MEDICAL PHYSICS PROFESSION

Presented at the 2003 Annual ACMP Meeting, Lake George, NY, May 10-15, 2003. Ivan A. Brezovich, Ph.D., Dept. of Rad. Onc., Univ. of Alabama at Birmingham, 1824 S. 6th Ave, Birmingham, AL 35294. Phone: (205) 934-1758, Fax: (205) 934-2546, e-mail: ibrezovich@uabmc.edu

INTRODUCTION

Ever since radiation has been introduced into medicine, medical physicists have been readily available to bring this lifesaving modality to the patient. Only a decade ago, an ad in the AAPM Placement Bulletin brought typically 20 responses, many from highly qualified, Board certified medical physicists.

In the last few years, however, the situation has taken a dramatic turn for the worse. Nationwide, about 80 positions remain unfilled, and even established training programs are struggling for qualified applicants. At our own institution, which is a highly ranked NCI designated Comprehensive Cancer Center, only two medical physicists responded to our last ad for an academic position. None of the applicants had Board certification. Other institutions are even less successful in their recruitment efforts.

Despite the seeming shortage of medical physicists, there are indications for a vast oversupply. Board certified medical physicists are manning manufacturers’ booths at ASTRO, RSNA and other meetings, are accepting work outside health care, and are retiring at an early age. No other medical specialty is hemorrhaging talent at such an alarming rate.

While a simultaneous glut and shortage of medical physicists may be a paradox of academic interest, its effect on patients is real. Radiation oncologists are often limited in the sophistication of treatments they can prescribe due to unavailable medical physics expertise. The situation is especially regrettable since reimbursement from Medicare and private carriers is generally sufficient to provide the very best patient care.

This paper tries to identify root causes of the problem, and outline a comprehensive solution.

MEDICAL PHYSICISTS ARE MEDICAL SPECIALISTS – IN ADDITION TO BEING PHYSICISTS

Medical physicists typically start their specialization after graduating in a field of the natural sciences, usually physics or engineering. In addition to their original studies, they go through specialty training in medical sciences, as postdoctoral fellows or as residents. In their role as medical specialists, medical physicists are directly involved in patient care, and assume full responsibility for their area of expertise. The Chairman of the Board of ASTRO (American Society for Therapeutic Radiology and Oncology) acknowledged the role of medical physicists in a letter to HCFA (now CMS), by stating “... physicists orchestrate the entire treatment process ...”

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Despite a commonly held belief that medical physics services are bimodal, i.e., that all medical physics services are equal in quality unless an outright mistake has been made, the outcome of radiotherapy depends in a graduated way on the skill of the medical physicist. The reason for that is the narrow therapeutic window in radiotherapy. A dose deficit of only 10% can more than double the probability of tumor recurrence, whereas a similar excess dose can lead to quality of life degrading side effects. The necessary precision can be achieved only by a most competent physicist who can devote sufficient time and resources to his work. The cumulative error of machine calibration, inaccuracies in TMR measurements, output factors, wedge factors, data entry into the treatment planning system, etc., can exceed 10%, even if all individual steps are performed within acceptable tolerances. It should therefore not be surprising that cancer death increases when medical physics services rendered to patients are reduced (New England Journal of Medicine 1992, Vol. 327, p.1499).

In addition to the high esteem in which physicists are held by virtue of the demanding nature of their field, medical physicists are recognized throughout the medical community as medical specialists. American Board of Radiology (ABR) certified medical physicists are listed by the American Board of Medical Specialties (ABMS) like radiologists, urologists, neurosurgeons, or other specialists. Their credentials can be checked by dialing 1-800-ASK-ABMS. Others are certified by the American Board of Medical Physics (ABMP), a certification that the ABR considers equivalent to its own. A report by Larry Reinstein on the ACMP website, dated 7-26-2001, says that a letter of equivalence from ABR entitles ABMP certified medical physicists to listing by ABMS. According to the Guide To Radiological Physics Practice, American College of Radiology (ACR), 1990, p.1 and p. 18, “The radiological physicist is a colleague of the radiologist.”

