AAPM Newsletter September/October 2006 Vol. 31 No. 5

Newsletter

AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE VOLUME 31 NO. 5

SEPTEMBER/OCTOBER 2006

AAPM President’s Column P4P E. Russell Ritenour Minneapolis, MN The annual meeting took place just a few weeks before this writing. I know it will be quite a bit longer before you read this, but I still want to mention the meeting. There were some surprises. First of all, many of us had been dreading going to Orlando, FL in late July. We were just sure that it was going to be very hot and unbearably humid. How ironic it was that many parts of the country­­—including Minneapolis, of all places—were even hotter that week. We went to Orlando in July to cool off! We’ll have to arrange a reversal of that trend for the annual meeting next year—in Minneapolis. There was also a surprise in the ‘Night Out.’ A criminal incident at one of the theme parks forced closure of the park area and unbelievable traffic jams. This led to some frustration, but people seemed to find things to do and people to

talk to until the buses finally left.

The food was good and plentiful and they kept the venue open for an extra hour. All in all, the outcome was satisfactory.

Satisfactory outcomes are what we would like to achieve in medicine, as well. (That was the clumsiest segueing I’ve ever seen. If I think of something better before deadline, I’ll erase all this. Sure hope I do). It seems inevitable that reimbursement rates will become linked to measures of outcomes in what is referred to as Pay for Performance (P4P) programs. A P4P program offers financial incentives to groups of physicians who meet specific performance standards.

To measure performance, the medical process is divided into three main components in what is known as the Donabedian system.

Avedis Donabedian, a physician with a master’s degree in public health who spent most of his career at the University of Michigan, pioneered the study of

(See Ritenour - p. 2)

William D. Coolidge Award Congratulations to Dr. Ervin B. Podgorsak who is the 2006 William D. Coolidge Award recipient!

The following is an introduction of Ervin Podgorsak by colleague Michael Evans from McGill University Health Center in Montreal.1 This highest honour, presented once a year by the AAPM, requires the candidate to have demonstrated, through an eminent and longstanding career in medical physics, both leadership and excellence in three major (See Coolidge - p. 4)

TABLE OF CONTENTS Awards Coolidge Award Speech Chairman’s Report Executive Dir’s. Column Science Council Report CAMPEP News Education Council Report Summer School Health Policy/Economics Clinical Trials New Members Chapter News Mammography FAQs Letters to the Editor

p 3 p 5 p 9 p 11 p 13 p 14 p 15 p 17 p 18 p 23 p 24 p 25 p 26 p 29

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Ritenour (from p. 1) the many parts of healthcare as a complex system. His seminal paper of 19661 introduced the concepts of structure, process and outcome. Structure refers to infrastructure, such as medical equipment and information systems. Process involves actions taken during care of the patient.

Outcomes are the results of actions taken during patient care.

For each of the three components, metrics are developed to determine how well each is functioning. These three concepts are still considered to be key to the analysis of health systems and I predict that you will hear these terms from administrators and others over the next few years.

Why am I going on about P4P? Because radiology is going to have to set up metrics to measure performance and medical physicists are involved in structure, process, and outcomes. The Center for Medicare and Medicaid Services is implementing physician P4P beginning with a “starter set” of 16 indicators for primary care physicians. The Medicare Payment Advisory Commission is also pushing for a P4P and other private programs are beginning. Premier Hospital has a Quality Incentive Demonstration (www.premierinc. com/all/quality/hqi). Finally, the American Medical Association has committed to working with CMS and Congress to implement P4P within the next two years. They have proposed the development of 140 performance measures during the next year. As part of this effort, the

American College of Radiology is working on developing performance metrics and has asked the AAPM to help. I will be appointing liaisons to the ACR P4P initiative, certainly before you read this. A task group will probably be formed under the Government Affairs Committee of the Professional Council.

Imaging and oncology groups who work with qualified medical physicists and practice with the kind of equipment, staffing, and safety standards that the AAPM promotes in its task group reports expect to be more highly reimbursed than physician groups who don’t. This is an effort that is clearly in the best interest of the AAPM. As physicists, we are already helping to set up these metrics.

An example of a metric is “Are all of your X-ray tubes surveyed yearly by a qualified medical physicist?” Another example is “What percentage of your medical physicists are board certified?” Answering yes to these questions might earn a radiology group points in the performance system. Other metrics deal with patient safety, speed of reporting results, number of incidents, etc.

Certainly, there are medical metrics in which physicists play little or no role. However, at a meeting held just before our annual meeting, I had the opportunity to see, first hand, how much of a role we will play.

The topic of the Intersociety Summer Conference held July 21-23 in Banff, Alberta, Canada was “Quality, a Radiology Imperative.” Representatives 2

of all major organizations in radiology, radiation oncology, and medical physics were present.

The AAPM was represented by Chairman of the Board Howard Amols and by me. The purpose of the meeting was to discuss the many issues surrounding P4P and to come up with an actual list of metrics. We formed into work groups and then discussed the workgroup’s recommendations in a plenary session the next day.

The results are still being refined, but at one point, by my count, we came up with 72 metrics. It surprised me how many of these metrics involved physicists. The final results will, I believe, be published in the JACR. P4P is coming. The AAPM will continue to play an important role in establishing quality metrics in radiology and radiation oncology.

Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly, 1966, 44: 166–206.

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Coolidge (from p. 1) categories, most notably having had a significant impact on the scientific practice of medical physics; a significant influence on the professional development of the careers of other medical physicists; and demonstrated leadership in national and/or international organizations, with specific emphasis on AAPM activities.

Prof. Podgorsak, Ph.D., FCCPM, FAAPM, DABMP, director of the McGill University Medical Physics Unit and director of the Medical Physics Department of the McGill University Health Centre, was born in Vienna, Austria in 1943 and graduated with a major in physics from the University of Ljubljana, Slovenia in 1968. In 1969 he began graduate studies at the University of Wisconsin where he completed his M.Sc. degree in physics (1970) under Dr. John R. Cameron (1980 Coolidge Award recipient) and his Ph.D. degree in physics (1973) under Prof. Paul R. Moran with a minor in radiological sciences. Following an invitation

by Dr. Harold E. Johns (1976 Coolidge Award recipient), Dr. Podgorsak moved to Toronto where he was first employed as a postdoctoral fellow at the University of Toronto Department of Medical Biophysics, and then as a clinical physicist at the Ontario Cancer Institute under Dr. John Cunningham (1988 Coolidge Award recipient).

Traveling against the political tide, he headed east to McGill

University in Montreal in 1975 and took up a double load as tenure track professor and clinical physicist in radiation oncology.

In 1979 he assumed directorship of the hospital-based departments of radiation oncology physics at three McGill University teaching hospitals (Montreal General, Royal Victoria and Jewish General), as well as director of diagnostic radiology physics at the Montreal General Hospital.

Fully tenured in 1985 as profes-

Dr. Ervin Podgorsak

sor of medical physics in the Faculty of Medicine at McGill, Dr. Podgorsak also became director of the academic-based McGill University Medical Physics Unit in 1991, and continues to serve both the hospitals and the university in all of these positions.

In terms of ‘significant impact on the scientific practice of medical physics,’ it is clear that Dr. Podgorsak’s practical approach to clinical radiation oncology physics is an example of translational research which has had a true impact on the life and well being of many patients.

The author or co-author of 140 peer-reviewed publications, 18 4

invited book chapters, 66 conference proceedings, 185 published abstracts, and some 340 invited and proffered presentations, Dr. Podgorsak has been involved in basic medical physics research, as well as the development of numerous innovative cancer therapy techniques. Showing no signs of slowing down, two recent publications (both in 2005) are textbooks that are likely to be reference material for medical physicists for years to come. These are the 657-page Radiation Oncology Physics: A Handbook for Teachers and Students published by the IAEA and edited by Dr. Podgorsak, as well as a 450-page textbook based on 30 years of lectures given to graduate students at McGill entitled Radiation Physics for Medical Physicists authored by Dr. Podgorsak and published by Springer from Heidelberg.

The AAPM’s second criterion demands a ‘significant influence on the professional development of the careers of other medical physicists.’ As a professor in the McGill Medical Physics Unit since its establishment in 1979 and its director since 1991, Dr. Podgorsak has been a graduate course teacher and mentor to the 140 MSc and 19 PhD graduates. Of these graduates, he was a direct supervisor to 30 MSc and eight PhD students, and has helped many others with the arduous task of thesis writing.

