Executive Summary Report. Medical Dosimetry Workforce Study. April Prepared For: American Association of Medical Dosimetrists

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1 Executive Summary Report Medical Dosimetry Workforce Study April 2012 Prepared For: American Association of Medical Dosimetrists Prepared by Michael D. Mills, Ph.D. Brown Cancer Center, Department of Radiation Oncology School of Medicine, University of Louisville 529 South Jackson Street Louisville, KY (502)

2 Medical Dosimetry Workforce Study Executive Summary Report Background The American Association of Medical Dosimetrists (AAMD) funded a study of the medical dosimetry workforce to understand better the professional opportunities and the current supply and demand. The study was designed to guide future policy initiatives related to education, training, and credentialing of qualified medical dosimetrists (QMDs). The study was conducted by Michael D. Mills, Ph.D., Department of Radiation Oncology, School of Medicine, the University of Louisville, at Louisville, KY. The research was conducted between July 2010 and December Project activities included: a survey of all currently active QMDs and medical dosimetrists in training, including students, residents, educators, consultants, and employed QMDs conducted in 2010 (N=2,246, response rate 43.1%); a detailed workforce survey and study based on the time, intensity and work required of medical dosimetrists to perform tasks described in the American Medical Association s Current Procedural Terminology (CPT) physics codes; development of simulation models to project supply and demand for QMDs over the next 8 years under a number of training scenarios using data collected in the annual AAMD Salary Surveys, information from AAMD headquarter, information from the Medical Dosimetry Certification Board (MDCB) headquarters, and the 2010 Membership Survey; interviews and focus groups with 20 individuals knowledgeable about the medical dosimetry profession; and a survey of members of other professions in radiation oncology that work directly with medical dosimetrists to illuminate how other professionals view the medical dosimetry profession. Reports were produced that described findings from each of these activities. These reports are available from AAMD. The following is a summary of key findings for the entire project. Project Goal: The overarching goal of a workforce study is to help the AAMD and other stakeholders to identify strategies to assure that the educational system will produce Certified Medical Dosimetrists educated at an appropriate level for the knowledge base and skills required to provide a high level of professional services. The initial task in the study was to compile all existing data relevant to the Medical Dosimetrist workforce and production of Medical Dosimetrists, with special attention to identifying any information gaps that must be filled by some sort of data collection process. The five surveys were designed to measure the information needed to inform the profession and its leadership that was then unknown.

3 So what did AAMD get out of these components and objectives? Elucidation of the medical dosimetrist role in the clinic Quantification of the value of the work of the medical dosimetrist A working plan to meet the demand for medical dosimetrists with an adequate supply of trained professionals An education model that provides funding for an adequate number of programs and slots awarding appropriate degrees and/or diplomas What are some key and critical questions for the AAMD to consider? Is the AAMD primarily about medical dosimetrists or about medical dosimetry? How may medical dosimetrists defend their workload, and staffing? Under what set of circumstances medical dosimetrists might be trained remotely? What about training in other countries? What model of medical dosimetry training and practice best serves the interests of the patient? Membership Survey (Report #1) Historically, individuals were trained to work in medical dosimetry through on-the-job non-accredited training programs. Radiation therapists (RT (T) s) were frequently although not universally selected for this training. Entry requirements for such training were not specified, and the training could have been under the direction of a physician, a medical physicist, or a medical dosimetrist. However, entry requirements into medical dosimetry are now being tightened, with the final restrictions scheduled for In that year, candidates to take the MDCB Certification Examination must have completed a bachelor s degree and must have completed a Joint Review Committee on Education in Radiologic Technology (JRCERT) accredited training program. QMDs have come to the profession with diverse educational backgrounds, but are largely dominated by those who have completed training leading to an RT (T) certificate. Standardized education and entry requirements will likely contribute to improvement in clinical skills and increased quality of clinical services. Some of the data from the 2010 Membership survey revealed the current diversity of QMDs. According to the 2010 Membership survey, 710 of 968 respondents indicated they held an RT (T) certificate. The high percentage of active QMDs who indicated in the survey that medical dosimetry was not

