Draft Updated Scope of Practice

Comment Period Ended April 30, 2019

The AAMD Board of Directors would like to thank everyone who reviewed and commented on the draft updated Scope of Practice of a Medical Dosimetrist. All comments are being sent to the Scope of Practice Task Group for consideration. It is anticipated that the final document will be presented at the AAMD 44th Annual Meeting in Anaheim, CA, this June. Questions? Email us at aamd@medicaldosimetry.org

SCOPE OF PRACTICE OF A MEDICAL DOSIMETRIST
AAMD Task Group - Revised Draft March 2019

Preamble
The Scope of Practice of a Medical Dosimetrist is designed to assist the Qualified Medical Dosimetrist (QMD) in defining their role in the technical services they provide in patient care. This document also defines the QMD, provides a statement of basic responsibility of the QMD, and addresses their education, certification, continuing education, and maintenance of certification. Statements are included on supervision by and of the QMD; stressing the importance that the QMD be an active participant in the collaborative, team approach to patient care and that effective communication with the radiation oncology team is essential for providing quality patient care and patient safety. (1,2)

In addition, this Scope of Practice is designed to educate professionals in the fields of health care, education, other communities of interest and the general public regarding the expectations of the QMD. (1,2) This document can be used by individual facilities to develop job descriptions and practice parameters.

The Scope of Practice defined in this document is meant to have some flexibility in interpretation and is not intended to be used to establish a legal standard of care. (2) Professionals who use this document must be aware of state and federal laws affecting their practice as well as institutional policies and guidelines, as the intent is not to supersede these laws or affect the interpretation or implementation of such laws. (1)

The American Association of Medical Dosimetrists (AAMD) is an international society established to promote and support the Medical Dosimetry profession. The AAMD is committed to advance the science, education, and professional practice of medical dosimetry. The AAMD periodically reviews and updates the professional practice guidelines for the QMD to help advance the technical services provided by the QMD and to improve the quality of services to patients. In addition, the AAMD provides opportunities for education, a forum for professional interaction and a representative voice in the healthcare community. The Society seeks to promote an ideal of professional conduct to which its members should aspire and endorses the highest standards of patient care. (3)

I. Qualified Medical Dosimetrist (1,2)
A Qualified Medical Dosimetrist is an individual who obtains the basic competency to practice in collaboration with a Radiation Oncologist (RO) and/or a Qualified Medical Physicist (QMP). The individual uses critical thinking and problem-solving skills as well as exercises their discretion and judgment in the performance of medical dosimetry procedures.

It is expected that an individual will hold themselves qualified to practice in Medical Dosimetry only when the knowledge and skills to perform dosimetric tasks has been established. An individual shall be considered eligible to practice if they are certified by the Medical Dosimetrist Certification Board (MDCB).

Effective as of 2017, all United States candidates for MDCB certification will be required to apply as Route 1 candidates holding a Bachelor’s Degree and be graduated from a formal dosimetry program accredited by the Joint Review Committee on Education in Radiologic Technology (JRCERT) by the late application deadline. The American Association of Medical Dosimetrists (AAMD) has fully endorsed this educational level for new candidates in the United States. (2)

The AAMD recommends all personnel practicing in Medical Dosimetry attain, at a minimum, certification provided by the MDCB. Accordingly, the Certified Medical Dosimetrist (CMD) is recognized as the appropriate credential for the QMD. (2)

II. Professional Competence
Professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served. (1)

III. Statement of Basic Responsibility
The essential responsibility of the QMD is to generate a clinically acceptable treatment plan, utilizing clinical knowledge including, but not limited to, anatomy, physiology, radiation biology and oncology, radiation safety and protection, mathematics, and radiation therapy techniques, physics and technology. The QMD is expected to communicate with the RO during the treatment planning process and participates in communicating the plan to the QMP and to the Radiation Therapist (RT) for implementation. The QMD must maintain a commitment to a high degree of accuracy, attention to detail, and safety. The QMD must use critical thinking skills when performing radiation treatment planning, plan evaluation, recognizing and resolving equipment problems and treatment discrepancies. (1)

IV. Definitions
The Qualified Medical Dosimetrist (QMD) is a member of the radiation oncology team who has a knowledge of the overall characteristics and clinical relevance of radiation oncology in the management of cancer or other radio-responsive conditions, with special expertise in radiation therapy treatment planning. (1,2)

