Jordan, David W.

Mills, Michael D.

Newhauser, Wayne D.

English

PubMed

LSU Scholarly Repository (Louisiana State Univ.)

Louisiana State University LSU Scholarly Repository Faculty Publications Department of Physics & Astronomy 12-1-2021 Current state of the imaging physics workforce and financial model David W. Jordan University Hospitals Case Medical Center Wayne D. Newhauser Louisiana State University Michael D. Mills University of Louisville Follow this and additional works at: https://repository.lsu.edu/physics_astronomy_pubs Recommended Citation Jordan, D., Newhauser, W., & Mills, M. (2021). Current state of the imaging physics workforce and financial model. Journal of Applied Clinical Medical Physics, 22 (12), 4-6. https://doi.org/10.1002/acm2.13489 This Editorial is brought to you for free and open access by the Department of Physics & Astronomy at LSU Scholarly Repository. It has been accepted for inclusion in Faculty Publications by an authorized administrator of LSU Scholarly Repository. For more information, please contact ir@lsu.edu. Received: 18 November 2021 Accepted: 18 November 2021DOI: 10.1002/acm2.13489EDITORIALCurrent state of the imaging physics workforce andfinancial modelNearly every citizen depends, directly or indirectly, onthe services of medical physicists to ensure high-qualityand safe medical care. Medical physicists have a largesocietal impact, like those of engineers and teachers.In contrast to these professions, the number of medicalphysicists is tiny (about 9000 in the USA) and our knowl-edge of the profession’s characteristics is incomplete.1Multiple publications have examined supply anddemand, workforce characteristics, and staffing levelsfor qualified medical physicists (QMPs) (defined as perhttps://www.aapm.org/org/policies/details.asp?id=449)specializing in radiation therapy (e.g., see Millset al. https://doi.org/10.1120/jacmp.v11i2.3005;https://www.astro.org/Patient-Care-and-Research/Patient-Safety/Safety-is-no-Accident; and Swansonhttps://doi.org/10.18297/etd/3224). At present, thesedetails are lacking for diagnostic imaging physics andnuclear medicine physics. This is probably becauseabout 75% of medical physicists work in therapy. As westudy the imaging physics workforce, it is worthwhileto step back and consider how the current workforceserves the public interest and how the profession shouldmonitor and manage it in the future. In this column, weappeal to our colleagues to contemplate how the futureworkforce may evolve from its present state.Consider differences in financial models for radiationoncology physics and diagnostic imaging physics in theUSA. Many of the clinical services provided by ther-apy physicists are associated with current proceduralterminology codes and are eligible for reimbursement(e.g., from health insurance entities). In this direct reim-bursement model, therapy physics is a revenue centerand staffing models are directly linked to patient volumeand revenue. In contrast,diagnostic physics services aretypically treated as an overhead model. That is to say,diagnostic physics services are not eligible for directreimbursement and are only indirectly linked directly topatient volume and revenue. With the overhead model,staffing models are largely driven by compliance withminimum requirements set by regulations and clinicalaccreditation programs.This is an open access article under the terms of the Creative Commons Attribution License,which permits use,distribution and reproduction in any medium,providedthe original work is properly cited.© 2021 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in MedicineThus, differences in financial models can influencephysicist staffing. The financial models may or may notbe sufficient to provide optimal care to every patient.Research is needed to quantify the incremental improve-ments in patient care that can result from additionalimaging physics support once the minimum require-ments are met. The literature on diagnostic errors doesnot directly link diagnostic medical physics effort to out-comes, but it does show that applications with exact-ing image quality requirements, such as mammographyand other cancer detection exams, are responsible for alarge proportion of errors leading to suboptimal patientoutcomes. Given the frequency of errors in diagnosticradiology procedures (14–15 diagnostic error malprac-tice claims per 1000 person-years) and the potentialseverity of associated outcomes (42% of claims involv-ing high-severity injury and patient death), it is reason-able to posit that medical physicists will play essentialroles in improving patient outcomes in at least somecases.2–5The American Association of Physicists in Medicine’s(AAPM’s) most recent published assessments of thediagnostic physics workforce are outdated (see discus-sion in AAPM Report 301:https://doi.org/10.37206/163).Ongoing efforts, including a survey completed in 2020and the development of models and future projections,will provide a current snapshot of the workforce andmarketplace for clinical imaging physics services. Somepreliminary data are available that will be fully detailedin forthcoming AAPM publications.We can estimate the current size of the US diagnos-tic physics workforce from data sources like the AAPMmember database and directories of QMPs. While it isimpossible to reliably predict the future workforce size, itis possible to estimate the future supply of QMPs,whichis governed by the integral capacity of medical physicsgraduate programs and imaging physics residency pro-grams. One of the most pressing questions for our pro-fession is whether these