Resource Allocation in Radiation Oncology: Where We’ve Been, Where We’re Going
By Navneeth Hariharan, ME
2024;17(2):8
Radiation oncology is a dynamic field that has evolved significantly in recent years, from integrating advanced technologies to using multidisciplinary care pathways. This article delves into resource allocation in radiation oncology and describes the current clinical practice environment, the changes that have led us here, and how we can manage resources to provide the care needed for our patients.
The American Society for Radiation Oncology (ASTRO) document “Safety Is No Accident: A Framework for Quality Radiation Oncology Care,” highlights the growing technical complexity in radiation oncology, which has led to shifts in the distribution of tasks and the scope of practice within clinics.1 Simple staffing ratios based on equipment and patient numbers alone are insufficient to reflect the unique resource requirements of each clinic due to its procedural mix and technology profile. The rapid adoption of new technologies in radiation therapy over the last two decades has led to an influx of documents from professional societies that guide us in navigating the evolving scope of practice of radiation oncology. For instance, the average number of AAPM guidance documents has increased from about two annually in 1990 to over 10 per year in 2020.
Changes in Clinical Practice
In addition to the use of ancillary technologies such as surface guidance and automated tools for contouring and planning, there has been increased adoption of hypofractionation and retreatment in radiation therapy, intensifying the workload for physicians, physicists, and dosimetrists. This is due to the proportionate increase in treatment planning-related tasks and the need for personal supervision of more patient treatments, mainly with stereotactic radiosurgery and stereotactic body radiation therapy.
The average number of treatment fractions has been roughly halved compared to a decade ago. Treating the same number of patients with hypofractionation each year compared to conventionally fractionated patients gives a sense of having fewer patients on the linac at any point in time due to the reduced overlap of patient treatment schedules. This, combined with cuts in reimbursement, could lead to a focus on increasing throughput, adding risk to a system that has absorbed a significant amount of additional workload with a marginal increase in workforce. To add to this mix, we see high levels of vacant positions, as evidenced by postings in the AAPM’s placement service. Many facilities have had positions open for more than a year due to the lack of clinical medical physicist applicants.
Resource allocation studies in modern radiotherapy services have identified opportunities for improved resource utilization by integrating advanced technologies and workflows. These studies aim to establish requirements based on determining clinic-specific resource demands. The increasing complexity of the treatment process, the growing reliance on multiple data inputs, and the role of automation and artificial intelligence in treatment planning and delivery are critical focal points.
A comprehensive review of these studies and models provides valuable insights for optimizing resource allocation. Approaches such as time studies, staffing models, and algorithms developed by international organizations contribute to understanding resource needs. Several key factors influence resource requirements: the scope of practice, the adoption of current practices (e.g., CT vs MR-guided HDR), fractionation schedules, physician/staff schedules, and special considerations such as retreatments, standardization, and automation. Process optimization is crucial to improve the effectiveness of resource utilization. This involves standardizing processes, documentation, and delegating tasks efficiently.
What We All Feel Has Yet To Be Quantified
There is an intricate balance between technological advancements, clinical workflows, and resource allocation in radiation oncology. The field has undergone significant changes in recent years, leading to increased complexity. Resource optimization is essential to ensure the effective and efficient delivery of patient care. We need tools to calculate staffing requirements based on complexity while incorporating trends such as increased utilization of SBRT and SRS, increased number of implanted devices, and patients returning for retreatment.
How Do We Evolve With the Field?
Personnel level – OLA and peer review
Online Longitudinal Assessment (OLA) is a readily available tool for medical physicists to continually evaluate and address knowledge gaps. This method offers a unique opportunity for real-time assessment with instantaneous feedback, enabling practitioners to identify areas that may require further attention in the clinic. In a 2023 ABR survey, 79% of respondents acknowledged OLA’s effectiveness in pinpointing clinical knowledge gaps, and 76% affirmed its role in facilitating remediation efforts. This underscores OLA’s potential as an evaluative tool and a dynamic component of continuous learning and professional development for medical physicists.
Another important tool in radiation oncology is peer review, which offers a valuable opportunity for colleagues to collaborate and address potential challenges faced in the clinic. Implementing structured peer review, particularly leveraging tools outlined in guidelines such as TG1032 and MPPG15,3 provides a systematic approach to identifying process gaps. By engaging in peer review, clinics can tap into the collective expertise, fostering a collaborative environment that can lead to the development of a more robust and effective radiation oncology program. The insights gained from peer review can be instrumental in refining protocols, enhancing the quality of patient care, and ensuring ongoing alignment with best practices in the field.