The Practice of Medical Dosimetry is performed by health care professionals responsible for the process of patient data acquisition, radiation treatment planning for the administration of ionizing radiation, and quality management for radiation oncology patients. The QMD may have to ensure accurate transfer of patient information to a number of software, which may include record/ verify systems, surface guidance and/or image guided systems and treatment delivery systems. In addition to the above, the QMD may perform or assist in other duties under the direction of the Board-Certified Radiation Oncologist (RO) and a Qualified Medical Physicist (QMP). (1, 4)

A Board-Certified Radiation Oncologist (RO) denotes a Doctor of Medicine who is licensed to practice their medical specialty and who prescribes and/or utilizes radiological procedures for individuals for the diagnosis or treatment of their ailment. The RO directs and utilizes the services of many interdisciplinary professions. (2,3)

For providing clinical professional services, a Qualified Medical Physicist (QMP) is an individual who is competent to independently provide clinical professional services in one or more of the subfields of medical physics. A QMP is qualified to practice only in the subfields(s) in which they are certified. A QMP must hold a professional medical physics license where required. (2, 3)

QMDs are educated to independently perform duties and complete responsibilities under the direction of a RO and a QMP. (1)

V. Specifics of Practice
This document summarizes the activities that the QMD can undertake based on the individual’s training, qualifications, and demonstration of competence. Each QMD must exercise professional and prudential judgment in determining whether they are educationally prepared and clinically competent to perform a given activity. The QMD understands when to seek guidance and assistance with assigned activities (1).

The decision-making model described in Appendix 1, provides rational and logical guidance to QMDs. When these guidelines are used to analyze whether a QMD may perform a task, the conclusion is reached that this act is or is not within the scope of practice of the individual QMD. (1)

QMDs should adhere to the AAMD Code of Ethics and the Ethical Standards of the MDCB. (1,2)

VI. Education and Certification
The AAMD recommends that QMDs entering the field be prepared for this profession by earning the minimum of a baccalaureate degree, completing a Medical Dosimetry educational program accredited by the JRCERT and obtaining certification by the MDCB and continuing education following MDCB’s Maintenance of Certification. (1-3)

The AAMD fully supports the MDCB routes of eligibility change beginning in 2017 that requires all examinees to have a baccalaureate degree and to have graduated from JRCERT accredited medical dosimetry educational program. (4)

VII. Continuing Education / Maintenance of Certification
Radiation oncology is a rapidly changing and technologically-advanced field. It is imperative that the QMD maintain a level of expertise and awareness of changes and advances to remain current in the field.

Maintenance of certification by the MDCB is part of the continuing education of the QMD. Once certified, the QMD is personally and professionally responsible for the maintenance of certification according to the guidelines established by the MDCB. (1,2)

VIII. Supervision (1)
A QMD receives supervision from the RO, QMP, and senior / lead QMDs.

A QMD may supervise other QMDs and other allied health professionals.

IX. Collaboration and Communication (1,2,3)
Collaboration and communication are essential to the process of patient data acquisition, radiation treatment planning, treatment plan evaluation, accurate treatment delivery, and quality management for radiation oncology patients. It is imperative that QMDs actively and openly collaborate and communicate with:

RO, QMPs, and other allied health personnel for radiation treatment planning and radiation dose delivery.
RO and to ensure accurate radiation dose to each pateint.
QMPs regarding quality assurance and quality management.
QMPs regarding radiation safety for patients, staff, and the general public.
Research and development scientists, RO, and equipment manufacturers involved in the development and advancement of products and procedures designed for patient care.
Educators with graduate programs in medical physics, residency programs in radiation oncology and medical physics, medical dosimetry programs and other allied health programs to assist with the training and education of these individuals.

