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Apparent Paradox. 80 Positions for medical physicists unfilled. High-quality applicants for residency programs scarce. Shortage?Board certified medical physicists working as sales reps., leaving the field. Oversupply?. Reality. Patients don
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1. MEDICAL PHYSICS PROFESSION Presented at the 2003 Annual ACMP Meeting,
Lake George, NY,
May 10-15, 2003.
Ivan A. Brezovich, Ph.D.,
Dept. of Rad. Onc.
University of Alabama at Birmingham
Birmingham, AL 35294
3. Reality Patients dont receive optimal treatment
Cancer centers lose revenue
Medical physicists not working in the profession of their choice
4. Purpose of Talk Identify causes of paradox
Suggest Solution
5. Medical Physicists are Medical Specialists - in Addition to Being Physicists Medical specialists listed by ABMS.
Credential can be checked 1-866-ASK-ABMS
Certified by ABR or have Letter of Equivalence
Same specialty board that certifies Diagnostic and Therapeutic Radiologists
Guide To Radiological Physics Practice, American College of Radiology (ACR), p. 1, 1990.
6. Medical Physicists are Medical Specialists - in Addition to Being Physicists (contd) These individuals (medical physicists) are Professionals in every sense of the word and they deserve the respect, support, and compensation relative to their positions.
John D. Watson, JR., MD., one of the founding members of radiation oncology as a medical specialty
7. Responsibility Accurate delivery of prescribed radiation dose (quantity and geography)
.. physicists orchestrate the entire treatment process
Chairman of ASTRO (American Society for Therapeutic Radiology and Oncology) in letter to HCFA (now CMS)
8. Direct Effect on Cancer Patients Cancer death 0.9% higher in Florida where medical physicists in many centers spend 18% less time per patient than national average [~ 360 avoidable deaths/year]
Charges 42% higher in centers with low medical physicist time per patient
Mitchell and Sunshine, New England Journal of Medicine 327:1497-1501, 1992
9. Tumor Control/Normal Tissue Complication:Effect of a 3% Error in Delivered Dose
10. Small Error-Tragic Consequences Qualified medical physicist replaced by unqualified
Inappropriate calculation method
Too many duties, not enough time in clinic
Patients get too much radiation
~ 1,000 patients are injured, many die
Medical physicist mentally destroyed
Radiation oncologist dies the night before court trial
11. Critical Tasks of Medical Physicists Design and verification of tx plans for individual patients, special treatment devices ~ 80% of time
Design of facility, especially shielding
Acceptance testing
Calibration
Commissioning
Beam data entry into treatment planning system
System checkout (CT data transfer, etc)
Quality Assurance (QA) of dose and alignment
Continued vigilance for software and hardware changes
Special procedures (seeds for prostate cancer, HDR, whole-body tx, intravascular tx, brain irradiation, etc.)
12. Responsibility for Treatment Planning It is the responsibility of the Qualified Expert to verify the results of each specific calculation
13. Acceptable Tolerances NIST Calibration 0.5%
Temperature/Pressure 0.5%
Field size dependence 2.0%
Depth dependence (TMR) 2.0%
Wedge factor 3.0%
Variation of accelerator 2.0%
TOTAL 10.0%
14. Historical Background 1895 Roentgen discovers x-ray
Takes image of wifes hand.
First medical physicist in radiology
1896 Becquerel discovers radioactivity
Therapeutic benefits soon recognized
Evolution of equipment and procedures
15. Historical Background contd Physicists provide equipment
radiologists operate and maintain equipment
radiologists do treatment planning
Obstacles:
Radioisotopes scarce
x-rays have poor penetration (skin burns)
1940: Betatron (Donald Kerst, Ph.D.)
1948: Kerst and Henry Quastler, MD, treat brain tumor (radiosurgery)
1950s: Reactor made Isotopes (137Cs, 60Co)
16. Historical Background contd 1960s - 1980s Close collaboration between radiologists and medical physicists
Linear Accelerators
Treatment planning computers
Custom blocks (Cerrobend)
Treatments become complex
Medical physicists become part of the the clinic
Payment for services in lump sum to hospital, based on reasonable and customary fees
17. Historical Background - Uncertainty During 1980s (contd0 HCFA widens use of CPT codes
Recognition of medical physicists as professionals, but only in few areas
Inadequate reimbursements
HCFA proposes RAPS
Radiology, Anesthesiology and Pathology Services to be paid as hospital expenses
Shortage of residents
Radiologists ask medical physicists for help
18. Medical Physicists Join Radiologists in Opposition to RAPS
19. Letter Campaign Succeeds RAPS no threat for radiation oncologists after 1990s
Radiation oncology becomes attractive
Residents plentiful
20. Hope for Physicists HCFA asks for public comments to clarify CPT 77300 Physics Codes
(Attn: BPDD770DP, published in Federal Register)
Users Guide, American College of Radiol., p.21, 1990
21. Tragedy Strikes Medical Physicists - and Cancer Patients No dialogue. No consideration of 77336 and 77370 codes
Letters to Radiation Oncology Societies unanswered
Pseudo doctors .