The following transcript shows the high esteem in which of one of the most prestigious radiation oncologists holds medical physicists. The original letter has been obtained by the author from Dr. Watson, a radiation oncologist who was instrumental in securing Medicare recognition of radiologists. (A copy of the letter is attached as Appendix I)

John D. Watson, Jr., M.D. F.A.C.R., F.A.C.N.M.

TO WHOM IT MAY CONCERN: October 2002

Regarding: Medical Physicists as True Professionals

My name is John P. Watson J., M.D. I was Boarded by the American Board of Radiology in 1967, in Radiology, Nuclear Medicine and Radiation Therapy. However, I have practiced Radiation Therapy or Oncology for the past 30 years. I have had the privilege of witnessing the change in Radiation Oncology over those years. From the Orthovoltage units, from 250 KV to 400 KV, to Cobalt-60 and Cesium, to the Linear Accelerator. From the exclusive use of Radium for implants to the multiple units we have today utilizing the gamma rays and beta rays.

I am a Fellow of the American College of Radiology, and the American College of Nuclear Medicine. I have been a member of the American Radium Society for many years. I have served on the Council of the American College of radiology and am a past-President of the American College of Nuclear Medicine. I present all of this data to inform you of my experience.

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I cannot conceive that comprehensive Radiation Oncology could be practiced in this day and time without the assistance and guidance of the Board Certified Medical Physicist. The complexity of the units from small shaped fields to total body irradiation, to implants and combinations. The field of Physics in Radiation Oncology is so complex that it requires extensive training in both Physics and Computers.

These individuals are "Professionals" in every sense of the word and they deserve the respect, support, and compensation relative to their positions. Thank you for your time and attention

Signed: John D. Watson Jr., M.D.

HISTORICAL BACKGROUND

Soon after he discovered x-rays in 1895, Wilhelm Conrad Roentgen used this groundbreaking technology to image the hand of his wife. Thus, he may be considered as the first medical physicist in radiology, although his clinical involvement was limited. Physicians throughout the world readily adopted this modality, and their clinical skills were often judged by their ability to keep the temperamental equipment working. Similarly, soon after discovery of radioactivity by Becquerel in 1896, physicists provided radioisotopes to physicians who assumed full responsibility for their handling and medical use, and later for calibration of teletherapy units.

As the knowledge about radiation effects on cancer and normal tissues deepened, medical physicists joined radiologists to adapt steadily emerging new technology for specific disease sites, and to better quantify the radiation dose. In 1948, Dr. Donald W. Kerst, a physicist who had developed the Betatron, teamed up with Dr. Quastler, a radiologist, to treat the brain tumor in one of his graduate students. They invented a procedure known today as “radiosurgery.” With the introduction of custom cast beam blocks by a team of physicians and physicists, treatments could be tailored to suit individual patients. As the benefits of individualized treatment planning were recognized, medical physicists became an integral part of the clinic. With better tumor control and strongly reduced side effects, radiotherapy advanced from a mainly palliative, last resort treatment to become one of the major modalities in the war against cancer.

Cancer therapy was usually paid for in a lump sum that was divided between radiologists and medical physicists by the hospital. Medicare and private carriers reimbursed the amount that was charged, provided the charges were “reasonable and customary.” Outpatient clinics did not come into existence until later. Although distribution of funds was not quite even, it was understood that medical physicists and radiologists provided services of equal value to the patient. Medical physicists were entitled to the same office space, parking, etc. as radiologists. Medical physicists and radiologists from that era have many fond memories of their close professional and often personal relationships.

Future of Radiation Oncology Becomes Uncertain

The 1980s push by Medicare to contain cost strongly affected radiation oncology, as the “reasonable and customary” charges were replaced by a rigid fee schedule. Reimbursement was

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in two categories, referred to as “professional” or “provider” and “technical” charges. There was great concern that fees would not cover cost.

In an additional effort to contain health care costs, HCFA proposed in the late 80's and early 90's to pay for the services rendered by Radiologists (including Radiation Oncologists), Anesthesiologists and Pathologists indirectly through the hospital as part of the general hospital bill (RAPs). Radiologists and medical physicists recognized that this would all but destroy the specialty of radiation oncology and diagnostic radiology.

