Yi Rong

Artificial intelligence will reduce the need for clinical medical physicists

In 2011, IBM’s supercomputer Watson defeated the former human winners and won the first prize on Jeopardy! game. It has created an overly publicized attention on machine learning and Artificial Intelligence (AI). Early this year, Google AlphaGo has marked a major breakthrough in AI by winning the first game against the world’s best champion human player in the world’s most complex game, the ancient Chinese Go game. With no doubt, the interests in AI and its related products had reached a global frenzy. As scientists advance in technology, a concern of job security has risen up: will robots take our jobs? IBM Watson has evolved from a “question answering machine” to a highly intelligent “cognitive diagnostic engine” or a “decision support system” over the past 6 yr. Based on Carl Frey and his collaborators, future family health centers may transition to a team of nurse practitioners with the support of Watson Health and overseen by one single doctor. Will AI technology also marginalize medical physicists in the near future? In this series, we have Dr. Xiaoli Tang arguing for the proposition that “AI will reduce the need for clinical medical physicists” and Dr. Brian Wang arguing against it. Dr. Xiaoli Tang received a Ph.D in Electrical Engineering from the Rensselaer Polytechnic Institute. She then did her postdoctoral training in Medical Physics at the Massachusetts General Hospital and the University of California at San Diego. She previously worked at the University of North Carolina and now is working as an Assistant Attending and chief physicist at the Memorial Sloan Kettering Cancer Center Westchester regional site. She is an expert in motion management, Deep Inspiration Breath Hold (DIBH) for left-sided breast cancer, and machine learning algorithms on medical physic applications. She is interested in developing related clinical trials, and bringing new technology to the clinic. She is a member of the American Association of Physicists in Medicine (AAPM), and the American Society for Radiation Oncology. Dr. Brian Wang received his PhD in nuclear engineering from Rensselaer Polytechnic Institute in Troy, NY in 2005. He currently works at University of Louisville as the chief of physics and medical physics residency director. Dr. Wang is an associate editor for the JACMP. His research interests include motion management, image guidance, and SRS/SBRT. Dr. Wang has been involved with the AAPM Spring Clinical Meeting and its predecessor ACMP annual meeting as a program director or the subcommittee chair for 8 yr. Dr. Wang serves on several committees at ASTRO, RSS, and ABR.

3D printing technology will eventually eliminate the need of purchasing commercial phantoms for clinical medical physics QA procedures

3D printing is not a new concept. The recent advances in printing speed, technology, and material selection are promoting its significant impacts in several industries, including health care. For our medical physics field, researchers are also finding its applications in various clinical aspects. However, the interests still remain in a few academic centers who have the luxuries of owning such an unconventional device in the radiation oncology department, or collaborating with a local 3D printing lab. As the 3D printing technology is becoming an unstoppable driving force in manufacturing revolution, are we also envisioning a future that 3D printing will become as common as a block‐cutting machine in a radiation oncology department? In this debate, we invited two researchers who are experienced in studying the clinical use of 3D printing in medical physics field. Dr. Eric Ehler is arguing for the proposition that “3D printing technology will eventually eliminate the need of purchasing commercial phantoms for clinical medical physics QA procedures” and Dr. Daniel Craft is arguing against. n nDr. Eric Ehler is an Assistant Professor in the Department of Radiation Oncology at the University of Minnesota. He is the medical physics residency program director at the University of Minnesota Medical Center. His education and research interests are 3D printing, pediatric radiotherapy, radiation dosimetry, and machine learning. n nDr. Daniel Craft is currently a medical physics resident at The Mayo Clinic in Phoenix, AZ. Prior to the beginning of his residency, Dr. Craft was a graduate research assistant and PhD student at the University of Texas MD Anderson Cancer Center in Houston Texas, where he studied techniques to deliver postmastectomy radiation therapy using 3D printed patient‐specific tissue compensators. He completed his Ph.D. in Medical Physics in May, 2018, and also holds an undergraduate degree in Physics from Brigham Young University.

Are in-house diagnostic MR physicists necessary for clinical implementation of MRI guided radiotherapy?

