How To Become an Invaluable Dosimetrist in This Competitive Market Dr. Camille McGann
How To Become an Invaluable Dosimetrist in This Competitive Market Dr. Camille McGann Legacy Health Educators ACKNOWLEDGEMENTS Thanks to Varian Medical Systems for their Sponsorship Legacy Health Educators - www.LegacyEducators.org a nonprofit “video” cancer education website for patients OBJECTIVES Be able to identify area(s) of deficiency and have a plan to implement changes to improve as a Dosimetrist Recognize the indispensable qualities and areas of being an Excellent Dosimetrist Improve communication with ALL parties involved in patient care (Physicians, Physicist, Therapist) and develop a sense of “ownership” for your work in the RO clinic More knowledgeable on requirements to remain relevant and competitive in this market About Me… Why … I think you should know … Notice increase trend of Physicist doing Dosimetry work NEW Requirement for ALL Medical Physicist to c0mplete a “Clinical Residency Training” The pool of Excellent Dosimetrist is depleting Veteran Dosimetrists are concerned about younger generation Work quality… An Excellent Dosimetrist … As a Medical Dosimetrist, the primary objective is to use your training, experience, skills, and talents for the benefit of society. To this end, a Dosimetrist recognizes his/her professional relationship with and obligation to; Patient – although never directly responsible for prescribing medical procedures, the health and welfare (even life) of many patients, may directly depend upon the skill and dedication with which the Medical Dosimetrist carry out his/her work Employer – As professionals, Medical Dosimetrist have the obligation to act as faithful agents for their employers and to devote their skills and talents to further the legitimate aims of their employers Medical Dosimetrist should strive continually to improve their knowledge and skills and participate in programs that lead to the improvement of the Medical Dosimetry profession and the health f the community An Excellent Dosimetrist … As a Medical Dosimetrist, the primary objective is to use your training, experience, skills, and talents for the benefit of society. To this end, a Dosimetrist recognizes his/her professional relationship with and obligation to; Patient – although never directly responsible for prescribing medical procedures, the health and welfare (even life) of many patients, may directly depend upon the skill and dedication with which the Medical Dosimetrist carry out his/her work Employer – As professionals, Medical Dosimetrist have the obligation to act as faithful agents for their employers and to devote their skills and talents to further the legitimate aims of their employers Medical Dosimetrist should strive continually to improve their knowledge and skills and participate in programs that lead to the improvement of the Medical Dosimetry profession and the health f the community Case 1 Pt AC was diagnosed with Breast Cancer and was receiving adjuvant XRT post surgery and chemotherapy The patient’s planning incorporated the use of a wedge The wedge was left out of her treatment and the error was not noticed for the entire 27days of her treatment Pt AC received 3.5 times the desired dose Patient died from her injuries Fatal Radiation Overdose Define the Problem Fatal Radiation Overdose Over 27 dys Missing Filter, 3x more than intended RT dose 3D CRT for Breast Cancer Patient received overdose on 27 occasion Organization impact: Fine from the city Cause & Process Maps Patient Safety Goal impacted - Killed Patient services goal – overdose 27 times Employee Impact – error missed, inadequate safeguard, checks Organization Impact - $$ fine from city Case 2 Pt SJP is being treated for tongue cancer with XRT and is being treated with IMRT Pt c/o oral soreness halfway through the treatment and an adjustment was made by the Physician to minimize the scatter from teeth with filling During the reprogramming the computer crashed. The therapists were asked if they would like to save changes, though “yes” was selected some of the treatment information was lost – specifically the collimator setting The collimator settings were lost, leaving the collimator wide open, delivering 7 times the desired dose; this error was not noted until 3 treatments later The patient died of his injuries Fatal Radiation Overdose Define the Problem Fatal Radiation Overdose Over 3 dys Computer Error IMRT for Tongue Cancer Patient received overdose on 3 occasion - killed Employee impact: Unable to properly program equipment Cause & Process Maps Patient Safety Goal impacted Patient services goal Employee Impact Organization Impact Analysis of Outcome In both cases, patients died from their radiation overdose injuries In both cases, the Physicist, or Physician, or Therapists were highlighted In both cases, the error was reported by the Physicist or Therapist In cases of Radiation therapy treatment overdoses, the Physician and/or Physicists are often times named in the lawsuits; the therapist, if gross negligence noted, are often times released – High Stakes Dosimetrist? Need Change… Become more involved; CT simulation Patient set-up 1st day VERBAL Communication with RTT of deviation from NORM Improve Communication Use Resources for plans Develop (& use) Peer Review System Develop a Physician Template Written Respect Model D/W Physician past comparative treatment plans (esp in difficult cases) Communication = TEAM work! Exponential change = exponential growth = exponential opportunities for errors! Co-60, 2D-RT, 3D-CRT, Linacs, IMRT, IGRT, PET-CT, SBRT, SRS, RapidArc, Tomotherapy … What are the current AAMD standards for Peer Review? 