Had RAPs been implemented, radiation oncologists would have experienced the same problems that medical physicists face today. They would have lost their professional independence. Patients would have suffered, and recruitment of young physicians would have become nearly impossible. Indeed, during those years of uncertainty, radiation oncology was not a popular choice for graduates from medical schools. For several years in a row our department had few or no applicants for our previously popular residency program.

Responding to numerous requests from radiology societies and from individual radiation oncologists, medical physicists joined a letter writing campaign to Congress. I still have a stack of responses from our representatives, assuring me that they would do their best to keep radiation oncology afloat. It worked. HCFA abandoned RAPs. Radiation oncology was saved by the team effort of radiologists and medical physicists.

TRAGEDY STRIKES MEDICAL PHYSICISTS – and Cancer Patients

Based on an examination of the work done by medical physicists, Medicare carriers in a few geographic regions recognized medical physicists as professionals and paid them directly for their work. Medicare then wanted to launch a more thorough investigation concerning all services rendered by these specialists. Unfortunately, many of the radiation oncology organizations opposed this objective evaluation, and resorted to political lobbying (using, among others, money collected from their medical physicist members) to “derail” this effort. The objective evaluation never took place.

HCFA singled out medical physicists as the only medical specialists who were not entitled to direct payment. Other providers, including physicians, nurse anesthetists, nurse practitioners, social workers, and many others continued to enjoy this privilege. In an article on Managing the Reimbursement Crisis in the July 1992 issue of Administrative Radiology, the chief executive officer of a major cancer center lamented “ .... The ‘professional’ component was clearly intended to be reimbursed for the non-physician professional physicist. Unfortunately, over the years, ....this revenue stream was lost in the system....”

A few months later, a devastating article “DON’T GET BETWEEN THE DOG AND THE TREE” was circulated throughout the radiation oncology community. It came from a professional radiation oncology society that had previously asked for and obtained generous support from medical physicists. The article found similarities between medical physicists and urinating canines. Another society insisted that medical physicists were working under the direction of the radiation oncologist and thus were not entitled to a professional physics fee. Radiation oncologists were entitled to the physics fees since their ABR Board exams involved

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physics. Letters to this effect were sent to HCFA and to cancer centers to affect reimbursement policy and billing.

Unfortunately, medical physics societies failed to take a stand. Lacking input from organizations that would be the most affected and should be the most knowledgeable ones, HCFA accepted the verdict of others. From then on, medical physics services were paid to the cancer clinic through purely “technical” codes, or through the “technical” component of combined CPT codes. Medical physicists received little credit, as the reimbursement check from the carrier was made out to the clinic, not to the person who performed the service.

Medical Physics Loses It’s Professional Status

With revenue no longer identified with the medical physicist, administrators, especially those of the younger generation who had not witnessed the development of radiotherapy, started to view medical physicists as overpaid technicians, as resources to be managed, as expenses to be cut. Consequently, recognition and authority of medical physicists started to dwindle, privileges were lost. The erosion of the profession continues through the present date, as many of the previously distinct physics codes are now grouped into “delivery” codes.

“HMO’s can brutalize medical care if their goal is to make money from the sick …”, complained Drs. Robert Kagan and Oliver Goldsmith in the July/August 2002 issue of The Journal of Oncology Management (p. 18). Yet for medical physicists these brutal conditions have become the norm, even in geographic locations with little or no HMO penetration where high quality services could be rendered. Patients are equally brutalized by being denied the high quality medical physics services for which they or their insurance carriers are paying.

Today, medical physicists have little control over their own profession. They often lack adequate equipment and the authority to do their work safely, and have to report to staff members who should be their subordinates. Some have to accept an excessive number of patients. An unmanageable workload and micro-management by the administration forced the medical physicist at Riverside Methodist Hospital in Columbus, Ohio into adopting unsafe practices and procedures. These led to the tragedy that left nearly one thousand patients dead or injured. When misadministrations occur, incident reports are highly discouraged at some cancer centers, leaving the medical physicist in a legal and ethical dilemma.

Pay and other benefits are rarely within the range of other medical specialists, despite profits from medical physics that greatly exceed the standards of other industries. The 10% higher pay, compared to physicists in industry, (see Appendix II, The Industrial Physicist, American Institute of Physics, April/May 2003, p.13) does not adequately compensate for the typically extra four years of training to become Board certified in medical physics. Specialization more than doubles the income in other medical fields.

