Post-graduate education and training
Options for additional training after completion of the terminal graduate degree include enrollment in a residency training program, a post-doctoral training program, and continuing education, with continuing education being necessary for maintenance of certification. The medical physics residency training programs train medical physicists to achieve a level of competency needed to practice in their subspecialty of medical physics in a safe and independent manner and typically includes at least 2 y of clinical training; the AAPM has recommended curricula for medical physics residency programs (AAPM 2006, 2013). The capacity of such training programs in the United States has grown rapidly in recent years, with much of this growth being motivated by the introduction of a requirement for board eligibility. Specifically, to become eligible to sit for an ABR certification exam in 2014 and beyond, applicants must have graduated from a CAMPEP-accredited residency program. In 2014, there were 95 CAMPEP-accredited residency programs, including 80 in oncology physics, 11 in diagnostic physics, and two in nuclear medicine physics (Clark 2015). In 2015, these programs had 117 openings, of which 104 were for oncology physics programs and 13 were in diagnostic imaging physics programs (Clark 2015). However, as discussed above, the number of residency training openings is scarce in relation to the number of applicants; in 2014, only one-third of all applicants were admitted (Clark 2015). Consequently, the application process is extremely competitive and residency admissions are, at present, the predominant factor governing the supply of new workers. In addition, although use of the Medical Physics‐Residency Application Program has streamlined the application process for applicants and residency programs alike (AAPM 2016c), only 39% of applicants were matched and 31 programs received more than 150 applications in 2014 (Clark 2015), evidencing an imbalance in the capacities of academic and residency programs. The number of openings for residents increased slightly in 2015, but the imbalance is expected to worsen in coming years (Ibbott and Frey 2016).
With respect to post-doctoral training, until about 2010, many Ph.D. holders entered the profession through post-doctoral fellowships in medical physics. For many of these trainees, i.e., those with degrees other than medical physics, the post-doctoral fellowship was an alternate pathway to the more common pathway of earning a degree in medical physics from an accredited program. However, some trainees received didactic and practical clinical instruction while others did not, depending on the program’s capabilities, career goals of the fellows, and other factors. Thus, the length and type of post-doctoral training varied strongly. Variability on the research topics helped to invigorate the profession scientifically; however, variability in clinical training complicated the assessment of qualifications to become a clinical medical physicist. A formalized approach to the alternate pathway to clinical medical physics was proposed in 2011, including a recommended curriculum (AAPM 2011) and standards for accreditation of post-doctoral certificate programs (CAMPEP 2013, 2015). However, the certificate programs are a relatively new development and the available statistical data are insufficient to discern trends that will impact the supply of medical physics workers. Nonetheless, anecdotally, even with the advent of accredited certificate programs, the prevalence of post-doctoral training in medical physics appears to have declined substantially in the last decade. This can be attributed to reductions in federal research spending (Britt 2015), increased requirements for eligibility for professional board certification that took effect in 2014 (ABR 2014), and other factors. It is interesting to consider trends in the broader discipline of physics, for which statistical data are available. Since the turn of the century, initial employment of holders of Ph.D. degrees in physics has declined from about 68% in 2005 to about 46% in 2014 (Pold and Mulvey 2016). It is difficult to discern if, or to what extent, these broader national trends apply to the niche field of medical physics.
In summary, it appears that certificate programs are important, yet their potential role is not fully understood. The number of post-doctoral fellows at present is relatively small (corresponding to 7% of the number of graduates from medical physics degree programs) and uncertain. However, the certificate program has features that increase the elasticity of the supply of medical physics workforce. Most importantly, compared with any other medical physics training pathway, it has the shortest period. Second, its graduates hail from diverse backgrounds, which will help to ensure that medical physicists with intellectually diverse strengths are available when needed. Third, for those certificate holders that also have traditional post-doctoral research training (either as a part of the certificate training or separately), they are the most versatile in principle, with the training needed for clinical, research, and academic activities.
