1. RAS6038 - The Clinical Training Program Strengthening Medical Physics through Education & Training in the Asia Region A/Professor John Drew Institute of Medical Physics, University of Sydney, Australia Lead Country Coordinator, RAS6038

2. What’s In a Name? Name for a qualified medical physicist in this specialty Radiation Oncology Medical Physicist (ROMP) Name for trainee Resident

3. Developing the Training Program Guide Steps Steps Define the “Roles and Responsibilities” Define the “Roles and Responsibilities” Define the required knowledge and competencies to undertake these roles and responsibilities Define the required knowledge and competencies to undertake these roles and responsibilities Prepare a competency based clinical training program which meets the required knowledge and competencies Prepare a competency based clinical training program which meets the required knowledge and competencies

4. Roles and Responsibilities IPEM, 2001 IPEM, 2001 RAS6038 has used this document as the starting point RAS6038 has used this document as the starting point

5. Roles and Responsibilities - IPEM The broad areas are: Equipment procurement, acceptance and commissioning Radiation dosimetry External beam treatment planning, delivery and verification (including optimisation and safety) Brachytherapy Unsealed sources Radiation protection Specialised treatment techniques

6. Roles and Responsibilities - IPEM More … Mould room Management, scientific responsibility, advice and direction Computing and networking Quality control, safety and maintenance of radiotherapy equipment Quality Management Teaching and training Research and development

7. Developing the Training Program Guide Steps Steps Define the roles and responsibilities Define the roles and responsibilities Define the required “Knowledge and Competencies” to undertake these roles and responsibilities Define the required “Knowledge and Competencies” to undertake these roles and responsibilities Prepare a competency based clinical training program which meets the required knowledge and competencies Prepare a competency based clinical training program which meets the required knowledge and competencies

8. Knowledge and Competencies ACPSEM, 2005 ACPSEM, 2005 RAS6038 has used this document as the starting point RAS6038 has used this document as the starting point

9. Developing the Clinical Training Program Guide Steps Steps Define the roles and responsibilities Define the roles and responsibilities Define the required knowledge and competencies to undertake these roles and responsibilities Define the required knowledge and competencies to undertake these roles and responsibilities Prepare a “Competency Based Clinical Training Program” which meets the required knowledge and competencies Prepare a “Competency Based Clinical Training Program” which meets the required knowledge and competencies

10. Clinical Training Guide ModuleTitle % of Entire Program 1 “Clinical Introduction” 3% to 7% 2“Radiation Safety and Protection” 5% to 10% 3“External Beam Dosimetry” 5% to 10% 4“External Beam Therapy” 15% to 20% 5“External Beam Treatment Planning” 15% to 20% 6“Brachytherapy” 10% to 15% 7“Professional Studies and QM” 7% to 12% 8“Research and Development” 10% to 15% Expected time: 2 to 3 years

11. Clinical Training Guide Each sub-module defines a unified portion of clinical knowledge or skills. Each sub-module defines a unified portion of clinical knowledge or skills. There is a competency (or a small number of competencies) associated with each sub- module. There is a competency (or a small number of competencies) associated with each sub- module. An assessment matrix is provided specifically for each sub-module An assessment matrix is provided specifically for each sub-module Each competency is broad and there are over 60 in total. Each competency is broad and there are over 60 in total. The sub-modules to be undertaken and the level of competency required to be achieved can be adjusted to suit the country. The sub-modules to be undertaken and the level of competency required to be achieved can be adjusted to suit the country.

12. Example of a Module – 1 st Part

13. Example of a Module – 2 nd Part

14. Sub-module Example

16. Competency Assessment for a Sub-module

17. A Modified Competency Assessment

18. Assessment Procedures Assessments may be run by: Assessments may be run by: National professional body National professional body Regional professional body Regional professional body Assessment methods: Assessment methods: Competency check list Competency check list Theory exams Theory exams Supervisor reports Supervisor reports Log book, portfolios Log book, portfolios Practical & oral exam Practical & oral exam

19. Suggested Assessment Guide Assignments One each at 9, 15 and 21 months (assuming a 2 year program) Achieved all competencies to the required level Portfolio Requires examples of work from at least 5 modules Oral (practical?)

