Doctorate of Medical Physics Handbook in Radiation Oncology Physics

Transcription

1 Doctorate of Medical Physics Handbook in Radiation Oncology Physics Program Director: Niko Papanikolaou, Ph.D. Professor and Chief Phone: Fax: Associate Program Director: Sotirios Stathakis, Ph.D. Associate Professor Phone: Fax: Last updated on 5 April 2017 by P. Candia

2 Contents SECTION 1: GENERAL INFORMATION INTRODUCTION A: Training Facilities in Collaboration with UTHSCSA B: Licensure/Liability/Risk Management C: Educational Objectives D: Resident Supervision Policy E. Reading Requirements : GENERAL ORGANIZATION OF THE RESIDENT STAFF : VACATION AND LEAVE FOR ACADEMIC PURPOSES A: Leave Policy B: Scientific Meetings C: Family Leave/Sick Leave D: Maternity and Paternity Leave E: Workers' Compensation/Holiday : MOONLIGHTING : DRESS CODE : SMOKING : EVALUATION AND ADVANCEMENT : RESIDENTS' BENEFITS INFORMATION A: Parking B: Uniforms C: Identification Cards D: Educational Loan Deferment : RESIDENT GRIEVENCES, DISCIPLINARY POLICY & APPEAL PROCEDURE A: Levels Of Discipline B: Formal Grievance Procedure C: Hearing SECTION 2: EDUCATION Requirements for Successful Program Completion Clinical Rotation 1 Schedule and Objectives Objectives Master Checklist References Introduction to Radiation Oncology Nursing Worksheet (NEW PATIENT) Introduction to Radiation Oncology Nursing Worksheet (ON-TREATMENT PATIENT) Introduction to Radiation Oncology Nursing Worksheet (FOLLOW-UP PATIENT) Introduction to Radiation Oncology LINAC Checklist (Form R.1.A) UTHSCSA-Division of Medical Physics Page 2/93 Resident Handbook

3 Introduction to Radiation Oncology CT SIMULATION (Form R.1.B) Introduction to Radiation Oncology LINAC Engineer Checklist (Form R.1.D) Introduction to Radiation Oncology MU CALCULATIONS Checklist (Form R.1.E) Clinical Rotation 2 Schedule and Objectives Objectives Master Checklist References: In vivo/patient specific dosimetry Checklist (Form R.2.A) Air Chamber and Electrometer Checklist (Form R.2.B) HDR Checklist (Form R.2.C) On Board MV and kv Imaging Checklist (Form R.2.D) IMRT QA Checklist (Form R.2.E) TREATMENT PLANNING Proficiencies (Form R.2.F) CT simulator checklist (Form R.2.G) Treatment Planning Terms 1 (Form R.2.H) Treatment Planning Terms 2 (Form R.2.I) Clinical Rotation 3 Schedule and Objectives Objectives Master Checklist References: ExacTrac (kv) (Form R.3.A) Total Skin Electron Treatment (Form R.3.B) Total Body Radiation Therapy (Form R.3.C) Intensity Modulated Radiation Therapy (IMRT) Planning(Form R.3.D) Annual Linac QA (Form R.3.E) TG-51 Calibration Checklist (Form R.3.F) Informatics (Form R.3.G) Objectives Master Checklist References: Normal Tissue Tolerance Checklist (Form R.4.A) (cont from Rotation 2 and 3) Low Dose Rate (LDR) Brachytherapy Checklist (Form R.4.C) Radiation Protection Checklist (Form R.4.D) Patient Safety (Form R.4.E) Clinical Rotation 5 Schedule and Objectives Objectives Master Checklist References LINAC Design and Function Checklist (Form R.5.A) Treatment plan and patient chart checks (Form R.5.B) Brachytherapy Checklist (Form R.5.C) COMS Eye Plaque Applicator Checklist (Form R.5.D) Clinical Rotation 6 Schedule and Objectives UTHSCSA-Division of Medical Physics Page 3/93 Resident Handbook

4 Objectives Master Checklist References Stereotactic Body Radiation Therapy Checklist (Form R.6.A) Stereotactic Radiosurgery Checklist (Form R.6.B) Stereotactic Radiosurgery Checklist (Form R.6.C) Treatment planning system QA (Form R.6.D) Clinical Rotation 7 Schedule and Objectives Objectives Master Checklist References Imaging List (Form R.7.A) Linac Selection/Acceptance/Commissioning (Form R.7.B) CT simulator Selection/Acceptance/Commissioning (Form R.7.C) Clinical Rotation 8 Schedule and Objectives DESCRIPTION OF EDUCATIONAL EXPERIENCE A: Research Experience B: Facilities C: Work Hours Policy : EDUCATIONAL CONFERENCES : RESIDENT ROOM and LIBRARY ROOM Radiation Oncology New Employee Orientation Checklist : Department Organizational Chart : Oral Exam Evaluation : Evaluation Forms : In-service Presentation Evaluation Course Evaluation Form : Residency Curriculum Evaluation Form Resident Evaluation Form : Residency Mentor Evaluation Form : Medical Conferences Attendance Log Program Evaluation Form Milestones Agreement Form 92 UTHSCSA-Division of Medical Physics Page 4/93 Resident Handbook

5 SECTION 1: GENERAL INFORMATION 1.1 INTRODUCTION Welcome to the Medical Physics Residency Program in the Department of Radiation Oncology at the University of Texas Health Science Center at San Antonio (UTHSCSA). The faculty and staff hope that the time you spend with us will be both educational and enjoyable. This handbook serves as a guide for our medical physics residents and third/fourth year graduate students in the Doctor of Medical Physics (DMP) program. Hereforth, in this document the word resident shall refer to both Medical Physics Residents and DMP students. In addition to clinical assignments, this handbook contains general information which pertains to the policies of the department of radiation oncology at the University of Texas Health Science Center and the Cancer Therapy and Research Center. Residents are responsible for familiarizing themselves with and adhering to the policies and guidelines contained in this manual. Ad hoc additions and clarifications may become available via from the Program Director and are considered policy. Mission Statement: The mission of the Department of Radiation Oncology is to conduct high quality education with state-of-the-art radiotherapy equipment, and cutting-edge basic and clinical research and to provide excellent quality patient care. Our residency program offers education and training for medical physicists to become skillful professionals in the practice of clinical radiation physics. Our Division, the Department of Radiation Oncology and UTHSCSA are committed to serve the needs of the citizens of Texas, the Nation, and the world through clinical, educational and research programs of excellence. 1.1.A: Training Facilities in Collaboration with UTHSCSA The University of Texas Health Science Center at San Antonio (UTHSCSA) is the major source of health professions education and life science research and a major center for patient care in South Texas. UTHSCSA has enjoyed innovative partnerships within the community and has excelled at fostering mutually beneficial, collaborative arrangements with its primary teaching hospitals in San Antonio - the University Hospital and clinics of the University Health System, the Audie L. Murphy Division of the South Texas Veterans Health Care System (VA) and Christus Santa Rosa Hospital and its military partners - Wilford Hall and the Brooke Army Medical Center. The Cancer Therapy and Research Center (CTRC) is part of the UTHSCSA and is the NCI designated cancer center of the University. 1.1.B: Licensure/Liability/Risk Management It is expected that all residents shall obtain a temporary Texas Medical Physics License prior to or during the first rotation of the Radiation Oncology Physics Residency Training Program. It is the responsibility of the physics resident to ensure that the license remains current throughout the two year training program. UTHSCSA practices a no tolerance rule if the license is to lapse during the training period. This may also affect Visa status. UTHSCSA-Division of Medical Physics Page 5/93 Resident Handbook

6 1.1.C: Educational Objectives The objective of a medical physics residency training program is to educate and train medical physicists to a level of competency sufficient for them to become qualified for independent, professional practice in their subfield of medical physics. To accomplish this goal the appropriate facilities, staff, patient mix and educational environment must be provided. The program emphasizes a close personal working relationship between the faculty and the resident as well as the other specialties in our department. Knowledge, skills and other resident characteristics are evaluated and informally addressed by faculty on an on-going basis and formally reported through scheduled evaluations. Residents are expected to participate in research activities during their training. Special effort is made to identify and mentor those who have the interest and talent to pursue careers in academic radiation physics. 1.1.D: Resident Supervision Policy The educational program is designed to provide close supervision of residents' clinical activities by designated faculty. The resident is assigned to a designated faculty for a period of three months. At the end of the assigned period, the resident will be evaluated and will rotate with another faculty until the completion of the twenty-four month program. Regular communication between residents and attending faculty is one of the key factors in quality learning. Any clinical issues must be brought to the attention of the supervising faculty. 1.1.E. Reading Requirements Reading is an essential part of learning in Radiation Oncology Physics. Self-discipline and good study habits are required. All residents should set up a study schedule and adhere to it. 1.2: GENERAL ORGANIZATION OF THE RESIDENT STAFF Annually, a chief resident will be designated by the faculty. The chief resident should guide the junior resident(s) by serving as a role model and mentor. He/she may delegate responsibilities to other residents: CHIEF RESIDENT MAJOR DUTIES: a. Acts as liaison between faculty/residents i. holds meetings with residents as necessary ii. meets regularly with Program Director to discuss areas of concern b. Coordinates medphys resident coverage for the TBI and TSE program c. Coordinates the IMRT patient QA validation assignments d. Attends departmental meetings as the resident representative as directed by the division chief UTHSCSA-Division of Medical Physics Page 6/93 Resident Handbook

7 e. Helps orient new residents, post-doctoral researchers and medical physics graduate students 1.3: VACATION AND LEAVE FOR ACADEMIC PURPOSES The leave policy for the DMP students in the didactic years (years 1 and 2) follows that of the UTHSCSA academic holiday calendar. However, for the DMP students in clinical rotations (years 3 and 4) the leave policy follows the clinical coverage guidelines of the department that the DMP student is assigned. Pursuant to the CAMPEP guidelines for the clinical residency requirements, the DMP students in clinical rotations will have to provide coverage any time the clinics are open. A coverage schedule will be posted ahead of time to provide adequate coverage on those special occasions. 1.3.A: Leave Policy The general policy in the Department of Radiation Oncology is to grant DMP students 12 days per year vacation leave and 3 days per year of Personal leave. This includes actual vacation time and time for attending meetings for scientific purposes. Doctor of Medical Physics students are allowed three additional days a year if they present an abstract at a meeting. As a general rule, only one week of vacation is allowed at any given time, exceptions must be discussed with the respective attending faculty and Program Director well in advance. In general, only one DMP students is allowed to take vacation at a time unless under special circumstances. First preference is given to those who are presenting or attending meetings. All other times are on a first- come, first-serve basis. Additionally, no more than one week of vacation may be taken during any three-month rotation period. Exceptions must be discussed with the assigned faculty and Program Director well in advance. All vacation and meeting time must be arranged at least one month in advance. The faculty of that rotation should sign off on it to indicate their awareness. Actual approval is granted by the Program Director. Manage your time off well, especially during your final year. All time spent at academic meetings, job interviews, house hunting, etc. is taken from the overall 3-week yearly allotment of vacation/meeting time and must be taken in the academic year in which it is accrued; unused time may not be carried forward into the following year. Any DMP student who is absent without leave (AWOL) will be subject to disciplinary action which may include expulsion from the program. Timely communication with the Program Director can avoid disciplinary actions of this magnitude. 1.3.B: Scientific Meetings In general, only one DMP student may be on leave at any time. However, under special circumstances, up to two DMP students may attend meetings with the Program Director s approval. For attending any meeting, priority is given first to those as follows: oral presentations, poster presentations, and senior DMP students who have not attended any and other DMP students. For DMP students presenting at a meeting, an additional three days of leave is allocated per year (also no carry-over). UTHSCSA-Division of Medical Physics Page 7/93 Resident Handbook

8 1.3.C: Family Leave/Sick Leave DMP students are eligible for family leave as outlined in the UTHSCSA family leave policy. Any requests for family leave must be reviewed by the Program Director and the Administration Office. The Administration Office will obtain the appropriate information/forms. A DMP student may request from his/her department family and medical leave for the birth of the DMP student s own child, for the placement of an adopted or foster child with the DMP student, for the DMP student s own serious health condition, or for the serious health condition of the DMP student s parent, spouse, or child. The duration of the family medical leave is governed by UTHSCSA policy. 1.3.D: Maternity and Paternity Leave The DMP student shall be entitled to parental leave without pay for up to twelve (12) weeks after one year of employment in accordance with the Family and Medical Leave Act. The DMP student will be responsible for completing the rotation competencies upon return and complete the 24 month mandatory clinical training. 1.3.E: Workers' Compensation/Holiday Refer to policies outlined in UTHSCSA operating procedures and UTHSCSA Calendar 1.4: MOONLIGHTING In general, the practice of moonlighting is not allowed, but under certain circumstances a waiver can be obtained from the Program Director. If a resident is allowed to moonlight, they have to do so on their personal time. Note: University malpractice insurance will not cover a resident engaged in either locum tenens or moonlighting activities. 1.5: DRESS CODE The overall appearance of personnel in the Department of Radiation Oncology must reflect professional standards and departmental attitude. Professional attire is required at all clinical areas. All members of the staff must have a clean, professional appearance. Men should wear collared shirts, tie, slacks and closed toe shoes. Women should wear blouse/skirt or dress (at least knee length) or Blouse/slacks (ankle length). No sandals, jeans, t- shirts, or shorts are allowed and no open toe shoes in procedure areas. Halters, leotard tops, T- shirts, tube tops, shorts, sweatshirts, sweat pants, and excessive ornamental earrings, necklaces and bracelets are not permitted; simple rings, earrings and necklaces are appropriate. Hair longer than shoulder length must be tied back during direct patient care. Hats, scarves, large colorful hair ornaments and headbands worn around the forehead are not allowed. Head coverings for ethnic, or religious reasons are permitted. Should the attending faculty object to a resident's grooming or clothing, the Program Director will be responsible for counseling that resident. UTHSCSA-Division of Medical Physics Page 8/93 Resident Handbook

