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Newsletter

A MERIC A N ASSOCIATION OF PHY SICISTS IN ME DI CI NE VOLUME 34 NO. 2

MARCH/APRIL 2009

AAPM President’s Column given a strained economy? How do our decisions affect the field and profession of medical physics now, in five years, in twenty years, and so on? Let’s think outside of the box!

Maryellen Giger University of Chicago

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s each new year progresses, many people become motivated to act on their “new year’s resolutions.” Some think about them, some add them to their “to do” lists, some form committees relevant to the resolutions, and some make them happen. I hope at the end of my Presidential year, I can look back and say that we did “all of the above.” Each day, I am amazed at the number of AAPM activities that aim to expand the role of the AAPM in the field of medical physics and the role of the medical physicist in the public arena. Such activities arise from all three Councils – the Science Council (chair: John Boone), the Education Council (chair: Tony Seibert), and the Professional Council (chair: Per Halvorsen). As we progress in these activities, we need to continuously reflect and ask ourselves various questions. Times change, and we need to be flexible. For example, what is motivating AAPM to take such actions? How would we prioritize the activities if

I believe it is important for AAPM members to be updated in the activities of the AAPM president. Throughout the year, at least one of the members of the “presidential chain” in the executive committee, (i.e., the president-elect, the president, and the chairman of the board), try to attend the various Council retreats and special meetings of the AAPM, as well as many chapter meetings. I have found these interactions to be beneficial at multiple levels – serving to update EXCOM (the executive committee) on the pulse of the AAPM and the various activities, and to impart EXCOM views and questions to the particular attendees. Just as different members of the AAPM come from different areas within the field of medical physics (e.g., diagnostic vs. therapy, research vs. clinical practice, etc.), so do the different members of EXCOM. Thus, the education of EXCOM via these retreats and meetings is crucial to ensure that a broad perspective is achieved within EXCOM and extended to the board, and that the needs of all members of AAPM are addressed. I thank Angela Keyser and Lisa Giove for helping me stay organized relative to these activities. I recently attended the AAPM Science Council retreat held at MD Anderson in Houston, Texas. Science Council retreats are usually held at

an institution of one of the various Council members, thus allowing the other Science Council members to expand their scientific knowledge base. For example, the evenings at the Houston meeting included tours of the MD Anderson’s Proton Therapy Facility and of the Radiation Physics Center. During the daytime, council chair, John Boone, led an exciting retreat. Science Council, with its various committees, subcommittees, and task groups, is quite involved in analyzing and producing documentation on scientific matters that affect members of the AAPM as well as the public. For example, as diagnostic imaging/ therapy systems evolve, phantoms are necessary for obtaining information on image quality, validating quantitative imaging TABLE OF CONTENTS Chair of the Board Column President-Elect’s Column Editor’s Column Executive Director’s Column Education Council Report Science Council Report Professional Council Report Website Editor’s Report E & R Fund Contributors Image Gently Update Leg. & Reg. Affairs IAEA Liaison Report American Board of Radiology Health Policy/Economics ACR Accreditation Letter to the Editor

p. 2 p. 3 p. 5 p. 6 p. 9 p. 10 p. 11 p. 13 p. 14 p. 15 p. 17 p. 21 p. 23 p. 25 p. 27 p. 27


AAPM Newsletter output, and/or determining patient dose (or other measures of potential patient effects). What is the role of AAPM in developing such phantoms? Subcommittees may task a working group with the determination of the phantom specs, the methodology with which to evaluate the phantom, the procedure with which to use the phantom in research or clinical calibrations, the process for technology assessments, and/or the potential role of the phantom in regulatory aspects. In addition, AAPM is investigating, via John Boone and the Science Council, the potential of NIH grant funding to the AAPM to create such phantoms for multi-modality quantitative imaging as the existence of advanced phantoms could benefit a broad group of AAPM members. And phantom development is just one of many topics that Science Council is addressing. Councils also respond to public and government requests for AAPM comment on issues such as clarification of radiation dose risk and priorities for research funding. In addition, the Science Council hosts special scientific forums and meetings such as its upcoming “Promises and Perils of Proton Radiotherapy” in which the science of proton radiotherapy will be “debated” in terms of the physics, the contribution to patient care, and economics.

March/April 2009 I look forward to attending the retreats of the Professional Council and the Education Council. Exciting activities also result from these councils. As many of you are already aware, the Professional Council is investigating board certification and the need for licensure, as well as a new initiative involving the assessment of the workforce of medical physicists. The Education Council along with EXCOM has invested much effort in the actions needed to reach the 2012/2014 requirements for board certification including the hosting of workshops to help training programs become CAMPEP approved. The second 2012 initiative summit meeting will be held at the end of this month, and many should be proud of the dedicated efforts that have resulted in terms of increased graduate programs and residency programs. While more residency programs are still needed, it is evident that clear progress has been made. I will report on my involvements with these two Councils in upcoming newsletter articles. Each day, email discussions occur concerning multiple actions of the AAPM in response to, e.g., a member’s request, a government agency announcement, and/or a media controversy. Many of these

are coordinated by Lynne Fairobent, the AAPM’s Legislative and Regulatory Affairs Manager, and have included, for example, our involvement in the “Image Gently” campaign, our input to the Isotopes Subcommittee of the Nuclear Science Advisory Committee (NSAC), and our request to President Obama for support of funding for the National Institutes of Health (NIH). Besides attending Council retreats and meetings, I also continue to attend AAPM chapter meetings/ symposia as well as other medical physics organizations such as graduate programs. At a recent visit to the University of Wisconsin – Madison, I enjoyed many discussions with faculty and students on both the science of medical physics and the future of medical physics education. As I have found on various campuses, our next generation of medical physicists are quite concerned about their future and await the outcome of the upcoming 2012 summit. I hope my newsletter update has broadened your awareness of AAPM activities. Next month, I will describe some new initiatives relative to AAPM’s involvement in quantitative imaging, technology assessment, and public outreach. Thank you.

AAPM Chairman of the Board’s Column

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Gerald A. White Colorado Springs, CO

ost of the columns I have written over the last few years have been composed while sitting in my office at home. It’s comfortable, familiar and conducive to thoughtful reflection. It is altogether a very satisfactory place. Tonight, however, there is a change in that pattern. Were I to be able to capture a photo to attach to the column, you would find me in the lobby of a small hotel in Silicon Valley with a pint of local beer, a plate of cheese and a laptop with little bits of cheese and drips of

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beer on the keyboard. All this brought about by changes in our clinic; new techniques, new equipment and the need to spend some time with those who know, who are comfortable with what is new to me, who are working (10 hours of their effort today) to lead me to embrace machines and techniques that are different but clearly hold great promise. This process will be familiar to nearly everyone who reads this. There is, within the medical physics community,


AAPM Newsletter a uniformity of desire to learn what is new, to sift opportunities for substantive and beneficial change from a background of novel fluff and to move ideas to execution. We are, as a group, fearless in this regard. (One of my colleagues is fond of the quote “if it works, it must be obsolete.”) So, here is my catchphrase for this time in the life of AAPM. “Change, it’s not just for linacs and scanners anymore.” Even a casual reading of this newsletter, the parallel publications of our sister societies will yield information about opportunities or imperatives for change in one way or another. Some of these we, as an Association, embrace. But there are others from which we withdraw.

Elsewhere in this edition of the newsletter you will find a discussion the dues increase for AAPM rejected recently. An opportunity lost. The work of the Association requires funding, and more than that, requires the commitment of all of us, either through our time, our treasure or both. Dues increase—a change certainly, without it other changes are sure to come, changes that are unlikely to be desirable. We move forward with substantial enthusiasm and skill to create and embrace change in science and technology and in the professional and educational domains. We will need the infrastructure to support these efforts. Some of that infrastructure will come from new

March/April 2009 ways of operating, organizational changes and from the well run (and well respected by their peers) AAPM Headquarters. As you read this article the Board of Directors will be meeting to engage in long range planning, both financial and programmatic. The AAPM staff will be providing support and guidance. About a thousand of you will be engaged in active volunteer effort within the Association. All of us can find a way to nurture and embrace change. A dues increase would be a change, but surely it is a change we can believe in. We have prepared for this future, let’s get on with the work.

AAPM President-Elect’s Column services in a complex technological environment. In any case, specific training and experience are required to become a medical physicist.

