1 11 I '* / TRAINING PROGRAMS IN MEDICAL PHYSICS IN THE UNITED STATES Lawrence H. Lanzl, Ph.D. Professor of Medical Physics Department of Radiology and The Franklin McLean a '" Memorial Research Institute, The Uniyersity of Chicago, Chicago, Illinois, U.S.A. i and Vice President of the Symposium on Training Programs in Medical Physics Invited paper presented at the Symposium on Training Programs in Medical Physics, XIV Congresso Internacional de Radiologica Rio de Janeiro, Brazil, October 23-29, 1977 DISTRIBUTION 0f~ TiilS J'/.J
2 Two spectacular scientific developments in our recent history had a profound effect on medical physics training, on medical physics as a profession, and on medicine in general. I refer to the development of the nuclear reactor in 1942 at The University of Chicago by Enrico Fermi and his colleagues, and the development of the multiplicity of particle accelerators in the late 1930's and early 1940's. The reactor, a self-sustained nuclear chain device, serves as an abundant source of neutrons. Since neutrons are readily captured by the nuclei of all elements, it became possible to produce literally hundreds of new and different radioactive isotopes easily and cheaply for all sorts of technical uses, including medicine. The predominant diagnostic medical application of these isotopes has been and continues to be in static and dynamic tracer studies. For radiotherapy, the predominant radioactive isotope used has been and continues to be cobalt-60. Electron accelerators such as betatrons, Van de Giaaff generators, and linear accelerators were first used for therapy in the period The reason for their acceptance by the medical community is that the radiation dose required to eradicate a tumor could be delivered to the tumor without a limitation of dose set by the tolerance of the intervening skin, as had been the case with orthovoltage equipment. The impact of these two new technologies on medicine was significant. It created a demand for hundreds of physicists trained in radiation and nuclear physics to work in hospitals and clinics. The areas of expertise required of these physicists were restricted essentially to radiation therapy, nuclear medicine, and radiation protection.
3 Since the implementation of these technologies required a high degree of technical training as well as knowledge and skill in physics, a number of physicists working in physics laboratories were persuaded to enter into hospital service. Those who did so in the late 1940's and early 1950's without prior specialized medical physics training saw the necessity of developing appropriate training programs, since the academic programs in a typical physics department did not satisfy all of the academic, practicum, and in-service needs of medical physics practice. Thus, medical physicists on universitymedical school faculties, with the help of their medical colleagues, developed graduate programs in medical physics. There was consensus that the training should terminate in a degree. The degrees awarded in the United States are typically those of Master of Science and Doctor of Philosophy. Past experience has shown that, when shortages of qualified medical physicists occur or when shortages of posts for non-clinical physicists exist, a number of physicists trained in non-clinical physics departments have changed to medical physics without the benefit of specialized training. In part to assist in the training of such physicists, a number of postdoctoral programs have also been developed. Several surveys have been published giving the number of medical physics training programs in the United States. These surveys have been carried out by members of the Committee on the Training of Medical Physicists of the American Association of Physicists in Medicine. Table I lists the number of institutions offering training, together with the number of trainees in various categories for the
4 TABLE I MEDICAL IHYSICS TRAINING PROGRAMS (1) Trainees Number of Post- Year Institutions M.S. Ph.D. doctoral Total (33) (124) (117) (43) (284) past several years. The curricula of these training programs have been studied. Since the university-medical schools are not bound by government regulation and are not reviewed by an accrediting board for their graduate programs in medical physics at this time, there are many variations in the course curriculum from one program to the next. In addition, some programs stress research and others stress clinical service. In 1972, the International Atomic Energy Agency and the World Health Organization held a Seminar on Training and Education of Medical Physicists (2). The seminar included a proposed curriculum which has much in common with programs in the United States. It might be in order to list the conclusions and recommendations of the seminar and to comment on the similarities and differences of programs in the United States. 1. Meaning of the term "Medical Physics". Medical physics consists of the application of the concepts and techniques of physics to medical care and health services. It is not a special kind of physics unrelated to ncn-clinical physics.