20. Available Documents The following documents form the overall program: “RCA Radiation Oncology Medical Physics Clinical Training Guide” “Handbook for Clinical Supervisors of Residents in the RCA Clinical Training Programme for Radiation Oncology Medical Physicists” “Handbook for Residents in the “Handbook for Residents in the RCA Clinical Training Programme for Radiation Oncology Medical Physicists” “Competency Assessments of Residents Enrolled in the “Competency Assessments of Residents Enrolled in the RCA Clinical Training Programme for Radiation Oncology Medical Physicists” “Implementation of the “Implementation of the RCA Clinical Training Programme for Radiation Oncology Medical Physicists” “RCA Clinical Training Programme for Radiation Oncology Medical Physics: Information for Administrators” “RCA Clinical Training Programme for Radiation Oncology Medical Physics: Information for Administrators”

21. Some IAEA Resources A Handbook which “provides the basis for the education of medical physicists initiating their university studies in the field”. (http://www-naweb.iaea.org/nahu/dmrp/syllabus.shtm) A Handbook which “provides the basis for the education of medical physicists initiating their university studies in the field”. (http://www-naweb.iaea.org/nahu/dmrp/syllabus.shtm) Self learning PowerPoint presentations with more than 2000 slides. (http://www-naweb.iaea.org/nahu/dmrp/slides.shtm) Self learning PowerPoint presentations with more than 2000 slides. (http://www-naweb.iaea.org/nahu/dmrp/slides.shtm)

22. Some IAEA Resources

24. Suggested Training Overview Suggested Clinical Training Program Overview Resident Clinical Supervisor External Reviewers IAEA External Coordinator Certificate of Completion External Resources e.g.text+ documents AV material etc National Responsible Authority National Steering Committee Relevant Professional Body Resident’s Handbook Clinical Training Guide National coordinator Handbook for Clinical Supervisors Administrator’s Guide Implementation Manual Competency Document Assessments

25. National Responsible Authority The programme should be managed under the direction of a national organisation: The programme should be managed under the direction of a national organisation: Medical physics professional body Medical physics professional body Regulatory or licensing body Regulatory or licensing body National Atomic Energy Authority National Atomic Energy Authority Ministry of Health or Education Ministry of Health or Education Provides formal recognition of the qualification “Radiation Oncology Medical Physicist” (or equivalent) Provides formal recognition of the qualification “Radiation Oncology Medical Physicist” (or equivalent)

26. Role of National Responsible Authority In partnership with stakeholders: In partnership with stakeholders: Ensures that guidelines for participation are strictly followed by clinical Departments and Residents Ensures that guidelines for participation are strictly followed by clinical Departments and Residents Ensures that standards for assessment, as set by the relevant professional bodies, are maintained Ensures that standards for assessment, as set by the relevant professional bodies, are maintained Maintains records of the Resident’s progress and performance Maintains records of the Resident’s progress and performance Issues certificates that provide an accurate record of the Resident’s performance Issues certificates that provide an accurate record of the Resident’s performance Monitors clinical departments performance in providing training Monitors clinical departments performance in providing training Develops a process for appeals and complaints Develops a process for appeals and complaints

27. National Steering Committee Is the working arm of the Authority Is the working arm of the Authority Administers the programme as required by the Authority Administers the programme as required by the Authority It consists of representatives from It consists of representatives from The relevant professional body (where one exists) and should form the majority of the Committee. The relevant professional body (where one exists) and should form the majority of the Committee. Other relevant interest groups and stake holders Other relevant interest groups and stake holders Works in partnership with other relevant professional bodies Works in partnership with other relevant professional bodies

28. Role of National Steering Committee Reviews the ongoing development of the training program Reviews the ongoing development of the training program Communicates on program development with RCA, IAEA, National bodies and other stake holders Communicates on program development with RCA, IAEA, National bodies and other stake holders Undertakes funding facilitation, review and promotion Undertakes funding facilitation, review and promotion Supervises the National Programme Coordinator Supervises the National Programme Coordinator Deals with complaints and appeals Deals with complaints and appeals

29. The Professional Body Forms a Standards Committee Forms a Standards Committee Sets the training standard as defined by the assessment criteria Sets the training standard as defined by the assessment criteria Sets the competency levels and guidelines Sets the competency levels and guidelines Carries out assessments at the National level Carries out assessments at the National level Makes recommendations on whether a Resident should be considered qualified Makes recommendations on whether a Resident should be considered qualified Identifies personnel for support groups Identifies personnel for support groups

30. National Coordinator Routine administration of the training program Routine administration of the training program Monitoring training: Monitoring training: Site visits Site visits Assisting with Assisting with Clinical rotations Clinical rotations External competency tests External competency tests Study groups Study groups