Michael G. Herman Mayo Clinic Clinical Quality and the 2012/2014 Initiative

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ister Generose said to the staff at my clinic “We need to be the people our patients think we are.” This includes medical physicists. We remain focused on efforts that improve the application of physics in medicine, primarily toward the benefit of patients. We are scientists, we are professionals dedicated to performing fundamental and applied research, providing education to students and peers, delivering clinical

In the clinic, where there is currently pressure for consistency and public accountability, we review the accepted definition “A Qualified Medical Physicist is an individual who is competent to practice independently one or more of the subfields of medical physics…. With board certification in the appropriate medical physics subfield and continuing education…” (AAPM Professional Policy 1E). And from the Medical Physics Scope of Practice AAPM Professional Policy 17A) “The essential responsibility of the Qualified Medical Physicist’s clinical practice is to assure the safe and effective delivery of radiation to achieve a diagnostic or therapeutic result as prescribed in patient care.” There is a converging expectation for consistency of training, experience and credentials to practice medical physics. The CARE act, Consistency,

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Accuracy, Responsibility, and Excellence in Medical Imaging and Radiation Therapy Act of 2007, when reintroduced and eventually passed, will lay the foundation for federally mandated prerequisites to practice in medical imaging and radiation oncology. The law would require all states to recognize minimum qualifications to practice medical physics. The draft text for these requirements includes specific medical physics training and experience followed by board certification. Meanwhile, the ABR forecast in 2003 [1] that by 2012, a CAMPEP accredited clinical residency could be required to sit for the board exam in medical physics. The ABR was receiving pressure from the American Board of Medical Specialties (ABMS), where all but two certification examinations (one being radiologic physics) within ABMS required accredited clinical training as board pre-requisites. The AAPM (PP-19A) and the ACMP both went on record supporting the requirement that accredited


AAPM Newsletter clinical residency precede board certification. Evidence suggests that graduates of CAMPEP accredited residency programs fully pass the ABR exam on the first attempt at a 95% rate, as compared to the overall ABR average pass of 53% over the same time period. [2] The updated AAPM report 90 on residency training makes the supporting statement: “It has never been possible to learn medical physics by unstructured self-study or by observation alone. It is now no longer possible to become a fully competent, qualified medical physicist by on-the-job training even under the mentorship of a single, experienced medical physicist. Over the past few years, it has become increasingly clear that the training standards and documentation associated with accreditation are needed to properly train individuals to be capable of practicing medical physics independently. It is also clear that high quality training can take place effectively in hospital setting as well as in an academic environment.”[3] The dilemma facing us was that while the concept of a more standardized, consistent path is the right thing to do and CAMPEP recognized that a number of possible mechanisms could achieve this consistency, the existing clinical training programs were unable to produce the expected necessary volume of individuals to meet market demands. First Task Group 133 on alternative pathways to clinical medical physics training was commissioned (Nov 2006) followed by The AAPM 2012/2014 initiative. Together these provided a focus on developing methods to increase the production of individuals trained in accredited clinical residency programs and possible financial and infrastructure support through the AAPM Board.

March/April 2009 A series of meetings of leaders from graduate and clinical education programs were held and continue to be held while the TG133 report was completed. All of this brought the options more into focus of just how we will meet the 2012 and 2014 requirements. To reiterate the ABR requirements to sit for the exam in medical physics found at http:// theabr.org/Policy_Pri_CAMPEP. htm : • 2012 - CAMPEP-accredited degree program or residency required

• 2014 - CAMPEP-accredited residency required

Task Group 133 (published on the AAMP website), details various options to deliver the required clinical training. These are: a) Expand current CAMPEP accredited medical physics residency program structure b) A structured mentorship, affiliated with a core CAMPEP accredited residency program c) The professional doctoral degree in the practice of medical physics. d) An enhanced M.S. or Ph.D. medical physics graduate program that could provide some or all of the necessary clinical training and if not all, how that fits in to the residency, and a, b or c above. TG133 focused on option b) above, while a new working group was formed to address option c) (chaired by Charlie Coffey). The bottom line from TG133 is that there are specific training and documentation requirements necessary to achieve CAMPEP accreditation. These can be achieved in a conventional residency or some type of affiliation, where for example a non-academic practice can receive CAMPEP accreditation. These examples are detailed in the TG133 report. Further, whether an

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academic program or not, CAMPEP is evaluating applications based on the ability to train in a structured manner and provide documentation. A substantial number (54%) of respondents to a survey that the Medical Physics Residency Training and Promotion Subcommittee performed suggested that they train in an on-the-job environment. Many or most of these could become CAMPEP accredited, either on their own or through an affiliation. This training mechanism has major advantages, because the on-the-job training positions already exist with salary and could be in part or fully dedicated to (lower cost) residency positions that provide accredited training. AAPM is organizing workshops as part of the 2012/2014 initiative, where program directors from any type of clinical training program will develop and complete most of the paperwork for their CAMPEP application and self study. The first workshop was in early February and had a full enrollment of 24 directors. Additional workshops will be scheduled. If you have interest in future workshops, please let us know. A final point is that no matter which mechanism of the 4 listed in TG133 is chosen to follow, there will be needs to find collaborators or affiliates for some clinical training and possibly some didactic training. If you are doing any training now, please consider cooperating with other programs to provide a complete set of training. If academic residency and graduate programs work together with each other and with non-academic practices, together the 2012/2014 goals can be achieved. AAPM Dues Last year, a motion for a $15 per year for five years dues increase failed a


AAPM Newsletter

March/April 2009

Editor’s Column

Mahadevappa Mahesh Johns Hopkins University

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s we are slowly coming out of the frigid winter, it is already time for the 2nd issue this year.

membership on-line vote. On average, AAPM membership dues account for 20.5% of budgeted revenue annually, with the annual meeting accounting for 34.3% and our Medical Physics journal for 28%. In other words, for each dollar of the $285 we provide to AAPM, we get nearly $5 of leverage. This is excellent. The Board of Directors has approved various initiatives which it believes will improve our profession and the quality of services that and work that we deliver. With active councils, there is no shortage of excellent proposals coming before the board. For the board to continue to direct the future of the AAPM, without relying on reserves, it is necessary to consider a dues increase. The AAPM is as strong as it is, because of member participation through personal work effort and through dues payment. I would appreciate any comments on the above items (or any topic of interest to you). Herman.Michael@ mayo.edu

There are many interesting articles in this issue including reports from all three of the AAPM councils. In addition, I would like to draw your attention to the article discussing the second phase of the highly popular “Image Gently Campaign” that aims to provide resources to users and providers alike on how to reduce radiation dose during pediatric x-ray imaging. The weblink to this campaign and all of the educational resources available from this program is on the AAPM website.

the activities of the International Atomic Energy Agency (IAEA) and the relationship with the AAPM. Also included in this issue is a letter to the editor highlighting the educational resources that are available on the IAEA website to which many of our AAPM members have contributed. Finally, I wish all of the readers a warm spring and encourage you to contact me with any comments or concerns, at any time, regarding any content included in the AAPM Newsletter.

In addition to the regular columns, this issue includes an article outlining

1.Paliwal, B., W. Hendee, and S. Thomas, ABR Update. AAPM Newsletter, 2003. 28. 2.Herman, M.G., H.I. Amols, and W.R. Hendee, Graduation from a CAMPEP or equivalent accredited graduate or residency program should be a prerequisite for certification in radiological physics. Medical Physics, 2005. 32(4): p. 835-6.

3.Lane, R., et al., AAPM Report 90, Revision of AAPM Report No. 36 - Essentials and Guidelines for Hospital Based Medical Physics Residency Training Programs. American Association of Physicists in Medicine, 2006.

AAPM Service Project Beach Clean-Up with the Surfrider Foundation The Surfrider Foundation is a non-profit environmental organization dedicated to the protection and enjoyment of the world’s oceans. Does your travel schedule allow you to arrive in Anaheim a day early? Join your colleagues on a California beach for a little community service, a little physics chatter, a little sun. You and your family members are invited to participate in a local beach clean up on Saturday morning, July 25. A bus will transport volunteers from the Anaheim Convention Center. All volunteers will receive a boxed meal and a service project baseball cap. Pre-registration is required (no fee). Go to www.aapm.org/meeting/09AM for more information and to register.

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AAPM Newsletter

March/April 2009

AAPM Executive Director’s Column Virtual Library

Angela R. Keyser College Park, MD

Upcoming AAPM Meetings he Science Council is organizing a Symposium on the Promises and Perils of Proton Radiotherapy, May 8 – 9 in Baltimore, Maryland. The program is aimed at radiation oncologists, medical physicists, and biologists. For more information, go to: http://www.aapm.org/meetings/ 09PRS/

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Registration for the 2009 Summer School, “Clinical Dosimetry Measurements in Radiotherapy”, will open in early March. AAPM is returning to Colorado College, home of the 2003 Summer School that received rave reviews. Make sure to register by May 13 for discounted registration. For more information, go to: http://www.aapm.org/ meetings/09SS/ Anaheim in 2009! AAPM’s 51st Annual Meeting will be held July 26 - 30 in sunny Anaheim, California. Registration will open on March 18. Consider joining your colleagues in the AAPM Service Project on Saturday, July 25, from 8:00 AM – Noon, when AAPM partners with the Surfrider Foundation on a local beach cleanup.

Presentations posted in the Virtual Library include streaming audio of the speakers, transcription of the audio presentations and slides of the presentations. A few of the new offerings include: • Presentations made during the 50th AAPM Annual Meeting and 2008 AAPM Summer School • Presentations made during the 2008 CRCPD Annual Meeting on Radiation Dose and Quality Control for SPECT/CT and PET/CT Clinical Studies • Interviews with prominent medical physicists Access to this valuable online service is FREE for AAPM members,

so let technology and the AAPM work for you! Join the hundreds of other AAPM members who are using the AAPM Virtual Library for their continuing education, research, and information needs. For more information, go to http://www.aapm. org/meetings/virtual_library/ Staff News Congratulations to Jennifer Hudson, AAPM’s Membership Services Coordinator, and her husband Brad on the birth of their first child, daughter Natalie Ann. Natalie was born on Monday, January 19 and mom reports that all is well. Jennifer plans to return to work at the end of April.

