Medical Dosimetry ] (2015) ]]]–]]]

Medical Dosimetry journal homepage: www.meddos.org

The future of medical dosimetry Robert D. Adams, Ed.D., CMD Department of Radiation Oncology, University of North Carolina, 101 Manning Drive, Chapel Hill, NC

A R T I C L E I N F O

Keywords: Medical dosimetrist Economic factors Technological factors Social factors Political factors

A B S T R A C T The world of health care delivery is becoming increasingly complex. The purpose of this manuscript is to analyze current metrics and analytically predict future practices and principles of medical dosimetry. The results indicate five potential areas precipitating change factors: a) evolutionary and revolutionary thinking processes, b) social factors, c) economic factors, d) political factors, and e) technological factors. Outcomes indicate that significant changes will occur in the job structure and content of being a practicing medical dosimetrist. Discussion indicates potential variables that can occur within each process and change factor and how the predicted outcomes can deviate from normative values. Finally, based on predicted outcomes, future opportunities for medical dosimetrists are given. & 2015 Published by Elsevier Inc. on behalf of American Association of Medical Dosimetrists.

Introduction We live in a world that is incredibly complex.1 As medical dosimetrists, we work with individuals, systems, and organizations with interactive, sociologic, economic, political, and technological factors. Moreover, the odds of change occurring continue to increase as our future health care delivery system organizations and culture become more complex, and our traditional linear work interactions become more interactive based. However, we really should not or cannot become Luddites or alarmists, that is, stop the world and not let it move forward, or shout that changes are ending the medical dosimetry world as we know it. As medical dosimetrists, we must learn to adapt to complex systematic changes in an increasingly complicated health care delivery organizational and workplace environment. What has been known in the past is increasingly going to change in our future radiation therapy workplaces. However, even as our medical dosimetry work, tools, and organizations evolve, it is important that we maintain and develop our professional values, morality, and culture.2 In medical dosimetry practice, we do not use or talk about the term “future” very often. For most medical dosimetrists, the concept of future concerns what work is due the next day or perhaps next month's rotation, but for the most part, it is not part of our lexicon or culture. The definition of the word future can be threefold: (a) time that is to come, (b) what is going to happen, and (c) an expectation of advancement or progressive development. We often hear the word future when talking about large concepts. For example, the stock market is big on future values.

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However, these tend to be only for the next week, month, or the coming year. Another example is the weather, but again future weather patterns concern only the coming week or 10 days. It is very difficult to predict the medical dosimetry future 10 to 20 years out, but there are methodologies to make sound decisions, including related strategic management techniques.3

Previous Change: Revolutionary Based During the past 40 years, medical dosimetry has gone through major changes. Most of our changes were evidence or evolutionary based; a few times the changes were revolutionary and had unforeseen major effects on the profession. For example, the concepts that developed virtual simulation in the last 1980s were somewhat revolutionary. That is, it took radiation oncology pairing with computer scientists to have the cognitive ability to visualize and create the knowledge to rethink how we image anatomy in a 3-dimensional fashion. This concept literally came out of nowhere, but the effect was enormous. A decade before virtual simulation, it took a convergence of mathematical ideas, links to engineering principles, and then communication with radiology clinicians to master the idea of a computerized tomography unit for radiology to construct anatomy in 3 dimensions (note: the words medical imaging did not exist in the 1970s and 1980s). These changes were not evolutionary, but rather revolutionary and would not have been predicted before they occurred. Again, this revolutionary idea came out of nowhere and had a huge effect on clinical practice. In our future, we can better predict evolutionary types of changes, but we must remain

http://dx.doi.org/10.1016/j.meddos.2015.03.003 0958-3947/Copyright Ó 2015 Published by Elsevier Inc. on behalf of American Association of Medical Dosimetrists

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cognizant that revolutionary change can have large effects on our profession.4

