AAPM Newsletter July/August 2004 Vol. 29 No. 4

Newsletter

AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE VOLUME 29 NO. 4

JULY/AUGUST 2004

AAPM President’s Column G. Donald Frey Charleston, SC There is an odd disassociation between the time these newsletter articles are written and when you read them in print. As I write this in early June we are preparing for the AAPM Annual Meeting. Those of you who read this in print have probably just returned from that meeting. It reminds me a little of the odd time paradoxes one gets in relativity theory. As of now, this planning is going very well. We have the largest number of abstracts ever, registration appears to be close to that of Montreal, our largest

meeting ever, and booth sales are excellent.

The success of the annual meeting is one of the foundations of the association’s financial stability and it looks like 2004 will be a good year. I want to thank Bruce Curran and all the members of the Meeting Coordination Committee for planning and executing our meeting.

What We Do is Important Medical physics is important.

The measurements we make, the calculations we do and the deci-

sions we make can have life and death consequences for patients.

It is sometimes hard to remember this when we are alone in a CT room doing the annual survey, but if the image quality is not optimized, illness and suffering may be prolonged. Patients and their families may endure (See Frey - p. 2)

TABLE OF CONTENTS

“We know that Los Angeles is a celebrity town, but as medical physicists go, we were amazed when John (“Jack”) Cunningham, author of the famous textbook, The Physics of Radiology, surprised us with a visit.” —AAPM Member Marianne Plunkett at the May Southern California Chapter Meeting. Cunningham is pictured here on the left with AAPM Member Tim Solberg.

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Educ. Council Report Executive Dir’s. Col. Leg. & Reg. Affairs Chapter News In Memoriam ACR FAQs Letters to the Editor

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Frey

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unnecessary emotional trauma, or the patients may die. It is important that we take the responsibility to be sure that we are doing a good job. We have to insist that we have adequate time and resources to do the work properly. We have to have time to think about what we are doing and to make reasoned decisions about the data we are analyzing. I am discussing this because it seems that, because of increased workloads and pressure to maximize the clinical availability of equipment, that we may be compromising our work, our patients and ourselves.

Studies across a broad spectrum of human activities have shown that errors occur when we are affected by fatigue and distraction. It is also interesting that people almost universally fail to recognize how much they are impaired. Thus, for many workers—from truck drivers to airline pilots to resident physicians— standards have been adopted to limit work hours. Medical physicists are not immune to fatigue, distraction or self-deception. Yet, in the complex environment where we work, we are frequently asked to do more and more, so we, and our patients,

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One of the reviewers of this column commented, “After I made the edits to your article I loaded up the … mobile HDR to return it from our sister hospital. A week of 10-12 hour days, then I had worked Thursday from 05:00 to 21:00, no breakfast,

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are more likely to become victims of that fatigue and those distractions. In addition, because the equipment that we test and measure is expensive and used for patients during the day, we are frequently asked to extend our work hours well into the evening.

This leads to the dangerous situation where we are doing complex measurements when we are fatigued to the point that our performance is impaired.1 Like airline pilots, our decisions can have consequences for large numbers of individuals. The improper calibration of a therapy beam can cause severe complications in, or even the death of, the patients we are responsible for.

The problem, then, is to balance the short term needs of our employers against the needs of our patients, who are our primary responsibility. Regardless of the contractual relationship between the physicist and the facility (employee, professional service contract, consulting agreement), there may be a conflict between a particular administration’s imperative to complete tasks without adequate time or resources and our professional obligation to those who seek care at the facility. We must recognize that our primary obligation is to the patient’s well being and make in-

formed judgments with that in mind. Physicists are frequently “can do” individuals who are willing to take on additional tasks without analyzing the possible negative effects on patient care.

So, what should we do as individuals and what should the AAPM do as our professional association?

As individuals we have an obligation to our patients, our employers and ourselves to refuse to do work when we are impaired. We must constantly make the case that what we do is important, and that we need appropriate equipment and sufficient time to do the job correctly. The association has to provide us with the data that allows us to make our case.

In my last column I mentioned the many quality of life issues that affect our working life. The Professional Council is charged with analyzing these issues and making recommendations. They are presently considering this problem and we hope to have recommendations soon. They are also planning a seminar to address this issue in 2005.

lunch at my desk, dinner after I left the hospital. Arrived at the hospital this morning at 06:15, worked straight through when I loaded up the van about noon. Read your article and thought how hard I had worked the week and was glad my faculties had

not been impaired. Driving north back from … to … I became increasingly irritated that the air conditioning wasn’t working (it’s hot in …) and in fact seemed to continue to pump out warm air. I checked and adjusted the controls several times. Only after

Peter Wootton I sadly report that Peter Wootton, who served as presi-

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dent of the AAPM in 1978, passed away this spring. His many colleagues and friends will miss Peter.