9 1.6: SMOKING Smoking is prohibited in any area of the Department, CTRC, VA or UTHSCSA. 1.7: EVALUATION AND ADVANCEMENT Residents in the program will be given graded responsibility under appropriate supervision according to their level of training, ability and experience. A resident's progress during residency training is evaluated formally, in writing, by the resident's attending faculty at the end of their respective rotation. Every effort is made to help residents with any problem during the rotation. The Program Director will discuss as needed residents' performance and progress with residents individually. They will be reviewed with the faculty at least annually at a residency review committee meeting. Yearly advancement within the training program is contingent on evidence of satisfactory professional growth of the resident, including demonstrated ability to assume graded responsibility. Increased responsibilities include assignment of additional specific skill tasks over the course of the residency. The annual reappointment and promotion of a resident is not automatic and requires a demonstration of competence at each educational level. Failure to advance to the next level may result in dismissal from this residency program. If it becomes apparent that a resident is having trouble with a rotation, he/she should make an appointment to discuss the problem with his/her staff and the Program Director. Residents will also be asked to evaluate each faculty member confidentially at the end of rotation and these evaluations will be submitted to the Program Director. 1.8: RESIDENTS' BENEFITS INFORMATION 1.8.A: Parking Parking is under the auspices of the UTHSCSA police department and the residents can purchase a parking tag. This permit is valid on all UTHSCSA campus locations (with the exception of spaces that are numerically marked as reserved). The program coordinator can assist you in obtaining a parking permit. 1.8.B: Uniforms Hospital white laboratory coats are ordered in advance by one of the department administrative assistants. The department provides residents with a standard laboratory coat at the start of their residency. 1.8.C: Identification Cards Residents are required to have UTHSCSA identification cards and wear them at all times when on any UTHSCSA campus sites. The program coordinator will facilitate obtaining the ID cards from the police department. UTHSCSA-Division of Medical Physics Page 9/93 Resident Handbook

10 1.8.D: Educational Loan Deferment For the residents that qualify, loan deferment forms, may be obtained from the department administrator. 1.9: RESIDENT GRIEVENCES, DISCIPLINARY POLICY & APPEAL PROCEDURE This department adheres to the policy established by the Graduate Medical Education Committee. Dismissal or non-renewal of appointment could occur because of failure to comply with the resident s responsibilities or failure to demonstrate progress in acquiring appropriate medical physics knowledge or skill as determined by the program's supervising faculty. This appeals mechanism is open to all residents subject to dismissal or non-renewal. Formal disciplinary action is reportable to credentialing and licensing agencies. 1.9.A: Levels Of Discipline If indicated, the initial level of discipline can be probation or dismissal 1. Informal counseling minor For minor issues, counsel is given, no record is kept (i.e. Dress code adherence). 2. Informal counseling moderate For issues not considered serious enough for defined, disciplinary action, a memo will be placed in a file outside of the resident s record for reference and tracking by the Program Director (Timeliness of assigned clinical tasks (e.g. IMRT QAs, missing conferences, and tardiness). 3. Administrative Status Letter Although not considered formal disciplinary action, the delivery of an administrative status letter should be seen as a strong warning that the resident is on unsteady ground and that the next step is formal disciplinary action. A copy of this letter and any documents related to its resolution are kept in the resident s file for the duration of the residency. This is the last step that is considered non-reportable (considered an informal, intradepartmental matter). The administrative status letter outlines the problem and a plan for remediation and a designated time frame. For the lack of resolution (such as ongoing clinical problems, repeated tardiness), the progression would lead to formal probation. 4. Probation. This is the last opportunity for correction before dismissal. A formal record is kept of the violation, a plan for remediation with measurement criteria and a time frame. Failure to meet the goals and requirements within the prescribed time frame is cause for dismissal. This record is maintained permanently in the residents file. 5. Immediate dismissal It would be unusual to dismiss a resident without a probationary period except in instances of flagrant misconduct. Immediate dismissal would be for conduct beyond that which is not considered professionally acceptable and in any way denigrates or endangers an individual or the reputation of the Department or Institution. Examples include, and are not limited to: being under the influence of intoxicants or drugs; disorderly conduct, harassment of other employees (including sexual harassment), or the use of abusive language on the premises; violation of medical record privacy; fighting, encouraging a fight, or threatening, attempting, or causing injury to another person(s) on the premises. UTHSCSA-Division of Medical Physics Page 10/93 Resident Handbook

11 1.9.B: Formal Grievance Procedure In the event that a resident is to be dismissed or his/her contract is not renewed, he/she may initiate a formal grievance procedure. The resident shall present the grievance in writing to the Department Chair within thirty (30) calendar days after the date of notification of termination or non-renewal. The grievance shall state the facts upon which the grievance is based and requested remedy sought. The Department Chair shall respond to the grievance with a written answer no later than fifteen (15) calendar days after he/she receives it. If the resident is not satisfied with the response, he/she may then submit, within fifteen (15) days of receipt of the Department Chair s response, a written request for a hearing. 1.9C: Hearing The hearing procedure will be coordinated by the Department Chair, who will preside at the hearing, but will not be a voting participant. The hearing will be scheduled within thirty (30) days of the resident's request for a hearing. The hearing panel will consist of at least three (3) members of the faculty. The Department Chair will determine the time and site of the hearing in consultation with the resident and program leadership. The resident shall have a right to self-obtained legal counsel at his/her own expense; however, retained counsel may not actively participate or speak before the hearing participants, nor perform cross-examination. The format of the hearing will include a presentation by a departmental representative; an opportunity for a presentation of equal length by the house officer; an opportunity for response by the representative, followed by a response of equal length by the house officer. This will be followed by a period of questioning by the hearing panel. The Department Chair in consultation with the departmental representatives and the resident will determine the duration of the presentations and the potential attendees at the hearing. The resident will have the right to request documents for presentation at the hearing and the participation of witnesses. The Department Chair at his/her discretion will invite the latter, following consultation with the hearing panel. A final decision will be made by a majority vote of the hearing panel and will be communicated to the resident within ten (10) working days after the hearing. This process will represent the final appeal within the Health Science Center. UTHSCSA-Division of Medical Physics Page 11/93 Resident Handbook

12 SECTION 2: EDUCATION Requirements for Successful Program Completion The UTHSCSA Medical Physics Residency is a two-year program. To complete the Residency Program, the resident must: 1. Successfully complete all eight clinical rotations as defined in the Clinical Rotation Schedule and Objectives (CRSO) (see rotations in following section). The rotation schedule has been structured to include all clinical topics in radiation oncology physics. For each rotation, the resident is assigned a mentor from the physics staff and performs clinical tasks under the mentor s direct supervision. A rotation is considered complete when all rotation assessments have been signed off by the mentor and resident. Failure to complete a rotation or unsatisfactory progress in a rotation will be reviewed by the residency committee. The resident will be notified in writing of their probationary status and will be given a plan for remediation. The resident will have one month to complete the remediation plan. Failure to complete the remediation plan will be grounds for termination. 2. Successfully complete the didactic courses on Treatment Planning Techniques (RADI 7005 and RADI 7006) and the AAPM task group review courses (RADI 6031 and RADI 6035). The courses are offered during the fall and spring semester of each academic year. Passing grade is considered to be a grade of B or higher. The program director can issue a course waiver upon request by the resident, provided the resident can prove that they have taken the equivalent course at another institution. If a resident does not obtain a passing grade for any of the courses, they will be presented with a plan for remediation. 3. The Medical Physics resident must complete a learning module on ethics and professionalism as specified in AAPM Report 159. The resident is expected to complete the ABR/ACR/RSNA/AAPM/ASTRO/ARR/ARS, Online Module on Ethics and Professionalism anytime during the rotation one of residency program. ( 4. Secure a passing grade for twenty one (21) monthly written exams on the assigned topics that will be covered during each rotation (see table 3). Each exam is two hours long, and has up to 50 multiple choice questions. Passing grade is considered to be a score above 70%. In case of a failing exam grade, a second exam will be given within 7 days. After a second failed attempt, the resident will be given a plan for remediation that has to be completed before the next examination. 5. Complete a comprehensive oral examination every 6 months. The topics of all oral examinations are listed below. See Table 4 for the specific topics of each exam. Oral examinations are considered complete when the oral evaluation form has been signed by the appropriate faculty mentor and student. A blank oral evaluation form is included in the Appendix. The resident will be given feedback on their performance and it is possible that the examining committee will ask the resident to be prepared to answer question on the same topics (in addition to the new ones) for the next oral examination. A minimum of two faculty members must be present during the examination or else the examination will be rescheduled. 6. Attend the new patient QA conference and didactic lectures that are given by the faculty. The expectation is that the residents will make a best effort to attend 50 of such conferences and will document in their portofolio log a minimum of 50 attendances for the duration of the residency. The UTHSCSA-Division of Medical Physics Page 12/93 Resident Handbook

13 attendance log will be reviewed at the end of each rotation and a remediation plan will be presented if the resident has not attended the required number of conferences. 7. Residents are required to teach a minimum of two lectures per year in one of our degree programs (medical physics program, medical dosimetry program) or the medical residents physics course. An evaluation will be completed for each lecture. 8. Complete twenty-four months of clinical training at which time a certificate of training will be awarded to the resident. 9. Milestones Agreement Form Table 1. Monthly Exam topics August Written Exam 1 Radiation Safety, Patient CT Simulation September Written Exam 2 MU Calculations October Written Exam 3 Periodic Linac QA November Written Exam 4 Dosimeters, IMRT QA December Written Exam 5 OBI MV and kv Imaging January Written Exam 6 CT Sim QA, HDR Daily QA February Written Exam 7 TSET, TBI March Written Exam 8 Annual Linac QA, ExacTrac April Written Exam 9 TG 51 May Written Exam 10 Patient Safety, Tissue Dose Tolerance June Written Exam 11 LDR planning for Prostate Seed Implants July Written Exam 12 Radiation Protection August Written Exam 13 Linac Design September Written Exam 14 Chart Checks October Written Exam 15 Brachytherapy November Written Exam 16 SBRT/SRS delivery and Planning, Narrow Field Dosimetry December Written Exam 17 Treatment Planning System QA January Written Exam 18 Imaging in Radiation Therapy February Written Exam 19 Acceptance and Commissioning of Linac March Written Exam 20 Acceptance and Commissioning of CT Simulator May Written Exam 21 Comprehensive UTHSCSA-Division of Medical Physics Page 13/93 Resident Handbook

14 Table 2. Summary of oral and written exams Rotation Month Oral Exam topics 1. Simulation and patient setup 1 2. Monitor Unit Calculations 3. In-vivo and patient specific dosimetry 4. Dosimeters 2 5. AAPM Task Group-51 Calibration AAPM Task Group 142 QA kv and MV other position verification technologies and QA AAPM Task Group 25, Electrons Treatment Planning Total Body Irradiation (TBI) and Total Skin Electrons (TSE) 13. HDR/LDR LINAC design and function Shielding Design and Accepted Dose Limits Normal tissue tolerance and dose response models 17. Eye plaques 18. Pregnant patients/pacemakers/hip Replacements Stereotactic Radiosurgery (AAPM TG 101) 22. Comprehensive UTHSCSA-Division of Medical Physics Page 14/93 Resident Handbook