In 1991 he was instrumental in changing the MSc degree to the combination didactic and thesis-based program, resulting in McGill’s MSc and PhD

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medical physics programs being the first in Canada to attain the CAMPEP accreditation in 1993. His continuing interests in advancing the careers of young medical physicists prompted him to develop a Medical Physics Residency Program in radiation oncology physics, and his ability to once again join the academic and clinical worlds ensured the CAMPEP accreditation for the McGill Residency Program in 2000, another Canadian first. Dr. Podgorsak also participates in the IAEA development and assessment of medical physics teaching programs around the world.

Having known Ervin since 1982, I would say that his teaching legacy is the one he is most proud of, however, the third requirement of the AAPM to be hurdled is the ‘demonstration of leadership in national and/or international organizations, with specific emphasis on AAPM activities.’ Dr. Podgorsak has served the AAPM as an associate editor of Medical Physics, a board member, on various task groups and councils, and as Local Arrangements Committee chair for the 2002 AAPM summer meeting held in Montreal. In a similar manner, he has served the Canadian College of Physicists in Medicine (President: 1985–1987), the Canadian Organization of Medical Physicists, the American College of Medical Physics and the International Stereotactic Radiological Society.

His ability to function in five languages has made him a sought after member of several committees of the IAEA in Vienna.

In addition to his accomplishments at the professional level, I believe it is the opinion of his family, friends and colleagues that is most important to him, and he has had successes on all three levels. His wife, Mariana, has been a constant support, and has probably spent enough time in medical physics departments to qualify as an honorary physicist. In true biblical fashion, he has ‘given’ his first son, Dr. Matthew Podgorsak, to the medical physics profession, and I am sure that they, along with their other son, Gregor, and Ervin’s mother, would agree that his life in many ways has been dedicated to serving the medical physics community.

To quote one of the many reference letters solicited in support of this award, “Ervin is the dean of our profession in Canada but his influence extends to the United States and the rest of the world.

He is a symbol of integrity, truth and excellence both inside and outside our field. Bestowing the Coolidge Award upon Dr. Ervin Podgorsak honors all of us.”

Congratulations Ervin!

This introduction is an excerpt from Evans’ speech at the award ceremony during the AAPM Annual Meeting in Orlando and from an article in Interactions (July 2006, pp. 94-95), the newsletter of the COMP and the CCPM. Evans is a medical physicist and assistant professor at McGill University in Montreal, Canada.

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Coolidge Speech by Dr. Podgorsak AAPM Annual Meeting Orlando, FL July 31, 2006 Mr. President, officers of the AAPM, members of the Honors and Awards Committee, distinguished guests, ladies and gentlemen, family, colleagues and friends: It is a great privilege and honor for me to stand before you here tonight. I accept the Coolidge Award with great pleasure but also with a realization that I have many colleagues, some of whom are here tonight, who are just as deserving of this honor as I am.

When President Ritenour notified me of the award, I was, of course, delighted but, upon examining the list of previous 5

awardees, I felt, in addition to pride, a sense of unease; most of the previous honorees I know, all of them have been and still are my role models, and three of them were my mentors. To become a member of this distinguished group is an exhilarating, yet humbling, experience. Medical physics is a profession like no other, and I consider myself privileged to have been able to contribute to it to an extent that is deemed worthy of this award.

Acknowledgments: No man can be successful in any endeavor without help from others, and everybody follows the life’s (See Podgorsak - p. 6)

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Podgorsak (from p. 5) winding road with turns that are influenced by lucky and unlucky breaks. Many lucky breaks in my private and professional life contributed to my standing here tonight; let me list a few: I had a widowed mother who instilled in me the understanding that my only way to succeed in life was through hard work and education.

I was associated with four universities, each one of them great in its own way: Ljubljana in Slovenia gave me excellent training in undergraduate physics; Wisconsin in Madison gave me graduate physics training and introduced me to medical physics; Toronto trained me in clinical physics; and McGill in Montreal allowed me to devote my professional life to medical physics, a specialty and profession that I truly love.

I had mentors who, in addition to physics, taught me about work ethics, interaction with colleagues, dealing with administrators, and coping with professional frustrations. It was a real privilege to have been taught by Drs. John R. Cameron and Paul R. Moran at the University of Wisconsin, and Drs. Harold E. Johns and John R. Cunningham at the University of Toronto. I am probably one of only a few medical physicists who trace their roots to two distinguished medical physics dynasties: Cameron’s in the U.S. and Johns’ in Canada.

I benefited from my interaction with Dr. Montague Cohen who

was my physics director during my first four years at McGill and who established the graduate programs in medical physics at McGill in the late 1970s.

During my long tenure at McGill I dealt with many administrative directors, such as academic deans and directors of hospital services, but I had only one clinical director, Dr. Carolyn R. Freeman, the director of Radiation Oncology at McGill since 1979. She has always been supportive and respectful of my academic and clinical interests, and together we created an excellent atmosphere of collaboration between the Radiation Oncology and Medical Physics departments that resulted in a respectable academic performance, as well as in many innovations that benefited the patients directly.

I had clinical colleagues who always respected the contribution of medical physicists to the treatment of their patients. In particular, my clinical interactions with Dr. Luis Souhami, the associate director of the McGill Radiation Oncology Program, were very fruitful, especially in the field of radiosurgery, and taught me a lot about clinical work and medicine in general.

In the Medical Physics Department I had colleagues who, in addition to expecting of me to look after their interests, were always supportive of my departmental and professional goals. I am particularly grateful to my colleagues Marina Olivares, Michael Evans, and Jan Seuntjens who nominated me for the award.

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I had students who, with their enthusiasm and youthful naïveté, forced me to be the best teacher I could be, and showed me that teaching was the most enjoyable, rewarding and important aspect of my professional career.

My mentors and superiors gave me the tools and opportunities to develop my interests; my medical physics colleagues and students provided me with support and motivation to move ahead. To these men and women I owe great gratitude, but to my wife, Mariana, I owe my love and appreciation for 41 years of unequivocal support, care and understanding; for giving me two sons, one of them also a medical physicist; and for keeping the family sane despite the pressures of moving countries and my academic work. Mariana, it gives me great pleasure to be able to thank you publicly for your help and support. I am happy that both my sons, Matthew and Gregor, are here tonight, and so are Matthew’s wife, Kristine, and children, Alex, Anthony and Kimberly. We have two generations of medical physicists in our family, but this is not all that unique, as shown by other families such as the Balters, Detories, Heintzs, Hendees, and Ortons.

Alex, Anthony and Kimberly, we can make it three generations, if you study hard and at least one of you becomes a medical physicist. Wouldn’t this be cool?

And, last, I am fortunate to be a member of an organization, the American Association of Physicists in Medicine, which showed remarkable openness to the world by selecting for the 2006

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Coolidge Award a naturalized Canadian citizen of Slovenian descent.

Recent trends in medical physics: I started in medical physics in the early 1970s in an era when medical physics was just coming of age and professional life was significantly simpler than it is today. Our medical physics organizations, the AAPM and the precursor of the Canadian Organization of Medical Physicists (COMP), were already established and, similar to today, the responsibilities of medical physicists were divided into four areas: clinical service, research, administration, and education. Linear accelerators had already been in clinical use for several years and rudimentary CT scanners were just appearing on the scene.

During the past three decades, medical imaging and dose delivery have undergone tremendous advances, mainly as a result of solid-state technology and computerization. Concurrently with exciting technological developments, the job of medical physicists was becoming increasingly more cumbersome and complex, and this not just because of technological advances.

In all areas of medical physicists’ responsibilities there was a slow but steady move from basic models that worked, toward more “sophisticated” models that attempted to supplant basic concepts with unnecessary sophistication. This sophistication did not make much sense to medical physicists but surely

pleased the bureaucrats, giving them “raison d’etre,” material to analyze, and an upper hand over medical professionals.

The clinical service was becoming increasingly more complex with new bureaucratic management models, such as the TQM, CQI, and QUM, substituting for the basic quality assurance (QA) and quality control (QC) models of the 1970s. The ever-increasing cost of health care was the excuse for the increased bureaucratization of the health care system; however, the cost associated with the escalation in the health care bureaucracy exceeded by far the cost increases in all other areas of health care delivery.

Research in medical physics was becoming concentrated in a few large centers, while in smaller centers the clinical demands and relatively small number of physicists precluded meaningful research efforts. Moreover, the research emphasis moved away from basic concepts in medical physics and concentrated on technological problems.

Administration of the health care system and equipment acquisition have become extremely bureaucratic, wrought with meddling and interference by government, its agencies, and hospital bureaucrats.