The Public Limit for Radiation Exposure It appears that we have made significant progress toward resolution of the disagreements about the public limit for shielding design. As I write this, the report on diagnostic shielding is scheduled to be published with the 1 mSv recommendation intact.

We appear to have gathered significant support within the regulatory community, a sign that AAPM’s efforts to improve relations with the regulatory community through the CRCPD have been yielding significant benefits.

The many years of work by Keith Strauss and Melissa Martin have been very fruitful.

We owe them and the many other medical physicists who attend the CRCPD meetings a vote of thanks.

Certain issues remain unresolved. The ICRP seems likely to keep the current recommendations for “restraints” in the revision of ICRP-60. Also the EPA will be making federal guidance recommendations soon. The

about five miles did I realize I had confused the temperature color-coding; I had set the dial to full red. Once I remembered that red was not cold but rather hot and blue was cold, the air conditioner started to work again.

QED”

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AAPM is reviewing these issues and will comment as necessary.

Finally, these values are actually set at the state level. If you live in a state that has reduced or is planning to reduce the shielding design limit to 0.25 mSv, I strongly encourage you to become involved with your local AAPM chapter and/or your state ACR chapter to present data to the regulators and legislators showing that this reduction is not in the public’s best interest. I want to thank Bob Dixon for representing our point of view at the International Shielding meeting and at the CRCPD, and Jim Rodgers for representing us at the International Radiation Protection meeting.

If one defines ϑ as ϑ = t/t1/2

dNR = - ln(2)NR dϑ However, for light bulbs a different equation applies3, 4. dNLB = - 5 ln(2) ϑ 4 NLB dϑ Problems: Plot NLB and dNLB vs ϑ What is the probability that a light bulb will make it to 2ϑ ?

Extra Credit: What is ϑ avg?

Just For Fun Thomas Pynchon inserted a subplot about a light bulb that lasted beyond its expected life into his novel Gravity’s Rainbow. A hit team from the electric cartel is sent to dispatch the bulb, setting up a series of adventures.

The adventures of the bulb form the subplot.2 However, it turns out the company could have saved some money as you can see from the following:

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The usual radioactive decay equation is defined by

Pynchon, Thomas, Gravity’s Rainbow, Viking Penguin, New York, 1973 – ‘The Story of Byron the Bulb’ page 647.

3 Harvey S Leff, “Illuminating physics with lightbulbs,” Phys. Teach. 28, 30-35 (Jan 1990).

(Answers later in the newsletter) ■

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VJ Meno & DC Agrawal, “Lifetimes of Incandescent Bulbs,” Phys.

Teach. 41, 100-101 (Feb 2003).

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Education Council your needs. Feel free to communicate your needs, desires, and time and financial constraints relative to achieving your ‘maintenance of certification’ requirements.

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Herb Mower Council Chair The production schedule for the newsletter is such that I am writing this before the annual meeting and you will probably not receive it until or shortly after the annual meeting. Thus, I will not be updating you on Education Council items from the annual meeting until the next issue.

Most of the committees, subcommittees, task groups and other working entities of the Education Council meet twice a year; first at our annual meeting and also, depending upon the activities of the group and the membership, at either the ASTRO meeting or the RSNA meeting.

Those groups with a heavier therapy slant often pick ASTRO for their ‘mid-year’ meeting. If you will be at either ASTRO or RSNA, check our Web site to see which groups will be meeting there. We always welcome members as visitors to our activities.

At the RSNA meeting this year, we will continue to offer the various activities we have had available in the past. These include minicourses, categorical courses, update courses, and special offerings for residents, those involved with equipment selection, radiological technologists, and those in associated sciences. This year we are adding a four-hour tract on IMRT on Monday, November 29th. We also expect to see the return of the “Physics Case of the Day” presentation.

If you are at the RSNA meeting, please attend some of these physics-related sessions. Also, let me know what you think of the physics offerings we have and what changes or additions you think would benefit our offerings at this meeting.

At the annual meeting we offered a half-day tract on the shipping of radioactive materials.

Anyone shipping radioactive materials in the United States is supposed to attend a course similar to this at least once every three years to meet Department of Transportation requirements. We look forward to your feedback on this presentation. Also, let me know if you feel the AAPM Annual Meeting is a good place for this and how often we should offer it.

The AAPM has always been interested in providing quality continuing education opportunities. As the ABR moves into time-limited certifications (the ABMP certifications were always time limited), we are becoming more sensitive to the various options we should provide to meet 5

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Executive Director’s Column Angela Keyser College Park, MD

Maryland suburbs, please do not hesitate to visit.

Policies and Procedures – Here you will find a listing of the Administrative Policies and Procedures as well as the Professional/Education/Science Policies. You can search on the complete listing to find policy text, approval date and sunset date.

Did you know…

A wealth of information is available via the AAPM Web site. In this article I will highlight the types of information that you can find under the “Organization” heading on the left-hand side of the main aapm.org page.