Department Level – Practice Accreditation and Volunteering
Accreditation in radiation oncology provides many benefits beyond the evident advantages of quality improvement, enhanced patient safety, and increased credibility. Accreditation processes offer an opportunity for professional development, prompting clinics to pause their daily routine and thoroughly assess the state of their practices and associated processes. The rigorous audit requirements encourage teams to standardize procedures, manage risks, and foster continuous improvement over time. Additionally, the accreditation journey prompts teams to critically review current guidelines, facilitating timely adaptations to ensure alignment with evolving industry standards.
Professional volunteering offers a multitude of benefits. First, it provides volunteers with a unique insight into the current progress and challenges within the field, allowing them to stay abreast of the latest developments. Second, interacting with peers at various career stages becomes an invaluable source of mentorship, fostering professional growth and networking opportunities.
In addition, collaborating with like-minded peers on projects to address shared challenges can be exhilarating and intellectually stimulating. This collaborative effort contributes to the field’s advancement and allows individuals to learn from different perspectives and approaches. The experience of working collectively on a project can generate innovative solutions and enhance problem-solving skills. While volunteering demands time and effort, the benefits extend beyond the immediate commitment.
Volunteering can reinvigorate one’s sense of purpose and passion for their profession. And finally, the knowledge and experiences gained through volunteering can directly translate into improved practices within one’s clinic.
Conclusion
These strategies converge on a central theme – the value of dedicating scheduled time for reflection and learning amidst our routine work. As highlighted by Eduardo Briceño in his TED talk, delineating between performance and learning modes is crucial for skill enhancement and improved patient care. By embracing these proactive measures, medical physicists can navigate the dynamic landscape of radiation oncology, ensuring continuous improvement and staying at the forefront of the field’s advancements.
References
- Safety is No Accident: Digital Book. American Society for Radiation Oncology. 2019. https://www.astro.org/patient-care-and-research/patient-safety/safety-is-no-accident/sina-digital-flipbook
- Halvorsen PH, Das IJ, Fraser M, et al. AAPM Task Group 103 report on peer review in clinical radiation oncology physics. J Appl Clin Med Phys. November 22, 2005. https://doi.org/10.1120/jacmp.v6i4.2142
- Halvorsen PH, Baydush AH, Buckey CR, et al. AAPM Medical physics practice guideline 15.A: Peer review in clinical physics. J Appl Clin Med Phys. September 14, 2023. https://doi.org/10.1002/acm2.14151
Navneeth Hariharan is a clinical medical physicist at Beth Israel Deaconess Medical Center in Boston. He is passionate about improving patient safety and treatment quality in radiation oncology. He serves as a member of multiple American Association of Physicists in Medicine committees, as a physicist surveyor for the Radiation Oncology Practice Accreditation at the American College of Radiology, and an active volunteer for the American Board of Radiology. He co-authored two recent medical physics practice guidelines published through AAPM. In his free time, he enjoys listening to audiobooks and music.
He’s Moved From Taking Exams to Making Them
By Rodney Campbell, ABR Communications Manager
2024;17(2):5
As a physician who switched career paths, Derek Johnson, MD, has passed his share of Initial and Continuing Certification exams. He’s now lending his expertise to making ABR exams fair and relevant by serving as a volunteer.
Dr. Johnson started his medical career as a neuro-oncologist and was certified by the American Board of Psychiatry and Neurology in 2009. In that field, he spent a lot of time looking at MR scans with patients and their families to determine whether a tumor had grown.
“I became more interested in imaging, and particularly the scenarios where radiology didn’t seem to have the answer, like when the patient was declining but the imaging was stable, or the patient felt great, but the tumor had grown significantly,” he said.
He became so fascinated by imaging that he changed careers and completed a radiology residency, followed by neuroradiology and nuclear medicine fellowships at the Mayo Clinic in Minnesota.
“I decided that I wanted to spend the rest of my career focusing on these fascinating imaging questions,” said Dr. Johnson, who has been on staff at Mayo since 2012. “At the time, I was 100% sure I was going to practice in neuroradiology, and I really didn’t consider other subspecialties. However, I fell in love with nuclear medicine during my residency rotations.”
In 2021, Dr. Johnson became certified by the ABR in both diagnostic radiology and nuclear radiology. The following year, he added a certificate in neuroradiology. The second experience of pursuing Initial Certification inspired him to assist with exam development.