PROFESSIONAL ASPECTS OF RELEVANCE TO WORKFORCE SUPPLY
With respect to the size and adequacy of a professional workforce in medical physics, self-regulation has been broadly effective to date (with the disclosure that the author is a medical physicist and therefore is not entirely disinterested). However, it is prudent to question the effectiveness of self-regulation in the future to ensure the adequacy of the workforce to meet national needs. In particular, can the profession appropriately self-regulate in an era of rapid, pervasive, and unprecedented changes to the profession, science and technology, healthcare system, and the demographics of the workforce? There are certainly reasons for concern, particularly with respect to supply. Currently, the regulation of supply is distributed and decentralized. Each link of the supply chain independently regulates its production; e.g., graduate programs may admit any number of students they can attract without regard for the prospects of their graduates to gain admission to residency programs. Residency programs may admit any number of trainees that they can attract without regard for the prospects of their graduates to find entry level positions. Board certification organizations do not discriminate examinees based on the total number of examinees or the number of available entry level positions. Thus, it could be summarized that the profession relies on laissez-faire self-regulation, where control over the supply is distributed among various organizations, programs, and trainees. This autonomy is clearly helpful to at least some of the educational and training institutions to match their training loads with local resources and goals. A compelling rationale for more active or centralized approach to regulation is lacking and increased regulation is controversial (Bayouth et al. 2011).
As a practical matter, the domestic supply is apparently most strongly constrained by resources available for costly education and training. In recent years, tuition has increased while state spending on higher education has plummeted (AAAS 2015), as seen in Fig. 4. In the same era, federal funding for research, which is vital to graduate programs, decreased significantly (Britt 2015). The net effect of these changes is that the cost of higher education has shifted from the government to students and parents. Unless subsidized (e.g., with stipends for teaching assistants), these costs are probably too high for most prospective students and parents to bear. Indirect evidence of this, for both graduate and residency training programs, is the large ratio of applications to admissions. If the cost-barrier hypothesis is correct, this suggests that federal education and research grants would be an effective mechanism to stimulate production of the supply of future workers, should that become necessary.
In the United States, the largest source of funding for research and development (R&D) is the federal government, at over $60 billion per year. Broadly, federal R&D funding has been declining for decades. For example, R&D comprised 10% of the federal budget in 1968 vs. 4% now. R&D comprised about 1.25% of gross domestic product vs. 0.78% in 2014. In 2014, federal funding for higher-education R&D failed to outpace inflation for the third straight year, the longest decline since 1972 (Britt 2015). In 2014, the largest proportions of federal funding for R&D were medical sciences (~$20 billion), biological sciences (~$10 billion), and engineering (~$10 billion). These are huge sums by almost any measure, but are they trickling down to medical physics researchers? A recent analysis suggests they are not. An analysis of National Institutes of Health (NIH) funding in 2013 for radiation oncology, radiation biology, and radiation physics revealed 197 awards held by 118 full professors, 49 associate professors, and 27 assistant professors (Steinberg et al. 2013). Eighty percent of these awards focused on topics in radiation biology, and only 13% of the awards included a physics topic. Furthermore, they noted that only 18 institutions had three or more investigators with active NIH grants, which creates a critical mass problem for research groups. The low renewal rates were thought to jeopardize the establishment of durable programs. They concluded that “the overall state of NIH funding in radiation oncology raises great concern.” Many academic radiation oncology departments have already become “service departments, where novel research is limited and little or no translational research occurs.” They also stated that “radiation oncology is underfunded by NIH and that the current level of support does not match the relevance of radiation oncology…”. This suggests that the medical physics profession, perhaps through its professional associations, should advocate for increased federal R&D funding to support medical physics workforce development. Specific recommendations were proposed by Jagsi and Wilson (2013).
