This editorial arose out of a project with the AAPM Working Group on the Prevention
of Errors. The goal was to publish an interview with one of the authors in the AAPM
Newsletter about tips and tricks of leading quality and safety initiatives in the
clinic.1 The Newsletter covered strategies of change management, working with a team,
building a culture of safety, and leading when you're not the leader.
While anchored in quality and safety, the interview was fundamentally about leadership.
The interview triggered some deeper thought about medical physics and the future clinical
role of medical physicists, especially related to quality and safety. Over many discussions
between the authors of this editorial, we came to the conclusion that the continued
emphasis on quality and safety is likely a threat to the long‐term viability of clinical
medical physicists in radiation oncology. Clearly, this viewpoint would benefit from
some explanation.
Clinical medical physics1 consists of a number of routine responsibilities such as
equipment calibration and QA, patient‐specific QA including treatment plan checks,
weekly chart checks, and patient‐specific measurements (e.g., IMRT QA, diode measurements,
etc.). Physicists lend assistance to radiation oncologists, dosimetrists, and therapists
at the treatment machines for hypo‐fractionated cases, gating or 4D cases, and troubleshooting
equipment faults. Some external beam treatment planning is still done by physicists
as well as LDR and HDR brachytherapy planning. Ad‐hoc meetings with a patients or
staff to discuss issues related to radiation dose, the associated risks of radiation
exposure, or other concerns about their treatment is a part of a physicist's routine
job function. Physicists are equally valuable at managing technical issues when things
go wrong usually by figuring out what actually happened, performing necessary dose
estimations, and recommending follow‐up actions. Some physicists spend a majority
of their time on quality improvement, safety initiatives, and designing processes.
Of all these activities, only a few actually require the expertise of a physicist.
Generally speaking, radiation detection and measurement requires physics knowledge
and training. Calibrating radiation output for external beam or brachytherapy, for
example, fall into the physicist‐required category. The far majority of a physicists’
day‐to‐day value comes from assisting our clinical colleagues and checking the work
of others or checking equipment performance. The raison d’être of a physicist's job
is ensuring high‐quality treatments and patient safety.
Over the past ten years or so, we thought that physicists can have a bigger and more
meaningful impact on patient care by learning and implementing modern quality and
safety approaches.2, 3 While this is still true, we have now come to realize that
the landscape where physicists add value to patient care is much more tenuous. The
reality is that the current emphasis on quality and safety may lead to a decrease
in job security. There are several reasons for physicists to be concerned about the
status quo.
The maturation of equipment design and manufacturing does not require as many routine
checks and quality monitoring as in the past. It is likely that any remaining QA deemed
essential will be largely automated. Rather than requiring an army of highly trained
physicists for the purposes of equipment QA, only a small team will be needed with
a couple of local or regional experts to address issues that are detected. This has
already been observed in some radiology departments primarily in the community setting.
The usefulness of physicists’ treatment plan quality checks will decrease with automated
treatment planning and the radiation oncologist's final plan approval. Workflow and
process problems that physicists work on can be effectively addressed by other professionals
that are trained in quality and safety. Physicists must recognize that they are primarily
facilitators of patient treatments but not absolutely essential.
There are radiation oncology departments that regularly treat patients without a physicist
on site and little or no evidence exists to indicate that those departments are systematically
providing subpar treatments. One cannot imagine a radiation oncology department without
each patient being assigned to a radiation oncologist. The same is not true for physicists
— we emphasize the obvious, that a chart or a treatment plan is not a patient. Any
time you are helping the process rather than driving it, you are susceptible to being
replaced or worse yet, marginalized.
The good news is that physicists have the potential to add value to patient care way
beyond what they are currently providing. Physicists think differently than medically
trained healthcare professionals such as radiation oncologists or nurses. This provides
a perspective on the care of a patient that would uniquely and positively impact outcomes.
