AAPM Newsletter January/February 2010 Vol. 35 No. 1 by AAPM Docs

Newsletter

AMERICAN ASSOCIATION OF PHY SICISTS IN MEDICI N E VOLUME 35 NO. 1

JANUARY/FEBRUARY 2010

AAPM President’s Column

Michael G. Herman Mayo Clinic

would like to wish everyone a happy new year, and because this newsletter is now electronic, my column was only written a few weeks prior to publication! It is an honor to serve our American Association of Physicists in Medicine as your President. We have left behind us a year of uncertainty as the economy churned in varying directions, as a new United States President began to grapple with health care reform, as high profile medical errors hit very close to home, as new federal regulations impacted accreditation, as 2012 moved another year closer. Please join me in thanking Jerry White and Mary Moore for their service to AAPM. Jerry for his sage leadership of the AAPM though his service on EXCOM. I will miss his cool, collected guidance and vast knowledge of our profession. Mary for her watch over our finances and for providing insight on EXCOM.

New AAPM Mission Statement At the November 2009 AAPM Board of Directors meeting, the Board adopted a new AAPM Mission Statement. This document was developed through numerous iterations and most recently honed by an adhoc committee composed of Chris Marshall (chair), Geoff Ibbott and George Sherouse. The italicized text below represents our Vision, Mission and Goals. I have commented on each of the goals in normal text. Our Vision: The American Association of Physicists in Medicine is the premier organization in medical physics, a broadly-based scientifi c and professional discipline encompassing physics principles and applications in biology and medicine. Our Mission: The mission of the American Association of Physicists in Medicine is to advance the science, education and professional practice of medical physics. Our Goals: The goals of the American Association of Physicists in Medicine are to: 1. Promote the highest quality medical physics services for patients. The focus on direct clinical services, where patient care is immediately impacted by our work. 2. Encourage research and development to advance the discipline. The science that brings new technology, innovations and techniques into medicine to the ultimate benefit of patients.

3. Disseminate scientifi c and technical information in the discipline. Task Groups, committees, national and regional meetings, our electronic and print publications are among the mechanisms to communicate essential information throughout Medical Physics. 4. Foster the education and professional development of medical physicists. Support for undergraduate, graduate, and post graduate education in the clinic, the laboratory and the academic setting. 5. Support the medical physics education of physicians and other medical profes-

TABLE OF CONTENTS Chair of the Board’s Column

p. 3

Executive Director’s Column

p. 4

President-Elect’s Column

p. 5

Editor’s Column

p. 7

Professional Council Report

p. 8

AAPM Response

p. 11

Leg. & Reg. Affairs

p. 13

ACR Accreditation

p. 15

2009 Treasurer’s Report

p. 18

Website Editor’s Report

p. 22

ABR Report

p. 23

CRCPD and AAPM

p. 25

Health Policy/Economics

p. 29

ISEP Report

p. 32

AAPM Newsletter

January/February 2010

sionals. Provide important basic and ongoing education about and related to medical physics to those in related positions and outside of our profession. 6. Promote standards for the practice of medical physics. Develop and promulgate consensus best practices based on AAPM efforts and in cooperation with other professional groups that impact clinical procedures. 7. Govern and manage the Association in an effective, efficient, and fiscally responsible manner. Keep the BOD involved, with committees and headquarters tuned to most effectively and efficiently serve the Vision and Mission of the AAPM.

this year.

Strategic Planning With a new AAPM Mission adopted, there is much work to be done. We must now articulate specific objectives and actions to achieve each goal. To this end, a Strategic Planning Committee is being proposed. This group will meet for the first time in the spring 2010. The committee will be comprised of officers, board members and members of the AAPM. The objectives will be drafted and brought to the BOD for approval. These will guide our councils and committees to develop mechanisms and activities that achieve our goals, to carry out our mission.

Dues increase – The BOD at the November meeting did endorse an increase in membership dues. This was felt to be essential to continue to support the activities of the AAPM and to offset increases in costs of doing business. Details of the proposal will be forth coming.

Administrative Council At the 2008 November BOD meeting, the concept of an Administrative Council was approved, to be further developed by an Ad hoc committee. The new council will house a number of the administrative committees as well as some committees that cut across all councils. This will facilitate better communication, representation and focus for councils and committees. The structure of the Administrative Council should be finalized

Recent Board Actions Term limits – in the fall of 2009, term limits for committee appointments were established in the AAPM rules to make them consistent across the association. Each appointment to committee is for three years, once renewable. The AAPM has 7000 members, many of whom have served or wish to serve the profession through our committee system. The term limits provide opportunities to increase diversity and bring in new ideas, while allowing individuals to stay focused for a substantial, yet defined period of time. Term limits are not lifetime limits, rather consecutive service limits.

Quality Care The high quality of medical physics services in patient care, in education and in research is due to the

effort that each of you direct toward your profession daily and I thank you for this. The success of the AAPM in support of our Mission is also due to the tireless energy and effort that you, the membership volunteers put into the Association, working with headquarters staff and participating in our activities. I also thank you for this. Why We are Here Remember who we are. Everything we do, practice, research and education is directly related to delivering and improving health care for fellow humans. We were very active in response and in prospective action to the educational, professional and scientific challenges of the last year. We will continue short term and long term initiatives that will guide improvements in our practice, an increased presence for our science and further success in our education. We will leverage strengths, partner where possible, and stand up for what is the right thing for patient care. Let’s make this an active, successful and productive year for medical physics.

Now online…

Selected presentations given at the:

2009 AAPM Annual Meeting 2009 AAPM Summer School “Clinical Dosimetry Measurements in Radiotherapy” 2009 CRCPD Meeting Physicists of Note Interviews • Anaheim, CA - 2009 AAPM Corporate Affiliate - Vendor Presentations as presented during the 2009 AAPM Annual Meeting www.aapm.org/meetings/virtual_library/

AAPM Newsletter

January/February 2010

Chair of the Board’s Column

Maryellen Giger University of Chicago

s I enter this year as the Chair of the AAPM Board and my seventh year on EXCOM, I am amazed at how time has flown. As I mentioned at the end of my last newsletter article, I will focus my 2010 efforts on progress with the various ad hoc committees, and on strategic planning with Board members and past presidents for the growth of our association. I hope we can learn from the past as we plan our future. Please email me on how you see the future of the AAPM. The mission of the AAPM is to advance the science, education and professional practice of medical physics. This new mission statement of the AAPM is now posted on the AAPM website at http://www.aapm. org/org/objectives.asp. We continue to show tremendous growth in all these aspects, although all seem to increase in complexity. The Ad hoc Committee on the Establishment of a Technology Assessment Institute (chaired by Bill Hendee; http://www.aapm. org/org/structure/?committee_ code=AHETAI) has been active in multiple activities throughout the

year. While currently an entity without walls, it has been discussed with interest at AAPM, RSNA, and FDA, as well as presented at a Federal Listening Session on Comparative Effectiveness (http:// www.aapm.org/publicgeneral/ C o m p a r a t ive E f f e c t ive n e s s. asp). For example, technology assessment in terms of both image quality and dose continues to be a crucial issue as concerns are raised on the amount and variation in dose from computed tomography. I am impressed with the rapid response of AAPM members to the current CT dose discussions, and their initiatives to address the situation with the goal to standardize exam protocols across vendors and institutions. I look forward to the TAI Ad hoc contributions via statements, protocols, grants, and workshops, as well communications to the public. The ad hoc Committee on Quantitative Imaging (chaired by John Boone; website at http://www.aapm.org/ org/structure/?committee_ code=AHQI) has also been progressing this year. It now hosts the TG189, Task Group on “Validation of software tools for quantification of DCE MRI data” with Yue Cao as chair. Also AAPM members were involved in the planning of the RSNA’s “Reading Room of the Future” in which stations demonstrated the potential implementation of quantitative imaging in clinical radiology reading rooms. The Ad hoc Committee on the Electronic Presence of the AAPM (chaired by Marty Weinhous; website at http://www.aapm.

org/org/structure/?committee_ code=AHCEP) has been busy investigating various means of electronic communication. What is most effective for communication from one to many, between many and many, etc? They are experiencing Twitter, Skype, Google Wave, Linkedin, AIP’s UNIPHY, and others. The ad hoc has two major issues – with whom should we be communicating and how? And how to implement these electronic developments in a timely and smooth manner? And last, I would like to thank all the members who attended the AAPM reception at the recent RSNA meeting, as well as our two event sponsors – Landauer, Inc. and RTI Electronics, Inc. Landauer, Inc. also pledged to support a newly-developed, private-practice imaging physics residency program, and challenged other companies to support such residencies in the training of our future medical physicists. Thank you again for taking the time to read the newsletter. You might have noticed that I placed more and more links within this electronic newsletter. And as always, I welcome any comments or suggestions.

AAPM Newsletter

January/February 2010

AAPM Executive Director’s Column

Angela R. Keyser College Park, MD Summer Fellowship Programs lease consider participation as a mentor in AAPM’s Summer Undergraduate Fellowship Program (SUFP) or Minority Undergraduate Summer Experience Program (MUSE).

The SUFP is designed to provide opportunities for undergraduate university students to gain experience in medical physics by performing research in a medical physics laboratory or assisting with clinical service at a clinical facility. In this program, the AAPM serves as a clearinghouse to match exceptional students with exceptional medical physicists, many who are faculty at leading research centers. Students participating in the program are placed into summer positions that are consistent with their interest. Students are selected for the program on a competitive basis to be an AAPM summer fellow. Each summer fellow receives a stipend from the AAPM. Both student and mentor applications are due by February 2. For details, go to: http://www. aapm.org/education/SUFP/ . The MUSE program is designed to expose minority undergraduate university students to the field of medical physics by performing

research or assisting with clinical service at a U.S. institutions (university, clinical facility, laboratory, etc). The charge of MUSE is specifically to encourage minority students from Historically Black Colleges and Universities (HBCU), Minority Serving Institutions (MSI) or non-Minority Serving Institutions (nMSI) to gain such experience and apply to graduate programs in medical physics. For details, go to: http://www.aapm.org/ education/MUSE/. The deadline for applications is February 9. Funding Opportunities Make sure to check out the funding opportunities online at aapm.org: •

•

The 2010 Research Seed Funding Initiative provides start-up funds for research-oriented medical physicists. A $25,000, one-year award will be made in 2010. Deadline for applications is February 16. For details, go to: http://www.aapm. org/education/ResearchSeed/ Applications are being accepted until April 15 for the AAPM 2010 Fellowship for Graduate Study in Medical Physics. Go to http://www.aapm.org/education/GSFMP/ for more details.

