachytherapy, and Intravascular Brachytherapy. Participating faculty were Keith Strauss, Ed Nickoloff, Melissa Martin, Don Frey, Charlie Coffey and Bruce Thomadsen. All of the excellent presentations covered procedures, patient doses, and radiation safety recommendations for personnel and patients. The Center for Devices in Radiological Health (CDRH) provided training entitled “MQSA Overview for Supervisory Personnel.” A session was provided by the CRCPD on “Performance Based Inspections.” The ACR sponsored an afternoon session on “Emerging Modalities in Medicine” at which PET Scanning, high dose brachytherapy, and multislice/ CT fluoroscopy were discussed. The CRCPD provided a session on “Nonionizing Radiation is Everyone’s Business.” At this session the results of a survey were presented on the states’ current participation in regulating MRI, ultrasound,
tanning salons, lasers, microwave ovens, cell phone towers, radio antennae, microwave communications, police radar, etc.
Opening Session Paul Schmidt, chairman of the CRCPD, summarized the past year’s activities. He highlighted some of the CRCPD’s discussions with the twenty odd groups, e.g. AAPM, ACR, HPS, CDRH, EPA, NRC, etc., they had worked with. He commented on some of the more active committee and task force work within the CRCPD, including the “Task Force to Minimize the Risk from Fluoroscopy.” Based on his attendance and promotion of the CRCPD at the International Conference of Radiation Protection of Patients in Spain, Paul congratulated the membership on being an “international player” at that meeting. John C. Villforth, former director of the CDRH, delivered the first annual lecture named for him, “Radiation – What Don’t Hit Nobody, Don’t Hurt Nobody.” He delivered a historical review of the various federal agencies established to address radiation protection beginning in 1922. He praised the CRCPD for surviving the many directives from federal agencies. He noted that federal agency staffing has diminished
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dramatically at a time when issues are growing. He told the CRCPD they needed to step forward to fill the federal vacuum! Since four of the six named concerns are medical, we submit that the patient’s needs would be better served if the AAPM, ACR, ACMP, and individual physicists filled this “federal vacuum” by providing leadership and working effectively with CRCPD members in their states. Charles B. Meinhold, president of the NCRP, represented the ICRP and NCRP in his remarks. He briefly summarized the most recent data in the UNSCEAR report. He expressed concern that the 9% risk of fatal cancer resulting from receiving 50 mSv annually over a 50 year career might not be acceptable. He pointed out that the fatal cancer risk from 20 mSv annually for the same period was only 3.6%. Roger H. Clarke, chairman of the ICRP, discussed the “Changing Philosophy in the ICRP.” He summarized the evolution of protection principles and ethics within the ICRP by discussing three time periods. The first, 1896 – 1955, was marked by an effort to maintain radiation workers’ occupational doses below the threshold required for deterministic radiation injury. The second period, 1955 – 1990, recognized stochastic radiation injuries for the first time. The concept of “ALARA” was born. A utilitarian ethical approach was adopted—greatest good for the greatest number.
The final period, 1990 – present, initiated an egalitarian ethic—maximum individual doses must be addressed. Optimization now is centered on “ALARP”, as low as reasonably practical.
for review by the state inspector prior to their visit. A significant improvement in both dose and image quality has already been noted under this program.
Radiation Shielding Concerns
General Medical Presentations Prabhakar Tripuraneni, M.D., from Scripps Clinic, discussed “Coronary Intravascular Brachytherapy—A New Standard of Care.” Dr. Tripuraneni presented data illustrating the rapid growth of this new modality. He stressed the need for a team approach between the cardiologist/radiologist, radiation oncologist, and medical physicist to ensure an efficient procedure that also properly addresses patient and personnel radiation safety.
Regulatory QA in NJ Jill Lipoti, Ph.D., director of the State Radiation Control Program in New Jersey, presented the new program started in 2001 that requires all radiographic and fluoroscopic tubes including podiatric and chiropractic to be evaluated annually by a physicist approved by the state. In addition, a phantom evaluating not only dose but image quality for radiographic exams has been developed and is being used by state personnel to evaluate these machines on a regular basis. The facilities are required to have a physicist report available
David Keys identified problems presented in both the design and evaluation of some diagnostic and therapeutic facilities using the requirements recently implemented by some states that are more stringent than the current and recently proposed methods for shielding designs by the AAPM task groups and the NCRP. An overview of the economic impact of adding more shielding than is currently required by the national standards emphasized the effects of this in the current economic environment of medicine. These items will be considered further in the training session presented by the AAPM at the 2002 CRCPD Annual Meeting in Wisconsin.
