ACR Guide to Medical Physics Professional Practice

Revised by the ad hoc Subcommittee of the
Standards & Accreditation Committee of the
Commission on Medical Physics

Richard L. Morin, Ph.D., Chair
Krishnadas Banerjee, Ph.D.
J. Thomas Payne, Ph.D.
Kenneth N. Vanek, Ph.D.
Marilyn C. Wexler, M.S.

TABLE OF CONTENTS

Acknowledgment

Medical Physics
Types of Practice
Employee/Employer Relationship
Written Agreements
Relationships

Appendix A Sample Position Description
Appendix B Sample Application for Medical Staff Privileges
Appendix C Retirement Plans

Acknowledgment

This "ACR Guide to Medical Physics Professional Practice" revises and updates the previous document entitled "A Guide to Radiological Physics Practice." This revision was the work of many dedicated individuals under the auspices of the Standards and Accreditation Committee of the ACR Commission on Medical Physics. In particular, I wish to thank the members of the ad hoc subcommittee: Krishnadas Banerjee, Ph.D., J. Thomas Payne, Ph.D., Kenneth N. Vanek, Ph.D., and Marilyn C. Wexler, M.S. In addition, the Chair of the Standards and Accreditation Committee, David Vassy, M.S., is thanked for his guidance and assistance during revision. Particular recognition is made of the hard work of Ken Vanek and Marilyn Wexler for their dedicated time and energy in major changes in direction and content. We hope this is a useful tool for those involved in the practice of medical physics.

Richard L. Morin, Ph.D.
Chair, Ad Hoc Subcommittee

I. MEDICAL PHYSICS

A. Definition

Medical Physics is primarily an applied branch of physics and deals with the application of physical principles to the diagnosis and treatment of human disease. It encompasses those branches of medical physics that are generally referred to as therapeutic medical physics, diagnostic medical physics, medical nuclear physics, and the combined field of medical physics. Due to the specialized professional knowledge that medical physicists possess, they are regarded as colleagues of the radiologist by the medical profession. The American Board of Radiology (ABR) awards certification to physicists who pass stringent written and oral examinations in one or more of the subfields of medical physics.

B. Education and Training

A medical physicist must have a graduate degree in medical physics or a related discipline. In addition to the above academic preparation, completion of a medical physics residency is preferred. As an alternative to formal residency, a qualified medical physicist must have at least two years of full-time experience in a clinical department of radiology or radiation oncology under the preceptorship of a certified medical physicist. If the physicist intends to practice more than one of the subfields of medical physics, the clinical training and experience should encompass each area.

C. Qualified Medical Physicist

A Qualified Medical Physicist is an individual who is competent to practice independently one or more of the subfields in medical physics.

The American College of Radiology considers certification and continuing education in the appropriate subfield(s) as evidence that an individual is competent to practice one or more of the subfields in medical physics, and to be a Qualified Medical Physicist. The ACR recommends that the individual be certified in the appropriate subfield(s) by the American Board of Radiology (ABR).

A Qualified Medical Physicist should meet the ACR Standard for Continuing Medical Education.

D. General Responsibilities

Some typical responsibilities of a medical physicist may include, but are not limited to, the following items. The scope of these varies widely based on the size and staffing of the institution.

1. Performance of acceptance testing, calibration, and safety surveys of imaging and radiation therapy equipment.

2. Development of purchasing and acceptance specifications for imaging and radiation therapy equipment.

3. Consultation with the radiologist and radiation oncologist concerning patient and fetal dose determinations.

4. Consultation with other physicians and patients regarding radiation exposure and safety.

5. Participation in department financial and personnel planning.

6. Teaching and presentation of continuing education programs for medical students, radiology or radiation oncology residents, graduate students, physicians, nurses, technologists, ancillary personnel and other staff.

7. Participation in planning for future radiology or radiation oncology facilities.

8. Direction of radiation safety program.

9. Development, implementation and supervision of quality control programs in the radiology or radiation oncology department.