31. National Coordinator Initiate national training initiatives (workshops, forum at conferences, etc) Initiate national training initiatives (workshops, forum at conferences, etc) Development and coordination of training infrastructure Development and coordination of training infrastructure Supporting residents Supporting residents Coordinating the development of and access to training resources eg. Coordinating the development of and access to training resources eg. Inter-centre training days Inter-centre training days Assignments Assignments e-learning e-learning Investigating and resolving issues or complaints from Residents Investigating and resolving issues or complaints from Residents

32. Clinical Training

33. Training Pathway Observes new task Observes new task Covers background knowledge Covers background knowledge Performs task supervised Performs task supervised Assesses task supervised Assesses task supervised Review how task was performed Review how task was performed Assesses unsupervised Assesses unsupervised Performs unsupervised as part of duties Performs unsupervised as part of duties

34. Professional Training Know basics before more complex tasks and clinical responsibility are assigned Know basics before more complex tasks and clinical responsibility are assigned Assessment criteria should reflect professional competency as the level of experience increases: Assessment criteria should reflect professional competency as the level of experience increases: Define a problem and formulate strategies for solving it Interpret novel or non-standard data Make value judgements in unfamiliar situations Communicate scientific advice clearly and accurately to others Recognise fault situations and take suitable corrective action Appreciate the limitations of one’s knowledge  Encourage/facilitate training experiences where the Resident can develop and demonstrate these qualities

35. Level of Supervision TIME

36. Importance of the Clinical Supervisor Quality education and training is an investment in your department’s service to cancer patients. Quality education and training is an investment in your department’s service to cancer patients. A Supervisor using this programme, even to a small degree, will improve the training that is currently being performed in your country. A Supervisor using this programme, even to a small degree, will improve the training that is currently being performed in your country. The resident should re-pay the time spent training: The resident should re-pay the time spent training: The resident is a worker, NOT a student The resident is a worker, NOT a student Residents must be self directed Residents must be self directed A resident’s contribution will increase more quickly with a good training program A resident’s contribution will increase more quickly with a good training program At least 1 supervisor per centre is essential At least 1 supervisor per centre is essential

37. “Handbook for Clinical Supervisors of Residents in the RCA Clinical Training Programme for ROMPs”

38. Nature of a Supervisor Manager Manager Instructor Instructor Observer Observer Mentor (if Resident chooses and appropriate) Mentor (if Resident chooses and appropriate) Giver of feedback Giver of feedback Assessor Assessor

39. Responsibility of a Supervisor Ensuring that the Resident is trained in all aspects of radiation oncology medical physics to a standard acceptable to the profession. Don’t have to do all the training and assessments Appoint suitably qualified specialists to train various competencies Supplement a Resident’s clinical duties with probing questions to test the depth of understanding, such as “Why are you doing the task that way?” “What aspects of the task has the greatest clinical impact?” “How do you think you went?” Reflect on what helped you learn!

40. Acceptance of Supervision Role Role of Supervisor must be mutually agreed to by Supervisor, Head of Department and Regional Coordinator Role of Supervisor must be mutually agreed to by Supervisor, Head of Department and Regional Coordinator Enthusiasm, confidence and organisation of the Supervisor is very important Enthusiasm, confidence and organisation of the Supervisor is very important Supervisor should be a life-long learner Supervisor should be a life-long learner Head of department must Head of department must Adjust for additional workload of the Supervisor at least until the Resident repays time by assuming more responsibilities. Adjust for additional workload of the Supervisor at least until the Resident repays time by assuming more responsibilities. Provide access to training resources Provide access to training resources Foster relationships with internal and external Departments for clinical rotations and external assessments Foster relationships with internal and external Departments for clinical rotations and external assessments

41. Regular meetings Meet regularly with the Resident to Discuss progress Review training plan, particularly deadlines Allocate resources Provide guidance as to how to achieve competency Update assessment matrix Provide adequate supportive and corrective feedback Level of competency to achieve Competency achievements which have fallen behind.

42. Reporting Ensure that the Resident’s clinical training and performance is monitored, documented, assessed and reported as required. Provide reports (as required eg. 6 monthly) on the Resident’s progress to the National Programme Coordinator.

