Medical Physics

Medical physics education residency curriculum

Clinical Rotations

Rotation cycle #1
This first cycle is designed to introduce the resident to the clinical duties for each rotation. In the first six-month rotation through the clinical assignments, the resident observes the clinical medical physicist performing the duties of that rotation. During this time they are expected to learn all clinical medical physics responsibilities for each rotation and document all clinical procedures. The resident has a limited hands-on role during the first cycle of rotations. All duties will be approved by the supervising clinical medical physicist.

Rotation cycle #2
For each rotation, the staff medical physicist shall briefly review the contents covered in the first rotation cycle. The staff medical physicist will address insufficient knowledge in any area. The resident will perform all clinical duties under the supervision of the staff medical physicist. The resident is expected to independently perform all duties while using the staff medical physicist as a reference resource when necessary. Independent performance of clinical duties is expected for adequate performance at completion of this cycle of rotations.

Rotation cycles #3 and #4
The resident will be credentialed at UMMC prior to the beginning of Clinical Rotation #3. For cycles #3 and #4 (i.e., residency year #2) the resident is expected to cover a clinical FTE medical physicist workload. The resident is expected to independently perform all applicable clinical duties. A staff medical physicist will not be assigned to the resident in these rotation cycles except as necessary. However, clinical medical physics faculty will be available as necessary to address any resident issues to ensure completion of assigned resident duties.

Monthly Rotation Assignments

1. UMMC Initial Checks/Insert Factors/Chart Closeouts
Initial Plan Checks: The staff physicist shall explain and demonstrate procedures for initial checks of patient treatment plans. This includes performance of the plan check, approval of all fields in R&V system, and completion of any documentation required for billing or patient records. All documentation is to be signed by the staff physicist on the rotation. The rationale for performing initial plan checks shall be explained. Checks will include verification of the following information in the treatment plan and MOSAIQ:

Prescription and fractionation
Correct patient CT data set
Correct CT-to-density table selection
Correct CT matrix size
Couch removal
External contour density threshold
Dose matrix voxel dimensions
Density overrides
Treatment unit (for each beam)
Field name (for each beam)
Modality (for each beam)
Delivery type (for each beam)
Monitor units (for each beam)
Beam modifiers or applicators (for each beam)
Number of beam segments if applicable (for each beam)
Dose (for each beam)
Secondary jaw settings (for each beam)
Field shape (for each beam)
Tolerance table (for each beam)
SSD (for each beam)
Couch angle (for each beam)
Collimator angle (for each beam)
Gantry angle (for each beam)
Dose calculation algorithm (for each beam)
Evaluation of doses to target volumes and normal tissues
Performance of BED calculations when necessary

The resident shall independently review all plans assigned to the clinical physicist. For rotation documentation, the resident shall select 10 sample plans with 2 from each of the following anatomic sites:

Lung
Brain
Prostate
Breast
Head and neck

The resident shall check these plans under the review of the staff physicist. Once the staff physicist has verified the resident’s competency for the 10 plans, the resident will print copies of the plan .pdf files, remove any protected health information (PHI), and compile a binder for resident rotation documentation and review by the staff physicist and Program Director.

Secondary MU checks: The staff physicist will explain and demonstrate the performance of secondary MU calculations to verify the MU’s determined by the planning system. This includes performance of the calculation and completion of any documentation required for billing or patient records. The staff physicist shall review manual calculation of MU’s (SSD and SAD calculations) using data from the UMMC clinical physics data book. The staff physicist shall explain differences in dose calculation methods between the planning system and secondary MU check program, including examples of when there are expected differences between the two. The resident shall independently perform secondary MU checks for all plans assigned to the clinical physicist. For rotation documentation, the resident shall print the secondary MU check documentation for the 10 treatment plans previously described after removing any PHI, and add the documentation to the rotation binder for resident documentation, which will be reviewed by the staff physicist and Program Director.

Electron MU calculations: The staff physicist will explain and demonstrate procedures for determination of electron insert factors by measurement and the use of these factors in MU calculations. The staff physicist shall demonstrate and explain the completion of all documentation required in the performance of these tasks. The resident will retain copies of electron MU calculation forms performed on the rotation in the rotation binder.

