Journal of Applied Clinical Medical Physics | 2019
Continued emphasis on quality and safety jeopardizes clinical medical physics careers in radiation oncology: What can be done about it?
Abstract
This editorial arose out of a project with the AAPMWorking 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. 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 physics 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. 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