Previous Change: Threats to Our Existence The medical dosimetry profession has been threatened with its own existence almost each decade since the 1970s. For many years, the literature had articles, abstracts, and speakers who stated that cancer would be cured by more aggressive chemotherapeutic drugs, which ultimately would have stopped the medical dosimetry profession from existing. Additionally, for several decades, surgeons have stipulated that their assertiveness with the scalpel would eventually cure all cancers, and again if this had come true, medical dosimetry would have no longer existed. Currently, we are being told that biologic therapies will render cures “beyond imagination,” and from this type of miracle medicine, medical dosimetry has the potential to become extinct. In our profession, there will always be threats to our survival, there will always be alarmists, and there will be the risk assessors. The purpose of this article is to create a conversation among ourselves regarding our professional future and how we may better fit into an increasingly complex health care delivery system integrated with radiation oncology practice. This article is written from the perspective of the possible future of medical dosimetry in relation to 4 indicator areas: (a) social factors, (b) economic factors, (c) governmental factors, and (d) technological factors. Finally, there will be ideas on areas that we potentially may need to change.

Social Factors The first area of our medical dosimetry future relates to social factors. In medical dosimetry practice, we tend to overanalyze how technology affects us while overlooking critical social factors even though they can have a tremendous effect on our professional lives and how we practice. A great example of social factors affecting our profession is higher education and the concept of labor. The great majority of current medical dosimetrists, who are older than 38 years, probably entered the profession via on-the-job training. When these “radiation therapists” came along as radiation therapists, a natural work-related progression step was to train as a medical dosimetrist. This process began in the 1970s as each department developed a “medical dosimetrist.” However, there was no national board certification pathway. Because of external social forces and a national trend of increased status of certification in health care delivery services, in 1988, the first medical dosimetry examination (Certified Medical Dosimetrist) was developed and implemented in the United States. As social forces affected our medical dosimetry profession, different criteria began to enter our profession. For example, most recently there has been the implementation of Joint Review Committee on Education in Radiologic Technology accreditation for medical dosimetry educational programs. This allows medical dosimetry certification only for graduates of accredited educational programs. This concept of “raising a profession” to a higher level of education is based on social factors related to higher education and professional status. Because of what has happened in the past, it is easy to say in the future that social factors will continue to affect our profession. An obvious social factor we can confidently predict is the retirement in large numbers of the “first generation” of medical dosimetrists, which is already beginning to happen. Medical dosimetry vaguely began in the 1970s and rapidly developed in the 1980s. The mean age difference is quite pronounced when comparing the

average age of attendees of a radiation therapy conference with that of a medical dosimetry conference. The medical dosimetrists mean ages are definitely larger at their meetings when compared with radiation therapists. Moreover, I feel we can predict that by 2020 we will have a significant number of retirees in the medical dosimetry profession. Consequently, a social factor for our profession will be a turnover in medical dosimetry leadership and “who is doing the work.” Second, the number of medical dosimetrists with higher education degrees, both undergraduate and master's, will continue to increase in terms of percentage. As members of this profession, we will become smarter and hopefully wiser. In other professions, the pursuit of professional autonomy and increased recognition correlates with an increase in higher education levels within the profession. Hopefully, this social factor will lead to greater associations with higher education and academia in general, and move the profession vertically. All of us who are certified medical dosimetrists hope that in the future our certification (Certified Medical Dosimetry [CMD]) will be of “a higher value” and give us large returns for what we invested to accomplish the goal of certification. The same can be said of degrees from many higher education institutions: the degree tends to increase in value as the brand of the university becomes stronger. Hopefully, our brand as medical dosimetrists will increase in value owing to having smarter people lead us. Third, the world is becoming flatter and smaller. There are approximately 180 countries in the world. Of these, approximately 30 are wealthy countries with a per capita income of $15,000 or more. Approximately 60 countries are intermediate level countries with per capita incomes of $4000 to $15,000. Finally, there are approximately 90 countries (emerging or third world) with per capita incomes of less than $4000 per year per individual citizen. Why is this important? Currently, the International Atomic Energy Association has a 15-year initiative to place radiation therapy facilities in emerging or third world countries ($4000 or less per capita income).5 Socially, there are international initiatives to put radiation therapy facilities in most countries in the world, including the emerging or third world countries. This is somewhat of an easy futuristic prediction. What is not answered, however, is the question of “who will be the radiation therapists and medical dosimetrists in these facilities?” This question really begs for the answer that it may be “us” in the first world countries. In the United States, we have some of the best trained and educated medical dosimetrists in the world. It is not just that we are good but also that we have very high technical and medical standards. Coupled with our technical treatment planning abilities with a world that will be looking for people like us, I predict that in the future we will have medical dosimetrists who travel and work in other countries. If this seems unreasonable, think of the oil industry and how companies (Exxon, for example) send employees all over the world. I really think we may have companies developed who employ medical dosimetrists and have them work internationally. In 2015, it may be hard to visualize this, but in the future with the amount of money that is being poured into international cancer care, there is a great possibility this may happen. So this begs the following question: as a medical dosimetrist, would you rather live here for $100,000 plus or minus 20% or would you be willing to travel internationally for $250,000 with some of the money tax free? In the future, your medical dosimetry education and knowledge may be the ticket to a higher quality lifestyle and more money in your own personal bank account. The decisions we make about “where we will work” for future medical dosimetrists may not be “in which state will I work,” but rather ‘in which country will I work.”

