Academic program recommendations for graduate degrees in medical physics: AAPM Report No. 365 (Revision of Report No. 197).

Abstract

This report details curricular recommendations for graduate degrees in medical physics and serves as an update to Report No. 197. In this section, we review the history of American Association of Physicists in Medicine (AAPM) curricular recommendations, present the aims of this report, and detail how these recommendations should be interpreted. The first AAPM publication on curricular recommendations for graduate education in medical physics was AAPM Report No. 44, published in 1993, describing the recommendations for the Master of Science Degree in Medical Physics.1 AAPM Report No. 79 was published in 2002 and established a core curriculum for all graduate training in medical physics, as well as more specific education and training associated with the individual subspecialties in medical physics.2 In 2009, Report No. 79 was updated and published as AAPM Report No. 197, and in 2011, AAPM Report No. 197S was published on the essential didactic elements for alternative pathway entrants into the clinical medical physics profession.3, 4 Report No. 197S defined the curriculum for a postdoctoral certificate program in medical physics, the first of which was accredited by Commission on Accreditation of Medical Physics Education Programs (CAMPEP) in 2011. The AAPM Working Group on the Revision of Report No. 44 was initially created with the charge of periodically reviewing and updating the recommended curriculum for medical physics graduate education programs. In 2012, the AAPM renamed this as the Working Group on Medical Physics Graduate Education Program Curriculum (WGMPGEPC). The WGMPGEPC was further charged to ensure that the graduate education curriculum reflects current needs of clinical practice and provides a broad foundation upon which to base future innovations. The profession of medical physics has undergone substantial growth and change over the years since the publication of Report No. 197 in 2009, and the WGMPGEPC has updated the curricular recommendations to reflect these changes and prepare the profession for the future. There exists a common core of similar coursework across all programs accredited by the Commission on Accreditation of Medical Physics Education Programs, Inc. (CAMPEP), yet each program has the latitude to adapt its curriculum to best leverage the strengths and resources of its faculty and host institution. The number of CAMPEP-accredited graduate programs has more than doubled since the publication of Report No. 197, increasing from 24 in 2009 to over 50 in 2021. A common goal of the AAPM curriculum recommendations is to ensure that the core curriculum meets the current and anticipated future needs of the medical physics profession. The curriculum recommendations in this report support these aims in three ways. They provide guidance to graduate programs in medical physics regarding the topics that should be covered in their curricula. They provide guidance to instructors regarding the breadth of coverage of relevant topics. Finally, they provide a basis for developing standards for graduate medical physics education. The curriculum provides substantial detail within the topics provided for each section. This is primarily to assist graduate programs and course instructors, and it is not our intention to recommend that any accrediting or supervisory body would expect that a program would cover every item explicitly mentioned in the curriculum. A bibliography of suggested resources, categorized by topical area, is included, and entries are duplicated, as appropriate, when relevant to multiple topical areas. There is a considerable degree of intellectual diversity of students entering graduate programs, including previous degree(s) earned, courses taken, and topics previously learned. The recommendations on graduate medical physics curricula in this report are designed to apply to all students. However, individual programs should determine whether to give credit to incoming students with previous course work that fulfills didactic medical physics training requirements (e.g., previous study of anatomy and physiology). One major change since the publication of Report No. 197 is the requirement to complete an accredited residency training program to gain knowledge and skills needed to practice independently as a qualified medical physicist and to acquire professional board certification. The residency increases the amount of practical clinical training by at least 2 years, yet there remains a substantial benefit to providing practical learning experiences during graduate education. Benefits of this include baseline learning for all students (including those who pursue nonclinical careers, e.g., in industry and government), reinforcement of didactic learning, enhanced preparedness for clinical research, and preparedness to enter residency training. It is important for programs to design curricula to strike an appropriate balance between theoretical coursework and practical experiences. Graduate programs should provide ample opportunities for practical, hands-on experiential learning in the clinical and laboratory environments. The practical learning experiences appropriate to graduate education are narrower in scope, more selective in topics, and more limited in time when compared with those of a residency program. Although many practical clinical topics are explicitly mentioned in this curriculum, it is left to the individual program to determine the breadth and depth of coverage. The graduate certificate program remains an important part of the medical physics training infrastructure as the didactic medical physics preparation for alternative pathway entrants into medical physics practice. AAPM Report No. 197S defined the essential elements of this didactic preparation. As Report No. 365 supersedes Report No. 197, it also provides guidance to supersede the