X. The Scope of Practice of the Qualified Medical Dosimetrist Shall include, but is not limited to: (1,2,3)

Acquisition of patient data via computer generated data sets from medical imaging devices such as CT, PET, MR, etc., or manual methods such as physical measurements and wire contours, and incorporation of this data into radiation treatment plans, calculations, and treatment devices.
Assisting the RTT in the treatment simulation process.
Provision of input for the use or necessity of ancillary treatment devices, patient immobilization techniques, and other patient positioning techniques as needed for simulation and treatment. May assist in fabrication of these ancillary treatment devices.
Generation of isodose distributions, and performance of dose calculations according to the RO intent and prescription.
Incorporation of patient data from medical imaging procedures as the imaging data pertains to simulation, radiation treatment planning, treatment delivery and quality assurance.
Contouring and delineating of clearly discernable normal critical structures using different imaging modalities.
Generating planning treatment volumes (PTV) around the tumor volume as segmented by the RO.
Registration and fusion (including image deformation) of multi-modality image sets.
Reviews with the RO the completeness of target and organ(s) at risk (OAR) delineation prior to treatment planning.
Evaluation for accuracy of information generated from radiation treatment plans such as isodose distributions, Dose Volume Histograms (DVH’s) and other data in establishing the appropriateness of the treatment plan.
Application of knowledge of radiobiology with respect to dose tolerances, time dose fractionation calculations, hypo-fractionation, BED and EQD2 calculations and other applications of radiobiology to the radiation therapy treatment process.
Accuracy in the transfer and documentation of treatment parameters either manually or electronically according to departmental policies.
Participation in accepted departmental, institutional, and national standards concerning the process of patient and treatment site identification.
Application of principles and concepts of radiation physics in radiation treatment planning, which includes, but is not limited to, 2D treatment planning, 3D conformal treatment planning, intensity modulated treatment planning (IMRT), 4D treatment planning, proton treatment planning, and brachytherapy treatment planning.
Accuracy in the performance of dose calculations, both manual and computer generated, for treatment delivery.
Accuracy in the performance of calculations pertaining to, but not limited to beam modifying devices, irregular fields, gaps for adjacent fields, and off-axis calculations.
Participation in special treatment procedures including, but not limited to, Total Body Irradiation (TBI), Total Skin Electron Irradiation (TSEI), Intra-Operative Radiation Therapy (IORT), Stereotactic Radiosurgery (SRS), Stereotactic Body Radiation Therapy (SBRT), and other treatment procedures. Participation may include treatment planning of any special procedures. Involvement in any of these special treatment procedures requires completion of vendor based training or equivalent and credentialing by the institution to be able to practice medical dosimetry in these areas.
Performance of or assistance with quality assurance procedures as directed by a QMP.
Performance of or assistance with the application of specific methods of radiation measurement including, but not limited to diodes, optically stimulated luminescent dosimeters (OSLD), ion chambers, thermo-luminescent dosimeters (TLD), or film measurements as directed by a QMP.
Having been appropriately trained in emergency procedures and in accordance with state and federal guidelines, under the supervision of the Authorized user, as defined by the Nuclear Regulatory Commission (NRC), participates in procedures that involve radioactive material.
Participates in the preparation, measurement, transportation, loading and/or removal of radioisotopes adhering to state and federal regulations under the supervision of the Authorized User, as defined by the NRC.
Participates in low dose rate (LDR), pulsed dose rate (PDR), and high dose rate (HDR) procedures, adhering to state and federal guidelines under the supervision of the Authorized User, as defined by the NRC.
Application of the principles of ALARA to minimize exposure to patients, staff and the general public.
Application of critical thinking skills during the simulation, radiation treatment planning, treatment evaluation, and treatment delivery processes.
Participation in quality management (QM) in accordance with departmental, and national QM guidelines.
Performance of daily and/or weekly chart checks per departmental policy.
Participation in the implementation of the radiation treatment plan; which includes, but is not limited to, collaboration with team members, plan documentation, treatment parameter verification and treatment charting.
Participation in fiscal practices, such as billing, in accordance with departmental policies.
Participation in clinical research for the development and implementation of new techniques in radiation therapy.
Participation in administrative duties when required.
Participates in the educational activities, instruction, training, etc. as required by departmental policies
Provides patients and their care providers with accurate explanations and instructions at an appropriate time and level of understanding.
Practice of infection control per departmental guidelines.
Adherence to high ethical standards in relation to patients, students or trainees and colleagues.

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Appendix 1

Decision Making
In addition to the Scope and Standards of Medical Dosimetry Practice, each QMD must exercise professional and prudent judgment in determining whether the performance of a given act is within the scope of practice for which the QMD is clinically competent to perform. The decision-making model, subsequently described, provides rational and logical guidance to QMDs. When these guidelines are used to analyze whether a QMD may perform a task, the conclusion is reached that this act is or is not within the scope of practice. (1) (See Figure 1)

Decision Making Model for Determining the Scope of Practice of a Qualified Medical Dosimetrist