In the most recent years, magnetic resonance imaging (MRI) has showed promising values in MR-guided radiotherapy (MRgRT) for both brachytherapy and external beam treatments, Thanks to its distinct imaging ability for soft tissue contrast and target identification. However, MRI technology has not been mostly included as part of the required curriculum for a therapy track medical physicist. Lack of sufficient knowledge and proper training may pose obstacles or even safety concerns for those early MRgRT adopters. One of the arguments stands in “the need of hiring in-house diagnostic MR physicists for clinical implementation of MRgRT.” Herein, we have Dr. Minsong Cao arguing for this proposition and Dr. Kyle Padgett against. Dr. Minsong Cao is an Associate Professor of Clinical Radiation Oncology at University of California, Los Angeles. He received his Ph.D. in Medical Physics from Purdue University and subsequently worked in the Department of Radiation Oncology at Indiana University before moving to his current position at UCLA. Dr. Cao has been actively involved in the early adoption and clinical implementation of MRgRT at UCLA. Dr. Kyle Padgett is an Assistant Professor of Radiation Oncology and Radiology at the University of Miami, Miller School of Medicine and is the Director of imaging services for Radiation Oncology. Prior to becoming a clinical physicist, Dr. Padgett was the director of the High-Field MRI Research Facility at the University of Miami focusing on preclinical research in the areas of cancer and spinal cord injury, among others. He holds a Ph.D. in Medical Physics and an undergraduate degree in Physics from the University of Florida. 2 | OPENING STATEMENTS

Medical physicists should meet with patients as part of the initial consult

These days cancer patients who have been advised to consult a radiation oncologist are generally very Internet savvy, and they are highly likely to go online and search for the “best” doctor, the “best” cancer clinic, the “best” treatment regimen, and/or the “best” available technology for their specific disease. Despite all of this Internet access and searching strategies, it is unlikely that they will consider searching for the “best” and most qualified physicists (or physics team). Frankly, most of the public probably don’t even realize the existence of medical physicists, not to mention the importance of our responsibilities in working with the radiation oncologists to provide high quality, reliable, and safe radiation therapy. As medical physicists and dosimetrists, we work with nurses, therapists, physicians, and a wide range of professionals for the care of our patients. However, since our work is largely technical and performed without patients’ present (e.g., treatment planning on computers and patient-specific quality assurance measurements on phantoms), we might be the only team members with zero direct contact with the patients. In an effort to increase the awareness of our profession and substantial role in the clinic, the AAPM Public Education Committee has been making efforts to promote public education in matters pertaining to medical physics. What more can we do? Well, would it be a good idea to increase medical physicists’ roles in patients’ consults? For this debate, we have Dr. Brad Schuller arguing for the topic that Medical physicists should meet with patients as part of the initial consult, and we have Dr. Kristi Hendrickson arguing against it. Dr. Brad Schuller received his PhD in radiation biophysics from the Department of Nuclear Science and Engineering at MIT in 2007. He then completed his postdoctoral training in therapeutic medical physics at the Massachusetts General Hospital and Boston Medical Center. He currently works for Banner Health at McKee Medical Center in Loveland, CO and is board certified by the ABR. Dr. Schuller’s current research focuses on prospective risk management and exploring new roles for medical physicists in clinical practice. He is a member of AAPM and ASTRO and serves on several AAPM committees. Dr. Kristi Hendrickson is currently an Assistant Professor of Medical Physics at the University of Washington in Seattle. She is the Director of the Medical Physics Residency Program in Therapy Physics at UWMC, which includes four total residents and 17 physics faculty mentors. Her education interests focus on medical physics residency training. She is interested in curriculum development and sharing those ideas with other institutions and programs, as evidenced in her publication and sessions created for the annual AAPM meetings. Her research interests include bioinformatics, SBRT, functional imaging, and neutron therapy. Her current AAPM committee involvement includes the Women’s Professional Subcommittee and the Medical Physics Residency Training and Promotion Subcommittee. She previously served as on the course director team of the 2014 AAPM Summer School on SRS/SBRT/SABR.

Parallel/Opposed Editorial: DMP/residency programs are more sustainable than MPAs for the future of the medical physics profession

