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Arguing against the Proposition is Dr. Eric Klein. Dr. Klein is Professor of Radiation Oncology at Washington University, St. Louis, where he has been for 18 years. He has published 64 papers, half as first author. Many publications deal with quality assurance issues. Dr. Klein served as the AAPM's Annual Meeting Scientific Program Director from 1999 to 2001. He is very active in the AAPM and ASTRO, currently serving as Chair of the AAPM's Quality Assurance and Outcome Improvement Subcommittee and Chair of TG-142 (Linear Accelerator Quality Assurance), and he serves on AAPM's Therapy Physics Committee, ASTRO's Physics Committee, and many others. Dr. Klein has been involved with CAMPEP's Residency Review Committee since 1995, and directs the longest standing accredited residency program. Remote high-speed internet access to computers has created the potential for greatly improving the productivity of clinical medical physicists and thereby has the potential of partially mitigating the medical physics shortage in radiation oncology. Software from major treatment planning system (TPS) vendors provides for not only remote treatment planning and review, but also simultaneous multiclient access through secure virtual private networks. The advent of the electronic medical record (EMR) allows for review of patient charts from anywhere in the world. These advances in technology can significantly enhance medical physics productivity. Radiation oncology physicists can be divided into three groups: (1) highly specialized and employed at large institutions; (2) providing consultation for a single task, e.g., commissioning machines or shielding calculations; and (3) “generalists” performing all aspects of clinical medical physics and often serving one or more institutions. Physicists in groups 1 and 2 can perform much more efficiently than those in group 3 who often serve a distributed network of institutions requiring travel time. This third group, which is quite large in the United States, can reap major benefits in efficiency with remote access technology. The need for coverage of several sites is due to the existence of satellites (or free standing centers) of a larger center. These typically treat 30 patients/day or less and are located miles apart. Professional and market forces exert pressure to implement highly technical procedures that are, by nature, physics intensive, while the general workload does not support the need for a full time physicist. A case in point is intensity modulated radiotherapy (IMRT), for which treatment planning and associated QA requires a day or more per case. Remote computer access can afford the necessary physics commitment with significant gains in productivity. The IMRT treatment planning process requires several iterations often separated by long time intervals. Each iteration requires the intervention of the medical physicist. Through remote control of the TPS the physicist can consult with the dosimetrist and/or physician after each iteration and, if need be, personally generate optimized treatment plans while being offsite. Through the use of standard protocols and the assistance of a dosimetrist or technologist onsite, the associated necessary quality assurance can also be performed by the physicist offsite. Data collected from a planar array of dosimeters can subsequently be compared with TPS-generated “planar doses” from the remote location. A secondary monitor unit check can then be performed remotely from segmentation data read from the TPS or the record and verify system. Other tasks such as chart checks using the EMR can also be performed offsite with the same ease and security afforded the TPS. Routine QA as defined in TG-40 (and more recently in TG-100) can also be performed remotely with the assistance of ancillary personnel using written protocols. In addition, hardware/software that can be remotely operated continues to be developed and this will further increase the productivity of the radiation oncology physicist. Our profession is at a critical crossroad. The ABR is about to mandate that in order to sit for the boards a candidate must have successfully completed a CAMPEP accredited Physics Residency Program.1 This will elevate our profession significantly in the eyes of our physician colleagues. The number of Physics Residency programs, especially in Radiation Oncology, is increasing dramatically, with likely 30 accredited programs by the end of 2008. Also, the number of resident candidates continues to remain strong (for our institution's single position for this year, we had 72 applications, most quite strong). The manpower demand will be met, and in the most ideal way, with properly trained physicists. Admittedly, the current demand will not be met overnight, or even within the next 1–2 years. So what do we do in the meantime? At first thought, remote capabilities could facilitate remote treatment planning, but at what penalty. Treatment planning is no longer limited to strategic beam placement/weighting/energy/modification to achieve idealized plans. The treatment planning process now involves image registration, fusion, critical contouring, treatment- and organ at risk-margins, decisions on optimization parameters, beam placement/weighting/energy decisions, creation of images for localization, careful review by physicians, careful review by physicists before data/image/contour transfer, review of the transfers, communication with the therapists, etc. Performing these steps without direct communication among physicists, physicians, dosimetrists, and therapists is not only unproductive, it is also dangerous. This is not easily remedied by telephone or remote PC access. Combining remote planning with periodic visits by consulting