Peer reviews of medical physics practices often yield little information because theAAPM has not been proactive in developing appropriate peer-review guidelinesMichael Gossman, Per Halvorsen, and Colin G. Orton Citation: Medical Physics 34, 3701 (2007); doi: 10.1118/1.2775663 View online: http://dx.doi.org/10.1118/1.2775663 View Table of Contents: http://scitation.aip.org/content/aapm/journal/medphys/34/10?ver=pdfcov Published by the American Association of Physicists in Medicine Articles you may be interested in The terminal M.S. degree is no longer appropriate for students interested in a career in clinical medical physics inthe United States Med. Phys. 38, 1737 (2011); 10.1118/1.3533901 Medical Physics should adopt double-blind peer review of all manuscripts Med. Phys. 37, 5151 (2010); 10.1118/1.3470099 Reviewing Papers for Medical Physics Med. Phys. 35, 1619 (2008); 10.1118/1.2842077 Review of Medical Physics Manuscripts Med. Phys. 34, 1521 (2007); 10.1118/1.2716414 Early Organizations of Medical Physics Med. Phys. 25, 1238 (1998); 10.1118/1.1584291

POINT/COUNTERPOINTSuggestions for topics suitable for these Point/Counterpoint debates should be addressed to Colin G. Orton, ProfessorEmeritus, Wayne State University, Detroit: ortonc@comcast.net. Persons participating in Point/Counterpoint discussions areselected for their knowledge and communicative skill. Their positions for or against a proposition may or may notreflect their personal opinions or the positions of their employers.

Peer reviews of medical physics practices often yield little informationbecause the AAPM has not been proactive in developing appropriatepeer-review guidelines

Michael Gossman, M.S.Tri-State Regional Cancer Center, Ashland, Kentucky 41101(Tel: 606-329-0060, E-mail: mgossman@tsrcc.com)

Per Halvorsen, M.S.Radiation Oncology, Middlesex Hospital, Middletown, Connecticut 06457(Tel: 860-358-2100, E-mail: per@halvorsen.name)

Colin G. Orton, Ph.D., Moderator

�Received 2 July 2007; accepted for publication 3 July 2007; published 30 August 2007�

�DOI: 10.1118/1.2775663�

OVERVIEW

In a recent Point/Counterpoint, Dr. Stephen Thomas statedthat “…peer review would be included underthe…professional and regulatory guidelines…” of the Prac-tice Performance Evaluation program required for Mainte-nance of Certification for ABR diplomates.1 In anticipationof this, or for other reasons, many medical physicists havebegun to organize such peer reviews. Unfortunately, how-ever, comprehensive guidelines for peer reviews have notbeen developed. Lacking such guidelines, some medicalphysicists have been known to conveniently “select” indi-viduals who will provide “friendly” reviews of their prac-tices. Such peer reviews are neither useful nor are they suit-able for proper practice performance evaluation. It might beargued that leadership organizations such as the AAPMshould have taken a more proactive role in development anddissemination of such guidelines for peer review, and this isthe topic debated in this month’s Point/Counterpoint.

Arguing for the Proposition isMichael S. Gossman, M.S.,DABR. Beginning academi-cally at Indiana University andthe University of Louisville,he received B.S. and M.S.physics degrees, followed bymedical physics education atVanderbilt University, and cer-tification in Therapeutic Ra-diologic Physics by the Ameri-can Board of Radiology in2003. He currently serves as a

member of TG-152 and the Therapy Physics RadiationSafety Subcommittee of the AAPM, and has served as areviewer for the Medical Dosimetry and Applied ClinicalMedical Physics journals and as a Medical Consultant to theU.S. Nuclear Regulatory Commission. Mr. Gossman is theChief Medical Physicist and RSO at the Tri-State RegionalCancer Center in Ashland, KY.

3701 3701Med. Phys. 34 „10…, October 2007 0094-2405/2007/34„10…/3701/4/$23.00 © 2007 Am. Assoc. Phys. Med.

Arguing against the Proposi-tion is Per Halvorsen, M.S.,DABR. Mr. Halvorsen is a ra-diation oncology physicist atthe Middlesex Hospital CancerCenter in Middletown, Con-necticut. Since receiving hisMS degree in RadiologicalMedical Physics from the Uni-versity of Kentucky in 1990,he has worked in large aca-demic medical centers and pri-vate community clinics. He

has been active in the AAPM and the ACR on professionalpractice issues with particular focus on practice standardsand peer review, serving on the ACR’s Radiation Oncologyaccreditation committee and chairing or serving on manycommittees and Task Groups within the AAPM ProfessionalCouncil. He is currently an At-Large member of the Board ofDirectors.