Medical Physics has been a popular profession to enter for science program graduates, which include students from medical physics, physics, biomedical engineering, chemistry, etc. For many years, there were minimal academic limitations for students that graduated from a nonmedical physics program to get into this profession. However, things have changed since the American Board of Radiology (ABR) created strict eligibility requirements for taking the certification examinations, with the completion of a CAMPEP (Commission on Accreditation of Medical Physics Education Programs) accredited graduate program beginning in 2012 and a CAMPEP accredited residency program beginning in 2014. Meanwhile, the first Professional Doctorate in Medical Physics (PDMP or DMP for simplicity) was established and admitted their first student in the Fall of 2009. The same program received CAMPEP accreditation in the following year. Also, around the same time, the concept of Medical Physicist Assistants (MPA) was introduced into our field first in the diagnostic subfield and then legitimized in the Medical Physics profession in 2013 through the formation of Medical Physics Practice Guideline (MPPG)‐3. Residency continues to be a mainstream option for most eligible graduates, yet the existence of DMP and MPA has brought heated debates in the past years. As it is approaching a 10‐yr mark since the inception of DMP/MPA, a decline in DMP positions and an increase in MPAs have been observed in our field. This begs the question: “whether DMP/residency or MPA is sustainable for the future of the medical physics profession?” Herein, we have invited Dr. Chengyu Shi arguing for the proposition that “DMP/residency programs are more sustainable than MPAs” while Dr. Brent Parker argues against it. n nDr. Chengyu Shi is an associate attending medical physicist, and the lead physicist overseeing clinical physics operations at Memorial Sloan Ketterings outpatient locations in Basking Ridge and Monmouth, New Jersey. His research interests are in Monte Carlo simulation, virtual human phantom development and applications, special treatment techniques including stereotactic body radiotherapy, stereotactic radiosurgery, and more. Dr. Shi received his Ph.D. (2004) in nuclear engineering and science from Rensselaer Polytechnic Institute in Troy, New York, and finished his residency training at the University of Arkansas for Medical Sciences. He taught and mentored residents at the University of Health Science Center at San Antonio, Texas, for several years. n nDr. Brent Parker obtained his Ph.D. (2004) and M.S. (2001) in Medical Physics from the University of Texas Health Science Center at Houston and M.D. Anderson Cancer Center Graduate School of Biomedical Sciences and his B.S. (1997) in Physics from Louisiana Tech University. He has been involved in both clinical and academic medical physics in his entire career. Although arguing against the presented statement, he is a proponent of medical physics residency programs. He helped establish the Medical Physics Residency Program at Mary Bird Perkins Cancer Center in Baton Rouge, LA and served as its Program Director. He is currently an Associate Professor and the Director of Physics in the Department of Radiation Oncology at the University of Texas Medical Branch in Galveston, TX. Dr. Parker has served the AAPM at both the national and chapter levels in a variety of committee and elected positions. He is certified by the American Board of Radiology in Therapeutic Radiologic Physics.

CAMPEP graduate program standards should require a dedicated course in Magnetic Resonance Imaging physics

In a previous parallel opposed editorial, a heated debate was conducted on the topic whether an in-house diagnostic Magnetic Resonance Imaging (MRI) physicist is needed for a radiation oncology department, considering the increased use of MRI-guided radiotherapy. Interestingly, upon being presented with this topic, the therapy physicist chose to argue for the proposition, while the MRI physicist argued against. As a therapeutic physicist myself, I attribute that to the human nature of “we all fear what we do not understand.” The use of MRI infiltrates every aspect of radiotherapy, that is, diagnosis and staging, target definition, treatment planning, and more recently onboard image guidance for treatment delivery. The more we employ MRI in radiotherapy, the more we feel short in our fund of knowledge of MRI physics. Undoubtedly, “hiring an in-house diagnostic MR physicist” would alleviate this feeling of inadequacy, but it is logistically difficult to justify from a practical standpoint, considering the substantial financial commitment of hiring a dedicated MRI physicist to complement our staff of therapy physicists. As pointed out by the opposing side, one viable alternative would be to join in collaboration with colleagues in radiology when MRI expertise is needed. Yet that also involves logistical considerations in terms of shared cost for the personnel, responsibility, liability, scheduling, etc. Considering most therapeutic physicists lack a full and satisfactory MR knowledge, would it be an appropriate response for CAMPEP to mandate dedicated MRI courses within graduate medical physics programs? Herein, Dr. David Jordan is in support of the idea that “CAMPEP graduate program standards should require a dedicated course in Magnetic Resonance Imaging physics,” while Dr. Jing Cai argues against it. Dr. David Jordan is a senior medical physicist at University Hospitals Cleveland Medical Center and Associate Professor of Radiology at Case Western Reserve University in Cleveland, Ohio. He is certified in Diagnostic Medical Physics, Nuclear Medicine Physics, and MRI Physics, and as a MR Safety Expert. He is active as the chair of the MR subcommittee for AAPM and serves as a board member for the American Board of Magnetic Resonance Safety and the International Accreditation Commission (IAC) MRI Accreditation Program. His main interests are MRI, dual-energy CT, nuclear medicine, and radiology and medical physics resident education. Dr. Jing Cai is currently an Associate Professor at Hong Kong Polytechnic University. Dr. Cai received his PhD degree in Engineering Physics in 2006 and completed his Medical Physics residency in 2009 from the University of Virginia. Afterward, Dr. Cai joined Duke University from 2009 to 2017 as a faculty physicist. Dr. Cai has published more than 70 referred journal articles and over 200 conference abstracts. Dr. Cai’s research is focused on developing and clinically implementing novel image-guided radiation therapy (IGRT) techniques, with an emphasis on MRI, and has received a number of federal, charitable, and industrial funding.