10. Research and development of new devices and modalities for improved diagnostic and therapeutic uses of radiation and ultrasound.

11. Membership on applicable committees, such as the Safety Committee, the Radiation Safety Committee, Radioactive Drug Research Committee, Continuous Quality Improvement (CQI) Committee, Disaster Committee Cancer Care Committee, and Institutional Review Board.

12. Participation in clinical and basic research.

Appendix A contains an example of the responsibilities of the medical physicist in radiation oncology.

II. TYPES OF PRACTICE

A. Employee of a Medical Institution Health Care Organization

A medical physicist may be an employee of a hospital, clinic, medical school, university, or health care organization. The association with radiologists, radiation oncologists, other physicians and a wide diversity of support staff provides a broad base for expansion of interests and expertise.

In many institutions, the medical physicist holds a professional appointment in the department of radiology or radiation oncology and is a member of the medical or professional staff. Some large institutions may have an extensive staff of medical physicists organized into separate divisions. In many such institutions, the facility may require the medical physicist to possess a doctoral degree in order to be considered a full member of the faculty or staff. Some institutions do not require a doctoral degree; however, a master's degree in an appropriate discipline, as defined by the American Board of Radiology, is considered a minimum requirement.

The work required of the medical physicist will vary depending on the size of the institution and the number and specialty of the physicists on staff. In smaller facilities the medical physicist may be responsible for the physics support of all areas including therapy, diagnostic nuclear medicine and radiation safety. In larger facilities, the medical physicist may only be responsible for the support of one of these areas. Even then, the responsibilities could include clinical support, teaching and research.

B. Membership in a Radiology or Radiation Oncology Group

A medical physicist can be a member of a radiology or radiation oncology group. Any agreements concerning employment should strive to parallel those of physician members of the group as much as possible. In particular, the medical physicist should be considered one of the professional members of the group.

In a group practice, the medical physicist is responsible to the group and not to a hospital, which may not understand the functions and needs of the medical physicist as well as it understands those of the radiologists.

As a professional member of the group the physicist has access to the managerial, legal and accounting services of the group. In addition to saving a lot of the physicist's time, these professionals can also provide legal advice and financial management advice.

Group practice takes many forms. Several radiologists may practice together in a loose association for convenience in consolidating billing. They may bill together in a hospital facility, but each may have additional radiology or radiation oncology practices, such as a private office or consulting agreements with other clinics or offices.

The practice may be in the form of a partnership. In one form of the partnership, all professional members of the group become equal partners (either immediately or after a short trial period). In another form, there may be one or more senior partners, and one or more categories of associate partners. In either case, the medical physicist should discuss partnership mechanisms available.

The group may also have a corporate structure. Usually the particular form of corporation adopted by medical groups is the Professional Corporation (P.C.). There are several benefits of corporate structure that are not available to loose associations or partnerships. These include limited liability for errors by other members of the group and tax consequences for certain benefits. All professional members (who are usually stockholders in the corporation) are employees of the corporation as are members of the non-professional staff. Only stockholders have voting privileges, and it is desirable for the medical physicist to be a stockholder if this is legally permitted.

C. Private Medical Physics Practice

This type of practice refers to the medical physicist who is self-employed or is a full partner in a medical physics consulting group. In this context, the medical physicist is responsible for all aspects of conducting a private business. The variety of contracts involved with this type of practice can be quite diverse; so can the business arrangements for profit sharing, retirement, vacation coverage, and other such benefits. General guidelines to consider for this type of practice will be presented in a subsequent section.

As with any other type of employment, there are advantages and disadvantages to this type of employment. A major consideration that needs to remain constantly in business negotiations is that benefits such as medical insurance, retirement, disability, continuing education, and coverage during any absences are as much a cost of doing business as automobile expenses, office supplies, equipment, secretarial expenses, etc. These costs must be factored into contracts and hourly or daily consulting fees.

1. Possible advantages of private medical physics practice:

a. Scope of work can be strictly defined.

