EDUCATION AND TRAINING OF MEDICAL PHYSICISTS James A. Purdy, Ph.D. Professor and Director Division of Radiation Physics Department of Radiation Oncology Washington University School of Medicine St. Louis, Missouri, USA Evolving Strategies in Radiation Oncology Rome, Italy, June 3-5, 2004

EDUCATION AND TRAINING Education of the clinical radiation oncology physicist can be divided into three stages. 1st Stage: University education in physics, engineering, mathematics, and other relevant topics (B.S.). 2nd Stage: Graduate education leading to M.S. or Ph.D. (Medical physics courses may be introduced into curriculum). 3rd Stage: Physics residency training in a clinical environment.

EDUCATION AND TRAINING First Stage Bachelors degree in physics or equivalent. Medical physicists should be educated primarily as physicists (or biomedical engineers?) and be qualified and competent to apply the many branches of physics to continually evolving problems and situations which occur in medical environs of hospitals and clinics.

EDUCATION AND TRAINING Second Stage Graduate degree ( Masters or Doctorate ) in physics or medical physics. Masters program: typically, about 2 calendar years required. Doctoral program: typically about 4 to 5 years required. emphasis on developing research capabilities of individual

EDUCATION AND TRAINING: Second Stage Note! If medical physics Masters and Doctorate degree program, it should be subjected to the same scrutiny and approval requirements as all other graduate degree programs of the University.

EDUCATION AND TRAINING Third Stage Formal comprehensive training and experience in areas of clinical dosimetry, treatment planning, treatment aid design and fabrication, brachytherapy, radiation safety, special procedures, machine calibration, and quality assurance. Length of clinical physics residency training period should be 2 years or longer.

EDUCATION AND TRAINING Third Stage Note! Graduate degree in physics or medical physics is no longer adequate by itself in order to work independently in a clinical situation. Note! Informal “on-the-job” training working under the tutelage of a more senior medical physicist is no longer adequate.

EDUCATION AND TRAINING Accreditation Accreditation of graduate educational programs in Medical Physics program conforms with standards that should result in its graduates being qualified for more specialized training or professional practice in clinic medical physics. Establishes minimum levels of educational and training opportunities that must be offered by program.

EDUCATION AND TRAINING: Accreditation Clinical Physics Residency Programs are based on AAPM Report No. 36

EDUCATION AND TRAINING: Accreditation Commission on Accreditation of Medical Physics Education Programs, Inc. (CAMPEP) degree programs in medical physics (11) clinical physics residency programs (6)

CAMPEP ACCREDITED DEGREE PROGRAMS McGill University University of Alberta - Cross Cancer Institute University of British Columbia University of California - Los Angeles University of Florida University of Kentucky Medical Center The University of Texas - Houston Health Science Center (M. D. Anderson Cancer Center) University of Texas HSC - San Antonio University of Wisconsin-Madison Vanderbilt University School of Medicine Wayne State University

CAMPEP ACCREDITED RADIATION ONCOLOGY CLINICAL PHYSICS RESIDENCY PROGRAMS Washington University/Barnes-Jewish Hospital St. Louis (1997, 2003) University of Minnesota Medical School (2000) University of Florida (2000) McGill University (2000) Mayo Clinic (2003) University of Louisville School of Medicine (2003)

EDUCATION AND TRAINING: Certification Certification board performs several functions: evaluates qualifications of candidates requesting examination in specific medical physics subspecialties. arranges, controls, and conducts certification examinations. grants and issues certificates in to applicants who have been found to be qualified by the board. maintains registry of holders of such certificates. serves medical and lay public by providing lists of names of certified medical physicists.

EDUCATION AND TRAINING: Certification American Board of Radiology Radiological Physics Therapeutic Radiological Physics Medical Nuclear Physics Diagnostic Radiological Physics American Board of Medical Physics Radiation Oncology Physics Diagnostic Imaging Physics Hyperthermia Physics Medical Health Physics Magnetic Resonance Imaging

EDUCATION AND TRAINING: Licensure In addition to training program accreditation and individual physicist certification, licensure for clinical medical physicists is recognized as an added means to credential and ensure that the clinical medical physics profession is practiced by competent professionals. Only three states, Texas, Florida, and New York, have passed legislation requiring licensure of medical physicists, and much work remains.