Teaching has been slowly eroded in favor of instruction. Instruction, of course, is important but it only represents the lower echelon of education; it is the teaching that makes the students think on their own and stimulates them to formulate their own ideas based on the instruction 7

they received. Education based solely on instruction produces technicians, not professionals with graduate degrees; good instruction transmits knowledge, good teaching provides understanding.

After 2000, it became obvious that the tandem of “sophistication” and technology had resulted in unsustainable health care cost of which administration represented a major component at the expense of patient care, education and research. In medical physics we now find ourselves in a gradual, yet noticeable, trend toward a blend between modern technology and the basic concepts that worked well in the 1970s. The grip of bureaucracy is slowly diminishing; QA and QC are again the preferred management models; the relevance of basic research is again recognized; and the importance of teaching over instruction is again being promoted.

Manpower shortage in medical physics: During the past two decades medical physics became a well-defined and mature physics specialty and profession.

Unlike in the 1970s and before, when physicists who were trained in one of the traditional physics specialties entered medical physics largely by chance and received on-the-job medical physics training, today a more common entry into the medical physics profession is through a graduate program in medical physics preferably followed by a two-year residency in a medi(See Podgorsak - p. 8)

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Podgorsak (from p. 7) cal physics subspecialty. In the future, completion of residency will become mandatory, but this is not so now because of the severe shortage of available residency positions in North America.

The two national medical physics organizations, the 5800-member AAPM in the US and the 500-member COMP in Canada, are strong and already have a 50-year tradition. The future is bright for medical physics and our organizations, however, there is one serious, chronic and growing problem—the shortage of properly educated and trained medical physicists.

The rapid expansion in imaging and dose delivery technologies during the past two decades has been accompanied by a rapid increase in available medical physics positions. Unfortunately, medical physics graduate programs and residencies did not grow accordingly so that accredited graduate programs produce less than half of the number of new medical physicists needed per year, and the residency programs run at about 10%. This gives universities an excellent opportunity for program expansion provided, of course, that they have a medical school and a physics department. Since in the U.S., there are currently 125 medical schools and 150 graduate physics departments but only nine accredited medical physics academic programs; the growth potential for medical physics programs is obvious.

The corresponding numbers for Canada are 17 medical schools, 30 physics departments, and four accredited medical physics programs.

Most of the work of medical physicists is indirectly related to people who have only one wish.

We must not forget that despite our scientific and technical training, our strongest guiding attributes must be compassion for patients and discipline toward our work.

I am proud to be a medical physicist, I am proud to be an AAPM member, and I thank you for honoring me tonight.

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Conclusion: Ladies and gentlemen, I will conclude with a Slovenian proverb that I believe is very relevant to our work: “A healthy man has a thousand wishes, a sick man has only one.”

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‘Chair-man’ of the Board Report Howard Amols New York, NY “If everything seems under control, you’re just not going fast enough.”

- Mario Andretti Like many of you I’ve just returned from the unexpectedly frigid Orlando summer to the oppressive heat of the Northeast.

Fortunately no bookmaker would give odds on Orlando in August being cooler than New York because if they had, I’d have lost a considerable amount of money.

So let me add my congratulations to the Meeting Coordination Committee, Program Committee, Local Arrangements Committee, and AAPM headquarters staff for another very successful annual meeting.

In my previous column I discussed plans for improving the efficiency of the AAPM Board of Directors via various means including decoupling the times of committee and council meetings from board meetings in order to give the board more time to digest the issues they’re supposed to deal with, reducing the amount of time spent at board meetings on perfunctory functions such as rubber stamping committee reports, task group reports, and EXCOM actions so that the board can devote more time to discussion of key issues (more on that below). We also continue to explore plans for restructuring the board (i.e., reducing its

size) as an additional means of improving its efficiency, but recognize that restructuring is one of several possible ways to improve efficiency. We must proceed simultaneously with both approaches.

The Regional Organization Committee headed by Dan Pavord has made recommendations on restructuring the board and these recommendations were sent to chapter presidents for comments and to the board for discussion. This report is an excellent start, but more work and more discussion are required before any Bylaws changes (such as were voted down last year) can be presented to the membership for another vote.

Future columns will have more on this topic.

The board also received, in their infamous ‘pre-board packet,’ reports from the Ad Hoc Committee of the Board on ‘Board Meetings’ chaired by Ken Vanek and the Ad Hoc Committee on ‘Systems for Virtual Meeting Presence’ chaired by Donna 9

Siergiej. So how did the board meeting go? Probably a qualified success. We did curtail drastically the perfunctory portions of the meeting thereby enabling almost three hours for open discussion, most of which was devoted to discussing the above two reports and strategies for changing the basic operating mechanisms of the board. In this regard I think good progress was made. There was, for example, consensus on the following items: 1. Beginning in 2007 the board will meet three times per year with the third meeting being in spring, probably at a centrally located airport (such as Chicago), decoupled from any other AAPM committee meetings, and devoted to long range planning and policy making.

2. Rescheduling the time of the board’s regular meeting in November-December at RSNA to earlier in the week.

3. Conducting more of the board’s work via the Web, emails, and real-time virtual meetings. For this purpose we tested a virtual meeting software package (thanks to Donna Siergiej, George Sherouse, and Michael Woodward for setting this up) that could be made available to all board members, and in the future possibly also to any AAPM committees interested in virtual meetings. The jury is still out on this particular software package but there is consensus that this is the logical way to go.

(See Amols - p. 10)

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Amols (from p. 9) 4. Some of the tasks currently performed by EXCOM could be delegated either to other board members and/or to ad hoc subcommittees of the board.

5. Changing the title of ‘Chairman of the Board’ to ‘Grand High Exalted Mystic Ruler.’

I am mindful, however, of a quote from Ernest Hemingway; “Never mistake motion for action.” Changing the mindset and the modus operandi of the board is a necessary first step and I am encouraged that progress in this direction was made at our Orlando meeting, but we must also keep in perspective the fact that little, if any, actual AAPM policy or long range planning made it to our agenda. Hopefully once the board has finished designing and implementing its ‘efficiency tools,’ it can then actually build something. To whit, we should not lose site of the fact that the board’s real purpose is to: •set organizational direction and determine the AAPM’s mission •participate in regular strategic planning and set a vision for the future •set major goals and develop strategies •approve operational and annual plans, and oversee financial management •measure progress on strategic plan, monitor and evaluate programs and services •provide legal and moral oversight •be responsive to the general

membership of the organization.

Hopefully we’ll do some of that at our next meeting in Chicago at the RSNA. In a final note, I am pleased to announce that the AAPM has its first Web site editor in the person of Chris Marshall. With the growing importance of the AAPM Web site as our ‘window to the world,’ the increasing need for editorial decisions regarding Web content, and visions of expansion of

Web site content, it was deemed necessary that someone with medical physics and AAPM experience should be guiding the growth of the Web site to complement the technical expertise of Mike Woodward and AAPM’s IS group. Last year the board approved the creation of this position and I appointed a search committee chaired by Colin Orton to define job duties and recruit candidates. Many thanks to Colin and best of luck to Chris.

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Just For Frustration: Answer to last month’s ‘Thinking out of the box’ problem: Without lifting your pencil, draw four lines thru all nine points.

The 2007 Call for Nominations and Applications is available on the AAPM Web site at http://www.aapm.org/org/committees/awards_honors/index.html Please note that the deadline to receive nominations and applications is October 15, 2006 10

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Executive Director’s Column Angela Keyser College Park, MD

2006 Annual Meeting Night Out

United States Physics Team The United States Physics Team is co-sponsored by the American Association of Physics Teachers and the American Institute of Physics. The AAPM joins with other societies to provide financial support for the team in preparation for the International Physics Olympiad.

The 2006 U.S. Physics Team won four gold and one silver medal at the 37th International Competition held July 8-17 at the National Institute of Education, Nanyang Technological University in Singapore. The Olympiad is an international competition among pre-university students from more than 60 nations. The goals of the Olympiad are to encourage excellence in physics education and to reward outstanding physics students. Competitors are asked to solve challenging theoretical and experimental physics problems. The 24 members of the U.S. Physics Team were selected through two competitive examinations.

Team members attended a nine-day training camp during which time the team members refined their problem-solving and laboratory skills. Five students were selected from this group to represent the 2006 U.S. Physics Team. For more

information, go to: http://www. aapt. org/olympiad2006/ .

