The 2014 initiative is not only unnecessary but it constitutes a threat to the future of medical physics

Arguing against the Proposition is Kenneth N. Vanek, Ph.D. Dr. Vanek obtained his Ph.D. in Nuclear Engineering Sciences/Medical Radiation Physics from the University of Florida, Gainesville in 1976. After serving in the United States Air Force for 20 years, he joined the H. Clay Evans Johnson Cancer Treatment Center, Memorial Hospital, Chattanooga, Tennessee and then, in 1988, the Department of Radiation Oncology, Medical University of South Carolina, Charleston, where he is currently Associate Professor and Director of Medical Physics and New Technology, Associate Professor in the Department of Neuroscience, and Director of the Radiation Oncology Medical Physics Residency Program. Dr. Vanek has been active in several societies, having served as Chairman of the ACMP, Chair of the AAPM Annual Meeting Coordination Committee, President of the Deep South Chapter of the Health Physics Society, President of the AAPM Southwest Chapter, and a member of the AAPM Board of Directors. He is certified by the ABR in Therapeutic Radiological Physics and by the ABMP in Radiation Oncology Physics, and is a Fellow of the ACMP, the AAPM, and the American College of Radiology. Debate over the relative importance of research, education, and professional practice of medical physics, which has generated heated arguments over the entire five-decade history of the AAPM, reached a fever pitch following the AAPM Board recommendation to focus exclusively on CAMPEP residency training to qualify for ABR certification. This so-called 2014 initiative is not only unnecessary but also it constitutes a threat to the future of medical physics. Medical physicists have traditionally led teams designing tests to validate new technologies for radiology and radiation oncology ranging from computed dosimetry, linacs, MRI, PET, US, and PET/CT among many others. Each technology needed objective research to validate patient benefit. Medical physics research training in Ph.D. programs provided intellectual tools and methods supporting these important leadership roles. Traditional undergraduate and professional doctorate degrees are inadequate as they teach students to seek solutions to problems by recapitulating the work of others from books, journals, and professional references. North American graduate programs in medical physics evolved primarily in research-oriented graduate schools with an increasing fraction of programs becoming CAMPEP-accredited providing a more uniform level of clinical education. They provided large numbers of both MS (professional focus) and Ph.D. (research focus) graduates well versed in medical physics to integrate with graduates of traditional physics programs to provide strong multidisciplinary physics teams in clinical practice. The financial underpinnings typically included graduate research fellowships from host universities, return of tuition from undergraduate and MS level students to provide teaching assistantships, and research grant funding to provide research assistantships. Due to the 2014 initiative, programs in Graduate Schools must close and reopen as degree programs in Professional Schools. Medical Physics graduate programs with large research portfolios cannot move, however. This induces financial instability by fracturing academic medical physics into separate schools with entirely different demands and practices. Presently many regulatory agencies demand Qualified Medical Physicists (QMPs) for critical roles in the implementation of complex clinical technologies for patient care. Demand for QMP services with required qualifications has caused healthy increases in salaries and respected positions in the health care infrastructure in both Canada and the United States of America. Reducing didactic education to 2 yrs followed by 2 or 3 yrs of clinical (practical) training reduces the range of medical physics capabilities and responsibilities. The idea that new technology can be learned from a book without using research methods seems patently ridiculous when one reviews the past 20 yrs. The intent of the AAPM Board of Directors was to improve the practice of clinical medical physics using established paradigms for physician training. This laudable goal ignores the fact that medical physicists must be educated differently than physicians to do jobs for which physicians are untrained. The physician is responsible for patient care. The medical physicist is responsible for assisting the physician to use technologies that physicians do not understand in sufficient detail to implement by themselves. The AAPM needs to make a course correction and time is growing short. The 2014 initiative may be separated into two components: (1) the ABR eligibility requirement for completion of a CAMPEP residency program and (2) the 2014 effective date. The purpose of ABR certification is reflected in its mission statement11 “to serve patients, the public, and the medical profession by certifying that its diplomats have acquired, demonstrated, and maintained a requisite standard of knowledge, skill, and understanding essential to the practice of diagnostic radiology, radiation oncology, and radiologic physics.” The importance of clinical training has long been recognized. The ABR requires 4 yrs of residency for both diagnostic radiology and radiation oncology certification. The American Board of Medical Specialties (ABMS) web page “About Board Certification”22 states “Before a doctor can become Board Certified, each must complete: 4 yrs of premedical education in a college or university; a course of study leading to an MD or DO degree from a qualified medical school and 3 to 5 yrs of full-time experience in an accredited residency training program.” Clearly, residency training is an inherent component of the