15 Clinical Rotation 1 Schedule and Objectives Chief Mentor: (Year 1, July-Sept) Objectives Master Checklist Activity Employee Orientation Radiation Oncology Orientation HIPAA Training Introduction to Radiation Protection. Introduction to Nursing. Introduction to Simulation. Introduction to LINACs. LINAC QA and warm up. Monitor Unit Calculations. Electronic Medical Record orientation. Regulations, Professionalism and Ethics References i. AAPM's "The Roles, Responsibilities, and Status of the Clinical Medical Physicist ii. AAPM Report No. 38, "Statement on the Role of a Physicist in Radiation Oncology" iii. AAPM Report No. 79, "Academic Program Requirements for Graduate Degrees in Medical Physics iv. AAPM Report No. 90, "Essentials and Guidelines for Hospital-Based Medical Physics Residency Training Programs" v. Comprehensive QA for Radiation Oncology (Reprinted from Medical Physics, Vol. 21, Issue 4) (1994) Radiation Therapy Committee Task Group #40 vi. Task Group 142 report: Quality assurance of medical accelerators Medical Physics, Vol 36, Issue 9 vii. AAPM Code of Practice for Radiotherapy Accelerators (Reprinted from Medical Physics, Vol. 21, Issue 7) (1994) Radiation Therapy Task Group #45 viii. Medical Accelerator Safety Considerations (Reprinted from Medical Physics, Vol. 20, Issue 4) (1993) Radiation Therapy Committee Task Group #35. ix. Title 25 Texas Administrative Code, Part 1, Department of State Health Services, Chapter 289: Radiation Control, Subchapters C-F x. Texas Department of State Health Services, Texas Health & Safety Code; Subtitle D. Nuclear and Radioactive Materials; Chapter 401. Radioactive Materials and Other Sources of Radiation. xi. Requirements of the Texas Board of Licensure for Professional Medical Physicists xii. Nuclear Regulatory Committee regulations 10 CFR 19, 10 CFR 20, and10 CFR 35. xiii. NCRP Reports 151, 79, 116, and 147 xiv. NRC Regulatory Guide 8.13, "Instructions Concerning Prenatal Radiation Exposure" xv. NRC Regulatory Guide 8.39, "Release of Patients Administered Radioactive Material" xvi. Khan, The Physics of Radiation Therapy 4 th Edition. xvii. Verification of monitor unit calculations for non-imrt clinical radiotherapy: Report of AAPM Task Group 114 Medical Physics, Vol 38, Issue 1 xviii. ESTRO booklet #3 Monitor unit calculation for high energy photon beams, 1997

16 Introduction to Radiation Oncology Nursing Worksheet (NEW PATIENT) Observe and assist in at least three new patient exams from three different services. Identify the patient s name, diagnosis, stage of disease, and treatment techniques to be used. Note the anatomical structures of interest. New Patient Exam 1. Patient s initials: 2. Diagnosis: 3. Stage of disease: 4. Describe treatment to date and the proposed treatment technique: Faculty/staff: Date Resident: Date Comments: UTHSCSA-Division of Medical Physics Page 16/93 Resident Handbook

17 Introduction to Radiation Oncology Nursing Worksheet (ON-TREATMENT PATIENT) Observe and assist in at least three on-treatment patient exams from three different services. Identify the patient s name, diagnosis, stage of disease, treatment technique, number of treatments received, cumulative dose, and reactions noted. Current Patient Exam 1. Patient s initials: 2. Diagnosis: 3. Stage of disease: 4. Describe treatment to date and the proposed treatment technique: 5. Number of treatments and dose received to date: 6. Description of reaction (tumor response and/or normal tissue) Faculty/staff: Date Resident: Date Comments: UTHSCSA-Division of Medical Physics Page 17/93 Resident Handbook

18 Introduction to Radiation Oncology Nursing Worksheet (FOLLOW-UP PATIENT) Observe and assist in three follow-up patient exams from three different services. Identify the patient s name, diagnosis, stage of disease, treatment technique and current status of patient s health. Follow-up Exam 1. Patient s initials: 2. Diagnosis: 3. Stage of disease: 4. Describe treatment technique and area(s) treated: 5. Total dose received: 6. Discuss the current status of patient s health and any past and/or present side effects due to treatment: Faculty/staff: Date Resident: Date Comments: UTHSCSA-Division of Medical Physics Page 18/93 Resident Handbook

19 Introduction to Radiation Oncology LINAC Checklist (Form R.1.A) Competency Demonstrate an understanding of the warm-up of treatment units. Demonstrate an understanding of pre-treatment chart checks Demonstrate an understanding of pre-port procedures Demonstrate an understanding of checking of MLC blocked fields Demonstrate an understanding of port film acquisition, analysis and approval Demonstrate an understanding of the pertinent recommendations for quality assurance of linear accelerators used in radiation therapy; Demonstrate an understanding of in-house quality assurance documentation and procedures; Perform and be competent in routine (daily/weekly/monthly) quality assurance tests of external beam treatment units; Perform and be competent in the analysis of routine quality assurance tests of external beam treatment units; Demonstrate an understanding of the basis of accepted tolerances for routine quality assurance tests performed on treatment units and required actions should any of the checks fall out of tolerance; Demonstrate an understanding of the operation of the linac and the interlock codes; Perform and be competent in end-to-end checks of patient treatment plans using phantom images and data; Demonstrate an understanding of MOSAIQ / 4D Console Demonstrate an understanding of grouping/auto sequencing of fields and remote movement of gantry and collimator. Observe/assist in the treatment of TBI patient (when available) Observe/assist in the treatment of a Total Skin Electron patient(when available) Observe/assist in acquisition of TLD/OSL readings (when available) Faculty: Date Resident: Date Resident Initials Mentor Initials** Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 19/93 Resident Handbook

20 Introduction to Radiation Oncology CT SIMULATION (Form R.1.B) Competencies Demonstrate an understanding of morning warm-up and QA of equipment Demonstrate an understanding of positioning of the patient for simulation Demonstrate an understanding of placement of BB s or other radiographic markers Demonstrate an understanding of in the selection of an isocenter and the transfer of the isocenter to the treatment planning system Demonstrate an understanding of what treatment information needs to be recorded in the patient s chart during simulation Demonstrate an understanding on how CT scans are transferred to the treatment planning computers Review the differences of CT simulators versus diagnostic CT scanners (e.g. lasers, table top and indexing, localization software, bore size); Demonstrate an understanding of the theory of CT image reconstruction and operation of a CT simulator; Demonstrate an understanding of the major subsystems and components of a CT simulator; Demonstrate an understanding of the room shielding and other radiation protection requirements of a CT-simulator. Understand the reasons for using contrast in imaging Resident Initials Mentor Initials** Faculty/staff: Resident: Date Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 20/93 Resident Handbook

21 Intro to Radiation Oncology-RADIATION PROTECTION CHECKLIST (Form R.1.C) Activity Participate in receipt, assay, inventory and disposal of radioactive material, such as 32 P and 131 I. The resident shall accompany a radiation safety technician three mornings during the receipt of radioactive material by the Radiation Safety Office. Participate in survey meter calibration Demonstrate an understanding of the operation/limitations of a hand-held survey meter Demonstrate an understanding of DOT regulations for transport and labeling or radioactive material by attending Radioactive Materials Certification Course Demonstrate an understanding of the room preparation for 131 I and 32 P patients Demonstrate an understanding of regulations for labeling rooms containing radioactive sources: radiation area, high radiation area, very high radiation area Demonstrate an understanding of function/limitations of a personnel monitoring badge Demonstrate an understanding of concepts of: time, distance and shielding Demonstrate an understanding of definitions for: dose equivalent, effective dose equivalent, deep dose equivalent, committed dose equivalent, quality factors, organ dose weighting factors, planned special exposure, declared pregnant worker, occupational dose Demonstrate an understanding of Nuclear Regulatory Commission (NRC) and/or state licensing (by-product materials and x-ray producing devices); Demonstrate an understanding of the appropriate regulations for radiation protection and dose limits for radiation workers and members of the general public; Explain the ALARA (As low as reasonably achievable) concept; Discuss the role and significance of the Joint Commission; Discuss the role and responsibility of a radiation safety committee; Discuss the role and responsibility of a radiation safety officer; Discuss the significance of ACR, ASTRO, and AAPM recommendations; Demonstrate an understanding of release of patients (with sealed or unsealed sources). Resident Initials Mentor Initials** UTHSCSA-Division of Medical Physics Page 21/93 Resident Handbook

22 Activity Demoinstrate and understanding of the following concepts: Failure mode effects analysis (FMEA) principles/applications Root cause analysis (RCA) principles/applications Sealed source storage/safety/protection Sealed source inventory/check in/out procedures Sealed source packaging/transportation (e.g. Title 19 CFR) Calibration of sealed sources Exposure and contamination surveys Radiation signage Definition and reporting requirements for medical events Radiation safety of personnel during radionuclide therapy Patient release criteria following radionuclide therapy and radiation safety for the public Safety policies/procedures Compliance audits Occupational and public dose limits National and state regulations Radiation exposure to the public Site design and shielding (primary and secondary barrier computations) Neutron shielding Facility radiation surveys Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 22/93 Resident Handbook

23 Introduction to Radiation Oncology LINAC Engineer Checklist (Form R.1.D) Activity Observe/participate in the daily start-up of each of the treatment units with a service engineer. Prints detailed operating parameters of the LINAC and understand the use of this data. Observe/participate in the daily shut-down of each of the treatment units with a service engineer. Record machine logs and understand the use of this data. Be able to identify and explain the function of linac mechanical components and geometry Be able to identify and explain the general clinical fault indicators, causes and reset levels Demonstrate understanding of laser alignment geometry and verification Demonstrate understanding of tomographic geometry and laser systems for the CTs. Observe and assist in a linac MLC motor change. Observe and participate in a linac MLC PM Observe and participate in a single modality (low energy) gantry PM Observe and participate in a multimodality (high energy) collimator PM Observe and participate in a linac digital readout calibration Observe and participate in linac beam tuning Demonstrate understanding of linac anatomy Demonstrate understanding of machine ionization systems and selfcalibration Demonstrate understanding of tolerances and what to do if they are exceeded. Observe/understand operation of linac oscilloscope signals Observe/understand OBI preventive maintenance Resident Initials Mentor Initials** Faculty/Staff: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 23/93 Resident Handbook

24 Introduction to Radiation Oncology MU CALCULATIONS Checklist (Form R.1.E) Competency 1) Demonstrate an understanding of the following factors: a. Percent depth dose (PDD) b. Tissue-air ratio (TAR) c. Tissue-maximum ratio (TMR) d. Tissue-phantom ratio (TPR) e. Scatter factors (Sc, Sp, Scp) f. Off-axis factors g. Inverse square factors h. Calibration factor (MU reference conditions) i. Standard wedge factors j. Virtual and dynamic wedge factors k. Compensator factors l. Tray and other insert factors 2) Perform MU calculations for photon and/or electron beams with the following configurations: a. SSD setup b. SAD setup c. Extended distance setup d. Off-axis calculation points e. Rotational beams Demonstrate an understanding and perform MU calculations using heterogeneity corrections; Faculty: Date Resident: Date Resident Initials Mentor Initials** Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 24/93 Resident Handbook

25 Clinical Rotation 2 Schedule and Objectives Chief Mentor: (Year 1, Oct-Dec) Objectives Master Checklist Activity Monthly LINAC QA. IMRT QA. EPID QA. QA of the HDR unit. CT Simulator QA. LDR brachytherapy. 2D/3D External Beam Planning (RADI7005). In vivo/patient specific dosimetry and Dosimetry References: i. Protocol for Clinical Dosimetry of High-Energy Photon and Electron Beams ( Reprinted from Medical Physics, Vol. 26, Issue 9) (1999) Radiation Therapy Committee Task Group #51 ii. A protocol for the determination of absorbed dose from high energy photon and electron beams. (Reprinted in Medical Physics, Vol. 10, Issue 6, 1983). Radiation Therapy Committee Task Group #21 iii. ICRU 50, Prescribing, recording, and reporting photon beam therapy. iv. ICRU 62, Supplement to ICRU 50 v. Pinnacle manuals as needed. vi. Diode In Vivo Dosimetry for Patients Receiving External Beam Radiation Therapy. AAPM report #87 (2005). Radiation Therapy Committee Task Group #62. vii. viii. ix. Introduction to Radiological Physics and Radiation Dosimetry. F.H. Attix, (Good for TLD) The Essential Physics of Medical Imaging. Second Edition. Bushberg (Good for film). Clinical electron beam dosimetry. Med Phys, Vol. 18, Issue 1, (1991). Radiation Therapy Committee Task Group #25. (good summary of electron detectors) x. Khan, The Physics of Radiation Therapy 4th Edition. xi. Halvorsen PH. Dosimetric evaluation of a new design MOSFET in vivo dosimeter. Med Phys 32, (2005). xii. Dosimetry of Interstitial Brachytherapy Sources. Report of AAPM Radiation Therapy Committee Task Group 43. Reprinted from Medical Physics, Vol. 22, Issue 2, xiii. Update of AAPM Task Group No. 43 Report: A revised AAPM protocol for brachytherapy dose calculations. Medical Physics, Vol. 21, Issue 3, xiv. Permanent Prostate Seed Implant Brachytherapy. Report of AAPM Radiation Therapy Committee Task Group 64. Reprinted from Medical Physics, Vol. 26, Issue 10. xv. Report of TG142 (Quality Assurance of Medical Accelerators) Med. Phys. Volume 36, Issue 9, pp , September xvi. The Calibration and Use of Plane-Parallel Ionization Chambers for Dosimetry of Electron Beams (Reprinted from Medical Physics, Vol. 21, Issue 8) TG#39 xvii. Radiochromic Film Dosimetry (Reprinted from Medical Physics, Vol. 25, Issue 11) Radiation Therapy Committee Task Group #55 xviii. Clinical use of electronic portal imaging (Reprinted from Medical Physics, Vol. 28, Issue 5) Radiation Therapy Committee Task Group #58 xix. Quality assurance for image-guided radiation therapy utilizing CT-based technologies: A report of the AAPM TG-179 Medical Physics, Vol 39, Issue 4 xx. The Role of In-Room kv X-Ray Imaging for Patient Setup and Target Localization: Report of AAPM Task Group 104 xxi. Radiation Therapy Committee Task Group #58, Clinical use of electronic portal imaging (Reprinted from Medical Physics, Vol. 28, Issue 5) xxii. Radiotherapy Portal Imaging Quality Radiation Therapy Committee Task Group #28 xxiii. xxiv. Khan. treatment Planning in Radiation Oncology. IMRT commissioning: Multiple institution planning and dosimetry comparisons, a report from AAPM UTHSCSA-Division of Medical Physics Page 25/93 Resident Handbook