Financial Update The 2005 audit report has been reviewed by the Audit Committee and submitted to the board of directors. Here are a few highlights from the 2005 financial summary: •excess of income over expenses of $456,451, including an unrealized gain on investments of $134,635 •an improvement of $840,830 over the original 2005 budgeted deficits of ($384,379) •AAPM reserves at the end of 2005 were $7 million.

Conservative projections for the 2006 year indicate a deficit of ($370,604) versus a budgeted deficit of ($498,406). The major portion of the difference in estimate versus budget is due to the success of the 2006 annual meeting and greater-than-anticipated membership growth.

11

The 2006 Annual Meeting Night Out festivities at Universal’s City Walk were delayed due to security issues in the Orlando area. It was very disappointing for the hot and hungry attendees who were anxious to get to the party, and for the organizers who had worked hard to plan a fun evening! I appreciate the graciousness and patience of everyone as we worked through many logistical issues. These circumstances were completely out of the AAPM’s control. Because the event did take place from 7:30–10:30PM, the AAPM did not receive a refund for the tickets that were not used. Therefore, the AAPM will not be able to refund any tickets.

Membership Renewal Process for 2007 Dues renewal notices for the 2007 year will be sent out during October. I encourage you to pay your dues via the AAPM Web site to reduce administrative costs.

■

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

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8/10/2006 11:11:16 AM

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Science Council Report John M. Boone Council Chair I recently had the privilege to lecture in an AAPM-sponsored course on medical imaging to 350 students and medical physicists in New Delhi, India, along with AAPM members Mahadevappa Mahesh, Tony Seibert, and Ramesh Chandra.

Being my first time to India, I was taken back by the extreme poverty that exists there in some places. In spite of this, our Indian host, Dr. Pant, was able to lobby various agencies of the Indian Government to help support the travel costs for the majority of students from all over India who attended. Over the five days of lectures on medical imaging, with lecture hall temperatures in the 90s and tea break venue temperatures over 100 degrees with monsoon-level humidity (and hot tea!), the delegation from the AAPM had ample time to interact with many Indian scientists, both established and in training.

A few weeks later we were all in Orlando attending the AAPM meeting with a familiar U.S. venue and an excellent meeting.

I am nevertheless struck by the vast contrast between our medical physics meetings in New Delhi and that in Orlando—yes, there were differences in wealth, hotel accommodations, women’s clothing, and the food, but far more striking in India was the

hunger for knowledge and the desire to learn. In New Delhi, despite the oppressive heat, the large audience was attentive, enthusiastic, and focused. No one was slouched and I saw no nodding heads. Breaks were opportunities for interaction, and each of the lecturers was thronged by enthusiastic, intelligent, and extremely polite young scientists asking excellent questions. They were having fun! In the U.S., conference-goers mosey in late for the lecture, monitor their blackberries, answer e-mails, and some take cell phone calls—right in the middle of the lecture hall. Have we become jaded and distracted, slaves to the electronic leashes that tether us to relentless, never-ending responsibility?

Medical physics is a fledgling discipline in India, and is mostly associated with academic physics departments, whereas in the United States it has become a discipline of its own, usually centered in radiation oncology or radiology departments in a medical school, hospital, or clinic. The 13

maturation of medical physics in the U.S. has led to increased salaries for sure—no complaints there—but I wonder if we have given up something profound—perhaps innocence, certainly time for lunch, but have we also lost something more basic—our bond with physics and our connection with science? At our meetings do we come together to learn about actual physics, or do we learn about evolving DICOMRT standards, new MQSA regulations, or a new protocol for quality assurance in IMRT? I know in my own case, the latter examples outnumber the former. Now that I think about it, I find that sad, but why?

The answer for me is simple: there is no joy in DICOM, and regulations are hard for anyone to love. It is the math and science that attracted me to this field—positron decay, Fourier analysis, the Brateman equations, and the wonderful solid state physics that occurs when a photon meets a teeny crystal of cesium iodide…

This is the challenge of Science Council: to provide our AAPM members with the opportunity to reconnect with, and engage in, real science. I don’t mean just research, as science lingers, sometimes just below the surface, in most of what we medical physicists do.

Despite earlier comments, Jeff Siewerdsen and Gig Mageras really did do an excellent job (See Boone - p. 14)

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Boone (from p. 13) of bringing more real science to our annual meeting. I salute and congratulate them for their efforts. I know for myself that

in addition to the obligatory attendance at symposia for CMEs, I will make more effort in the future to attend courses and symposia in which science comes to the surface, and to

better connect with the fundamental joys which are at the roots of this profession. I owe this to myself, and to the many Indian physicists who taught me this lesson.

■

CAMPEP News Brenda Clark CAMPEP President brclark@ottawahospital.on.ca There are currently 13 graduate programs accredited by CAMPEP. Two applications for re-accreditation are under review and one new application has been received—the initial review has been done and a site visit will be scheduled.

If you are considering applying for graduate program accreditation, please submit your application before the 1st of May. This will allow a preliminary review to be done and available for discussion at the summer committee meeting. If the initial review is positive, a site visit will be scheduled early in the fall such that the accreditation process may be completed before the end of the calendar year. This schedule has been found to work well with our volunteer review teams. Applications received later in the year may take longer to process.

The Residency Program Review Committee works somewhat differently and is able to process applications throughout the year. We currently have 14 residency programs accredited, four under review and six pending. If all these new applications are successful, we will have 24 accredited residency programs—a dramatic increase over a relatively short period of time! This clearly represents many hours of work, both for the individual programs and also for the program review teams.

We also are working with the AAPM TG133 subcommittee on “Alternative Clinical Medical Physics Training Pathways.”

14

This group has a mandate “To consider and propose a model or models by which extensive clinical medical physics training as outlined in AAPM Report #36 (and its revisions) and delivered in a CAMPEP accredited clinical training program can be achieved.”

The new CAMPEP Continuing Education online application system has now been in use for several months. After a rocky start, the system is working well and considerably simplifies the application process for both program directors and reviewers. One of the simplifications that has been made in the process, for example, is that biographical forms are no longer needed for speakers; they are only required for the program director. More improvements have been planned and will be coming soon. Also new this year, there are continuing education credits for ABR examiners.

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Education Council Report Herbert W. Mower Council Chair The 2006 Annual Meeting is now over and no one can argue that the Night Out was the most exciting (and frustrating) part of the meeting. Hopefully all are aware that the AAPM, the Meeting Coordination Committee and the transportation service were individually and collectively not responsible for the events and delays in the evening schedule.

It did, however, provide something for us to talk about for many days.

Attendance at our ‘Educators’ Day’ probably hit a new low this year. The summer is always a difficult time to get secondary school and college faculty to attend our meetings. Amy Readshaw put together a great program that was taped. This year we will also be doing an ‘Educator’s Day’ at ASTRO. Our ‘Student Meeting’ had a much stronger attendance.

Many thanks to Charlie Coffey for stepping in at the last minute and helping to make this a big success.

Due to a last minute change, our History Committee was not able to take part in the Education Council Symposium. Many thanks to Ben Stein, AIP, for expanding his presentation on the Discoveries and Breakthroughs in Science (DBIS) Program.

The AAPM has been involved with this for the past few years and it is a great way to educate

the public on the interaction of science and medicine. If you didn’t get a chance to attend the symposium, you can learn more about it by going to the link on the AAPM Web site. Mary Fox and the Public Education Committee are taking responsibility for the 2007 Education Council Symposium. They will be addressing items such as: •information on the available Web, but perhaps hard to find •information available to include in your talks and presentations •information for patients •how to deal with the press when they come knocking on your door •various public relations strategies This should be an exciting and educational program.

The Medical Physics Education of Physicians Committee, chaired by Richard Massoth, is busy as usual. As a result of the 2006 Physics Summit, coordinated by Bill Hendee and by me, the committee is reactivating its subcommittee on ‘Radiation Physics Syllabi for Residents.’

Due to the current focus on this, the subcommittee is being divided into two groups, one for ‘Imaging Physics Syllabi’ and one for ‘Radiation Oncology Syllabi.’ Phil Heintz chairs the imaging subcommittee. The radiation oncology subcommittee will be working closely with its counterpart committee at AS15

TRO. The goal is to have a fairly good handle on the curriculum revisions needed by the end of January 2007. This will allow us to bring a fairly substantial proposal to the RSNA Physics Education Conference in midFebruary 2007.

This committee continues to work with the various cardiology groups to provide physics training at their national meetings.

The committee also proposed to the council and the board that we be a co-sponsor at the upcoming Association of University Radiologists Residency Training Program. Several AAPM members will be involved in this program at the AUR annual meeting.