2009 AAPM Grant Offering 2009 ASTRO/AAPM Radiation Oncology Physics Residency Training Grant: The purpose of the Grants is to provide assistance to newly established programs working towards accreditation. Sponsored by the American Society for Therapeutic Radiology and Oncology (ASTRO) and the American Association of Physicists in Medicine (AAPM) Fellowship Offerings Application Deadline: June 15, 2009

2009 RSNA-AAPM Fellowship Offering 2009 Fellowship for the training of a doctoral candidate in the field of Medical Physics is awarded for the first two years of graduate study leading to a doctoral degree in Medical Physics. Sponsored by the Radiological Society of North America (RSNA)and the American Association of Physicists in Medicine (AAPM) Application deadline: April 15, 2009

Information and applications are available at:

http://www.aapm.org

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AAPM Newsletter AAPM HQ Team…at your service! AAPM has an Information Services team of seven professionals who are hard at work in support of AAPM’s growing electronic presence. Although their valuable work is often behind the scenes, the IS team plays a vital role in all HQ service areas. Michael Woodward joined the staff in October 1996 as Internet Services Manager. As AAPM’s first webmaster, Michael worked closely with the newly formed Electronic Media Coordinating Committee (EMCC) to develop AAPM’s web presence. With the reorganization of the IS department in 1998, Michael was promoted to Director, Information Services. Michael continues to play a critical role in AAPM’s HQ operations and leads the IS efforts. Farhana Khan started with AAPM in May, 1998, as a temporary staff person and was later hired full-time to gear up for AAPM’s management of the Chicago 2000 World Congress. After the World Congress, Farhana was named as AAPM’s Webmistress. Farhana works closely with Website Editor Chris Marshall to maintain and enhance AAPM’s web presence. She is also responsible for AAPM email services and a number of other sites hosted by AAPM. She is our resident “graphic designer” and works closely with the staff to create logos for meetings and other programs. Zailu Gao joined the IS team in March, 2001 as an Applications Developer and was promoted to Senior Applications Developer at the end of 2003. Zailu is responsible for the e-commerce areas of the AAPM website including Online Dues Payments and meeting registration. Zailu is also a key player in the abstract submission process.

Receptionist and was promoted to Membership Services Coordinator in 2004. In 2006, the membership process was moved to the IS team in recognition that the AAPM database and website are an integral part of the membership process. Jennifer serves as the first point of contact for membership questions and works closely with the Membership Committee in the review and processing of membership applications and requests. Yan-Hong Xing, AAPM’s Database Administrator, joined the team in October of 2006. She handles all technical matters related to the Associations’ databases as well as fulfillment of mailing list orders. Tammy Conquest came on board in November of 2007 as an Applications Developer. Tammy is responsible for design and implemen-

March/April 2009 tation of new and existing database programs. One of her first projects was a re-write of the CAMPEP CEC database. She recently established a wiki for AAPM council and committee use and is in the final stages of an application that will assist AAPM members with Maintenance of Certification Part 2 - Practice Quality Improvement (PQI). The newest member, Onasis Budisantoso, joined the IS team in May of 2008. Onasis first tackled a rewrite of the online tracking system for the Executive Committee tasks and is now working to develop a database of relevant research and/or researchers in the field of Medical Physics and related disciplines. Coming next issue….group profile of the AAPM Accounting team.

AAPM Information Services Department (L - R) - Onasis Budisantoso, Tammy Conquest, Yan-Hong Xing, Michael Woodward, Farhana Khan & Zailu Gao (not included - Jennifer Hudson)

Jennifer Hudson began her career with AAPM in April, 2001 as the

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AAPM Newsletter

March/April 2009

Therapy Program Scientific Symposia • • • • • •

Proffered Abstract Submissions

The Physics and Challenges of Novel Proton Accelerators Small Animal Image Guided Radiotherapy Improving the Radiation Therapy Process Using Industrial Process Development Techniques Locating and Targeting Moving Tumors Automated Segmentation for Radiotherapy Volume Definition Imaging and Treatment Planning for Adaptive Radiotherapy in the Head and Neck

• • • • • • •

IMRToptimization, treatments & QA Monte Carlo method & validation Dosimetry instrumentation methods & QA Brachytherapy isotopes, pharmaceuticals, methods & applications Stereotactic radiosurgery & radiotherapy Radiobiology modeling & treatment planning Networks & informatics

Imaging Program Scientific Symposia • • • • • • • •

Advances in Photon Counting Detectors in X-ray Imaging Developments in Breast Imaging Advances in Ultrasound Imaging Advances in CT Advances in Quantitative MRI and MR Spectroscopy Advances in Molecular Imaging Advances in Cardiovascular Imaging Brain Interventional and perfusion Imaging

Proffered Abstract Submissions • • • • • •

Digital Radiography, Fluoroscopy, Angiography, Cardiac CT, MRI, Molecular Imaging, Ultrasound, Optical & Breast Imaging Image Processing, Display, Visualization Functional Imaging, Image Analysis, CAD Multi-Modality Imaging, Registration & Fusion Image Quality Evaluation, QC, Dosimetry

Joint Imaging/Therapy Program Proffered Abstract Submissions

Scientific Symposia • • • • • • •

Challenges of Post-treatment and Real-time Imaging of Dose Deposition During Proton Therapy Frontiers in Physics Imaging as a Biomarker Nanotechnology in Imaging and Therapy Breast Cancer Imaging and Treatment/Optical Diffuse Tomography and Therapy MR-Guided Radiotherapy Image Guided Interventions: Imaging Guidance, and New Technologies for Interventional Procedures

• • • • • • •

Target and normal organ definition Image guided procedures and interventions Portal imaging Cone beam CT Imaging for therapy assessment Small animal imaging Nanotechnology applications

Professional Program • • • • • • • • •

Licensure/Registration Women and the AAPM New member Symposium Economic Issues & Update Proffered Papers MOC PQI - SAM session Contract Negotiation Professional Doctor of Medical Physics

More than 50 hours of continuing education in medical imaging and radiation therapy physics will be offered. This will include SAMS courses for diagnostic, medical nuclear, and radiation therapy physicists.

www.aapm.org/meetings/09AM

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AAPM Newsletter

March/April 2009

Education Council Report

J. Anthony Seibert Education Council Chair

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have officially been the chair of the Education Council for nearly one month as I write this column, and am gaining a better appreciation for how busy we are as an organization, not only from the educationally focused themes and issues for which I am responsible, but also for the myriad number of interconnected topics and details that have significant overlap and effects on the Science and Professional Councils as well (and by default, the Executive Committee and AAPM headquarters personnel). One case in point is the topic of erroneous and misleading media messages that was recently brought up by a concerned AAPM member to the AAPM leadership and Council Chairs, involving various so-called “professional societies / activist groups” that sponsor and publish alarmist propaganda related to radiation risks. In this specific situation, reference to “standard man” that does not account for women and children is used to promulgate incorrect information via the media, and the lay public consumes the content as scientific fact. It is up to professional scientific organizations such as the AAPM and others to take an active stand to counter misleading arguments and educate the public in an objective and unbiased way. From

within the AAPM, this can best be accomplished by cooperation and communication amongst the Councils. The Education Council, through advice of the Public Education Committee chaired by Mary Fox, actively promotes public education in matters pertaining to medical physics, and can assist in the formulation of appropriate response to this as well as other issues. Congratulations and sincere thanks to John Bayouth, who organized a very successful Residency Training Program Workshop designed for the Organization and Completion of CAMPEP Self-Study on February 6 and 7, 2009 in DallasFort Worth. John and seven other experienced faculty, including Art Boyer, Charley Coffey, Peter Dunscombe, Bruce Gerbi, Mike Herman, Eric Klein and Mike Mills, interacted with a total of 24 attendees and their respective institutions to assist them in navigating the application process for Medical Physics Residency Program certification. In addition, many practical issues and potential institutional barriers were discussed. Each participant created a draft of their institution’s CAMPEP selfstudy document to identify deficient areas of their programs along with potential solutions. Appreciation goes to the faculty and attendees alike. There are other residency program support initiatives planned by Education Council committees in the coming year in preparation for the approaching 2012 and 2014 deadlines that will be discussed in future newsletters. Emphasis on training medical physicists to be good teachers has initiated an invitation for

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AAPM members to submit a one page description of innovative medical physics education activities, including projects that describe scientific research, novel teaching strategies, team teaching, and other innovations such as unique lectures and websites. The Education Council is sponsoring a symposium at the AAPM Annual Meeting in Anaheim for the presentation of these ideas, with the award of a plaque to the presentation, methods, ideas deemed most innovative. The deadline for submission is March 4, 2009, and authors of selected submissions will be notified by April 21, 2009. More information can be found on the AAPM website under Meeting Program Information on how to submit information for consideration. Many thanks go to Don Frey for organizing this effort, and please consider submitting your ideas! This will undoubtedly be a very interesting and fun symposium, so plan on attending at the annual meeting.