26 Task Group 119 Medical Physics, Vol 36, Issue 11 xxv. Emami, B. et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys May 15;21(1): xxvi. Lyman, JT. Complication probability as assessed from dose-volume histograms. Radiat. Res. 104:S-13 S-19; xxvii. Kutcher GJ and Burman C. Calculation of complication probability factors for nonuniform normal tissue irradiation: the effective volume method. Int J Radiat Oncol Biol Phys. 104: ; xxviii. Kutcher G J, Burman C, Brewster L, Goitein M, Mohan R. Histogram reduction method for calculating complication probabilities for three-dimensional treatment planning evaluations. Int J Radiat Oncol Biol Phys. 21: ; UTHSCSA-Division of Medical Physics Page 26/93 Resident Handbook

27 In vivo/patient specific dosimetry Checklist (Form R.2.A) Competency TLD 1) Demonstrate an understanding of the physical mechanisms involved in the process of radiation detection and readout using thermoluminescent dosimeters, including Randall-Wilkins theory, intrinsic sensitivity, linearity, energy dependence, chemical composition, physical forms, and TLD reader design and operation; 2) If possible, perform TLD measurements and readout including calibration using standard irradiation; 3) Demonstrate understanding of the method and rationale for TLD annealing; 4) Discuss the advantages and disadvantages of TLDs including their limitations of use. Diodes 1) Demonstrate an understanding of the physical mechanisms involved in the process of radiation detection and readout using semiconductor dosimeters; 2) If possible, perform diode measurements including investigation of angular and dose rate dependence, temperature sensitivity, etc.; 3) Discuss the advantages and disadvantages of diodes, including the inherent limitations of diodes. Film (silver bromide, radiochromic) 1) Demonstrate an understanding of the physical mechanisms involved in the process of radiation detection and measurement using film, including measurement of the optical density and its characteristics as a function of absorbed dose, and dependence on radiation energy and on film handling and processor conditions; 2) If possible, perform film dosimetry including creation of calibration curve; 3) Discuss the advantages and disadvantages of using film, including the inherent limitations of film. MOSFET detectors 1) Demonstrate understanding of the physical mechanisms involved in the process of radiation detection and readout using Metal Oxide Semiconductor Field Effect Transistor dosimeters; 2) Discuss the advantages and disadvantages of using MOSFETs, including their limitations of use. OSLD 1) Demonstrate an understanding of the physical mechanisms involved in the process of radiation detection and readout using optically stimulated luminescent dosimeters; 2) Discuss the advantages and disadvantages of using OSLDs, including their limitations of use. 3) Demonstrate an understanding of the following components of an in vivo dosimetry program. a. Acceptance, commissioning, calibration, and ongoing quality assurance procedures for in vivo dosimetry systems; b. Use of in vivo dosimetry systems for patient specific measurement; c. Limitations of specific in vivo dosimetry systems. Faculty: Date Resident: Date Resident Initials Mentor Initials** Comments: UTHSCSA-Division of Medical Physics Page 27/93 Resident Handbook

28 **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic Air Chamber and Electrometer Checklist (Form R.2.B) Competency Demonstrate an understanding of absorbed dose calculation and measurement; Demonstrate an understanding of Bragg-Gray, Spencer-Attix, and Burlin cavity theories; Demonstrate an understanding of dosimeter design considerations including detection mechanism, sensitivity, size, shape, thickness of sensitive volume and wall, materials, energy dependence, detector/phantom media matching, dose and dose rate range, stability of reading. Demonstrate an understanding of design considerations for cylindrical ionization chambers including size, shape, materials, electrical characteristics, etc.; Demonstrate an understanding of design considerations for parallel-plate ionization chambers including size, shape, materials, electrical characteristics, use for measuring dose in the buildup region, etc.; Demonstrate an understanding of advantages and disadvantages of each ionization chamber design, including detector limitations; Demonstrate an understanding of ionization chamber measurement techniques including electrometer, operational amplifiers, triaxial cable and connections, etc.; Perform acceptance testing for ionization chamber and electrometer including measurements of leakage and evaluation of relevance, polarity effects, and stem effects; Perform ionization chamber measurements using Farmer, parallel-plate, scanning chambers, and large volume survey ionization chambers; Demonstrate understanding of ion chamber correction factors including PTP, Ppol, Pelec, Pion, Pwall, Pgrad, Pfl, and Pcel. Calculate corrected charge reading for ion chamber measurement using TG-51 formalism; Demonstrate an understanding of ion chamber calibration process through NIST/ADCL; Demonstrate an understanding of design and characteristics of monitor chambers. Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 28/93 Resident Handbook

29 HDR Checklist (Form R.2.C) Competency Demonstrate an understanding of HDR morning QA procedures, tests performed, level of accuracy required Demonstrate an understanding and performance of comprehensive periodic QA (daily, monthly, annually) of remote afterloader ; Discuss and perform periodic treatment planning QA; Demonstrate an understanding of implant specific QA. Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 29/93 Resident Handbook

30 On Board MV and kv Imaging Checklist (Form R.2.D) On Board imaging (MV and kv) Discuss the different detector technologies that have been used for on-board MV and kv imaging; Discuss the imaging dose associated with on-board MV and kv imaging technologies; Discuss the different measures of radiographic image quality. Demonstrate an understanding of the quality assurance processes and frequencies for on-board MV and kv imaging, including cone-beam CT (e.g., image quality, image integrity, safety and mechanical checks, network connectivity, imaging dose, and localization software, and isocenter calibration). General Demonstrate an understanding of the basic imaging principles behind CT; Define the 4 generations of CT imaging systems; Demonstrate an understanding of the detector technology, e.g., scintillation detectors, xenon gas chamber; Demonstrate an understanding of the basic principle of reconstruction algorithms (i.e. filtered back-projection); Demonstrate an understanding of image artifacts that may arise in CT images and be able to identify their causes; Discuss how to perform density calibration of a CT scanner, and how this calibration is used for tissue density corrections in treatment planning systems; Discuss the differences between a free breathing helical CT and 4D-CT; Discuss the differences between prospective versus retrospective image acquisitions, and cine versus helical scanning techniques; Discuss the imaging dose associated with various CT protocols; Discuss how 4D data is used for target definition and describe MIPs, averaged, maximum inhale and exhale scans. Quality Assurance Demonstrate an understanding of the quality assurance processes and frequencies for CT-simulators (e.g., image quality, image integrity, safety and mechanical checks, network connectivity, imaging dose, localization software, and CT#). Image Registration/Fusion Discuss the motivation as well as the advantages/challenges of image registration and image fusion; Define the image features on which registration can be based (i.e. landmarks, segments, intensities); Define the different forms of registration (i.e. rigid, affine, deformable), and discuss their advantages/limitations; Define similarity metrics used to assess quality of registration (i.e. squared intensity differences, cross-correlation, mutual information); Resident Initials Mentor Initials** UTHSCSA-Division of Medical Physics Page 30/93 Resident Handbook

31 Discuss how to commission imaging modalities such as MRI, PET-CT, and diagnostic CT for the purpose of image registration to a radiation oncology planning CT; Discuss issues associated with the transfer of images (i.e. connectivity and image dataset integrity); Discuss issues associated with patient positioning (i.e. bore size, couch-top, lasers, compatibility of immobilization devices, differences in patient position/organ filling and motion). Discuss issues associated with image acquisition technique (i.e. length of scan, slice thickness, FOV, kv and mas). Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 31/93 Resident Handbook

32 IMRT QA Checklist (Form R.2.E) Competency Demonstrate an understanding of commonly used QA procedures and guidelines, delivery and dosimetry equipment, and QA analysis techniques; Demonstrate an understanding of verification plans creation within the treatment planning system along with independent checks with secondary MU calculation software; Demonstrate an understanding of IMRT delivery QA measurements using 2D/3D array, film, and/or ion chamber techniques, including analysis of these results and determination of passing criteria (including familiarity with the concept of gamma analysis); Demonstrate an understanding of acquisition and analysis of MLC QA measurements designed for accelerators used for IMRT; Perform review of individual patient-specific QA results with staff physicists and physicians. Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 32/93 Resident Handbook

33 TREATMENT PLANNING Proficiencies (Form R.2.F) Competency Register a new patient and import imaging studies, Be able to export a treatment plan and import to MOSAIQ Be familiar with IMRT concepts and have a basic idea of IMRT planning. Review the Pinnacle Physics manual and become familiar with the commissioning data requirements and beam modeling. Beam Properties Demonstrate an understanding of photon and electron percent depth dose in tissue and other media; Demonstrate an understanding of electron ranges (Rp, R80, R90, and dmax) for different energies; Demonstrate an understanding of proton percent depth dose in tissue and other media and proton ranges for different energies (e.g. stopping and scattering power and range); Demonstrate an understanding of the potential uncertainties in dose deposition in proton radiotherapy; Demonstrate an understanding of flatness and symmetry of photon and electron beams; Demonstrate an understanding of the differences between an SAD and SSD treatment. Compare electron and photon therapy, their advantages and disadvantages; Discuss the impact of dose and fractionation on normal and tumor tissues; Demonstrate an understanding of the impact of beam quality (e.g. LET) on the RBE of different forms of ionizing radiation (e.g. electrons, photons, and protons); Discuss the uncertainties related to electron and photon therapy (e.g. physics, biology, machine, and patient related) and how they may be detected and mitigated during the planning and delivery process. Beam Modifiers Demonstrate an understanding of the effect of beam modifiers (wedges, compensators, etc.) on the dosimetric characteristics of the incident beam; Demonstrate an understanding of wedges (wedge angle, hinge angle), and the different style wedges clinically utilized (physical, universal, dynamic); Demonstrate an understanding of the design of the different commercially available MLCs; Demonstrate an understanding of blocking and shielding for therapy beams; Demonstrate an understanding for the use of custom bolus; Demonstrate an understanding of the design and use of tissue compensators; Resident Initials Mentor Initials** UTHSCSA-Division of Medical Physics Page 33/93 Resident Handbook

34 Treatment simulation techniques Demonstrate an understanding of common patient positioning and immobilization devices; Demonstrate an understanding of when and how to use specific treatment devices for specific treatments; Discuss how to account for beam attenuation from patient positioning and immobilization devices in treatment planning. Tumor localization and normal tissue anatomical contouring: Perform region of interest contouring on CT data sets; Perform region of interest contouring on MRI data sets; Perform region of interest contouring on PET and PET/CT data sets; Perform region of interest contouring on SPECT and SPECT/CT data sets; Demonstrate an understanding of target volume determination, including the design of ICRU target structures (e.g. GTV, CTV, ITV, PTV, and PRV). Demonstrate an understanding of how 4D data is used for target definition and relevant radiation treatment prescription parameter such as GTV, PTV, CTV and ITV; Demonstrate an understanding of the role of MIP images in the treatment planning process; Demonstrate an understanding of the role of DRR images in the treatment planning process; Demonstrate an understanding of and perform image registration and fusion of data sets, including CT/CT, CT/MRI, CT/PET, deformable registration, and image/dose registration. Plan evaluation Define and discuss each of the following treating planning evaluation tools, including their limitations: Dose volume histograms (V(dose), D(volume), mean dose) (cumulative and differential) Conformity index Homogeneity index Biological evaluators (e.g. geud, EUD, NTCP, TCP) Discuss dose tolerances for various normal tissue structures along with relevant volume effects Faculty: Date Resident: Date Comments: *A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a UTHSCSA-Division of Medical Physics Page 34/93 Resident Handbook

35 Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 35/93 Resident Handbook

36 CT simulator checklist (Form R.2.G) Quality assurance Competency Perform and be competent in routine quality assurance test processes for CTsimulators and understand their relationship to acceptance testing and commissioning measurements; Understand the basis of recommended measurements and their tolerances specified by the AAPM, ACR and other professional bodies for CT-simulators; Understand, perform and be competent in determining the geometric accuracy of laser alignment, couch motion, gantry motion, and CT-simulator images for both static and moving objects; Understand, perform and be competent in assessing image quality for CTsimulators in any mode of operation and image reconstruction. Be able to discuss the impact of image artifacts and distortion on treatment planning; Understand the connectivity requirements of a CT-simulator to other computer systems that form part of a modern radiation therapy treatment process as well as be familiar with the internet and DICOM RT image data transfer protocols. CT protocols Demonstrate an understanding of the following parameters, their typical values, and how these parameters are combined in CT protocols: slice thickness, pitch, kv, mas, FOV, and scan length; Demonstrate an understanding of how CT protocols consider multi-slice capabilities, tube heating, and max scan time; Demonstrate an understanding of the relationship between image quality and patient dose from examination; Demonstrate an understanding of the need to define dose optimized imaging protocols for various body parts and sizes of patient; Demonstrate an understanding of image artifacts that may arise in CT images. Be able to identify their causes, and assess or mitigate their impact on radiation treatment planning; Understand the different imaging protocols used in tumor motion management (e.g. voluntary breath hold, active breathing control, shallow breathing by compression, free breathing helical CT and 4D-CT); Understand the different CT image acquisition modes available with a modern CT-simulator (prospective, retrospective, cine, helical, 4D and image sorting based on breathing phase and breathing amplitude). Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 36/93 Resident Handbook

