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• W2013670409 abstract "The American Association of Physicists in Medicine (AAPM) advocates licensure of medical physicists in order to assure that only qualified individuals practice the profession. For well over ten years, the AAPM has provided financial, staff, and member support for the establishment of licensure in several states yet, so far, only four states have enacted licensure laws. Consequently, it has been suggested that maybe registration of medical physicists rather than licensure might be a more efficient way of assuring appropriate qualification of medical physicists, at least in some states, and this is the premise debated in this month's Point/Counterpoint. Certification by an appropriate certification board, Scope of practice, Continuing education, Adherence to practice standards, both ethical and behavioral, and Due process for revocation of the credential. A comprehensive regulatory approach to medical physicist credentialing can provide many of the benefits of licensure without the cost and complexity associated with legislating professional licensure. Currently, 30 states have some form of registration of medical physicists.1 Where registration exists, the path is direct with the cooperation of the State Regulatory Authorities. For example, in Colorado, a very direct statement was adopted that specific tasks in radiation therapy shall be performed by a registered medical physicist, where the term “registered” is equivalent to the term “qualified” as used by AAPM and ACMP in the definition of a qualified medical physicist (QMP). This simple approach established acceptable credentials and scope of practice. Regulations can be written to provide audits for QMPs to ensure continued competency, as has been accomplished in Colorado. It can be specified that any decisions to deny or revoke registration are to be performed by a selection of peers. It is already common to require continuing education within a regulatory framework. The path to regulatory changes can be much more direct and less expensive than the legislative approach, depending on the wording of the enabling act. The governing radiation control office is often given broad authority to regulate the use of radiation within the state. This usually includes rules for the training and experience of radiation workers, including medical physicists. Rather than money, the capital required is an excellent working relationship between the regulatory authority and the medical physicists of the state. No lobbyists are required, no time vying for the attention of busy legislators, trying to convince them that medical physicists exist. Instead, regulators and physicists work together toward a common goal. It is also important to remember that a “suggested” national regulatory structure already exists through the Conference of Radiation Control Program Directors (CRCPD) and their suggested state regulations.2 Many states have it in their authorizing legislation that they must adopt the SSRs in whole or with some exceptions. The CRCPD is currently close to adopting language regarding the qualifications of medical physicists; efforts can then move to trying to get the organization to adopt other features as discussed above. In short, almost any line item of a licensure act can be incorporated into a regulatory structure. It is most often less expensive and less difficult to achieve regulatory changes than to establish new legislation and a new recognized license. The AAPM must look at a regulatory approach as an adjunct to achieving the goals of medical physicist licensure. The rather tangled legal status of the clinical practice of medical physics in the United States was highlighted recently by our AAPM President, Dr. Herman, in his remarks before the House Subcommittee on Health when he pointed out that “Medical physicists are licensed in four states (TX, NY, FL, and HI) and regulated at widely varying levels in the other 46 states.”3 The fact that a congressional committee convened a hearing, prompted by a series of articles in The New York Times detailing radiation therapy accidents across the country, means that the discussion in our profession of licensing and regulation is no longer an academic pursuit; there will be consequences, both sooner and later. For that reason we need to clearly understand what licensing is, what it is not, and what alternatives may exist. Stated most broadly, a license is a form of permission granted by some competent authority which awards the holder with the privilege to do some act that is otherwise proscribed by law. Although there are forms of licenses that are private or that involve copyright or patents, we will focus on government licenses in this discussion. Through the grant or denial of a license, a government is able to regulate many different areas of human endeavor. A number of consequences flow immediately from the definition of a license. One way to view a requirement for a license to undertake an activity is that it is in fact the grant of a monopoly to an individual, or a group, in exchange for certain obligations. Stated another way, the holder of a license to practice medicine, for example, can practice medicine as it is defined in the statutes, and no one else can. Governments (local, state, and federal) have seen fit to create this type of restriction particularly in areas thought to pose significant risks to members of the public. Medicine, law, accounting, engineering, and insurance are just a few examples. There is the suggestion that the goal of restricting the practice of medical physics to competent individuals can be more easily achieved by a simple registration process with some well-defined education and training criteria. My objection to this approach is that it is essentially “license-lite” and ultimately fails to achieve the goal of effective regulation of the practice of clinical medical physics. Note that both law and medicine have specific education and training requirements as a part of the licensing (and registration) process. If one did not look any further than the possession of a degree from an accredited school and the appropriate postgraduate training, there is no difference between a law/medical license and “registration.” What is different is that both professions possess specific Codes of Ethics which govern how the professions are practiced, and are enforceable within the membership. Both types of professional licenses similarly have specific legal rights, both statutory and constitutional, that are granted to the license holders to protect them from arbitrary action terminating or suspending their license. A simple registration requirement does not offer that protection. For me, the concept of a formal license is preferable because it fuses the idea of enforceable ethical practice with training and education, and further offers protection from arbitrary adverse action to the holder of that license. Registration might restrict the field to qualified individuals in the sense of training and education, but not much past that. In an ideal world, universal licensure of medical physicists could ensure all of the goals that both my worthy colleague and I agree are important to achieve. We live in a less than an ideal world, however. Four states currently require licensure of medical physicists: New York, Texas, Hawaii, and Florida. Of these four, only Florida requires certification by a nationally recognized board.4 New York does not require certification; licensees must only pass ABR Parts I and II.5 Texas does not require certification at all, just their own exam.6,7 It is the stated policy of the AAPM that a qualified medical physicist is certified by an appropriate certification board.8 Practical and political realities reduce ideal licensure language to something palatable by the given state legislature. My colleague in this discussion has identified one of the most challenging aspects of registration, that of assuring adherence to ethical standards. I cannot argue that this is not difficult to achieve. However, the number of recorded instances of ethical misconduct in those states currently having licensure is small, as is the number of cases that have come before the Ethics Committee of the AAPM. Thankfully, this appears to be the least of our concerns compared to ensuring that qualified individuals are doing the work. Just as licensure cannot ensure complete adoption of our goals, neither can registration. We must recognize that there are some states in which licensure is not practicable. Prime examples reside in the Mountain West. These states are sparsely populated and will never have enough physicists to sustain the expense of a licensure program. Other states are simply not proponents of creating additional professional licensures. What is the answer in such states? Registration allows medical physicists to obtain some of their clinical practice goals, if imperfectly. The AAPM should work to make the registration regulations as strong and comprehensive as possible in parallel with efforts to achieve licensure. There is a very significant flaw in the suggestion that any line item of a licensure act can be incorporated into a regulatory structure. That might be true in principle, but it is not correct in fact. A regulatory agency can only do those things which are within the scope of its grant of authority. This is a fundamental principle of administrative law. Any proposed new regulation needs to withstand not only review by the legislative committees charged with supervision of agencies in the jurisdiction, but also review by the courts. The first place the challenge will focus on is the scope of the original grant when that regulatory body was created. The second challenge faced by any attempt to extend the jurisdiction of a regulatory agency is financial. Who is going to pay for this registration? If the taxpayers foot the bill through agency expenditures, that requires the approval of the legislature and its appropriations committees. If the physicists have to cover that bill, it may be just this side of oppressive in a state such as South Dakota, with fewer than a dozen physicists to pick up the expense. The credentialing requirements offered in my opponent's Opening Statement fit exactly into the definition of a license. It excludes all except a certain class of individuals from doing a particular set of activities backed by a penalty enforced by the state. A license by any other name is still a license." @default.
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• W2013670409 title "Authorization to practice as a medical physicist is sometimes better achieved by registration rather than licensure" @default.
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