Robust optimization in lung treatment plans accounting for geometric uncertainty

Abstract Robust optimization generates scenario‐based plans by a minimax optimization method to find optimal scenario for the trade‐off between target coverage robustness and organ‐at‐risk (OAR) sparing. In this study, 20 lung cancer patients with tumors located at various anatomical regions within the lungs were selected and robust optimization photon treatment plans including intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) plans were generated. The plan robustness was analyzed using perturbed doses with setup error boundary of ±3 mm in anterior/posterior (AP), ±3 mm in left/right (LR), and ±5 mm in inferior/superior (IS) directions from isocenter. Perturbed doses for D99, D98, and D95 were computed from six shifted isocenter plans to evaluate plan robustness. Dosimetric study was performed to compare the internal target volume‐based robust optimization plans (ITV‐IMRT and ITV‐VMAT) and conventional PTV margin‐based plans (PTV‐IMRT and PTV‐VMAT). The dosimetric comparison parameters were: ITV target mean dose (Dmean), R95(D95/Dprescription), Paddicks conformity index (CI), homogeneity index (HI), monitor unit (MU), and OAR doses including lung (Dmean, V20 Gy and V15 Gy), chest wall, heart, esophagus, and maximum cord doses. A comparison of optimization results showed the robust optimization plan had better ITV dose coverage, better CI, worse HI, and lower OAR doses than conventional PTV margin‐based plans. Plan robustness evaluation showed that the perturbed doses of D99, D98, and D95 were all satisfied at least 99% of the ITV to received 95% of prescription doses. It was also observed that PTV margin‐based plans had higher MU than robust optimization plans. The results also showed robust optimization can generate plans that offer increased OAR sparing, especially for normal lungs and OARs near or abutting the target. Weak correlation was found between normal lung dose and target size, and no other correlation was observed in this study.

The more IGRT systems, the merrier?

The field of radiotherapy (RT) has benefited substantially from advancements in Image‐Guided Radiotherapy (IGRT) in the past 15 years. IGRT now constitutes the integration of a wide range of imaging technology with modern RT delivery systems that include 3D anatomical and functional‐based imaging for tumor volume identification, 3D target volume localization, and motion management information for precise patient setup and monitoring.1, 2 To streamline this complex process, system integration of planning and delivery with multimodality IGRT technologies is now a primary selling point for vendors. This integration becomes more complex with the increased number of image‐guided patient positioning and motion management options. Current IGRT technologies include not only various x‐ray based imaging systems but also other modalities, such as video/infrared (IR) cameras, ultrasound (US), and electromagnetic field systems. The capital purchase decision makers at hospitals welcome tools that allow for improved image guidance when it is consistent with their strategies for return on investment. But this may raise multiple issues that need to be addressed by medical physicists, including safe and practical implementation and commissioning, personnel qualification and training of staff, updates and servicing to ensure integration between systems, and of course reimbursement constraints. This brings us to our debate topic: Will more IGRT systems implemented in the clinic lead to better outcomes for RT treatments? n nArguing for the proposition is Dr. Baozhou Sun. Dr. Sun is an assistant professor and chief of quality assurance services of radiation oncology at Washington University in St. Louis. He earned his Ph.D. in applied science from the College of William and Mary in 2005. Dr. Sun finished his medical physics residency training at Washington University in St. Louis in 2012 and became a faculty member at the same institution. He is certified in Therapeutic Radiological Physics by the American Board of Radiology. His research interests include quality assurance, proton therapy, imaging‐guided radiation therapy, and medical informatics. n nArguing against the proposition is Dr. Jenghwa Chang. Dr. Jenghwa Chang received his Ph.D. in electrical engineering from Polytechnic University and is an ABR‐certified medical physicist. He is currently an Associate Professor at Radiation Medicine of Northwell Health supervising the training/education of medical/physics residents and overseeing the quality assurance program for physics. Previously Dr. Chang held positions with Weill Cornell Medical College, NYU Langone Medical Center, and Memorial Sloan‐Kettering Cancer Center. He is also a physicist surveyor for ACR Radiation Oncology Practice Accreditation (ROPA) program. His research interest includes optical diffusion tomography, Electronic Portal Imaging Device (EPID) dosimetry, MV/kV cone beam CT (CBCT), magnetic resonance imaging (MRI)‐guided treatment planning, panoramic CBCT, and setup uncertainty of single isocenter for multiple targets technique.