Describe the act being performed.
Does the act follow the basic parameters of legal practice? (e.g. regulations regarding the handling of radioactive materials)
1. If the answer is NO, the act is not within your scope of practice.
2. If the answer is YES, continue to the next step
Does the act require you to have specialized medical dosimetry knowledge and skill?
1. If the answer is NO, the act is not within your scope of practice.
2. If the answer is YES, continue to the next step
Is the act consistent with the scope of practice based upon at least one of the following factors?
1. The Scope and Standards of Medical Dosimetry Practice.
2. Positive and conclusive data in the medical dosimetry, medical physics, or radiation oncology literature.
Is there an appropriately established policy and procedure of the employing facility?
1. If the answer is NO, the act is not within your scope of practice.
2. If the answer is YES, continue to the next step
Do you personally possess the depth and breadth of knowledge to perform the act safely and effectively as demonstrated by knowledge acquired in an educational or continuing education program?
1. If the answer is NO, the act is not within your scope of practice.
2. If the answer is YES, continue to the next step
Do you personally possess current clinical competence to perform the act safely?
1. If the answer is NO, the act is not within your scope of practice.
2. If the answer is YES, continue to the next step
Is the performance of the act within the accepted “standard of care” which would be provided in similar circumstances by reasonable and prudent medical dosimetrists who have similar training and experience?
1. If the answer is NO, the act is not within your scope of practice.
2. If the answer is YES, continue to the next step
Are you prepared to accept the consequences of your action?
1. If the answer is NO, the act is not within your scope of practice.
2. If the answer is YES, then:
Perform the act - based upon valid order when necessary, and in accordance with appropriately established policies and procedures.
Assume responsibility for your action(s).

Summary of Decision-Making Model

Designated act

scope

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Scope of Practice References
AAMD Task Group - Revised Draft March 2019

Preamble
1. American Association of Medical Dosimetrists. Scope of Practice of a Medical Dosimetrist, 2012.
https://pubs.medicaldosimetry.org/pub/416096BB-F21B-1D03-5673-1987E3E85D0B
Accessed February 7, 2018.

2. American College of Radiology. ACR - ASTRO Practice Parameter Radiation Oncology, Revised 2018 (CSC/BOC)
https://www.acr.org/-/media/ACR/Files/Practice-Parameters/RadOnc.pdf?la=en
Accessed February 7, 2019.

3. American Association of Medical Dosimetrists.
https://www.medicaldosimetry.org/membership/join/
Accessed February 13, 2019.

I. Qualified Medical Dosimetrist
1. American Association of Medical Dosimetrists. Definition of a Qualified Medical Dosimetrist.
https://www.medicaldosimetry.org/about/definition/
Accessed October 16, 2018.

2. American Association of Medical Dosimetrists. Scope of Practice of a Medical Dosimetrist, 2012.
https://pubs.medicaldosimetry.org/pub/416096BB-F21B-1D03-5673-1987E3E85D0B
Accessed February 7, 2018.

II. Professional Competence
1. Epstein, RM, Hundert, EM, Defining and Assessing Professional Competence, Journal of the American Medical Association 2002 January 9; 287(2): 226-235.
https://www.ncbi.nlm.nih.gov/pubmed/11779266
Accessed February 8, 2018.

III. Statement of Basic Responsibility
1. American Association of Medical Dosimetrists. Scope of Practice of a Medical Dosimetrist, 2012.
https://pubs.medicaldosimetry.org/pub/416096BB-F21B-1D03-5673-1987E3E85D0B
Accessed February 7, 2018.

IV. Definitions
1. American Association of Medical Dosimetrists. Scope of Practice of a Medical Dosimetrist, 2012.
https://pubs.medicaldosimetry.org/pub/416096BB-F21B-1D03-5673-1987E3E85D0B
Accessed February 7, 2018.

2. American College of Radiology, ACR-ASTRO Practice Parameter for Radiation Oncology, Revised 2018 (CSC/BOC).
https://www.acr.org/-/media/ACR/Files/Practice-Parameters/RadOnc.pdf?la=en
Accessed February 13, 2019.

3. American Association of Physicists in Medicine. AAPM Professional / Education /Science Policies; Definition of a Qualified Medical Physicist, August 2018.
https://www.aapm.org/org/policies/details.asp?id=449&type=PP
Accessed February 13, 2019.

4. Medical Dosimetrist Certification Board, MDCB Job Task Analysis November 2018
https://mdcb.org/sites/default/files/images/2019/MDCB Summary_ 2018 JTA.pdf
Accessed February 13, 2019.

V. Specifics of Practice
1. American Association of Medical Dosimetrists. Scope of Practice of a Medical Dosimetrist, 2012.
https://pubs.medicaldosimetry.org/pub/416096BB-F21B-1D03-5673-1987E3E85D0B
Accessed February 7, 2018.

2. Medical Dosimetrist Certification Board. Ethical Standards and Ethics Complaint Procedures of the MDCB. Amended August 15, 2011.
https://mdcb.org/about-mdcb/ethical-standards
Accessed February 7, 2018.