When formulating a contract with a client, the scope of work needs to be as precisely defined as possible. If additional services are required, any changes can then be negotiated. In other words, if additional equipment, new modalities or new facilities are added, the contract coverage and compensation can be modified. In an employee relationship, this ability is rarely an option, since one is usually asked to do more with less.

b. Immediate vesting in a retirement plan with complete control over investments.

As a solo practitioner, the medical physicist can establish a pension or profit sharing plan, which has major tax benefits. Most employers require a minimum of five years to become fully vested and may charge substantial penalties for withdrawal of any pension funds prior to retirement age. Frequently, this penalty applies even if one changes employers and desires to roll existing retirement funds into a new fund.

c. Potential added income tax benefits for the self employed.

Many expenses may be directly deducted as "business" expenses including meals, travel, office equipment, professional equipment, supplies, telephone, business gifts, entertainment, etc. Even though one may encounter these expenses as an employee, many are not eligible for deduction as "employee related business expenses" and, if they are eligible, they are subject to the base deduction criteria.

d. "Client" benefits are greater and more cost effective.

It may be more advantageous for the "client" to deduct the medical physicist cost as a contractor rather than an employee. In addition, the client may not require a full-time physicist, but may only need specified services (e.g., diagnostic equipment acceptance testing, performance evaluations, radiation safety services, shielding design, temporary assistance to in-house physicist). However, the professional medical physicist has an ethical responsibility to inform the client when full-time or additional medical physics services are required. Inadequate or incomplete coverage due to an overwhelming workload or a lack of understanding by the client about the scope and responsibilities of medical physics is not an acceptable practice.

2. Possible disadvantages of private medical physics practice:

a. Medical insurance is frequently more expensive.

Medical insurance outside of large group plans is usually more expensive for small self-employed practices. This is rapidly changing, since more opportunities are becoming available for small firms and medical costs through corporations are becoming more expensive.

b. Professional liability insurance is mandatory.

A medical physicist in private practice must have professional liability insurance. This insurance was previously difficult to purchase, but it is now readily available through the AAPM. Some employers’ professional liability coverage may provide adequate coverage for the employer but insufficient coverage for the employee.

Therefore, medical physicist, as employees, should consider purchasing professional liability insurance and consult a tax expert on the ability to claim their expenses as a tax deduction.

c. Disability insurance is an "added" expense.

Disability insurance is frequently an "employer provided benefit," and the self-employed must purchase independent disability insurance. Again, employer-provided disability insurance may be inadequate for one’s needs. If purchased independently from "taxable" dollars, the benefits from an independent plan are usually non-taxable. In addition, there are independent disability plans, which become effective if you are no longer able to practice your profession, whereas with most employer provided plans, one must be unable to work in any type of job before being able to collect.

d. Uncertain job stability.

Contracts with clients are subject to termination, competitive bidding, and, if nothing else, the hassle of negotiating contract renewals. The terms of contracts may possibly be lengthened in order to reduce the frequency of this process and the grounds for termination specifically defined. This process may, in fact, provide a more stable environment for a specified period of time than employment especially under an "employee at will " situation.

e. No sick leave, vacation, or professional development time.

If provision for this time is not included in contracts, then acceptable temporary coverage must be provided. This expense should be included in the final contract price.

f. Areas of authority and supervision may be uncertain.

In a clinical situation, the authority of the medical physicist as well as the supervisory role (e.g., supervision of dosimetrists who are hospital employees and any authority over technical staff) is often unclear and may lead to conflicts. These relationships should be identified in the professional services contract (Ref paragraph IV, C,3).

g. Private practice business operations.

Conducting the "business" operations of a private practice does take time. Details pertaining to expense accounting, insurance, retirement plans, equipment purchase and maintenance, contracts, attracting new business and maintaining current business, etc. are time consuming.

3. Types of private medical physics practices:

a. Solo medical physics general practice.