supplemental Report No. 197S. The topics defined here as Sections 2.1.1–2.1.10 represent the core elements identified during the development of this report. Topics in Sections 2.1.1–2.1.6 match those identified as essential didactic elements in Report No. 197S; however, their content has been updated. Topics in Sections 2.1.7–2.1.9 (“mathematical and statistical methods”, “computational methods and medical informatics”, and “research methods”) are the ones that may have been covered in the prior training of individuals entering the profession through the alternative pathway. Situations requiring remediation may or may not require the completion of full courses. This leaves topic in Section 2.1.10, “professionalism (leadership, ethics, communication),” as the notable addition to the recommendations of Report No. 197S. Report No. 197S recommended a curriculum, including a minimum of 18 credit hours of didactic coursework. Report No. 365 recommends the minimum curricular recommendations from Report No. 197S plus the delivery of training in professionalism. This may increase the credit hour requirements for programs that deliver this training within a formal didactic course. The AAPM recently commissioned a task group on Alternative Pathway Candidate Education and Training (TG-298) to provide updated recommendations for the alternative pathway.5 Although Report No. 365 aims to provide overarching curricular recommendations for all graduate education programs in medical physics, TG-298 aims to provide recommendations on the education and training of alternative pathway entrants into the medical physics profession. One important recommendation from TG-298 is that programs provide clinical experience and exposure to the application of the didactic material. This recommendation provides support for the emphasis of practical clinical training within graduate education programs. A related recommendation by TG-298 is that online delivery of curricular material should be carefully evaluated to assure that it does not limit the student's exposure to experiential, clinical aspects of medical physics. Lastly, TG-298 recommends that programs include ethics and professionalism as a component of their core curriculum. We have included those components in the recommendations in this report. The first professional doctorate degree in medical physics (DMP) was created in 2009 and accredited by CAMPEP in 2010. The DMP includes the same core curricular elements as the MS and PhD in medical physics and therefore does not warrant substantial changes in the curricular recommendations for graduate medical physics education. The DMP does provide additional opportunities and incentives for the inclusion of elective coursework that may be valuable for clinical practice, such as business and management coursework. These additional courses and others may also be valuable for students not intending to pursue clinical careers. Finally, DMP curricula must include clinical training of sufficient depth and breadth to prepare the student to become a qualified medical physicist. This training is the purview of other reports such as AAPM Report No. 2496 and Report No. 3737 and is not within the scope of this report. An aim of the recommendations on graduate curricula presented in this report is to identify the salient topical areas of medical physics graduate education required to prepare trainees for current and future practice in this profession. As such, current technology, techniques, and methodology are often explicitly identified. It is, however, often instructive for trainees to understand historical aspects of medical physics technology and practice in order to understand the evolution of our practice and help guide its future. Such historical context is not always explicitly mentioned within this curriculum. However, it is assumed to be incorporated within medical physics graduate education where useful for the benefit of our trainees. Similarly, another aim of this report is to prepare students and programs to adapt to future changes in the scope and nature of medical physics applications. This report represents a snapshot of current education and training requirements; however, we must also equip students with the education and skills necessary to contribute to, and be leaders of, future advances in medicine. Future contributions of physicists to medicine are often driven by understanding and training outside of traditional core topics. As such, training in nontraditional areas facilitates potential future contributions to science and medicine in general, and this emphasis has been explicitly incorporated into this curriculum. We should aspire to train our students to be multidisciplinary experts who are leaders in the science of medicine, who ensure the highest quality care and safety, and who initiate and create changes that enhance patient care. Incorporating these aspects and others that will arise in the future requires an increase in the breadth of education and training in medical physics. Programs should minimally strive to provide familiarity in these nontraditional areas, as it would be impossible to provide mastery in them all. Instilling critical thinking and lifelong learning skills will allow medical physicists to continue to enhance their ability to contribute to the science of medicine. Many nontraditional topics as well as applications of didactic material may be provided within seminar and/or practical application courses. Graduate programs are not expected to develop specific expertise in all of these areas, but outside lecturers and material developed by other departments and/or programs may be leveraged to fill these gaps. The recognition that graduates from medical physics graduate programs may choose to enter nonclinical careers has encouraged the creation and promotion of didactic elements of graduate education aimed at best preparing those who enter nonclinical careers. The AAPM created the Working Group to Promote Non-Clinical