37 Treatment Planning Terms 1 (Form R.2.H) Define the terms below giving examples and mathematical formulas where applicable. Attach additional sheets as necessary. 1. Air Gap 2. Attenuation 3. Beam Hardening 4. dmax 5. Obliquity Factor 6. Effective Field 7. Equivalent Square; A/P 8. Radiation Dose (Gy) 9. Fluence 10. Hot Spots 11. HVL 12. Isodose Curve 13. Radiographic Magnification Factor 14. Electron Output Factor 15. Maximum/Minimum Target Dose 16. Orthogonal Films 17. PDD or %DD 18. Penumbra 19. Build-up bolus 20. Primary Radiation 21. Scatter Radiation 22. Skin Sparing 23. Bolus 24. SAD Technique 25. SSD Technique 26. PTV/CTV/GTV/ITV/IV/TV/SM/PRV Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 37/93 Resident Handbook

38 Treatment Planning Terms 2 (Form R.2.I) Define the terms below giving examples and mathematical formulas where applicable. Attach additional sheets as necessary. 1. Absorbed Dose 2. Activity 3. Attenuation Coefficient 4. Buildup Region 5. Decay Constant 6. Dynamic Wedge 7. Entrance Dose 8. Exit Dose 9. Skin Gap Calculation (Craniospinal treatments) 10. GM Meter 11. Sensitometric Curve 12. Tissue Heterogeneity 13. Independent Jaw 14. ICRU 15. Irregular Field 16. Manchester Method 17. Mass Attenuation Coefficient 18. MLC 19. IMRT 20. 3D conformal 21. Paterson-Parker Method 22. Pig (not the animal) 23. Quimby Method 24. SAR 25. Sc 26. Sp 27. TMR 28. TLD 29. Normal Tissue Tolerance 30. Wedge Angle 31. Hinge Angle 32. DVH Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 38/93 Resident Handbook

39 Transperineal Ultrasound Guided Prostate Brachytherapy Checklist (Form R.2.J) Volume study Treatment plan Procedure Post plan: Date: Date: Date: Activity Participate in volume study including discussion of stepper function and slice spacing Participate in treatment plan including discussion of Rx dose, normal tissue constraints and peripheral loading Participate in ordering of seeds including different loading options for seed applicators (loose seeds, preloaded needles, suture-mounted sources, MICK cartridges) Participate in receipt, calibration, leak testing and inventory of radioactive material including discussion of applicable state regulations Learn DOT regulations for transport and labeling or radioactive material Participate in preparation of procedure room including discussion of regulations for signage on rooms containing radioactive sources, radiation area, high radiation area, very high radiation area Participate in brachytherapy procedure including discussion of position verification, seed accountability Participate in post-insertion cystoscopy including discussion of how to handle seeds in the bladder or urethra Participate in patient and room survey pre- and post-procedure including discussion of lost seeds Participate in release of patient with radioactive materials Participate in post-procedure treatment planning including discussion of seed migration and prostate edema Participate in disposal of radioactive material including discussion of applicable state regulations Discuss function/limitations of a personnel monitoring badge including energy discrimination Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 39/93 Resident Handbook

40 Clinical Rotation 3 Schedule and Objectives Chief Mentor: (Year 1, Jan-Mar) Objectives Master Checklist Activity On Board MV and kv Imaging ExacTrac design and function. ExacTrac Daily, Monthly QA Linac Annual QA The RPC: The resident knows what the RPC is/does. TBI and TSE. IMRT Planning. (RADI 7006) References: i. Comprehensive QA for Radiation Oncology (Reprinted from Medical Physics, Vol. 21, Issue 4) (1994) Radiation Therapy Committee Task Group #40 ii. Report of TG142 (Quality Assurance of Medical Accelerators) Med. Phys. Volume 36, Issue 9, pp , September 2009 iii. The Calibration and Use of Plane-Parallel Ionization Chambers for Dosimetry of Electron Beams (Reprinted from Medical Physics, Vol. 21, Issue 8 (1994) Radiation Therapy Committee Task Group #39; 10 pp. iv. AAPM protocol for kv x-ray beam dosimetry in radiotherapy and radiobiology. Medical Physics, Vol.28, Issue 6, (2001). Radiation Therapy Committee Task Group #61. v. A primer on theory and operation of linear accelerators in radiation therapy. 2nd ed., Karzmark and Morton, Medical Physics Publishing, vi. The Physical Aspects of Total and a Half Body Photon Irradiation (1986) Radiation Therapy CommitteeTask Group #29; 55 pp. vii. Total Skin Electron Therapy: Technique and Dosimetry. Report of AAPM Radiation Therapy Committee Task Group 30 (1987) viii. Clinical use of electronic portal imaging (Reprinted from Medical Physics, Vol. 28, Issue 5) (2001) Radiation Therapy Committee Task Group #58; 26 pp. ix. Quality assurance for CT simulators and the CT simulation process. AAPM report #83. (Reprinted in Medical Physics, Vol. 30, Issue 10, 2003). Radiation Therapy Committee Task Group #66. x. Khan. Treatment Planning in Radiation Oncology xi. Mellenberg DE, Dahl RA, Blackwell CR. Acceptance testing of an automated scanning water phantom. Med Phys. 1990; 17(2): xii. Emami, B. et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys May 15;21(1): xiii. Lyman, JT. Complication probability as assessed from dose-volume histograms. Radiat. Res. 104:S-13 S-19; xiv. Kutcher GJ and Burman C. Calculation of complication probability factors for nonuniform normal tissue irradiation: the effective volume method. Int J Radiat Oncol Biol Phys. 104: ; xv. Kutcher G J, Burman C, Brewster L, Goitein M, Mohan R. Histogram reduction method for calculating complication probabilities for three-dimensional treatment planning evaluations. Int J Radiat Oncol Biol Phys. 21: ; xvi. Varian manuals for OBI and conebeam CT xvii. Jaffray DA, Drake DG, et. al. A radiographic and tomographic imaging system integrated into a medical linear accelerator for localization of bone and soft-tissue targets. Int J Radiat Oncol Biol Phys. 45: ; xviii. Jaffray DA, Siewerdsen JH, Wong JW, and Martinez AA. Flat-panel cone-beam computed tomography for imageguided radiation therapy. Int J Radiat Oncol Biol Phys. 53: ; xix. Groh BA, Siewerdsen JH, et. al. A performance comparison of flat-panel imager based MV and kv cone-beam CT. Med Phys 29, (2002). xx. Balter JM, Wright JN, et. al. Accuracy of a wireless localization system for radiotherapy. Int J Radiat Oncol Biol Phys. 61: ; UTHSCSA-Division of Medical Physics Page 40/93 Resident Handbook

41 ExacTrac (kv) (Form R.3.A) Competency Demonstrate an understanding of the function of the ExacTrac System Demonstrate an understanding of how are images acquired Demonstrate an understanding of the image reconstruction Demonstrate an understanding of ExacTrac QA (Daily, Monthly, Annual) Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 41/93 Resident Handbook

42 Total Skin Electron Treatment (Form R.3.B) Competency Demonstrate an understanding of Simulation Measurements / technique determination Demonstrate an understanding of Hand calculations for treatment Demonstrate an understanding of Chart preparation and diagrams Demonstrate an understanding of Calibration of TSE setting in LINAC Discuss the rationale of TSET treatments (e.g. malignant and benign conditions treated with TSET); Demonstrate an understanding of TSET delivery techniques, issues related to the clinical commissioning and maintenance of a TSET program; Discuss and demonstrate an understanding of the significance of beam modifiers commonly used during TSET treatments (shields, beam spoilers); Participate in all aspects of a TSET treatment (simulation, planning, plan verification, treatment, treatment verification, and in vivo measurements). (Recommended but not required) Demonstrate an understanding of TSE Program a) Field size determination b) Field flatness determination, gantry angle matching c) Relative output determination at the patient plane d) Dose variation around the periphery of patient/phantom e) Absolute determination of dose per monitor unit at patient plane f) Boost field dose determination g) Shielding considerations for eyes, nails, top of feet Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 42/93 Resident Handbook

43 Total Body Radiation Therapy (Form R.3.C) Competency Demonstrate an understanding of Simulation Measurements / technique determination Demonstrate an understanding of Hand calculations for treatment Demonstrate an understanding of Chart preparation and diagrams Demonstrate an understanding of Calibration of TBI beam Demonstrate an understanding of TBI prescription and delivery techniques, issues related to the clinical commissioning and maintenance of a TBI program; Discuss and demonstrate an understanding of the significance of beam modifiers commonly used during TBI treatments (lung/kidney blocks, beam spoilers); Participate in all aspects of a TBI treatment (simulation, planning, plan verification, treatment, treatment verification, and in vivo measurements). (Recommended but not required) Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 43/93 Resident Handbook

44 Intensity Modulated Radiation Therapy (IMRT) Planning(Form R.3.D) Competency Inverse planning a) Demonstrate an understanding of the use of objective functions for IMRT optimization; b) Demonstrate an understanding of the optimization processes involved in inverse planning; c) Perform inverse planning optimization for a variety of treatment sites in sufficient number to become proficient in the optimization process; d) Demonstrate an understanding of commonly used planning procedures and guidelines, and optimization and dose calculation algorithms. IMRT delivery a) Demonstrate an understanding of various IMRT delivery techniques (e.g. compensators, static field IMRT, and rotational delivery techniques), including their relative advantages and disadvantages; b) Discuss the differences between DMLC and SMLC leaf sequencing algorithms in terms of delivery parameters and dose distributions; c) Participate in IMRT delivery for patients with a variety of treatment sites and demonstrate an understanding of the techniques and requirements for patient setup, immobilization, and localization. Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 44/93 Resident Handbook

45 Annual Linac QA (Form R.3.E) Competency Perform and be competent in the mechanical, safety, and radiation tests required during accelerator acceptance and commissioning; Demonstrate an understanding of the process for defining the treatment beam isocenter of a gantry based particle accelerator and its relation to the gantry s mechanical isocenter and any on-board imaging isocenters; Discuss how to perform treatment unit head radiation leakage and shielding adequacy tests; Independently setup and perform water tank scans for photon and electron beam measurements that calibrate and characterize those external beams to facilitate computerized treatment planning and hand calculations of radiation dose to a point; Analyze water tank scans and demonstrate an understanding of the results from these scans, including typically accepted tolerances for each test performed; Demonstrate an understanding of acceptance, commissioning and ongoing annual QA requirements for radiation treatment planning system modules dealing with external beam treatments. Demonstrate an understanding and use of the instrumentation (i.e. theory of operation, limitations) and protocols that may be employed in the process of calibration of radiation treatment beams of energy in the megavoltage and kilovoltage range; Demonstrate an understanding of how and why phantoms are utilized for physical measurements; Demonstrate an understanding of the correction factors utilized for photon and electron calibration measurements; Perform and be competent in the calibration of megavoltage and kilovoltage external beams of photons and electrons using a recognized national or international protocol Perform and be competent in photon calibration hand calculations; Perform and be competent in electron particle calibration hand calculations. Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 45/93 Resident Handbook

46 TG-51 Calibration Checklist (Form R.3.F) Competency Demonstrate an understanding of TG 51 protocol Calibrate photon and electron beams using TG 51 Discuss and/or demonstrate the following: a) energy range covered by TG-51 b) standard calibration equation: define each term for photons and electrons c) measurement corrections: define Pion, Pelec, Ppol, CTP d) calibration conditions: field size, SSD, depth of reference dosimetry e) specification of beam energy f) point of measurement: define for cylindrical and parallel chambers g) How is %DD10x determined for low and high energy photons? h) How is R50 determined for low and high energy electrons? i) How do you determine kq, kecal, k R50? j) What is beam quality Qecal? Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 46/93 Resident Handbook

47 Informatics (Form R.3.G) Topics Beam data acquisition/management Beam modeling Treatment planning algorithms Validation of imported images PACS systems and their integration HL7 DICOM standards DICOM in radiation therapy (DICOM-RT) Information acquisition from PACS/images o Quality/maintenance of imaging workstations Evaluation of viewing conditions Image registration, fusion, segmentation, processing Quantitative analysis Record and verify systems Treatment record design/maintenance IHE Radiation Oncology (IHE-RO) Network integration/management, and roles of physics and information technology staff Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 47/93 Resident Handbook