EDUCATION AND TRAINING: Continuing Education Attendance at seminars, scientific meetings, and advanced training courses is essential to maintaining professional competency. Provides opportunities for obtaining deeper knowledge in special branches of medical physics. Necessary due to increased specialization among clinical physicists and continuing technological advances.

CLINICAL PHYSICS RESIDENCY PROGRAMS Object of residency training program is to train physicists in the clinical practice of radiation oncology physics. To accomplish this goal, the following must be provided: adequate organization staff facilities patient resources educational environment

CLINICAL PHYSICS RESIDENCY: Program Director Certified in Radiation Oncology Physics Full-time staff member, qualified in and practicing radiation oncology physics Contribute sufficient time to program to insure adequate direction Responsible for training program: Instruction/supervision of physics residents insure adequate facilities, teaching staff, clinical resources and educational resources selection of physics residents (must insure that the appointed residents meet eligibility requirements).

CLINICAL PHYSICS RESIDENCY: Faculty and Staff Faculty must include at least the following: 2 full-time radiation oncology physicists, both certified by the American Board of Radiology or its equivalent. 1 full-time radiation oncologist certified by the American Board of Radiology or its equivalent. accessibility to 1 full time radiation biologist .

CLINICAL PHYSICS RESIDENCY: Faculty and Staff Faculty must be qualified in those areas in which they instruct/supervise physics residents. Must have a real interest in teaching and devote necessary time/effort to residency program.

CLINICAL PHYSICS RESIDENCY: Faculty and Staff Faculty should ALSO be engaged in scholarly activities such as: participation in national scientific societies participation in their own continuing education scientific publications and presentations active involvement in radiation oncology physics development and research.

CLINICAL PHYSICS RESIDENCY: Facilities Space. There must be space adequate for the conduct of a good clinical physics practice and training program. Clinical Resources Training program must provide sufficient patient volume and variety of cancer patients for adequate resident experience. Number of patients treated per year at least 500.

CLINICAL PHYSICS RESIDENCY: Facilities Equipment Required: Two or more multi-modality megavoltage linacs Desirable, superficial/orthovoltage x-ray units Dedicated therapy simulatorand CT-simulator Interstitial & intracavitary brachytherapy equip. Computerized treatment planning system Equipment to construct special treatment aids Physics dosimetry equipment Availability of electronics and machine shops

CLINICAL PHYSICS RESIDENCY: Educational Environment Environment that encourages exchange of knowledge and experience among physics residents and with clinical residents located in the same institution. Library Resources Sufficient variety of journals, reference books, and resource materials pertinent to radiation oncology physics and associated fields in oncology and basic sciences must be immediately accessible for resident study. Access to a general medical library.

CLINICAL PHYSICS RESIDENCY: Educational Environment Conferences Conferences and teaching rounds must provide for progressive resident participation. Adequate frequency of conferences and attendance by physics residents, radiation oncology physicists, radiation oncologists and other staff should be documented. Adequate conference room and audio-visual facilities must be provided.

CLINICAL PHYSICS RESIDENCY: Educational Environment Conferences New Patient conferences Weekly Chart Reviews & Problem Case Conferences Physics/Dosimetry Conference Morbidity Conference Radiation Biology Conference Journal Review Conference

CLINICAL PHYSICS RESIDENCY: Requirements for Completion Complete a series of clinical rotations (3 months each)over 2 year period. Pass a set of special training sessions and didactic courses. Participate in clinical conferences and special lectures. Prepare handouts and make presentation for 3 assigned topics each year. Pass Year 1 Oral Exam Pass Year 2 Oral Exam

WUBJH PHYSICS RESIDENCY PROGRAM Washington University/Barnes-Jewish Hospital (WUBJH) Radiation Oncology Center formalized their previous "post-doctoral" training approach and established Radiation Oncology Physics Residency Program in 1992. Became first physics residency program to be accredited by CAMPEP in Oct. 1997.