AAPM Newsletter

March/April 2009

Science Council Report

John Boone Science Council Chair

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cience Council has had a number of meetings recently. At the Houston AAPM annual meeting in July 2008, we had a town hall meeting with the intention of engaging the membership. We were happy to see that 13 AAPM members were sufficiently interested in the scientific activities of the Association to come to this meeting, and we had a good exchange of ideas. The ~0.4% turnout could be interpreted as (1) a vote of confidence in the operation of Science Council, (2) a tacit statement suggesting apathy of medical physicists in scientific matters of the Association, or (3) a reflection of the many other quality symposia taking place simultaneously. We are happy to believe it was a combination of 1 and 3, but we are thankful to those 13 members who did come and share their ideas. We had a fall meeting of Science Council at the Department of Medical Physics at University of Wisconsin, Madison, with Rock Mackie hosting. Two solid days of good discussion, and among other things, we discussed the important scientific issues surrounding the growing interest in proton therapy. As a result of these discussions, Science Council will be hosting a scientific meeting on the Promise

and Peril of Proton Therapy in Baltimore on May 8-9. The meeting is being organized by Jatinder Palta, Eric Klein and Chris Rose. This premiere meeting on particle beam radiation therapy will feature many of the world’s authorities on proton therapy, and we are sure that the scientific presentations and panel discussions will result in lively dialog which add both scientific and societal perspective to the emerging field of particle therapy. AAPM members who are interested in participating in this scientific meeting are encouraged to attend. This will be a premier event on the possible future of radiation therapy, and registration and logistical information can be found on the AAPM web site. While we were in Madison, one of the most enduring medical physics programs in North America, Rock had the members of Science Council engage about 70 medical physics students in an open discussion setting. Science Council members took turns making short comments about the future of medical physics, and then took questions from the student audience. I was personally struck by the genuine concern of one student who inquired about the fate of radiation oncology physicists if a cure to cancer were to happen. This excellent question reminded me of the unbridled optimism of my own youth. As I like to frequently remind the Director of the Cancer Center where I work (and run the cancer imaging program), the CURE to cancer if and when it comes (as it does to many patients daily) will be (is) due to a combination of early detection, prevention, surgery, chemotherapy, and sophisticated radiation oncology procedures. I think we all hope that a cure to

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cancer for all patients happens in our lifetimes, and personally I think that medical physicists are likely to play an important role in it. Thanks for that good question! Science Council met in Houston in January 2009 with Jeff Shepard hosting. In addition to 2 days of discussion, Mike Gillen gave us a tour of the very impressive proton facility at MD Anderson Cancer Center, and Geoff Ibbott educated us and demonstrated the activities of the Radiation Physics Center at MD Anderson. There are few institutions in the world that can match MD Anderson’s focus on cancer treatment and the science that is necessary to maintain clinical excellence and advance state-of-the-art therapeutic techniques, and our visit to this premier facility was inspiring. There are some changes on Science Council. We are thankful to Bob Nishikawa for his dedicated service, and Rebecca Fahrig has replaced his position as co-chair of the Research Committee. Other new members of Science Council include Paul Kinahan and Dave Rogers. I am grateful to all the talented medical physicists who commit their time and energy to serve on Science Council, and I am happy to welcome Rebecca, Paul, and Dave to the Council. As always, if you have any comments, questions or ideas in regards to the activities of Science Council, please Email me.


AAPM Newsletter

March/April 2009

Professional Council Report Newsletter by Wendy Smith Fuss and the Professional Economics committee, providing an overview of the recent CMS rules regarding the 2009 Physician Fee Schedule and the 2009 HOPPS payment rates, with a detailed description of the CPT changes and decreased HDR payments. Per Halvorsen Professional Council Chair

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e’re in a season of change, and the Professional Council is no exception…. With the arrival of the new year, we welcomed several new members and leaders into the Council’s committee structure. First and foremost, we’d like to thank Mike Herman for his expert leadership of the Professional Council in recent years, and wish him well as PresidentElect. Mike led the Council with a calm, task-focused approach that served the Association well, and we are very grateful for his service. As the incoming Chair, I have big shoes to fill, but am thankful that Mike Mills graciously agreed to continue as Vice Chair – with his help, we hope to continue meeting the Association’s professional needs. You are hopefully all aware that we have a new Code of Ethics – if you haven’t already read it, please take a moment to become familiar with it. The Code is the result of much deliberation and reflection by a diverse group of your colleagues, with input from many other members, legal counsel, and consideration of other Associations’ codes. Every member should have received a hardcopy edition in the January/February member mailing. Look for the article elsewhere in this

The AAPM and ACMP are cosponsoring a daylong session at the ACMP annual meeting in Virginia Beach in May. The session is titled “Medical Response to Radiation Incidents” and will focus on how medical physicists can assist in responding to radiation incidents. Participants will learn about the Medical Reserve Corps and how to become engaged within their local communities. Check the ACMP website www.acmp.org for details. The AAPM and ACMP joint effort to promote minimum standards for clinical medical physics has taken a significant step forward, thanks to the efforts of the Joint Medical Physics Licensure Subcommittee and the continued commitment and financial support from the two organizations. The subcommittee has expanded its focus to include both licensure and registration with minimum criteria for registrants, and has identified five states for its initial advocacy phase at the state legislative level. Contact Amanda Potter at AAPM headquarters for more information, or go to www. aapm.org/government_affairs/ licensure/default.asp. The Professional Services Committee, led by George Sherouse, has been very active lately, with several new Subcommittee and Working Groups. The Medical Physicist Workforce SC has engaged an expert panel to perform

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an in-depth analysis of the medical physicist workforce – we lack good data as a profession on the supply and demand for properly trained medical physicists, and this study will provide important information for the Association as well as for educational and training programs. The New Professional Subcommittee was started in December to support the transition of new professionals into the field by providing informational resources regarding topics of particular interest to those just beginning their medical physics careers, including an introduction to the AAPM structure and operation, volunteer opportunities and membership benefits, peer support in the board certification process, and social networking with peers and elders to promote career development. The Peer Review Clearinghouse Subcommittee was formed in January to implement a structure for matching parties seeking independent peer review with individual reviewers. To eliminate the inherent conflicts in direct payment for reviewer services, the service will be provided at a fixed fee, payable to the AAPM, and the reviewer will be assigned and reimbursed by the AAPM. Last but not least, the Professional Contracts Working Group is in the formative stage. The PCWG will develop guidance that discusses the essential and important elements to be included in effective written agreements (contracts) for the provision of professional Qualified Medical Physics services. The guidance document will be developed and delivered as a WWW Wiki and will form the foundation of an online resource and open collaborative document available to all registered AAPM members. Check the PROFS committee page


AAPM Newsletter for details. All of these efforts on your behalf are performed by volunteers – your colleagues across the country who give their time and effort after their “day job� hours, in order to help our profession remain vibrant and continue to serve the best interests of patients everywhere. If you have a suggestion, criticism, or (better yet) wish to help your fellow colleagues in this endeavor – just look through the Committee Tree on the AAPM w e b s i t e ( w w w. a a p m . o r g / o r g / structure) and identify the relevant Council or Committee/SC/WG chair. Drop him/her a line and offer your help!

March/April 2009

Wanted: Medical physics and engineering feature articles, news and meeting reports The Institute of Physics and Engineering in Medicine (IPEM) is the UK equivalent of the AAPM. IPEM publishes a quarterly magazine for its membership, entitled SCOPE, that contains feature articles, news updates, meeting reports, book reviews etc. The SCOPE editorial board has recently decided to include an international section in the magazine to contain articles and news from around the world. To this end, I invite any, or all, of you to forward interesting news items, meeting reports, or even feature articles (3000-4000 words with figures) for publication in SCOPE. For more details, or to submit an item for consideration for publication in SCOPE, please contact me at the address below: Richard A. Amos, M.Sc., MIPEM SCOPE International Editor (North America) Department of Radiation Physics The University of Texas M. D. Anderson Cancer Center Proton Therapy Center 1840 Old Spanish Trail Houston, Texas 77054 Tel: (713) 563-6894 Fax: (713) 563-1521 e-mail: richamos@mdanderson.org

   





        

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AAPM Newsletter

March/April 2009

AAPM Website Editor Report reinforced. Speaking personally, I find it useful to be able to glance at items under “What’s New” and group them intuitively - it is certainly much faster than reading each line. If you have strong opinions, either way, please pass them along using the feedback link, below.

Christopher Marshall NYU Medical Center

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s we turned the page on 2008 we retired the golden anniversary logo from the AAPM homepage and featured “Anaheim in 2009” instead. This is a link to the 2009 Annual Meeting pages, and we will use a corresponding icon to mark all associated meeting announcements. We had mixed reactions to our initial use of icons on the AAPM home page. The website editorial board was not enthusiastic when we discussed them last year, but I decided that we needed to try harder before abandoning the idea. Icons are used in modern visual interfaces. However, we clearly needed to use them consistently over time before they could take on any special meaning to our audience, and we are closer to that goal. We now intend to carry the iconography onto some of our content pages as opportunities arise, so that their meaning is

The current absence of information about Maintenance of Certification (MOC) on the home page is recognized. TG127 is reportedly close to completion of resource pages related to MOC. A draft version is accessible on their committee website. Once complete, we will migrate this material over to the AAPM home page using a new link under “Education”. The ABR website is also an immediate resource. In the current design of the website we have typically used vertical menu choices to select content. We have recently been experimenting with the use of horizontal tabs to select content. We like the additional degree of freedom that these give us for organizing the content of individual pages. Expect to see tabs on new pages as opportunities arise, such as the planned roll-out of additional items related to the International Affairs programs. Medical Physics recently added RSS feeds to Medical Physics Online.

You can subscribe from that page or from the AAPM home page. If you click on the RSS feed icon on the AAPM home page you can also subscribe to “What’s New” feeds from the AAPM home page. If you subscribe to both, you will receive an alert when any new Medical Physics article or any new item under “What’s New” is released. Google Desktop (and similar products) has a tool that allows you to passively monitor these alerts from your desktop. The IS group is working on a more powerful version of the Committee Wiki tool at the time of writing. This should be released by the time this Report appears in the printed Newsletter. The first version of the Wiki was announced late last year and discussed in my December editorial. This version is easy to learn to use and will remain accessible as Wiki Lite. The new version will be made available as Wiki Full for those who need extra features, such as the ability to create sub-pages. Thanks are due to everyone who tested and made comments and suggestions based on version 1 and we look forward to more input as these new resources are used. I hope that you find the Website useful, visit it often, and send me your feedback at http://www. aapm.org/pubs/newsletter/ WebsiteEditor/3402.asp

AAPM Summer School Clinical Dosimetry Measurements in Radiotherapy Colorado College • June 21-25, 2009 http://www.aapm.org/meetings/09SS/

Clinical dosimetry for radiotherapy covers the most important task in clinical medical physics: getting the dose measured correctly. Topics covered will include fundamentals of dosimetry, theory and application of AAPM dosimetry protocols (TG51-accelerators, TG61-x rays, TG43-brachytherapy), IMRT dosimetry, primary standards and the dosimetry chain to the clinic, instrumentation from ion chambers to MOSFETs and everything in between. There will be plenty of opportunity to interact with the Summer School faculty during this 4.5 day meeting in the Pike’s Peak region of scenic Colorado. Registration opens March 11.