Linac and CT QA: The staff physicist shall explain and demonstrate the monthly QA procedures for the Elekta Versa HD (SN 156094), Elekta Synergy (SN 151828), Elekta Synergy S (SN 151250) linear accelerators and Phillips Brilliance 16-Slice Big Bore CT Simulator (SN 7329). This includes both mechanical and dosimetric tests where applicable. The staff physicist shall demonstrate preparation of all appropriate documentation and placement of documentation in appropriate data books. Documentation of monthly QA performance shall be maintained in the resident’s rotation binder.

Chart closeouts: The rationale for performing chart closeouts shall be explained. The staff medical physicist shall explain and demonstrate procedures for chart closeouts of patients who have completed or discontinued treatment. Chart closeouts shall include verification of the following information:

Total delivered dose
Completion of all appropriate documentation
Signatures and approval for all documentation
Verification and completion of all appropriate billing charges

The resident shall independently perform chart closeouts for all patients assigned to the staff medical physicist. The resident shall select 10 patients for evaluation by the staff medical physicist. The resident will perform chart closeouts for these 10 patients under the supervision of the staff medical physicist. Once the medical physicist has verified competency, the performance of these closeouts will be documented in the resident’s rotation binder.

2. UMMC Treatment Planning

The staff dosimetrist and physicist will explain and demonstrate treatment planning procedures for the following treatment planning system:

RayStation

The staff dosimetrist and physicist shall explain the rationale for various treatment parameters such as modality, beam energy, delivery technique (3DCRT, static beam IMRT, VMAT and SBRT etc.), beam modifiers (wedges, blocks, etc.), selection of IMRT optimization parameters, review of dose limitations for various structures, dose limits for various normal tissues, etc. The staff dosimetrist and physicist shall explain and demonstrate all procedures for treatment planning. For external beam planning, this includes:

Creation of patient file in treatment planning system
Import of imaging data (CT, MRI, PET)
Modeling of CT couch
Image fusion
Contouring of structures
Selection of isocenter
Selection of treatment modality
Selection of beam orientations
Selection of beam energies
Use of beam modifiers (wedges, blocks, etc.)
Creation of MLC and block shapes
Selection and positioning of reference calculation point
Entering of prescription
Selection of dose grid
Verification of correct dose voxel size
Verification of correct CT-to-density table
Verification of external contour
Selection of correct dose algorithm
Evaluation of plan for clinical acceptability
Export of plan
Creation of data required for IMRT QA
Import of plan into R&V system (MOSAIQ)
Appropriate documentation for billing and patient records

The resident shall observe the treatment planning process for a number of anatomic locations during the rotation assignment. The minimum number for each anatomic site is listed below.

1 lung with off-cord
2 SBRT Lung
1 SBRT Spine
2 breast (1 3DCRT; 1 forward-planned IMRT)
2 GU (1 3DCRT; 1 IMRT)
2 GYN (1 3DCRT; 1 IMRT)
2 GI (1 3DCRT; 1 IMRT)
2 head and neck (1 3DCRT; 1 IMRT)
1 lymphoma
1 melanoma
1 pediatric
1 sarcoma
1 thoracic
2 brain (1 3DCRT; 1 IMRT)
2 palliative or non-malignancy treatments (e.g., cord compression, heterotopic bone)

3. UMMC LDR (Low Dose Rate) Brachytherapy: Eye Plaque

The staff physicist shall explain and demonstrate the performance of pre- and postplan checks for all LDR COMS Eye Plaque procedures occurring during the rotation. Duties include performance of the plan check and completion of any documentation required for billing or patient records.

The staff physicist shall explain and demonstrate the performance of assays for all received LDR brachytherapy sources. This includes the preparation of all appropriate documentation and placement of all documentation in the appropriate binders. The staff physicist shall explain and demonstrate the performance of the LDR physics duties. The resident shall accompany the staff physicist to all LDR cases that occur during the rotation assignment. The resident shall independently review all LDR (pre- and post-plans) assigned to the staff physicist. For rotation documentation, the resident shall select 2 sample plans for documentation. The resident shall check these plans under the review of the staff physicist. Once the staff physicist has verified the resident’s competency for the 2 plans, the resident will print copies of the plan .pdf files, remove any protected health information (PHI), and compile a binder for resident rotation documentation and review by the staff physicist and Program Director.