4 their first career (72.3%) provided further evidence of the underlying diversity in the profession. Although many of these had a first career as a radiation therapist, a significant plurality worked in professions of widely varying backgrounds. About 1/3 of practicing medical dosimetrists have an Associate Degree, 1/3 have a Bachelor s degree, and 1/3 either have no degree or have another type of degree including Master s and Doctorate degrees. About half of medical dosimetrists report that they work 40 hours per week, and about half either report that they work less than full time, or report they work more than 40 hours per week. Slightly less than half report they are hourly employees while more than half report their positions are salaried and not tied to any set number of hours per week. QMDs report their work is largely dominated by clinical service, with relatively small percentages of time devoted to administration, teaching, research, equipment QA, radiation safety and other activities. Only a small percentage (less than 10%) of QMDs report they provide consulting services in addition to their primary employment. About 20% of QMDs report they are involved in training of medical dosimetrists. About 50% of open medical dosimetry positions are filled within 2 months of being posted. Medical dosimetrists without any clinical experience successfully compete for about ¼ of the open dosimetry positions. The median starting salary for a medical dosimetrist is $ 82,500. per year as reported in In the United States in 2011, the median and average salary for a medical dosimetrist was $100, and $102,040.00, respectively. Medical dosimetrists are largely uncertain about the 2017 MDCB entry requirements. More than half of medical dosimetrists oppose the Bachelor s degree requirement. More than half of QMDs also want the on-the-job training option to remain open for radiation therapists. About 70% of medical dosimetrists report they are adequately compensated for their work as a medical dosimetrist. About 95% of QMDs would recommend medical dosimetry as a career.

5 Time and Work Survey (Report #2) The Current Procedural Terminology (CPT), developed by the American Medical Association, has defined a set of codes entitled Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services (the series) which are applicable to the activities performed by the medical dosimetrist in providing the quality of radiation delivery to the patient. Under the current policy of the Health Care Financing Administration (HCFA), the dosimetrist is reimbursed through the technical component of these codes A formal study assessing the medical dosimetrist work associated with the series has never been previously conducted. In evaluating the dosimetrist work associated with the series, the Time and Work Study focused on the work actually performed by the QMD. The workforce study applied the standard model of work, which underlies the physician work relative value units on the Medicare Fee Schedule, to the analysis of QMD work. A three-phase methodology, which combined primary data collection via survey and the expertise of the Workforce Committee functioning as a Technical Consulting Panel (TCP) was implemented to generate estimates of the QMD work associated with these services. Preliminary work estimates were produced from the survey of 100 QMDs. The TCP reviewed the data compiled from the survey and validated the resulting work values. The Time and Work Survey measures QMD work for routine and special procedures. How did the survey measure QMD work? Collected time estimates (non-procedural and procedural) associated with providing medical dosimetry services Collected intensity estimates (relative to CPT code Complex Isodose Plan) for each service relative to the baseline service Collected service-mix data (annual number of procedures provided by service) Analyzed survey data to develop preliminary QMD work estimates by service Procedural time is that spent with a specific patient, performing a service for that patient (including the time to bill the patient) Non-procedural time is that spent with equipment commissioning, daily and monthly checks, annuals, recommissionings after repair, etc. Although some medical dosimetrists perform machine QA as a small percentage of their duties, the survey process revealed that the median medical dosimetrist does not perform significant non-procedural time respecting medical dosimetry services.

6 Summarized findings of the AAMD Time and Work Survey are: Numbers of survey respondents closely match AAMD demographics by Practice Type and Region. Procedural time, intensity and work values were reported. Work = time X intensity We select a common representative procedure and use it as a benchmark with intensity = 1.0 The preliminary panel selected as our benchmark and assigned it an intensity of 1.0 Respondents assigned all other procedures an intensity using as a reverence The median medical dosimetrist performs services measured at 2878 hours, equivalent to 3293 work units. This does not mean that the median medical dosimetrist works 2878 hours per year. The magnitude estimation method used in this survey overestimates total time; this is a well-known characteristic of these surveys. The service mix profile (number of CPT codes in each category billed per year) for the median practicing QMD in the United States is reported. The time and work values along with the median service mix profile may be used as benchmarks to estimate time and work requirements of a local center with respect to a national benchmark. The median center treats 563 patients and 452 new patients per year. A median 245 patients are treated per FTE QMD. The median center employs 2 FTE medical dosimetrists, 2 FTE radiation oncologists, and 1.4 FTE medical physicists along with 6 radiation therapists and 2 radiation oncology nurses. Patient numbers may also be used as a benchmark for staffing. The difference between staffing and work: 1) Staffing applies to the entire radiation oncology program; work applies only to the QMD. 2) Staffing may include non-professional effort; QMD work is professional in nature. For professionals, work is directly related to compensation with respect to services provided, staffing is not. The resulting work values indicate that the QMD spends a substantial amount of time on the different radiation oncology dosimetry services. Most of these services require one or more hours of the QMD s time. The AAMD believes that the work values produced from the workforce methodology possess clinical face validity and reflect the true variation in the QMD s time and effort for different services. The AAMD perceives these results as a starting point to understanding the QMD s contributions in providing the medical dosimetry CPT codes. The relative work value scale developed in this study could be useful to future assessments of the reimbursement policies and levels for medical dosimetry services by providing quantified measures of the work of the QMD.