FOR THE PROPOSITION: Michael Gossman, M.S.

Opening Statement

Peer reviews are best accomplished by outsiders, yetmedical physicists routinely self-review. Changes are neededto ensure the effectiveness of peer reviews. The purpose ofthe peer review process is to provide the incentive and op-portunity for medical physicists to improve their physicsquality assurance programs.2,3 The recommendations of anoutside qualified medical physicist can be extremely valuablein establishing policies and procedures, including implemen-tation of quality assurance guidelines developed by theAAPM and/or patterned throughout the field. This is alsoimportant in order to ensure operational conformance toregulations governing a medical physics practice.

To maintain high professional performance standards formedical physicists, the AAPM, ACR, and other organizationshave recommended that peer reviews be conducted.4–7 Manymedical physicists are still not obtaining peer reviews. A solomedical physicist should obtain a peer review on an annualbasis.2 Where multiple physicists are involved, the chiefmedical physicist should obtain a peer review separate fromthe review for staff physicists. Staff physicists have no obli-gations other than those tasks assigned and directed by thechief physicist. Staff medical physicists should receive anannual performance review by their chief physicist, but theprogram as a whole is solely the responsibility of the chiefphysicist.

The routine of a physics program and the governing poli-cies and procedures for the practice are strictly the obligationof the physicist in charge. In this sense, the solo physicist isthe chief. Whether acting as consultants or not, the obliga-tions of the physicists are to control and implement the qual-ity management programs for all facilities in which they op-erate. For each facility, peer review analysis should beconducted on the whole program.

As it exists in our field currently, some chief medicalphysicists assign a staff physicist or part-time consultingphysicist to review the very same program or group withwhich they work. Even if a subordinate physicist agrees totake on that responsibility, the peer review process suffers.This is absolutely not what is meant by “mutual agreement”4

for two reasons. First, subordinate medical physicists providesome of the operational work and would, therefore, be attest-ing to the accuracy of their own work. Second, subordinatemedical physicists would be commenting on the programtheir superior instituted, including opinions on the chiefmedical physicist’s actual work. This creates significant con-flicts of interest.

For any purpose, whether for satisfying site accreditationrequirements or for application toward certification mainte-nance, this type of review is a “sham”! The effectiveness ofthe peer review process boils down to the fundamental un-derstanding of its intended purpose: a peer review shouldevaluate the entire physics quality assurance program of thechief medical physicist. A review should be made by an out-side qualified medical physicist who specializes in the samearea. That individual should be unaffiliated with, and shouldnot be providing physics work of any sort for, the facility soas to avoid bias or impropriety. Where appropriate guidanceon the peer review process is lacking, the AAPM should takethe initiative and recommend new peer review proceduresthat will improve the profession.

AGAINST THE PROPOSITION: Per Halvorsen, M.S.

Opening Statement

Our work as medical physicists can have a significantimpact on the health and safety of our patients. The Instituteof Medicine recognized that the continued professional com-petence of healthcare staff must be periodically assessed.8

Our professional organizations have recognized the impor-tance of peer review in this context.2,4,5,7 This shows broadagreement on the value of peer review in medical physics,and on this point I am sure that Mr. Gossman and I agree.

The debate centers instead on whether “peer reviews ofmedical physics practices often yield little information be-cause the AAPM has not been proactive in the developmentof appropriate guidelines.” Most medical physics peer re-views do not yield little information. In the rare cases thatthis occurs, the villain is not any failure by the AAPM todevelop appropriate guidelines. Rather, the blame lies withthe individual medical physicists participating in the reviewfor failing to consult the many resources available to ensurethat the peer review is appropriately comprehensive andyields a productive critique.

Though no peer-reviewed publication directly addressesthe assertion at the center of this debate, I can relate mypersonal experience with more than 40 peer reviews. Formore than a decade, I have been a surveyor for the ACR’sRadiation Oncology accreditation program. During the sameperiod, I have performed several privately arranged peer re-views, and have also been reviewed myself through bothmechanisms several times. In all instances, the physicists in-

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volved worked conscientiously to ensure that the review wassubstantive in scope, appropriate in depth, and resulted inproductive collegial critique.

