medical physics profession

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 don�t 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 (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

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 wife�s hand. First medical physicist in radiology 1896 Becquerel discovers radioactivity Therapeutic benefits soon recognized Evolution of equipment and procedures

15. 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 (137Cs, 60Co)

16. 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

17. 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

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) User�s 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 ��. (cont�d) 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 cont�d

24. Tragedy Strikes ��. (cont�d) Political lobbying against neutral evaluation

25. Tragedy Strikes ��. (cont�d) 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 �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

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 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

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 today�s 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