5 2. Role of medical physics in medical care. The training programs in the United States reflect the view of a given faculty in regard to the role of medical physics in medical care and health services. If the faculty of a university is strongly research-roinded, then the program at that university tends to stress research and often will play down the service and teaching aspects of medical physics. The reverse is also true. If the faculty stresses patient service, the students will work more closely with clinicians in their day-to-day work of ministering to patients, and they receive, in general, less research training. 3. In the long term, 10 medical physicists are needed per one million population. In 1972, we had about 2 trained medical physicists per million population in the United States. As of 1977, we probably have closer to 4 per million. Our emphasis in training should reflect that we have a way to go to reach the desired 10 per million population. 4. National government authorities should: (a) Recognize medical physics as a scientific discipline. Our government, mostly through our National Cancer Institute, as well as through the National Institutes of Health as a whole, has increasingly recognized medical physics as a scientific discipline both by its support of individuals seeking training and by seeking counsel from practicing medical physicists in regard to advising on institutional training programs and research projects throughout the United States.
6 (b) Create conditions for physicists to work in medical physics> The creation of conditions for physicists to work in medical physics is not solely in the hands of the federal government. However, the federal and state governments are pursuing programs of radiation safety and quality control in diagnostic radiology and nuclear medicine that almost mandate the employment of medical physicists by hospitals. (c) Collaborate in establishing training programs. The United States government in the past has collaborated in establishing training programs; it has increasingly recognized, however, that there has to be a balance between the supply and demand for trained medical physicists. If we trained physicists at too rapid a rate, we can have an oversupply. An oversupply of a given professional group is both wasteful and demoralizing. 5. Training program for junior medical physicists. (a) Minimum Entrance Requirement B.S. in Physics. To enter a graduate training program in medical physics, the entrant should have the B.S. degree with a physics major or equivalent background in engineering. The physics preparation must include electricity and magnetism, as well as atomic, nuclear, and quantum physics. -Courses in experimental laboratory physics are necessary. In mathematics, the background should include differential equations and differentiation and integration of functions of several variables. Knowledge of computer programming and electronics is necessary.
7 (b) Two years of full-time work courses and some in-service training. Several years ago, there were a number of Master of Science programs, in United States universities, which could be completed in one year (3). However, a recent unpublished report entitled "Guidelines for Training Programs in Radiological Medical Physics," prepared by the AAPM Committee on Training of Medical Physicists, states that two years are the normal period of a M.S. program (4). (c) Formal Courses A. General Course B. Special Course - i.e. Medical Radiation Physics The Seminar recommended that the general course of study be given to all entering graduate students in medical physics. For those who desired to specialize in radiation medicine, the special course would also be required. For students who desired to specialize in non-radiation medical physics, another special course would be recommended. An alternate special course was not determined by the Seminar. (d) Courses should have university recognition and terminate with master's degree or equivalent. The whole structure of medical physics training in the United States is in agreement with thi;. recommendation. (e) Two years of full-time in-service training. The in-service training is not adequate in many of the academic programs in the United States, even though these programs
8 are generally associated with hospitals and clinics. As a means of assuring adequate preparation, we have a certification program for medical physicists under the American Board of Radiology (5). This board was organized primarily for the certification of physicians who specialize in radiation medicine. However, the board was requested in June, 1947, to undertake the examination, certification, and registration of physicists as well. Physicist applicants for the examination in radiological physics, which includes all of the sub-fields, i.e., therapeutic radiological physics, diagnostic radiological physics, and medical nuclear physics, must have had at least three years of full time association with an approved department of radiology. Applicants for examination in one sub-field must have had at least two years of full-time association with an approved department of radiology. "Association with an approved department" means in-service training. In addition to such training, applicants for the Board examination are required to have a Master of Science degree with an appropriate major field, which may be radiological physics, biophysics, physics, health physics, or public health when the bachelor's degree is in a physical field. 6. Senior medical physicist 3 to 5 years beyond basic stage. We have a number of academic programs leading to the Ph.D. degree in the United States. The Ph.D. is a research degree and thus requires an in-depth research thesis on some medical physics problem. Our Ph.D. programs also require course work over and above that required for the Master of Science degree.