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Economic Factors There are several economic factors that can affect future medical dosimetry practice. From my perspective, perhaps the greatest economic factor is the future conglomeration of health care services. I am from the State of North Carolina. Currently, in North Carolina, there are approximately 100 radiation therapy centers, and most of these centers are independent. However, this economic business model of health care delivery is rapidly changing. This is because the larger health care systems in North Carolina are busily buying out the lesser economic hospitals and health care systems. Health care delivery is always, from a business perspective, approximately 10 years behind the “real business world.” The idea of consolidation in large-scale health care delivery system business has been going on for many years, but in this century, it really has begun to gain steam. For example, the concept of conglomeration is so much part of the business culture that current young entrepreneurs (20- and 30-year olds) are constantly trying to develop companies. A young entrepreneur's goal is to develop a company with assets of $20$25 million dollars. The reason for this is that when the dollar figures get this high, the larger based companies will buy them out and ultimately shelve the company because they do not want the competition with their own products. In health care delivery, this type of modeling has taken a hold of the health care delivery system for the past 5 to 10 years. We really are beginning to see the consolidation of larger health care systems purchasing smaller systems. Needless to say, the big get bigger and the small guys (independents) are either absorbed or get shelved if they are not profitable. In radiation oncology, again we have primarily been sheltered from this type of business modeling. However, as medical dosimetrists of the future, perhaps we need to understand what is probably going to happen. First, reimbursements to standalone facilities will continue to decline via both insurance payments and from government entitlement programs including Medicare (social health insurance for the elderly now designated by the acronym CMS) and Medicaid. This has already happened this year with the federal budgeting process and will continue. Second, just to give you an example of what is expected to happen in North Carolina during the next 10 years, there will be a consolidation of more than 100 radiation therapy facilities into 6 to 8 major companies administrating health care delivery. For us in medical dosimetry where the majority of the jobs are in smaller facilities, from an economic perspective, we can predict that in the future perhaps a majority of medical dosimetrists will change employers at some point. That which is and what has been will no longer be. The employers will become large corporations and the smaller departments will be following the larger facilities' policies and procedures. This economic reality is important because if you are working as a medical dosimetrist, in the future you need to understand that your current work culture is probably going to change. Owing to legal and patient safety issues, we should all understand that in the future there will be both a streamlining and standardization of departmental policies and procedures. I am not sure if most medical dosimetrists really conceptualize what is happening and is going to happen economically. It is not just that your local department/practice will be purchased, it is also that you will be following “the rules” of a major health care system, and those rules will include doing the work just like it is done in the major health care system. As medical dosimetrists, we take great pride in our rugged individualism and ability to treatment plan. In many ways, medical dosimetrists tend to be quite competitive with each other with their treatment planning abilities. However, in the future, we may