The History Committee under Bob Gould, is working on our upcoming 50th anniversary in 2008. They expect to be soliciting brief biographical information for a ‘History and Heritage’ Web site shortly. They are also considering a ‘History and Heritage’ Symposium at the 2008 annual meeting. Watch future editions of the AAPM Newsletter for historical anecdotes.

(See Mower - p. 16)

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Mower (from p.15) The Education and Training of Medical Physicists Committee, under the direction of Ervin Podgorsak, continues to strive to meet the educational needs of our members. The Summer Undergraduate Fellowship Program allocated 12 fellowships this year. In reviewing the program, we find that 70-75% of awardees enter medical physics. The program has no shortage of qualified applicants.

The committee’s Subcommittee on Minority Recruitment, chaired by Paul Guèye, had a very strong first year. They approved three fellowships for minorities in the Summer Undergraduate Fellowship Program,

FILM

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hosted a medical physics symposium aimed at minorities at the 2006 APS March meeting, and provided lectures on medical physics opportunities at minority institutions.

The committee also proposed a Workgroup on the Coordination of Residency Programs, which was approved by the council.

The Continuing Professional Development Committee, chaired by Mike Yester, noted that the search engine for the online continuing education program is now functional.

About 100 hours of educational and symposia presentations will be captured at this year’s annual meeting. Maintenance of Certification continues to be a major focus of this committee and more

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on this will be forthcoming in the upcoming months.

Our new committee, the International Education Activities Committee under Don Frey, reviewed their Policy for Funding International Education Activities. Under the restructuring of the international activities, funding for educational programs comes through the Education Council budget. Over the years several great programs have been co-sponsored by the AAPM, including the International Science Exchange Program (ISEP). The policy gives priority to the funding of various programs in order to have the greatest effect.

In early 2007 the Education Council, composed primarily of the chairs of the various

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AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

committees, will be taking a critical look at our direction for the next couple of years. If you have any questions, suggestions or concerns, feel free to contact

the appropriate chair or me. As always, if you are at the RSNA meeting in Chicago, feel free to drop by the Education Council meeting, or any of the commit-

tee, subcommittee or related task group meetings. We value your input and look forward to seeing you there.

■

Summer School The Physics of a Beer Robin Miller 2006 Local Arrangements Task Group A few weeks ago I sat around a table drinking a beer talking about physics. Weird? Maybe.

But I was picking the brains of colleagues—some old friends, some new ones—about the intimate details of IGRT and Monte Carlo. I didn’t know the nitty gritties, they did and they wanted to share. Where was I? At the 2006 AAPM Summer School located at the University of Windsor in Ontario, Canada. One of the better aspects of medical physics is that, for the most part, people are willing to share. All you have to do is ask.

I also got an education on the finer points of soccer as the World Cup was raging. It was approximately one thousand degrees in the shade at the University of Windsor yet we had our own version of the World Cup every lunch break.

And everyone’s Monte Carlo skills were further honed later in the evening at the Casino in downtown Windsor.

Summer School Local Arrangements Committee, l to r, front row: Rojano, Robin, Karen, Vrinda, and Shi-Hu, back row: Sherry, Paul, John, Will, Igor and Jeff. Please see Summer School group photo at: http://www.aapm.org/meetings/06SSgroupphoto.pdf

There were 192 attendees and 29 faculty from 15 different countries for over 32 CMEs at the summer school.

That is a very diverse and knowledgeable crowd. A few new ideas were tried this year; the proceedings distributed at the summer school were on CD and a soft cover ‘book’ comprised of copies of most of the faculty presentations were given out so the fastidious could take notes.

A huge thank you goes to our scientific course directors Bruce Curran, James Balter and Indrin Chetty. The local 17

crew, headed by Jeff Richer, included Igor Shishkov, John Agapito, and Siobhan Ozard.

Also assisting from the U.S. side were Vrinda Narayana and students Rojano Kashani, Shu-Hui Tsu, Yun Wang, and Ning Wen, in addition to the usual suspects from the Summer School Subcommittee, Chair Paul Feller, as well as Sherry Connors and Will Parker, and our ever-helpful AAPM staff person, Karen McFarland.

See you next year.

■

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Health Policy/Economic Issues Wendy Smith Fuss Health Policy Consultant

CMS Releases 2007 Medicare Physician Fee Schedule Proposed Rule The Centers for Medicare and Medicaid Services (CMS) recently released two Physician Fee Schedule proposed rules (June 21 and August 8, 2006).

major change to calculating practice expense relative value units (RVUs). CMS proposes to implement a methodology that is the complete opposite of the current “top-down” system.

Although the proposed “bottom-up” methodology is more transparent and understandable, payments favor equipment-intensive procedures and do not benefit the majority of medical physics codes, especially CPT codes 77336 and 77370 (see Table 1 below). However, the proposed changes to the practice expense RVUs for all

AAPM will submit written comments to CMS regarding both proposed regulations. Key highlights of the proposed rules include:

Sustainable Growth Rate & Conversion Factor

The conversion factor is updated on an annual basis according to a formula specified by statute, which is designed to rein in the growth in outlays for physician services. The proposed rule indicates that

Table 1 CPT Code

77336 Continuing medical physics consult 77370 Special medical radiation physics consultation

The Physician Fee Schedule provides payment to physicians and to freestanding radiation oncology centers.

Two major policies effect medical physics payments proposed for 2007. First, the annual update factor (also known as the conversion factor) is reduced by 5.1% across all payments.

Second, CMS is proposing a

2006 PE RVU

2007

2010

2006-2007 PE RVU Percent Change

2006-2010 PE RVU Percent Change

2.99

2.48

0.93

-17.1%

-68.9%

3.50

3.22

2.36

-8.0%

-32.6%

radiation oncology codes will have an overall positive impact of 4.0% in 2010 at the end of the four-year transition period.

The AAPM met with CMS officials on August 14th to discuss the role of the medical physicist and the impact of the reduction to the medical physics codes under the new practice expense methodology. In addition, the 18

payment rates for physicians’ services would be reduced across-the-board by 5.1% for 2007. CMS forecasts payment reductions under the Sustainable Growth Rate (SGR) system for 2007 and subsequent years. Congressional action will be necessary to alter physician payment reductions in 2007 and beyond.

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

The AAPM will recommend that CMS replace the SGR in 2007 with an annual update system like those of other provider groups so that payment rates will better reflect actual increases in physician practice costs.

Practice Expense Methodology

Direct practice expense RVUs (PE RVUs) include non-physician clinical labor, medical supplies and medical equipment.

Indirect PE RVUs include administrative labor, office supplies, office rent and other overhead expenses.

CMS proposes several changes to the existing “top-down” practice expense methodology including: •calculate the direct practice expense using a “bottom-up” methodology •elimination of the non-physician work pool (NPWP) and calculate the practice expense RVUs for all services using the same methodology •utilize the practice expense per hour data from accepted supplemental practice expense surveys (which includes radiation oncology) •modify the current indirect practice expense methodology •transition the resulting revised practice expense RVUs over a four-year period The AAPM supports the use of AFROC and ASTRO supplemental practice expense data to calculate an average practice

expense per hour (PE/HR) for radiation oncology of $175.90, which is used to determine indirect practice expense inputs.

The current rate for radiation oncology is approximately $66.00 per hour. The AAPM has concerns, however, that CMS used an incorrect fraction of hospital vs. nonhospitalbased providers in their current PE/HR calculation. The AAPM will provide recommendations regarding the correct fraction of radiation oncology providers for each site of service.

The AAPM advised CMS that the current practice expense RVUs for medical physics codes 77336 and 77370 are undervalued. The AMA’s Practice Expense Advisory Committee (PEAC) has not reviewed these codes since 2002 and the standard of patient care has changed significantly since then. The AAPM informed CMS that the reduction in RVUs for CPT 77336 and 77370 need to be reevaluated. As technology continues to advance in radiation oncology, cancer treatments are becoming more complex and medical physicists are spending more time on cases that involve IMRT, IGRT and SRS/SBRT. The role and responsibility of the medical physicist is of greater importance now than in 2002. The AAPM advised CMS officials that a large decrease in RVUs, which leads to significant reductions in reimbursement, may result in the disastrous end effect of poorer quality and safety of treatments for those cancer patients undergoing radiation therapy.

19

Last, the AAPM believes that the proposed indirect practice expense methodology is flawed and one of the calculations should be eliminated. The AAPM will provide recommendations to CMS in a written comment letter.