Press releases and brochures of cancer centers praising newly introduced high-tech equipment and procedures rarely give proper credit to the medical physicists who get those miracles to work. Close parking, adequate office space, reserved areas in the cafeteria, and similar privileges enjoyed by other medical specialists are often denied to medical physicists.

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Unfortunate Consequences

Although it is difficult to quantify the effect of the individual problems, there are indisputable objective indicators that the profession is in a crisis.

Medical physics relies disproportionately on immigrants. Whereas, according to the last census, 11.5% of the current US population has been born in another country, a recent survey by the American Institute of Physics (APS) shows that more than 50% of current graduate students in physics are from abroad. At some institutions the number has grown to 100%. Statistics for medical physics are not available, but it seems that this profession depends even more heavily on recent immigrants, primarily from economically deprived countries. Immigration from Western Europe and Japan has all but disappeared. While influx of fresh talent per se is essential and needs to continue unabated (I came to the US 35 years ago), other medical specialties have an ample supply of highly motivated applicants from within the country and from abroad. Applications for our residency program in radiation oncology, e.g., are numerous and representative of the national demography.

Parents seem to be discouraging their children from becoming medical physicists. I know countless medical physicists whose children have become physicians. I know only few medical physicists whose children have adopted the profession of their parents. I know countless physicians whose children have adopted the profession of their parents, including radiation oncology. Yet I am not aware of even one radiation oncologist whose son or daughter has become a medical physicist. Furthermore, medical physicists often leave the specialty, forfeiting the potential benefits of more than 10 years of college education, specialty training and grueling Board exams. Career changes in the opposite direction are all but non-existent.

To make matters worse, the problem was initially masked by a vast oversupply of physicists. Those who had entered the field many years earlier to work on the space program or national defense, and were later laid off as these programs were cut, had no other place to go and accepted almost any available position. Physicists who were enrolled in graduate programs continued their studies and were emerging in nearly undiminished numbers from the long pipeline, even after the input had shrunk to a trickle. Finally, the oversupply of physicists, on which the medical community so heavily relied, has ended. According to an article in The Industrial Physicist (American Institute of Physics, April/May 2003, p.13), the 2002 unemployment rate of physicists who had obtained their Ph.D. degree 10 years before was about 1%, and dropped to 0.5% for 30-year veterans (see Appendix II).

SOLUTION: Medicare Recognition as Providers

The vast majority of problems facing the medical physics profession today has one common denominator: Lack of proper recognition by Medicare.

With Medicare recognition as providers, Blue Cross and other carriers would follow suit. Hospital administrators would see medical physicists as revenue generators, and treat them like all other medical specialists. Current problems, such as adequate parking, office space, secretarial help, and similar privileges granted to other medical specialists, would become non-

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issues. Having the authority of specialists, medical physicists could provide the quality services dictated by their conscience.

The prospect of joining an established, government recognized, revenue generating field would attract much needed talent into the profession, from within the United States and from abroad. Recruiters for training programs could tell prospective students the full, unfiltered truth about the profession, without fear of losing the best applicants. Radiation oncologists would equally benefit, as they would have a much broader selection of medical physicists to choose from for their referrals. Of course, the ultimate winners would be the patients.

Obtaining Provider Status is a Realistic, Desirable Goal

The following list of providers from the Medicare website indicates that provider status is more the rule than the exception for trained specialists.

Ambulance Service Supplier Ambulatory Surgical Center Audiologist Certified Clinical Nurse Specialist Certified Nurse Midwife Certified Registered Nurse Anesthetist Clinic/Group Practice Clinical Psychologist Community Mental Health Center Comprehensive Outpatient Rehabilitation Facility Durable Medical Equipment, Prosthetics, Orthotics, or Supplies End Stage Renal Disease Facility Federally Qualified Health Center Histocompatibility Lab Home Health Agency Hospice Hospital Hospital Department Billing for Part B Practitioner Services Independent Clinical Laboratory Independent Diagnostic Testing Facility Indian Health Services Facility Licensed Clinical Social Worker Mammography Screening Center Managed Care Organization Mass Immunization Roster Biller Medical Faculty Practice Plan Multi-Specialty Clinic or Group Practice Nurse Practitioner Occupational Therapist in Private Practice Occupational Therapy (Group) Organ Procurement Organization Other Medical Care Group Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services Pharmacies