4. UMMC Clinic/IMRT

Linac and treatment planning system problems: The staff physicist shall involve the resident in addressing any machine problems that arise at the UMMC for any machine during the rotation assignment. If the problem requires a service engineer, the resident shall shadow the engineer until the problem is resolved. The staff physicist shall explain the rationale and demonstrate the performance of any QA tasks required after resolution of the problem before the equipment is released back into clinical use.

The staff physicist shall involve the resident in addressing any RayStation planning system problems that arise during the rotation assignment. If the problem requires a service engineer, the resident shall shadow the engineer until the problem is resolved. The staff physicist shall explain the rationale and demonstrate the performance of any QA tasks required after resolution of the problem before the equipment is released back into clinical use.

Patient MOSFET dosimetry: The staff physicist shall involve the resident in any InVivo dosimetry requests that arise during the rotation assignment. This includes:

Placement of patient MOSFET dosimeters
Documentation of MOSFET locations relative to patient anatomy and treatment field
Readout of dose received by MOSFET Dosimeters
Preparation of all documentation required for billing or patient records

4DCT: The staff physicist shall explain the rationale for and use of 4DCT imaging in radiation oncology. The staff physicist will explain and demonstrate procedures for 4DCT acquisitions. The staff physicist shall explain and demonstrate processing of 4DCT data and import of the data into Pinnacle. The resident will attend all 4DCT scan acquisitions that occur during the rotation assignment.

IMRT patient QA: The staff physicist shall explain and demonstrate the procedures for performance of IMRT QA using the MapCHECK2 and Delta4 dosimetry devices. This includes performance of the QA measurements, comparison of measured and calculated doses, generation of the IMRT QA report, and completion of any documentation required for billing or patient records. The resident shall perform IMRT QA for at least 10 patients per device during the rotation. The resident will perform these QA measurements with the UMMC staff physicist. Copies of IMRT QA results and reports for these patients will be copied, with all PHI removed, and placed in the resident’s binder for review.

Linac QA: The staff physicist shall explain and demonstrate the monthly QA procedures for the Elekta linear accelerators. This includes mechanical, imaging and dosimetric tests where applicable. The staff physicist shall demonstrate preparation of all appropriate documentation and placement of documentation in appropriate data books. Documentation of monthly QA performance shall be maintained in the resident’s rotation binder.

The resident shall create a binder for documentation of all required materials for the rotation. For any linac or treatment planning problems that arise during the rotation assignment, the resident shall write a summary of the problem and the steps taken to resolve it. The resident shall document any QA tasks (reports and results) required before release of equipment into clinical use. The resident shall retain copies of all MOSFET measurement reports and results generated during the rotation assignment. All PHI must be removed. The resident shall create a procedure sheet documenting all the steps involved in 4DCT acquisition. The resident will document the number of observed 4DCT procedures during the rotation assignment. The resident will retain copies of all IMRT QA reports for patient QA performed with a staff physicist. All PHI shall be removed. The binder will be available for review by the supervising staff physicist and the Program Director.

5. UMMC HDR Brachytherapy

HDR planning and delivery: The staff physicist shall explain and demonstrate the procedures involved in HDR treatment planning and delivery. This includes:

Observation of applicator insertion
Acquisition of treatment planning images
Import of imaging data into the treatment planning system (Oncentra TPS)
Contouring of relevant structures
Identification of applicators
Catheter reconstruction
Positioning of dose calculation/optimization points
Placement of normal tissue points (e.g., ICRU bladder and rectum points)
Dose calculation and evaluation
Export of approved treatment plan
Performance of secondary dose check
Pretreatment QA procedures
Delivery of treatment
Preparation of all documentation required for billing or patient records

The resident shall participate in the treatment planning and delivery process for all HDR patients during the rotation assignment. The staff physicist shall provide the resident with 6 practice cases (2 tandem and ovoid, 2 tandem and ring, and 2 cylinder). The resident will generate treatment plans for each case and present them to the staff physicist. The physicist shall evaluate and provide feedback on the plan for each case. Once the resident is able to generate clinically acceptable treatment plans, the resident will perform the rest of the treatment process (i.e., secondary dose check, pretreatment QA, and delivery) for each of these practice plans. A copy of each of these plans without PHI and all associated documentation will be kept in the resident’s binder for the rotation.

