C. MATTHEW HAWKINS, MD

RESIDENTS’ AND FELLOWS’ COLUMN

Shifting Focus of Medical Physics Education During Residency Training Kevin Day, MD HISTORICAL LOOK AT MEDICAL PHYSICS EDUCATION

Advances in imaging technology depend heavily on the work of physicists, in collaboration with engineers and mathematicians. As radiologists, our profession is firmly based in and dependent on new advances in physics. We are required to have a fundamental knowledge of medical physics to provide optimal patient care in a safe and effective manner by optimizing the risk/benefit ratio involved in the vast array of imaging modalities. The importance of medical physics in radiology is evident in the required radiology resident curriculum devoted to medical physics. Moreover, testing of trainees’ comprehension of that curriculum began in 1968 with a written examination covering physics, radiobiology, and basic sciences. At that time, radiography and fluoroscopy were the only imaging modalities in active use. One large academic medical center’s radiology residency program included medical physics instruction totaling 473 hours [1]. The considerable amount of time dedicated to medical physics was feasible given the limited clinical duties and imaging modalities of the era. Intuitively, one would expect that with the advent of advanced imaging modalities, there would be an increase in the required medical physics education. In the mid1970s, the ABR began to examine residents in CT, diagnostic ultrasound, and nuclear medicine. In the 1980s, MRI was added to the ABR examination. At that time, the physics examination was given 1192

during the third or fourth year of training. With the incorporation of these advanced imaging modalities, our example academic medical center had reduced its curriculum in physics to 429 hours of instruction. Further increases in the demands on trainees for clinical service have reduced the time available for medical physics instruction. In 1999, the ABR allowed residents to take the physics examination during their second year. Our example academic medical center’s medical physics curriculum was compressed into 1 year, and instruction time went down to 141 hours. Over time, there have been further reductions to 78 hours just before the implementation of the Core Examination [1]. With the advances in imaging, the extent of knowledge required of a radiologist has grown rapidly. Over the same time, the invested time and effort dedicated to teaching medical physics have diminished, in part because of the growing clinical duties of residents. Medical physics has long been relegated to a written examination taken early in training and seen more as a hurdle to overcome rather than an aspect of radiology to be incorporated into a career. To address the declining attention on medical physics education, the Association of Physicists in Medicine convened a 2006 summit to revamp medical physics education during radiology training. The results from those efforts include renewed residency requirements focusing on medical physics education, along with a larger focus on medical physics in the new Core Examination.

INTEGRATED MEDICAL PHYSICS IN THE NEW CORE EXAMINATION

The ABR Core Examination is a qualifying examination to be taken at the end of 36 months of radiology residency training and was first given in 2013. Within the Core Examination, physics is integrated into all 18 categories constituting the test; however, physics is still graded separately. Those taking the examination must pass the physics portion to qualify for eventual ABR certification. Many physics questions are image based, with an emphasis on working backward from images to medical physics principles, as recommended by the American Association of Physicists in Medicine [2]. The idea is that medical physics education should become a more integral aspect of residency and better reflect the importance of medical physics in the field of radiology. In an effort to improve physics education among radiology trainees, the American Association of Physicists in Medicine and the RSNA developed web-based physics modules to supplement medical physics education in residency programs [3]. The initial set of 16 modules was released in 2009. With the subsequent addition of modules, the number now totals 43 online modules. The modules were developed with the expertise of a radiologist and a physicist to bridge the gap between these two fields. These modules provide a resource to uniformly improve medical physics education, even at institutions lacking a medical physicist.

ª 2014 American College of Radiology 1546-1440/14/$36.00  http://dx.doi.org/10.1016/j.jacr.2014.07.007

Residents’ and Fellows’ Column 1193

SHIFTING MEDICAL PHYSICS RESIDENT EDUCATION

With the new ABR Core Examination, medical physics education should now persist throughout residency, better reflecting the incorporation of medical physics into practice throughout one’s career. The shift from the medical physics written examination early in residency to the ABR Core Examination late in residency requires that physics education occurs not only early in training but throughout. As residency programs adjust to the new Core Examination, educators have proposed differing methods to expand current medical physics curriculums, including early residentto-resident education, continuous, multiyear didactic lectures, and Internet-based self-study modules [1,4,5]. As residency programs adjust and implement new medical physics curricula to meet the expectations of the ABR Core Examination, residents are burdened with preparing to meet the ABR’s expectations without clear-cut guidelines. In this regard, the Association of Program Directors in Radiology, American Alliance of Academic Chief Residents in Radiology, and Association of Program Coordinators in Radiology Core Exam

Survey has provided insight into senior residents’ perceptions about the Core Examination. Out of the top 5 rated study resources, 2 were specifically physics oriented, with external physics review courses scoring as the most helpful study resource for the examination and the RSNA modules scoring fourth [6]. Senior residents stated that there was a “lack of good [physics] teaching during residency and resources to study for the exam.” Widely given advice included “[to] start physics early,” “complete the RSNA physics modules multiple times throughout residency,” and “build a solid foundation of physics (including nuclear medicine) prior to reviewing all the sections.” The recurring theme of “starting physics early” demonstrates the success of the Core Examination in refocusing medical physics education during residency. Most residency programs will be adjusting their medical physics curricula in the next few years to meet the new ABR expectations. In the meantime, the burden remains on us, the residents, to be aware of the expectations in medical physics and adequately prepare for the Core Examination and beyond. It may be difficult for trainees to realize the

importance of medical physics, given the amount of clinical work each day and the extraordinary amount of clinical knowledge to master. Nonetheless, residency programs and the examining board are not arbitrarily adding physics to our training but rather returning our training and profession back to its roots. Those roots are firmly planted in medical physics. REFERENCES 1. Nachiappan AC, Wynne DM, Katz DP, Willis MH, Bushong SC. A proposed medical physics curriculum: preparing for the 2013 ABR examination. J Am Coll Radiol 2011;8:53-7. 2. Hendee WR. Improving physics education in radiology. J Am Coll Radiol 2007;4: 555-9. 3. Radiological Society of North America. RSNA/ AAPM online physics modules. Available at: http://www.rsna.org/RSNA/AAPM_Online_ Physics_Modules_.aspx. Accessed May 11, 2014. 4. Kansagra AP. Early resident-to-resident physics education in diagnostic radiology. J Am Coll Radiol 2014;11:59-62. 5. Hendee WR. Web-based modules for the physics education of radiology residents. J Am Coll Radiol 2010;7:306-8. 6. Deitte L, DeStigter K, Grajo J, et al. The APDR/A3CR2/APCR Core Exam Survey. Available at: http://www.aur.org/uploaded Files/Alliances/A3CR2/Resources_for_Chief_ Residents/CORE_Exam_Survey-Results_ Presentation.pdf. Accessed May 10, 2014.

Kevin Day, MD, University of Arizona Medical Center, Department of Medical Imaging, 1501 N Campbell Avenue, PO Box 245067, Tucson, AZ 85724; e-mail: [email protected].

Shifting focus of medical physics education during residency training.

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