With respect to compensation, medical physics salaries vary strongly with country, region, degree, certification status, subspecialty, type of employer and employment setting. In the United States, compensation for medical physicists is determined by free market principles. According to the AAPM’s salary survey for 2015 (AAPM 2016a), the average total income was $184,000, excluding benefits. The median salaries ranged from $120,000 for those with an M.S. and without certification to $190,000 for those with a Ph.D. and certification. It is interesting to compare compensation of medical physicists with corresponding rates from other radiation-related professions. In general, the average salaries for medical physicists are nearly double that of health physicists and less than half that of radiation oncologists. Similarly, stipends for trainees in graduate and professional degree programs in medical physics vary strongly with the institution and degree. Some programs provide stipends and waive tuition and fees, while others collect tuition and provide no financial support (Mills 2014). Compensation for post-graduate trainees is typically intermediate to graduate student stipends and entry-level professional salaries. Medical physics residents earned an average of $51,598 per year and post-doctoral fellows earned $46,551 per year (AAPM 2016a). Is important to keep in mind that education and training times are typically protracted, including 4–5 y for a B.S. degree, 2–6 y for a graduate degree, and two or more years of post-graduate training (residency and/or post-doctoral fellowship). An adequate level of compensation for trainees is an important and potentially vital workforce issue in the long term.
The future outlook for the medical physics profession as a whole is favorable. The profession will likely continue to increase in importance, mainly because of the increasing number of incident cancers and the “endless frontier” of science and technology that will continue to improve human health. Certain aspects of the professional workforce, however, are uncertain. Among these is the adequacy of the supply of workers to fulfill future national needs. In the short term, the workforce in the United States generally appears sufficient; however, in the long term, beyond about 2020, the situation is extremely difficult to predict with certainty.
That said, the predicted increase in cancer incidence of about 2% per year (Weir et al. 2015) suggests that, all other things being equal, demand for medical physicists will continue to increase. The present demand is diverse and large, with about two-thirds of all cancer patients receiving radiation at some point (Delaney et al. 2005). In terms of the workforce demands for a particular clinic, the number of workers needed can vary considerably depending on which model is selected (e.g., Battista et al. 2012), the patient case mix, practice setting (private or community hospital, medical school, university hospital, physician group, medical physics group), and other factors. Furthermore, the number has changed dramatically over time; for example, one medical physicist was required per 424 patients in the era prior to intensity modulated radiotherapy (IMRT) vs. one per 302 patients in the IMRT era (Mills 2005). How these factors change in the future will have a large impact on demand.
The future size of the medical physics workforce is likely determined by the size of the current workforce, the continued addition of entry level workers, and future attrition. The size of the current domestic workforce is about 8,200. In 2014, CAMPEP-accredited medical physics training programs conferred 297 degrees and certificates (Clark 2015). However, in 2015 CAMPEP-accredited residencies admitted only 108 applicants (Clark 2015). Indeed, as discussed, residency training capacity has been lagging behind the output of degree and certificate programs, creating a bottleneck in the supply line of entry level medical physicists and, consequently, a glut of graduates who have been unable to gain admission to residency programs. Although the number of accredited residency programs appears likely to continue to grow, the growth rate is already showing signs of slowing. Thus, at present there is a large imbalance between the output of degree programs and the admissions of residency programs, and this will likely persist for some years. The imbalance has garnered attention and, indeed, controversy regarding if and how to regulate admissions to reduce it (Bayouth et al. 2011). It is the author’s opinion that relevant indicators to modulate admission are cancer incidence and workforce attrition, and that current production rates of graduate programs should not necessarily govern residency admissions or vice versa. Past production and admission rates are historical in nature and are unreliable indicators of future demand for medical physics work.
Future attrition warrants further discussion because it is expected to accelerate as the cohort of baby boomers retires. According to Mills et al. (2010), the rate of retirement between 2010 and 2020 is approximately triple that between 1990 and 2000. Parenthetically, it is noteworthy that older workers may add some elasticity to supply; e.g., by delaying retirement or by consulting after retirement. The survey data from Chen et al. (2015) suggest that the workforce at large has very little excess capacity or elasticity: 94% of medical physicists work full-time, 4% part time, only 1% as locum tenens, and only 1% were not working at the time of the survey but were looking for work.
The supply and capabilities of workers are tied to the status of training programs, and they are closely coupled with federal support for higher education and research. In particular, the number, size, and capacity of graduate education programs depend to varying degrees on federal funding. Nationally, funding for both higher education (AAAS 2015) and research are in decline (Britt 2015). Research funding for radiation oncology and medical physics are underrepresented (Jagsi and Wilson 2013; Steinberg et al. 2013). These data suggest that the current supply of new graduates could shrink even further in the future. Ensuring adequate capacity of medical physics education and training programs seems likely to depend on the allocation of sufficient resources from state and federal sources.