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need to take a step back and understand that the rules will be changing. So the question arises, how can I handle these potential future changes? First, understand the culture of the health care system from where you are purchased. Speak to some of the dosimetrists who work there. All of us are well networked with each other, so this should not be a problem. Second, if anyone is asked to volunteer for anything, please do so. In the past, you may not have been a leader or a person who volunteers, but the future will be different. One of the best moves you can make will be to become assertive and take a leadership role. By doing so, you will let central management know that you are “on board” and willing to transition to the new owner's way of thinking. On the contrary, it probably will be career suicide to not transition and rely only on your skill sets and technical abilities to carry you through a transition. Perhaps the medical dosimetrists who think that way will eventually become our dinosaurs. Third, be ready for change. It is coming, so expect it, embrace it, but in addition try to understand what is happening. Those who think “it will not happen to them” are really not working in the real world. As a medical dosimetrist, to think you will be insulated because you work in a small room with a computer in front of you is not the way to remain employed in the near future. In the future, we are looking at unprecedented change in business models, major consolidation, and smaller centers becoming part of larger centers at an alarming rate. Finally, in the future, do not be the person who “freaks” when this happens. Do not be the person who fights the change because you are the best treatment planner in the world (and have been told this by your bosses). Integrate into the coming standardization, understand that your hierarchy is going to change, and try to conceptualize how you fit into the much larger picture. The medical dosimetrists who can “see” the future and how economics will drive change perhaps will be ready to transition into the newer business models and have a job.6 The second economic area to be discussed for the future of medical dosimetry is the controversial word “protons.” Protons are an emerging specialty within the field of radiation oncology, and a proliferating number of multimillion dollar proton centers are being built in the United States. Currently, either built or under construction are 23 proton centers in the United States. The viabilities for the use and building of proton centers have become almost analogous to those of a nuclear arms race. When the inception of proton therapy was being touted then, as it is now, the marketing poster for the use of proton treatments has been children. However, we now are seeing a proliferation of proton treatments becoming mainstream into areas such as prostate, breast, and esophagus. As medical dosimetrists, when we look and try to understand the future, we should have to answer the following question: this is where the world is now, 20 years into the future will protons be as viable and part of our job structure? The perception is that the answer to this question will not be based on technology, but rather will be based on economics. Currently, the reimbursement for protons is approximately 3 times that of conventional photon radiation therapy treatments. Moreover, in what began as treatment for children, protons have now merged into revenue-producing areas such as prostate, breast, and esophagus. As we see the pattern of marketing “for children” emerging into profitable mainstream treatments, what will happen in the future? First, there are very little data coming out that have demonstrated that protons are better for prostate, breast, and other cancers as compared with conventional radiotherapy. For example, Dr. Ronald Chen, a radiation oncologist at the University of North Carolina at Chapel Hill, did a recent study on 12,000 men, which was presented at the annual meeting of the American Society of

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Clinical Oncology, that demonstrated no outcome differentiation of prostate treatment between photons and protons. From this perspective regarding a lack of studies and the current data showing no outcome differences, the use of proton therapy may become restricted. Second, as stated earlier, the reimbursements for protons are currently 3 times that of conventional radiation therapy. Hence, let me ask the following question: if protons are primarily used and multimillion dollar facilities are being built for children, why are there 2 proton facilities in Oklahoma City, Oklahoma? The answer really comes back to economics: proton treatments present an opportunity for investors to make a great deal of money from mainline treatments. Medical dosimetrists are needed in proton facilities, and these jobs pay very well. In the future, however, the viability of these jobs and the use of protons are really going to depend on not just reimbursements, but reimbursements that are 3 times that of photons. And the part we are not talking about is the relationship of cost of protons with other modalities such as surgery and chemotherapy, both of which are even less. Ultimately, there is a void in data and discrepancy in money to appropriately validate the use of protons in terms of their efficacy in cancer therapy.8,9 But perhaps the future question will be the following: as the United States potentially declines from its superpower status, can we as a nation afford to support protons at the current economic levels? Are the health outcomes supported in the academic literature? And for us as medical dosimetrists, will protons be as viable to our profession as it is now? My guess is that 20 years from now, as in all technologies, protons will either be fading or will fade out. Think about it, for reimbursements to be cut to where they are, “just double” photon reimbursement would have a huge effect on the diminished returns of protons, from a business economic model. From my perspective, this component of medical dosimetry practice will change in the future and the change will be evolutionary and at a slow pace. Finally, it is economically predicted that the use of photon radiotherapy facilities will continue to increase. As our number of patients continue to increase, our use factor and ability to achieve professional growth both quantitatively and qualitatively will also increase. Economic data do demonstrate this for the coming 10 years. Perhaps the real economic questions will be for medical dosimetrists who are 40 years or older (25 years to work or less) vs medical dosimetrists younger than 40 years (30 or more years to work). The economic indications for the younger group are almost too hard to predict accurately 30 years out. However, for the medical dosimetrists 40 years or older, the economic and social factors do indicate a steady flow of employment for the next 15 to 25 years.