“After all those exams over the years, I was interested in the process,” he said. “Particularly taking the certifying exam and the subspecialty exams through the ABR. I was really impressed that they’re very relevant to practice.”
ABR Trustee Christopher P. Wood, MD, has known Dr. Johnson for more than 15 years. They met at Mayo Rochester when Dr. Johnson was a neuro-oncologist. As a neuroradiologist, Dr. Wood worked closely with his colleague and supported him to become an ABR volunteer in 2022.
“He is a consummate physician, dedicated educator, outstanding researcher, and excellent administrator,” Dr. Wood said. “Most importantly, his primary focus is on providing meticulous and compassionate care to our patients and supporting all of our physician, nursing, and allied health staff.”
As a volunteer, Dr. Johnson writes questions for two exams: IR/DR Certifying and Nuclear Radiology Subspecialty. Working with fellow subject matter experts on his committees gives him a perspective he didn’t have as a candidate.
“Collectively, there are decades and decades of experience in nuclear medicine and in exam writing,” he said. “We have many people who are not only active in clinical practice, but also in research or nuclear medicine … division and department heads and chairpersons. Everyone recognizes the value of what the ABR is doing in this process.”
As a volunteer, writing questions is never far from his mind. Even in the reading room, Dr. Johnson finds cases weekly that he believes are relevant for examinees.
“I’m a busy clinical nuclear medicine radiologist,” he said. “When an especially interesting case crosses my desk, I usually make a note and put it aside thinking this is going to end up as a test question someday.”
When writing questions, Dr. Johnson usually works backward, basing his queries on relevant cases with good imaging.
“Coming up with a question and then finding a picture that goes along with it that’s the same as the one you have in your head is difficult,” he said. “When you start with a really good clinical image, it’s much easier to then put a question to it.”
Dr. Johnson works with residents and fellows at Mayo, so he has a good idea of what they should know when taking an ABR exam. He and his colleagues work diligently to ensure that there’s nothing opaque about the correct answer when prepared examinees look at their options.
“In an ideal circumstance, we want the examinee to be able to read the question, look at the image, and know the answer,” he said. “The question should pass what we call the ‘cover test,’ where everything you need to know is in the stem and the images, and you’re only looking at the answer choices to confirm the one that ideally is already in your head.”
As is the case for many of the organization’s approximately 1,300 volunteers, Dr. Johnson finds meaning and purpose in his ABR volunteerism. He’s passed enough exams to appreciate the importance of board certification and its benefits to the public.
“I think there’s a sense of accomplishment in giving back to the field and making sure that we’re writing exams that are going to help the next generation of nuclear medicine trainees and nuclear medicine physicians,” he said. “We need to assess their knowledge to ensure that these are people who are able to safely take care of patients and help us push the field forward.”
AI/ChatGPT Will Not Be Used To Generate OLA or Exam Content
By Brent Wagner, MD, MBA, ABR Executive Director, and Matthew B. Podgorsak, PhD, ABR Board of Trustees Chair
2024;17(2):4
The accelerated evolution of generative artificial intelligence (AI), including ChatGPT, has revealed not only a new horizon of seemingly boundless applications but also myriad concerns, as large language models produce content that is often indistinguishable from human speech or thought.1 Citing the use of source material as inputs to such models, institutions, including the New York Times, have recently sought to protect their copyrighted work through the judiciary.2
The ABR has three specific challenges related to AI. First, we want to ensure that questions administered as part of our Online Longitudinal Assessment (OLA) are not introduced into the public domain via generative AI tools. Second, acknowledging that there may be significant limits to copyright protections of content that is not produced by humans, the ABR has an interest in reminding volunteers that writing questions for ABR exams is a human endeavor. Last, if an ABR question were written by generative AI software, it may violate the copyright protections of the original authors of the work.
Individuals engaged in OLA agree, as a condition of their participation, not to distribute or share the questions and related content outside of the interface. ABR volunteers are required to refrain from using generative AI when developing exam content. In this video, Board of Trustees Chair Matthew Podgorsak, PhD, shares more details about these requirements.
1 Mahowald, K, et al. “Dissociating language and thought in large language models: a cognitive perspective.” arXiv preprint arXiv:2301.06627 (2023). 2301.06627.pdf (arxiv.org)
2 Grynbaum M and Mac R. “The Times Sues OpenAI and Microsoft Over A.I. Use of Copyrighted Work.” https://www.nytimes.com/2023/12/27/business/media/new-york-times-open-ai-microsoft-lawsuit.html