Globalism versus Nationalism in Medical Physics

Nowadays we medical physicists are bombarded with guidelines and task reports, and we may see similar ones from different organizations in the United States of America or worldwide. Many extraordinary and diligent medical physicists have devoted their time and knowledge in creating these documents. Yet some of us might be wondering: should we optimize the use of our resources by establishing a global medical physics society? One global medical physics organization may eliminate redundancies and improve cost-effectiveness. However, it may also bring in inefficiency, lack of diversity, or poor environmental adaptation. Our debate topic in this issue is: A global medical physics organization in science, education, professional, and administrative structures will result in greater advancement of the medical physics profession. Arguing for the proposition is Scott Dube. Mr. Scott Dube is a solo medical physicist at Morton Plant Hospital in Clearwater, FL. He is also on the faculty of Radiological Technologies University and enjoys teaching aspiring medical physics and medical dosimetry students. Arguing against the proposition is Jeroen van de Kamer. Mr. Jeroen van de Kamer is a medical physicist working at the Netherlands Cancer Institute at the department of radiation oncology. Together with his colleagues, he is involved with linac and patient-specific QA, the clinical use of PET/CT, and the continuous development of the treatment for head and neck cancer. Jeroen is chair of the Netherlands Commission on Radiation Dosimetry, a Dutch–Belgium consortium of scientist aiming to promote the appropriate use of dosimetry of ionizing radiation. He was course director of the 2016 pre-meeting ESTRO course “Multidimensional dosimetry systems.” Jeroen is a member of the advisory board of the Dutch Metrology Institute VSL. 2 | OPENING STATEMENT

MBA degree is needed for leadership roles in Medical Physics profession

Medical Physics 3.0 (MP3.0) advocates that the roles of medical physics need to be redefined and reinvigorated, and furthering leadership roles was identified as a key focus. Inevitably, most medical physicists are called upon to be actively involved in major decision making at their place(s) of business, and this includes managing human resources, administrative oversight, consulting, budgeting, grand capital purchasing, and strategic planning, all of which are duties that require a wide array of leadership qualities. In an effort to address the need to improve leadership in the medical physics profession, the AAPM Summer School in 2016 provided a focused and hands-on environment for medical physicists who had interests in developing their leadership and management skills. As an outgrowth of these activities, the AAPM has formed a Leadership Academy Working Group on providing resources and course training for medical physicists to further improve those skills. These approaches to improve leadership among our AAPM members are surely helpful, but are they sufficient? In that regard, many of our physician colleagues have adopted a different tactic, and it is common to see dual degree of M.D./M.B.A.. I herein take a notion for this debate, and we pose the question: is an MBA degree needed for leadership roles in Medical Physics profession? To address the question from different perspectives, Dr. Alonso N. Gutierrez argues for the proposition that “an MBA degree is needed for leadership roles in Medical Physics profession”, and Mr. Per H. Halvorsen argues against. Dr. Alonso N. Gutierrez received his Ph.D. in Medical Physics from the University of Wisconsin-Madison in 2007, his M.B.A. in Business of Health from the University of Texas San Antonio in 2016 and was certified by the American Board of Radiology in 2010. He is currently Chief Physicist for the Department of Radiation Oncology at the Miami Cancer Institute where he oversees both the photon and proton physics divisions. Additionally, he serves as an Associate Professor and Vice Chair of the Department of Radiation Oncology at Florida International University (FIU) Herbert Wertheim College of Medicine. Dr. Gutierrez has authored and co-authored a number of peer-reviewed journal articles and has been an active volunteer in professional societies serving on multiple AAPM committees, chairing the ACR TXIT physics section, and serving as an item writer for ABR. Mr. Per H. Halvorsen received his M.S. in Radiological Medical Physics from the University of Kentucky in 1990, and was certified by the American Board of Radiology in 1995. He has practiced in large academic and community hospital settings, including a term as Vice President of Medical Physics for a company operating Radiation Oncology centers nationwide. He is currently Chief Physicist in Radiation Oncology at Lahey Health in suburban Boston. Mr. Halvorsen has been an active volunteer in professional societies, chairing the Professional Council of the AAPM and serving on the Board of Directors. He is a volunteer surveyor for the American College of Radiology, serving on its accreditation program oversight committee for many years. He is Associate Editor-in-Chief of the open-access JACMP.