1 Dosimetrist per plan 2nd check by Physicist or Dosimetrist Independent 3rd check of dose calculations Records transferred to R&V ARE verified Checklist? No good … unless they are indeed checked Dr. C. McGann, MD Legacy Health Educators www.LegacyEducators.org RO Communication Model Patient Therapist Physicist Physician Dosimetrist Dr. C. McGann, MD Legacy Health Educators www.LegacyEducators.org Physician Therapist Patient Dosimetrist Physicist Dr. C. McGann, MD Legacy Health Educators www.LegacyEducators.org Physician Physicist Medical Dosi RT Therapist Patient Dr. C. McGann, MD Legacy Health Educators www.LegacyEducators.org Physician Physicist RT Therapist Dosimetry Dr. C. McGann, MD Legacy Health Educators www.LegacyEducators.org Weekly or Bi-monthly meeting with Therapist Chartrounds – d/w Physician timing for tx plan reviews Dosimetry Journal – Review Articles ? Develop Continuing Quality Improvements (CQI) RO Clinic Charges/Billing Medical Physicist new requirement of clinical experience – how will this affect you? Equivalent Education Requirement for all? RO Departments are cutting back … Dr. C. McGann, MD Legacy Health Educators www.LegacyEducators.org Physician Physicist RT Therapist Dosimetry Dr. C. McGann, MD Legacy Health Educators www.LegacyEducators.org “The single biggest problem in communication … is the illusion that it HAS taken place.” George Bernard Shaw An Excellent Dosimetrist … As a Medical Dosimetrist, the primary objective is to use your training, experience, skills, and talents for the benefit of society. To this end, a Dosimetrist recognizes his/her professional relationship with and obligation to; Patient – although never directly responsible for prescribing medical procedures, the health and welfare (even life) of many patients, may directly depend upon the skill and dedication with which the Medical Dosimetrist carry out his/her work Employer – As professionals, Medical Dosimetrist have the obligation to act as faithful agents for their employers and to devote their skills and talents to further the legitimate aims of their employers Medical Dosimetrist should strive continually to improve their knowledge and skills and participate in programs that lead to the improvement of the Medical Dosimetry profession and the health f the community SIMULATION INVOLVEMENT • CT Sims discuss at AM Huddle (PRN) • Be present for ALL Peds cases • Consider being present for H&N, and any unusual cases or pts with difficult body habitus • Recent case of 78yo woman with bilateral ER-/PR-/Her2neu- breast Ca s/p neoadjuvant chemotherapy and bilateral lumpectomy (T4 on Rt) • Unable to lift head • Kyphotic • Bilateral partial shoulder replacement; cannot raise arm • Cannot lay flat • Thin Pendulous Breast AVAILABLE RESOURCES Protocols are your friend! Be familiar with RTOG – section 6 is always Radiation Oncology section www.RTOG.org PHYSICIAN TEMPLATE Know what your Doc likes…It is that simple! Personal Folder or Book – ALWAYS ask, “Anything different about this case?” Prostate – margins? 6mm, except post/rectum 5mm Breast – visible tumor bed? Whole Brain – really? H&N/GI/Gyne – normal structures ONLY! Know “some” anatomy – RTOG atlas Know the DVH for the plan you are working on OK to keep a file on “unusual/difficult” cases THE WRITTEN RESPECT MODEL The MOST difficult thing in a Radiation Oncology department is securing time with physician for plan review … more than a few hours before patient actually start! Agreement – 15min on the Docs schedule to review a plan (we can always do dictation later or have the resident do it) Be prepared to have a discussion – we want to know your thoughts! Multiple plans (if necessary) – actually different based on DVH … so MUST have/know the DVH (Quantec, MDA, Sloan Kettering, Fox Chase, etc., - Gold Standard - RTOG) Hold your Doc accountable! An Excellent Dosimetrist … As a Medical Dosimetrist, the primary objective is to use your training, experience, skills, and talents for the benefit of society. To this end, a Dosimetrist recognizes his/her professional relationship with and obligation to; Patient – although never directly responsible for prescribing medical procedures, the health and welfare (even life) of many patients, may directly depend upon the skill and dedication with which the Medical Dosimetrist carry out his/her work Employer – As professionals, Medical Dosimetrist have the obligation to act as faithful agents for their employers and to devote their skills and talents to further the legitimate aims of their employers Medical Dosimetrist should strive continually to improve their knowledge and skills and participate in programs that lead to the improvement of the Medical Dosimetry profession and the health f the community Treatment planning skill set I 3 DAY PLAN Treatment planning skill set II 90 Min PLAN Which Plan? 90 Min PLAN 3 DAY PLAN Skill Improvement 18 years of experience…how do you improve? What should the physician do for the Dosimetrist that gave the initial plan? What responsibilities (if any) does the Physicist / 2nd Dosimetrist have to the 1st? Should the Physicist be involved in this? Is there a reporting system within the AAMD? 4 months later… 90 Min PLAN 3 DAY PLAN Recommendations… Weekly or Bi-monthly meetings with your Therapist Ask to establish a Quarterly CQI for your department Review Billing Process - Medical Necessity Discuss with your Radiation Oncologist your plan to establish a DVH folder/Physicians folder (standardization?) Sign-up for the Free Varian Medical Systems on-line lectures Read up on and talk to your colleagues about new technologies – do you know how to; Use at least 2 treatment planning systems? Plan with rapid-arc? Tomotherapy? Advance treatment planning to include other modalities ( Brachytherapy, Gamma knife, etc.,) Talk to your Colleagues and Physicist about how you can improve ATTEND AAMD meetings! THANK YOU! AAMD – Felita James, CMD Thanks to Varian Medical Systems for their Sponsorship Legacy Health Educators - www.LegacyEducators.org a “video” patient cancer education website TWILIGHT ZONE
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