physicists only exacerbates the problem. The physicist's role in the modern clinic has changed dramatically. Many anticipated that direct data and image transfer would reduce errors and reduce the need for constant physics availability within the clinic. However, due to incompatibility of systems, the ever-changing versions of hardware, along with the increased role that the physicists must play as trainer and problem solver, physics presence is more important than it has ever been. In addition, today's patients are being treated with monitor units that can be in the thousands for IMRT. Therefore errors can be catastrophic. To ensure that the radiotherapy community acknowledges the importance of the presence of well trained physicists, the last thing our profession wants to do is degrade itself with short-term, short-cut solutions. Though there are very reputable consulting physicists and consulting groups, there are examples of visiting physicists who do not take ownership of occasionally visited clinics. Therefore, other manpower solutions to guarantee patient safety and professional credibility are needed. For example, technical personnel rather than clinical physicists can perform tasks such as IMRT quality assurance. And rather than hiring untrained physicists or no-one at all, physics assistants that provide relevant skill sets, such as engineering and IT professionals, could be hired. In addition, time saving measurement equipment must be purchased by hospitals. In conclusion, remote treatment planning and periodic physics visits may have been appropriate in 1987, or even 1997, but not in 2007. What is implied in my colleague's discussion is that use of remote access is not a proper surrogate for physical presence and compromises quality, and that remote access need not be embraced because new educational programs will alleviate the dearth of qualified physicists. His discussion of education programs seems to evade the discussion of efficiency and quality afforded remote access as it pertains to the shortage of medical physicists, which is paramount to this debate. Explicit counterpoints to Dr Klein's other assertions follow. Dilution of direct communication: Currently, we successfully use conference calling while shadowing a TPS work station with one or more terminals simultaneously and find that it enhances “direct communication” rather than dilutes it. We have also found access to physicians in general is increased, because their physical presence for discussion and consultation is not mandatory. Direct intervention and training: There are indeed times when “incompatibility of systems and changing versions of hardware” warrant direct intervention and training by physicists. However, once a system is functioning, the need for intervention by the physicist is minimized and incidental daily problems can most often be addressed remotely. Training, on the other hand, is most efficient person-to-person and can be scheduled for the next regular visit. Lack of ownership and quality: Well-delineated tasks supplemented with written protocols separate those to be addressed by a physicist from those to be performed by ancillary personnel (see the discussion in my opening statement). Such protocols circumvent any lack of “ownership” and ensure required quality. Treatment planning systems and electronic medical records accessible through a virtual private network offer remote, secure access not only to treatment planning, but also to images, patient diagnoses, and treatment records. To contend that the use of remote access is inappropriate, would fail to embrace the advancements in telecommunications used by a significant proportion of society, and would thus prevent the potential increase in efficiency afforded by remote electronic access to EMR and TPS systems. Undoubtedly, advances in remote high speed internet access can increase productivity by providing the ability to remotely review treatment charts, plans, and quality assurance tests. But this comes at a cost. By not having physicists on-site, the chance of error for patients receiving treatments with exorbitant monitor units and localized by complex and incompatible systems only increases. If the physics community demonstrates to our clinician partners and administrators that we can do the current job with insufficient FTEs, then when the current shortage is over, as will probably be the case in a few years, our profession could be subjected to a surplus by having more physicists than jobs available. Instead we must work to increase the physics FTEs needed for today's IMRT/IGRT clinics. In addition, removal of the dedicated physicists from the process chain of dosimetrist-physicist-physician-physicist-therapist will be severely broken and many processes and procedures will be developed without physics input. In Dr. Zellmer's opening statement, he defines three categories of physicists, namely: a single task physicist, specialized physicist, and roaming specialist. He is missing the fourth and most important category, the physicist who is able to handle most of the tasks either as a solo physicist or as part of a small group dedicated to that facility. As physicists we must ask the question: “Are consulting groups potentially hurting our endeavor to appropriately increase the number of qualified FTE physicists?” This may be a slippery slope since consulting groups often place less than the needed number of FTEs at a facility and, unfortunately, often with undertrained people. Our physics community needs to be patient until properly trained physicists enter the job market. Our profession will then be elevated as we work alongside our physician partners on equal footing and with pride that we take our profession very seriously, demonstrating dedication to our patients.