VI. Education and Certification
1. American College of Radiology. ACR - ASTRO Practice Parameter for Radiation Oncology, Revised 2018 (CSC/BOC)
https://www.acr.org/-/media/ACR/Files/Practice-Parameters/RadOnc.pdf?la=en
February 13, 2019.

3. American Association of Medical Dosimetrists. Definition of a Qualified Medical Dosimetrist, 2012.
https://www.medicaldosimetry.org/about/definition/
Accessed February 7, 2018.

4. Medical Dosimetrist Certification Board. Applicant Handbook, 2018.
https://mdcb.org/sites/default/files/documents/2018/Exam Handbook_2018.8_FINAL.pdf
Accessed March 5, 2018.

VII. Continuing Education / Maintenance of Certification
1. Medical Dosimetrist Certification Board. Applicant Handbook, 2018.
https://mdcb.org/sites/default/files/documents/2018/Exam Handbook_2018.8_FINAL.pdf
Accessed March 5, 2018.

VIII. Supervision
1. American Association of Medical Dosimetrists. Scope of Practice of a Medical Dosimetrist, 2012.
https://pubs.medicaldosimetry.org/pub/416096BB-F21B-1D03-5673-1987E3E85D0B
Accessed February 7, 2018.

IX. Collaboration and Communication
1. American Association of Physicists in Medicine. Professional / Education/ Science
AAPM medical physics practice guideline 10.a.: Scope of practice for clinical medical physics
https://aapm.onlinelibrary.wiley.com/doi/full/10.1002/acm2.12469
Accessed February 13, 2019.

2. American College of Radiology, ACR-ASTRO Practice Parameter for Communication:
Radiation Oncology, Revised 2014 (CSC/BOC)
https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Communication-RO.pdf?la=en
Accessed February 13, 2019.

3. American Association of Medical Dosimetrists. Scope of Practice of a Medical Dosimetrist, 2012.
https://pubs.medicaldosimetry.org/pub/416096BB-F21B-1D03-5673-1987E3E85D0B
Accessed February 7, 2018.

X. The scope of practice of the Qualified Medical Dosimetrist may include, but is not limited to:
1. American Association of Medical Dosimetrists. Medical Dosimetrists General Job Description, 2011.
https://www.medicaldosimetry.org/about/job-description/
Accessed March 5, 2018.

3.Medical Dosimetrist Certification Board. MDCB Job Task Analysis November 2018.
https://mdcb.org/sites/default/files/images/2019/MDCB Summary_ 2018 JTA.pdf
Accessed February 13, 2019.

Appendix 1
1. American Association of Medical Dosimetrists. Scope of Practice of a Medical Dosimetrist, 2012.
https://pubs.medicaldosimetry.org/pub/416096BB-F21B-1D03-5673-1987E3E85D0B
Accessed February 7, 2018.

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AAMD Scope of Practice Task Group 2018-2019

Daniel Bailey, PhD, DABR
Medical Physicist
Department of Radiation Oncology
Northside Hospital Cancer Center
Atlanta, GA
Committee Member
Member, AAPM Subcommittee on the Training and Practice of Medical Dosimetry
AAPM Liaison to AAMD

Paula A. Berner, BS, CMD, FAAMD
Brachytherapy Dosimetrist
Bellaire, TX
AAMD Task Group Chair

Minsong Cao, PhD, DABR
Clinical Associate Professor
Department of Radiation Oncology
University of California, Los Angeles
Los Angeles, CA
Committee Member
Member, AAPM Subcommittee on the Training and Practice of Medical Dosimetry

Shiv Srivastava, PhD
Medical Physicist
University of Arizona Cancer Center
Dignity Health
St. Joseph’s Hospital and Medical Center
Phoenix, AZ
Committee Member
Member, AAPM Subcommittee on the Training and Practice of Medical Dosimetry

Walter L. Tang, MS
Senior Consulting Medical Physicist
MRPC, Inc.
Minneapolis, MN
Committee Member
Chair, AAPM Subcommittee on the Training and Practice of Medical Dosimetry

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Draft Updated Scope of Practice

Comment Period Ended April 30, 2019

SCOPE OF PRACTICE OF A MEDICAL DOSIMETRIST AAMD Task Group - Revised Draft March 2019

Appendix 1

Scope of Practice References AAMD Task Group - Revised Draft March 2019

AAMD Scope of Practice Task Group 2018-2019

SCOPE OF PRACTICE OF A MEDICAL DOSIMETRIST
AAMD Task Group - Revised Draft March 2019

Scope of Practice References
AAMD Task Group - Revised Draft March 2019