programs are “right-sized” tomeet the demand for imaging physicists now and in thefuture.4 wileyonlinelibrary.com/journal/acm2 J Appl Clin Med Phys. 2021;22(12):4–6.EDITORIAL 5Demand is harder to predict. The most recent projec-tion of the future demand and required residency capac-ity in imaging was an AAPM-sponsored study in 2009.6The projection of required imaging physics residencycapacity by 2020 was about 30 graduates per year,and there are now 35 Commission on Accreditation ofMedical Physics Education Programs-accredited imag-ing programs. However, forthcoming AAPM publicationswill report that over the same period, the total workforcesize grew much faster than projected. Our professionhas at its disposal historical trends, surveys, and demo-graphics of the current workforce, and these can informprojections of attrition.Despite the known difficulties,ourprofession can and should project demand more fre-quently and with more attention to each of the majorsubspecialties, including diagnostic imaging physics.The task of projecting the size of the diagnosticphysics workforce would be a rather neat problem if allinflows and outflows of practicing diagnostic physicistscould be identified and measured. For example, inflowsinclude both certified and non-Board-certified medicalphysicists (NCMPs). Accreditation bodies (such as theAmerican College of Radiology and Joint Commission)and some state regulatory agencies grant independentpractice authorization to NCMPs who meet educationand experience requirements. Since these individualsqualify via a variety of pathways, there is an unknow-able number of inflows that are impossible to moni-tor. It makes sense to assume that where allowed, anyshortage of board-certified physicists would be madeup, at least in part, by NCMPs in response to the excessdemand.In addition, medical physicist assistants (MPAs) inimaging physics have existed, informally, for a long time.Medical physics practice guidelines have clarified themedical physics scope of practice (Clements et al.https://doi.org/10.1002/acm2.12469) and the role of the MPA(Seibert et al.https://doi.org/10.1002/acm2.12774).Withappropriate supervision by QMPs, MPAs can be effec-tive to extend the workforce.To our knowledge,MPAs arenot yet included in tallies of the imaging physics work-force.The formal definition of the MPA role is recent and,in the future, it will be important to take into accountMPAs’ impact on the capacity of the imaging physicsworkforce.There is anecdotal evidence of a current shortageof certified diagnostic imaging physicists. For exam-ple, numerous NCMPs currently practice on a perma-nent basis, outnumbering those who are temporarily anNCMP between completion of training and Board certifi-cation.Employers report that imaging physicist job post-ings (whether they require board certification or not) takea long time to fill, elicit smaller than desired pools ofapplicants and that candidates typically receive multiplecompetitive offers. Published survey results from 20047and unpublished AAPM survey data from 2012 and2020 consistently show about 30% of respondents whoprimarily specialize in radiation oncology are providingdiagnostic imaging support part-time. It is possible thata shortage of diagnostic imaging physicists is a con-sequence of hyper-specialization of professional certi-fication requirements (see Mills, https://doi.org/10.1002/acm2.12781), which is a type of measurement bias inworkforce assessments.Taken together, these and otheravailable data suggest that a shortage of imaging physi-cists may exist today.If a true shortage exists, the profession is obligated tounderstand why and to take corrective measures.To thisend, it must be ascertained if the shortage is real (i.e.,patients’ interests are not being fully met) or an artifact(e.g.,caused by measurement bias).When a shortage ina profession occurs, it is incumbent upon the professionto determine its own causative role, if any. Specifically,professions enjoy title protection, limited monopoly, andpower to regulate who may enter the profession. Theseprivileges, if exercised imperfectly, can cause shortages.Hence, we must determine if the apparent shortage isreal, and if so, what role we played in its creation.There is always some degree of turnover in exist-ing positions as individuals seek new opportunities for avariety of personal and professional reasons. A reviewof current or recent job postings will show a large num-ber of diagnostic physics job postings, but it is diffi-cult to determine which posts are net-new positions andwhich result from a sort of “musical chairs” among cur-rent physicists. Even if all job postings clearly indicatedwhether they were for new or replacement positions, jobvacancies are a lagging indicator for demand.First-order demand growth results from increases infactors such as the number of machines and facilitiessupported, exams performed, staff trained, and compli-ance with regulations, accreditations, registrations, andlicenses maintained. At a minimum, these increasesrequire more Level-1 services, in the context of the lev-els of service model described in AAPM Report 301.Weshould expect such demand changes to be roughly lin-ear,with new growth occurring predictably with new facil-ities and equipment. A simple demand model based onpopulation would likely encompass first-order demandgrowth on a regional or national basis.Second-order demand growth is more difficult to pre-dict. Second-order demand change results when thereis a change in the number of imaging physicists neededper basis unit of service, that is, per exam, machine,or