Career Paths for Medical Physicists in 2016, and the Working Group for Non-Clinical Professionals in 2018. In order to address the educational needs of some nonclinical careers, in particular industrial career paths, we have included education and training in “Industry and Regulatory” as a component of the curricular recommendations in this report. It should be emphasized, however, that these training elements would also benefit those medical physicists that choose clinical career paths, as many of the challenges (e.g., interaction with industry, good business practices) are areas of essential strength of clinical medical physicists as well. The provision of training in research is an important element in preparing for the future of our profession. Indeed, the AAPM description of the role of the medical physicist states that “medical physicists play a vital and often leading role on the medical research team.” This includes both basic and clinical research and the problem-solving skills of the medical physicist. As such, we must provide the medical physics student with more than knowledge. We must provide the understanding that allows them to think beyond the present, to do more than just prescriptive problem-solving, and to innovate and solve previously unsolved problems. Additionally, medical physicists have not been sufficiently integrated into clinical trials research in the past, particularly in leadership roles, which has often negatively impacted the quality of clinical research. Specific recommendations for such training are provided in this report that addresses particular areas of research training. In addition, every effort should be made to foster critical thinking skills throughout the education and training of future entrants into our profession, as this is a distinguishing feature of a medical physicist and one that makes us valuable to the medical profession. Finally, this report is primarily intended to provide recommendations on what to teach rather than how to teach it. The recommended depth of understanding for each topic is not specifically prescribed here, and it is left to the individual program to determine, for each recommended topic, whether mere familiarity is sufficient or whether deep understanding and mastery of a topic is warranted. The application of Bloom's taxonomy or other models to classify educational learning objectives is helpful in determining specific goals for competence.8 We also do not recommend specific courses but rather curricular content presented within topical areas. As there can be significant overlap between topical areas, we have attempted to simplify the report by assigning particular curricular elements to only one topical area and referencing them to that area from others in which they may be relevant. Finally, we make no recommendations on pedagogical aspects of graduate education, including how or when material is provided. Discussion of the merits or application of online coursework, flipped classrooms, or other aspects related to the cognitive science involved in developing and delivering education is not included here. Section 2 provides a description for each of the sections within the report, whereas Section 3 provides detailed curricular recommendations where applicable. Sections 2.1 and 3.1 provide recommended core topics, whereas Sections 2.2 and 3.2 provide additional (optional) topics. Sections 2.3–2.7 and 3.3–3.7 represent professional specializations (diagnostic imaging, nuclear medicine, radiation therapy [RT], medical health physics, and industry). These respective sections provide curricular recommendations for students specializing in each of these professional practice areas. These areas are denoted as optional and some programs do not provide an option for specialization. DATA AVAILABILITY STATEMENT Data sharing is not applicable to this article as no new data were created or analyzed in this study. An understanding of the structure of matter and the manner in which ionizing radiation interacts with it is critical to the application of radiation to imaging, nuclear medicine (NM), RT, and health physics. This material builds off concepts of modern physics and is recommended within an introductory course to serve as a foundation for many of the other sections contained within this curriculum. The primary learning objectives include an understanding of individual interaction mechanisms, including both the physics involved in describing the probability for each interaction and the way in which energy is dissipated in the interaction. The student should be able to apply these concepts to all particles of interest, including uncharged particles (photons and neutrons) and charged particles (electrons, protons, alpha particles, etc.) with the ability to analyze differences between the mechanisms involved in charged and uncharged particle interactions. The physics and mathematics of radioactive decay should be understood along with all decay mechanisms. A broad understanding of the measurement of radiation, specifically including the measurement of absorbed dose, should be attained, including radiation dosimetry concepts, techniques, and equipment. This should include concepts such as radiation equilibria, cavity theory, microdosimetry, and all quantities and relationships involved. Finally, the student should be familiar with the various types of radiation dosimetry equipment, along with their mechanisms of operation and limitations. Radiation protection and safety pervades the various subspecialties of medical physics. Although technologies will change, having a fundamental understanding of how radiation works and how to protect oneself and others are crucial principles to the medical physics profession. A comprehensive study of radiation protection and safety could be structured by providing the answers to these major questions: Why does radiation need to be managed? What can you do to manage radiation exposure? How can you detect radiation? How