2010 Meeting Dates AAPM is partnering with ASTRO, ESTRO, RSNA and NCI to host the first biennial meeting to focus on quantitative imaging in radiation therapy: Imaging for Treatment Assessment for Radiation Therapy. ITART 2010 will be held June 2122, 2010, at the Gaylord National right outside Washington, DC. Early registration opens January 4, with abstract submission opening

on January 11. For more information, go to: http://www.aapm.org/ meetings/2010ITART/ . The 2010 AAPM 52nd Annual Meeting will be held July 18 – 22 at the Philadelphia Convention Center in Philadelphia, Pennsylvania. The online abstract submission process opens on January 6, with the deadline for submission on March 3. Registration and housing information will be posted by March 18. More information is available online at: http:// www.aapm.org/meetings/2010AM/ . The 2010 AAPM Summer School, Teaching Medical Physics: Innovations in Learning, will immediately follow the Annual Meeting, from July 22 – 25. Bill Hendee is serving as Program Director. Registration opens on January 27. For more information, go to: http://www.aapm.org/ meetings/2010SS/ . This 2.5 day program is designed to help medical physicists become better teachers of physicians, graduate students and technologists. In addition to hearing several keynote speakers, participants will engage in work sessions where they will share experiences and learn from one another. Each participant will leave with an action plan he or she has designed to be a better teacher. There will be plenty of opportunity to interact with the Summer School faculty. The Summer School will take place on the historic and scenic University of Pennsylvania campus. Scholarships in the form of a full waiver of tuition fees for the entire AAPM 2010 Summer School are being offered for applicants who are early in their careers in medical physics. In addition to the tuition scholarships, two $500 grants to assist with other expenses related to the AAPM

AAPM Newsletter

January/February 2010

President-Elect’s Column

J. Anthony Seibert

UC Davis Medical Center

his is my first newsletter article as president elect, and I’m in the midst of a steep learning curve in the transition from Education Council chair regarding the role of the Executive Committee and the leadership positions. The AAPM as a whole is so much more than the simple sum of its parts, and with the many issues that we, the membership are collectively confronting, the challenges from the educational, scientific and professional venues are quite daunting. In order to responsibly plan future budgets for the association, we need to develop a solid strategic plan that can efficiently and producSummer School (i.e., housing, travel) are being sponsored by Capintec in memory of Dr. Arata Suzuki, Ph.D. The deadline for applications is February 11. 2010 Dues Payments 2010 renewal notices were sent several times since October, 2009, with payments due by March 1. If you have an email address on file, the invoice was sent electronically in an effort to make it more convenient for you to pay your dues and to re-

tively achieve the aspirations of the AAPM through its vision, mission statement, and goals, which have been revised and recently adopted by the board of directors in November 2009. ( http://aapm.org/ org/objectives.asp for the latest documentation). Moving forward on the development of a strategic plan is essential in the coming year, and I will be asking for your input and help.

the AAPM response in terms of patient care and safety. A groundswell of support for an AAPM-sponsored two day meeting in the near term is in the works from the Science, Education, Professional Councils and the Executive Committee to address these issues. Medical physicists representing the AAPM must take the lead role in developing a scientific, educational and professional response to this very public concern.

A dues increase for AAPM membership will be essential to maintain the many value-added membership services and programs that we all have access to, and to project our association as the premier national and international educational, scientific, and professional society for medical physicists. I urge all of you to consider the direct and indirect benefits we have enjoyed over the last decade that have enhanced the status and importance of medical physics as a result of AAPM activities.

I am very proud and honored to serve with the leaders of the AAPM on the Executive Committee, and look forward to working with all of you in the coming years. Yes, these are challenging times, but with your help I am confident that we can effectively meet the challenges of today and tomorrow. I certainly welcome your input and suggestions at any time.

We have to be aware of and react to current issues that have a direct impact on the medical physics profession, such as the widely publicized topic of CT overdoses and duce administrative costs. There is a mechanism provided to print a copy of the invoice if you wish to mail your payment. Please go to the AAPM Homepage, log in and click on “Pay Your 2010 Dues Online.” Remember, you can pay Chapter dues with your AAPM dues for any Chapter of which you are already a member! The AAPM Rules are very specific regarding the cancellation of membership if dues are not paid by the

deadline and the fees required for reinstatement. As the administrative staff of the AAPM, we must consistently enforce the rules of the organization. It would be very difficult to make exceptions for some members and enforce such fees on others. If you need any assistance or have any questions about the dues process, please contact Peggy Compton at 301-209-3396.

AAPM Newsletter

January/February 2010

All sessions and technical exhibits will take place in the Pennsylvania Convention Center, 1101 Arch Street in the Center City neighborhood of Philadelphia. Adjacent to the convention center is Reading Terminal Market, a restored Victorian train shed which houses the oldest continuous farmers market in North America. Philly is a city of neighborhoods, including Chinatown, which offers more than 50 authentic Asian restaurants; Rittenhouse Square; South Philadelphia with its Italian Market; and the Museum District. AAPM’s education program and professional program will offer a significant opportunity to gain practical knowledge on emerging technical and professional issues. A major focus of the scientific program is the increasing integration of advanced imaging concepts in the routine practice of various therapies, especially radiotherapy. Continuing Education Therapy Track The Therapy Physics CE series will feature approx. 30 lectures. The program will feature courses on standard therapy physics practices including linac calibration and QA as well as special clinical procedures including volumetric modulated arc therapy (VMAT), accelerated partial breast irradiation (APBI), and SBRT. Additional topics include data flow and management, outcomesdriven IMRT treatment planning, and a physicist’s guide to QUANTEC.

Therapy Track Secondary cancer risks. The use of GPUs in radiation therapy. Machine learning techniques for radiation therapy. Laser accelerated heavy charged particles. Nano-Cancer and radiation therapy. Enablement technologies for adaptive RT. The science of error reduction and applications to radiation therapy. Technical aspects of SBRT. Imaging Track Scientific imaging symposia will include advances in CT technology, novel methods in image reconstruction and radiation dose reduction, developments in breast imaging, image guided intervention, ultrasound contrast agents, and new trends in cancer imaging. Joint Imaging-Therapy Track Optimization of MRI for treatment planning. Real-time image guidance for radiation therapy. Compressed sensing in image reconstruction and dose optimization. Opportunities for new investigators: Clinical trials research using data from multi-institutional clinical trials. Functional MRI for imaging tumor vasculature in conjunction with radiation therapy and anti-angiogenic therapies. Electron paramagnetic oxygen imaging. The use of Magnetic Resonance Imaging and Spectroscopy for in-vivo dosimetric and verification of therapy photon and proton beams.

Continuing Education Imaging Track There will be approximately 30 Continuing Education courses in Diagnostic Imaging Physics and Technology. They will cover all imaging modalities, radiation safety and risk management issues, issues related to accreditation and recent developments in medical imaging physics education. Professional Track A number of sessions will be provided to keep our members abreast of the latest professionally related developments. A session for Hazardous Materials training will also be included. Topics are likely to include: news on licensure, a leadership development presentation, negotiation skills, PQI session, a session for new members to meet the medical physics leaders, and a historical look at medical physics.

Innovations in Medical Physics Education Since this symposium was so successful at our meeting in Anaheim last year, the Education Council of the AAPM will again be sponsoring the Innovations in Medical Physics Education symposium to honor and publicize innovations in Medical Physics Education. AAPM members are invited to submit a one page description of innovative medical physics educational activities for radiology residents, radiation oncology residents, medical physicists, technologists or others. The projects can be scientific research, novel teaching strategies – team teaching or adult learning efforts, novel educational materials – lectures, websites, or other innovations.

NEW IN 2010 - Proffered Submissions Proffered submissions will have a new requirement this year. In the supporting documentation, the author will be asked to include a section describing the “Innovation and Impact” of their work. We expect that this will allow the most innovative work to be identified and highlighted at the meeting.

John S. Laughlin Science Council Research Symposium Topic: Advanced Screening, Diagnostic and Treatment Technologies for Lung Cancer

Additional information is available at: http://www.aapm.org/meetings/2010AM/help. asp#Innovations

AAPM Newsletter

January/February 2010

Editor’s Column lished in electronic form only starting with this issue. As I discussed in my previous column, for the immediate future the format will remain the same, however a change in the format is being considered and will be tried in future.

Mahadevappa Mahesh Johns Hopkins University

s we leave behind the first decade of the 21st century, I wish all of you a warm, happy and prosperous new year and a new decade. As decided during the AAPM budgeting process, the Newsletter will be pub-

Many of you have already heard the “media frenzy” regarding CT scans and the associated radiation risks. I would like to draw your attention to John Boone’s column, in this issue, which includes the AAPM position statement on this highly publicized issue. This issue is placing medical physicists in the front-and-center and giving us the opportunity to play key roles in assisting clinicians in providing safe and optimal use of radiation in imaging and treatment.

It is also giving us the opportunity to interact with patients to answer their concerns about radiation and imaging procedures. In fact, this year’s Radiological Society of North America (RSNA) meeting included more presentations than usual dealing with the topic of CT and radiation dose. Again, I wish all of you a very happy and productive New Year.

AAPM Mission Statement

Adopted by the AAPM Board of Directors - November 28, 2009

Vision: The American Association of Physicists in Medicine is the premier organization in medical physics, a broadly-based scientific and professional discipline encompassing physics principles and applications in biology and medicine. Mission: The mission of the American Association of Physicists in Medicine is to advance the science, education and professional practice of medical physics. Goals: The goals of the American Association of Physicists in Medicine are to: •

Promote the highest quality medical physics services for patients.

•

Encourage research and development to advance the discipline.

•

Disseminate scientific and technical information in the discipline.

•

Foster the education and professional development of medical physicists.

•

Support the medical physics education of physicians and other medical professionals.

•

Promote standards for the practice of medical physics.

•

Govern and manage the Association in an effective, efficient, and fiscally responsible manner.

AAPM Newsletter

January/February 2010

Professional Council Report ways to increase our value to our employer, so let us discuss some ways to do this.