48 Clinical Rotation 4 Schedule and Objectives Chief Mentor: (Year 1, Apr-Jun) Objectives Master Checklist Activity LDR planning. Eye plaque process Patient Safety Learn shielding techniques for CT, kv imaging, LINAC and isotopes. References: i. Comprehensive QA for Radiation Oncology (Reprinted from Medical Physics, Vol. 21, Issue 4) (1994) Radiation Therapy Committee Task Group # pp. ii. AAPM Code of Practice for Radiotherapy Accelerators (Reprinted from Medical Physics, Vol. 21, Issue 7) (1994) Radiation Therapy Committee Task Group #45. Report #47. iii. High dose rate brachytherapy treatment delivery. Med Phys, Vol. 25, Issue 4 (1998). Radiation therapy committee task group #59. Report #61. iv. Dosimetry of 125I and 103Pd COMS eye plaques for intraocular tumors: Report of Task Group 129 by the AAPM and ABS Medical Physics, Volume 39, Issue 10 v. Niemierko A. Reporting and analyzing dose distributions: A concept of equivalent uniform dose. Med Phys. 24, (1997). vi. Wu Q, Mohan R, Niemierko A, and Schmidt-Ullrich R. Optimization of intensity modulated radiotherapy plans based on the equivalent uniform dose. Int J Radiat Oncol Biol Phys. 52: ; 2002 vii. Report of the AAPM Low Energy Brachytherapy Source Calibration Working Group: Third-party brachytherapy source calibrations and physicist responsibilities Medical Physics, Vol 35, Issue 9 viii. Hall, Eric J. Radiobiology for the radiologist. ix. UTHSCSA tissue tolerance planning guidelines for SBRT x. Shaw E, Scott C, Souhami L, Dinapoli R, Kline R, Loeffler J, Farnan N. Int J Radiat Oncol Biol Phys May 1;47(2): PMID: [PubMed - indexed for MEDLINE] xi. RTOG 90-05: the real conclusion. Buatti JM, Friedman WA, Meeks SL, Bova FJ. Int J Radiat Oncol Biol Phys May 1;47(2): xii. A dosimetric uncertainty analysis for photon-emitting brachytherapy sources: Report of AAPM Task Group No. 138 and GEC-ESTRO Medical Physics, Vol 38, Issue 2 xiii. QUANTEC data for radiation does tolerances xiv. Neutron Measurements Around High Energy X-Ray Radiotherapy Machines (1986) Radiation Therapy Committee Task Group #27; 34 pp. xv. NCRP 49: Structural Shielding Design and Evaluation for Medical Use of X-rays and Gamma Rays of Energies up to 10 MeV xvi. NCRP 51: Radiation Protection Design Guidelines for 0.10 MeV Particle Accelerator Facilities xvii. NCRP 79: Neutron Contamination from Medical Electron Accelerators xviii. NCRP 102: Medical X-Ray, Electron Beam and Gamma-Ray Protection for Energies Up to 50 MeV (Equipment Design, Performance and Use (Supersedes NCRP Report No. 33) xix. NCRP 147: Structural Shielding Design for Medical X-Ray Imaging Facilities xx. NCRP 151: Structural Shielding Design and Evaluation for Megavoltage X- and Gamma-Ray Radiotherapy Facilities xxi. Shielding Techniques for Radiation Oncology Facilities. Patton H. McGinley. xxii. Fetal Dose from Radiotherapy with Photon Beams (Reprinted from Medical Physics, Vol. 22, Issue 1) (1995) Radiation Therapy Committee Task Group #36. xxiii. NRC Regualtory Guide 8.13, "Instructions Concerning Prenatal Radiation Exposure" xxiv. Management of Radiation Oncology Patients with Implanted Cardiac Pacemakers(Reprinted from Medical Physics, Vol. 21, Issue 1) (1994) Task Group #34; 6 pp. Also be aware of ERRATUM published by Stovall, et al., Med Phys 22(8), August xxv. Dosimetric considerations for patients with hip prostheses undergoing pelvic irradiation. Med Phys Volume 30, Issue 6, (2003). Radiation therapy task group committee #63. UTHSCSA-Division of Medical Physics Page 48/93 Resident Handbook

49 Normal Tissue Tolerance Checklist (Form R.4.A) (cont from Rotation 2 and 3) Resident Topic Initials Retina, optic nerves, chiasm and lens: fractionated and single dose Brain: fractionated Brainstem: single dose Spinal cord: fractionated and single dose Parotid: fractionated Lung: fractionated Kidney: fractionated Small bowel: fractionated Large bowel: fractionated Heart: fractionated Liver: fractionated Bladder: fractionated Rectum: fractionated, prostate implant Urethra: prostate implant Femoral Head: fractionated Skin: fractionated Lyman-Kutcher model for calculation of NTCP Definition and understanding of geud Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 49/93 Resident Handbook

50 PINNACLE Treatment Planning Cases Checklist (Form R.4.B) (cont from Rotation 2 and 3) Irregular Fields Lung 3D Pelvis 3D Pancreas 3D Brain 3D Larynx 3D GYN 3D Abdomen (seminoma) Prostate 3D Breast 3D Lung IMRT Pelvis IMRT Pancreas IMRT Brain IMRT Larynx IMRT GYN IMRT Prostate IMRT Breast IMRT Electron fields Topic Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 50/93 Resident Handbook

51 Low Dose Rate (LDR) Brachytherapy Checklist (Form R.4.C) Competency Discuss the program requirements for control of radioactive material, isotope room layout, logout-login procedures for Cs-137, Ir-192, I-131 Demonstrate an understanding of TG-43 formalism and update Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 51/93 Resident Handbook

52 Radiation Protection Checklist (Form R.4.D) Competency Megavoltage photons (linear accelerators and/or cobalt-60 units) and electrons, kilovoltage, superficial x-rays, and/or protons Demonstrate an understanding of the Nuclear Regulatory Commission (NRC) and/or state licensing (by-product materials and x-ray producing devices); Explain the principles behind a radiation protection program, including the rationale for the dose limits for radiation workers and members of the general public; Demonstrate an understanding of NRC and/or state, local, and institutional regulatory requirements; Explain the ALARA (As low as reasonably achievable) concept; Demonstrate an understanding of site planning and how to supervise construction (key elements to monitor); Demonstrate an understanding of structural shielding designs for a radiotherapy department (e.g. NCRP 151) and discuss the key parameters necessary to perform a shielding calculation; Perform shielding calculations for an accelerator vault. Calculations should include primary and secondary barrier transmission calculations; Discuss the shielding requirements for the maze and door of a high energy room; Perform radiation survey of a facility including low energy (4 6 MV) and high energy (15 25 MV) units; Discuss advantages and disadvantages of various materials that may be used for shielding; Discuss how special procedures such as TBI and SBRT may impact shielding parameters. IMRT Demonstrate understanding of effects of IMRT delivery on leakage radiation and its potential effects on patients and personnel exposure; Demonstrate understanding of the effects of different IMRT delivery techniques on the amount of leakage radiation produced; Demonstrate understanding of effects of IMRT delivery on vault shielding requirements. Conventional Simulator (Radiographic/Fluoroscopic) Demonstrate an understanding of state licensing (x-ray producing devices); Explain the principles behind a radiation protection program, including the rationale for the dose limits for radiation workers and members of the general public; Discuss the key parameters necessary to perform a shielding calculation; Demonstrate an understanding of structural shielding designs for a conventional simulator and perform a shielding calculation (walls, ceilings, floor, and control area); Demonstrate an understanding of film processing and darkroom design. CT Simulator Demonstrate an understanding of state licensing (x-ray producing devices); Resident Initials Mentor Initials** UTHSCSA-Division of Medical Physics Page 52/93 Resident Handbook

53 Explain the principles behind a radiation protection program, including the rationale for the dose limits for radiation workers and members of the general public; Discuss the key parameters necessary to perform a shielding calculation; Discuss the significance of an isodose distribution plot for the CT simulator; Demonstrate an understanding of structural shielding designs for a CT simulator and perform a shielding calculation (walls, ceilings, floor, and control area); Demonstrate an understanding of film processing and darkroom design. Brachytherapy Demonstrate an understanding of shielding calculations for primary and secondary barriers (i.e. NCRP 151); Discuss the key parameters necessary to perform a shielding calculation; Discuss and/or perform a shielding calculation for a brachytherapy vault; Discuss and/or perform a radiation survey for a brachytherapy vault; Discuss requirements for personal radiation safety badges; Discuss labeling, shipping, and receiving requirements for radioactive material; Discuss management of isotope inventory; Discuss patient-release criteria for radioactive patients (i.e. patients with temporary or permanent implants and radiopharmaceuticals); Discuss how to handle changes in medical status for radioactive patients (i.e. medical emergency or death, NCRP 155); Explain the key concepts of Title 10 of the Code of Federal Regulations parts 19, 20, and 35; Demonstrate how to safely operate a remote afterloader unit, including emergency procedures. Regulations/recommendations/licensing Demonstrate an understanding of Nuclear Regulatory Commission (NRC) and/or state licensing (by-product materials and x-ray producing devices); Demonstrate an understanding of the appropriate regulations for radiation protection and dose limits for radiation workers and members of the general public; Demonstrate an understanding of NRC and/or state, local, and institutional regulatory requirements; Explain the ALARA (As low as reasonably achievable) concept; Discuss the role and significance of the Joint Commission; Discuss the role and responsibility of a radiation safety committee; Discuss the role and responsibility of a radiation safety officer; Discuss the significance of ACR, ASTRO, and AAPM recommendations; Demonstrate an understanding of release of patients (with sealed or unsealed sources). Survey meters (ionization chamber, Geiger Müller (GM), scintillation) Discuss the operation and appropriateness of different survey instruments (i.e. Geiger-Muller counter, ionization survey meters, and scintillation counter); Performs battery and constancy checks. Understands the allowable deviation from baseline reading; Understands how a survey meter is calibrated, who may calibrate a meter (i.e. ionization versus GM) and the required frequency of calibration; Personnel monitoring UTHSCSA-Division of Medical Physics Page 53/93 Resident Handbook

54 Demonstrates an understanding of the physical mechanisms involved in the process of radiation detection and readout of personnel monitors (film, TLD, and OSLD). Understands the rationale for occupational dose limits and the federal/state limits; Understands the definition of a declared pregnant woman ; Understands the federal/state personnel monitoring requirement; Understands the rationale for ALARA investigation levels; Understands the role and responsibility of physics in developing a radiation safety culture; Understands the requirements for providing personnel monitoring reports to staff; Reviews and discusses the results of personnel monitoring reports. Guidelines and instructions for personnel Understands the roles and responsibilities of a radiation worker (i.e. NRC Form 3). Understands the requirements and frequency of radiation safety refreshers for staff; Understands the personnel radiation safety hazards specific to the uses of radiation in a therapeutic setting (e.g. linear accelerator, brachytherapy, radioisotope handling); Demonstrates the ability to tailor a radiation safety training program for the intended audience (e.g. physicists, therapists, dosimetrists, nurses, physicians, physician residents, students, and maintenance staff). Hazards of low levels of radiation Understands the linear no-threshold (LNT) hypothesis, its origins and limitations; Understands the collective dose theory as it applies to large populations; Understands the potential biological effects associated with prolonged exposure to low levels of radiation; Knows the major natural sources of background radiation; Knows the major man-made sources of background radiation. Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 54/93 Resident Handbook

55 Patient Safety (Form R.4.E) Competency Resident Initials Mentor Initials** General Understand the principles behind the development of a general patient and staff safety management program within the hospital; Discuss the physicist s role in developing and overseeing an overall quality assurance program both for equipment and for procedures, including a discussion of allocation and management of resources necessary to carry out these tasks, incorporation of tools and techniques, and inclusion of various groups within the structure of the radiation oncology department; Discuss the principles and rationale of the Joint Commission Universal Protocol and discuss the use of pre-procedure verification and time-outs for the prevention of treatment errors; Discuss the implementation of a continuous quality improvement (CQI) program, including the use of both internal review and external audits/peer review for the assurance of high quality care; Discuss the concept of a Failure Mode and Effect Analysis (FMEA), how to design and implement an FMEA, and how to use the results for error prevention minimization of risks to patients and staff; Discuss charting systems for prescription, delivery, and recording of treatment information, standardization of such systems, and the use of such systems within a record and verify / electronic medical record system; Discuss mechanisms for independent checking of treatment information. Equipment Discuss the implementation of an effective set of equipment operating procedures including preventative maintenance and repair, maintenance and repair records, emergency procedures, and systematic inspection of interlock systems; Discuss the development of a program to prevent mechanical injury by the machine or accessory equipment, including the need for visual and audio contact with the patient while under treatment; Understand potential patient safety hazards related to the use of blocks, block trays, wedges, and other ancillary treatment devices and accessories and mechanisms to minimize these risks; Understand potential patient safety hazards related to patient support and immobilization systems and mechanisms to minimize these risks; Understand the potential patient safety hazards with respect to potential gantry patient collision and mechanisms to minimize this risk. Other Patient/Staff Safety Issues Understand potential electrical hazards to patients and staff; Understand potential hazards of strong magnetic fields to patients and staff; Understand the mechanisms of ozone production and potential hazards to patients and staff; Understand potential hazards to patients and staff from the use of cerrobend. Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 55/93 Resident Handbook

