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Radiotherapy physicists have become glorified technicians rather than clinical scientists

2010; Wiley; Volume: 37; Issue: 4 Linguagem: Inglês

10.1118/1.3298378

2473-4209

Howard Amols, Frank Van den Heuvel, Colin G. Orton,

Radiation Therapy and Dosimetry

With the advent of the requirement for graduation from an accredited medical physics residency program in order to become certified and the emergence of Doctorate in Medical Physics, there has been some concern that radiotherapy physicists are becoming more like “trained” professionals, or even “glorified technicians,” than “educated” scientists. This is the concern debated in this month's Point/Counterpoint. Unlike most Point/Counterpoint columns which debate the pros and cons of something (e.g., PET scanning is or is not useful, etc.), this column is a semantic debate. What are the definitions of “technician” and “scientist,” and which more accurately describes most medical physicists? Let us start with the dictionary. Okay, nobody under the age of 107 uses a dictionary anymore, so let us consult Wikipedia.1 Scientist: Any person who engages in a systematic activity to acquire knowledge; an individual that engages in such practices and traditions… linked to schools of thought or philosophy… who uses the scientific method.1 Physicist: A scientist who studies physics. Physics… deriving from the Greek “” meaning “nature” or natural science. The study of matter and its motion through spacetime and all that derives from these, such as energy and force… the general analysis of nature, conducted in order to understand how the world and universe behave.2 A “real” dictionary3 defines science as “a branch of study concerned with observation and classification of facts and especially with the establishment of verifiable general laws.” I can end my argument here—Not one in ten medical physicists meets this definition of scientist, but I am supposed to write 500 words, so—If we are not scientists, maybe we are clinical scientists? Clinical science… the practical study of medical principles or investigations using controlled procedures to evaluate results.4 Other than occasionally participating in clinical trials, most of us (medical physicists) rarely do that, so we are not clinical scientists either. By process of elimination then we must be technicians. Technician: Someone in a technological field who has a relatively practical understanding of the general theoretical principles of that field… more versed in technique compared to the average layman… A midlevel of understanding of theory and a high level of technique is generally mastered by the technician… to become expert in a specific tool domain… a medical technician is an employee who provides technical support in the medical industry or to the medical profession.5 Webster's definition is similar: Technician: A person who has acquired the technique of a specialized skill or subject.3 Is not that us? Is not the current “anti-Ph.D./pro-residency” trend indicative of the shift toward training medical physicists for a “specific tool domain” rather than a “high level of understanding of theory?” Do some medical physicists “engage in a systematic activity to acquire knowledge,” or study “how the world and universe behave” as per any reasonable definition of scientist? Sure, but what about the other 95% of us who spend less than 5% of our time engaged in such endeavors and instead have only a “midlevel of understanding of theory” and are “employees who provide technical support… to the medical profession?” Calibrating x-ray machines, running computer programs, designing and implementing a QA program, and evaluating new technology and making it work is all important stuff but it is not science. “Be happy in your work.”6 “To thine own self be true.”7 There is a lot of routine in what we do and a lot of the things we do can be done by people with other skills and background. This involves doing monthly QAs, calibrations, making and checking treatment plans, etc. All of this is straightforward and can be done by following recipes (TG51, TG142, etc.…), and making checklists.8–13 It does not take someone who has passed quantum mechanics to do this. So why do we need someone like that? There are several reasons. First, what happens if things on the checklists or recipes do not have the expected results? Now you need someone who really understands why the recipes are set up as they are. What is the theory behind it? What types of errors can generate the results? Why is it that you need to measure dose in an electron field at a given depth? What if you cannot use water for your measurement medium? Second, what are the boundaries within which the given techniques and algorithms work? Remember the first IMRTs when we obtained strong skin reactions? That is right, most algorithms do not work at tissue interfaces. Which algorithm to use for which technique? Does everything work out when you install or upgrade a planning system? I have seen weird stuff in very expensive software by reputable companies. Third, the technology in RT is evolving rapidly. New techniques (IMRT, VMAT, IGRT, protons, carbon ions, gating, nanotechnology, and mini x-ray sources) are introduced with increasing speed. Who has the background to understand these techniques rapidly? Get