Michael D. Mills Professional Council Vice-Chair

Economic Issues in Uncertain Times When times are better, there is (almost) enough financing to do everything we want to do; but now winter is at the door and we are tightening our belt. While the advent of special procedure technologies and competition for those that have the skills to perform them has driven up salaries in medical physics over the past 15 years, managers are looking for ways to lower costs. In case you did not know, there is a big “C” on your forehead that only your administrator can see. There is heightened uncertainty about the future, and many of us are hunkering down in our positions, waiting for better times to take the risk of a move, or trying to squeeze out just a few more years before retirement. Most of us agree, now is not the time to give ground on the professional front; if there is an erosion in the consensus respecting the minimum standards required to practice medical physics, or an erosion in practice standards, the risk to our profession is palpable. More importantly, we will not have done all we could to give patients our very best. We must navigate the stormy seas and look for

Wendy Smith has some questions for you: Are you aware of the new Medicare regulations that take effect January 1, 2010 and the impact to your facility? Did you know that freestanding center payments for diagnostic CT and MRI will decrease? Is your practice aware of the new 2010 CPT codes? Are you aware of changes to brachytherapy reimbursement in freestanding centers and hospital outpatient departments? If not, you should participate in AAPM’s free web event “Understanding Radiation Therapy Reimbursement in 2010.” There may be several presentations of this webinar, so check the announcements for when it will take place. Clinical Practice Committee activities: •

•

The Practice Guidelines Subcommittee is, in addition to its ongoing valuable review of AAPM publications for impact on clinical practice, beginning a program of drafting Minimum Practice Guidelines (MPG) on pertinent topics. These guidelines will distill the information in one or more AAPM reports and other pertinent recommendations to assist practicing members in meeting the obligation of maintaining compliance with current recommendations in a busy clinic. The first MPG will be on the subject of Linac QA and will draw from current reports including TG 142, ACR Technical Standards and CRCPD model regulations. The Working Group on Vendor Relations & Product Usability is

•

slated to be elevated to Subcommittee status and will continue to be a valuable conduit for contact between the Association and affiliated vendors. At the suggestion of Council Chair Per Halvorsen, CPC ViceChair Dan Pavord has drafted a White Paper on the ABR’s 2012 – 2014 changes to the training and certification requirements. This valuable document has as a target audience, hospital administrators and others who are unfamiliar with, but may be impacted by these significant changes. Joint Medical Physics Licensure Subcommittee Summary - Following the July 2009 Board of Directors’ (BOD) meeting, Professional Council (PC) asked JMPLSC to prepare a report to the BOD to assure that clinical medical physics is practiced by qualified medical physicists. With the help of Amanda Potter and Lynne Fairobent, a sub-group of JMPLSC prepared an extensive report evaluating four strategies, including licensure. Professional, political and financial advantages and disadvantages were analyzed. The report was finalized by JMPLSC and supported by the Clinical Practice committee (CPC) and PC. The entire report was included with the November BOD materials, and will be available on the JMPLSC web site:

http://www.aapm.org/org/committees/committee/default. asp?committee code=JMPLSC At the November BOD meeting, Bob Pizzutiello (Vice-chair of JMPLSC) presented a summary of the report. JMPLSC has reduced its 2010 budget, consistent with PC and other AAPM

AAPM Newsletter committees and councils. The recommendations are • Continue work on the licensure initiative on a state-by-state basis; • Promulgate the National Registry of QMPs; and, • Monitor the AAPM/ACMP licensure strategy in light of national health care priorities. JMPLSC plans to continue its efforts, working within the 2010 budget and with enhanced communication with the AAPM and ACMP membership as a key goal. PC plans to integrate support for the regulatory approach for those states where professional licensure is not feasible. From the Governmental and Regulatory Affairs Committee: Task Group 160, Radiation Safety Officer Qualifications for Medical Facilities, has completed its report. It has been approved by GRAC and sent up to PC for its approval. The Nuclear Regulatory Commission is looking at implementing ICRP Report 103, which includes a reduction in the annual personnel exposure limit from 50 Sv to 20 Sv. These limits would apply beyond Nuclear Medicine departments and include Cardiology and Interventional Radiology workers. AAPM is responding to NRC on this issue, but individual comments are welcome. Please see http://www. nrc.gov/about-nrc/regulatory/rulemaking/opt-revise.html for more information. NRC is also placing more emphasis on licensees maintaining a “safety culture” [http://www.nrc. gov/about-nrc/regulatory/enforcement/safety-culture.html]. Please note the NRC activities have much wider impact than just NRC licensees, as agreement states are generally required to adopt NRC regulations in some form. AAPM has provided comments to CMS stating that CMS should require accrediting bodies to have credentialing standards, specifically regarding the accepted

definition of the Qualified Medical Physicist (QMP), to be approved as an accrediting body for MIPPA. GRAC discussed forming a working group to lobby in Washington for funding of those organizations granting research funds; this effort is on hold until agreement by and coordination with Science Council has been achieved. See Lynne Fairobent’s Government Relations article elsewhere in this Newsletter for a report on the CARE Act, and the E-News updates, for an overview of legislative and regulatory developments. Also, look for the article elsewhere in this Newsletter by Wendy Smith Fuss and the Professional Economics committee, providing an overview of the proposed cuts in Medicare reimbursement and other economic news. The New York Center for Health Workforce Studies of the University at Albany (State University of New York) continues to make progress on the Medical Physicist Workforce Study. The overarching goal of this workforce study is to determine whether the supply of medical physicists will meet future demand for their services and to identify potential strategies to avert future shortages in the profession. Five specific objectives have been identified as critical to achieving this goal: 1. To compile existing data and collect any new data required to understand the roles, responsibilities, education, and career paths of medical physicists in the U.S.; 2. To develop accurate and reliable projections of the supply of and demand for medical physicists (separate projections will be developed for two discrete medical physics disciplines: radiation oncology and diagnos-

January/February 2010 tic radiology) based on the latest information and insights about the current composition of the medical physicist workforce and likely future demands for their services. 3. To learn from key stakeholders

about barriers to and facilitators of expanding the number of accredited residency programs and adding more positions to these programs;

4. To understand the workforce implications of shortages of medical physicists (i.e., accredited residency programs and positions are not sufficient to produce enough medical physicists to meet demand); and 5. To recommend potential strategies that American Association of Physicists in Medicine (AAPM) and other stakeholders may want to consider to assure a sufficient supply of medical physicists to meet demand for them. The survey of medical physicists was sent to all full, resident, junior, student and emeritus members (N=5,487) of AAPM on October 19, 2009 by email with the help of staff at AAPM. A reminder email was sent to members by AAPM on November 9, 2009. To date, there are 1,850 responses, for an approximate response rate of 34%. AAPM staff are reminding non-responding medical physicists as they log onto the Association website of the opportunity to complete the survey. A reminder email will again be sent in early December and early January to all qualifying members who have not yet responded to the survey. Finally, I recently discovered my stash of AAPM Quarterly Bulletins (a gift from Howard Thames at MD Anderson a long time ago). Reading the Letters to the Editor during

AAPM Newsletter the years 1971 – 1973 is quite an education! It seems that the leaders of that day were struggling with who should be qualified to be a full member of the AAPM (and promote themselves as a medical physicist), the place of Board Certification and board eligibility, whether the AAPM should concern itself with professional issues and form a Professional Council or initiate another society to handle such issues, and whether or not to begin the journal Medical Physics with a proposed subscription of $15.00 per year. These old Quarterly Bulletins contain a wealth of articles, history and insight; I personally would very much like to see the AAPM provide these in pdf form and online. Let me quote the words of Professor C. J. Karzmark from the March 1973 Bulletin: “Fiscal Problems – A contemporary problem for virtually all scientific societies and scientific journals is fiscal. In this era of increasing specialization and inflating costs it is mandatory, in my opinion, to examine all existing and projected AAPM programs, collaborations and affiliations, in terms of income and expense in addition to other objectives. One of our scientific committees provides advice for a governmental agency and thereby gains travel support for quarterly committee meetings. Such an avenue, with appropriate cautions, may be useful to explore by several of our committees. Our urgent financial needs, as I assess them, are for travel expense of major committees, for an executive secretary, and for publication activities, including an AAPM journal.”

January/February 2010

Imaging for Treatment Assessment in Radiation Therapy The first biennial meeting to focus on quantitative imaging in radiation therapy June 21-22, 2010, Gaylord National® Resort & Convention Center, National Harbor, MD Topics to include

ImagIng for target defInItIon How do we define the treatment target? How do we image the treatment target? How are we going to define the treatment target in 20 years?

ImagIng for treatment assessment What can anatomical treatment assessment tell us? What can biological treatment assessment tell us? Are we forgetting normal tissue?

Image quantIfIcatIon

Dates to remember

How important is image quantification? How can we improve image quantification? What are broader coordinated initiatives to improve image quantification?

early regIstratIon opens

Industry, regulatory Issues

more InformatIon

What is industry perspective on imaging as a biomarker? What are regulatory issues to qualify imaging biomarkers?

http:/ www.aapm.org/ meetings/2010ITART/

Sponsoring Organizations

It seems the more things change...

January 4, 2010

abstract submIssIon opens January 11, 2010

AAPM Newsletter

January/February 2010

AAPM Response in Regards to CT however there have been several misleading statements made with respect to radiation hazards from CT scanning. The AAPM believes in an open discussion, but one that is based on facts. The goal of this statement is to present these facts. John Boone UC Davis Medical Center

he radiation dose associated with CT scanning has been the focus of a media frenzy recently. First was the revelation that patients undergoing head CT perfusion studies at a facility in Southern California received 8 times the typical dose, resulting in epilation and erythema in some cases. More recently, there were two articles in the Archives of Internal Medicine that suggested CT is inducing an alarming number of cancers in the U.S. population. It was felt that our organization, representing medical physicists, should produce a response to the media attention that these issues sparked. Therefore, Science Council, working with CT experts around the country, with EXCOM and Professional Council input, developed the following text which was posted on our web site and was the topic of a press release: AAPM Response in Regards to CT: Radiation Dose and its Effects The American Association of Physicists in Medicine (AAPM) is a scientific and professional society comprised of scientists (medical physicists) who establish radiation measurement procedures and perform them on radiation emitting devices, including computed tomography (CT) scanners. There have been a number of CT related issues in the news over the past months pertaining to radiation dose,

We should state from the outset that medical physicists are partnering with technologists, radiologists, regulators, manufacturers, administrators and others to strive for CT scans that are medically indicated; and when they are performed that the minimum amount of radiation is used to obtain the diagnostic information for which the CT scan was ordered. CT brain perfusion overexposures The Food and Drug Administration (FDA) issued an alert in regards to high dose levels used in head CT perfusion studies at a hospital in Southern California(1). Over 200 patients apparently received excess radiation during these time-lapse (repeated) CT studies of the head. Subsequently, similar incidents have been identified at two other hospitals in Southern California and potentially in other locations as well. Early investigations of these incidents revealed a misunderstanding of some of the automated dose selection features on the scanner, and this led to an estimated 8 fold increase in radiation to the patient. This was discovered when a number of the patients experienced some temporary hair loss (epilation) and skin reddening (erythema). This incident apparently resulted from a lack of adequate training of CT technologists, and perhaps an overreliance on the use of preselected CT protocols. There is no excuse for such radiation overexposures, and improved training as

well as machine interface features may need to be improved to prevent future occurrences. News of these incidents has led to a nationwide mobilization of medical physicists, working with hospital administrators, radiologists, and CT technologists to get a better handle on CT protocols at each individual institution. Longer term, the AAPM has responded to this incident by developing a scientific symposium on this topic to be held in late April 2010, which will be led by two medical physicists who have vast experience with developing and managing CT protocols at large institutions. This course will be open to lead CT technologists, radiology managers, radiologists, medical physicists, and all others interested in learning more about CT protocol optimization and management. (www. aapm.org). Cancer Risks from CT in the United States Two articles were published backto-back in the Archives of Internal Medicine (2,3) recently, suggesting that increased use of diagnostic CT leads to the cancer deaths of tens of thousands of Americans each year. The fact that large radiation exposures to an individual can cause cancer is not controversial, however the supposition that much smaller radiation exposures (such as with CT) to many individuals can cause substantial increases in cancer incidence is certainly controversial and not universally accepted. Indeed, many of the series of assumptions used in these articles (and their source materials) make use of worst case scenarios and most conservative assumptions. One example of this is in the Smith-Bindman article(2), where the risk of cancer was illustrated in Figure 2 for 20 year old women. The

