By Thomas J. Petrone
Hospital and health system administrators are unlikely to be experts in medical physics.
This lack of specialized knowledge is completely rational — their skills and experiences lie elsewhere — but it nonetheless creates uncertainty: are they spending too much to meet their institution’s medical physics needs? And if those needs aren’t being met, how much more should they be spending, and on what?
Recognizing this gap in knowledge (and in keeping with ever-increasing cost consciousness in healthcare), the American Association of Physicists in Medicine (AAPM) has conducted a series of surveys intended to clarify the needs and costs of various medical physics services. Drawing on the expertise of academic physicists and outsourced consultants alike, one 2017 study supplies consensus time estimates and effort considerations for essential functions like equipment testing, as well as value-added services like acting as the hospital’s radiation safety officer (RSO). The report also touches on the intangible and harder-to-quantify contributions that a medical physicist can make to a health system’s diagnostic medical radiation safety, effectiveness, and operations overall. Hospitals and health systems can use this report (and similar resources on the therapeutic side) to identify an appropriate scope of work and an appropriate range of costs for that scope.
As the report indicates, however, intangibles and unknowns will always remain, especially in such a swiftly evolving field. On the diagnostic side especially, where many physics activities might be done after hours when rooms are not needed, hospitals must navigate past acting “pound foolish” while also avoiding being too “pennywise.” Between the two is where an institution will derive the proper value from its medical physics investment.
Assessing unique needs
The right mix of in-house medical physicist positions and outsourced consulting services will be different for each institution — and many will not need a mix at all. For those trying to strike the right balance between the two, some fundamental questions apply:
What type of medical radiation equipment do you use?
How many machines do you have?
What are the applicable regulations for the equipment’s calibration and monitoring?
Is there a teaching or training component of the medical physicist’s job, or other administrative work you need him or her to do?
What resources are available for this purpose?
Knowing what you need means taking into account the institution’s focus (e.g., cancer, cardiac disease, pediatrics) and overarching goals (e.g., research, growth in a certain area). In terms of medical physics, here are some examples of how these aspects can affect the proper medical physics service mix:
Some hospitals simply don’t have enough equipment and radiation-based procedures to have a physicist around 40 or 50 hours a week. A large academic institution, on the other hand, will undoubtedly need the specific expertise of a medical physicist (or several) on staff. In between is where a hybrid solution is most common: hospitals with in-house physicists might outsource routine tasks that nonetheless require meticulousness and expertise specific to a consultant, especially when the tasks can be identified and allocated for in advance. The in-house physicist oversees that work but is also available to handle unexpected problems, and tasks outside of routine monitoring and maintenance.
Institutions that focus on cancer will usually need to have medical physicists on staff. The choice is more complicated at a large hospital focusing on cardiac issues: it will likely need in-house diagnostic medical physics expertise (for cardiac CTs, say), but might successfully manage a hybrid in-house/outsourced mix rather than employing numerous physicists. Pediatric hospitals, too, may feel they need in-house physicists to optimize radiation dosage and minimize exposure when diagnosing the hospital’s vulnerable patients, but might usefully pursue outsourcing assistance for other applications. The ROI here derives from ensuring that the radiation is optimized for the practitioners working with this sensitive cohort.
As administrators know all too well, the healthcare dollar is not infinite — hence reports like the AAPMs that seek to estimate the time and cost of necessary services. When the responsibilities of a medical physicist are understood as regular, easily anticipated, and discrete, then consultants on the whole are a safer investment: their job is to knowledgeably and consistently estimate the time a task will take, and to stick to that time. Knowing that the client will want to account for every minute of time they spend — and knowing that they’re in constant competition for that client’s business — consultants are contractually committed to efficiency. The institution can thus be assured that a consultant will not waste time on irrelevant meetings or matters where they can’t make a meaningful difference. This is not an assurance that an employed medical physicist can provide. Avoiding “pound foolishness” is, thus, more easily done when the institution relies on consultants to do the work. However, outsourcing these responsibilities completely also raises the chances of being “too pennywise”: missing out on the informal conversations that can lead to quality or process improvements, like a chance coffeeshop meeting between a cardiologist and physicist where they discuss ways to improve imaging of vessels, or the ability of a physician to call an in-house physicist in to witness an unusual case.
Measuring what counts
In laying out the basic landscape of possible medical physics services, reports like the AAPMs perform an important role for administrators seeking a balanced medical physics solution. The report divides that landscape into three levels:
Level 1. Services and duties mandated by regulatory bodies (these are relatively easy to identify and quantify);
Level 2. Responsibilities and tasks not mandated by an outside entity, but still widely recognized as valuable (possible to identify and quantify);
and Level 3. Neither mandated nor well-defined, but still part of a medical physicist’s contribution — this comprises things like research, development, and exploration of new tools and methods (possible to identify, difficult to quantify).
These levels are useful both in informing decision-makers about what medical physicists already do and in reminding them that those duties, like the technology they’re based on, are always changing. In other words, the very presence of a “Level 3” demands that administrators acknowledge the intangible knowledge work, collaboration, and evolving skills medical physicists must do to succeed in the field. Or, as the report puts it: those same Level 3 activities that are less quantifiable “are also often those that are novel, emerging, or have not yet become a universal standard practice in all institutions. As such, they are growth opportunities for diagnostic medical physics.”
Striking the balance
When an institution decides to hire a consultant for some amount of Level 1 duties, where efficiency and accountability are paramount, they still need to decide who will handle those in Levels 2 and 3. Depending on the hospital’s size and focus, hybrid solutions work well when the in-house physicist or physicists handle the programmatic aspect of the work, overseeing quality assurance across the institution. On the diagnostic side this could mean managing several buildings’ worth of radiologic equipment; on the therapeutic side it could mean overseeing proper patient delivery and safety during radiation oncology treatments (while still relying on consultants to create efficiencies within the required regular tasks). In either case, having consultants take care of the Level 1 duties frees up the in-house physicist to take a broader view of their program.
What in-house employees do with that freedom is, of course, where both the greatest risk and the greatest potential reward lie. Medical physicists, as a whole, are adept, dedicated, and driven, and there are many instances where they contribute to an institution’s operations and mission in untold ways. If they aren’t making these contributions, however, that may also prove difficult for non-experts to recognize. For example, the Joint Commission requires that CT and fluoroscopic dose be optimized. Yet those efforts vary widely across institutions: some do a loose reporting of metrics while others create robust and structured programs where the data collected are continually used to improve quality and safety. Often, institutions in the former group will be found compliant — but those in the latter group are the ones meeting the true aims of the standard.
Evaluating the mix
Evaluation can also be thought of as a range from simple questions to the more robust. On the simple side, questions like, “have we passed our inspections?” and “have our staff passed the radiation safety exams we’ve trained them for?” are some of the easiest to assess and some of the most important. Another one that falls into this category is how the institution has done with accreditation, whether for the Joint Commission or for the American College of Radiology.
More qualitatively, an evaluation of a medical physicist’s performance can be requested of those who would understand it best: the chair of radiology, the chair of radiation oncology, or other experts who rely on medical physics to keep their equipment optimized and their patients and staff safe. When the people in these different positions return a consensus, it should be respected.
With such a specialized area, the evaluation of a medical physics program, no matter the mix, will require the input of trusted experts. Those experts must in turn understand the particularities of the institution or site as well as an awareness of the intangibles in play. To avoid being pound foolish or “too pennywise” requires putting all of this knowledge together.
About the author: Thomas J. Petrone, Ph.D., DABR, is the chief medical physicist and CEO of Petrone Associates.