much exposure can you safely receive? For whom is this important? How can you develop a safety culture? By posing these questions, a broad spectrum of topics can be discussed, including fundamental physics interactions, biological effects of radiation, and basic principles of radiation protection. Special attention is given to protection and safety of the radiation worker, patients, the public, and the environment. It is important to consider the present regulatory environment and the interactions with the recommendations from multiple organizations outside of the AAPM. Complementary tutorial instruction could include a sequence of laboratory experiences focusing upon radiation detection instrumentation, shielding methodology, and clinical applications for radiation protection and safety. The emphasis in this topic is to provide a broad knowledge base of radiation safety and protection supportive of the varied environments of medical physics practice. Medical imaging is a foundational component of medical physics and has been developed and advanced over decades to become a cornerstone of healthcare. Because of the ubiquitous use of imaging, all medical physicists need a working knowledge of key imaging physics concepts. The core competencies presented in this section include concepts of image processing, image display and image quality; image reconstruction from projections; and the key hardware, software, and operational details of each imaging modality. These modalities are projection X-ray imaging (radiography, mammography, and fluoroscopy), volumetric X-ray imaging (computed tomography [CT], cone-beam CT, and tomosynthesis), nuclear imaging (scintigraphy, single-photon emission CT, and positron emission tomography [PET]), ultrasound imaging (echo 2D and 3D imaging, and Doppler imaging), and magnetic resonance imaging (MRI). The details listed for each core competency indicate the minimum depth of coverage. The core competencies presented in this section can be supplemented by application-specific knowledge about targeted use of imaging technologies, whether for imaging or therapeutic applications. RT is a foundational component of medical physics, with 2/3 of all cancer patients receiving RT and numerous applications for RT for nonmalignant conditions. Medical physicists in all disciplines should have basic familiarity with the clinical, technological, and radiobiological concepts involved in RT. The significant overlap of imaging and NM with RT and the associated potential for collaborative work across these specialties underscores the need for cross-disciplinary training. The core elements of RT are presented here, including clinical and radiobiological principles, equipment and technology used for RT, specific treatment techniques and principles of radiation protection and quality management. The information presented here should ideally be supplemented by practical exposure to these technologies and techniques in the clinical environment. All subspecialties of medical physics require an understanding of the biological effects of radiation. Specifically, radiobiological principles comprise foundational knowledge in underpinning theories of radiation protection, RT, radiation imaging of humans, and NM. Radiobiology provides the basic connection between microscopic and molecular interactions of radiation with cellular and tissue responses. This material provides a solid biological and physiological background for understanding the effects of radiation on human tissues and cancers and the resulting safety policies and therapy regimens. These topics should be presented in a cohesive and consistent manner, not distributed among subspecialty applications such as RT physics, imaging physics, radiation protection and safety, and NM. Anatomy and physiology underpin the entirety of medical physics. Familiarity with normal anatomy is fundamental to radiotherapy treatment planning and medical imaging optimization. Cancer biology must also be understood at a basic level, as it drives many aspects of RT and medical imaging. Key linking concepts can be covered where they exist, such as cardiotoxicity from radiotherapy and the link between normal glucose metabolism and PET imaging. An organ system approach is logical for presenting the content in this section, with particular emphasis on normal imaging appearance, common imaging tasks related to pathology, and disease sites related to radiotherapy. Competency in mathematical methods is foundational to the understanding of medical imaging, radiological physics, and dosimetry. Incoming graduate students should have a strong background in mathematics demonstrated by their undergraduate or graduate coursework. Medical physics graduate training should enhance the understanding of mathematical techniques as they relate to medical imaging, computational science, and optimization. Graduate training should also provide a foundation in statistical methods as it relates to experimental design and analysis. It is becoming increasingly important that medical physicists possess a working knowledge of computational methods and informatics. Graduate curricula should include the basics of programming and machine learning as they relate to the many potential applications in medical physics. They should also include informatics as it relates to medical image storage and transfer. These skills could be developed through opportunities to practice implementation such as class projects, assignments, and research. Students should be exposed to and participate in research and be familiar with research methods, ethics, and scientific communication, which includes academic writing, reviewing, and presentation. In addition, protocol and grant writing, clinical translation/implementation, literature search and reading, and laboratory management are important skills with which students should become familiar. As the experience a student gains from their research endeavors will vary depending on