February 4, 2020
Should Medical Physicists Play a Role in Direct Patient Care?
There has been recent debate within the AAPM on the topic of broadening the scope of medical physics practice to include increased participation in direct patient care. Physicists have long played a critical role in the safe and effective delivery of the prescription as directed by the radiation oncologist, but direct patient interactions have been limited, mostly to a handful of procedures (brachytherapy, SBRS/SBRT, and other special procedures). But by and large, physicists are often only interacting with patients offline via their charts. In terms of direct patient care, the past has held physicists to limited contributions. Does the future of medical physics involve more direct patient interaction?

Background and Present State

The 2019 update to ASTRO’s seminal publication Safety is No Accident: A Framework for Quality Radiation Oncology Care suggests physicists play a role in patient and/or family education, a change from their recommendations originally published in 2012.

AAPM published guidelines in MPPG 10.a. also suggesting physics-patient interactions are included in the standard scope of practice for clinical physics. The report’s comprehensive list of duties includes patient communication and education, including discussions of risk.

Some clinical physicists are already engaged, at least partially, in direct patient care. Wang and White assert in a 2019 Journal of Applied Clinical Medical Physics (JACMP) article that “while the logistics and practicality of assigning each patient a single medical physicist for the duration of their treatment seem both daunting and of dubious value, having the medical physicist interact directly with patients on a daily basis is common in our practice experience, particularly in brachytherapy, stereotactic procedures, isotope therapy, and the very common occurrence of solving set‐up problems in the treatment room.”

Pros and Cons

Is additional physics involvement in direct patient care a good idea? In a recent “Parallel Opposed” editorial in JACMP, Kristi Hendrickson argued that physicist participation during the initial patient consult would be an “inappropriate utilization of a limited and expensive resource—physicist time…” Indeed, clinical physicists are often spread thin with a multitude of tasks that make up the clinical workload: routine quality assurance, equipment calibrations, patient chart reviews, etc.

On the other hand, if physicists are filling time originally allotted for physicians to address similar physics-related questions and concerns, oncologists could reclaim this time for other care-related activities. This reallocation of time could actually lower patient costs.

But what about training? Soft skills? The educational background of a medical physicist includes limited patient contact—at best—as part of a residency’s clinical rotation. It could also be argued that physicists aren’t the best of communicators or even that we might potentially confuse patients further instead of clarifying difficult concepts.

Some in the field are more optimistic about physicist inclusion in patient education prior to treatment. A study by Habboush et al. suggests there are legitimate gaps in patient education—ones physicists could potentially address. The study shows anxiety associated with radiation therapy “medical procedures” is higher than average when compared to other radiation treatment-related stressors. “Feeling nervous or anxious” is also a major stressor that ranks higher than average.

Because there is so much uncertainty in radiation therapy and cancer treatment, patients often search for additional information where they can find it. But while as many as two-thirds of radiation therapy patients seek information online to learn more about these procedures and their upcoming treatments, the information published is too complex for the general population.

Physicist involvement in patient care clearly has potential to improve the quality of care for patients undergoing radiation therapy. But beyond that, the idea of increased patient-physicist interaction satisfies a number of the core strategic goals of the Medical Physics 3.0 initiative. Independent physics consults could benefit the profession as a whole by enhancing physicists’ visibility in the clinic and beyond. By interacting directly with patients, physicists can have more control of the technical process, earlier in the treatment timeline. Ultimately, carving out a new clinical role has the potential to expand the scope of practice for medical physicists, supporting the long term sustainability of the field.

Direct Patient Care Initiative

To that end, a group of physicists and physicians at University of California San Diego (UCSD) is investigating the idea’s feasibility with its Direct Patient Care Initiative. Led by Todd Atwood, Derek Brown, and others, USCD is looking to establish an independent professional relationship with patients to improve their treatment experience.

According to Atwood, the idea of physics involvement in patient care came about as a result of an interaction he had as a resident at Stanford. “I was talking to a patient that was concerned and had a lot of questions. Her questions were by no means challenging, but you could just see how much more relieved she was after she got confident answers from a physicist. It completely changed the way she perceived her treatment,” says Atwood.

The UCSD Direct Patient Care Initiative team conducted a phase II trial published in 2018 that showed promising results. In addition to significantly decreasing patient anxiety, surveyed patients showed an increase in technical satisfaction leading up to the first treatment fraction. Overall patient anxiety scores were considered to be low at all questionnaire time points throughout their treatment. The response encouraged the group to continue their investigation with a randomized phase III trial which is nearing completion.

UCSDs Todd Atwood explaining the radiation treatment delivery process to a patient
As to how this initiative serves patients, Atwood offers an analogy: “I am not a surgeon, but conceptually I get what’s involved in the process. You make an incision and the doctor goes to remove or fix something. The skill set is so complex with so much training required, but you understand more or less how it works. Now take radiation therapy: right off the bat, people often think of something negative like a radiation accident or, in the best light, something strange like Bruce Banner or the Teenage Mutant Ninja Turtles. Add on the fact that it’s invisible and there is a 16,000 pound robot delivering the radiation—it couldn’t be a more complex process.”

Admitting uncertainty about where this patient interaction might fit into a clinical routine, Atwood admits he and his team don’t have all the answers. “First we’ll try to show that this is beneficial, that it makes a difference, and then we’ll see how to best integrate it clinically. Realistically, it’s a while before this is something that is a huge component of everyone’s life and maybe not everyone needs to do it, but that doesn’t mean it might not be the right thing for our field,” he says.

Conclusion

Expanding patient care responsibilities to physicists could play a role in improving patient care and has the potential to expand physics duties and increase visibility for the field. But even if the concept shows promise, there are hurdles to implementation.

What do you think? Will medical physicists play a greater role in direct patient care in years to come? Or is physicist participation in patient education an overblown and unnecessary abstraction?

written by Tyler Blackwell

Tyler Blackwell is a board-certified medical physicist with extensive clinical experience in radiation therapy. He is active in several AAPM committees, has served as secretary-treasurer for the Northwest Chapter of AAPM, and is an ABR orals examiner. Tyler dabbles in real estate investing and loves preparing breakfast for his two kiddos.

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