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AAPM Newsletter

March/April 2009

AAPM Education and Research Fund AAPM wishes to acknowledge and thank the following individuals for their 2008 contributions to the AAPM Education and Research Fund Education and Research Fund: E. Theodore Agard Hassaan Alkhatib Elwood Armour Chantal Audet Luther Aull Michael Bailey Morris Bank Jonathan Bareng Areg Bejanian Clyon Wayne Bell Patrick Booton Giovanni Borasi Vera Burtman Harry Bushe Terry Button Jean Jacques Chavaudra Mark Colgan Robert Comiskey Kevin Corrigan Edmund Cytacki Mojtaba Dahbashi Andrew Daniel Cupido Daniels Jerome Dare Paul DeLuca John DeMarco Godwin Dorbu Maximian Felix D’Souza Ravimeher Errabolu Carlos Esquivel Karl Farrey Jennifer Hann Fisher Martin Fraser D. Jay Freedman G. Donald Frey William Geisler Bruce Gerbi Maryellen Giger Steven Goetsch David Lee Goff David Lloyd Goff Bennett Greenspan Madhup Gupta Per Halvorsen Homayoun Hamidian

Shashi Perera Douglas Pfeiffer John Pfund Bhaskaran Pillai Robert Pizzutiello Surendar Rao Prema Rassiah-Szegedi Peter Riley Dante Roa Gene Robertson James Sample Edwin Sham S. Jeff Shepard Deborah Shumaker Michael Silver Douglas Simpkin Larry Simpson Ramon Alfredo Siochi Jerry Soen Emilie Soisson David Spencer Donna Stevens Palmer Steward Michelle Svatos John Sweet Joseph Takahashi Raymond Tanner Michael Tassotto David Taylor Charles Tenney James Terry Stephen Thomas Kenneth Ulin Gnanaprakasam Vadivelu Stephen Vastagh Steven Wang Marilyn Wexler Gerald White John Willins Robert John Wilson Charles Wissuchek Genevieve Wu Shigeru Yokoyama Ellen Yorke James Zagzebski

Russell Hamilton Joanna Harper Herman Haymond Chris Hearn Joseph Hellman Kenneth Hogstrom Gulkan Isin Christopher James Zheng Jin Stergios Kaidas Paul Keall James Kereiakes Angela Keyser Jayne Knoche Roger Ladle Itembu Lannes Renee Larouche Joel Lazewatsky Jesse Lee Richard Lee Norman Lehto Edwin Leidholdt Lisa Lemen David Lightfoot Hui Helen Liu Jeffrey Long T. Rock Mackie Gig Mageras Mahadevappa Mahesh William Malloy Christopher Marshall Mary Martel Rafael Martin Howell Kerry Maughon James McDonough Sharon McMillan Michael McNitt-Gray Ira Miller Mohamedo Minhaj George Mitev Raj Mitra Jose Morales Monzon Lee Myers Uwe Myler David Nelson Robert Nishikawa Mark Oldham James O’Rear

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John R. Cameron Memorial Fund: Frank Bolin WilliamGeisler Lawrence Rothenberg David Spencer Michelle Svatos

Hy Glasser Memorial Fund Lawrence Rothenberg

Jack S. Krohmer Memorial Fund William Geisler David Lloyd Goff Matthew Kowalski David Spencer Raymond Tanner

John S. Laughlin Memorial Fund David Lightfoot Lawrence Rothenberg

Members Memorial S. Jeff Shepard


AAPM Newsletter

March/April 2009

Image Gently Campaign Update

Medical Physicists Key to “Image Gently” Success Campaign targets parents in educational push aimed at prudent pediatric imaging by Keith Strauss, AAPM Representative to the Alliance for Safety in Pediatric Imaging

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he second phase of the Image Gently™ campaign finds the Alliance for Radiation Safety in Pediatric Imaging raising awareness among parents through their pediatricians and imaging professionals with educational materials that explain medical imaging in clear language and an easy-to-use record card for documenting their child’s past imaging exams. The Alliance, representing 34 medical organizations and serving more than 400,000 healthcare providers worldwide, encourages radiologists, pediatricians, medical physicists, and other imaging professionals to download these free resources from the Image Gently™ web site (www.imagegently.org) and make them available in their waiting rooms and offices. These tools consist of: • “My Child’s Medical Imaging Record.” This free, downloadable card (also available in wallet size) lets parents record and retain basic information about their child’s imaging examinations: when and where performed, and the type of study. It also helps future medical providers make more informed decisions regarding optimal timing of additional radiologic exams.

• “What Parents Should Know About CT Scans for Children: Medical Radiation Safety” and “What Parents Should Know About Medical Radiation Safety.” These free, downloadable brochures provide parents with lay definitions so they can understand potential benefits and risks of certain imaging exams. The brochures also provide dose estimates in comparison to natural background radiation, discuss possible alternative examinations that do not utilize radiation, and provide follow-up questions that parents might ask imaging providers to guide their decisions regarding their child’s care. Accurate record-keeping is important in today’s “scattered healthcare system,” said the head of this parent-focused campaign phase, Dorothy I. Bulas, MD, professor of radiology and pediatrics at the Children’s National Medical Center in Washington, D.C. “Parents may not recall imaging that occurred at hospital A, studies performed at hospital B, or procedures at a physician’s office. My Child’s Medical Imaging Record reminds parents and pediatricians of exactly what imaging studies occurred over an extended period of time.” “The brochures will help raise awareness among referring physicians, radiologists, and radiologic technologists. The Alliance encourages them to work closely with medical physicists to get a better understanding of radiation dose in the procedures they order, interpret, or perform,” said Priscilla F. Butler, senior director in the ACR’s Department of Quality and Safety. “As experts in the radiation sciences, medical physicists have a key role in ensuring the campaign’s success and are best suited to be a

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resource regarding all radiation safety and dose concerns.” Image Gently™ targets a broad spectrum of medical professionals in addition to medical physicists and radiologists. “Because pediatricians order the pediatric radiologic exams and radiologic technologists perform the study, it’s important for both groups to be comfortable discussing the issues of radiation appropriately and accurately with the family,” Bulas said. “The Alliance seeks to enhance the pediatrician’s understanding of radiation exposure in imaging exams so they can educate their own patients and families. Sometimes there is pressure from families to do a study, whether for additional information or double-checking a diagnosis. It behooves us to inform families of the potential risk.” The Alliance urges health care providers to visit the Image Gently™ web site and pledge to do their part to “child-size” the radiation dose used in children’s imaging. Medical physicists will find on the Image Gently™ website a dedicated section with the latest research and educational materials to help determine the appropriate radiation techniques to image children and how the radiation received from these exams may affect pediatric patients over time. Among the site’s features is a universal guide on adjusting adult CT protocols to more appropriate protocols for imaging children of various sizes and ages. This guide was developed to work with all CT scanners by Keith Strauss, M.S., director Radiology Physics Engineering at Children’s Hospital Boston and AAPM representative to the Alliance. “Medical physicists can also download an excellent set of slides


AAPM Newsletter

March/April 2009

to use to present technical radiation information in a very understandable way to physicians,” Butler said. “Increasingly, medical physicists are receiving more questions about radiation dose and are making themselves available at their hospitals by providing in-services and conferences to medical staff, nonradiologists, as well as radiologists. Medical physicists have been extremely positive about the Image Gently™ campaign.” Background on Image Gently™ The Image Gently™ campaign has focused on computed tomography (CT) scans. In 2006, there were approximately 4 million pediatric CT scans performed in the United States. This figure is triple the number of

five years ago and is a reflection of rapidly evolving CT technology, with reliance on the diagnostic information available, that has replaced more invasive and often more costly techniques. The campaign is an effort to help ensure that medical protocols for the imaging of children keep pace with advancing technology. As medical imaging exams have replaced more invasive procedures, benefiting patients and revolutionizing medicine, the average American’s exposure to medical radiation has increased, raising concerns of potential harmful effects among imaging providers. Children are particularly sensitive to radiation received from imaging scans compared to adults, and cumulative radiation exposure

to their smaller, developing bodies could, over time, have adverse effects. Therefore, guidelines for providers who perform imaging exams on children include: • “Child-size,” the amount of radiation used in imaging • Notover-scan: - Scan only when necessary - Scan only the indicated region   - Scan once; multi phase scanning (pre-and post contrast, delayed exams) is rarely helpful • Be a team player: - Involve medical physicists to monitor pediatric CT techniques - Involve technologists to optimize scanning