Deficit Reduction Act Imaging Provisions

The Medicare Physician Fee Schedule proposed rule for 2007 includes proposals to implement two provisions of the Deficit Reduction Act of 2005 (DRA) affecting payment for imaging services under the fee schedule. The first provision addresses payment for certain multiple imaging procedures, with full payment for the first procedure, but a 25% reduction in payment for additional imaging procedures furnished on contiguous body parts during the same session. This is a smaller reduction than had previously been proposed.

The second DRA provision limits the payment amount under the Physician Fee Schedule to the hospital outpatient department payment amount for the technical component (TC) of certain imaging services. Under this provision, the Physician Fee Schedule payment amount for furnishing certain imaging procedures would not exceed the amount paid to a hospital outpatient department. Radiation oncology has been spared, for the most part, from the 2007 mandatory capped payment policy. CMS proposes to in(See Fuss - p. 20)

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Fuss (from p. 19) Table 2 CombinCombined Impact with 2007 Medicare Update

Specialty

Slcja,xxxxxxxxSRSpcial

Allowed Charges (million) Changes

Impact of Work RVU Changes

Impact of 2007 PE RVUs Changes

Impact of DRA

Impact of 2007 Update Factor Impact of 2007 Update Factor

Combined Impact with 2007 Medicare Update Impact of 2007 Upda

Radation Oncology Radation

$1.448

-2%

clude some radiation oncology and related ancillary procedure codes but did not include all 77xxx codes. Effected codes include fluoroscopy (76000, 76001), image guided radiation therapy (76370, 76950, 76965, 77421) and port films (77417).

Summary of 2007 Impacts to Radiation Oncology

The AAPM cautioned CMS that reductions in global RVUs combined with the forecasted decreases in the annual update factor could have a major impact on the provision of radiation oncology procedures to Medicare beneficiaries in the freestanding radiation oncology center setting (see Table 2).

A complete summary of the proposed rule and impact tables is on the AAPM Web site at: http://www.aapm.org/government_affairs/CMS/default.asp The final rule will be available

by November 1st with all policies and payments being finalized and effective on January 1, 2007. The AAPM will alert its members on key changes in policy and the final payment rates for 2007.

■

+1%

0%

-5%

2007 Proposed Payments to Hospital Outpatient Departments Released by CMS On August 8th, the Centers for Medicare and Medicaid Services (CMS) published the 2007 Hospital Outpatient Prospective Payment System (HOPPS) proposed rule. The majority of radiation oncology procedure codes will realize increases in hospital payments in 2007, however, hyperthermia treatments (CPT 77600-77620), some stereotactic radiosurgery codes (HCPCS G0173, G0339 and G0340) and IGRT codes (CPT 76965 & 77421) have significant reductions slated.

The proton beam therapy codes have proposed increases of 20% next year and CPT 77778 for prostate brachytherapy has a 54% increase in payment.

Medical physics codes 77336 & 77370 have slight reductions 20

-7%

of 4% slated for 2007 (see table on p. 21).

Also of note, CMS proposes to continue separate payment for brachytherapy sources, basing payment on the source-specific median costs, as reflected in the hospital claims data.

Payment would be on a per unit source basis to recognize the high variability of treatment costs. Currently, brachytherapy sources are paid based on the hospitals’ charges reduced to costs.

A complete summary of the proposed rule and impact tables is on the AAPM Web site at: http://www.aapm.org/government_affairs/CMS/default. asp The final rule will be published by November 1st, with an effective date of January 1, 2007.

■

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

2007 Hospital Outpatient Proposed Payments APC

Description

CPT Codes

2006 Payment

2007 Proposed Payment

Proposed Payment Change 2006 to 2007

Proposed Percentage Change 2006 to 2007

65

Level I Stereotactic Radiosurgery

G0251

$1,150

$1,381.38

$231.38

20.1%

66

Level II Stereotactic Radiosurgery

G0340

$3,750

$2,906.52

($843.48)

-22.5%

67

Level III Stereotactic Radiosurgery

G0173, G0339

$5,250

$4,045.47

($1,204.53)

-22.9%

127

Level IV Stereotactic Radiosurgery

G0243

$7,304.87

$7,808.15

$503.28

6.9%

257

Level I Therapeutic Radiologic Procedures

77421

$75.00

$60.14

($14.86)

-19.8%

260

Level I Plain Film

77417

$43.42

$44.78

$1.36

3.1%

299

Misc. Radiation Treatment

77470

$343.25

$371.29

$28.04

8.2%

300

Level I Radiation Therapy

77401-77409,77789

$87.24

$92.35

$5.11

5.9%

301

Level II Radiation Therapy

77411-77416,77422, 77423,77750

$131.26

$139.54

$8.28

6.3%

303

Treatment Device Construction

77332-77334

$168.07

$182.42

$14.35

8.5%

304

Level I Therapeutic Radiation Treatment Prep

77280,77299, 77300, 77305,77326, 77331, 77336,77370, 77399

$103.09

$98.86

($4.23)

-4.1%

305

Level II Therapeutic Radiation Treatment Prep

77285, 77290, 77310, 77315, 77321, 77327, 77328

$234.09

$247.63

$13.54

5.8%

310

Level III Therapeutic Radiation Treatment Prep

77295, 77301

$826.12

$865.27

$39.15

4.7%

312

Radioelement Applications

77761,77762,77763, 77776, 77777, 77799

$331.32

$308.89

($22.43)

-6.8%

313

Brachytherapy

77781, 77782, 77783, 77784

$774.85

$824.41

$49.56

6.4%

314

Hyperthermic Therapies

77600-77620

$332.31

$225.17

($107.14)

-32.2%

412

IMRT Delivery

77418, 0073T

$318.82

$338.66

$19.84

6.2%

651

Complex Interstitial Radiation Source Application

77778

$666.21

$1,025.35

$359.14

53.9%

664

Level I Proton Beam Therapy

77520, 77522

$947.93

$1,136.83

$188.90

19.9%

667

Level II Proton Beam Therapy

77523, 77525

$1,134.08

$1,360.10

$226.02

19.9%

21

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

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AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Clinical Trials This is another in a series of articles brought to you by the AAPM Work Group on Clinical Trials. These articles are intended to educate the AAPM membership on a wide range of issued related to quality assurance for clinical trials and to help the physics team be a more knowledgeable and active participant in the treatment and data submission for patients treated on protocol. â&#x20AC;&#x201C;Art Olch, Chair

Resource Center for Emerging Technologies Vincent A. Frouhar, James F. Dempsey, & Jatinder R. Palta, Department of Radiation Oncology, University of Florida, Gainesville, FL The task of safely implementing advanced technology radiation therapy requires innovative and efficient methodologies of remote peer-review and clinical quality assurance. It requires an electronic infrastructure that allows the transmission of voluminous multimodality clinical data for rapid review, archiving and data mining, while maintaining patient confidentiality. The Resource Center for Emerging Technologies (RCET) at the University of Florida (UF) is a member of the National Cancer Institute-funded Advanced Technology Consortium. The RCET has designed and developed an infrastructure for a distributed database, visualization and analysis system for collecting, sharing and distributing information for remote peer review of advanced technology imaging, radiotherapy plan data, and demographics information.

The system is a four-tier, Web-based system which pro-

vides secure auto-anonymizing and auto-archiving of clinical data. It consists of a centralized database, Web server, including Web-based visualization applets, 3D data visualization client applications, and automated data collection from other servers. The underlying network technology is HTTP, XML, Active Server Pages and Web services. The system supports DICOM RT modules and RTOG clinical data formats. It can also import most standard formats of electronic image storage. A suite of PC-based application software, NetSys and WebSys, provide facilities for clinical data preparation and submission, as well as tools for automatic data retrieval, modification and resubmission. All data are annonymized before they are transmitted. The visualization tools included in the NetSys software are designed specifically for radiotherapy applications, which provide multiview screens that can include 3D contours, 3D dose, DRR and portal images. Editing of these objects is still performed within the treatment planning system.

The WebSys software automatically creates an electronic folder of all submitted data for each submitted case. The submitted data are immediately available for a rapid Web-based review 23

and data integrity evaluation.