7 Supply and Demand for Medical Dosimetrists (Report #3) Simulation models on supply of and demand for QMDs were developed to understand the potential workforce ramifications of the changing education and training requirements for Medical Dosimetry Certification Board (MDCB) certification. The Demand information used as input to the model is: Cancer incidence and prevalence (American Cancer Society) Median new cancer patients treated per Clinical FTE Medical Dosimetrist (Abt Study of Medical Physicist Work Values for Radiation Oncology Physics Services) The Supply information used as input to the model is: Non-JRCERT medical dosimetrists trained and MDCB Certified and projected through 2017 (calculated based on information provided by Felicia Lembesis, Medical Dosimetry Certification Board, and Spencer Boulter, American Association of Medical Dosimetrists JRCERT accredited program medical dosimetrists trained and MDCB Certified and projected through 2020 (calculated based on information provided by Felicia Lembesis, Medical Dosimetry Certification Board, and Spencer Boulter, American Association of Medical Dosimetrists Number of Working Medical Dosimetrists (calculated based on information provided by Spencer Boulter, American Association of Medical Dosimetrists The demand forecasts are based on the forecasts of incident and prevalent cancer cases, as well as the estimated age and gender-specific oncologist visit-rates for cancer patients developed by the National Cancer Institute (NCI) in July The model showed the following: Simulations based on the models suggested that the new certification requirements would dramatically reduce the production of new board-eligible QMDs, due to a lack of JRCERT-accredited academic and training positions. The annual number of new board-eligible QMDs required to meet demand for medical dosimetry services was projected to increase from 140 to more than 200 for QMDs through If steps are not taken to increase the number of new board eligible QMDs produced each year, from JRCERT-accredited programs, shortages of QMDs were possible. At current rates of production, shortages of medical dosimetrists would begin to occur as early as 2016.

8 The models suggest that the retiring wave of medical physicists coupled with demographic population growth will expand the market for employment of medical dosimetrists between 2012 and As the new education and training requirements fall into place, this likely will decrease the supply of new graduates looking for entry level employment. It seems likely that the medical dosimetry community will struggle to create enough training positions to meet demand for several years after With a large employment pool, the dosimetry community should be able to meet the additional work challenges during this period. If existing medical dosimetry training programs are willing to expand, it is likely this challenge will be met within several years. After 2020, supply and demand should balance as the first wave of graduates from the expanded programs enters the workforce. Complexity Study (Report #4) The survey of Medical Dosimetrists professional colleagues (Complexity Survey) was designed by the Workforce Committee appointed by the AAMD to oversee this project. The pool of surveyed professions included radiation therapists, medical physicists, radiation oncologists, oncology administrators, oncology nurses, and equipment engineers. Survey questions asked about demographic information, educational and career pathways to the profession, certification, current professional activity, and future plans. The survey also solicited opinions and attitudes of Medical Dosimetrists professional colleagues on a number of subjects relevant to current professional issues. Each question provided defined response options including, in some cases, an other category with the opportunity to describe the meaning of other if that response was selected. Some findings from the Complexity Study: Colleagues of medical dosimetrists were much more likely than medical dosimetrists (55.4% versus 38.4%) to agree or strongly agree that a Bachelor s degree should be a requirement to enter the medical dosimetry profession. Colleagues of medical were much more likely than medical dosimetrists (53.2% versus 39.1%) to agree or strongly agree that a Bachelor s degree in a science and an RT (T) Certificate or Associate Degree is also required. Other professionals agree (at a consensus of 73.9% that agree or strongly agree) that the work of the Medical Dosimetrist is of sufficient importance and complexity that delegation of these responsibilities to less trained individuals is not appropriate. Colleagues agree that the medical dosimetrist should interact with patients and supervise the simulation and initial treatment as part of his/her duties as a radiation oncology team member (58.5% agree or strongly agree).