HDR QA and source exchange: The staff physicist shall explain and demonstrate the procedures for daily QA on a treatment day and quarterly HDR source exchanges. This includes both mechanical and dosimetric tests where applicable. The staff physicist shall demonstrate preparation of all appropriate documentation and placement of documentation in appropriate data books. The resident will perform a practice source exchange and complete all procedures and documentation required for an actual source exchange. Documentation of source exchange performance shall be maintained in the resident’s rotation binder.

6. UMMC Gamma Knife Icon SRS and SFRT

SRS/SFRT planning and treatment: The staff medical physicist shall explain the rationale for SRS/SFRT treatments. The staff medical physicist shall explain and demonstrate all procedures for SRS/SFRT treatments. These include:

Observation of head frame placement
Bubble measurements when applicable
Placement of indicator box
Setup of patient on MRI/CT scanner
Parameters for MRI/CT scan (FOV, slice thickness, extent of scan volume in AP, LAT and SI directions, use of contrast, etc.)
Transfer of imaging data to GammaPlan system
Import of imaging data (CT, MRI, angio, etc.) into planning system
Stereotactic reference system definition for both frame-based and mask based immobilization
Performing CBCT
Rationale and performance of image registration
Rationale for prescribed dose
Rationale for use of mask vs. frame immobilization
Selection of collimator size and number of shots
Forward and inverse planning
Normalization of dose/prescription isodose
Plan evaluation
Export of protocol
Secondary MU check
Observation and performance of daily QA on a treatment day
Pretreatment QA procedures
Setup of patient on treatment couch
Delivery of treatment
Preparation of all documentation required for billing or patient records

The resident shall observe the performance of daily QA and patient treatment delivery on all days where an SRS/SFRT procedure occurs. The resident shall participate in the treatment planning and delivery process for all SRS/SFRT patients during the rotation assignment. The staff medical physicist shall provide the resident with practice cases using the patient data for selected SRS/SFRT patients treated during the rotation. The resident will generate treatment plans for each case and present them to the staff medical physicist. The medical physicist shall evaluate and provide feedback on the plan for each case. Once the resident is able to generate clinically acceptable treatment plans, the resident will perform the rest of the treatment process for each of these practice plans (i.e., export of plan information, secondary dose check, pretreatment QA, and treatment delivery). A copy of each of these plans and all associated documentation will be kept in the resident’s binder for the rotation.

For all SRS/SFRT treatments during the rotation, the resident will print copies of the plan .pdf files, remove any PHI, and add the plans to the binder previously described. The binder shall also contain the secondary MU calculation documentation for each case. The binder shall be available for review by the supervising staff medical physicist and the Program Director.

Gamma Knife Icon QA: The staff medical physicist shall explain and demonstrate the monthly QA procedures for the Gamma Knife Icon treatment unit. This includes both mechanical and dosimetric tests where applicable. The staff medical physicist shall demonstrate preparation of all appropriate documentation and placement of documentation in appropriate data books. Documentation of monthly QA performance shall be maintained in the resident’s rotation binder.

Sample schedule and description of resident’s projects

UMMC Residency Program Project Rotation

Cycle 1: July Year 1 – December Year 1
Project Description:	Mentor:
MLC QA & Commissioning for Gantry Static IMRT	Duggar
Dosimetric Systems I	He
IGRT QA and Commissioning	Mobit
VMAT (Gantry-Dynamic) QA and Commissioning	He
TG-100 Workshop (or other elective)	MBPCC

Cycle 2: January Year 1 – June Year 1
Project Description:	Mentor:
Shielding (LINAC, CT, HDR)	Mobit
SRS QA and Commissioning	He
TG-51	He
HDR Brachytherapy QA and Commissioning	Duggar
Secondary MU Calculations in Radiation Therapy	Mobit
Radiation Safety and Regulations	RSO

Cycle 3: July Year 2 – December Year 2
Project Description:	Mentor:
CT QA, Acceptance, and Commissioning	Duggar
4DCT, Motion Management, & Gating: Commissioning and QA	Duggar
LDR Brachytherapy QA and Commissioning	Mobit
Dosimetric Systems II	He
Proton Therapy Workshop (or other elective)	WHKS
TPS QA & Commissioning	Duggar

Cycle 4: January Year 2 – June Year 2
Project Description:	Mentor:
LINAC QA, Acceptance, and Commissioning	Mobit
Total Body Irradiation Commissioning (or other elective)	He
IROC Phantom Study (or other elective)	Yang