Interventional Fluoroscopy John F. Candella, Syracuse Health Science Center, discussed the interventionalist’s perspective of radiation management during interventional radiology procedures. He noted that fluoroscopy has recently become a tool of many physicians with insufficient ra-
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CRCPD (from p.15) diation management training. Dr. Candella called for a concise policy that required appropriate training and licensing of all users of fluoroscopy. He reviewed the current training requirements of radiologists and suggested an appropriate number of training hours. Louis Wagner, University of Texas, Houston Medical School, discussed some of the lessons learned from documented radiation injuries. Dr. Wagner called for patient monitoring and management with respect to radiation dose. Despite the severity of some of the injuries he discussed, he cautioned that it would be tragic if a patient refused a potential life saving procedure out of fear of receiving a radiation injury. Tom Shope (CDRH) discussed the center’s current activities to reduce radiation risks from interventional radiology. Dr. Shope noted that approximately two million of the eleven million fluoroscopy procedures performed annually in the U.S. are interventional procedures. Minimal training in radiation management of operators and the complexity of the cases, not equipment failure, are the primary reasons for radiation injuries. In response to this need, a FDA grant was provided to the CRCPD to establish a task force to minimize the risk from fluoroscopy. A special interest meeting of the CRCPD task force to minimize these risks provided dis-
cussion. The CRCPD asked the medical community to address training needs. It was explained that neither the ACR nor the SCVIR could spearhead this training without the development of a turf war. Both of these professional organizations have suggested using the AAPM as a neutral body to teach the existing 225,000 physicians who desire to use fluoroscopy. One observer tried to summarize the comments of a number of different physicists: 1) any fluoroscopic exam results in a higher patient dose than necessary when the operator is not properly trained in proper radiation management, 2) members of the medical community can provide this training, but must avoid turf battles, 3) necessary training would be expedited if the state programs mandated facilitybased programs that provided appropriate training of all users that lead to licensing or credentialling.
3rd. Typically, approximately a dozen medical physicists attend representing local AAPM and ACR chapters. Attendees at this year’s meeting not already noted included Charles Wilson, Chuck Kelsey, Mike Tkacik, Herb Mower, Rick Morin, Don Tolbert, and Geoff Ibbott. The AAPM cannot be over-represented at this meeting. Thank you for the opportunity to represent you at this year’s meeting. The published proceedings should become available prior to the fall. Copies of these can be purchased by contacting the CRCPD’s executive office: 205 Capital Avenue, Frankfort, KY 40801, ■ (502) 227-4543.
State Presentations Each state was given five minutes during the meeting to share “the most important things about their radiation control program.” Many states shared funding challenges, the need to replace retirees from their staffs, or other fee structure/ business/bureaucratic issues. Next year’s CRCPD Meeting will be in Madison, Wisconsin, May 5-8, 2002 with the AAPM training day on Friday, May 16 1
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Announcement Letters to the Editor IMRT R. J. Schulz Johnson, VT From the various announcements and ads I’ve recently received, it appears that both professional and commercial proponents of IMRT are going into high gear to promote the use of this complex, costly and yet unproven method for delivering radiation treatments. Corporate newsletters show the happy, smiling faces of physicists, therapists and physicians who have just treated their first patient, and are already extolling the virtues of this 21st century modification of the megavoltage x-ray beams first applied to patients over 50 years ago. Various organizations offer short courses on how to master this new technology, and a forthcoming international conference purports to provide attendees with its biological and physical basis, such as it is. There can be little doubt that IMRT is one of the most exciting things to happen to medical physics since computerized treatment planning came along in the 1970’s. There is, as you may have suspected, only one problem: IMRT is unlikely to have a significant impact upon cancer mortality. There are many readily available sources of information about cancer but those that I have found most illuminating are the SEER Cancer Statistics
Review, 1973-19961, and The American Cancer Society’s Cancer Facts & Figures 20012 and Clinical Oncology 3 , a comprehensive review of cancer characteristics, survival as a function of stage, prognostic factors, current treatment methods, etc. These publications should be familiar to all physicists in radiation oncology, and especially those promoting new treatment modalities, as they can provide a per-
spective on the disease that I find sadly lacking at present. A quick start may be gained from Cancer Facts & Figures which shows graphs of mortality data for common cancers starting in the first one third of the 20th century. For example, the reader may be surprised to learn that breast cancer mortality today is about the same as it was in 1930, and as pointed out in Clinical Oncology, this is because “Patients die of breast cancer because of distant metastases implanted months or years before the primary lesion is diagnosed and treated with surgery or radiotherapy.” These data and this statement make it
clear that the achievement of local control usually comes too late, and that, contrary to what I read in advertisements, IMRT has at most a minor role to play in breast cancer. A more detailed examination of the data in these reports reveals that there are 20 specific disease sites which will account for 93% of the 1.27 million new cases and 91% of the 553 thousand cancer deaths in the U.S. in 2001. Of these 20, surgery or chemotherapy is primary therapy at 14 which account for 72% of incidence and 87% of mortality. Radiation therapy is primary or competitive with surgery at only six which account for 28% of incidence and 13% of mortality. For a variety of cogent reasons, it is unlikely that IMRT will displace surgery or chemotherapy from these fourteen sites. As for the other six, to gain a foothold, IMRT would have to produce significantly better results than those obtained by current modalities, perhaps cutting the 13% mortality figure in half. Short of this, it would be difficult to justify the costs, risks and complexity of IMRT. I would be remiss if I failed to mention the prostate which probably bears more responsibility for the development of IMRT than all other forms of cancer combined. The mortality of prostate cancer grew from 16 per 100,000 in 1930