Political Factors Role of government For more than 50 years, our government has faced a crisis in health care. We have struggled with the fundamental goals of providing cost-effective, high-quality care to all Americans. Yet politically accepted answers to these problems have eluded us. The nature of the health care system continues to evolve and dramatic changes are taking place. Government's role in the radiation therapy industry has changed substantially during the past 50 years. Gradually, the forms of involvement have shifted from the local government to the federal government. This began in 1935 with the establishment of traditional public health programs: public health departments, communicable disease programs, maternal and child programs, and public assistance for specific groups such as disabled children. Direct federal involvement began with the

Hill-Burton Act of 1947, which gave federal money to communities to build hospitals (the money was matched with money from the community level). The Hill-Burton Act assisted in the construction of 40% of the beds in the nation's short-term general hospitals. In 1967, the federal program “Medicare” (CMS) was established. The first federal political interaction with radiation therapy departments began with the 1969 American Medical Association's recommendation to establish Radiation Oncology Medical Residency Programs for physicians. This, in turn, coincided with developing specific billing codes for radiation therapy practice. From this process, federal political interaction, and procurement of funding, medical dosimetry eventually evolved as a profession.7 From a political perspective, CMS is probably the greatest political factor that can affect the future of medical dosimetrists. Currently, almost 2 out of every 3 patients with cancer are older than 65 years and these patients are on CMS insurance plans, which means the federal government is paying for approximately 60% of radiation therapy costs of patients. When looking at these data, it is easy to establish that political changes in CMS reimbursement practices can greatly affect medical dosimetry. The recent drop in CMS reimbursement patterns is currently sending alarms through the radiation therapy community. Each year the American Society for Radiation Oncology (ASTRO) works diligently with federal congress to delay these financial cuts, but the cuts are inevitable. The role that congress takes in CMS reimbursement patterns will most assuredly have a continuous effect on the survival of medical dosimetry practice as we know it. This will also tie into medical dosimetrists being able to continuously bill for their services. If billing is taken away, it may be difficult to justify the existence of medical dosimetrists in a radiation therapy department. The second political area is ASTRO and its upcoming national Accreditation Program for Excellence (APEx) accreditation, which should begin in the summer of 2015. The APEx accreditation process began with the New York Times' articles by Walter Bagdonich. It is important that the president of ASTRO, Tim Williams, met before congress within 30 days of Bogdanich’s articles. From this historic meeting, it was determined that ASTRO would begin a program to nationally accredit radiation oncology departments. As a medical dosimetrist, you may be asking the question, “well, how does accreditation affect me?” The reality is that accreditation will probably be associated with higher or lower reimbursements. That is, if you are accredited by ASTRO, you will have a higher reimbursement pattern than if your department is not accredited. The ASTRO APEx accreditation will have a political effect on most radiation therapy departments in the United States and consequently will have an effect on medical dosimetrists in the United States. It is interesting to note the power of politics when reviewing the 16 Standards for ASTRO APEx accreditation. Of the 16 Standards of APEx, 3 deal with patient safety (almost 20% of the Standards for accreditation). This is going to change the future of how medical dosimetrists perceive their job activities. The APEx Standards stipulate that “patient safety has to be demonstrated with metrics.” This is going to force future medial dosimetrists to think different about how “they” participate in patient safety. And the key point is that, as medical dosimetrists in the future, we cannot just say “we are safe” or that “we practice safely”; moreover, we will need to develop work/treatment planning metrics that demonstrate that we are safe. The work world and accountability will be very different from those that we now enjoy. The first 2 political factors (CMS reimbursement and APEx Accreditation) are going to lead to greater standardization of work and less independence when working. Political factors will be critical for future medical dosimetrists. It will be increasingly important for medical dosimetrists to work with their professional

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society, the American Association of Medical Dosimetrists (AAMD), to make sure medical dosimetry is offered a “seat at the political table.” That is, the concept of being a member of the team may need to be reinforced. Finally, when interviewing different people and researching this article, when asked the question, “what do you see as the future of medical dosimetry?” 99% of the respondents talked about technology. However, as more research was done on this subject, it indicated to me that perhaps technology will not be the biggest driver in the future of medical dosimetry. What emerged in this research is that political factors most likely will have bigger effects on the medical dosimetry profession than any other factors. And from this perception, it appears that the medical dosimetrist and professional society of the future may have to “up their game” with political interaction. The political factors area may be the critical key to holding the profession together.