AAPM Newsletter authors acknowledge that this is an extreme example because younger women are the most susceptible group to radiation induced cancers, even though the median age for women undergoing CT scans is well into the 5th decade(3); in fact CT scanning of women in their 20s is relatively uncommon. If we accept the claim that 29,000 cancers were caused by CT in 2007 among the 70 million people in the U.S. receiving about 13.8 mSv from one CT session as reported in the Berrington de Gonzalez article(3), then it follows that 21,000 cancers are likely to be induced from background radiation levels of 3.1 mSv to the other 230 million Americans who have not had CT. The average background level of 3.1 mSv per year is 22% (3.1/13.8) of the average effective dose from CT. Predicting cancer deaths from radiation is not the same as assessing deaths from other causes such as automobile accidents or gun shots – in these latter cases the victims can be counted without much ambiguity in the cause of death. Because radiation induced cancers are exactly the same clinically as normally occurring cancers, there is no way to know who died from a radiation induced cancer and who died from a naturally occurring cancer. This issue is compounded by the fact that the number of predicted radiation induced cancers is tiny compared to the very large cancer incidence rate in humans (~25-30%), making the impact of radiation on cancer rate very hard to measure. Observations and Recommendations in Regards to CT Examinations Most of the 70 million CT scans performed each year in the U.S. are medically indicated, resulting in more accurate diagnostic assessment of patient health, which in turn results

January/February 2010 in more appropriate treatment and better health outcomes. Many CT scans, however, are ordered without sufficient medical justification and the most efficacious way to reduce CT radiation levels to the U.S. population is to substantially reduce unnecessary CT scans. Patients and their referring physicians should discuss the risks of a CT scan, as well as the risks of not having a CT scan (i.e. potentially compromising an accurate diagnosis). A radiologist should be consulted if there remains any ambiguity as to whether or not a CT scan should be performed. By confirming the presence or absence of disease or injury, an appropriately-ordered CT examination is of tremendous benefit to the individual patient, and far outweighs the radiation risks in the vast majority of cases. Providers of CT scanning services – hospitals, clinics, and radiologists – have in general made good progress in reducing the dose levels of CT scanning, however the patient should ask the CT technologist if all appropriate measures for dose reduction for a particular CT study have been used – and if an adequate answer is not obtained from the technologist, they should insist on talking to the radiologist prior to the scan. Patients and referring physicians should inquire if their CT facility is accredited by the American College of Radiology – if so, this is an excellent way of assuring that the CT facility is practicing state of the art, low dose CT. For a patient undergoing a specific CT scan, the factors which need to be considered for reducing dose include (1) the scanned area should be limited to the region of the body where the suspicion exists, (2) the CT technique factors should be adjusted according to the size of the patient’s body – newer scanners can

adjust radiation output automatically, which is useful, and (3) repeated CT scans should be avoided whenever possible, and certainly if the scans are only being repeated because the physician does not have access to the images from a recent CT scan. The patients who experienced hair loss and skin reddening from head CT perfusion studies are in general gravely ill, many are comatose, and a large fraction will die from their head injury or stroke. Indeed, the procedure itself is one way of assessing brain death. The CT perfusion study gives practitioners essential guidance as to the need for or success of interventional procedures such as angio-

plasty or surgery. By comparison, patients with cancer routinely lose all of their hair when treated with some forms of chemotherapy, but this is presumed to be an acceptable consequence of the treatment. While there is no excuse for unnecessarily high radiation levels in CT perfusion, hair loss and skin reddening can and will occur even with appropriate levels of radiation when the procedure is repeated or is combined with other x-ray examinations such as interventional angiography. SUMMARY CT scans are a very important tool for diagnosis and assessment of response to treatment in the practice of medicine. The detailed assessment of anatomy and function that CT imaging provides does require the use of x-rays, which do result in some small, but not zero, risk to patients. Medical Physicists are working with technologists, radiologists, regulators, and manufacturers to assure that CT is practiced uniformly across the U.S. in a low dose manner. (1) FDA Safety Investigation of CT Brain

AAPM Newsletter

January/February 2010

Legislative & Regulatory Affairs tion warranted by their significance.

Lynne Fairobent College Park, MD NRC Requests Comments on Draft Safety Culture Policy Statement

n the November 6, 2009 Federal Register (74 FR 57525) [http:// edocket.access.gpo.gov/2009/pdf/ E9-26816.pdf], the Nuclear Regulatory Commission (NRC) requested comments on a draft Safety Culture Policy Statement. Comments are due February 5, 2010 (90 days after publication). The NRC is issuing a draft policy statement that sets forth the Commission’s expectation that all licensees and certificate holders establish and maintain a positive safety culture that protects public health and safety and the common defense and security when carrying out licensed activities. The Commission defines safety culture as that assembly of characteristics, attitudes, and behaviors in organizations and individuals which establishes that as an overriding priority, nuclear safety and security issues receive the atten-

Perfusion Scans: Update 12/8/2009, http:// www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm185898.htm, accessed 16 Dec 2009. (2) Radiation dose associated with common

It is important that we provide comments to the NRC regarding this draft policy statement. Although the concept of “safety culture” is not new within the NRC regulatory framework it was traditionally applied to commercial nuclear power facilities - the first NRC Policy Statement on Safety Culture was published in the Federal Register January 24, 1989 (54FR3424). In his vote on proceeding with this initiative, Commissioner Klein stated: “In the world of NRC-licensed facilities for handling nuclear materials, especially within the medical community, human errors of commission and omission occur too frequently to discount the possibility that a weak safety culture may be a contributor. Many Commissioners have raised this concern over the years, and I agree with Commissioners Jaczko and Lyons that all NRC-licensed facilities (i.e., fuel cycle, medical, industrial, academic facilities as well as existing and new reactors) should establish and maintain a healthy safety culture. The staff is currently considering whether the safety culture components in the Reactor Oversight Process could be applicable to all of our licensees. I suspect that a graded approach could be feasible, so that for small materials licensees, some of the components or safety culture attributes can be made more applicable than others.”

computed tomography examinations and the associated lifetime attributable risk of cancer, R Smith-Bindman, J Lipson, R Marcus, et Al., Arch Intern Med 169(22); 20782086 (2009)

Background information related to NRC Safety Culture can be found at: http://www.nrc.gov/about-nrc/regulatory/enforcement/safety-culture. html. NRC is specifically seeking responses to the following questions: 1. The draft policy statement provides a description of areas important to safety culture, (i.e., safety culture characteristics). Are there any characteristics relevant to a particular type of licensee or certificate holder (if so, please specify which type) that do not appear to be addressed? 2. Are there safety culture characteristics as described in the draft policy statement that you believe do not contribute to safety culture and, therefore, should not be included? 3. Regarding the understanding of what the Commission means by a ``positive safety culture,’’ would it help to include the safety culture characteristics in the Statement of Policy section in the policy statement? 4. The draft policy statement includes the following definition of safety culture: ``Safety culture is that assembly of characteristics, attitudes, and behaviors in organizations and individuals which establishes that as an overriding priority, nuclear safety and security issues receive the at-

(3) Projected cancer risks from computed tomographic scans performed in the United States in 2007, A Berrington de Gonzalez, M Mahesh, K-P Kim, et Al., Arch Intern Med 169(22); 2071-2077 (2009)

AAPM Newsletter

tention warranted by their significance.’’ Does this definition need further clarification to be useful? The draft policy statement states, ``All licensees and certificate holders should consider and foster the safety culture characteristics (commensurate with the safety and security significance of activities and the nature and complexity of their organization and functions) in carrying out their day-to-day work activities and decisions.’’ Given the diversity among the licensees and certificate holders regulated by the NRC and the Agreement States, does this statement need further clarification? How well does the draft safety culture policy statement enhance licensees’ and certificate holders’ understanding of the NRC’s expectations that they maintain a safety culture that includes issues related to security? In addition to issuing a safety culture policy statement, what might the NRC consider doing, or doing differently, to increase licensees’ and certificate holders’ attention to safety culture in the materials area? How can the NRC better involve stakeholders to address safety culture, including security, for all NRC and Agreement State licensees and certificate holders?

NRC is planning on holding public meetings in early 2010 to further gain input on this topic. If you have input that AAPM should consider in drafting its response, please send your comments to Lynne Fairobent, Manager of Legislative and Regulatory Affairs at lynne@aapm.org by January 15, 2010.

January/February 2010 NRC considering revising Radiation Protection Regulations

he U.S. Nuclear Regulatory Commission (NRC) is seeking public comment on potential changes to the NRC’s current radiation protection regulations to achieve greater alignment between the regulations and the 2007 recommendations of the International Commission on Radiological Protection (ICRP) contained in ICRP Publication 103. The Nuclear Regulatory Commission is looking at implementing ICRP Report 103, which includes a reduction in the annual personnel exposure limit from 50 Sv to 20 Sv. These limits would apply beyond Nuclear Medicine departments and include Cardiology and Interventional Radiology workers. AAPM is responding to NRC on this issue, but individual comments are welcome. Please see http://www. nrc.gov/about-nrc/regulatory/ rulemaking/opt-revise.html for more information. The Federal Register notice can be found at: http://edocket.access.gpo. gov/2009/pdf/E9-15950.pdf. If you have input that AAPM should consider in drafting its response, please send your comments to Lynne Fairobent, Manager of Legislative and Regulatory Affairs at lynne@aapm.org by February 1, 2010. NEW CARE Bill: H.R. 3652 – Consistency, Accuracy, Responsibility, and Excellence in Medical Imaging and Radiation Therapy Act of 2009 The CARE Bill (stands for the Consistency, Accuracy, Responsibility, and Excellence in Medical Imaging and Radiation Therapy Act of 2009) has been introduced in the House

[H.R. 3652] by Rep. John Barrow (D – GA) [http://thomas.loc.gov/ cgi-bin/query/z?c111:H.R.3652:]. As of December 10, 2009, this Bill had 11 co-sponsors [Rep. Marsha Blackburn (TN-7); Rep. Michael Castle, (DE); Bob Etheridge (NC2); Tom Latham,(IA-4), Edward j. Markey (MA-7), Patrick Tiberi (OH12), Bruce Braley (IA-1), Stephanie Herseth Sandlin (SD), Randy J. Forbes (VA-4), Russ Carnahan (MO3), and Jim Moran (VA-8), ]. The House Bill, with one exception, is identical to that introduced in the 110th Congress. The exception is the inclusion [Page 12, lines 8-10] recognizing the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) Bill passed in the 110th Congress. The MIPPA Bill only applies to advanced imaging procedures (PET, CT, MR and nuclear medicine) performed in free standing clinics. Work is under way identifying a sponsor and introduction of a parallel bill in the Senate. House Passes H.R. 3672 - American Medical Isotopes Production Act of 2009. http://thomas.loc.gov/cgi-bin/ query/z?c111:H.R.3276: Representative Markey (MA-7) introduced this bill July 21, 2009. The purpose of this legislation is to help patients who rely on medical imaging for the treatment and diagnosis of many common cancers by authorizing funding and providing a clear road map to create a domestic supply of Mo-99 while also allowing a responsible timeline and safeguards for the transfer of HEU to low enriched uranium (LEU). AAPM supports this legislation and continues to work with the Senate on passage. AAPM correspondence related to this can be found at: http://www.aapm.org/government_ affairs/default.asp.