56 Clinical Rotation 5 Schedule and Objectives Chief Mentor: (Year 2, July-Sept) Objectives Master Checklist Activity Treatment plan checks. Brachytherapy Eye Plaque Weekly Chart Checks. LINAC Design. Assume primary oversight of all QA, operations and service activities on Novalis. The resident shall not make any adjustments to their LINAC without faculty supervision. References i. Quality Assurance for Clinical Radiotherapy Treatment Planning (Reprinted from Medical Physics, Vol. 25, Issue 10) (1998) Radiation Therapy Committee Task Group #53; 57 pp. ii. Bortfeld T et al, X-ray field compensation with multileaf collimators. Int J Radiat Oncol Biol Phys. 28(3):723-30, iii. Bortfeld T et al, Realization and verification of three-dimensional conformal radiotherapy with modulated fields. Int J Radiat Oncol Biol Phys. 30(4): , iv. Ezzell G et. al., Guidance document on delivery, treatment planning, and clinical implementation of IMRT: Report of the IMRT subcommittee of the AAPM radiation therapy committee, Med. Phys. 30(8): , v. S Webb, Intensity Modulated Radiotherapy, Institute of Physics Publishing, vi. Intensity Modulated Radiation Therapy, A Clinical Perspective, Mundt AJ and Roeske JC Eds. BD Decker Inc, vii. Intensity Modulated Radiation Therapy Collaborative Working Group, Intensity- Modulates Radiotherapy: Current Status and Issues of Interest, Int. J. Radiation Oncology Biol. Phys., 51(4): , viii. ix. Philips Pinnacle3 P3IMRT Instructions for Use. High dose rate brachytherapy treatment delivery. Med Phys, Vol. 25, Issue 4 (1998). Radiation therapy committee task group #59. Report #61. x. A primer on theory and operation of linear accelerators in radiation therapy. 2nd ed., Karzmark and Morton, Medical Physics Publishing, UTHSCSA-Division of Medical Physics Page 56/93 Resident Handbook

57 LINAC Design and Function Checklist (Form R.5.A) Competency LINAC Design: discuss schematic of major components Klystrons and Magnetrons Circulator Waveguide Modulator Accelerator structure: Standing wave, traveling wave Buncher and side couple cavities Bending magnet Treatment head: primary collimator, monitor chamber, flattening filter, jaws, MLCs, electron foils, x-ray target Electron gun Mechanism for energy change: photons and electrons Mechanism for dose rate change Mechanism for change between photon and electron mode Can you identify a picture of all components above Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 57/93 Resident Handbook

58 Treatment plan and patient chart checks (Form R.5.B) Competency Perform treatment plan verification including: Review of patient history (including prior radiotherapy and potential overlap with current treatment), disease, course of treatment, and dose prescription; Review of appropriateness of treatment plan and dose distribution to achieve goals of treatment course; Review of simulation (e.g. patient positioning and immobilization), planning, imaging, and treatment field parameters; Review of monitor unit or time calculations; Review of images to be used for patient positioning and/or monitoring; Review of transfer of plan parameters and images to record and verify system and any other patient monitoring systems. Perform ongoing review of treatment records (chart checks) including verification of delivered treatments; Perform ongoing review of patient imaging and/or tracking using: a) Film b) Electronic portal imaging device (EPID) c) Real time planar imaging d) Cone beam CT (CBCT) e) Ultrasound (US) f) External fiducial and/or surface tracking g) Internal radiofrequency beacon tracking Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 58/93 Resident Handbook

59 Brachytherapy Checklist (Form R.5.C) Competency SOURCES Sealed Radionuclide Sources Demonstrate an understanding of how commonly used sources are generated; Discuss the decay, decay energies (mean energy), and half-life of commonly used sources; Discuss the form and construction of sealed sources; Discuss and define the different units of source strength that have been used, past and present; Perform a decay calculation, total dose delivered for temporary and permanent implants; Discuss personal protection techniques (time, distance, and shielding) and safe handling of sealed sources; Discuss the appropriate methods of storage of radioactive material (security and accountability); Perform routine receipt procedure and check-out and check-in temporary and permanent sources into inventory; Perform a source room survey and quarterly inventory; Discuss and/or perform leak checks on sealed sources; Demonstrate an understanding of and gain hands-on experience of radioactive material packaging and transportation (Title 49 of the Code of Federal Regulations); Demonstrate an understanding of the equipment used to calibrate sealed sources; Discuss the process by which sealed sources are calibrated; Discuss the process by which measurement equipment (i.e. electrometers, well ionization chambers) is calibrated; Explain the theory of operation of a well ionization chamber; Discuss and/or perform an assay for sealed sources; Demonstrate an understanding of licensing issues and requirements (i.e. NUREG 1556); Discuss the operation and appropriateness of different survey instruments (i.e. Geiger-Muller counter, ionization survey meters, and scintillation counter); Demonstrate an understanding of the regulatory requirements for sealed sources (i.e. state regulations or 10 CFR 35). Unsealed radionuclide sources Demonstrate an understanding of how commonly used radiopharmaceuticals (i.e. I-131, P-32, Sm-153, Sr-89) are generated; Demonstrate an understanding of the decay, decay energies (mean energy), and half- life of commonly used radiopharmaceuticals; Discuss personal protection techniques (time, distance, and shielding) and safe handling of unsealed sources; Discuss the process by which unsealed sources are calibrated; Discuss the process by which measurement equipment (i.e. dose calibrator) is calibrated; Resident Initials Mentor Initials** UTHSCSA-Division of Medical Physics Page 59/93 Resident Handbook

60 Discuss and if possible, perform an assay for unsealed sources; Demonstrate an understanding of licensing issues and requirements (i.e. NUREG 1556); Discuss the operation and appropriateness of different survey instruments (i.e. Geiger-Muller counter, ionization chamber, and scintillation counter); Demonstrate an understanding of the regulatory requirements for unsealed sources (i.e. state regulations or 10 CFR 35); CLINICAL APPLICATIONS Discuss the various brachytherapy sources that have been used, past and present, clinically. Discuss the rationale for source selection. Discuss the how a brachytherapy program is developed. Discuss in detail the use and operation of different brachytherapy modalities, including their advantages and disadvantages. Low dose-rate (LDR) High dose-rate (HDR) Pulsed dose-rate (PDR) (optional) Electronic Discuss and perform source strength (Air Kerma Rate, S k) verification and comparison between measured and vendor s specification; Discuss radiation protection for radiation workers and visitors; Demonstrate an understanding of commissioning and acceptance of Remote After Loaders (RAL); Demonstrate an understanding of GYN and GU anatomy; Demonstrate an understanding of the treatment of cervical and endometrial cancer with LDR, HDR, and PDR (recommended); Demonstrate an understanding of prostate cancer and the treatment with HDR and LDR; Treatment planning Perform brachytherapy treatment plans for a cylindrical applicator; Perform brachytherapy treatment plans for a cervical applicator (e.g. tandem and ovoids, tandem and ring); Discuss the differences between point and volume based treatment planning (ICRU 38 and the GEC ESTRO recommendations); Perform interstitial brachytherapy treatment plans (e.g. prostate, gynecologic, sarcoma); Perform a brachytherapy treatment plan for an eye plaque (Recommended but not required); Perform a brachytherapy treatment plan for microsphere therapy (Recommended but not required). Demonstrate an understanding of applicator acceptance, commissioning, and performance of periodic quality assurance; Demonstrate an understanding and performance of daily QA; Describe emergency training requirements (10CFR35); Demonstrate an understanding of Quality Management Program (QMP) as required by the federal/state for auditing; Discuss the criteria and subsequent handling of recordable and reportable events. UTHSCSA-Division of Medical Physics Page 60/93 Resident Handbook

61 IMAGING Demonstrate an understanding of the mathematics of localization of target volume and catheter reconstruction by orthogonal films (2D); Demonstrate an understanding of CT/MRI/US/PET based localization of Region of Interests (ROIs) and catheter reconstruction. TREATMENT PLANNING Demonstrate an understanding of source strength of radioactive sources; Discuss dose rates and dose calculation formalisms (HEBD, LEBD); Demonstrate an understanding of the performance of computerized planning of various imaging modalities of LDR and HDR; Discuss in details the advantages and disadvantages of dose optimizations; Discuss and perform secondary calculations as a QA check for computerized planning. Demonstrate an understanding testing of new sealed sources Discuss the calibration check of new sealed sources Discuss the calibration check of well chambers Discuss the elongation factor determination for well chambers (LDR Ir-192) Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 61/93 Resident Handbook

62 COMS Eye Plaque Applicator Checklist (Form R.5.D) Competency Demonstrate an understanding of seed strength determination Process for ordering seeds Demonstrate re-planning using actual seed strength Source logging and calibration Perform Implant preparation including gathering of required equipment Demonstrate an understanding of eye plaque sterilization procedure Participate in all OR activities for an eye plaque Perform the Recovery room Radiation Protection survey and documentation Discuss the home radiation precautions or hospital room precautions Participate in OR applicator removal procedures Perform Post implant Radiation protection survey of OR Discuss End of implant duties, source inventory, seed removal from plaque Demonstrate an understanding of proper disposal of seeds Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 62/93 Resident Handbook

63 Clinical Rotation 6 Schedule and Objectives Chief Mentor: (Year 2, Oct-Dec) Objectives Master Checklist Activity Stereotactic Treatment Planning Concepts Stereotactic Quality Assurance Daily Monthly Annual Participate in all aspects of SBRT treatment Treatment planning QA. References i. Quality Assurance for Clinical Radiotherapy Treatment Planning (Reprinted from Medical Physics, Vol. 25, Issue 10) (1998) Radiation Therapy Committee Task Group #53; 57 pp ii. Stereotactic body radiation therapy: The report of AAPM Task Group 101 (2010) Treatment Delivery Subcommittee Task Group #101 Med. Phys. 37 (8) iii. Stereotactic Radiosurgery. iv. Novalis, and Eclipse manuals as needed. UTHSCSA-Division of Medical Physics Page 63/93 Resident Handbook

64 Stereotactic Body Radiation Therapy Checklist (Form R.6.A) Competency Participate in shaping of Body Frame immobilization device Demonstrate an understanding of various mechanisms monitoring respiratory motion Demonstrate an understanding of various mechanisms for respiratory motion mitigation Participate in 4D CT image acquisition Perform retrospective binning of 4D CT data Generate MIP images and transfer to treatment planning computer Participate in SBRT treatment planning Demonstrate an understanding of mechanisms of SBRT localization at the linac Participate in cone-beam CT patient setup Participate in SBRT patient treatments Discuss the rationale for SBRT treatments, what are the common treatment sites, and typical dose and fractionation schemes; Discuss immobilization and localization systems for SBRT treatments; Discuss use of simulation imaging for SBRT target definition, including multi-modality imaging and 4D imaging for cases requiring motion management; Discuss treatment planning objectives for SBRT treatments, including OAR dose limits, dose heterogeneity, dose gradient and fall-off, and beam geometry; Discuss treatment verification and delivery for SBRT treatments, and use of in-room imaging. Discuss TPS validation tests including tissue inhomogeneity corrections and small-field dosimetry measurements. Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 64/93 Resident Handbook

65 Stereotactic Radiosurgery Checklist (Form R.6.B) Competency Participate in shaping of SRS mask Discuss fluoro-guided motion assessment Participate in CT image acquisition Import of imaging sets to Treatment planning system Perform fusion of image sets Participate in SRS treatment planning Understand mechanisms of SRS localization at the linac Participate in ExacTrac patient setup Participate in SRS patient treatments Discuss rationale of SRS treatments, examples of malignant and nonmalignant lesions treated with SRS, and typical dose and fractionation schemes for linac-based and Co-60 SRS techniques; Describe, in general, the components of commissioning for an SRS system (accurate localization, mechanical precision, accurate and optimal dose distribution, and patient safety); Discuss the stereotactic localization of a target (i.e. from angiography versus CT and MRI) and how the accuracy of this localization is measured; Describe the alignment of coordinate systems (i.e. target frame of reference to linac frame of reference) and how the mechanical precision of this alignment is measured; Describe issues associated with dosimetry measurements for an SRS system (i.e. choice of dosimeter, phantom geometry, etc.); Describe the components of pre-treatment QA for an SRS system, including linac-based and Co-60 SRS techniques. Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 65/93 Resident Handbook

66 Stereotactic Radiosurgery Checklist (Form R.6.C) Topic Simple spherical targets (cones) Non-spherical targets (micromlc) Multiple targets Arteriovenous Malformations (AVM) Trigeminal Neuralgia Image fusion Monitor Unit Calculations Physics Scatter Factor Measurements (cone and mlc) TMR measurements OAR measurements Isocentric accuracy (Winston-Lutz) Targeting accuracy (image guidance) Daily QA Monthly QA Annual QA Imaging CT scanner accuracy MR scanner accuracy Angiographic localizer accuracy Resident Initials Mentor Initials** Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 66/93 Resident Handbook