9 Interviews with Selected Medical Dosimetrists (Report #5) The survey of Medical Dosimetrists professional colleagues (Complexity Survey) was designed by the Workforce Committee appointed by the AAMD to oversee this project. The content of the questionnaire was determined after completion of a comprehensive literature review and after examining historical data on the Medical Dosimetry profession. In addition, interviews with practicing Medical Dosimetrists, directors of Medical Dosimetry education and training programs, industry representatives working with Medical Dosimetrists, government regulators, the professional association, the certification board, and with other stakeholders with an interest in Medical Dosimetry. Survey questions asked about demographic information, educational and career pathways to the profession, certification, current professional activity, and reporting structure. The survey also solicited opinions and attitudes of medical dosimetrists on a number of subjects relevant to current professional issues. The survey instrument was approved by the members of the Workforce Committee who reviewed the survey. The Workforce Committee made adjustments to survey content and finalized the survey questions in late summer, The Workforce Committee of the AAMD developed and approved a master list of professional medical dosimetrists that were considered representative of the leaders of the profession. The list contained contact information for all targeted professionals. Twenty-five individuals were selected, including students, new professionals, program directors, members of industry, and present and past leaders of the profession. The medical dosimetrists were interviewed via audio conference call with Michael D. Mills, Ph.D. and Mellonie Brown, MET and CMD. The conference call feature of SKYPE was utilized for this effort. Interviews were scheduled for thirty minutes. No audio recordings of these interviews were made. Sample Results: Formal education and training requirements were solved by the MDCB. We need better standards for plan training and plan evaluation. There is not enough focus on retiring dosimetrists. We are losing a significant knowledge base. Medical dosimetry is a professional model that should be exported. Australians do an excellent job training medical dosimetrists. I know an administrator s wife who was trained to generate treatment plans. This sets a bad precedent for our profession and should not be allowed. The profession should train only BS and MS individuals. Metrics and class solutions will become an important component of our clinical activities. We have a huge problem with the MDCB respecting how disputes are addressed. Two students who applied to take the exam were ruled ineligible due to a ruling as to when clinical hours had to be taken. A BS is required in 2015; a BA will not qualify you to take the exam. The curriculum guide has no clinical component.

10 BS, MS and certificate programs offer three different diplomas and three different types of experience. Training programs, clinical time and distance learning are key concepts for the future. The AAMD Board is doing a good job. We should consider having more local chapters and more chapter activities. The profession has added continuing educations, practice exams and study materials. There are very helpful for students preparing to take the MDCB exam. I love my job and love radiation oncology. I have been in the field a number of years and I stay involved. Dosimetrists can be outraged if they cannot get jobs locally. Nationwide, there are still plenty of jobs, but there are localized regions of oversupply. The AAMD should take over the Dosimetry Training Tool from Stanford. I am concerned about the increasing chasm between the reality of radiation oncology and how the training is prioritized. IMRT is not magic. The creative planning skill set is decaying. Physicians are insufficiently knowledgeable or too lazy to demand quality planning. A MS is fine, but is mostly outside the mainstream need for quality planning. The AAMD should not try to pattern itself after the AAPM, but should find its own unique identity. It should keep focusing on serving the members and their needs. The MDCB has established the training paths, and that is a big step forward. I am happy with our interactions with physicians and with technologies. The profession works just fine for me. Plan challenges are important to bring out the best in our planning. The dosimetrist is the person in the middle; the quarterback of the department. The dosimetrist is becoming a practitioner. More requirements and tools are needed to establish baselines and develop class solutions for clinical procedures. We need metrics for professional achievement and completion of competencies. The profession is maturing. It must maintain high standards. There is not enough peer review in medical dosimetry. We are having a hard time getting to best practices. The MDCB Board exam needs to be more specific to medical dosimetry. It has too much physics and too little dosimetry in its emphasis. It seems logical to have division of labor doing dosimetry tasks. Year ago QA was simple; not it is quite complex. People need to be trained as medical dosimetrists as a separate profession start to finish. Not as RTTs first. The knowledge base is important. We need to expand the profession with higher standards. We need to engage the public and educate those that do not know about radiation oncology.

11 The most important issue is developing standards for best practices in planning techniques. We need online training in these best practices. Medical dosimetry must consider what the market is and what the market is prepared to pay for, then hit it exactly. The market is prepared to pay for BS level medical dosimetrists, and this should be the standard. The most efficient way is to design the BS curriculum to provide exactly what is needed. While substantial time treating patients can be included in a BS medical dosimetry program, the ultimate goal is to produce medical dosimetrists, not RTTs. Years of treating patients are of marginal value compared to mastery of best practices, class solutions, and other knowledge unique to medical dosimetry. Conclusion and Thoughts for the Future: There is a shortage coming unless the medical dosimetry community is able to double the number of accredited training slots by MS medical physicists that cannot get into residencies will compete for slots now occupied by medical dosimetrists. The market is aimed right at a BS prepared medical dosimetrist from a JRCERT training program. It may be possible to design a BS program that prepares the student either for a career as a radiation therapist or a medical dosimetrist; this should be considered. Medical salaries will likely go down significantly in the future, however there will likely be jobs available for medical dosimetrists Finally, you guys are beginning to ask the right questions! Physicists have carved their niche and so have other professions like engineering. You had better start carving one for dosimetrists or the profession will eventually die by training therapists to do treatment planning as a rotational condition of employment or it will be taken over entirely by physicists who will be looking for a greater slice of the pie since so many of them are being graduated from the schools. Comment from a practicing medical dosimetrist