The AAPM Task Group 103 published guidelines for peerreview in clinical radiotherapy physics,2 and TG 127 is cur-rently working on a peer review model for all medical phys-ics specialties, in accordance with the ABR’s Maintenance ofCertification requirement for Professional Quality Improve-ment. The ACR maintains an active accreditation program,and physicists serving as volunteer surveyors gain valuableexperience in how to review and critique a medical physi-cist’s practice. The American Board of Medical Specialties�ABMS� maintains links on its website to all 24 memberboards; many contain useful information about their peer re-view programs.

The medical physicist, as an independent professional,should construct a peer review method that is appropriate forthe practice environment by consulting the aforementionedresources and others as appropriate. I trust that most medicalphysicists have the intellect and integrity to exercise theirprofessional judgment on what format would be most appro-priate for their situation. Hopefully, most of us prefer to re-ceive a tangible benefit from the effort in the form of a usefulcritique, rather than spending effort on an uninformativereview.

In summary, the AAPM is active in developing guidelinesand tools for its members to practice medical physics effec-tively, including providing guidelines for peer review. We arenot a society of technicians, but of professionals. Each indi-vidual professional should have the ability and integrity toinvest the effort to assess the possible formats and appropri-ate scope of review in order to design a peer review processthat will be productive for the reviewed physicist.

Rebuttal: Michael Gossman, M.S.

The question that remains after these opening remarks is“how can the AAPM astutely direct the process of peer re-views?” I agree with Mr. Halvorsen that medical physicistsshould work conscientiously to ensure that their peer reviewsare substantive in scope and appropriate in depth, resulting inproductive collegial critiques. Such critiques cannot be pro-ductive when they are not independent. My colleague cannotdispute that some peer reviews are in fact shams or, at thevery least, are not conducted with the level of independenceneeded to ensure that they are unbiased and, hence, construc-tive.

Nevertheless, the debate cannot end here. Neither theABMS nor the ACR has published resources that specificallyaddress peer review methods for medical physicists. Al-though the ACR suggests that procedures should be in accor-dance with AAPM guidelines, the current set of resources,including those made available in TG-11, TG-40, and TG-103, are insufficient and therefore inappropriate. More com-prehensive guidelines that encourage independence will leadto more productive critiques and foster a higher level of sup-port and quality assurance for medical physicists at all levels.

I challenge the currently active AAPM Task Group 127 tolead the medical physics community to a quality peer reviewprocess that is complete and broadly supportive of all medi-cal physicists within our association. I believe the work fromthis group can produce a report which encompasses themethod of peer review for all specialties of medical physicsincluding solo practice, as well as for larger facilities wherea chief medical physicist oversees work from subordinatephysics staff.

It is my hope that this Point/Counterpoint will provideinsight to those members who are considering participationin this professionally constructive quality assurance processand, equally, those who are currently involved, all of whomshould consider the points mentioned here as a step towardimproving the peer review process.

Rebuttal: Per Halvorsen, M.S.

Mr. Gossman appears to believe that staff medical physi-cists are merely well paid technicians; how else to explainthe statement that “Staff physicists have no obligations otherthan those tasks assigned and directed by the chief physi-cist.” I strongly disagree. The AAPM-ACMP joint definitionof a Qualified Medical Physicist �QMP�9 states: “For thepurpose of providing clinical professional services, a Quali-fied Medical Physicist is an individual who is competent topractice independently one or more of the subfields of medi-cal physics” �emphasis added�. While medical physicists intraining �e.g., residents or junior physicists not yet boardcertified� may not be subject to the type of peer review beingdebated here, all QMPs are capable of practicing indepen-dently and should therefore be expected to contribute theirprofessional judgment and suggestions for practice improve-ment, even when serving as staff medical physicists.

Mr. Gossman states: “…some chief medical physicists as-sign a staff physicist or part-time consulting physicist to re-view the same program or group with which they work…Thisis absolutely not what is meant by ‘mutual agreement’…”On this point I agree with Mr. Gossman and, indeed, theTG-103 report that he references clearly states that “The re-viewer should, as much as practical, be independent from thereviewed physicist (for example, no business partnership orclose personal relationship).”

In summary, Mr. Gossman fails to substantiate the propo-sition that peer reviews of medical physics practices oftenyield little information and, furthermore, fails to recognizethat our QMP colleagues are professionals expected to con-tribute their independent judgment to their practice environ-ment regardless of their job title. I believe we can, indeedmust, meet that higher standard.

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