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Physical Therapist in Private Practice Physical Therapy (group) Physiotherapy Physician Assistant Physician Portable X-ray Facility Psychiatric Unit (of hospital) Public Health/Welfare Agency Registered Dietitian/Nutrition Professional Rehabilitation Agency Rehabilitation Unit (of hospital) Religious Non-medical (e.g., Christian Science Center) Rural Health Clinic Rural Primary Care Hospital Skilled Nursing Facility Voluntary Health/Charitable Agency

To verify my interpretation of “provider”, I called a social worker who had recently left our department and opened her own private practice. She informed me that she had to fill out a few forms to obtain a provider number, and can now bill CMS for the services she renders to her patients, under CPT codes 90801 and 90806. I also found out that there are a total of 466 social workers in the State of Alabama who are entitled to direct billing. A phone call to an audiologist picked at random from the Yellow Pages verified that he is also a Medicare provider.

Some medical physicists are concerned about the logistics and the extra paperwork associated with direct billing, and a potential loss of job security. Additional paperwork should not be a problem. Even now, medical physicists have to fill out and sign forms for each and every service they render, and the bills have to be submitted to the insurance carriers. Hence, the total amount of paperwork would not increase. Billing clerks who are now handling the paperwork would certainly be willing to continue the service for the proper fee. Medical physicists preferring the status quo could sign their billing rights over to their employers, and still enjoy the higher professional standing and increased job security associated with he recognition as revenue generators. The current anonymity of medical physicists does not enhance job security. Hospital administrators are consistently on the lookout for potential cost reductions, and do not hesitate laying off personnel if they can improve the bottom line.

Steps for Achieving Provider Status

Contrary to common belief, physicists are excellent politicians – if they put their minds to it. Two of our US Congressmen are physicists by training. Few, if any, other professions have such a large percentage of their members in Congress.

Professional oath

While medical physicists are faithfully discharging the duties toward their patients, they do not have a formal oath of office like most other medical professions. Making a formal pledge would elevate our profession, at a modest increase of administrative burden.

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I, hereby, propose that ACMP introduce a formal swearing-in of all clinical medical physicists, similar to the oath of Hippocrates taken by physicians. Physicists would be eligible to take the oath after passing their Board exams. The wording would have to be acceptable to all physicists who believe in the highest ethical standards, regardless of their particular religion or absence thereof.

Obtain letters of support from well-known radiation oncologists.

Many of the best known radiation oncologists openly acknowledge that the development of their field would not have been possible without a close cooperation between oncologists and physicists. As the letter from Dr. Watson indicates, some are willing to write very strong letters of support for our profession. A thick folder, with many such letters, carries substantial weight with all parties involved. Medical physicists who have close relations with well known, respected radiation oncologists should be able to secure such letters.

Obtain support from radiation oncology societies – but don’t expect too much

Medical physicists and radiologists are interdependent, and have a long tradition of mutual support, like physicists helping radiation oncologists to obtain direct billing privileges. Nevertheless, more needs to be done. For example, RSNA, ACR, and other radiological societies provide gold medals and other awards to physicists who made outstanding contributions to the field. Unfortunately, no such awards are given by medical physics societies to physicians. I, therefore, propose that the awards committees from ACMP and AAPM create a special award for deserving radiation oncologists. Of course, awardees would have to be carefully selected on an objective basis, e.g., on their pioneering and use of high-tech procedures.

Radiologists have also shown generosity in giving substantial discounts to medical physicists at their training classes, refresher courses, etc., yet comparable acts of courtesy from medical physics societies are rare. We need to reciprocate by extending similar consideration to radiologists. Since the number of participants from the radiology community in physics courses is generally low, the potential revenue loss would be affordable.

