1. RAS6038 – Setting the Scene Strengthening Medical Physics through Education & Training in the Asia Region A/Professor John Drew Institute of Medical Physics, University of Sydney, Australia Lead Country Coordinator, RAS6038

2. The Ultimate Goal “Every patient with cancer deserves to receive the best possible management to achieve cure, long term tumour control or palliation”. (Inter-Society Council for Radiation Oncology, 1986) “Every patient with cancer deserves to receive the best possible management to achieve cure, long term tumour control or palliation”. (Inter-Society Council for Radiation Oncology, 1986)

3. Goal of Radiotherapy The goal is to cure or control the disease while minimizing complications to normal tissue The goal is to cure or control the disease while minimizing complications to normal tissue Since the “window” for optimal treatment is very narrow, the radiation dose must be delivered accurately and consistently Since the “window” for optimal treatment is very narrow, the radiation dose must be delivered accurately and consistently No matter how good the radiation oncologist is, if the medical physicist gets it wrong then the treatment is wrong! No matter how good the radiation oncologist is, if the medical physicist gets it wrong then the treatment is wrong!

4. What Can Go Wrong?

6. Exeter Hospital, UK, 1988 Exeter Hospital, UK, 1988 Incorrect calibration -207 patients with a 25% overdose Incorrect calibration -207 patients with a 25% overdose North Staffordshire, UK,1982-1991 North Staffordshire, UK,1982-1991 Incorrect use of treatment planning computer - 989 patients Incorrect use of treatment planning computer - 989 patients Zaragoza, Spain, 1990 Zaragoza, Spain, 1990 Faulty linac repair - 27 patients with doserates of 3 to 7 times Faulty linac repair - 27 patients with doserates of 3 to 7 times Panama, 2000 Panama, 2000 Incorrect use of treatment planning computer - 28 patients Incorrect use of treatment planning computer - 28 patients

7. What Can Go Wrong? US US Gamma Knife incorrectly calibrated – very high patient does for a number of months Gamma Knife incorrectly calibrated – very high patient does for a number of months IMRT dose delivery – substantial patient over dose IMRT dose delivery – substantial patient over dose Asia and Pacific Region Asia and Pacific Region Japan Japan Australia Australia ??? ???

8. What Can Go Wrong? Beatson Oncology Centre, Glasgow, 2006 Beatson Oncology Centre, Glasgow, 2006 Lisa Norris, age 15 “A teenage cancer patient who last week celebrated her recovery from a brain tumour has been told that she was accidentally given 17 potentially fatal radiation overdoses.” “Three physicists and two hospital administrators failed to spot the mistakes.” “… are calling for those who made the errors to be sacked.”

9. Some Underlying Causes Identified by the IAEA IAEA conclusion 1 : IAEA conclusion 1 : Frequent contributors to accidents were: Frequent contributors to accidents were: Insufficient education (and training) in radiotherapy physics; Insufficient education (and training) in radiotherapy physics; A lack of a set of procedures and protocols integrated into a comprehensive quality assurance program; A lack of a set of procedures and protocols integrated into a comprehensive quality assurance program; And/or the lack of supervision over compliance with the program. And/or the lack of supervision over compliance with the program. 1 “ Lessons learned from Accidental Exposures in Radiotherapy. ”, IAEA, Vienna, 2000.

10. Part of the Solution! Clinically qualified medical physicists This requires: “ Thorough and proper training to achieve a high standard of safety and quality in patient care.” But what defines “clinically qualified”?

11. What is a Clinically Qualified Medical Physicist? AAPM AAPM “A Qualified Medical Physicist is an individual who is competent to practice independently in one or more of the subfields of medical physics.” “A Qualified Medical Physicist is an individual who is competent to practice independently in one or more of the subfields of medical physics.” Other organisations use similar words This concept has been adopted in RAS6038

12. Essential Role of Medical Physics “The essential role of the qualified medical physicist’s clinical practice is to assure the safe and effective delivery of radiation to achieve a diagnostic or therapeutic result as prescribed by a licensed practitioner in patient care.” (AAPM) “The essential role of the qualified medical physicist’s clinical practice is to assure the safe and effective delivery of radiation to achieve a diagnostic or therapeutic result as prescribed by a licensed practitioner in patient care.” (AAPM)

13. Knowing all we need to know in our specialty This Means … TechnicallyCompetent ProfessionallyCompetent Knowing all we need to know in our specialty Plus being able to (IPEM): Define a problem and formulate strategies for solving it Interpret novel or non-standard data Make value judgements in unfamiliar situations Communicate scientific advice clearly and accurately to others Recognise fault situations and take suitable corrective action Appreciate the limitations of one’s knowledge.

14. Training for a Competency Based Environment There are standard training models for people who require advanced theoretical and extensive practical skills. For example, consider these two groups: There are standard training models for people who require advanced theoretical and extensive practical skills. For example, consider these two groups: Airline pilots Airline pilots Medical specialists Medical specialists

15. Training for a Competency Based Environment What do they have in common? What do they have in common? Advanced theoretical knowledge Advanced theoretical knowledge Extensive practical competencies Extensive practical competencies Quality Quality Time taken (many years) Time taken (many years) Licensing Licensing Which is competency based Which is competency based On going continual professional development On going continual professional development

16. Training for a Competency Based Environment Why? Why? They take full responsibility and may work independently They take full responsibility and may work independently If they get it wrong people die If they get it wrong people die Are medical physicists any different? Are medical physicists any different? No! We satisfy both the above points. No! We satisfy both the above points. Therefore, it is reasonable that our training is just as thorough and rigorous. Therefore, it is reasonable that our training is just as thorough and rigorous.