Chapters – Look here to find a list of regional chapter officers with links to their contact information and links to chapter Web sites and bylaws. Chapters are encouraged to let HQ know of upcoming meetings so that information can be posted.

Committee tree – In this area you can browse the committee tree or view the organizational structure of the AAPM. You can work your way down from the board of directors to the councils and all the various committees, subcommittees and task groups that are the backbone of your association. Click on a specific group to get a listing of its membership and committee charge. You can even send an email to all members of the specific committee from this site.

Many committees now maintain their own committee Web sites where you may find committee minutes and drafts of documents the committee has shared with the membership. Look for a link to

the committee Web site at the top of the committee’s listing in the committee tree.

The Annual Business Meeting minutes and board of director minutes are included in this area, as well as a general AAPM fact sheet, Mission Statement, Articles of Incorporation, Bylaws and Rules. You can also review past headquarters site visit reports.

Financial Information – Members now have access to each committee’s financial history.

Actuals of the prior year plus current year budget and year-todate figures are also included in a dynamically generated spreadsheet. Copies of audited financial reports are available as well.

Headquarters staff – Included in this area is contact information for the HQ team and a brief description of our individual responsibilities. Directions to the American Center for Physics and a map of the local area are included. If you are ever in the

Travel expense voucher – The AAPM travel expense form can be downloaded as a PDF or an Excel file.

2003 Salary Survey The 2003 Salary Survey is available via the Web only. A hardcopy of the results will no longer be mailed to you. You can download a PDF from the Web or have the document e-mailed to you. If you have any problems with the file, please contact HQ.

Staff News Sharon Lehman and her husband Sean are expecting a baby in December. The couple and their three children are anxiously awaiting the new arrival!

The headquarters team welcomed two new members on June 7. Lynne Fairobent is the new legislative and regulatory affairs manager. Many of you may recognize her name as she most recently served as the director of federal programs for the Ameri-

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can College of Radiology. Nikki Williams is another new team member filling the position of database administrator that was vacated by Sean Benedict in April. Nikki is a Microsoft-certified database administrator and a Microsoft-certified solutions developer with a strong background in technical support and IT training. I’m sure you will join me in welcoming both Lynne and Nikki to their new roles.

The AAPM’s membership manager, Kathy Burroughs, left the AAPM on June 11 to be a fulltime homemaker and devote more time to her twin daughters.

Kathy has been an important part of the HQ team since joining the staff in 1998. We wish her all the best!

I am pleased to announce that Jennifer Delp has been promoted to the position of membership services coordinator. Jennifer joined the team in 2001 as the receptionist. As her responsibilities increased, her position was upgraded in 2003 to administrative assistant. Jennifer has been working with Kathy for some time now and I anticipate an easy transition.

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Legislative and Regulatory Affairs Column Lynne Fairobent College Park, MD

A New Perspective for Government Relations As Angela indicated in her column, I have joined the AAPM as the legislative and regulatory affairs manager. Prior to joining AAPM, I served as the director of federal programs for the American College of Radiology (ACR) for the past four years. I am a health physicist by training and have worked for the National Council on Radiation Protection and Measurements, the Nuclear Regulatory Commission, the Department of Energy, the Nuclear Energy Institute and as a consultant.

I spent my first week at the AAPM attending the Twelfth Annual Invitational Liaison Forum sponsored by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The purpose of the forum is to bring together a diverse group of individuals with an interest in JCAHO’s programs and initiatives. Roughly 55 organizations were represented.

Some of them very well known to AAPM, such as the ACR, the Conference of Radiation Control Program Directors (CRCPD), the American Medical Association, Blue Cross Blue Shield Association, Centers for Disease

Control and Prevention, Center for Medicare & Medicaid Services and various state health organizations. Some were totally unknown to me such as the National Association of Institutional Linen Management, National Association of Catholic Chaplains, and the American Music Therapy Association. All in all it was an interesting mix of representatives and indicates the diverse interests of and groups involved with the JCAHO. Why should the AAPM be concerned about what the JCAHO is doing? This was the question I asked myself before attending the meeting. However, after participating and listening to the issues the JCAHO is focused on, I believe that the AAPM should be more actively involved in JCAHO activities. In 2004 the JCAHO totally revised their standards. In doing so, a standard on the use of fluoroscopy that the CRCPD, ACR, AAPM and FDA were involved with has been dropped. The CRCPD and I have initiated discussion with the JCAHO on this. The essence of the standard as confirmed by the CRCPD resolution passed this May was: to encourage healthcare facilities to require appropriate education and training of all personnel, including physicians, before they are permitted to operate fluoroscopic machines; that this training include radiation safety and the biologi-

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(See Fairobent - p. 8)

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(from p. 7)

cal effects of radiation exposure; that the facilities communicate to patients, through personnel cognizant of radiation exposure effects, the risks from radiation exposure, from procedures in which the radiation exposure may be significant or approach a threshold for injury, and institute follow-up actions in high exposure situations; that healthcare facilities performing fluoroscopic procedures monitor patient dose arising from procedures with a potential for producing radiationinduced injury; that the facilities compare their radiation doses for fluoroscopic procedures to published values, and if they exceed accepted values for specific procedures, that the facility take corrective action; and that the CRCPD, in cooperation with the Food and Drug Administration and the Joint Commission on Accreditation of Healthcare Organizations, strive to implement these recommendations, and invite all other interested professional groups and government agencies to participate as partners in the prevention of unnecessary radiation exposure to patients from fluoroscopy.