On behalf of the American Institute of Physics’ Corporate Associates, AAPM members are invited to attend the 2009 Industrial Physics Forum (IPF). For each of the past 51 years, this forum has brought together industry, academic, and government leaders to examine applications of scientific research to emerging industrial R&D activities. The theme of this year’s IPF is “Frontiers in Quantitative Imaging for Cancer Detection and Treatment” and will be held in conjunction with the 51st Annual Meeting of the American Association of Physicists in Medicine (AAPM) on July 26-30, 2009 in Anaheim, CA. The IPF sessions are imbedded in the AAPM Scientific Program, beginning with the Presidential Symposium and continuing on Monday and Tuesday, July 27-28. A highlight of each IPF is a special session dedicated to Frontiers in Physics, addressing the most exciting research going on today, regardless of field. In Anaheim, there will a speaker on next-generation DNA sequencers, on opto-genetics for brain imaging, and on theoretical and practical challenges for the next-generation accelerators. Details at http://www.aapm.org/meetings/09AM/IPForum.asp Monday, July 27 10:00 am – 12:00 pm • Present and Future Role of Computers in Medicine 1:30 pm – 3:20 pm • Challenges of Post-treatment and Realtime Imaging of Dose Deposition during Proton Therapy • Advances in Photon Counting Detectors in X-ray Imaging 4:00 pm – 5:30 pm Frontiers in Physics Session: • Opto-Genetics - Karl Deisseroth, Stanford University • Next-Generation DNA Sequencers - Steve Turner, Pacific BioSystems • Next-Generation Accelerators- Joseph Lykken, Fermilab

Tuesday, July 28 10:00 am – 12:00 pm • Small Animal Image Guided Radiotherapy • Developments in Breast Imaging 1:30 pm – 3:20 pm • Improving the Radiation Therapy Process Using Industrial Process Development Techniques • Nanotechnology in Imaging and Therapy • Advances in Ultrasound Imaging 4:00 pm – 5:30 pm • Locating and Targeting Moving Tumors • Breast Cancer Imaging and Treatment/Optical Diffuse Tomography and Therapy • Advances in CT

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AAPM Newsletter

March/April 2009

Legislative & Regulatory Affairs Concern Remains High over the Availability of Isotopes Used in Medicine and Research.

Lynne Fairobent College Park, MD

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mage Gently™ launches the second phase of the campaign. As discussed in the associated article in this issue of the AAPM newsletter, this phase focuses on making parents aware of the number and types of imaging procedures their children have. The “My Child’s Medical Imaging Record and the “What Parents Should Know About CT Scans for Children: Medical Radiation Safety” and “What Parents Should Know About Medical Radiation Safety” can be accessed from the AAPM website by clicking on the “Image Gently™” logo on the main page of the AAPM website or by going to www.imagegently.org and clicking on the “Parents” link on the left side of the main page. These free, downloadable brochures provide parents with lay definitions so they can understand potential benefits and risks of certain imaging exams. The brochures also provide dose estimates in comparison to natural background radiation, discuss possible alternative examinations that do not utilize radiation, and provide follow-up questions that parents might ask imaging providers to guide their decisions regarding their child’s care. Don’t forget to “Take the Pledge” to Image Gently™ when on the website and join the 1,541 medical professionals to date that have already taken the pledge.

The FY2009 President’s Budget Request proposed to transfer the Department of Energy (DOE) Isotope Production Program from the Office of Nuclear Energy to the Office of Science’s Office of Nuclear Physics and rename it the National Isotope Production and Applications Program (NIPA). The Nuclear Science Advisory Committee (NSAC) has been charged to establish a standing subcommittee to advise the Office of Nuclear Physics on this program. The Nuclear Science Advisory Committee Isotope Subcommittee (NSACI) has two immediate charges with relatively short time frames namely: 1) to consider broad community input regarding how research isotopes are used and to identify compelling research opportunities using isotopes, and 2) study the opportunities and priorities for ensuring a robust national program in isotope production and development, and to recommend a long-term strategic plan that will provide a framework for a coordinated implementation of the National Isotope Production and Applications Program over the next decade. As a first step in this process, the DOE Offices of Nuclear Physics and Nuclear Energy held a “Workshop on the Nation’s Need for Isotopes: Present and Future” in Rockville, Maryland on August 57, 2008. A report of the outcomes of the workshop is available can be found at http://www.sc.doe.gov/ henp/np/program/isotope.html. Additional information about the NSACI Subcommittee, its charges, members and activities can be

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found at http://www.phy.anl.gov/ mep/NSACI/. AAPM provided comments to the NSACI. In summary, AAPM stated: • Patient care should not be adversely impacted due to a lack of availability of critical isotopes used in molecular imaging, targeted therapies and brachytherapy applications. • The availability of isotopes to diagnose and treat disease especially cancer and to ensure their availability for research must be maintained. • AAPM believes that a U.S. solution to isotope production should be established and that efforts to establish U.S. production capacity are critical. • AAPM strongly encourages the NSAC to support efforts to identify a US production facility for 99Mo. One such example is the effort of the University of Missouri to add a 99Mo production facility to their existing reactor. • Coordination between all federal agencies that support the use of isotopes in medical applications and research and those involved in regulating the use of isotopes (such as the Nuclear Regulatory Commission and Agreement States) is critical to ensuring an effective U.S. solution to this critical problem. AAPM’s written comments can be found at: http://www.aapm.org/ org/committees/GRAC/nucelar%2 0sicence%20advisory%20committe e/aapm_letter_nsac_1-13-09_combined_final.pdf. A full report, slides and additional comments from ASTRO and ASCO can be found at: http://www.aapm. org/org/committees/committee/ article.asp?id=2479.


AAPM Newsletter

March/April 2009

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AAPM Newsletter The National Academy of Sciences report “Medical Isotope Production Without Highly Enriched Uranium” was released on January 14, 2009. This book is the product of a congressionally mandated study to examine the feasibility of eliminating the use of highly enriched uranium (HEU) in reactor fuel, reactor targets, and medical isotope production facilities. The book focuses primarily on the use of HEU for the production of the medical isotope molybdenum-99 (Mo-99) and secondarily on the use of HEU for research and test reactor fuel. The NAS committee stated that “[T]he supply of Mo99 in the U.S. is likely to be unreliable until newer production sources come online. The reliability of the current supply system is an important medical isotope concern; this book concludes that achieving a cost difference of less than 10 percent in

facilities that will need to convert from HEU- to LEU-based Mo-99 production is much less important than is reliability of supply.” A single copy of the full report can be downloaded at: http://www.nap. edu/catalog.php?record_id=12569. Natural Resources Defense Council (NRDC) Petition for Rulemaking. In September 2008, AAPM provided comments to the Nuclear Regulatory Commission regarding the Natural Resources Defense Council; Receipt of Petition for Rulemaking [Docket No. PRM-50-90; See 73 FR 30321 (May 27, 2008). In response to the Petition, AAPM stated: • That any decision to grant the Petition proceed with caution and ensure that if a date is set for terminating the exportation of highly enriched uranium (HEU), this date be established to ensure that the

March/April 2009 production of medical radionuclides will not be compromised in any manner. • Establishing a reliable supply of medical isotopes is an important issue for patients worldwide. • Continuity of medical isotope supply is critical, so the conversion to low enriched uranium (LEU) has to be technically and economically feasible to ensure medical isotope supply for patient care is not jeopardized or interrupted. To date, there is no demonstrated, qualified, large-scale commercial process for production of medical isotopes from LEU targets. AAPM’s response on this Petition and other comments letters to Federal Agencies can be found at: http:// www.aapm.org/government_affairs/default.asp.

World Congress 2009 on Medical Physics and Biomedical Engineering More than 4,000 experts attending the “World Congress 2009 on Medical Physics and Biomedical Engineering“ at the International Congress Center Munich (ICM) will explore and discuss medical challenges of the future. The Congress is the world’s biggest and most important scientific and medical event focused on research in the areas of medical physics, biomedical engineering and bioengineering. From September 7 to 12, physicians, engineers and scientists will be presenting their research findings in 13 technically oriented Congress theme areas. Each of the Congress days is dedicated to one of the five medical focal topics: oncology, radiology/ nuclear medicine, surgery/intervention, neurology/neurosurgery/neurological rehabilitation, and cardiology/cardiovascular diseases. In addition to the scientific program, enterprises and non-profit organizations will present innovations and services in the field of medical physics and biomedical engineering at an exhibition running from September 8 to 11. Further highlights will include recruiting events and a job market for the over 1,000 doctoral candidates and young professionals attending the Congress. More information on the Congress is available at: www.wc2009.org.

