Jerry Battista, Professor Emeritus, University of Western Ontario
Coordinator, Medical Physics Education Program, Cancer Care Ontario
An article published in Medical Physics (Fontenla, Doracy P., Gary A. Ezzell, and Colin G. Orton (moderator). Medical Physics 43 (1), 1-3 (2016)) presented a debate on the proposition “Medical physicist assistants are a bad idea.” Both sides presented their perspective, which I have paraphrased in the boxes below:
1. Bowing to Financial Pressure. In view of escalating salary levels for certified medical physicists, some duties have been delegated to “computer-savvy” radiation therapists, dosimetrists, and medical physics associates.
2. Delegation of Duties. Device-oriented work is patient-oriented work. They cannot be split.
3. Job Displacement. Associates are blocking job opportunities for junior medical physicists, especially recent graduates of CAMPEP residency programs.
4. Quality of Service. Staff with a B.Sc. degree (minimum) may lack depth of knowledge in some facets of medical physics. There is evidence of “bad outcomes” with delegation of clinical duties.
“Good Idea” – Counterpoint
1. Allocation of proper resources to the proper tasks is a cost-effective response to financial pressures. The right balance must be struck.
2. Device-oriented tasks can be identified and delegated. Patient-oriented tasks remain under the official responsibility a qualified medical physicist.
3. Serving society in a cost-effective manner trumps the protection of jobs.
4. Certified dosimetrists have provided excellent service as experts in a highly specialized delineated task. There has been no evidence of “bad outcomes” from this delegation. Redistribution of tasks frees up clinical physicists to engage in clinical procedures, conceive new imaging or treatment techniques, and stay abreast of rapidly changing technology. Team effort leads to timely and state-of-the-art services to cancer patients.
The Medical Physics article evoked a thorough and thoughtful response by a medical physics associate, Silvia Neuteboom of the Ottawa Hospital Cancer Center, published in InterACTIONS (April 2016) and broadcast on-line (https://ompac.ca). Silvia added a Canadian perspective and reinforced the counterpoint position. Her position largely coincides with my own point of view. Allow me to elaborate on Silvia’s commentary, and add an extra point (5) on the important educational role of associates:
1) Medical physics associates form a minority group in medical physics departments, but they have had a disproportionately large positive impact on their day-to-day function.
2) The assignment of specific tasks is practically achievable, with an appropriate level of supervision and understanding of “knowing one’s limits”. Medical physics associates share the workload with medical physicists, particularly in providing timely quality assurance (QA) of dosimetry for patient-specific procedures and radiation-producing equipment. Some associates also provide computational QA assistance, such as verification of dose distributions using Monte Carlo techniques.
3) It is true that recent graduates from clinical physics residency programs have experienced some delay in finding permanent work. This is more reflective of general economic conditions, and the elimination of mandatory retirement.
4) Medical physics associates enable physicists to do “what they can do best and what they are trained for”. Moreover, this activity can occur during clinical hours, including consultation with radiation oncologists, thinking, innovating, and educating. This fosters quality-of-service, job satisfaction, and adds stability to the workforce.
5) Associates also play an important role in hands-on training of university students (BSc/MSc/PhD) and post-graduate medical physics residents. They share ideas and equipment during the “evening shift”. This adds experiential learning to didactic courses – a paradigm for effective learning and longer-term retention of knowledge.
During my career in medical physics across Canada, concerns were raised when dosimetrists started to “infiltrate” medical physics territory. With eventual standardization of job credentials and certification, dosimetrists have evolved as cost-effective, valued, and trusted members of the medical physics team. The same is already true for medical physics associates, but progression to a nationally-recognized certification model remains very important. We work in a patient-focused environment, sensitized to medical risks and litigation. There is more to the division of labour – one must share the responsibility with mutual respect, and with clear lines of communication and authority across disciplines. It may be worthwhile to take a step back and consider the “bird’s eye view”. Radiation therapy is a multidisciplinary clinical procedure that has benefited humanity for over a century. Teams succeed when they share a common goal, engage in mutual respect, and have the support of a visionary leader. In the medical field, duties and responsibilities are split across medical doctors, registered nurses (RNs), and now Licensed/ Registered nurses (LPN/RPNs). In sports, each player has a specialized role. In music, an orchestra has an array of musicians with clearly assigned roles, specified on a music sheet. Medical physics associates already play an important role in radiation oncology and they will continue to do so, with the support and respect that they deserve from all team members.