Technological Factors: The Faustian Pact The spread of technology into society is called diffusion. It includes entry, adoption, use, and obsolescence. The use of technology has greatly changed medicine in the past century. We are an almost completely technology-dependent specialty. The 1980s and continuous integration of computer science and radiation oncology have catapulted our profession from an era of brachytherapy and cobalt machines to the technological wonders we have seen develop during the past 40 years. Technology has taken us on an incredible journey of knowledge creation and changes in how we practice. As the title of this section indicates, radiation oncology practice does have a Faustian Pact with technology. We are viewed by other medical professionals as being dependent on vendors and their constantly emerging technologies. For many of us, there is a fear that technology will make our jobs obsolete. For example, most people interviewed for this article commented on how “medical dosimetrists no longer will have to perform contours” or “treatment plans will be located in an electronic library.” So the question arises: for the future, will our Faustian Pact with technology be of more assistance or will it ultimately be our downfall as a profession? As during the past 40 years, technological concepts will continuously change the future practice of medical dosimetry. As a profession, technological concepts have primarily been driven by medical physicists collaborating with clinical physicians. For example, from a revolutionary research stance, Roentgen's discovery of x-rays was almost accidental. In some of the early interviews with Roentgen, he refers to the experience of discovery as almost happenchance. At the time, Dr. Roentgen as a physicist did not associate what he had discovered to medical radiographic imaging. It took a clinical physician to link radiation with patient imaging.10 The same can be said for Madam Curie and the discovery of radioisotopes—a physicist makes a discovery, but does not realize the practical applications of her idea. Again, the collaboration with physicians brought together the understanding of the implications and uses of radiation on humans for diagnostic and therapeutic uses. Finally, if you read medical physics books from the 1950s, where there is discussion about radiation therapy, it is described only from a brachytherapy perspective. Not only was there no external beam that could penetrate the body's tissues during that time period but also, more importantly, there was not even a discussion within the leading textbooks and journals that this was even on the radar. It was not until Dr. John's discovery and development of cobalt-60 (60Co) that this “idea” of treating cancers with external beam radiation therapy even became plausible.11,12

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So, for example, if you were a leading scholar in 1952 and someone asked you about the future of cancer treatment, there is a high likelihood that the thought of using radiation to treat cancer with an external beam would not be in your mindset during that time period. It took the revolutionary discovery of 60Co in 1953 to completely change how people thought about treating cancer with external beam radiotherapy. From 1895 until 1953, radiation and cancer treatments were done only by brachytherapy. With our current methods of treating cancer, we need to understand that both evolutionary and revolutionary technological discoveries will drive the future of the medical dosimetry profession. From an evolutionary perspective, it is becoming evident that medical imaging and medical dosimetry planning are becoming more linked to each other. At the 2014 ASTRO meeting in San Francisco, a keynote talk was about this re-emerging relationship of disciplines. In the future, medical dosimetrists are probably going to have a greater role in daily treatment because of imaging. Currently our roles in medical dosimetry are primarily prospective. That is, the treatment planning that is done is for a treatment that will happen in a few hours or a couple of days. It is in only a minority of cases that the medical dosimetrist is involved in the day-to-day treatment of the patient. However, with increased use of medical imaging, we can see the following scenario happening: the patient is imaged each day for treatment, changes are made at the linear accelerator, and the medical dosimetry treatment planning has to be redone at that moment and checked off. Hence, this brings in the following question: is a medical physicist going to be there all day to check that the new treatment plan is correct? As we probably can surmise, the answer will be no. Just from evolutionary changes taking place in the clinical setting, we can see that medical dosimetrists may be moving from “the office work area” to “the clinical treatment area.” Owing to the technological changes, medical dosimetrists will not only probably perform prospective treatment planning, but also a newer part of their job will be to perform “just-in-time” treatment planning every day on each patient's postimaging. Although the medical physicist could be involved with the latter “just-in-time” daily treatment changes, my guess is that this will become part of the medical dosimetrists' job.13 Another area of technological advancement from an evolutionary perspective is the idea of “canned” isodose curves for treatment planning. Using this type of technology, which is already occurring, the role of the medical dosimetrist could diminish as treatment plans are kept in libraries. This is very difficult for me to predict as it is hard to predict how accurate these new plans will be: will close enough be good enough or will medical dosimetrists still be treatment planning each and every patient. From a biologic perspective, the role of biologic therapies coupled with individual therapies may change the concepts of treatment planning, which again could be positive or negative to the profession. The emergence of radiogenomics will individualize treatments for each patient, which in turn will change how we treat. This may be the greatest technological ally for medical dosimetrists. As treatments become more individualized, there will be a need to offer comparisons between treatment plans and regimens. Finally, from a technological perspective, perhaps the greatest role the medical dosimetry community can now begin to undertake is the concept of assertively becoming “the gatekeeper to radiation therapy patient safety.” Instead of seeing themselves as only “treatment planners,” perhaps a strategic initiative with the medical dosimetry community should be to integrate medical dosimetry into patient safety leadership roles. Owing to the catastrophes that have recently happened in the United States, England, and France, the need for higher levels of patient safety