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AAPM Newsletter

March/April 2009

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AAPM Newsletter

March/April 2009

Liaison Report Report of AAPM Liaison to International Atomic Energy Agency (IAEA) by Howard Amols

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n June 2007 the AAPM created a new position of Liaison to the International Atomic Energy Agency (IAEA) in an effort to improve communications, and to expand and coordinate the interactions between the two organizations. The IAEA Liaison reports to 3 AAPM committees; International Educational Affairs (IEAC), International Affairs (IA), and Government and Regulatory Affairs (GRAC). In this report I will first introduce you to the IAEA— its mission and reason d’etre, and then update you on some recent activities that I’ve been involved with. The IAEA is an official agency of, and receives most of its funding from the United Nations. Its international headquarters are at the UN complex in Vienna which, like the UN complex in New York City, is diplomatically sovereign territory. Most UN member states are also members of the IAEA (approximately 145 out of 192 states). The IAEA is comprised of 6 departments, the most well known of which are the Departments of Nuclear Energy, Nuclear Sciences & Applications, Nuclear Safety & Security, and Safeguards. They are the people who received the 2005 Nobel Peace Prize for among many other things, informing the world that contrary to the reports of US and British `intelligence’ agencies there were no WMA’s to be found in Iraq. Less often in the international spotlight is the IAEA’s Department of

Nuclear Sciences and Applications (DNSA), within which is the Division of Human Health (DHH), who’s mission is most closely aligned with those of the AAPM. Part of the IAEA’s annual budget of approximately 294 million Euros is spent on human health related activities. The DHH itself consists of 4 main sections; Nuclear Medicine, Applied Radiation Biology and Radiotherapy, Nutritional and Health-Related Environmental Studies, and Dosimetry & Medical Radiation Physics. Among its’ many activities the DHH supports coordinated research projects, publication of manuals, technical reports, and educational documents, international codes of practice, training courses and workshops, and support of safe and effective use of radiation in medicine. The DHH runs dosimetry and QA services such as a postal TLD service, calibration, and QA site visits via its `Quality Assurance Team for Radiation Oncology (QUATRO), which functions much like the Radiological Physics Center in the US. One of the Agency’s major goals is to promote the implementation of safe and modern radiation medicine technologies in poor and intermediate income countries (formerly referred to by the now politically incorrect term `third world’). The Agency disburses more than $70 million annualy for equipment, services, expert missions and training in approximately 100 recipient countries. For most of the conferences and workshops that it organizes the Agency usually assists with the travel expenses of individual clinicians and scientists from low and middle income countries, and negotiates favorable hotel rates for

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attendees which in conjunction with travel grants brings these meetings within the financial range of many physicists who without the IAEA would have little if any exposure to international conferences or training. Any physicist from any IAEA member state can attend any IAEA meeting by obtaining only a `letter of endorsement’ either from their government (typically from an entity such as the State Department, Office of Scientific Development, Ministry of Health, etc.) or from a `Non-Government Agency’ (NGO) such as the AAPM. IAEA meetings are also open to the general public, but as observers rather than official attendees. Thus, AAPM endorsement and co-sponsorship of IAEA activities enables great leveraging of AAPM money, and increases the international exposure of the AAPM as many of these meetings are also cosponsored by societies such as ESTRO (European Society for Therapeutic Radiology and Oncology), EFOMP (European Federation of Medical Physics), ASTRO (American Society for Therapeutic Radiology and Oncology), ICRU ( International Commission on Radiation Units and Measurements), ABS (American Brachytherapy Society), and others. To date most of my activities as AAPM Liaison have entailed educational activities and in facilitating AAPM support (logistic, financial, recruitment of faculty and organizers, etc.) for various IAEA meetings, workshops, and training programs.  There have also been discussions on other issues such as development of a formal mechanism for co-endorsement of IAEA publications by AAPM and vice versa, and in drafting an official letter of `agreement and understanding’ between the AAPM and the IAEA. 


AAPM Newsletter The `letter of agreement’ will highlight areas of common interest such as the exchange and dissemination of information about scientific meetings and publications on medical physics; coordination of activities to promote the medical physics profession; the safe and effective use of radiation in diagnosis and treatment of patients; assistance in development of guidance documents for clinical training of medical physicists; assistance in training and capacity building in medical physics; and development of joint educational and training material. While most IAEA publications address scientific and clinical issues such as standards of care and new technologies, quite often IAEA activities and publications also have implications for professional practice, and for this reason the AAPM Liaison reports to the AAPM Professional Council as well as to the Education and Science Coucils.  Cooperation between the AAPM and the IAEA during the past two years has included activities such as:

March/April 2009 12, September 2008 at IAEA Headquarters in Vienna. The objective of the DCRP is to promote medical physics graduate education in low and intermediate income countries. In this, it’s first year, the DCRP matched 6 students and their thesis advisors with a remote advisor from a North American or European University, and the IAEA will support up to 12 months of thesis work by the students at the institution of their remote advisor. • School on Imaging and Advanced Radiation Therapy (SIART) which was held on October 20-24, 2008 at the International Center for Theoretical Physics (ICTP) in Trieste, Italy. AAPM, EFOMP and IAEA were cosponsors of this meeting which was organized much like an AAPM Summer School and hosted approximately 40 young international medical physicists plus invited speakers, including four from the AAPM.

• The International Conference on Quality Assurance and New Techniques in Radiation Medicine (QANTRM) which was held 13 - 15 November, 2006 in the Vienna Center, Vienna, Austria and attended by over 500 clinician scientists . QANTRM was cosponsored by the AAPM, ASTRO, IOMP, plus several other international professional societies.

• ICARO(InternationalConference on Advances in Radiation Oncology) which will be held April 26-29, 2009 at IAEA Headquarters in Vienna. AAPM will be a cosponsor of this meeting along with several other international physics and medical societies. Over 400 attendees are expected. Additional information can be found at http://www-pub.iaea.org/MTCD/ M e e t i n g s / A n n o u n c e m e n t s. asp?ConfID=35265.

• The 1st Research Coordination Meeting (RCM) for the Doctoral Coordinated Research Program (DCRP) which was held 8-

Since the AAPM Liaison position is new we are still `feeling our way’ with regard to making it as effective as possible. I know that many

times individual AAPM members are `recruited’ by individuals from the IAEA to be a participant, consultant, speaker, etc. for some IAEA activity. Often, however, such contacts are made directly with an individual AAPM member rather than officially through the AAPM. While this is all well and good, problems often arise if there is ultimately a request for AAPM to become a co-sponsor or endorser of the meeting, project, or ensuing report. According to AAPM rules such endorsements require review by at least one committee and/or council. Thus, unless you make it known to AAPM that you have been contacted by the IAEA and that you are involved one of their activities then you are not officially representing the AAPM in anything you do and AAPM endorsement could be problematic. Further, there may be misunderstandings with regard to whether things you say or recommend are your own opinions or those of the AAPM. To prevent issues such as these in future I urge you to contact me or the appropriate Council chair whenver you are asked to participate in IAEA activities. Additional information about the IAEA can be found on its homepage, iaea.org. and we are also making a concerted effort to add links to various IAEA activities on the AAPM website. Finally, I welcome any advice you might have how to best define the responsibilities of this new Liaison position and make if more effective.

IGRT Hospital Coding Alert Hospital outpatient departments are strongly encouraged to continue to report charges for all image guidance (e.g., 76000, 76001, 76950, 76965, 77011, 77014, 77417, 77421) and image processing services (e.g., 76376, 76377) regardless of whether the service is paid separately or packaged, using correct CPT codes. Medical Physicists should check with their department or hospital billing staff to ensure that they are aware of the need to report these charges. The goal is to continue to capture the costs of the packaged image guidance services utilized in radiation therapy procedures in the hospital data used to develop future APC payment rates.

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AAPM Newsletter

March/April 2009

ABR Physics Exam Question The Life of an ABR Physics Examination Question by G. Donald Frey Richard Morin Geoffrey Ibbott

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andidates for the examination in radiological physics for radiology residents often wonder about the source of the questions. Sometimes wild rumors circulate about these items. This article describes how the questions are written and reviewed. The process for the examination in physics for radiation oncology residents is very similar. Radiological physics questions are written by three groups of individuals. • A committee of physicists with many years experience in teaching medical physics. • A committee of radiologists. • Radiologists and physicists who are selected by reviewing the literature each year. Authors of articles that contain important physics concepts are asked to contribute questions. Questions begin life in the minds of these individuals. The question writers are aided by providing them with a guide to question writing, a style guide and sample questions. After it is written, the question is sent to an editor who reviews it for grammar, clarity of English expression and appropriate style. The question is then sent to a committee

of five physicists who reviews it for accuracy, appropriateness, and ambiguity. If a question survives this review, and many don’t, it is placed in the pool of questions. Each year the chair of the physics committee selects questions for the exam. This is done using a blueprint that lists the required number of questions on each topic. The blueprint is based on the AAPM physics curriculum. The exam has a mixture of old and new questions. The old questions are used to give the exam statistical validity. The new questions are used to cover new topics, like digital mammography or cardiac CT, as well as keeping the exam fresh. Questions that have been used before and did not perform well are analyzed, rewritten, or removed from the pool. A question can be rejected because it is too easy or too hard. Questions that are too easy or too hard don’t discriminate among the candidates so they are rewritten or removed from the pool. To determine the discriminator statistic, candidates are divided into quartiles based on their overall scores. Candidates in the upper quartile will answer a good question correctly more frequently than those in the lowest quartile. In addition, some questions demonstrate the right level of difficulty but still all groups of candidates do equally well. As before, if all quartiles of the candidates perform equally well the question is rewritten or removed from the pool. Once the exam questions are selected, a committee of five physicists, five radiologists, (including several ABR Trustees) and an editor meet to go over each question again. Frequently this final

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review results in the questions being edited again for clarity. Sometimes questions are removed because the radiologists don’t find them relevant or because they use language that might be obscure for a radiologist. Finally the exam is assembled in its final form but before it is sent to the testing centers it is reviewed by the editor and two medical physicists to detect any possible remaining errors. The exam is then sent to the testing service to be loaded into the testing system. After the administration of the examination the exams are electronically scored and the results are analyzed by ABR psychometricians. Questions that performed poorly are identified and sent to the Physics Committee Chair. The Chair (and a Trustee) determine if the stated answer is correctly identified on the answer key, review the correlation performance and decide if the question is to be included in the final scoring. In addition a decision is reached to retain the question, revise the question, or remove the question from the pool. Questions frequently age and are removed from the pool. There are some basic questions that have been in the pool since the early 1990’s but many questions become obsolete as the profession changes and are removed from the pool. The ABR takes the exam in radiological physics seriously and makes every effort to insure that every question is accurate, relevant, clear and discriminating.