AAPM Newsletter

January/February 2010

ACR Accreditation Diagnostic Radiologic Physics, Medical Nuclear Physics and Therapeutic Radiologic Physics.

Priscilla F. Butler, M.S. Senior Director - ACR Breast Imaging Accreditation Programs ACR Accreditation: Frequently Asked Questions for Medical Physicists Does 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. The ACR’s new CT, MRI, Nuclear Medicine and PET Accreditation Program requirements for medical physicists and MR scientists went into effect on January 1, 2010. The following questions are actual ones received by the ACR regarding these new requirements. To see more FAQs on this topic, please visit the ACR website. Q. I am certified by the Ameri can Board of Radiology (many years ago) in “Radiological Physics.” Does this meet the ACR’s board certification requirements for CT, MRI, nuclear medicine and PET? A. Yes. Although this particular certification is no longer granted by the ABR, the “Radiological Physics” certification was previously granted to those individuals examined in

Q. In 1984 I was board-certified by the ABR in Radiation Therapy Physics and in 1992 in Diagnostic Imaging Physics. I currently perform annual surveys for MRI, CT, nuclear medicine and PET. What type of documentation do I have to provide to show I meet the ACR-required initial experience in each accredited modality? A. Because you are board certified in Diagnostic Imaging Physics and have already provided documentation of initial experience to the ABR in order to sit for the exam, you do not need to provide documentation of initial experience in MRI and CT. However, since you are not board-certified in Medical Nuclear Physics, you will need to document that you have 3 years of experience in a clinical nuclear medicine and PET environment. Appropriate documentation includes copies of annual survey reports in nuclear medicine and PET over a 3 year period or letters from supervisors or clients documenting this experience. Q. Can you please tell me the procedure for submitting my application for the “Grandfathering” option under the new requirements? A. There is no application process to the ACR for approval of a medical physicist’s qualifications. In order to apply for accreditation, the facility must ensure that the personnel they use for the accredited modality meets the ACR qualifications. In addition, the facility must have documentation that you meet these

requirements. Medical physicists must provide this documentation to the accredited facility. Although the facility is not required to submit documentation of personnel qualifications as part of their accreditation application, they must have documentation on-site in the event of an ACR Site Visit. Q. If I am board certified, do I still need to document that I have 15 CME of credits in the last 36 months? A. Yes. Upon renewal of the facility’s accreditation, medical physicists must meet these continuing education requirements regardless of how they met their initial qualifications (i.e., through the “Board Certification,” the “Not Board Certified in Required Subspecialty” or the “Grandfathered” options.) Q. I am qualified to provide medical physics surveys for accredited nuclear medicine and PET facilities. Is it sufficient to have a fraction of the required 15 CEU/CME in nuclear medicine and PET but not ALL 15 credits? A. Yes. Upon renewal of the facility’s accreditation, medical physicists must show at least 1 CEU/CME in nuclear medicine and PET. The remaining credits may be in any other area that you believe would benefit your professional continuing education. Q. May I count time spent presenting courses/lectures and/or reading/writing articles/papers towards the continuing education requirements? A. Personnel may possibly receive continuing education credit for presenting courses/lectures and/or

AAPM Newsletter reading/writing articles/papers for journals. These credits must be from organizations who can assess and document the appropriate amount and type of continuing education awarded for the individual article/paper or course/lecture and are authorized to award such credit. Personnel should get a letter or other documentation from the authorized organization stating how many and what type of continuing education credits are awarded and the date the credit was given.

Faculty may claim credit for teaching in programs designated for AMA PRA Category 1 Credit by applying directly to the AMA. Two AMA PRA Category 1 Credits™ are awarded for every hour of interaction, up to 10 credits per year. The application is available at www. ama-assn.org/go/cme in the Physician Applications section. You will need to download, complete and submit the Direct Credit Application to the AMA for credit. No credits are given for repeat presen-

January/February 2010 tations of the same material, it is the responsibility of the applicant to only claim the credit once, and credit may not be simultaneously earned as both a presenter and learner. Additional information on obtaining continuing education credit for these activities is also available for medical physicists from CAMPEP at http:// www.campep.org/Criteria.asp and for technologists from ASRT at https://www.asrt.org/content/CESponsors/ASRTInFocus/Fall_05. aspx#6

This program includes presentations by six invited speakers, five of whom are nationallyrecognized physics teachers, and one who is a recognized expert in problem-based learning. •

The program includes discussions of the accreditation expectations of CAMPEP (Commission on the Accreditation of Medical Physics Educational Programs) and certification expectations of the ABR (American Board of Radiology), a panel of residents discussing physics education, and a demonstration of the RSNA-AAPM web-based physics educational modules.

•

The role of technology in the classroom will be explored, and break-out sessions will allow participants to learn from the experience of others.

•

Each participant will be expected to develop a Self-Directed Educational Program (SDEP) to become a better teacher.

•

Early registration is advised because attendance is limited and registration is expected to fill rapidly. Registration opens January 27, 2010 http://www.aapm.org/meetings/2010SS/

AAPM Newsletter

January/February 2010

2009 Treasurer’s Report income, but the best estimate is the actual deficit for 2009 will be $600,000.

Mary E. Moore, M.S. 2009 Treasurer

his is my final report as your Treasurer and I want to thank you for giving me this opportunity to serve the AAPM during the past 2 years. It has been a very rewarding and challenging experience. The following is a brief report for 2009. At the summer Board meeting we were facing a projected statistical deficit of about $600,000 in spending for operations. The Board requested that every possible effort be made to reduce expenses during the remainder of the year in order to significantly reduce the projected shortfall. The Finance Committee, Council and Committee Chairs, EXCOM and Headquarters staff performed an extensive and thorough review of current expenses, remaining unobligated 2009 budget allocations, and spending trends. As a result of this review, a revised estimate projected that the actual deficit for 2009 was closer to $990,000 due to lower than anticipated income from the Annual Meeting as well as the actual budgeted expenditures for programs. Over the course of two months, we reduced or eliminated as much as possible from remaining unspent expense budgets. This enabled us to revise our projected deficit down to the original $600,000 estimate. It is still too early in 2010 to provide an actual end-of-year net

Examples of some of the reductions that were implemented include the following: • Travel: Almost all in-person meetings were eliminated for both volunteers and staff. These included the Board Orientation meeting, the Meeting Coordination and Joint Medical Physics Licensure Subcommittee meetings, Science Council Retreat, staff travel, and exhibiting at ASTRO. •

•

RSNA: A number of expenses connected with the RSNA meeting were reduced. Projects: Council Chairs contacted their committee chairs to reduce or eliminate remaining projects. Headquarters: Staff reviewed all overhead and administrative costs, initiated some process changes, and eliminated one staff position at the end of October.

On a positive note, our investment portfolio has shown unrealized gains in 2009 and we are hopeful that a portion of the $2 million loss we sustained in 2008 will be re-gained this year. At the end of November 2009 our investment portfolio totaled $7,722,111. In light of the projected 2009 deficit, and the efforts to reduce it, the budgeting process for 2010 was focused on producing a statistically balanced budget. Each year many committee project funds remain unspent due to the competing time commitments of our volunteers. To estimate what fraction of bud-

geted funds will not be spent in the year budgeted, we developed a process for making a statistical estimate of this fraction. As a result, the draft 2010 budget projects a deficit of approximately $800,000, which is our best guess as to the funds that will not be spent in 2010. This $800,000 estimate for 2010 reflects a balanced budget using the statistical model. This approach complies with the Board’s directive to balance the budget to the statistical model. The first 2010 draft budget presented to the Budget Subcommittee carried a $1.8 million deficit. I am pleased to report that Council and Committee Chairs and Vice Chairs worked diligently with the Budget Subcommittee to reduce this original deficit by more than $1 million. It was difficult to accomplish this reduction because funding for many worthwhile scientific, educational, and professional programs had to be cut. Both the Budget Subcommittee and FINCOM are grateful for the cooperative and collegial approach by all as we worked together with staff to reduce the 2009 deficit and to bring the 2010 Budget in line with the Board’s directive. A copy of the Board approved budget for 2010 follows, together with several graphics illustrating the sources and categories of revenue and expenses. Actions taken in the last few months to cut spending to minimize the projected actual 2009 deficit were reactive. We need to be proactive to prevent the need for future reactive

cuts. The 2010 budget preparation process continued to highlight two important points: Current

AAPM Newsletter programs are not sustainable without additional revenue, and that programs and projects must be prioritized. Proactive actions taken in 2009 to increase revenue included grant applications, additional topical meetings, management services provided to other organizations, and formation of a Technology Assessment Institute. The financial results of these initial efforts were mixed.

Another proactive effort to increase revenue is being taken by the Board of Directors: They will soon be announcing a proposed increase in membership dues for 2011. This additional revenue is needed to maintain current professional, educational, and scientific efforts of our members.

January/February 2010 EXCOM, and FINCOM need your input to ensure programs you feel are high priority receive appropriate financial support. I hope you will join me in supporting our new Treasurer, Janelle A. Molloy, PhD, FAAPM, as she takes up the financial challenges ahead.

Prioritizing and sequencing projects are essential components to controlling expenses. The Board,

Major Variances from 2009 Budget

AAPM Newsletter

January/February 2010

Income by Major Source ‐‐ Approved 2010 Budget

Total = $6,822,253

Expenses by Major Source ‐‐ Approved 2010 Budget

Total = $7,580,186

Net Income – 2003 through Budget 2010 2003 through Budget 2010 Net Income –

AAPM Newsletter A

2010 Approved Budget

1 2

Revenue

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73

Approved by the Board of Directors Nov. 28, 2009 Membership Dues

Dues (Net of Journal) Renewal Notices Applications and Reinstatements

Direct 1,445,369

Subtotal

24,000 $1,469,369

Member Inquiries/Services AAPM eNews Membership Directory AAPM Web Site

1,950 $1,950

Subtotal

Organizational

Board of Directors Executive Committee Executive Committee - Contingency Elections & Society Votes

Subtotal

Councils and Committees

Education Council Professional Council Science Council Administrative Committees Liaisons with other Organizations

108,815 331,400 18,525 Subtotal

Education & Professional Development

2,222,560 95,681

Professional Services Headquarters Travel General Operations Credit Card Processing AIP Services

Credit Card Royalties Computers in Physics, Royalties AAPM Mailing Lists Membership Certificates RSEA Investment Earnings & Fees ACMP CAMPEP Contributions and Donations Dues and other payments Miscellaneous

2,000 1,500 25,400 300 1,600 250,000 71,600 73,500

Subtotal

$157,328

80,076 20,950 2,344 323,320 $426,690

(80,076) (20,950) (2,344) (323,320) ($426,690)

48,059 76,472

(78,509) (156,972) (34,111) (13,345) ($282,937)