The JCAHO also has a number of public policy initiatives about which AAPM members should be aware. The purpose of JCAHO’s public policy initiatives is to identify achievable solutions to critical issues affecting the quality and safety of health care. The JCAHO’s public policy action plan, identified as a strategic priority by its board of commission-

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ers, focuses on key areas related to patient safety and health care quality. In approaching these issues, the JCAHO has begun to: •Convene roundtables with experts and stakeholders who are knowledgeable about and affected by the issue. The role of the roundtables is to synthesize the problem and frame potential solutions and accountabilities.

•Develop white papers that include the prominent elements of the roundtable discussion.

Roundtable participants will continue to be engaged in refining the problem synthesis and proposed solutions.

•Hold an open national symposium that permits in-depth exploration of important aspects of the problem and the solutions.

•Finalize and issue white papers.

•Conduct follow-up regional summits and other activities to maintain the visibility of the issue and facilitate pursuit of its resolution.

The public policy issues currently being focused on are: nurse staffing crisis, emergency preparedness, emergency department overcrowding, health care professional education, organ donation, and tort resolution and injury prevention.

Emergency Preparedness This initiative caught my attention as I have spent a considerable part of my career involved in emergency preparedness and

response activities. Since September 11, 2001, JCAHO prepared a white paper issued in 2003 titled “Health Care at the Crossroads – Strategies for Creating and Sustaining Communitywide Emergency Preparedness Systems.” This document may be viewed on the JCAHO Web site: www.jcaho.org. Issues discussed by the roundtable that prepared the report were the resources and requirements for communitybased response systems; the need for collaboration between the medical care and public health establishments; as well as other new partnerships that must be forged; issues of accountability and mechanisms for validating readiness; and the appropriate roles of federal and state governments. The report concludes with the following recommendations: 1) enlist the community in preparing the local response; 2) focus on the key aspects of the preparedness system that will preserve the ability of the community health care resources to care for patients, protect staff and serve the public; and 3) establish accountabilities, oversight, leadership and sustainment of community preparedness systems.

In summary information provided, JCAHO states that “the absence of scalable templates to support community-based emergency preparedness planning remains a serious unmet need, and that JCAHO staff continue to work with HRSA [the Health Resources and Services Administration] to help frame the parameters of a national credentialing system for practioners who might

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sponse to emergencies—is also available as a link from the JCAHO Web site. (The competencies were developed by Columbia University Mailman School of Public Health and School of Nursing in collaboration with the Greater New York Hospital Association, supported by the Commonwealth Fund.)

The final point from the meeting that I found interesting was the remarks made for the need for a “Culture of Safety” and the recognition that this has always been instrumental in the nuclear industry. That if one, in fact, had a true “Culture of Safety,” that safety would permeate all parts of the organization and staff and that it would be through peer expectations and not rules and enforcement that safety would be met.

I believe that a closer link with JCAHO would benefit the AAPM community and ■ JCAHO’s programs.

respond to, or be called upon to respond to, national disasters or terrorist acts.”

In fact, a second Emergency Preparedness Roundtable is being appointed to further pursue the recommendation from the emergency preparedness white paper that calls for the development of scalable templates for community-based preparedness. The Joint Commission’s partners in

this initiative include the Illinois Department of Public Health, the State of Maryland’s Office of Emergency Management, and the National Center for Emergency Preparedness at Columbia University. In addition, Emergency Preparedness Competencies— a new guide to the core skills and abilities every hospital worker and every hospital leader should have to assure an effective re9

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Chapter News Southern California Chapter Gives Norm Baily Awards Steven Goetsch Chapter Education Chair The Tenth Annual Norm Baily Student Awards were given at a Southern California Chapter meeting held at UCLA in Los Angeles on May 6, 2004. This year’s winners included Kirsten Boedeker (advisor Michael McNitt-Gray) who gave a talk titled “CT Image Quality Metrics and Object Detectability.” Sumit Shah gave a talk titled “Solitary Pulmonary Nodule Contrast Enhancement Maps” (advisor Michael McNitt-Gray). The third award winner was John Sitko (advisor Nick Cacalano) whose talk was titled “Regulation of Cytokine and Growth Factor Signal Transduction.” All three students are enrolled in the UCLA Biomedical Physics Graduate program. A turn away crowd of 50 people attended the dinner meeting.