facility. This can occur when a facility with estab-lished diagnostic medical physics support seeks addi-tional services, such as the creation and implementa-tion of new programs or services, voluntary auditing,optimization, and accreditation programs, and so forth.Second-order demand growth also encompasses theimplementation of new mandatory requirements thatwere previously voluntary. Aging of the population andchanging disease prevalence can increase the imagingutilization per patient in the population, in turn altering6 EDITORIALthe per-patient demand for physics support. Researchis an essential activity. Research and development mayimpact first and/or second-order demand; for example,it may be optional for patient care but required for aninstitution to be a National Cancer Institute-designatedCancer Center.Second-order growth is likely to result when thereis increased adoption of Level-2 and Level-3 services.Voluntary demand for additional medical physics sup-port (and financial support to pay for it) would likelyincrease when it can be shown to produce tangible ben-efits to the organization, such as improved patient out-comes or access, reduced costs, increased revenue, orelevated patient or physician satisfaction.AAPM’s work-force assessment efforts are studying the current levelof such voluntary demand, but anecdotally, it appearsquite low.Throughout this discussion, we implicitly includenuclear medicine in diagnostic or imaging physics.As the smallest medical physics subspecialty, nuclearmedicine physics comprises just a few hundred QMPsin the USA (see Harkness et al. https://doi.org/10.1120/jacmp.v16i5.5661). There is a great deal of overlap withother specialties. Many diagnostic physicists supportnuclear imaging, and the emerging practice of radio-pharmaceutical therapy includes many therapy physi-cists, who provide essential support where no nuclearmedicine specialist is available. The nuclear medicinephysicist’s expertise in the safe handling and use ofradioactive material qualifies them as a radiation safetyofficer, but this does not drive demand for nuclearmedicine physicists since most medical RSOs comefrom other backgrounds in medical or health physics.The recent rapid growth of imaging and therapeuticradiopharmaceutical applications may create a rapidincrease in demand for nuclear medicine physicists,andit is unclear whether the current education and trainingpipeline would be able to fulfill such demand with QMPs.The current US workforce appears to have a shortageof QMPs specializing in imaging physics. The shortageappears to be ameliorated to some extent by NCMPs,MPAs, and medical physicists from other subspecial-ties. We must prepare for the possibility that growth andaging of the population, or increased utilization of imag-ing in medicine, will exacerbate shortages of imagingphysicists. This is especially urgent for QMPs becauseof the long time required for their education, training,and professional board certification. More broadly, weneed to fully utilize limited supplies of QMPs, MPAs,NCMPs,engineers,and other related professionals (e.g.,radiologists) to ensure that the needs of physicians andpatients for safe and high-quality imaging are met. Mostimportantly, our profession must better understand cur-rent and future needs for our services and, correspond-ingly, ensure that adequate numbers of imaging physicsworkers enter our profession.ACKNOWLEDGMENTSWe thank Deputy Editors-in-Chief Timothy Solberg andPer Halvorsen for their valuable and perceptive com-ments.AUTHOR CONTRIBUT IONSAll authors contributed equally to the drafting and revi-sion of the manuscript.CONFL ICT OF INTERESTAll authors have no conflicts of interest to disclose.David W. Jordan1,2Wayne D. Newhauser3Michael D. Mills41 Department of Radiation Safety, University HospitalsCleveland Medical Center, Cleveland, Ohio, USA2 Department of Radiology, Case Western ReserveUniversity, Cleveland, Ohio, USA3 Department of Physics and Astronomy, LouisianaState University, Baton Rouge, Louisiana, USA4 Department of Radiation Oncology, University ofLouisville, Louisville, Kentucky, USACorrespondenceDavid W. Jordan, Department of Radiation Safety,University Hospitals Cleveland Medical Center, 11100Euclid Ave, Cleveland, OH 44106, USA.Email: david.jordan@UHhospitals.orgORCI DDavid W. Jordanhttps://orcid.org/0000-0002-4738-9696REFRENCES1. Newhauser WD. The medical physics workforce. Health Phys.2017;112(2):139-148.2. Siegal D, Stratchko LM, DeRoo C. The role of radiology in diag-nostic error: a medical malpractice claims review. Diagnosis.2017;4(3):125-131.3. Baker SR, Patel RH, Yang L, Lelkes VM. Malpractice suits in chestradiology:an evaluation of the histories of 8265 radiologists.J Tho-rac Imaging. 2013;28(6):388-391.4. Harvey HB, Tomov E, Babayan A, et al. Radiology malpracticeclaims in the United States from 2008 to 2012: characteristics andimplications. J Am Coll Radiol. 2016;13(2):124-130.5. Whang JS, Baker SR, Patel R, Luk L. The causes of medical mal-practice suits against radiologists in the United States. Radiology.2013;266(2):548-554.6. Langelier M, Forte G. Workforce Study of Medical Physicists in theUS. Center for Health Workforce Studies; 2010.7. Cypel YS, Sunshine JH. Diagnostic medical physicists and theirclinical activities. J Am Coll Radiol. 2004;1(2):120-126.

Current state of the imaging physics workforce and financial model

David W. Jordan

Wayne D. Newhauser

Michael D. Mills

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Current state of the imaging physics workforce and financial model

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