(295,681) (619,579) (396,205) (169,583) (15,560) ($1,496,608)

387,293 29,789 62,696 37,049 $516,827

1,593,933 87,668 132,228 149,794 $1,963,623

628,627 8,013 (132,228) 7,736 $512,148

88,005

1,340,798 500 818 $1,342,116

648,675 500 682 $649,857

70,500 6,125 77,550 140,000 19,000 $313,175

100 1,600 22,000 2,000 9,700 50,022

318 $88,323

891,412 $891,412

2,663

110,178 49,294

70,500 6,125 968,962 140,000 19,000 $1,204,587

2,663 100 1,600 22,000 110,178 51,294 9,700 50,022

(70,500) (6,125) (968,462) (140,000) (19,000) ($1,204,087)

2,000 1,500 22,737 200 228,000 (38,578) 22,206 (9,700) (50,022)

$85,422

$162,135

$247,557

$178,343

TOTAL FROM OPERATIONS $6,822,253

$4,654,863

$2,925,322

$7,580,185

($757,932)

175,550

(27,000)

$7,755,735

($784,932)

Grand Total

148,550

175,550

$6,970,803

$4,830,413

21 12/15/2009, 10:54 AM

$155,378

1,289,991 (1,950) 24,000 $1,312,041

$425,900

AAPM Education & Research Fund

155,378 1,950

404,496 950,979 414,730 169,583 15,560 $1,955,348

Subtotal

Other Income & Expense

155,378

72,383 298,822 90,458 72,833 15,060 $549,556

1,252,793 500 500 $1,253,793

$500

Total

332,113 652,157 324,272 96,750 500 $1,405,792

1,989,473 1,000 1,500 $1,991,973

Subtotal

Overhead

Net

10,470 $135,001

157,530 $2,475,771

500

78,509 156,972 34,111 13,345 $282,937

Subtotal

Administrative

30,450 80,500 34,111 2,875 $147,936

$1,206,640 57,879 69,532 112,745 $1,446,796

Publications

Medical Physics Journal Books Reports

$458,740

Expenses

Membership Services

Annual Meeting Summer School RSNA Other Meetings (ITART)

January/February 2010

$2,925,322

AAPM Newsletter

January/February 2010

AAPM Website Editor Report

Christopher Marshall NYU Medical Center

will complete one term as Website Editor at the end of this year and I thank the AAPM for this experience and acknowledge the great work done by the AAPM staff to make it all happen. My hard-drive overflows with all the emails we have exchanged! What have we done, and what may need to be done in the future?

We have addressed the organization of content, which had previously accumulated on an “ad-hoc” basis. We made a distinction between the main website and “committee space” where committees can further their activities. Policy AP 81-A [http:// www.aapm.org/org/policies/details.asp?id=278&type=AP] was approved to formalize this distinction. Staff deployed new tools for committees, such as the Wiki, and provided a personalized experience for members through “My AAPM” and customized messages. We made gradual adjustments to the menu and submenu system to aid in navigation and we now have several topical home pages that provide an overview of our programs for members and the public with links or tabs to supplement and perhaps replace the submenus. The new Meetings page [http://www. aapm.org/meetings/default.asp] is

our most complete implementation to date. We deployed a new search engine which works very well in my opinion. We added icons and quick links to selected content and in doing so added more visual interest to the site. We featured each annual meeting through a prominent link at the top of our page, and created our own web presence for the RSNA meeting. We provided greater support and publicity for Chapters and their meetings. We implemented RSS feeds for our “What’s New” postings (and for Medical Physics articles) and encouraged members to subscribe. We also fed content to Twitter and LinkedIn (an ongoing experiment). We also facilitated growth in electronic advertising income through ads on the annual meeting pages and elsewhere on the website. What’s in the future? An ad-hoc committee of the EMCC [http://www. aapm.org/org/structure/default. asp?committee_code=AHCEP] is attempting to address that issue. However, it is clear that delivery of content directly to members and to a

broader audience through syndication will only get easier and more popular and that content will be viewed on a wide array of devices. We will have growing opportunities to lever webbased services and tools to facilitate communication between members and with the AAPM. We must also open up new opportunities for advertising across our entire web presence if we are to offset the declining interest in paper-based advertising, which is major source of income to the AAPM through the Journal. Our web presence began as a replacement for paper publication and communication – but it is evolving into a new paradigm. It has become our main identity as an organization and we need to embrace its possibilities if we are to address the Vision [http:// www.aapm.org/org/objectives.asp] that the AAPM is “The premier organization in medical physics.” I hope that you find the Website useful, visit it often, and send me your feedback at http://www.aapm. org/pubs/newsletter/WebsiteEditor/3501.asp.

2010 AAPM Grant and Fellowship Offerings Research Seed Grant • The Fellowship for the training of a doctoral candidate in the field of Medical Physics • The AAPM Summer Undergraduate Fellowship • The AAPM Minority Undergraduate Summer Experience (MUSE) Information and applications are available at: http://www.aapm.org/education

AAPM Newsletter

January/February 2010

American Board of Radiology Integration of Radiologic Physics within the Diagnostic Radiology Exam of the Future (EOF): A New Horizon

by Stephen R. Thomas, PhD, ABR Associate Executive Director, Radiologic Physics, in collaboration with the ABR Radiologic Physics Trustees: G. D. Frey, G. S. Ibbott, and R. L. Morin he ABR is launching a bold new initiative with regard to the certification exam process for diagnostic radiology residents. In brief, starting with the resident class of 2010 (PGY2), the Exam of the Future (EOF) will be structured in two phases. The first will be the Core Examination, taken at the end of the third year of residency, while the second will be the Certifying Examination, taken 15 months after completion of the residency. The purpose of this article is to describe the enhanced role of physics within the Core Exam.

Taken after 36 months of the diagnostic radiology residency, the Core Exam will test knowledge and comprehension of clinically relevant anatomy, pathophysiology, diagnostic radiology, and radiologic physics. The computer-based Core Exam will be image rich and administered over two days at regional testing centers. Ten categories based on organ systems have been established. They will combine with imaging modalities relevant to those organ systems, along

with physics and safety, to constitute 18 focus areas: breast, cardiac, GI, MSK, neuro, pediatrics, reproductive/ endocrine, thoracic, urinary, vascular, radiography/fluoroscopy, CT, MR, ultrasound, nuclear medicine, interventional techniques, safety, and physics. All of these focus areas will be scored separately, and each must be completed successfully in order to achieve a “pass” for the Core Exam as a whole. This format ensures that physics and safety aspects of radiologic technology are incorporated appropriately. Thirteen item-writing committees have been constituted, including the 10 organ systems along with nuclear medicine, ultrasound, and safety. A medical physicist has been identified and appointed to each of these committees and will serve as a critical member of the test assembly team. This organizational structure provides the opportunity to integrate physics and technology into the Core Exam in a comprehensive manner, with the objective of emphasizing only the clinically relevant aspects. Unique to the configuration is that the physicists have selected physician partners (who may or may not be members of the given committee) to work with them to create the physics items. This framework serves to ensure that the topics chosen represent fundamental physics principles, issues and situations that radiologists are expected to know. However, it should be noted that physics items will not be overtly labeled as such for the candidates’ information, but rather will be identified internally for the purpose of scoring. To initiate this exciting new concept, a kick-off meeting with the

physics members of the Core Exam committees was held at the ABR office in Tucson on April 16, 2009. That group brought considerable energy and dedication to the inauguration of this far-reaching reorganization of the examination format for diagnostic radiologists. The meeting addressed the following issues: •

•

The interactive nature of the category and committee member configuration. As stated, physics will be integrated throughout the Core Exam. The process of creating physics items will involve interactive collaboration among committee members. As one example, the physicist who is working in the cardiac category will need to communicate with the physicist who is assigned to nuclear medicine with regard to PET imaging aspects. In addition, an item that is put forth initially to address a clinical point also may contain physics content and thus spawn an associated, separately scored physics item. Case-based format design will be encouraged to take advantage of this interconnectivity. Thus, the interaction requirements are inherently extensive, both among physicists and among physicists and radiologists. It is exactly this aspect that will assist in ensuring that the physics component of the exam has a high clinical relevancy. Development of a content outline (i.e., a “blueprint”) for each of the 13 physics exam categories. As a psychometric axiom of exam construction, it is imperative that a blueprint be

AAPM Newsletter

•

January/February 2010

produced in advance to serve as a topic guide and weighting scheme for the item-writing stage. Part of the meeting was configured as a workshop; attendees were divided into groups for development of draft blueprints for specific categories. The blueprints will be available across categories, thus allowing the coverage of topic areas to be visible and transparent to other committees. Identification of a coding system that will be used to classify the physics items for each category. As the pool of items is expanded in the future, effective coding becomes essential to guide the actual exam assembly. Coding is also valuable for review processes that take place periodically, involving content

•

evaluation and updating. In this regard, the decision was made to use a coding system based on the recently completed AAPM physics curriculum for diagnostic radiology residents: http:// aapm.org/education/documents/AAPMRecommRadlPhysicsCurrDiagRad.pdf. Review of item-writing techniques. This phase involved two aspects: general concepts regarding construction of items in terms of appropriate format for the stem and options (items will be multiple choice with a single correct answer), and creation of items that are image rich and attempt to extend the level of knowledge beyond simple basic recall to include some degree of advanced comprehension, analysis, and syn-

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thesis regarding the principles involved. The item-writing guide produced by the ABR editorial staff is available upon request. Sample items prepared in advance were presented to illustrate the principles outlined. In summary, the Exam of the Future represents a milestone for radiology certification with regard to the integration of radiologic physics within the Core Exam. The innovative nature of this new initiative extends to the interactive structure of the committee system, as well as to incorporation of an image-rich item format. The medical physicist team has been assembled, energized, and is moving forward enthusiastically in collaboration with their radiologist colleagues on the journey toward this exciting new horizon.