All things considered, it appears that the greatest future risk is an undersupply of medical physicists (and other critical radiation specialists) that could lead to healthcare that is inadequate in supply, quality, or safety. If new medical physicists are produced in excess of clinical needs, they will likely find employment in nonclinical positions or in other disciplines and industries.
It may be fairly said that workforce issues are complex and the future of the workforce is uncertain. The workforce topic has received considerable attention in the literature, historical and current data are available, and various models are available that are of relevance to the workforce. Many governing factors are reasonably well known with small uncertainties; e.g., cancer incidence and the approximate capacities of training programs. However, clearly, imponderables abound, such as the impact of healthcare (economic) reform, use of radiation in medicine, efficiency of medical physics procedures, and the shape of the looming wave of retirements. For these reasons, trends in supply and demand are difficult to predict more than a few years in the future. Thus, at the present time, it is not known if the medical physics workforce will be adequate in several years’ time.
RECOMMENDATIONS TO MAINTAIN AN ADEQUATE WORKFORCE
To ensure the adequacy of the medical physics workforce, the following broad actions are recommended.
1. Professional societies should continue to surveil, analyze, and report data regarding the status of the medical physics workforce. Additionally, they should monitor recent or possible future changes in policy, law, regulations, and standards of relevance. The results of these activities should be interpreted, taking into account known and unknown factors that may influence the adequacy of the workforce. The findings should be disseminated and discussed openly. Longitudinal study will be essential.
2. Based on the available data, model projections, and other factors, consensus recommendations should be developed and disseminated. They should be accompanied by an assessment of the impact of implementation of the actions as well as the potential consequences of inaction. The impact assessment should include public health and economic analyses.
3. Professional organizations and regulatory agencies should assess the need for revised or new policies and regulations to ensure the adequacy of the future workforce. The policies might include political, economic, and administrative approaches. If policy actions are required, the well-established principles of policy cycle should be applied.
4. At present, it appears that the profession should apply established risk management principles to mitigate the risk that workforce shortages cause future societal needs to go unmet. Because of protracted training times to produce medical physicists and the unknown timing of the looming wave of retirements, it is possible that shortages could appear before mitigating strategies take full effect. Therefore, the profession should be prepared to implement established crisis-management principles if necessary. Both will require substantial planning.
The recommendations above complement those from the recent statement by the NCRP (2015). NCRP recommendations are broader, pertain to all of the radiation professions, yet are applicable to the profession of medical physics. Additional discussion and recommendations of relevance were reported by Coleman et al. (2003) and Dynlacht et al. (2015).
SUMMARY AND CONCLUSION
Medical physics is a well-defined, established, and mature profession. There is an expansive body of literature about the present-day workforce, and its present status is known in detail and with certainty. At present, the size of the domestic medical workforce as a whole appears in balance with the nation’s needs. On closer inspection, however, there are substantial problems, such as the severe national shortage of residency training positions, as evidenced by a large pool of graduates of medical physics programs who are unable to enter a residency program.
The profession and its workforce are undergoing rapid changes driven by advances in science and medicine, healthcare reform, and by increasing emphasis on professional aspects of medical physics. In addition, there are long-term trends involving the increasing age and size of the population and increasing numbers of incident cancers, suggesting the possible need for an expansion of the medical physics workforce. Current models and projections are highly uncertain and cannot reliably predict if the workforce will be adequate by year 2021 and beyond. A major obstacle to increasing the supply of medical physicists is the length of time required for education and training. For these reasons, vigilant surveillance and long-range planning are essential. Recommendations to mitigate against the risks of future workforce inadequacies include the collection and analysis of additional data, dissemination and discussion of findings, policy assessments, and risk management and crisis management activities as appropriate.
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Keywords:© 2017 by the Health Physics Society
National Council on Radiation Protection and Measurements; education; education, health physics; radiation protection