Each student received a certificate from Chapter President Ralph Mackintosh and an award of $500. These awards are given in memory of the late Professor Norm Baily of the University of ■ California.

Steve Goetsch (left) with UCLA Student Winners (left to right) Sumit Shah, Kirsten Boedeker, John Sitko, and Chapter President Ralph Mackintosh.

Melissa Martin and Peter Rosemark at the chapter meeting.

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Chapter News Upstate New York Balu Rajagopalan Buffalo, NY The Upstate New York Chapter of the AAPM held its semiannual meeting at Kodak Riverwood Facility in Rochester, NY on May 21, 2004. The meeting started with an invited lecture

by Michael Jackman, Kodak’s chief technical officer, who presented an overview of Kodak’s digital and PACS products.

There were seven other scientific presentations by members from Toshiba Stroke Research Center (SUNY), Buffalo, Roswell Park Cancer Institute, Buffalo and SUNY Upstate Medical Center, Syracuse.

The presentations covered a range of topics in diagnostic imaging and radiation oncology.

Ravi Chityala described a method to reconstruct high resolution CT images of small regions of interest in a large object. Petru Dinu presented a method to track skin exposure in a fluoroscopic C arm unit. Ciprian Ionita and Zhou Wang presented their work on flow in aneurysm phantoms with asymmetric stents. Iacovos Kyprianou talked about the MTF, DQE and detectability of the microangiographic system that is developed at the Toshiba center. All these student presentations come from the work done by the investigators of the Toshiba Stroke Research Center. Sanjay Raina, medical physics resident

(Left to right) Chapter Board Representative Stephen Rudin, President Matthew Podgorsak, Kodak Invited Lecturer Michael Jackman, and Secretary/Treasurer Ken Hoffmann at the Upstate New York Chapter Meeting in May.

at Roswell Park Cancer Institute, presented work on intraoperative high dose rate brachytherapy which dealt specifically with dose changes due to the scatter environment surrounding the applicators and target volume. Daniel Kim from SUNY, Syracuse presented an informative talk on network administration and information security in the radiation therapy department.

The meeting concluded with a business session. The next chapter meeting will be held in the fall of 2004. Information will be available on the chapter Web site http:/ /www.unyaapm.org/.

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In Memoriam Ira Kalet University of Washington On Monday, May 3, 2004, the world lost a great treasure, Peter Wootton. Peter was Professor Emeritus of Radiation Oncology (medical physics) at the University of Washington. During his long and distinguished career as a medical physicist, he had a lasting impact on the quality of cancer treatment. He was a joy to his family, and a teacher, mentor and friend to many students, medical residents, faculty and staff of the University of Washington, and others. The last three years of his life he put up a courageous battle with pancreatic cancer. He was wise, gentle, compassionate, steadfast and strong to the very end.

Born in Peterborough, England in 1924, Peter attended Birmingham University, where he earned the degree of B.Sc. with honors, in the School of Physics. He began his career as a radiation physicist in 1948 at the Royal Infirmary in Glasgow, Scotland.

During that time he met and married Jean Bell, and started a family, which now includes a son, Hamish, two daughters, Francesca and Katrina, and two grandsons, Iain and Aaron. In 1951, he came to the United States to take an instructor position at the University of Texas, Houston, and as a medical physicist at the M.D. Anderson Hospital. In 1953, Peter came to

Peter Wootton 1924-2004

Seattle as a radiation physicist at the Tumor Institute of the Swedish Hospital. He left in 1964 to go to the University of Washington as assistant professor of radiology and head of the Division of Medical Radiation Physics. He was promoted to associate professor in 1967 and to professor in 1972. He continued to lead the Medical Physics Division at the UW until his retirement in 1995, when he was recognized for his continued service to the university by his appointment as professor emeritus.

Peter was revered for his vision and insight, and for his many contributions to build the University of Washington Cancer Center to the world-class facility it is today.

In 1966 Peter established the Regional Medical Physics Program to provide this support throughout the Northwest region.

This led to the establishment of the Northwest Medical Physics Center in 1969.

Peter is most well known for his contribution to the technical aspects of the use of neutron radiation in cancer treatment. His leadership and expertise were the key to creating a unique cancer treatment resource, the University of Washington Clinical Neutron Therapy System (CNTS), which began to treat patients in October 1984. It continues to operate today, and is no longer considered experimental. It is an international resource, having treated thousands of patients from all over the world. The use of neutrons in cancer treatment at the University of Washington began in 1971, when Peter led a project to convert the UW Physics Department's experimental cyclotron to clinical use. This enabled the radiation oncologists at UW to evaluate the use of neutrons in treatment of several different kinds of tumors. This and related work led to a decision by the U.S. National Cancer Institute to widen the investigation of these therapies in a more clinical setting. As a result, in 1979, the UW received a $13 million contract from the NCI to build and operate the CNTS neutron treatment facility in the University of Washington Medical Center, and evaluate its effectiveness for various kinds of cancers. It is one of only three facilities of its kind in the United States.