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Letters to the Editor Schulz (from p. 17) to about 26 in 1990 but dropped to 22 in the year 2000. There are a variety of explanations for this recent decrease but the introduction of IMRT is certainly not one of them, and whether this trend will continue remains to be seen. Current treatment options for prostate cancer include surgical resection, radioactive seed implants, conventional irradiation with or without hormonal therapy, hormonal therapy alone, simple observation, IMRT, and various combinations of each of these. Space does not permit a review of their pro’s and con’s but what is clear is that there are viable alternatives to IMRT, that all of them will continue to be employed, and that it is unlikely that the touted superiority of
CCMP or CCPM? L. John Schreiner, FCCPM President, CCPM Kingston, Ontario
I read with interest Dr. Peter Almond’s “Letter to the Editor” in the AAPM Newsletter Volume 26 Issue 3 suggesting that the medical physics community in the United States, and beyond, would be better served if the American Association of
IMRT in this context will ever be proven in a carefully controlled randomized/prospective study. Incidentally, the reader should not be misled into believing that the increase in fiveyear survival from 65% to 93% over the past 25 years represents progress in its treatment. Earlier diagnosis always leads to increased survival times, which in this case is due to the widespread use of the PSA test. Let me make it clear that I find the technological accomplishments of IMRT to be brilliant, and that given a highly trained and dedicated team, there are several sites such as the head and neck where it can be a valuable adjunct to current treatment techniques. It is when we look at the characteristics of most cancers, current methods
Physicists in Medicine and the American College of Medical Physics were to merge. He reasons that such a merger would be easier if the AAPM created a membership category recognizing clinical medical physics service and expertise, and he suggests that such membership be designated by the initials CCMP, indicating Certified Clinical Medical Physicist. I wish to suggest that the initials CCMP will be easily misidentified with the acronym CCPM used by the Canadian College of Physicists in Medicine. I suspect that similarities
of treatment, and disease-specific survival that it becomes difficult, if not impossible, to justify the complexity, and capital and operating costs of IMRT. 1SEER
Cancer Statistics Review, 1973-1996. NIH Publication No. 99-2789, National Cancer Institute, Bethesda, MD; 1999. 2Cancer
Facts and Figures 2001. American Cancer Society, Atlanta, GA; 2001. 3Osteen, RT. Breast Cancer. In:
Lenhard, RE, Osteen, RT, Gansler, T, editors. Clinical Oncology. 1 st ed. American Cancer Society; 2001. p. 251. ■
in two designations used to indicate expertise (CCMP) or certification (CCPM as in FCCPM or MCCPM) as medical physicists will only confuse the oncologists, radiologists, administrators and others with whom we work and communicate. I look forward to the discussion in the next issue of the AAPM Newsletter that I assume will be generated by this proposal. My small contribution is to suggest that care be taken in adopting a designation for clinical expertise if a merger is undertaken. ■
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Letters to the Editor Working Together
It has been suggested that the model we should follow is the ACR/RSNA; perhaps a better model would be the Health Physics Society/American Academy of Health Physics/ American Board of Health Physics. The intention back in 1982 was that the AAPM and the ACMP would work together. How about this:
John R. Glover Stanford, CA The articles by Tolbert and Ibbott and by Almond were indeed provocative. There must have been a good reason why, nine years after the formation of the Professional Council, the AAPM, by a majority vote of the members and with a substantial donation of seed money, chose to create the ACMP. We should not return to the murky days of pre-1982.
1) The two organizations FORMALLY agree to strongly cooperate. (The members of both organizations should DE-
MAND that their leaders do this.) 2) The ACMP should liberalize its eligibility rules to maximize its membership while maintaining high professional standards. 3) The AAPM should strongly encourage its members to become members of the ACMP whenever possible. 4) The AAPM Professional Council should become a conduit by which professional concerns within the AAPM are funneled to the ACMP for action. (See Glover - p.20)
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Glover (from p. 19) 5) The dues of the AAPM could be reduced because the AAPM would no longer have to support an elaborate Professional Council OR its dues could stay the same but it could accomplish more of its mission within its tax status. 6) The dues of the ACMP
could be reduced because there would be many more members OR its dues could stay the same but it could accomplish more of ITS mission within ITS tax status. This scheme would maximize the benefits to both memberships while maintaining the professional stature and effective-
ness of having both a scientific/ educational organization and a professional college. The AAPM, with its thousands of members, is a powerful organization. Imagine how much more powerful the ACMP could be with many more members. Imagine how powerful both groups could be WORKING TOGETHER. â–
AAPM NEWSLETTER EDITOR, Allan F. deGuzman MANAGING EDITOR, Susan deGuzman Editorial Board: Arthur Boyer, Nicholas Detorie, Kenneth Ekstrand, Geoffrey Ibbott, C. Clifton Ling, Richard Morin
Please send submissions (with pictures when possible) to the editors at: e-mail: deguzman@wfubmc.edu (336)773-0537 Phone (336)716-7837 Fax 2340 Westover Drive, Winston-Salem, NC 27103 The AAPM Newsletter is printed bi-monthly. Next Issue: September/October 2001 Deadline: August 15th Postmark Date: September 15
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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