43. Clinical Rotations Departments approach each other directly Departments approach each other directly Experience in Experience in Techniques or equipment not available in Department Techniques or equipment not available in Department Eg. brachytherapy, CT scanner, IMRT, different linac Eg. brachytherapy, CT scanner, IMRT, different linac Radiology and Nuclear Medicine Radiology and Nuclear Medicine If physicist not on site, may be under supervision of Radiographer, Radiologist, etc If physicist not on site, may be under supervision of Radiographer, Radiologist, etc Pre-requisite knowledge Pre-requisite knowledge Objectives should be documented beforehand Objectives should be documented beforehand External competency test optional External competency test optional Day visits to months Day visits to months “Buddy system” versus job exchange “Buddy system” versus job exchange

44. Assessment Assessment should be Assessment should be Fair Fair Robust (valid) Robust (valid) Uniformly applied (reliable) Uniformly applied (reliable) Transparent to Resident Transparent to Resident Provision of feedback Provision of feedback Feedback should be non-judgemental, specific, focussed on changeable behaviour, prompt and private Feedback should be non-judgemental, specific, focussed on changeable behaviour, prompt and private Acknowledgement of ROMP attributes and not just technical skills Acknowledgement of ROMP attributes and not just technical skills

45. Use the Competency Assessment Guide

46. Assessment The assessment guide methodology allows the Resident to see progress made during the program. The assessment guide methodology allows the Resident to see progress made during the program. It shows how the Resident is progressing in taking on more responsibility and the decreasing level of supervision. It shows how the Resident is progressing in taking on more responsibility and the decreasing level of supervision. It is a motivational tool to both the Resident and the Supervisor. It is a motivational tool to both the Resident and the Supervisor.

47. Examples of Assessment Tools Observe and question during clinical work Observe and question during clinical work Resident to teach someone else or give presentation Resident to teach someone else or give presentation Mock scenarios Mock scenarios Written, oral and practical assessment Written, oral and practical assessment Logbook review Logbook review Patient or equipment scenario case studies Patient or equipment scenario case studies Clinical project work Clinical project work List steps and aspects of greatest clinical impact of the task List steps and aspects of greatest clinical impact of the task Portfolio reports Portfolio reports Problem based learning or tutorial programme Problem based learning or tutorial programme Competency assessments Competency assessments

48. Logbook Suggest that it is not assessable but kept as a record Suggest that it is not assessable but kept as a record Multi-purpose Multi-purpose Supervisor can monitor range and frequency of activities over time Supervisor can monitor range and frequency of activities over time Reference for retrospectively writing up of work Reference for retrospectively writing up of work Validation of competency completion - can list activities under competency headings instead of a chronological record of activities Validation of competency completion - can list activities under competency headings instead of a chronological record of activities Format Format Soft copy (chronological record of activities) or Soft copy (chronological record of activities) or Hard copy (workbook) Hard copy (workbook)

49. Final Oral vs Practical Assessment Oral Oral Quicker and easier Quicker and easier Tests knowledge but not competency Tests knowledge but not competency Requires a lot of preplanning Requires a lot of preplanning Practical Practical Best way of testing the competency of an individual Best way of testing the competency of an individual Very personnel and resource intensive Very personnel and resource intensive Typically requires half a day Typically requires half a day Ideal for small numbers; say 4 over a weekend Ideal for small numbers; say 4 over a weekend

50. Practical Exam This is an assessment on the clinical competency of the physicist. This is an assessment on the clinical competency of the physicist. Professional, not just technical Professional, not just technical An awareness of the relevance of the question to the bigger picture of correctly treating patients An awareness of the relevance of the question to the bigger picture of correctly treating patients It is not designed to test the theoretical knowledge It is not designed to test the theoretical knowledge

51. Practical Exam Assumption You are a consultant radiation oncology physicist brought into this hospital to carry out the following tasks. You are a consultant radiation oncology physicist brought into this hospital to carry out the following tasks. For each assignment, you must describe to the examiners what you intend to do and how it will be done as you undertake the work. For each assignment, you must describe to the examiners what you intend to do and how it will be done as you undertake the work. Any assumptions that you make must be disclosed to the examiners. Any assumptions that you make must be disclosed to the examiners.

52. Practical Exam – Examples The department has just taken delivery of a new parallel plate ionisation chamber. You have been asked to calibrate the chamber for determining absorbed dose in photon beams. The department has just taken delivery of a new parallel plate ionisation chamber. You have been asked to calibrate the chamber for determining absorbed dose in photon beams. The couch of an ageing linear accelerator has been completely reconditioned. You have been asked to perform the tests needed prior to returning the linear accelerator to clinical use. You should carry out these tests in order of importance. The couch of an ageing linear accelerator has been completely reconditioned. You have been asked to perform the tests needed prior to returning the linear accelerator to clinical use. You should carry out these tests in order of importance.