Despite our traditional ties with radiological societies, and the potential of further strengthening of those ties, we have to recognize that ACR, ASTRO, ACRO, etc. are primarily interested in the welfare of the majority of their membership, i.e., radiologists. Dr. John Watson, who had numerous top leadership positions in societies like ACR, cautioned me firmly against too heavy reliance on those societies. Indeed, a flyer from ACRO indicated that they would not oppose direct billing by medical physicists, but did not offer any help.

Obtain Legal Counsel

In the November/December issue of the 1997 AAPM Newsletter, p. 6-7, Dr. Hendee answered many of the frequently asked questions concerning direct billing. According to that article, Terry Kay from HCFA (Director of the HCFA Division of Practitioner and Ambulatory Care Plan and Provider Purchasing Policy Group Center for Health Plans and Providers) had informed him that neither licensure nor an independent certification board would be required for direct billing, but that an act of Congress would be necessary. Maybe a good lawyer could find a reason why

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medical physicists should fall into one of the many professions that have direct billing privileges, otherwise Congressional action may become necessary.

Form Political Action Committees

Medical physicists have to adapt to the new reality, and that includes the need for lobbying. Considering that our Representatives depend on contributions from their constituents for their election campaigns, we cannot expect help from Congress unless we do our part. We have to form a Political Action Committee (PAC) like other professions in the health care industry.

The details of any political action would have to be worked out by of one of the many Washington lobbying firms that specialize in such activities. For starters, I talked to a lawyer who specializes in lobbying, and visited the website of the Federal Election Commission (www.fec.gov). The Campaign Guide http://www.fec.gov/pdf/colagui.pdf, a 92-page document, was also very helpful. Here are some of the highlights.

The recently passed Campaign Finance Reform Bill makes the playing-field more even, giving a group as small as the medical physics community a chance for success. With restrictions on soft money, corporations can no longer give unlimited campaign contributions to their favorite members of Congress.

Corporations cannot use general funds for lobbying. All money for lobbying must come from voluntary contributions. ASTRO, for example, started a PAC in February and is soliciting contributions. The total amount of money raised since the PAC was formed is about $10,000. Medical physicists should be able to match that.

Because contributions to a PAC are voluntary, only those physicists who believe in a given cause would be spending money lobbying for it. This mechanism removes one of the previous obstacles of lobbying, as members of one group, especially those from abroad, would naturally object to spending their membership fees on activities of no value to them.

The amount that an individual can donate to any Congressman or Senator is limited to $4,000 per election cycle ($2,000 for the primary and the same amount for the main election), and to a total of $20,000 per year for all lobbying activities on the Federal level. Although such amounts are beyond the generosity of most physicists, nevertheless, the entire physics community could not be out-lobbied by one or two super rich individuals opposing our efforts. Lobbying on the State level is governed by local laws, and is not affected by Federal lobbying.

Holders of the “green card” (immigrant visa) are allowed to contribute to PACs. This is very important for our profession due to the large number of permanent residents who have not yet become citizens.

Timing Perfect, Request Reasonable

The current demand for our specialty, coupled with the recent campaign financing reform, opens a wide window of opportunity. Admittedly, the medical physicists community is relatively small and has limited resources, but our small size works also in our favor. The financial impact of any changes in Medicare reimbursement affecting our profession would be insignificant. Since asking for provider status is a reasonable demand, pushing through Congress such legislation

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should be easier and less costly than bills that have a strong impact on the Federal budget. A Congressman, supporting our view, would not have to justify the financial impact to his colleagues, could emphasize the benefits to cancer patients, and could submit the needed reform as an attachment to any bill.

CONCLUSION

In our role as health care providers, the first responsibility of every medical physicist is quality patient care. As individual physicists we must provide such care, even under the most difficult conditions. As a group, we must strengthen our profession so that every physicist in the clinic has the means to provide the required level of care. As educators, we have an obligation toward the future physicists who are considering medical physics as a career. We must make the profession as rewarding as any other medical specialty, so that the best and brightest will choose it enthusiastically, even after a frank and open presentation of all of its aspects.

Medicare recognition as providers would eradicate the root of most problems our profession is facing. Working toward that goal must become the focus of our professional activities.

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APPENDIX I. Letter of support from Dr. Watson

APPENDIX II. Employment statistics

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APPENDIX II

The Industrial Physicist (American Institute of Physics, April/May 2003, p.13)

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