17. Qualified Medical Physicist - IAEA Degree majoring in physics or equivalent Degree majoring in physics or equivalent Postgraduate degree in medical physics Postgraduate degree in medical physics Equivalent of at least two years of full-time comprehensive clinical in-service training in radiotherapy physics undertaken in a hospital. This training should be under the supervision of an experienced or senior radiotherapy physicist Passing an appropriate assessment Passing an appropriate assessment This training should preferably be approved by a suitable professional body, i.e. a Board that will issue a clinical certification

18. Developing a Clinically Qualified Medical Physicist Academic Education Clinical Training Certification Through university based MSc and PhD programs RCA Project RAS6038 “It is emphasized that the holder of a university degree in medical physics without the required hospital training cannot be considered clinically qualified.” IAEA, 2007

19. Training Schematic Formal tertiary education - university Formal vocational training - hospital Exams, tests - university, Professional body Work time BScMSc/PhD Clinical training CPDCPD CPDCPD CPDCPD supervised unsupervised Education Training Assessment

20. Supervision vs. Usefulness vs. Safety Clinical training Unsupervised Requiring Supervision In Training Accredited Fully useful Usefulness for Routine work Patient Safety

21. RCA Project RAS6038 Objective To improve the medical physics capability and capacity in the region To improve the medical physics capability and capacity in the region Through the establishment of regional approaches on education and training Through the establishment of regional approaches on education and training Which can be maintained through sustainable national programs Which can be maintained through sustainable national programs By developing an in-service clinical training programs for medical physicists in the specialties of radiation oncology, radiology and nuclear medicine By developing an in-service clinical training programs for medical physicists in the specialties of radiation oncology, radiology and nuclear medicine

22. RCA Project RAS6038 Vision Develop an in-service clinical training program which: Develop an in-service clinical training program which: Is competency based Is competency based Has an end point of “qualified to work unsupervised” Has an end point of “qualified to work unsupervised” Is modular in design Is modular in design Adaptable to suit individual country needs Adaptable to suit individual country needs Adaptable to suit the entry level of the individual Adaptable to suit the entry level of the individual Meets the needs of Member States, the RCA and the IAEA. Meets the needs of Member States, the RCA and the IAEA.

23. Acknowledgements The initial concept came from an in-service clinical “Training, Education & Accreditation Program” (TEAP) developed in Australia. The initial concept came from an in-service clinical “Training, Education & Accreditation Program” (TEAP) developed in Australia. The Australian model has had significant funds from the Australian Government and the New South Wales Government to help in its development The Australian model has had significant funds from the Australian Government and the New South Wales Government to help in its development It has been significantly enhanced by experts from around the world drawing upon a number of international sources. It has been significantly enhanced by experts from around the world drawing upon a number of international sources.

24. Program Development An Expert Steering Group was formed in 2005. An Expert Steering Group was formed in 2005. The Group met in Mumbai in April, 2005 The Group met in Mumbai in April, 2005 Its members were: Its members were: Mr. Deshpande (India) Mr. Deshpande (India) Mr. John Drew (Australia) Mr. John Drew (Australia) Mr. Kiyonari Inamura (Japan) Mr. Kiyonari Inamura (Japan) Mr. Fuad Ismail (Malaysia) Mr. Fuad Ismail (Malaysia) Ms. Anchali Krisanachinda (Thailand) Ms. Anchali Krisanachinda (Thailand) Mr. Tomas Kron Australia) Mr. Tomas Kron Australia) Mr. Frank Pernicka (IAEA TO) Mr. Frank Pernicka (IAEA TO) This meeting laid the foundations for a guide to the clinical training program. This meeting laid the foundations for a guide to the clinical training program.

25. Program Development – Next Stage An expert group was formed to develop the actual guide. The members of this group are: An expert group was formed to develop the actual guide. The members of this group are: Mr. David Bradley (UK) Mr. David Bradley (UK) Mr. KY Cheung (China) Mr. KY Cheung (China) Mr. John Drew (Australia) Mr. John Drew (Australia) Ms. Lisa Duggan (Australia) Ms. Lisa Duggan (Australia) Mr. Guenther Hartmann (Germany) Mr. Guenther Hartmann (Germany) Ms. Anchali Krisanachinda (Thailand) Ms. Anchali Krisanachinda (Thailand) Mr. Yoshie Kodera (Japan) Mr. Yoshie Kodera (Japan) Mr. Donald McLean (IAEA - TO) Mr. Donald McLean (IAEA - TO) Mr. Brian Thomas (Australia) Mr. Brian Thomas (Australia) This group has met three times – December 2005, July 2006 and January 2007 to develop the program. This group has met three times – December 2005, July 2006 and January 2007 to develop the program.

26. Developing the Training Program Guide Steps Steps Define the roles and responsibilities Define the roles and responsibilities Define the required knowledge and competencies to undertake these roles and responsibilities Define the required knowledge and competencies to undertake these roles and responsibilities Prepare a competency based clinical training program which meets the required knowledge and competencies Prepare a competency based clinical training program which meets the required knowledge and competencies

27. The Clinical Training Program To be continued tomorrow ……. To be continued tomorrow …….