Peter Wootton's career spanned the full history of the

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(See Wootten - p. 14)

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development of medical physics in the United States. He was a founder of the American Association of Physicists in Medicine, the leading professional and scientific society of his field, having served as a member of its first board of directors in 1965, and as president in 1978. He was also a member of the Institute of Physics of Great Britain, and the Hospital Physicists Association. He was elected a Fellow of the In-

stitute of Physics, the American College of Radiology and the AAPM. Throughout his career, Peter served on numerous local, state and national committees concerned with many aspects of radiation physics, cancer and radiation safety. His publications include over 80 scientific articles and book chapters.

Peter has had a profound impact in the Northwest. His work has helped save the lives of many people through successful cancer treatment with radiation, through

the quality control programs that he helped establish, and through his personal contributions over many years to cancer treatment at the University of Washington.

His colleagues, friends and family will remember him most, however, for his gentlemanly approach to everything, his attention to details, his commitment to a high ethical standard, and the love he gave to everyone and everything close to him.

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ACR Stereotactic Breast Biopsy Accreditation Frequently Asked Questions for Medical Physicists Priscilla F. Butler Senior Director, ACR Breast Imaging Accreditations Programs Does your facility need help applying for accreditation? Do you have a question about the Diagnostic Modality Accreditation Program? Check out the ACR’s Web site at www.acr.org; click “Accreditation” under “Quick Links” and then “Diagnostic Modality Accreditation Program.” You can also call the Diagnostic Modality Accreditation Information Line at (800) 770-0145. In each issue of this newsletter, we’ll present questions of particular importance for medical physicists.

Q. What is the Diagnostic Modality Accreditation Program?

A. The ACR offers voluntary accreditation in seven different imaging modalities: stereotactic breast biopsy, breast ultrasound, magnetic resonance imaging, ultrasound, computed tomography, nuclear medicine and radiography and fluoroscopy. Many radiology groups wish to accredit in multiple modalities but were discouraged by the duplicative applications that had to be submitted for each of their facilities.

The Diagnostic Modality Accreditation Program (DMAP) was designed to streamline the accreditation process by incorporating all the ACR voluntary diagnostic imaging accreditation programs under one application process.

Q. My facility is going through the accreditation renewal process for our stereotactic biopsy unit. Why do I need to submit a personnel list and attestations for physicians and physicists not at this site?

A. The new Diagnostic Modality Accreditation Program is designed to link all facilities under a group of radiologists called the “Group Practice.” Once your application is processed you will be assigned a Group number.

The group is then categorized by each physical location called a “Practice Site.” Listing all of the physicians, physicists and technologists at all Practice Sites on the personnel list and submitting required attestations with all applicable modalities will eliminate the need to do so on subsequent accreditation applications. Al-

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though setting up the initial Diagnostic Modality Accreditation Application takes time, it significantly reduces the amount of follow up paperwork. More information about the Diagnostic Modality Accreditation Program can be found on the ACR Web site at: http://www.acr.org/dyna/ ?doc=departments/ stand_accred/accreditation/ index.html.

Q. Our facility is accredited for stereotactic breast biopsy and will be relocating to a new office next month. What is the process for relocating a stereotactic unit?

A. You will need to complete a “Relocation” form and submit a Medical Physicist QC Test Summary obtained after the unit has been moved. If the unit is an upright mammography unit with an “add-on” stereotactic device, you must also submit the medical physicist’s Equipment Evaluation report that is required under MQSA. Documentation of all corrective action taken for failures of any tests noted in the medical physicist’s report must also be submitted. There is no fee or additional testing required.

Q. The Stereotactic Breast Biopsy Quality Control Manual calls for the SNR values (for an image of a uniform absorber) at the corners of the image field to be within ± 15% of that at the center. Our (USSC/ABBI, LORAD/ TREX) table unit fails this test at two of the four corners.

However, the LORAD service engineer has given me a copy of their protocol for this test (dated February 17, 1998), which calls for obtaining the SNRs with a 32x32 ROI box centered at the image coordinates (100, 100), (100, 400), (400, 100) and (400, 400), that is, in regions well away from the actual corners of the 512x512 image. (Using the same size box and remaining within the exposed area, I can center the box at coordinates (66, 67), (33, 494), (477, 48) and (48, 494). Thus arises the question: Do I accept the LORAD protocol or do I insist that they meet the ACR standard?

A. It appears that many LORAD-based systems exhibit a signal intensity gradient at one or more edges of the field, which leads to a SNR gradient. Since the non-uniformity occurs only at the edge of the field, it should not compromise patient imaging.

Also, it is the gradient, not isolated inhomogeneities that might be mistaken for abnormalities.