individual advisors and projects, programs should consider how to ensure the consistency of development of research skills across all students. The delivery of a seminar series, such as journal clubs or presentations from students, faculty, and invited speakers is one useful mechanism for the development of research skills. Although all formats should expose students to a breadth of current research topics, different formats inevitably emphasize different skills such as literature review, communication and scientific presentation skills, and others. Programs should keep this in mind when designing the seminar format to give students the opportunity to develop all of these skills. Programs that do not require a thesis project or a seminar series should consider how their students will develop the skills traditionally associated with such offerings. Alternatives practiced by some programs include class projects, laboratory sections, “special topics” courses focused on current literature and research, and student attendance at scientific conferences. Finally, exposure to areas such as clinical trials, grant/protocol writing, laboratory management, and clinical translation/implementation may be best acquired via a faculty advisor/mentor and is perhaps more suitable in a PhD program. As the certificate program pathway is open only to individuals holding a PhD degree, it is anticipated that these research requirements would have been fulfilled prior to entry into the certificate program. The medical physicist will be routinely involved in interactions with professional colleagues, collaborating clinicians, trainees, patients, research subjects, administrators, and/or support staff, to name just a few. In all such interactions, a number of critical skills must be applied. First and foremost, the medical physicist must understand the ethical obligations and responsibilities of this role. As many medical physicists will be involved in leadership and management within the hospital and university setting, as well as serving as the de facto leader of the technical, quality, and safety aspects of a clinical department, the development of leadership skills is very important. These skills allow the medical physicist to have an appropriate and sufficient influence within these areas, for example, to influence the safety culture of a clinical department. Good communication skills are critical for leadership as well as for patient and clinician interactions. Such skills not only enhance leadership capabilities but also efficiency and accuracy in clinical collaboration as well as facilitating the most effective patient care. Radiation biology and anatomy and physiology are essential for medical physics competency. However, additional training in biology subfields can provide further competency both for research and in clinical practice, enhancing the ability of medical physicists to contribute to medical science and practice in general. Some example areas include biochemistry and biomolecules, cardiology, computational biology, epidemiology, genomics, immunology, neurobiology, oncology, pathology, and clinical pharmacology. Although it would be impossible to include all of these topics within a graduate program in medical physics, familiarity with these topics, along with preparation in health science terminology, helps medical physicists better communicate with clinicians and other research scientists and contribute more integrally to clinical and research efforts. This additional training further facilitates the identification and exploration of nontraditional applications of medical physics and thus expands our contribution to medicine. Elective coursework provides students with the opportunity to broaden their understanding of related fields or deepen their knowledge of medical physics specialties. Advanced physics disciplines of interest to the medical physicist may include nuclear physics, electricity and magnetism, optics, and solid state physics. Engineering coursework can be found in the biomedical, nuclear, electrical and computer engineering disciplines. Computer science electives should focus on topics to prepare medical physicists to be effective collaborators within the scientific community. Example coursework may cover statistical software packages, team programming practices, including version control and best practices for readability, and artificial intelligence. Frontiers in medical physics represent areas in which physics has begun to contribute to the improvement of medical care and/or has the potential to further improve human health. In RT, examples include FLASH, RT for non-cancer treatments (e.g., cardiac ablation), radiomics, interplay with other therapies (e.g., immunotherapy, photodynamic therapy [PDT]). In imaging, examples include radiomics and theranostics, interferometry imaging, biophotonics, magnetoencephalography, and alternative (monochromatic) X-ray sources. In NM, examples include novel radiotracer development for radiomics and theranostics. Additional opportunities outside medical physics represent areas outside the current landscape of medical physics practice. Areas for potential involvement include surgery (image guidance), pathology (image display, automation), ophthalmology (optical modeling), dentistry (3D modeling), orthopedics (motion analysis), cardiology (electrophysiology), neuroscience, and psychology. There is no expectation that any particular program cover these materials, rather this functions as a survey of potential topics. Incorporation of these topics in a specific program should reflect that program's strengths and research. Medical physics as a profession has multiple facets that often interact and overlap with business principles in a wide range of areas. Although it is not necessary to have an intricate knowledge of business aspects, it is important to be able to effectively communicate in these areas. As with all roles, the effectiveness of the function of medical physi