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has never been higher. From what we now know, the roles of patient safety will continue to increase in the future for all of radiation therapy. If we know and understand that this component of the future is going to happen, perhaps as a community we should strategically plan to become “the gateway to patient safety.”14-17 There are many opportunities that present themselves to us. First, as medical dosimetrists we can become better advocates for our patients by using patient safety techniques. Second, we can learn higher level engineering techniques used by human factors engineers to actually use metrics and measure outcomes. Finally, we can become leaders, site visitors for ASTRO, and integrate with other radiation therapy professional societies to become the patient safety leaders. Just as a note, how many patient safety articles have been written by medical dosimetrists that are in professional journals? How many medical dosimetrists would like to be involved with patient safety, but really do not understand how they can do this? How many medical dosimetrists feel that becoming the “gatekeeper for radiation therapy patient safety” actually helps validate our jobs and what we do? From my perspective, this is the main point, from a technological perspective we understand from our past that “what we do today is going to change in the next 5 years.” Moreover, half of what we know and do today will no longer exist in the next 10 years (we just do not know which half is going to disappear). Therefore, with this history and knowing that technological change is occurring coupled with an increased emphasis on patient safety, perhaps we can get ahead of the curve by assertively putting ourselves into leadership roles and taking a stand to develop and create new patient safety initiatives. Alternatively, we can just wait and retrospectively act when other professional societies go ahead and make the move.

Opportunities As medical dosimetrists, the most significant part of thinking about the future is how we can better create our professional opportunities. In the past, there were significant achievements and milestones that have helped procure our current professionalism. Following are perceptions of the greatest achievements made by medical dosimetrists to put us into the future in the past 30 years: (1) 1985: American Association of Medical Dosimetrists Educational Committee politically mandates that we need a CMD National Examination. This begins the process of separation of medical dosimetrists from radiation therapists (who were just beginning to separate from radiologic technologists). (2) 1988: The Medical Dosimetrist Certification Board (MDCB) is formed as a separate entity with a board of directors. The first CMD examination is given nationally. Again, this allows our profession to better integrate with the future and keeps our profession separate from the professional radiologic sciences (American Registry of Radiologic Technologists and American Society of Radiologic Technologists). (3) 2005: The MDCB begins to think strategically and modify the MDCB examination access to sitting for the national examination from “on-the-job training” to a full “higher education” model. This goal will be achieved in 2017 with the minimum of a baccalaureate degree and graduation from an accredited medical dosimetry educational program. (4) From 2017 onward, all new medical dosimetrists will have, at the minimum, a baccalaureate degree and a CMD certification for access into the profession.