9 7. Proper career structure should be established. There are several career structures in the United States. For example, within the federal establishment such as the Veterans Administration Hospitals, staff members are within the federal civil service system. In university medical schools, we have academic steps rangirg from instructor to professor. In the United States, there is a lack of separate medical physics departments. Very few oncology institutes have such departments, but those that do exist have invariably developed into the mor 1 ; productive groups in the country. 8. IAEA and WHO should support medical physics on increasing scale. 9. IAEA/WHO seminar curriculum recommendations. A. General Course - Introduction to Medical Physics Section I Section II Section III General topics Medical radiation physics Medical Physics other than medical radiation physics B. Special course - Only medical radiation physics C. Practical work Student should perform 2/3 of experiments listed D. In-service training
10 10 Section I - General topics Introduction to medical sciences Biology, living tissues and organs, pathology, physio-pathology, biochemistry, human ecology, and hygiene. Mathematics as applied in medical physics. Data Processing Computer programming using scientific languages is included under data processing. Electronics as applied to medical physics Hospital organization and practices This subject is generally lacking in the curriculum in the United States. Training and teaching methods Most medical physicists in the United States get involved in teaching. At present, the curriculum does not include instruction in teaching methods.
11 11 Section II - Medical radiation physics Nuclear and radiation physics, radioactivity measurements Radiobiology Radiation measurements Radiation sources in radiotherapy Clinical dosimetry Radiation hazards and protection Physical aspects of nuclear medicine Physical aspects of x-ray diagnosis
12 12 Section III - Medical physics other than medical radiation physics Bioelectricity Liquid flow systems Physics of gases Acoustics Ultrasonics Non-ionizing electromagnetic radiation Optics and electron optics Biomechanics Traditionally, medical physicists in the United States have been associated with departments of radiology because of their responsibilities in the area of radiation therapy. As a result, new applications of physics to medicine often are developed and applied in departments of radiology. For example, ultrasound and thermography usually come under radiology departments, although they have no connection with ionizing radiations. In general, the curriculum in medical physics other than medical radiation physics needs strengthening in the United States.
13 13 B. Special courses - Only medical radiation physics Nuclear and radiation physics, radioactivity measurements Radiobiology Radiation measurements Radiation sources in radiotherapy Clinical dosimetry Radiation hazards and protection Physical aspects of nuclear medicine Physical aspects of x-ray diagnosis All of the above topics are covered in training programs in the United States.
14 CONCLUSION In conclusion, we find that recommendations of the IAEA seminar to be consistent with practice in the United States. Training in Radiological physics pertaining to radiotherapy, diagnostic radiology, nuclear medicine, and radiation protection is in good shape. On the other hand, medical physics can contribute a great deal to non-radiological branches of medicine. The technology exists, but the administrative patterns have not yet been developed.
15 REFERENCES 1. Kelsey, C.A., and Bjarngard, B. Medical Physics, Vol. 2, No. 3, May/June 1975, p Data in parentheses are from an unpublished report by Sayeg, J.A., Banerjee, K., and Mistretta, C. 2. Cook, H.F. et al. Report of an IAEA/WHO Seminar on the Education and Training of Medical Physicists. Kiel, Federal Republic of Germany, April World Health Organization Report RHL/72.2 Rev.l. Geneva, Switzerland. 3. Lanzl, L.H. et al. Status and Future Manpower Needs of Physicists in.medicine in the United States. U.S. Department of Health, Education, and Welfare Publication No. (FDA) , p. 41. Superintendent of Documents, U.S. Government Printing Office, Washington, D.C , U.S.A. 4. Bjarngard, B. et al. Guidelines for Training Programs in Radiological Medical Physics. Unpublished report of the AAPM Committee on Training of Medical Physicists. 5. Requirements for certification in "Radiological Physics of the American Board of Radiology." Office of the Secretary, Kahler East, Rochester, Minnesota, 55901, U.S.A., 1977.
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