The RCET system has the following characteristics: a) the protocol employed throughout is HTTP; security is provided by SSL and SSH encryption schemes b) low bandwidth requirement c) all stored data and transmitted data are encrypted and compressed d) it has fast response as most of the applications run native on the host client e) rendering and graphics are hardware-based and native to the host client f) both thick and thin client architectures are supported g) multiple users can view and interact with one or more sessions simultaneously h) it is designed for remote review i) Web browser is the only software required for data visualizations j) visualization components are automatically loaded on demand The RCET system designed and developed at UF will enable the clinical trial group member institutions to organize, submit, review, and share a large amount of clinical data. Currently, there is a fair amount of manipulation and sorting (See Clinical Trials - p. 24)

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Clinical Trials (from p. 23) of submitted data which can take enormous amount of time for the resource-stretched QA center. Our automated system has the potential for distributing and automating this effort by having the institution that is sending the data organize it

per the protocol guidelines in advance of sending it. The Webbased secure private network infrastructure will provide an opportunity for real-time peer review. A much broader goal of this project is to create a Webbased RT–PACS, which will allow exchange of annonymized RT data in a secure environment

over the wide area network. The RCET system is currently under evaluation by the National Cancer Institute of Canada for electronic archive and review of advanced technology clinical trials in radiation therapy.

More can be learned about RCET by visiting our Web site at: http://rcetsystem.org/. ■

New Members The following are AAPM ‘Change of Status’ and ‘New’ Members effective April ­– July 2006.

Change of Status Full Elizabeth Butker Atlanta, GA Vorakarn Chanyavanich Santa Barbara, CA Stephen Wong Boston, MA

New Members Associate Frank Bloe Cleveland, OH Corresponding Catherine Dejean Bordeaux, FRANCE Oyeon Kum Pohang, REPUBLIC OF KOREA Nicholas Menzies Wagga Wagga, NSW, AUSTRALIA Full Wamied Abdel-Rahman Montreal, QC CANADA

James Bowsher Durham, NC Dar-Yeong Chen Tustin, CA Bum Choi Houston, TX James Gelsomino Jacksonville, FL Kirpal S Kohli Mississauga, ON CANADA John Mathai Arlington Heights, IL Guangwei Mu San Francisco, CA Hussain Naseem Jeddah 21589, SAUDI ARABIA Edward Pombier Miami, FL Michael Staryszak Monticello, MN Alfred Strash Midlothian, VA Thomas Urrutia Plainview, NY

Srijit Kamath Mountain View, CA Heng Li Houston, TX Teh Lin Philadelphia, PA Cora Marshall Galway, IRELAND Natalya Morrow Milwauke, WI Joel Nace York, PA Vahagn Nazaryan Hampton, VA Mark Rose Melbourne, FL Dany Thériault Lévis, QC CANADA Student Jahangir Alam Gono Bishwabidyalay BANGLADESH Abdulrahman Alfuraih Guildford/ GU2 7XH UNITED KINGDOM Ahmad Alkhatib Ann Arbor, MI Jonathan Alspaugh Wyoming, MI

Junior John Gordon Richmond, VA

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James Cover Atlanta, GA Phillip Cubbage Durham, NC Nancy Huang Gainesville, FL Daniel Hyer Atlanta, GA Roman Melnyk Memphis, TN Alexander Mkrtchan Clifton, NJ Steven Moeckly Cincinnati, OH Brandon Poston Little River, SC Teboh Roland San Antonio, TX Krishnendu Saha Kansas City, MO Daniel Sanchez Albuquerque, NM Sunil Sharma Kent, OH Lilie Wang Ottawa, ON CANADA Brian Winey Rochester, NY ■

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Chapter News Steven de Boer Chapter President-elect On May 26th the Upstate New York Association of Physicists in Medicine held their biannual meeting. The UNYAAPM is a local chapter of the AAPM servicing the entire state of New York outside the metropolitan New York City area.

President Dr. Harish Malhotra hosted the business and scientific meetings at the State University of New York at Buffalo’s Center for Tomorrow conference center.

The scientific session included the work of many area

medical physicists. The association’s immediate past president, Dr. Daniel Kim, gave a very interesting and innovative presentation entitled “Packet-Level Quality Assurance of MLC Inform­atics.”

This work has won Dr. Kim the 2006 Jack Fowler Junior Investigator Competition. This work provides a very different and elegant look at the quality assurance of digital information in radiotherapy.

Invited speakers included Dr. Michael Sharpe from Princess Margaret Hospital in Toronto, Canada who presented a timely topic entitled “Image-Guided

Radiation Therapy: Clinical Experience and Implications for Treatment Plan Optimiza­ tion.” Dr. Sharpe’s experience and expertise was evident in a very educational presentation.

Dr. Dan Bassano shared his experience in commissioning a Cyber Knife unit at Upstate Medical University in Syracuse.

The next meeting is planned for October and will be held in Rochester, New York. For more information on our organization, visit www.unyaapm.org.

■

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AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

ACR Mammography Accreditation Frequently Asked Questions for Medical Physicists Does your facility need help applying for mammography accreditation? Do you have a question about the ACR Mammography QC Manual? Check out the ACR’s new accreditation Web site portal at www.acr.org; click “Accreditation,” then “Mammography.” The “Program Overview” and “Frequently Asked Questions” were completely updated and reorganized in July to provide more useful information on accrediting digital mammography equipment. In addition, most of the mammography accreditation application and QC forms are now available for downloading. You can also call the Mammography Accreditation Information Line at (800) 227-6440. In each issue of this newsletter, I’ll present questions of particular importance for medical physicists.

Full-Field Digital Mammography: Laser Film Printers Priscilla F. Butler Senior Director, ACR Breast Imaging Accreditation Programs Q. Does the ACR or the FDA require an FFDM facility to have a laser film printer at the facility?

May the facility use the laser printer of a third party to print hardcopies?

A. No and yes. Neither the ACR nor the FDA requires an FFDM facility to have an on-site laser film printer. However, for purposes of transferring films, the FDA does require a facility to be able to “provide the medical institution, physician, health provider, patient or patient’s representative, with hardcopy films of final interpretation quality.”

Consequently, the ACR and FDA require FFDM facilities to have access to a compatible laser film printer (either on-site or at a third party). The printer must exist and be tested by a qualified medical physicist according to the FFDM unit manufacturer’s

recommendations before the facility performs mammography on patients. The facility must also include information and QC data for the laser film printer in its accreditation application as it does for film processors.

Furthermore, MQSA inspectors will review the laser film printer QC when he/she inspects each FFDM unit.

summarizes the laser printer QC (at the time this question was written). Check with your FFDM manufacturer for the most current instructions.

Q. Should I follow the laser printer manufacturer’s QC manual when performing QC on the laser printer in order to comply with the FDA regulations?

A. Yes. Even though a third party may produce this hardcopy, the facility is responsible for ensuring that the quality of the hardcopy is of final interpretation quality. Evaluating laser printer quality control is part of this assurance. Furthermore, you must follow your FFDM unit’s manufacturer recommendations for laser printer QC.

A. Possibly. It depends on the instructions provided in the FFDM unit manufacturer’s QC manual.

FDA regulations require the quality assurance program at FFDM facilities to be substantially the same as the quality assurance program recommended by the image receptor manufacturer (i.e., GE, Fischer, Lorad and Siemens). Some FFDM QC manuals provide specific instructions on performing QC of the laser printer used with their systems; others instruct the user to follow the QC manual of the laser printer manufacturer. The table 26

Q. During accreditation of my FFDM unit, do I still need to send the ACR a laser printer quality control chart if hardcopy printing is done by a third party?

Q. Does a facility with an FFDM unit need to submit quality control data for its laser film printer even if the physicians interpret only from the soft copy?

A. Yes. Because the FDA requires that each facility be able to print hardcopy films of final interpretation quality for purposes of transferring images,

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

FDA-Required Laser Printer QC FFDM Mfr

Model

Laser Printer QC

General Electric

Senographe 2000D, DS and Essential

Follow the laser printer manufacturer’s QC manual

Fischer

SenoScan

Follow the laser printer manufacturer’s QC manual

Lorad

Selenia

Follow the Lorad Selenia QC manual

Siemens

Mammomat Novation DR

Follow the laser printer manufacturer’s QC manual (but conduct QC every day that images are printed)

we require facilities to submit hardcopy images. The ACR reviews a copy of the laser camera QC as part of accreditation. You must submit at least one calendar month of laser film printer QC data for each printer used for digital mammography even if it is performed by a third party. We recommend you use the QC chart provided in the laser film printer’s QC manual. Your printer’s QC program must be substantially the same as the quality assurance program recommended by the FFDM manufacturer. Finally, the clinical and phantom images must be taken within the same 30-day time frame and must be within the time period shown on the laser film printer QC chart.

printers. Facilities need to ensure that all printers used by the facility with its FFDM unit comply with a quality assurance program that is substantially the same as that recommended by the FFDM manufacturer and pass the facility’s accreditation body’s phantom and clinical image review process.