them working in a clinical environment with all the necessary checks and set them up so that some of the work can be delegated. It is part of the job of physicists to make themselves obsolete for the delivery of certain procedures. I remember introducing computerized planning into our practice (to be honest, George Sherouse wrote it14 and we introduced a few if-then-else statements to make it work in our place), networking, record and verify, and electronic imaging. All of this using the knowledge we had of computer science, hardware, and mathematics, including statistics. Now you buy a planning system with all the bells and whistles. Not all new technology introduced by these companies works in the way it is advertised. There is a lot of wishful thinking. You need these stubborn physicists with their models and calculations to tell you that the emperor has no clothes. Finally, physicists are in an interesting position in that they have oversight of the complete chain of events that is needed to treat a patient adequately and safely. It is the physicists who have the best knowledge to understand why and how things can go wrong. And if they go wrong, they go wrong disastrously. We should move away from the notion that all physicists do are chart checks and machine QA; they are the resident scientists and lubricant that makes a department tick. The education of physicists should reflect that they should be scientists with a thorough schooling in all the aforementioned areas. You can drive your car pretty far without lubricant but it will blow up in the end. I fear that my esteemed colleague's description of the work of medical physicists as being akin to that of other scientists or describing them as “resident scientists and problem solvers” is outdated. I think he is talking about Harold Johns, John Laughlin, John Cameron, and other dead people. Over recent years the AAPM has worked toward changing medical physics from a science into a profession, and has largely succeeded in this questionable goal. Most members of the AAPM now want to be medical professionals, not scientists. They do not want Ph.D. or even MS degrees—They want Doctorates in Medical Physics. They want to close the field to chemists, computer scientists, and the like, and accept only bona fide CAMPEP approved medical physicists. They do not want to do fellowships like other scientists, but rather residencies like other medical professionals. These are not just words, labels, or job titles. They represent genuine changes in philosophy and in the definition of our field. A university is composed of various schools. Scientists obtain degrees from Schools of Arts and Sciences as opposed to professionals who obtain their degrees from the professional schools within the university such as the Schools of Medicine, Law, Business, etc. In the School of Arts and Sciences you learn how to think, how to discover new knowledge, how to be a Renaissance man (or woman), and how to lubricate Dr. Van den Heuvel's car before it blows up. In the professional schools, you basically learn a trade and how to make a buck. Medical physics has become a trade. When something breaks in the hospital, such as a linac or a scanner, most people call the manufacturer's service engineer rather than the medical physicist. When the treatment planning computer starts giving strange results they call the manufacturer's software help desk. The medical physicist used to be the “resident problem solver,” but that is rapidly changing. I am afraid that Dr. Van den Heuvel has described yesterday's medical physicist, not today's, and certainly not tomorrow's. It is always rewarding in a debate to see your opponent go the “semantics” route. This is usually an admission of weakness with regard to the real content of the proposition. Essentially, Dr. Amols is telling medical physicists that they never were and never will be scientists, and that they are at best aides to the physicians without their own minds. Let us look at all of the definitions provided by Dr. Amols and pick the one that applies to a medical physicist, namely, scientist—One who uses the scientific method. I certainly hope that the medical physicists we train are well versed in the scientific method. By the scientific method I do not only mean the experimental validation and refutation of scientific facts, but also the use of physical models to describe reality, something our physician colleagues are not necessarily good at. By that definition I daresay medical physicists are scientists. Of course if you want to be considered a scientist, be a scientist. It is easy to be caught up in the routine of day-to-day work. Clinical physicists should stay interested in changes in the scientific environment. This means to educate themselves constantly on new concepts, techniques, and advances in their field. In order to be a scientist you have to act like one. Be curious, ask questions, find answers, and look further than your current knowledge. Try to develop new technologies yourself and not wait for someone else to develop (or sell you) them. There is nothing stopping you from proposing new technologies to companies: They will be happy to use anything you can bring them. Examples are legion: VMAT,15 RapidArc,16 TomoTherapy, etc., not all of which have been introduced by large academic departments.