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AAPM Newsletter

January/February 2010

CRCPD and AAPM CRCPD and AAPM: “A partnership to improve the quality of medical imaging and radiation therapy”

by Debbie Bray Gilley

he Conference of Radiation Control Program Directors (CRCPD) is a non-profit organization created to assist state radiation control programs efforts to regulate the beneficial uses of radiation, protect the citizens from unnecessary radiation and encourage consistency in regulatory programs among the state and federal governments. History In 1968, 24 state radiation control programs came together in an effort to develop uniform regulations, inspection and reporting forms for x-ray equipment. The 24 became the CRCPD and soon grew to 48 Director Members and the scope of interest grew to include not only x-ray, but radioactive materials, environmental issues and emergency response. Currently there are approximately 1000 CRCPD members primarily from state and federal radiation control programs, participating in 60 active task forces and working groups with over 250 individuals volunteering their time to promote consistency in addressing and resolving radiation protection issues, to encourage high standards of quality in radiation protections programs and to provide leadership in radiation safety and education. The American Association of Physicists in Medicine (AAPM) has been instrumental in assisting CRCPD and state radiation control programs in meeting these challenges. State Radiation Control programs did not always have this resource

available to them. AAPM had representation but both organizations had a “hands off ” approach to each others activities. The relationship with the CRCPD and the medical physicists was not always cordial, but somewhere and sometime in the 1990s Don Flater, Director of the Iowa Bureau of Radiological Health and Keith Strauss representing the American Association of Physicists in Medicine had the fortunate experience of meeting each other and having several lively conversations. Keith and Don, both “open-minded” individuals, were willing to learn and listen to each other and work on finding solutions for improving the quality of radiation medicine to reduce patient and occupational dose. Keith became an AAPM resource individual on the National Evaluation of X-ray Trends (NEXT). Keith helped bring creditability to the report by suggesting that the report would be better received by the medical physicist community if the procedures for conducting the evaluation were also published. Soon after Keith joined the committee, CRCPD began publishing the NEXT protocols. Both Keith and Don professionally disagreed on many issues, but overcame this through mutual respect and a fierce desire to focus on the importance of evaluating patient and occupational dose, thorough studies such as NEXT and the development of regulations. Thus AAPM became a resource for CRCPD assisting in the development of regulations, inspection guidance, training programs and issue papers. [1], [2]. CRCPD Efforts The CRCPD’s primary purpose is to assist its members in their efforts to protect the public, radiation

worker, the environment and patient from unnecessary radiation exposure. The Conference promotes collaboration of state, federal and international radiation control personnel to create a network of regulatory professionals who have come to depend on each other as friends and colleagues. Though not exhaustive, the focus of our efforts are to: conduct an annual meeting, adopt national position statements on radiation issues, develop and promote suggested state regulations, develop and promote technical and administrative publications, and develop training programs. AAPM participation has been instrumental in the success of all these CRCPD programs. Annual Meeting For over forty years CRCPD has held an annual meeting that brought together the state and federal regulators for the purpose of sharing information and discussing radiation issues. [3] Today’s meetings are attended by over 400 members of state and federal agencies, and industry. Keynote speakers in the past have included the Chairperson of the U.S. Nuclear Regulatory Commission; dignitaries from the U.S. Department of Energy, U.S. Environmental Protection Agency; National Conference of Radiation Protection; and from the international community representatives from International Atomic Energy Agency and the International Commission on Radiation Protection. The John C. Villforth Award is given to an individual who has made valuable contributions to the success of national radiation control programs to protect the public health of our citizens. This award has been bestowed to Keith Strauss (2005) and Melissa Martin (2008) [4], both AAPM members for their dedication to supporting state

AAPM Newsletter

January/February 2010

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AAPM Newsletter radiation control programs. Both have provided numerous presentations and updates on medical imaging advancements in an effort to keep state inspectors informed. AAPM has sponsored many other speakers on computed tomography, fluoroscopy, and radiation therapy.

diagnostic x-ray on subjects such as computed tomography, dental applications, exposure and fluoroscopy. Many of these were developed with assistance from medical physicists through participation as a technical resource nominated by the AAPM.

Position Papers and Resolutions There are times when the Conference has felt compelled to issue statements that have national significance. This has occurred over 35 times in the past 40 years. CRCPD resolutions have been introduced at Congressional hearings and used to promote changes in regulations [5]. These documents demonstrate the variation and diversity of CRCPD activities, mirroring our council activities. Those that impact the medical community include reports on mammography, quality assurance in

Suggested State Regulations The Conference is best known for its suggested state regulations [6]. Many states use regulations as written or modify them to meet an individual state’s needs. The regulations are developed by those who must use them to inspect against and evaluate noncompliance. The adoption of suggested state regulations is not taken lightly. A committee of expertise in the field starts the initial process through a needs assessment; those with regulatory development skills, draft language.

January/February 2010 The language is evaluated by a group of independent peer reviewers from other regulatory programs and the industry. AAPM is an active participate in providing advice and peer review. The comments are evaluated and a response to each comment is developed into a companion document. The Executive Board reviews the draft regulations and can make modifications or changes. Once the Executive Board has approved the suggested state regulations, they are forwarded to our federal partners for concurrency. This is a tedious process but worth the effort to have regulations that are based on sound health physics principles and can easily be adopted by states. If there are issues in the regulations at any step of the process, the document is returned to the committee to determine the correct action.

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AAPM Newsletter The advantages to the states of this activity cannot be measured. All CRCPD members can use the suggested state regulations to develop their regulations based on suggested regulations developed by experts in the field; peer reviewed by another subset of experts within government programs and industry; and has received federal government concurrence. Using AAPM as a resource to the CRCPD in rule development allows industry involvement without the need to provide notice on rule development for each state. This simplifies the rule process for states. No state on its own would have sufficient resources to carry out this process in every aspect of radiation protection; it is essential to share resources. Technical and Administrative Publications and Support In 1971 the Conference participated in the first NEXT providing the U.S. Food and Drug Administration (FDA) with the technical dose information from selected x-ray procedures. [7] Today, the Conference continues to support this activity through membership participation in developing the methodology for conducting the evaluations. CRCPD completed its most recent evaluation of CT doses and next year will be looking to evaluate patient dose from interventional radiography. The dose estimates from NEXT have been captured and referenced in the National Council of Radiation Protection standards and the International Atomic Energy Agency publications.* These reports are available on the CRCPD website. The AAPM participate in the development of the NEXT protocol, assisting FDA and the states in choosing parameters that can be measured. Again, the federal, state and industry partnership is an advantage and helps us clarify the data that should be collected and the best method to collect such data.

January/February 2010 Training Adequate resources to develop and provide training are an issue for all. Few states have the ability to develop a training program for all regulatory activities. The Conference, through the G-55 Training committee and the H-11 Mammography committee have developed and facilitated training programs for the last 20 years. Didactic training fully supported by the AAPM compliments our annual meeting, in recent years with state reduction in training and travel resources, states have supported attendance at the AAPM training when they have not been able to support attending the annual meeting. Recent topics included CT Dose, Interventional Fluoroscopy, Digital Radiography, New Medical Therapy Application, Mammography, Environmental Assessment and Security Training for Regulators. As travel cost increases, the Conference is appreciative of the AAPM support by sharing member only training material located on their web site with state radiation control programs. AAPM also provides complimentary registration to CRCPD members in the host state of the AAPM national meeting. Recently in California, 7 state radiation control program employees attended one day of the national meeting. This outreach helps CRCPD stay up to date with new equipment and medical applications. CRCPD is focusing on independent studies and has created several independent study modules for radioactive material and x-ray applications with the technical guidance of AAPM members. The Future AAPM and CRCPD will continue to work together on issues of mutual concern. The technological advancement in modern medicine poses new challenges to stay up

with radiation protection and regulatory oversight. Recent national issues concerning CT dose and permanent brachytherapy medical events will shape future regulations. There will be other challenges with homeland security and response issues, waste disposal options, credentialing of professionals and continuing to adjust and respond to quality of health care issues. The relationship between the two organizations will continue to evolve, but one thing that will not change is our commitment to provide quality health care promoting the beneficial uses of radiation. REFERENCES

[1] Personal contact with Don Flater Retired from the Iowa Bureau of Radiological Health Program (October 2009) [2] Personal contact with Keith Strauss former AAPM Liaison to the CRCPD (October 2009) [3] Conference of Radiation Control Program Directors, Inc., CRCPD, the First 25 years (2004). [4] Conference of Radiation Control Program Directors, Inc., Proceeding of the 40th Annual National Conference on Radiation Control, (2008) [5] Conference of Radiation Control Program Directors, Inc., Tracking of vehicles or devices carrying portable, highly radioactive sources that require Increased Controls, (2008) [6] Conference of Radiation Control Program Directors, Inc. Suggested Regulations for the Control of Radiation, (2008). [7] Conference of Radiation Control Program Directors, Inc. Thirty Years of NEXT, Trifold (2006).

Debbie Bray Gilley is an Environmental Manager for the Florida Department of Health, Bureau of Radiation Control and is the CRCPD Liaison to the AAPM. She can be contacted at Debbie_gilley@doh. state.fl.us or 850-245-4266.

AAPM Newsletter

January/February 2010

Health Policy/Economic Issues Wendy Smith Fuss, M.P.H. AAPM Health Policy Consultant 2010 Policies & Payments for Hospital Outpatient Departments Released by CMS

he Centers for Medicare and Medicaid Services (CMS) published the 2010 Hospital Outpatient Prospective Payment System (HOPPS) final rule. The rule includes a 1.9% increase to Medicare payment rates for most services paid under the HOPPS in 2010. The majority of radiation oncology procedure codes would realize slight increases in hospital outpatient payments. However, proton beam therapy yields significant increases in 2010 payments of 34% to 47%. Low dose rate brachytherapy (APC 312) and stereotactic radiosurgery treatment delivery (APCs 66, 67 & 127) have payment reductions slated for 2010. Medical physics codes 77336 & 77370 in APC 304 also decrease 10.3% (see table on page 31). Other key CMS policies include: •

•

Reassign Category III CPT 0182T for High Dose Rate (HDR) Electronic Brachytherapy from New Technology APC 1519 to APC 313 Brachytherapy. The 2010 payment of $777.55 is a significant 55.6% reduction to the 2009 payment of $1,750.00 per fraction. Based on hospital claims data for 0182T, CMS states that its hospital resource costs are similar to those of other services assigned to APC 313. Pay separately for each of the brachytherapy sources on a prospective basis, with payment rates to be determined using the 2008 claims-based median cost

•

per source for each brachytherapy device. Continue packaging of radiation oncology imaging guidance services for 2010. CMS is not proposing any new composite APCs for 2010 so that they may monitor the effects of the existing composite APCs on utilization and payment, including LDR prostate brachytherapy and multiple imaging services.

A complete summary of the final rule and impact tables is on the AAPM website at: http:// aapm.org/government_affairs/ CMS/2010HealthPolicyUpdate.asp All payments and policies are effective January 1, 2010.

Significant Cuts to Freestanding Centers Averted in 2010 Physician Fee Schedule Final Rule

he Centers for Medicare and Medicaid Services (CMS) recently released the 2010 Medicare Physician Fee Schedule (MPFS) final rule. The proposed rule released in July included several practice expense proposals that would have significantly reduced reimbursement to the technical component (TC) and global payments to freestanding and community-based cancer centers in 2010. AAPM working with other professional medical societies was able to minimize the 19% reductions slated for 2010 and instead overall radiation oncology payments will only decrease by 1.0% in 2010. CMS did not implement their proposal to change the utilization rate from 50% to 90% for radiation

therapy equipment that costs more than $1 million. This change averted a major impact to external beam, IMRT and stereotactic radiosurgery payments. CMS will, however, apply a 90% utilization rate for all diagnostic CT and MRI equipment over $1 million effective January 1st. CMS will use the recently collected practice expense data from the American Medical Association (AMA) Physician Practice Information (PPI) survey to establish Medicare payments starting January 1, 2010. CMS made technical revisions to the radiation oncology data, which results in a 3.0% reduction to payments that will be transitioned over four years. The new PPI survey data redistributes Medicare payments, which favors primary care specialties. Based on recommendations by the AAPM and other stakeholders, CMS did update and revise the practice expense inputs and relative value units (RVUs) for the new HDR brachytherapy codes (CPT 77785-77787). AAPM worked closely with the American Society for Therapeutic Radiology (ASTRO) to develop new inputs that more accurately describe the work of medical physicists and the equipment necessary to perform these procedures. CMS did not implement the proposal to utilize medical physicist professional liability insurance premium data as a proxy to update the malpractice expense RVUs for technical component services in 2010. Instead, CMS used data from Independent Diagnostic Testing Facilities (IDTFs) as a proxy for technical component malpractice RVUs, which results in a 2.0% reduction to radiation oncology payments.