See the “FDA’s Modifications and Additions to Policy Guidance Help System #9.” You should consult with your medical physicist to assist you in making this decision.

Q. Can a facility with an FFDM unit use its MRI laser printer to print its digital mammography images?

A. The ACR suggests that you print from the workstation you typically use to print hardcopy images to give to patients. Per FDA guidance, hardcopy images should be of “final interpretation quality,” therefore it is important for your radiologist to review and approve these hardcopy images before you submit them for accreditation.

A. Possibly. The FDA recommends that only printers specifically approved or cleared for FFDM use by the FDA’s Office of Device Evaluation be used.

However, a facility may use other

Q. My facility can print hardcopy images for our FFDM unit from three separate workstations.

Which one should I use to print images to submit for accreditation?

27

Q. When patients or physicians request mammogram hard­copies, may our film room staff print and release FFDM mammograms or must the hardcopy images be printed and released by mammography technologists?

A. The FDA does not specify who prints/releases records.

However, the FDA does require, for purposes of transferring films, that the facility be able to provide the medical institution, physician, health provider, patient or patient’s representative, with hardcopy films of final interpretation quality. See the “FDA’s Modifications and Additions to Policy Guidance Help System #9.” The facility should have a system in place to ensure that the printed and transferred hardcopy images are of final interpretation quality. The quality control technologist and lead interpreting physician should ensure the task is performed in accordance with these regulations.

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AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

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AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Letters to the Editor Response to Resurrected AAPM Board Reorganization Proposal Lee Goldman, MS Hartford, CT lgoldma@harthosp.org Despite its defeat in the last summer’s membership vote, the board reorganization process has been resurrected. A draft of a revised board reorganization plan is in circulation.

The reason given for continuing the pursuit is that although falling short of a required two-thirds majority, the 60% pro-reorganization tally suggested that most members favored reorganization.

Additional support is drawn from membership surveys conducted in 2004 and 2006, in which the over 60% of respondents felt that a smaller board might be more effective and only about 38% felt that the board is meeting our professional needs.

Among the most widely cited evidence supporting reorganization is AAPM’s “abnormal” board size, i.e., it is not in line with comparable organizations.

Extending this line of reasoning, consider other descriptors: for the cited organizations1, average budget expenditure per member and members per headquarters staff are $513 and 477 respectively. For AAPM,

they are $1200 and 238. To be in line, AAPM would need to cut its budget by 60% and its staff by half. I do not suggest that we slash our budget or decimate our headquarters. To the contrary, I believe our membership is better served by current staffing and budget levels. And that brings us to the point: better membership service is an appropriate criteria; “abnormality” is not.

Regarding the surveys, it is not at all clear that the results indicate a need or a desire to reduce the board size. The 2004 survey asked if a smaller board might be more effective; 78% responded “yes.” Disregarding whether “yes” responses to such a leading question imply that responders actually want a smaller board, it must be emphasized that 81% also stated they had never attended a board meeting. Write-in comments clearly indicate a general lack of knowledge of, understanding of (and unfortunately, even interest in) how the board functions.

The 2006 survey did ask more directly if the board should be smaller; 64% replied “yes,” but only about 400 responses were received. Nevertheless, reorganization supporters interpret all this to mean that members favor a reduced board size, and all that is needed is a clearer explanation of the need. On the other hand, it is possible that it failed despite an illusion created by a biased—albeit perhaps unintentional—presentation of the 29

issue in newsletter columns (if mentioned often enough, even a nonexistent issue becomes ‘real’ in the minds of the audience).

The 2004 survey results also state that only 38% of members feel the board effectively meets their professional needs; the 38% reflected only those indicating an “extremely effective” or “effective” board on a four-point scale; a third category, “somewhat effective,” is excluded from the total. There is, of course, no compelling reason to interpret this to mean that a smaller board would meet their professional needs.

The survey did not address this perception directly, but some insight is gained from write-in comments. Among the handful of comments that touched on this subject, the most common complaint seemed to be a perception of inadequate representation—either due to lack of access to board members or because the board’s composition did not reflect that of the membership (e.g., “the board is dominated by academic types, who do not have any idea what the community at large needs”). It is distinctly possible that both concerns could in fact be adversely impacted by a reduced board.

I do not ideologically oppose changes that are likely to benefit the membership (although I do object to continuing a process already defeated by our rules).

I do oppose the proposed plan because I believe that the board’s (See Goldman - p. 30)

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Letters to the Editor I nor any of those I’ve asked had ever been asked to do anything during our tenures on the board, although I believe most would be willing to contribute. Perhaps some meetings are too long and perhaps not all business is accomplished. Suggestions have already been made—and in some cases implemented—to optimize use of board meeting time. And, as a former representative, I believe we’ve been

Goldman (from p. 29) most important function—that of guiding and deciding AAPM policy—is best served by broader input and more viewpoints.

The best government is one that makes the best decisions, not the one that is most efficient (or “effective”, whatever that means)...

It has been mentioned that EXCOM is overworked while the board does little; in fact neither

blessed with talented chairs who’ve run effective meetings.

As a result I believe the proposal is neither beneficial nor needed.

ACR was excluded from the average because much of its budget and manpower is associated with clinical trials and other functions not comparable to AAPM activities. SPE was excluded due to uncertainty of about what SPE is.

■ 1

Appendix: Table 1 Members

Board Members

Budet (x $1000)

Employees

Member/ Board Rep

Budget per Member

Members per Employee

5,000

37

$6,000

21

135

$1,200

238

35,000

8

125

4,875

$857

280

ASTRO

7,200

14

$8,200

25

607

$1,139

288

SNM

16,000

18

$5,000

45

889

$313

356

ANS

11,000

22

54

477

$0

204

700

11,061

$697

523

Society AAPM RSNA

IEEE ARRS

APS

366,000

33

$30,000

$255,000

14,000 45,500

28 $42,300

46

Average of other societies:

30

500 $930

989

$513

477

AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY2006 2001 AAPM NEWSLETTER

Letters to the Editor Educational System Not the Problem

Ivan A. Brezovich, PhD Birmingham, AL ibrezovich@uabmc.edu In his Letter to the Editor (AAPM Newsletter, July/August 2006) Donald Daenzer reported that among about 25 applicants with master’s and PhD degrees for a hospital-based senior physics position, only one was a natural-born American citizen. The remainder were predominantly from Asia. Nothing special about that, many of us had similar experiences. However, I respectfully disagree with Donald’s implication that this dearth of natural-born American physicists is caused by our poor educational system.

I came to the USA as a physics student to enjoy the world’s best educational system, and it surpassed even my highest expectations. The problem is that we are losing out in the competition for high quality students.

I experienced that when I was interviewing applicants for our residency program in radiation oncology. Virtually all of the more than 20 top applicants were natural-born American citizens.

Many had advanced degrees in engineering, physics and computer science from some of the most prestigious universities in the nation. Any medical physics training program would have been proud to have such quality applicants.

To successfully compete for good students, the professional aspects of medical physics need to be addressed. To a foreignborn physicist who is unaware that medical physicists are neither considered professionals

nor necessarily part of the team (according to a radiologist consultant to ACMP), and who does not know that our working conditions have been likened to hanging drywall for a living (by a radiation oncologist editor of ASTRO News), medical physics seems quite attractive. As one gets to know the field, it quickly loses its luster. Indeed, one of our former residents became a physicist because physics was the most appreciated field in his native Bangladesh. After working for a number of years in the USA as a medical physicist, he switched to radiation oncology.

Lack of recognition and job security were his main reasons.

(See Brezovich - p. 32)

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AAPM NEWSLETTER SEPTEMBER/OCTOBER JANUARY/FEBRUARY 2006 2001 AAPM NEWSLETTER

Brezovich (from p. 31) So let’s not blame the recruiting problems on our educational system or anything else we can’t change. What we can change and need to change is the desirability

of medical physics. Achieving provider status has worked for physicians, nurse anesthetists and clinical social workers, and would work equally well for medical physicists. There may be even better solutions, but so

far they remain untested. Our patients and radiation oncologists need the expertise of the best physicists that the entire world, including the USA, has to offer.

The current system shortchanges all.

■

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)713-6565 Fax 2340 Westover Drive, Winston-Salem, NC 27103

The AAPM Newsletter is printed bi-monthly.

Next Issue: November/December 2006

Postmark Date: November 15

Submission Deadline: October 15, 2006

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

32