overall education required to become certified by a medical specialty board. Will physicists be able to maintain their status of being certified by the ABR without residency training? I contend that this is neither a sustainable situation nor is it in the best interest of patient safety. As medical professionals, we have a commitment to patients and our physician colleagues not only for the quality of our practice but also for insuring that future clinical physicists are well trained. The consequences of poorly trained physicists are life threatening and may adversely impact a considerable number of patients before clinical symptoms appear and the cause is discovered. Graduate academic programs should provide a firm basic foundation of knowledge that a medical physicist can utilize in clinical practice as well as important research experience. Even if clinical courses and a few weeks in a clinic are included in the curriculum, academic programs are not a substitute for 2–3 yrs of full-time structured and focused clinical training. The old-school method of hit and miss on-the-job-training is no longer adequate to train new medical physicists. Today, in order to fully prepare future medical physicists to independently practice in the clinic with increasingly complex technology, we must offer, in addition to a solid academic education, clinical training through an accredited residency program that offers a broad variety of procedures with state-of-the-art equipment and a sufficient number of faculty and patients to acquire the necessary clinical training and experience. The implementation date of 2014 is also a necessity. Prior to 2007 when the 2014 initiative was announced, there were only 12 CAMPEP radiation oncology and two diagnostic residencies. From 2007 to 2010, 31 radiation oncology and four diagnostic residencies have been added. Also, one diagnostic and 11 therapy programs are currently awaiting CAMPEP approval. Would this dramatic increase in residency programs have occurred without the 2014 initiative? I think not. In conclusion, the 2014 initiative is not only necessary but also mandatory for the future of medical physics, the safety of patients, and the quality of future clinical physicists. The risk to our profession is to falter on this initiative. Dr. Vanek's opening statement recalls the tale of blind men asked to describe the elephant.33 He identifies a version of truth with his description of the physicianlike patient care role of medical physicists. It is one truth among many. Expert clinical medical physics requires recognition of other truths such as those that involve regulatory functions, technical support, radiation safety, research programs, and development engineering. The medical physics team will be stunted by exclusive focus on the clinical training methods designed for physicians. While nodding to the importance of academic education in medical physics, Dr. Vanek does not see the impact of elimination of CAMPEP graduate medical physics education. Medical physics programs and departments in graduate schools will be forced to turn away from courses suited to clinical training toward topics more suited to fundamental medical research. Medical physics programs post-2014 must redirect activities toward their only remaining funding sources from general medical physics education (tuition income) and research (federal grants). While Dr. Vanek doubts that the ABR would continue to certify medical physicists with CAMPEP-accredited Ph.D. education in medical physics with on-the-job (nonresidency) experience in the clinic, he ignores the fact that the 2014 change in rules relative to admission to the ABR was proposed by the AAPM Board not by the ABR. The ABR Commissioners may have serious concerns about our ability to meet clinical needs post 2014 but are unwilling to contradict the AAPM on such an important decision. Physicians care for humans who evolve only slowly. Medical physicists care for the introduction and operation of technologies evolving so rapidly that no one today can predict the coming decade. We must not forget the differences in our zeal to excel. I disagree with Dr. Fullerton's speculative statement that graduate programs must close and reopen as programs in professional schools because of the 2014 initiative. The 2014 initiative requires graduation from a CAMPEP residency to be eligible to take ABR Part 2. Nothing in this initiative mandates the creation of programs in professional schools. Most statements by my opponent apply to academic program issues, which may indeed warrant review by both academic programs and CAMPEP. Since residency training will soon be mandatory for ABR certification, perhaps the amount of clinical training required in graduate school versus the need for more core courses and research should be reevaluated. A misconception seems to exist that residency programs simply teach residents technical procedures. In reality, a broad spectrum of challenges is encountered daily in the clinic and many require rapid as well as accurate decisions. Problem solving skills under clinical stress and urgencies must be learned on the front line. Although a solid theoretical foundation and analytical reasoning enhanced through research are invaluable in this decision process, so is that critical factor called clinical experience, which is best taught through a formal residency program. The irreplaceable importance of clinical training is well established and recognized throughout the health professions. It cannot be ignored by our profession. I must reemphasize that the 2014 initiative is essential for the future of medical physics, ABR certification, the safety of patients, and effectively teaching future medical physicists who choose a clinical career. We must not waver from this resolve.

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