Throughout the Stereotactic Breast Biopsy Quality Control Manual we have consistently deferred to manufacturer’s specifications, in the absence of hard data, on how performance variations might affect image quality in many areas. Therefore, one can accept the manufacturer’s test conditions and action limits.

That being said, it may be possible to improve the uniformity on your LORAD system. Some physicists have found, and

JANUARY/FEBRUARY 2001 JULY/AUGUST 2004 JULY/AUGUST 2004

LORAD engineers have confirmed, that the gradient problem may arise because of the way “flatfielding,” a service engineer’s task, is done. The digital image receptor is “flatfielded” without the steel compression paddle (which is also an X-ray beam-limiting aperture) in place to allow calibration of the image receptor to its edges. However, in phantom testing and in clinical use, the compression paddle/beam aperture is always in place, and the resultant reduced size X-ray beam may have a different symmetry with respect to the edges of the receptor than when it was “flatfielded.” This effect can be minimized if the collimation at the X-ray tube is adjusted so the Xray beam is larger than the compression paddle aperture by precisely the same amount on each of the four edges. LORAD recommends between 5-10 mm for this margin.

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JULY/AUGUST 2004

The 2005 Call for Nominations and Applications is available on the AAPM Web site at http://www.aapm.org/org/committees/awards_honors/index.html#nominations.

Please note that the deadline to receive nominations and applications is October 15, 2004.

Answers from Don Frey’s “Just For Fun” questions on page three:

2

90%

1.8

80%

1.6

70%

1.4

60%

1.2

50%

1

40%

0.8

30%

0.6

20%

0.4

10%

0.2

0%

Bulb Failure Rate

Surviving Fraction

100%

0 0

0.5

1

1.5

2

Half-lives

Probability that a light bulb will make it to 2ϑ is 2.34 x 10-10 (The cartel could have saved it’s money)

ϑ avg = 0.988 ϑ most = 1.03 is the point when the decay of the bulbs is greatest.

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AAPMNEWSLETTER NEWSLETTER AAPM NEWSLETTER AAPM

JANUARY/FEBRUARY 2001 JULY/AUGUST 2004 JULY/AUGUST 2004

Need Continuing Education Credits?

AAPM Remotely Directed Continuing Education Program Answering 8 of the 10 questions will provide you with one Medical Physics Continuing Education Credit (MPCEC). The results of your passing scores will be forwarded to the Commission on Accreditation of Medical Physics Education Programs (CAMPEP). You will receive a summary of your MPCECs earned through the RDCE program at the end of the year from CAMPEP.

RDCE

RDCE

Earn your medical physics continuing education credits online through the

Member Registration Fee: $30

www.aapm.org/educ/rdce.asp

Letters to the Editor Jean St. Germain, MS Former Development Chair stgermaj@mskcc.org There has been considerable discussion over the future of the Education Fund, and it is particularly unfortunate that our president chose to describe the fund in such negative language. In 1988, the Development Committee was a new committee given the charge of coordinating efforts to solicit donations to support the Education Fund and other research education purposes. The first charge given to the committee by the board was the funding of an endowment for an Education Fund. In concept the committee’s efforts are/were not limited to the Education Fund and

could/should be used for other efforts. There were a number of discussions about setting up the Education Fund as a trust in a manner similar to the RSNA Research and Education Fund. The Board chose not to do this.

A committee consisting of past officers of the association ran a funding campaign over a five-year period. The funding of the campaign costs came from the operating funds of the association.

Contributions were received from past and current officers, chapters, individual members, the AAPM itself and RSNA. It was our misfortune to run this campaign at a time when many members felt that there would be a surplus supply of physicists and did not want to contribute to a

fund that would train people to replace them. Other difficulties encountered were the tendency of some groups to fund their own programs and research first and ignore AAPM, or actively compete with AAPM for the same funding sources. After a Herculean effort on the part of many members, we raised about $800,000. Members of the campaign committee were successful in arranging funding of clinical residencies from Varian Corporation and ASTRO on a basis that continues to this day. These residencies contribute $30,000 per year to AAPM. This is the equivalent of a $600,000 endowment at an interest rate of 5% with no adjustments.

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(See St. Germain - p. 18)

AAPM NEWSLETTER

JULY/AUGUST 2004

Letters to the Editor St. Germain

(from p. 17)

It was recognized that the original endowment amount was insufficient to fund residencies without depleting the corpus. Therefore, to allow the endowment to continue to grow, the association chose to fund the initial residencies from operating funds. The spending of the interest on the fund originally intended to be within the purview of the committee, as envisioned in its charge, became subject to the policies of the Investment Advisory Committee (IAC). The policy statement of the IAC approved by the board limited spending of the interest from the fund to a formula based on the real rate of return on investments. This restriction severely limited the amounts available. A Planned Giving Campaign, started recently, has received a total of $50,000 from individual and corporate members. Donations to a member’s memorial fund have also been received. Continuing careful investment has resulted in an endowment now totaling around $1,000,000.