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AAPM Newsletter

March/April 2009

Health Policy/Economic Issues SIGNIFICANT PAYMENT DECREASES TO FREESTANDING CANCER CENTERS THAT PROVIDE HDR BRACHYTHERAPY by Wendy Smith Fuss, M.P.H. AAPM Health Policy Consultant

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n the 2009 Physician Fee Schedule final rule, the Centers for Medicare and Medicaid Services (CMS) established three (3) new procedure codes for High Dose Rate (HDR) brachytherapy 77785, 77786 and 77787 effective January 1, 2009 with interim relative value units (RVUs) of 5.16, 15.47 and 22.99 respectively. At the same time, the four (4) old HDR brachytherapy codes 77781-77784 were deleted on January 1st with 2008 RVUs of 14.97, 19.99, 27.38 and 40.41. The new codes are now defined by channels instead of dwell points and the RVUs were subject to public comment until December 29th. The new codes are considered interim for 2009. CMS will finalize the HDR brachytherapy RVUs in the 2010 Physician Fee Schedule final rule next November. • 77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel • 77786 Remote afterloading high dose rate radionuclide brachytherapy; 2-12 channels • 77787 Remote afterloading high dose rate radionuclide brachytherapy; over 12 channels The new HDR brachytherapy procedures codes yield significant decreases in Medicare payments to freestanding cancer centers and may cause some centers to abandon this cancer treatment entirely and redirect patients to more costly or invasive alternative treatments, which could result in

constricted access to this lifesaving cancer treatment for Medicare beneficiaries.  The American Association of Physicists in Medicine (AAPM) reviewed the direct practice expense inputs for the interim 2009 HDR brachytherapy codes and cited concerns regarding equipment, supply, and nonphysician clinical staff costs associated with these cancer treatments. The practice expense inputs for the new HDR brachytherapy procedure codes have been significantly reduced causing 2009 payment decreases in excess of 46%. Equipment Inputs & Useful Life: In the 2009 final rule, CMS presumes a 5-year useful life for the Iridium-192 renewable source, which is incorrect. The Iridium192 renewable source is typically replaced every 90-days or 4 times per year. ASTRO determined that the annual cost of the source is $45,326 and the Agency needs to correct the useful life of one (1) year. The current assumption of a 5-year useful life is significantly decreasing the renewable source costs associated with HDR brachytherapy. CMS could update the RVUs for the three new HDR brachytherapy codes through a Medicare Program Transmittal or Correction Notice in early 2009. In addition, AAPM identified several pieces of medical equipment that were not included in the practice expense inputs for HDR codes 77785-77787. AAPM recommended that CMS review the equipment practice expense inputs and correct the useful life for the Iridium-192 renewable brachytherapy source by changing the useful life to 1 year.

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Supply Inputs: CMS removed all supply costs associated with brachytherapy catheters, brachytherapy stylets and associated catheter/stylet costs from the new HDR brachytherapy procedure codes 77785-77787.  The catheter/stylet supply costs for the 2008 HDR brachytherapy procedure codes ranged from approximately $60 for 77781 to over $1,200 for 77784 per fraction of treatment. However, it is not clear where the costs of the brachytherapy catheters and stylets have been assigned for 2009. The majority of brachytherapy catheter placement codes do not have a nonfacility payment under the Physician Fee Schedule and the CMS database does not include the supply costs for these codes, with the exception of breast catheter placement codes 19296 and 19298. If CMS did include these supply costs in the brachytherapy catheter placement codes, a freestanding cancer center would be unable to recoup these costs as the brachytherapy catheter placement codes are surgical procedures typically provided in the hospital setting. AAPM recommended that CMS clarifies where the supply costs of brachytherapy catheters and brachytherapy stylets associated with HDR brachytherapy are captured and identifies the specific CPT codes that include these costs. Nonphysician Clinical Staff Inputs: Medical physicists play a key role in the delivery of cancer care and are an important provider of healthcare to Medicare beneficiaries. AAPM did not have the opportunity to review the recommended clinical staff types and times before submission to the AMA’s RUC and disagreed with several of the clinical staff times and types.


For example, the 2009 interim RVUs include a mix of a medical physicist and medical dosimetrist for HDR brachytherapy procedure codes 77785-77787. Only a qualified medical physicist would provide these services for the typical patient receiving HDR brachytherapy treatment. The medical physicist actively participates for the entire duration of the treatment delivery process. The participation of the Authorized Medical Physicist is required by the Nuclear Regulatory Commission (NRC) and Agreement State regulations and is clearly specified in professional practice recommendations. In addition, the interim RVUs do not include the preservice time to prepare the HDR afterloading equipment for treatment as required by the NRC. AAPM recommended that CMS assign 15 minutes of preservice time to each of the HDR brachytherapy codes. AAPM Recommendation: Based upon the flawed practice expense inputs, AAPM recommended that CMS delay implementation of the 2009 interim RVUs and reexamine the medical equipment inputs, staff types and times for HDR brachytherapy treatment delivery codes 77785-77787. Further, AAPM urged the Agency to crosswalk the 2008 RVUs to the new HDR codes effective January 1, 2009 until the impact on freestanding cancer centers may be appropriately mitigated.

March/April 2009

AAPM’s Science Council presents: A Symposium on the Promises and Perils of Proton Radiotherapy Dates: May 8 - 9, 2009 Radisson Plaza Lord Baltimore Baltimore, MD Registration opens March 2 http://www.aapm.org/meetings/09PRS

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To view a copy of the AAPM comment letter to CMS go to: http://aapm.org/g over nment_ affairs/CMS/default.asp

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At the time this publication went to press, no changes had been made to the 2009 HDR brachytherapy RVUs with significant freestanding center payment reductions implemented on January 1, 2009.

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AAPM Newsletter

March/April 2009

ACR Accreditation Q. What is MIPPA??

Priscilla F. Butler, M.S. Senior Director - ACR Breast Imaging Accreditation Programs ACR Accreditation: Frequently Asked Questions for Medical Physicists

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oes your facility need help on applying for accreditation? In each issue of this newsletter, I’ll present frequently asked questions (FAQs) of particular importance for medical physicists. You may also check out the ACR’s accreditation web site portal (www.acr.org; click “Accreditation”) for more FAQs, accreditation applications and QC forms.

A. Section 135 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) includes a provision requiring providers of advanced diagnostic imaging services (ADIS) to meet comprehensive accreditation standards by the year 2012. ADIS are defined as MRI, CT, and nuclear medicine/PET and specifically exclude x-ray, ultrasound, and fluoroscopy. Q. How does MIPPA impact reimbursement? A. The MIPPA policy is a condition of payment for the technical component (TC), or acquisition of the image, and covers the equipment, the technologists, and the supervising physician. Q. To whom do the MIPPA provisions apply?

A. Section 135 of the MIPPA amends the provision of the Social Security Act that deals with Medicare Part B physician payments. More specifically, it amends section 1848(b) of the Social Security Act which deals with the establishment of the physician fee schedule. Section 135 does not apply to Medicare Part A. Medicare Part A covers inpatient care in hospitals. Since Section 135 deals only with the physician fee schedule, it does not relate to hospital services. Therefore, it is important to note that hospitals are not required to meet the comprehensive accreditation requirement by 2012. Q. Will CT scans performed for radiation oncology treatment planning purposes be covered under MIPPA? A. No, MIPPA only applies to providers of diagnostic imaging services.

Letter to the Editor

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e would like to make members of the AAPM aware of a most valuable resource that is easily available to them. A wealth of material is available at no cost on the International Atomic Energy Agency (IAEA) Radiation Protection of Patients (RPoP) website, http:// rpop.iaea.org. Included are: 1. Training material (power point slides) in the areas of a. Diagnostic and Interventional Radiology b. Radiotherapy c. Nuclear Medicine d. Prevention of Accidental Exposure in Radiotherapy

e. Cardiology f. PET/CT 2. Publications for download including a. Safety Guides b. Safety Standards c. Safety Reports 3. Up-to-date references 4.

Answers to questions concerning radiation effects and risks for health professionals, patients, pregnant women, children and members of the public.

We urge all of you to become familiar with this most valuable source of medical and health physics information.

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Please feel free to contact us if you would like any additional information about this resource. Lawrence N. Rothenberg, Ph.D. , rothenbl@mskcc.org Madan M. Rehani, Ph.D., M.M.Rehani@iaea.org

AAPM and Doyle Printing Green Partners


Editor

Mahadevappa Mahesh, MS, PhD Johns Hopkins University e-mail: mmahesh@jhmi.edu phone: 410-955-5115

Editorial Board

Priscilla Butler, MS, Allan deGuzman, PhD, William Hendee, PhD, Chris Marshall, PhD (ex-officio) SUBMISSION INFORMATION Please send submissions (with pictures when possible) to: AAPM Headquarters Attn: Nancy Vazquez One Physics Ellipse, College Park, MD 20740 e-mail: nvazquez@aapm.org phone: (301) 209-3390

PRINT SCHEDULE • • • •

The AAPM Newsletter is printed bi-monthly. Next issue: May/June Submission Deadline: March 23, 2009 Postmark Date: week of May 4, 2009

American Association of Physicists in Medicine One Physics Ellipse College Park, MD 20740-3846

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AAPM Newsletter March/April 2009 Vol. 34 No. 2  

AAPM Newsletter March/April 2009 Vol. 34 No. 2  

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