67 Treatment planning system QA (Form R.6.D) Competency Data acquisition Explain the connection between linac commissioning and the data required for operation of a treatment planning system; For a particular treatment planning system, describe the required linac data needed for: i. Photon beams ii. Electron beams iii. IMRT and VMAT Acceptance testing Describe what tests of the treatment planning system need to be performed before patient specific planning can commence for: iv. Photon beams v. Electron beams vi. Brachytherapy sources Quality assurance Describe the accuracy of the above tests that need to be performed Describe accuracy checks for input devices: vii. Digitizers viii. Film scanners ix. Imported images from CT scanners, MRI scanners, etc., and PACs systems Describe accuracy checks for output devices: x. Printers xi. Record and verify systems xii. DICOM output Computer algorithms (models) Describe how the computer algorithm calculates dose for at least one major treatment-planning system for: xiii. Photon beams xiv. Electron beams xv. Brachytherapy calculations xvi. Proton beams (optional) Describe the advantages and disadvantages of the various treatmentplanning calculation algorithms; Describe how the computer algorithm determines the number of monitor units per beam or segment (for step-and-shoot IMRT). Plan Normalization Describe the numerous normalization capabilities available on a treatment planning system; Describe how different normalization schemes affect final isodose curve representation; Describe how the computer plan normalization relates to the calculation of monitor units for patient treatments. Inhomogeneity (heterogeneity) corrections Resident Initials Mentor Initials** UTHSCSA-Division of Medical Physics Page 67/93 Resident Handbook

68 Describe the type of data that needs to be taken on a CT scanner in preparation for treatment-planning using inhomogeneous material; Describe how this CT data is converted into inhomogeneity data usable in a treatment planning system; Describe how computerized treatments planning system takes inhomogeneities into account; Describe where the computer algorithm calculates dose with acceptable accuracy and in what regions the calculational accuracy is suspect; Describe how you would check the accuracy of the inhomogeneity corrections performed by a treatment planning system. Beam modeling Completely model at least one photon beam energy for a treatment planning system; Completely model at least one electron beam energy for a treatment planning system; Completely model at least one proton beam energy for a treatment planning system (optional); Test the accuracy of your modeling for the beams and be able to describe the criteria for acceptability of the modeling. Imaging tests Describe to tests that you would perform to ensure that the imported image data is correct; Demonstrate that you can import images from CT, MR, and PET or PET/CT scanners; Demonstrate the you can accurately fuse the above imaging sets with the primary treatment planning image set; Describe the different image fusion algorithms available on a treatmentplanning system and which method is most accurate for which fusions (i.e. CT-CT, CT-MR, CT-PET) and why. Secondary monitor unit check computer programs Describe what input data needs to be acquired; Describe the checks of that input data that need to be performed to ensure that the monitor unit check program is working correctly Describe how imported data from treatment-planning systems is handled in a monitor unit check program; Describe how the monitor unit check program calculates the number of monitor units for off central-axis normalization points; Describe how the monitor units check program calculates monitor units for treatments involving inhomogeneous material. Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 68/93 Resident Handbook

69 Clinical Rotation 7 Schedule and Objectives Chief Mentor: (Year 2, Jan-Mar) Objectives Master Checklist Activity Dosimetry Rotation (6-8weeks) Imaging Acceptance and Commissioning of Major equipment References i. The Essential Physics of Medical Imaging. Second Edition. Bushberg ii. Comprehensive QA for Radiation Oncology (Reprinted from Medical Physics, Vol. 21, Issue 4). Radiation Therapy Committee Task Group #40 UTHSCSA-Division of Medical Physics Page 69/93 Resident Handbook

70 Imaging List (Form R.7.A) Competency Magnetic Resonance Imaging (MRI) General Demonstrate an understanding of the basic imaging principles behind MRI; Discuss the advantages and limitations of MRI versus CT for treatment planning; Demonstrate an understanding of the role of MRI for radiation therapy applications, providing examples. Quality Assurance Demonstrate an understanding of the quality assurance processes and frequencies for MR-simulators, e.g., image quality, image integrity, safety and mechanical checks, and network connectivity. Ultrasound (US) Resident Initials Mentor Initials** General Demonstrate an understanding of the basic imaging principle behind US imaging; Demonstrate an understanding of the role of US for external beam and brachytherapy treatments using trans-rectal versus trans-abdominal probes, providing examples. Quality Assurance Discuss methods for QA of US imaging probes prior to clinical use, i.e., prostate implants, prostate external beam therapy. Positron Emission Tomography (PET) General Demonstrate an understanding of the basic imaging principles behind PET; Discuss the advantages and limitations of PET versus CT for treatment planning; Demonstrate an understanding of the role of PET for radiation therapy applications, providing examples. Quality Assurance Demonstrate an understanding of the quality assurance processes and frequencies for PET-CT simulators (e.g., image quality, image integrity, safety and mechanical checks, and network connectivity). SPECT General Demonstrate an understanding of the basic imaging principles behind SPECT; Discuss the advantages and limitations of SPECT versus CT for treatment planning; Demonstrate an understanding of the role of SPECT for external beam and radiopharmaceutical therapy applications, providing examples. Quality Assurance Demonstrate an understanding of the quality assurance processes and frequencies for SPECT-CT simulators (e.g., image quality, image integrity, safety and mechanical checks, and network connectivity). Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate UTHSCSA-Division of Medical Physics Page 70/93 Resident Handbook

71 knowledge of the topic UTHSCSA-Division of Medical Physics Page 71/93 Resident Handbook

72 Linac Selection/Acceptance/Commissioning (Form R.7.B) Competency Resident Initials Mentor Initials** Selection Demonstrate an understanding of the theory of operation of megavoltage electron and proton accelerators currently used in radiation oncology treatment and their limitations (e.g. linac, synchrotrons, cyclotrons); Demonstrate an understanding of the theory of operation of kilovoltage x-ray treatment units currently used in radiation oncology treatment; Demonstrate an understanding of the major subsystems and use of cobalt units; Demonstrate an understanding of the major subsystems and components of megavoltage accelerators; Review the steps required to select a new electron linear accelerator (linac) for use in radiation oncology - performance specification and feature comparison; Review and demonstrate an understanding of the development process for a Request For Proposal (RFP) aimed at vendors of a linac or other major radiation treatment unit; Review and discuss mechanical/architectural considerations when installing a new particle accelerator in both a new vault and an existing vault (including discussion on HVAC openings, cabling for communication and dosimetry systems, electric ports, plumbing and skyshine); Acceptance/commissioning Perform and be competent in the mechanical, safety, and radiation tests required during accelerator acceptance and commissioning; Demonstrate an understanding of the process for defining the treatment beam isocenter of a gantry based particle accelerator and its relation to the gantry s mechanical isocenter and any on-board imaging isocenters; Discuss how to perform treatment unit head radiation leakage and shielding adequacy tests; Independently setup and perform water tank scans for photon and electron beam measurements that calibrate and characterize those external beams to facilitate computerized treatment planning and hand calculations of radiation dose to a point; Analyze water tank scans and demonstrate an understanding of the results from these scans, including typically accepted tolerances for each test performed; Demonstrate an understanding of acceptance, commissioning and on-going annual QA requirements for radiation treatment planning system modules dealing with external beam treatments. Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 72/93 Resident Handbook

73 CT simulator Selection/Acceptance/Commissioning (Form R.7.C) Competency Resident Initials Mentor Initials** Selection Review the steps required to select a new CT simulator - performance specification and feature comparison; Review and demonstrate an understanding of the process to develop a Request For Proposal (RFP) for a CT simulator; Review and understand the mechanical/architectural considerations when installing a new CT simulator in both a new room and an existing room. Acceptance testing Demonstrate an understanding of the mechanical tests performed during a CT simulator acceptance procedure; Demonstrate an understanding of the tests of image quality and characteristics for a CT image and digitally reconstructed radiograph for a CT simulator; Demonstrate an understanding of the measurement of dose and CTDIs from a CT simulator for different body sites; Demonstrate an understanding of the measurement of CT number versus density calibration with kvp and its use in treatment planning systems; Demonstrate an understanding of the alignment of internal and external laser systems for a CT simulator; Demonstrate an understanding of network connectivity tests between other systems used in the radiation oncology process (e.g. treatment planning systems, treatment verification systems, and PACS); Demonstrate an understanding of the validation tests for transfer of CT imaged objects to treatment planning systems. Dose calculations Understand the physical basis of the use of CT-simulator images in treatment planning as the current standard for dose calculations and the calibration of these images for use in computing radiation dose deposition in different tissues. Faculty: Date Resident: Date Comments: **A sign-off for any of the competencies is equivalent to a passing grade for that competency. The competencies are scored on a Pass/Fail scale and the resident will have the opportunity to repeat any competency until they have demonstrated adequate knowledge of the topic UTHSCSA-Division of Medical Physics Page 73/93 Resident Handbook

74 Clinical Rotation 8 Schedule and Objectives Chief Mentor: (Year 2, Apr-Jun) Note: the comprehensive oral exam should be completed in the first month to allow time for catch up in areas of weakness. The resident shall: 1. Complete a final oral exam. The final oral exam will be comprehensive and structured similar to an ABR oral exam. 2. Complete any unfinished topics/check sheets. All objectives need to be completed to receive a certificate of completion for this residency. 3. Contribute to clinical service as guided by the Program Director. A resident should be capable of performing all the tasks of a clinical medical physicist with little supervision by the end of rotation #8. Faculty: Date Resident: Date Comments: UTHSCSA-Division of Medical Physics Page 74/93 Resident Handbook

75 2.1 DESCRIPTION OF EDUCATIONAL EXPERIENCE 2.1.A: Research Experience Residents are encouraged to participate in clinical research. There are several areas of research in which the medical physics group is engaged, including: image guided delivery techniques, IMRT optimization, radio-biological optimization and scoring, novel QA techniques, Monte Carlo simulation. 2.1.B: Facilities The residents have access to a several laboratories including: (1) a dosimetry instrumentation lab in the physics research area; (2) a brachytherapy lab in the Brachytherapy Suite; and (3) other research labs and offices in the Clinical Science Research Building. In all, the availability of dosimetry and clinical treatment areas and equipment is more than adequate to serve the needs of the residency training program. Procedures are in place that (1) allow the resident reasonable access time to clinical equipment, (2) provide residents sufficient training and technical support to ensure safe and proper use of equipment, and (3) to ensure equipment is left in the proper state for clinical use. Treatment planning and external beam delivery equipment utilized in the training program include 4 Varian LINACs, 1 Novalis Tx unit, 2 GE 4D CT-simulators (16-slice and 4-slice large bore scanners), 15 PINNACLE TP workstations, 1 Varian Eclipse workstation, iplan workstation. Specialized equipment includes DMLC-IMRT delivery, linac-based stereotactic radiosurgery/therapy and image guidance via on-board x-ray imaging and portal imaging. We also maintain a comprehensive in vivo dosimetry program with OSLD and TLD. 2.1.C: Work Hours Policy All residents are expected to be in the clinic promptly by 8:00 AM which is when most morning conferences begin. Often, special tumor conferences, didactic lectures, or other educational and clinical activities may require that the residents come at work earlier or stay later than normal work hours, which are from 8:00 AM to 6:00 PM except for the resident(s), who are assigned to the patient QAs and machine QAs services that are performed afterhours. Medical physics duties often require the faculty and the residents to work on evenings and on weekends 2.2: EDUCATIONAL CONFERENCES Educational conferences include the New Patient conference (twice a week), numerous tumor boards and the medical physics QA and clinical meetings. Tumor Board Schedules and New Patient Conference times will be distributed by the program coordinator. Residents are expected to make every effort to attend such conferences. 2.3: RESIDENT ROOM and LIBRARY ROOM Neatness, courtesy and order are essential in keeping the resident s room a pleasant workplace. The library contains some past journals and texts. Current journals are available online to all the residents. The departmental library should be considered a quiet area for reading and study. Again, keep this room neat and place journals back neatly where they belong. Material cannot be removed from the library room. UTHSCSA-Division of Medical Physics Page 75/93 Resident Handbook

76 2.4 Radiation Oncology New Employee Orientation Checklist Name: Start Date: 1. Radiation Safety Officer and employee Health ( ) Film badge and explanation ( ) Personal Protective Equipment ( ) Hepatitis B Vaccine ( ) TB testing ( ) Incident Reporting ( ) Schedule of new employee orientation 2. Tour of Facility (any staff member) 3. Review of Responsibilities with Medical Physics Director ( ) Received and reviewed Resident Handbook ( ) Who to notify for sickness or tardiness ( ) Lab coat REQUIRED - No blue jeans, shorts or cut-offs, the gentleman of the Department will wear ties. ( ) Foot wear - (no open toe shoes or sandals) ( ) Introductions to Medical Staff- Organizational chart ( ) CPR Certification optional ( ) Reporting structure, job description and work hours/schedules 4. Administrative Assistant ( ) Parking and ID (with police) ( ) Pager ( ) Office and PC usage ( ) Keys ( ) Supplies ( ) Picture for Directory and distribution ( ) Computer access UTHSCSA and CTRC I certify that I have review the above items with my supervisor or designated person(s) and I understand each of the items designated by a ( ) mark. Signature of Resident Date: SUPERVISOR OR DESIGNATED PERSON(S) I certify that the above resident has been instructed in each of the previously listed items. Signature Date: UTHSCSA-Division of Medical Physics Page 76/93 Resident Handbook

77 2.5: Department Organizational Chart UTHSCSA-Division of Medical Physics Page 77/93 Resident Handbook