WUBJH PHYSICS RESIDENCY PROGRAM: Clinical Rotations Provides for physics resident’s participation in clinical and technical subjects pertinent to radiation oncology physics including: Megavoltage photon and electron beam therapy Superficial x-ray therapy Simulation/CT-simulation 2D and 3D computerized dose planning Treatment aids Calibration and periodic QA of therapy equipment Brachytherapy Interstitial and intracavitary Radiopharmaceutical therapy Radiation safety procedures Special procedures (IMRT, radiosurgery, TBI, etc)

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Clinical Rotations July Orientation/Team 1 Treatment Planning August “ September “ October Team 2 Treatment Planning November “ December “ January Special Procedures incl. IMRT Planning February “ March “ April Brachytherapy May “ June Chart Checking (plan, calculations)

WUBJH PHYSICS RESIDENCY PROGRAM: Year 02 Clinical Rotations July External Beam/Radiosurgery August “ September “ October External Beam & IMRT November “ December “ January External Beam & Brachytherapy February “ March “ April External Beam May “ June “

WUBJH PHYSICS RESIDENCY PROGRAM: Training Sessions & Didactic Courses Orientation Course (first 2 weeks of year 01) Radiation Safety Exam (within 30 days beginning year 01) Physics Didactic Course (Sep-Mar. year 01) Cancer Biology Didactic Course (Mar-June year 01 or year 02) Clinical Oncology Conference ( 1 hr lecture every Friday for 2 years)

WUBJH PHYSICS RESIDENCY PROGRAM: Conferences Patient Management Conference (3 times a week for 2 years) Current Case QA Review Conference (once a week 3-4:30 PM for 2 years) Morbidity Conference (once a month 12:00 - 1:00 pm, 2 years Current Topic Conference (once a month 4:30- 5:40 pm for 2 years) Research Seminar (once a month 5:00 - 6:00 pm, 2 years)

WUBJH PHYSICS RESIDENCY PROGRAM: Conferences Treatment Planning/QA Conference (once a month for 2 years) Physics Resident Seminars (once a month Sep.-June for 2 years) Treatment Machine Operation Labs (1st year) Simulation Labs Annual Radiation Safety Review (one lecture a year) Annual Fire, Chemical, Biohazards Review (once a year)

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Clinical Rotations WUBJH operates one of the most comprehensive external beam services in the country (Over 2000 patients treated annually: traditional 2D photon and electron beam approaches advanced 3D conformal radiation therapy approaches inverse planning and IMRT. stereotactic radiosurgery total body photon irradiation

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Clinical Rotations Each physics resident spends a 9 month rotation in Treatment Planning working mainly with medical dosimetrists. Rotation is focused on learning: basic treatment planning and dosimetry skills developing familiarity with all clinical procedures performed.

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Clinical Rotations Emphasize developing communication skills with all personnel involved with radiation therapy treatment procedures

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Clinical Rotations Participates in simulation procedures.

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Clinical Rotations Treatment aid (beam shielding blocks, compensating filter, immobilization/repositioning devices, etc) design and fabrication, and treatment machine quality assurance tests are acquired.

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Clinical Rotations Patient Treatment Plan Data Acquisition Monitor Unit Calculations Point Dose Calculations

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Clinical Rotations Dosimetry Instrumentation and Measurements Daily, Weekly, Monthly, Yearly QA checks

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Conferences & Seminars Attends and participates in patient conferences. Assigned to deliver 3 seminars per year on various subjects that range from a detailed review of AAPM Task Group's 21, 25, 35, 40 and 45 Reports to site specific treatment planning reviews.

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Didactic Lectures Expected to master Resident's Physics course, which is a formal lecture series with assignments and examinations. Course utilizes the textbook by Faiz Khan, Radiation Therapy Physics, 3rd Ed, published by Williams and Wilkins plus handouts from the lecturers. Core readings are assigned to the trainees.

