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Medical Physics Profession - Ivan A. Brezovich, Ph.D. (984 kB)






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    Medical Physics Profession - Ivan A. Brezovich, Ph.D. (984 kB) Medical Physics Profession - Ivan A. Brezovich, Ph.D. (984 kB) Presentation Transcript

      • 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
    • 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’t receive optimal treatment
      • Cancer centers lose revenue
      • Medical physicists not working in the profession of their choice
    • Purpose of Talk
      • Identify causes of paradox
      • Suggest Solution
    • 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.
    • Medical Physicists are Medical Specialists - in Addition to Being Physicists (cont’d)
      • 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
    • 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)
    • 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
    • Tumor Control/Normal Tissue Complication: Effect of a 3% Error in Delivered Dose 0 20 40 60 80 100 120 0 20 40 60 80 100 Dose (Gy) Probability (%) 32.9% reduction   3.3% increase H&N SCC control probability Xerostomia probability
    • 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
    • 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.)
    • Responsibility for Treatment Planning
      • “… It is the responsibility of the Qualified Expert to verify the results of each specific calculation”
    • 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%
    • Historical Background
      • 1895 Roentgen discovers x-ray
        • Takes image of wife’s hand.
        • First medical physicist in radiology
      • 1896 Becquerel discovers radioactivity
      • Therapeutic benefits soon recognized
      • Evolution of equipment and procedures
    • Historical Background cont’d
      • 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)
      • 1950’s: Reactor made Isotopes ( 137 Cs, 60 Co)
    • Historical Background cont’d
      • 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
    • Historical Background - Uncertainty During 1980s (cont’d0
      • 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
    • Medical Physicists Join Radiologists in Opposition to RAPS
    • Letter Campaign Succeeds
      • RAPS no threat for radiation oncologists after 1990s
      • Radiation oncology becomes attractive
      • Residents plentiful
      • RAPS conditions continue for medical physicists
    • Hope for Physicists
      • HCFA asks for public comments to clarify CPT 77300 Physics Codes
      • (Attn: BPDD770DP, published in Federal Register)
      • User’s Guide , American College of Radiol., p.21, 1990
    • 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
    • Tragedy Strikes ……. (cont’d)
      • Example of letters to HCFA
      • “… . The technical work performed by the physicist is not immediately translated into direct care of a patient.”
    • Example of Letters to HCFA cont’d
    • Tragedy Strikes ……. (cont’d) Political lobbying against neutral evaluation
    • Tragedy Strikes ……. (cont’d) Physicists turned against each other
    • 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”)
    • 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
    • The Industrial Physicist (American Institute of Physics, April/May 2003, p.13)
    • Difficult Working Conditions
      • Medical physicists work under these brute conditions, even in areas with low HMO penetration
      • “ HMO’s 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
    • 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 manufacturer’s 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
    • The Industrial Physicist (American Institute of Physics, April/May 2003, p.13) Oversupply Ends
    • One common denominator: Lack of proper recognition
      • Solution: Provider Recognition by CMS
    • 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 ….
    • 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
    • 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 today’s environment
        • returns out of proportion with investment
        • is done by majority of radiological societies
    • 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
      • 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