53. Practical Exam – Examples As part of the regular Quality assurance checks for the superficial X-ray machine, you are required to measure the half-value-layers for the treatment unit. As part of the regular Quality assurance checks for the superficial X-ray machine, you are required to measure the half-value-layers for the treatment unit. You have just been presented with a new 60° wedge. Determine the 6 MV wedge factor. You have just been presented with a new 60° wedge. Determine the 6 MV wedge factor. Following repairs to the light system and blades on the simulator, carry out the appropriate acceptance tests before the simulator can be returned to clinical use. Following repairs to the light system and blades on the simulator, carry out the appropriate acceptance tests before the simulator can be returned to clinical use.

54. Pilot Testing of the Program Stage 1 Stage 1 Thailand is testing the documentation and concepts Thailand is testing the documentation and concepts Stage 2 Stage 2 To test the entire program (over two years) To test the entire program (over two years) To help develop clinical training programs in a number of countries To help develop clinical training programs in a number of countries

55. Pilot Testing – Stage 2 The IAEA has called for expressions of interest to participate in Stage 2. The IAEA has called for expressions of interest to participate in Stage 2. The Philippines have applied The Philippines have applied Several other countries have commenced discussion Several other countries have commenced discussion

56. Implementation Guide for the Pilot Program management Entry requirements for a resident Department requirements

57. Program Management of the Pilot - Minimum Professional Body Professional Body National Program Coordinator National Program Coordinator Oversees the implementation of the project. Clinical supervisor Each department must have at least one RCA External Management Coordinator RCA External Management Coordinator RCA/IAEA

58. Resident Clinical Supervisor External Coordinator External Reviewers RCA/IAEA National Responsible Authority Clinical Department Mentor National Steering Committee National Coordinator Programme Coordination of Pilot Program

59. Department Requirements for Pilot Program The clinical department must: Have a clinical supervisor who is trained in radiation oncology medical physics Have a full range of equipment (or access) Employ medical practitioners trained in radiation oncology Offer a full range of clinical services More than one department can be included from a country

60. Entry Requirements for Residents To enter this pilot program a person must: Have a basic undergraduate degree in physics or equivalent Alternative qualifications which are acceptable to the local authorities and the RCA will be considered Be undertaking or completed a post graduate degree in medical physics or equivalent Be employed as a medical physicist in a department and send to the National Program Coordinator. Fill out the “Application for Entry as a Resident to the Clinical Training Programme in Radiation Oncology Medical Physics” and send to the National Program Coordinator.

61. For Successful Implementation Robust training program Robust training program Documentation Documentation Support at the National level Support at the National level Government Government Regulatory bodies Regulatory bodies Bureaucracy Bureaucracy Professional organisations Professional organisations Support at the local level Support at the local level Hospital Hospital Department Department Infrastructure Infrastructure University University Committed clinical trainers (supervisors) Committed clinical trainers (supervisors)

62. Role of RCA/IAEA Appoints the RCA Management Coordinator Appoints the External Reviewers

63. Application If interested, talk to: If interested, talk to: Your National Project Coordinator Your National Project Coordinator Mr. Prinath Dias, IAEA, m.p.dias@iaea.org Mr. Prinath Dias, IAEA, m.p.dias@iaea.org m.p.dias@iaea.org Prof. Brian Thomas, Coordinator, bj.thomas@qut.edu.au Prof. Brian Thomas, Coordinator, bj.thomas@qut.edu.au bj.thomas@qut.edu.au Me! john.drew@internode. on.net Me! john.drew@internode. on.net Up to end of 2008. Up to end of 2008.

64. It is too Hard to Start! Where do I start? Where do I start? “It is too difficult to do all this” “It is too difficult to do all this” “We do not have the staff/money/time” “We do not have the staff/money/time” “We are OK” “We are OK” Add your own excuses Add your own excuses Step by step Step by step Think where you want to go Think where you want to go Take the first step Take the first step

65. Planned Extension to the Project In 2007/08 the focus of the medical physics training will move to radiology and nuclear medicine (imaging). In 2007/08 the focus of the medical physics training will move to radiology and nuclear medicine (imaging). New Expert Steering Groups and Program Developments teams will be formed for each specialty. New Expert Steering Groups and Program Developments teams will be formed for each specialty.

66. RAS6038 - Project Impact Improvement in education and training will produce more: Improvement in education and training will produce more: Which will: Which will: Improve the quality of medical physics services Improve the quality of medical physics services Enhance professional status Enhance professional status Qualified Radiation Oncology Medical Physicists