WUBJH PHYSICS RESIDENCY PROGRAM: Brachytherapy Rotations WUBJH has an active clinical brachytherapy service, encompassing intracavitary brachytherapy, temporary interstitial implants, permanent interstitial implants, and therapeutic radiopharmaceutical administrations. Manual afterloading, remote-afterloaded low dose-rate and high dose-rate treatments. Over 350 brachytherapy and radiopharmaceutical procedures are executed annually.

WUBJH PHYSICS RESIDENCY PROGRAM: Brachytherapy Rotations Each physics resident rotates through the Brachytherapy Physics Service twice during their two year program. First year: 3 month rotation which is focused on learning basic skills, background reading and procedure familiarity. Second year: 2 month rotation which emphasizes a more independent performance as a brachytherapy physicist.

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Brachytherapy Rotation Basic skills and concepts are emphasized. Trainee assigned to work with the Brachytherapy Technologists during GYN implant days for 4-6 weeks. Trainee learns to prepare applicators, assist physicians in the OR, perform daily QA on afterloading equipment, perform surveys, fill out required forms and records, and handle and prepare sources.

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Brachytherapy Rotation About 50% of first rotation is spent working alongside an experienced staff clinical physicist learning to perform basic treatment planning, chart checking and QA tasks. Computer treatment planning skills are acquired during previous Dosimetry Rotation. On completion, trainee is expected to function as on-call physicist to handle after-hours emergencies with backup from faculty physicist.

WUBJH PHYSICS RESIDENCY PROGRAM: Year 02 Brachytherapy Rotation Resident expected to function independently as a clinical physicist (within certain limits). Trainee can be authorized to independently: review treatment plans/manual calculations order radioactive material check in and calibrate radioactive sources/materials cover Brachytherapy Physics Service for short periods. More extensive clinical projects expected (e.g. developing written procedures for new treatment, commissioning new devices and instruments, or performing brachytherapy dose measurements.

WUBJH PHYSICS RESIDENCY PROGRAM: Year 01 Methods of Evaluation Informal evaluation on monthly/continuing basis including completion/ understanding of assigned reading and exercises. Evaluating staff include faculty physicists, dosimetrists, and attending radiation oncologists Pass Radiation Safety Exam during first month Treatment planning and dose calculation skills are monitored through review of completed tasks. Communication skills are evaluated by informal discussion with dosimetry and physician staff. Pass written and oral exam at end of year

WUBJH PHYSICS RESIDENCY PROGRAM: Year 02 Methods of Evaluation Evaluated on month-by-month basis. Must be able to perform treatment plan checking and chart checking without direct supervision. Expected to perform physics tasks independently. Must be able to carry out an independent annual review and calibration of a dual energy linac. Must be capable of conducting her/himself with confidence in the clinic (input of physicians and dosimetrists is pertinent in this determination). Pass 2nd year oral exam. (Questions encompass entire two year training).

WUBJH PHYSICS RESIDENCY PROGRAM: Developmental Projects Physics resident is expected to participate in clinical implementation projects. Examples are acceptance testing and commissioning multi-leaf collimator system, enhanced dynamic wedge, and IMRT systems. Physics resident is encouraged to perform an independent clinical physics project suitable for submission as an abstract for AAPM annual meeting.

WUBJH PHYSICS RESIDENCY PROGRAM: Developmental Projects Any special developmental projects or assignments outside the norm of clinical physics support must be approved in advance by the Program Director with the understanding that all such projects must be clinically oriented and will benefit the trainee's clinical experience.

SUMMARY Training program accreditation Physics residency program Board certification Licensure

CONCLUSION As the various medicines in which physicists participate clinically continue to become more complex, pathway for clinical physics profession should become more formalized. graduation from an accredited medical physics degree program followed by clinical physics training in an accredited physics residency program subsequent board certification.

Thank you for your attention.