2020 Onward As medical dosimetrists, we will need to identify areas of expertise. An area that we should try to exploit is what we as medical dosimetrists do well: plan comparison. As new imaging modalities come into medical dosimetry treatment planning, a weakness of medical physicists is plan comparison. Hopefully, medical dosimetrists will be able to seize this opportunity to use this function and become subject experts. A second area that we can use is patient outcomes. We need to become a greater part of the patients and their treatment. The radiation oncologists and medical physicists do not understand many of the treatment functions that medical dosimetrists have. An example is treatment complications because of the fields. Our strength will be to develop better plans for treatment. A third area we should begin to develop is the development of “research dosimetrist”; this job title exists in England, Europe, Canada, Australia, and New Zealand. Perhaps it is time for the AAMD to consider developing research grants for practicing medical dosimetrists. To this point, most of our Foundation money has gone to student scholarships and the agenda of developing a student pathway to higher education. However, in the future, perhaps our money may be better spent by developing clinical medical dosimetrists for collaborative research projects with other members of the radiation oncology treatment team. For our profession, this would be a huge cultural shift, but one that may better fit our professions' future. Let me give you an example that is somewhat painful and for most of us not a good indicator of our future. Look into the journal “Medical Dosimetry.” In how many articles is the first author a medical dosimetrist? You will note there are hardly any first author medical dosimetrists in our own professional journal. Look at the Journal of Applied Medical Physics, which is a professional journal for clinical treatment planning ideas; how many comparison treatment planning articles are being written by medical physicists? The answer is most if not all of these. Almost none of the articles are being written by medical dosimetrists. The point is that for our profession to progress into the future, we need medical dosimetrists to begin doing research and writing professional articles. The professional society is there, the MDCB examination is there, higher education is now solely at the table for access. From my perspective, developing researchers may be the most important move we make to upgrade our profession going into the 2020s. The aforementioned 3 areas are based on evolutionary, predictable changes that are occurring. The part that cannot be written about or “seen” is revolutionary change. And this is both the scariest and conversely, the most exciting. With the explosion of technology and potential libraries of treatment plans, who knows if this technology will make medical dosimetrists less valuable? On the contrary, will libraries of treatment plans need trained medical dosimetrists who can better compare several plans and “choose” the best plan. What else may emerge from other disciplines that totally changes what we do? As we think about the effect of computed tomography scanners, virtual simulation, intensity-modulated radiation therapy, tomotherapy—these were all based on revolutionary ideas that have changed our profession. That is, the initial idea came from a different academic discipline and was integrated into radiation oncology practice. Finally, the worst future we can make is to “give away” what we have accomplished from our past. We are very lucky that we have a dedicated professional society: the AAMD. We are very fortunate to have our own national certification examination: the CMD. Physicians control their number of graduates and medical

R.D. Adams / Medical Dosimetry ] (2015) ]]]–]]]

physicists control their numbers, so now we can better control our number of graduates. It is important that we begin to control our number of graduates. It makes a profession more valuable if it can control the number of people practicing. If you produce too many laborers into any profession, their economic, technologic, and social value will decrease. Currently there are only 120 radiation oncology medical residents. To be a medical physicist, you have to go through a fellowship program, there are only approximately 15 of these programs in the United States. From a policy and strategic perspective, the radiation oncologist and medical physicist developed and implemented these policies to control numbers within the profession. When numbers are controlled, then the people who have the certification have greater value and power. This is how we should begin to think with our professional strategies. If we do not begin to think like this, we may end up like the radiologic sciences, where there is now less than a 1% national vacancy rate for certified radiation therapists. For us in medical dosimetry, our higher education is the right direction, but in the future, I feel we need to take an additional step: we need to limit either the number of people being certified each year or the number of students accepted into educational programs. For the viability of our profession, this needs to be done. It is a very difficult decision, but it will be the correct decision for our profession's future direction. The Flexnor Report on Medical Education was commissioned by the Carnegie Foundation in 1911. When the report was completed, the number of medical schools decreased in the United States from 500 to 65. When this happened, the prestige of being a certified physician increased many times. Since 2005, with the implementation of medical physics residencies as the only access, the prestige of being a medical physicist will surely increase. Now the burden is on us: what will we do—stay the same or move ourselves into the future? These are not easy decisions, and like what the physicians and physicists did, it will not be painless.

Conclusions The future medical dosimetry profession will be affected by social, economic, political, and technological factors. From a consolidation of these factors, medical dosimetry will need to develop

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a strategic plan to maximize its opportunities as a future profession. The greatest opportunities and threats to the future of medical dosimetry probably will be economic, political, and technological factors. It is important that future medical dosimetrists continuously build on their higher educational levels, become politically active in their professional society, and understand that their job functions will change.

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