Donations were contributed to the corpus of the fund with the implicit promise of the association to donors to preserve the fund endowment. Endowment money is the most difficult to find and raise as any fund-raiser will testify. Some persons now wish to use the moneys in the fund, not just the interest, to make up for deficits in the AAPM programs.

The funding of education becomes ever more tenuous as government funding programs have been scaled back over the last decade. There is no question that the interest on the fund should be available to be spent—that was the original intent. However, there are fundamental issues to be confronted regarding priorities, vis-a-vis, how we are spending our resources and conformance to the purposes of our society, particularly when we choose to dip into an endowment. Are there really no economies to be found among the various AAPM programs and administration? Do we really intend that AAPM should be the only organization among its sister organizations that has no endowment program? Are there any limits on what can be spent and if so, what are they? These are serious questions for all AAPM members that will affect the future of our profession.

“However, there are fundamental issues to be confronted regarding priorities, vis-a-vis, how we are spending our resources and conformance to the purposes of our society, particularly when we choose to dip into an endowment.”

Defending the Education Endowment Fund Steve Goetsch, PhD Former Development Chair SteveGoetsch@sdgkc.com I agree with much of what President Don Frey said in his March/April column but I take issue with the statement that the Education Endowment Fund is “a failure.” Thanks to hard work by many benevolent AAPM members the balance of the fund today is a little over $1 million. The original goal set by Jean St. Germain’s committee in 1989 was a perpetual endowment of $2 million, which was projected (with an estimated 8% to 10% yield) to be able to support 10 to 12 fellowships or residencies at $15,000 per year in perpetuity.

It was decided to solicit “soft money” to start supporting residencies and fellowships immediately. The AAPM home page (left hand column: Education/Education Endowment Fund) leads you to a list of 47 different trainees supported for two years each at 15 different institutions with this effort.

The original plan in 1990 was to make the fund a separate foundation with its own board of directors. Unfortunately that did not happen and AAPM politics played a role in subsequent events. The Investment Advisory Committee somehow asserted

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Letters to the Editor authority to limit spending of the fund to “3/4 of the Real Rate of Return,” a puzzling edict which baffled even the AAPM’s own financial advisor. What this was interpreted to mean, was that in the bad years (post dot.com) when the stock market was plunging down, the return was NEGATIVE and no money could be spent! Much of the Endowment Fund was invested in the stock market, which allowed the $250,000 founding grant from the RNSA and $150,000 more contributed by members to grow to over $1,000,000. Not a penny of the original fund was spent (by motion of the board) from 1990 to 1999 in order to let the fund grow. A Planned Giving Campaign was started during my fouryear tenure as chairman of the Development Committee, and a total of $50,000 was received from individual and corporate members during those four years.

Many of the original donors recently began to strongly urge the committee to “spend the money you’ve got” before they would even think of leaving money in their estate. This required re-directing the original philosophy of creating an “untouchable” endowment and instead spending down the corpus of the fund. I was unsuccessful in selling the board on this concept in 2002, but new Development Chair Joel Gray successfully challenged the board to “take the gloves off” and allow the committee to create a

$25,000 annual Seed Contract for Research, a new residency and a new fellowship by dipping into the balance of the fund.

What happens now is up to the membership: the fund will deplete itself with the newly approved annual commitment of approximately $100,000 per year in about 10 to 12 years. If members and corporate sponsors continue to give and some members leave money in their estate, the fund may last indefinitely. I urge all AAPM members to follow the lead of our former presidents and “put something back” for the physicists that follow us. Jean St. Germain and I have already taken advantage of Board Policy 18A which transfers $3,000 from the General Fund to the Education Endowment Fund in honor of any member who notifies the board that they have made a bequest to the fund in their estate. Several chapters have honored deceased members with contributions to the Members Memorial Fund, which honors fallen members with their name inscribed on a plaque in the AAPM office (which is on display at all meetings). I personally feel at this time, with a huge shortage of properly trained and credentialed medical physicists in North America, that the Education Endowment Fund is more important than ever. If we don’t help newcomers to this field, we will find ourselves facing untrained fraudulent pretend-

ers, an outcome which no one wants to see.

“I personally feel at this time, with a huge shortage of properly trained and credentialed medical physicists in North America, that the Education Endowment Fund is more important than ever.”

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Happy Independence Day!

AAPM NEWSLETTER

JULY/AUGUST JULY/AUGUST 2004 2004

AAPM NEWSLETTER Editor Allan F. deGuzman Managing Editor Susan deGuzman

Editorial Board Arthur Boyer Nicholas Detorie Kenneth Ekstrand Geoffrey Ibbott C. Clifton Ling Please send submissions (with pictures when possible) to the editors at: e-mail: deguzman@wfubmc.edu or sdeguzman@triad.rr.com (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 2004 Postmark Date: September 15 Submission Deadline: August 15, 2004

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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