AAPM Newsletter Based on the currently flawed sustainable growth rate (SGR) calculation, CMS estimates a 21.2% decrease to the 2010 conversion factor to $28.41. AAPM anticipates that Congress will avert the 21% decrease to the conversion factor slated for January 1st 2010. However, if Congress does not pass legislation, overall radiation oncology payments would decrease by approximately 23% in 2010. In addition, CMS finalized their proposal to remove drugs from the SGR calculation used to determine the annual update of the conversion factor. While the proposal would not change the projected 2010 negative update for services, CMS reports that it would reduce the number of years in which physicians are projected to experience a negative update. To read a complete summary of the final rule and to review impact tables go to: http://aapm.org/government_affairs/ CMS/2010HealthPolicyUpdate.asp

January/February 2010

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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.

AAPM Newsletter

January/February 2010

SUMMARY OF 2010 FINAL RADIATION ONCOLOGY HOPPS PAYMENTS

APC reassignments for 2010 are highlighted in bold *New CPT code effective January 1, 2010

AAPM Newsletter

January/February 2010

International Scientific Exchange Program Report AAPM ISEP Sponsored Symposium in Malaysia Image-Based Technology in Radiation Oncology Legend Hotel, Kuala Lumpur, Malaysia June 17th – 20th, 2009

Submitted By Cheng B Saw, PhD (AAPM Co-Director) Dr. Fuad Ismail (Host Co-Director)

four-day symposium with the theme, “Image-Based Technology in Radiation Oncology” was held at the Legend Hotel, Kuala Lumpur, Malaysia from June 17th - 20th, 2009. This symposium was sponsored by the American Association of Physicists in Medicine (AAPM) under the International Scientific Exchange Program (ISEP). The local organizational sponsors were the Malaysian Oncological Society (MOS) and the Malaysian Association of Medical Physicists (MAMP). The objectives of the symposium are multi-folds: (a) to share the US experiences in the implementation of image-based technology in radiation therapy, (b) to expose the AAPM organization, (c) to exchange information on the educational, training, and maintenance of quality for medical physicists, and (d) to provide a platform for combined radiation oncologists and medical physicists attendance to exchange knowledge and collaborate on the use of modern radiation therapy equipment and treatment techniques. The invited faculty members from the US for this symposium were: (a) Cheng B Saw, PhD (Penn State Hershey Cancer Institute, Hershey, PA), (b) Arthur Boyer, PhD (Scott and White Clinics, Temple, TX), (c)

Nagalingam Suntharalingam, PhD (Thomas Jefferson University, Philadelphia, PA), (d) Jack Yang, PhD (Monmouth Medical Center, Long Branch, NJ), (e) Henry Wagner, Jr, MD (Penn State Hershey Cancer Institute, Hershey, PA), and (f) Andrew Wu, PhD (Thomas Jefferson University, Philadelphia, PA). The co-directors for this symposium were Cheng B Saw, PhD representing AAPM- ISEP and Dr. Fuad Ismail representing the Malaysian organizations. The official program commenced with a trip to the NCI Cancer Hospital & Specialist Clinics at Bandar Baru Nilai, Negeri Sembilan which is about 40 minutes from Kuala Lumpur by van. This facility has the first medical linear accelerator, the Trilogy installed in Malaysia about two years ago. This trip provides the US faculty the opportunity (a) to observe the clinical practice in Malaysia, (b) to acquaint with the host committee members, and (c) to discuss the medical physics manpower in Malaysia. The faculty was received by the Dato’ Dr. J Mehta, Head of the institution, Dr. G Selvaratnam, Head of Oncology & Radiation Therapy and Head of Research, and Ms. M Kala Krishnan, Senior Medical Physicist. After the visit, the US faculty took a tour around Putrajaya, the administrative city of Malaysia. The next day, the welcoming addresses were made by Dr. Wan Ahmad Kamil, the president of the Malaysian Association of Medical Physicists, and Dato Dr. Ibrahim Wahid, the president of the Malaysian Oncological Society. Both presidents highlighted the enthusiastic opportunity to jointly sponsored this symposium as it is the

only few meetings where radiation oncologists and medical physicists attended the same symposium. Such associations are necessary to foster closer collaboration among the disciplines to provide cancer care for patients in Malaysia. The lectures were presented in the morning sessions directed at imagebased technology of modern radiation therapy. The implementation of modern radiation therapy requires the use of new technologies to acquire patient data, 3D treatment planning, and dose delivery. The issues related to patient immobilization and positioning and there after the acquisition of patient data were presented by Drs. Wu and Yang respectively. Treatment planning in three dimensions (3D) is an essential component of modern radiation therapy. Dr. Saw presented the transition from 2D to 3D treatment planning and Dr. Suntharalingam on the definition of target and critical structures consistent with ICRU Reports No. 50 and 62. Dr. Wu presented the strategies for 3D treatment planning in the implementation of the conformal radiation therapy (CRT) and intensity-modulated radiation therapy (IMRT) treatment techniques and Dr. Yang on the dose calculation algorithms. Recent advances in radiation therapy, imageguided radiation therapy (IGRT) was presented by Dr. Saw and Dr. Wu on motion-gated technology. Dr. Wagner who is a radiation oncologist presented the perspectives of the radiation oncologist in the implementation of these new technologies. These include the awareness of the limitations of the imaging data in identifying the extent of the diseases, the contouring techniques, and the need for radiation oncologists to perform patient setup using the IGRT technologies.

AAPM Newsletter Specific lectures were included to comply with the requests of the local committee. Dr. Suntharalingam presented the two commonly used reference dosimetry protocols, TG51 by the AAPM and TRS398 by the IAEA. The quality assurance for modern medical linear accelerator was presented by Dr. Boyer. On the modality of brachytherapy, Dr. Yang reviewed the current practice of high-dose-rate remote (HDR) afterloading while Dr. Suntharalingam on the general aspects of low-dose-rate brachytherapy. Dr. Saw presented electronic management software in radiation oncology that will improve workflow and Dr. Boyer reviewed CT-based patient anatomy which should be helpful especially for those medical physicists whose primary responsibilities are designing individualized treatment plans for patients undergoing radiation therapy.

The afternoon sessions were allocated for practical workshops on the use of 3D treatment planning systems to design individualized treatment plans. Four treatment planning system vendors: Elekta, Philips, Varian, and Nucletron had graciously participated in this educational program. The application specialists demonstrated the full features of the 3D treatment planning capabilities to design individualized treatment plans for the implementation of CRT and IMRT. The educational and maintenance programs for medical physicists in the US were presented by Dr Suntharalingam on educational requirements, board certification, and also maintenance of qualification, Dr. Boyers on the educational requirements for medical physicists, and Dr. Wu on educational require-

January/February 2010 ments for medical dosimetrists. As part of the panel discussion, the question on Medical Physics residency and how to support such program was raised and discussed. The educational programs for the medical physicists in Malaysia were presented by Dr. Ahmad Zakaria, PhD, KwanHoong Ng, PhD, and Noriah Jamal, PhD. During the panel discussion, the issues on stringent requirements for graduation of medical physicists, the manpower, and the projected shortage were addressed. The presenters expect acute shortage of medical physicists in Malaysia in the very near future. Photo of both Malaysian and US faculty is attached. The course was an overwhelming success with 130 registrations. Unfortunately some people were declined registration because the lecture hall and practical workshops

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AAPM Newsletter

January/February 2010

AAPM Newsletter

January/February 2010 such as Chendul and Air Kachang provides excellent deserts. Stopping at the roadside stall during the return trip from NCI Cancer Hospital also allowed the faculty to taste local fruits such as rambutan, mangosteen and durians. An official dinner was held at the Malaysian Petroleum Club on the 42nd floor of the Petronas TwinTower (taller than the Sears TwinTower in Chicago) on June 19, 2009 to allow the faculty to view Kuala Lumpur at night.

were at full capacity. Besides Malaysian, participants attending the symposium came from other countries that included Thailand, Sri Lanka, and Singapore. Ten copies of the textbook “Foundation of Radiological Physics”, authored by C.B.Saw, were distributed as door prize to the participants from Malaysia. Based on the general conversation with the local committee, this meeting is timely for the local radiation oncology community. The local committee has expressed their interest to have this symposium every two years and also IMRT practical workshop in the very near future. The president of MOS supported such agenda and would encourage an annual symposium of such kind in the South-East Asia countries on a rotating basis among the countries. Dato Dr. Ibrahim Wahid has expressed the acute need for the knowledge of image-based technology at this time period as the South-East Asia countries are undergoing transition into the implementation of modern radiation oncology technologies. Prior to the meeting, the host together with the US faculty took tours of the Batu Caves, and Malaysia Tropical Rainforest. The Batu Caves is a limestone hill and also one of the most popular Hindu shrines located outside India. The Batu Caves serves as the focus of the Hindu commu-

nity’s yearly Thaipusam festival. The trip to the Malaysian Tropical Rainforest was a disappointment because the tour of the canopy of the rainforest was closed on that day. However, the faculty took a path through the rainforest viewing and appreciating the enormous undergrowths with a variety of tropical plants. The multi-ethnic cultures of Malaysia offer a large variety of food. The host made extraordinary efforts to ensure that the faculty tasted as many kinds as possible from Indian curries, Malays spices and Chinese noodles. Local delights

On behalf of the US faculty and AAPM ISEP, the US co-director (Cheng Saw, PhD) wishes to thank the host for provide such an extraordinary hospitality. The co-directors wish to thank AAPM-ISEP, MAMP, and MOS for sponsoring this symposium. The willingness of the US faculty to travel to Malaysia to participate in the symposium are well-appreciated by the co-directors and the local committee. Lastly, the co-directors recognized the contributions of the vendors that participated in the practical workshop to support the educational mission of this symposium by arranging application specialists to lead these sessions.

AAPM Summer School Tuition Scholarships and Grants Scholarships in the form of waiver of tuition for the AAPM 2010 Summer School are being offered for applicants who are early in their careers in medical physics. In addition to the above, two $500 grants to assist with other expenses related to the AAPM Summer School are being sponsored by Capintec, Inc. http://www.aapm.org/meetings/2010SS/ScholarshipInfo.asp

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

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) PRINT SCHEDULE

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 36

The AAPM Newsletter is produced bi-monthly. Next issue: March/April Submission Deadline: February 11, 2010 Posted On-Line: week of March 1, 2010