Unfortunately, the physicist's unique perspective is not being utilized because most
of their time is spent checking the work of others. Physicists need to establish a
role where they are required for the treatment of every patient — every patient should
“have a physicist” for their treatment just like they “have a physician”. The value
that a physicist would bring to a patient's radiation treatment should be akin to
the value that a medical oncologist, surgeon, and radiation oncologist bring to the
patient's overall cancer care. To achieve this, physicists need to move in a fundamentally
new direction. The first step is to establish an individual professional relationship
with every patient.
Our group is taking steps in this direction by developing an initiative where a physicist
has a consultation with the patient prior to simulation, then meets with the patient
again prior to their first treatment, and then any time the patient has a technical
question or concern during their course of treatment.4 Preliminary results show that
physicists have a positive impact on patient care by reducing patient anxiety.5 While
reducing treatment related anxiety is important and can be beneficial to outcomes,
this is only the beginning. We are investigating other areas where physicists can
directly impact patient care such as taking responsibility for treatment plan approval
or target volume delineation. There are many other possible directions to expand this
initiative.
Whatever the final landing place, the goal should be to augment the role of the radiation
oncologist, allowing him or her to have time for other important activities that improve
patient care and help advance the field. If radiation oncologists are going to have
more impact on patient care, they need to see patients earlier, perhaps soon after
diagnosis in a multi‐disciplinary clinic alongside surgeons and medical oncologists
instead of seeing patients after they have already met with other specialists. Another
way to raise the profile of the field is for radiation oncologists to take more leadership
roles in the Cancer Center and Medical Center. This ensures that radiation oncology
has a seat at the table where decisions are made and would benefit everyone including
physicists and, most of all, patients. Radiation oncologists will need to free up
time to work on these other activities. One way to achieve this is to share their
current clinical responsibilities. We are suggesting that the most appropriate group
to share with is the physicist. When physicists are truly integrated and required
to treat patients in radiation oncology, only then they will be recognized differently
by hospital administrators changing their perception of physicists as leaders in patient
care. This will also result in greater access to extra‐departmental leadership positions
for physicists within the hospital.
The intent of this new direction is not for the physicists to abandon their traditional
responsibilities in the department but to retain their current role as technical experts
while adding the additional work of direct patient care. Even though we are convinced
this future will take hold, something has to change. Physicists need to modify their
current approach to quality and safety to make time for direct patient care responsibilities.
Physicists need to spend more time interpreting quality and safety data rather than
acquiring it. But, it is not a sustainable strategy to simply transfer their current
activities to other staff members such as physics assistants. Job functions that add
minimal value need to be significantly modified or omitted all together. There are
a host of activities that fall into this classification such as monthly and annual
linac QA, patient‐specific IMRT and VMAT measurements, secondary MU calculation checks,
weekly chart checks, and traditional treatment plan checks. The future physicist will
be employed because of their cognitive reasoning skills and clinical experience, not
primarily for their ability to work hard at ensuring quality and safety. Physicists
will be essential because they have a specific and well‐defined clinical role that
is required to determine how each patient should be treated with radiotherapy.
The future quality and safety role of a physicist should be one of leadership with
an emphasis on quality management rather than directly checking equipment, charts,
or any other parameters. The responsibility of managing quality will include all aspects
of resource allocation as well as the design and oversight of the quality and safety
program. Tolerance levels and targets for different clinical processes will need to
be benchmarked and monitored. Perhaps the biggest challenge will be motivating and
ensuring a diverse group of professionals implement and maintain the required expertise.
In short, physicists need leadership and management skills to facilitate and sustain
this transformation.
It goes without saying that a very different training and education regimen will be
required. Even at this early stage, to perform effectively in a direct patient care
role requires systematically different approach to developing clinical skills.6 Other
aspects of clinical medicine will also have to be learned including disease progression,
staging, and monitoring outcomes just to name a few. Medical physics residency training
programs will need to be modified to ensure the necessary clinical experience is developed
for this future role.
We fully realize there are a bevy of clinical challenges to what we are suggesting
in addition to regulatory and financial issues. We are confident, however, that all
of these can be addressed with leadership from the AAPM in collaboration with physician‐led
professional societies. The future has never been brighter for radiation oncology
and clinical medical physicists provided that together they embrace change and forge
a new path.