Radiology societies make statements to the effect that medical physicists are not involved in professional physics services
Radiology societies encourage their members to write similar letters to HCFA
Radiology societies oppose neutral evaluation
22. Tragedy Strikes . (contd) Example of letters to HCFA
. The technical work performed by the physicist is not immediately translated into direct care of a patient.
23. Example of Letters to HCFA contd
24. Tragedy Strikes . (contd) Political lobbying against neutral evaluation
25. Tragedy Strikes . (contd) Physicists turned against each other
26. Medical physicists societies fail to take stand: Opportunity Missed Loss of Provider Status, only medical specialists not recognized as providers (Unlike social workers, nurse anesthetists, MDs, etc.)
Loss of financial recognition The professional component was clearly intended to be reimbursed for the non- physician professional physicist. Unfortunately over the years . This revenue stream was lost in the system (Administrative Radiology 1992)
Continuing erosion of recognition (Physics codes become delivery codes)
27. Profession Becomes Less Desirable Limited control over profession
Low professional standing
Outdated QA equipment, tx planning systems
Insufficient time for quality treatment planning and verification
Error prone (Riverside, Florida)
Limited input in equipment purchase and facility design - full responsibility
Insufficient secretarial and other help
Low pay, even when clinic profitable
28. The Industrial Physicist (American Institute of Physics, April/May 2003, p.13)
29. Difficult Working Conditions Medical physicists work under these brute conditions, even in areas with low HMO penetration HMOs can brutalize medical care if their
goal is to make money from the sick
Robert Kagan, MD and Oliver Goldsmith, MD The Journal of Oncology Management, p. 18, July/August 2002
30. Effects on Patient Care Impact at first masked by long pipeline and oversupply due to end of space program
Cumulative effect: Fewer physicists willing to work under the given conditions
Board certified physicists leaving profession (work as manufacturers reps, retire early )
Parents discouraging children
Disproportionate reliance on immigrants (> 50% of physics graduate students foreign born)
Language barriers
Selection decreasing (quality?)
Training programs suffering
31. The Industrial Physicist (American Institute of Physics, April/May 2003, p.13) Oversupply Ends
32. One common denominator: Lack of proper recognition Solution: Provider Recognition by CMS
33. Provider Status is Realistic Goal(50 Provider Categories on Medicare Website) Ambulance Service Supplier
Ambulatory Surgical Center
Audiologist
Certified Clinical Nurse Specialist
Certified Nurse Midwife
Certified Registered Nurse Anesthetist
Clinic/Group Practice
Clinical Psychologist
Community Mental Health Center
Comprehensive Outpatient Rehabilitation Facility
Durable Medical Equipment, Prosthetics, Orthotics, or Supplies
etc .
34. Provider Status is Desirable Higher professional standing
billing could be done by clerks as now
office space, secretarial help, parking, lunch room
signing billing rights to clinic would maintain status quo
More job security
More control over profession, allotment of time, working hours
quality of work
better QA equipment and Treatment Planning Systems
higher income
Easier recruitment of new medical physicists
35. Steps to Achieve Provider Status Professional Oath
Closer ties with Radiological Societies
awards for distinguished radiation oncologists
discounts at physics workshops for radiologists
Letters of Support from Well-known Radiation Oncologists and Radiological Societies
Obtain Legal Counsel
Political Lobbying - start PAC
necessary in todays environment
returns out of proportion with investment
is done by majority of radiological societies
36. Form Political Action Committee (PAC) Physicists are good politicians - 2 Congressmen
Lobbying has high returns
Recent limits are leveling playing field
All contributions voluntary - less disagreement
Provider status is reasonable request
helps cancer patients
financial impact small - easier to get through Congress
Timing is excellent
physicists in demand, supply will get worse
current pay scale makes lobbying affordable
37. CONCLUSION Medical physics has all the features of a medical specialty, except Medicare recognition as Providers
Provider status will eliminate the root causes of the majority of problems in our profession
Obtaining Provider status has been the primary reason for the formation of ACMP
Obtaining Provider status has to become again the primary goal of all professional activities of ACMP