In this type of private medical physics practice, the medical physicist is the sole proprietor of the business and operates independently of any other physicist. The medical physicist provides services to multiple clients under separate contracts. The form of private practice with the simplest administrative structure is the individual physicist. In this case, there are no inter-professional problems within the practice, and it is obvious to all that will provide services to the client. This is a common form of private practice. It calls for the widest range of both physics and business skills. Despite working alone, the individual physicist should investigate the possibility of incorporation, particularly if there are plans to employ or contract with others for specialized clerical or physics needs. If an individual physicist does use other physicists for substantial periods of time, the practice resembles a group practice more than an individual practice. Many individual practitioners have found it convenient to join a radiology or radiation oncology group or a group of other physicists. In both cases, the purpose of grouping is to share resources and expenses. The flavor of independent practice can still be retained if clients are kept separate and shared services are prorated.

b. Solo medical physics institutional practice.

In this case, the medical physicist has a professional services contract primarily with one institution or one company. Care must be taken to assure that the Internal Revenue Service requirements pertaining to an independent contractor are met. For example, "independent contractors" must control their own hours and schedule, and must not receive employee benefits from their institution. Guidelines and references concerning "worker classification" may be available through the ACR Legal Department, the IRS, or your personal attorney.

c. Group medical physics general practice.

In a group practice, multiple medical physicists have joined together to combine their talents and resources to provide a broad-based practice. It is definitely recommended that this type of practice strongly consider incorporation especially for liability reasons. Consultation with an attorney who is intimately familiar with professional practices is highly recommended. In a group practice, work and income are shared. The formulas for sharing vary from group to group. Due to their nature, certain activities will require specific assignment to individual members of the group. Other activities may be shared. Some groups prefer rigid assignments, while others employ a more flexible agreement.

Options for sharing the group’s income are many, but may be limited by either current tax laws or the group’s incorporation charter. The personal preferences of the members of the group for salary and types of fringe benefits are also important. It is desirable to have some flexibility in remuneration to allow for fluctuations in the group’s income. Whatever formula is used, it should be well understood and agreed to by all members of the group.

Often, groups start with a "handshake" agreement. Unfortunately such agreements frequently lead to problems later on when circumstances change. It is better to have a carefully drawn contract, which spells out the relationship between the parties and response to possible crises such as group dissolution, termination of one member, death or disability. No matter what form the agreement takes, it should be equitable to all parties.

Groups may be formed as partnerships or as corporate entities. The former is less flexible, and is rarely preferred. Corporations can be "public" (in which case stock is available for sale) or "closely held" (in which case the stock is held only by members of the group). A regular corporation is the most flexible, since it can invest in other companies and retain earnings. A professional or "Subchapter S" corporation is exempt from corporate taxes but cannot accumulate earnings or make investments.

d. Group medical physics institutional practice.

In this case, the medical physics group has a professional services contract primarily with one institution or one company. The comments pertaining to the solo medical physics institutional practice also apply in this situation.

III. EMPLOYEE/EMPLOYER RELATIONSHIPS

A. General

The most common type of work relationship that the new medical physicist will find will be as an employee of an organization. That organization may be a community hospital, a large academic institution, or a medical physics group. Usually the larger institutions define the duties, the responsibilities and the benefits of the medical physicist more clearly.

B. Duties/Responsibilities

This is a broad area, but it is most important to get a complete, specific, and clear understanding of what services are to be provided for the employer. It is highly desirable to have a written description of these duties and responsibilities (Section IV).

C. Chain of Authority

With the changing atmosphere in health care, there have also been changes in the relationships of the medical staff and the hospital administration. In general, it is beneficial to report to the medical director for clinical matters and the facility’s senior administration (e.g., vice president) for administrative matters.

D. Benefits

The monetary value of benefits commonly totals over 25 percent of the actual salary. Any agreement should clearly specify what benefits are included and when such benefits increase. A listing of some common benefits include:

1. Medical Insurance (individual or family). There are many medical insurance plans available and they vary widely in the benefits and cost to the employee. Each plan should be carefully studied to ensure that particular needs are met.

2. Dental Insurance (individual or family).

3. Life Insurance. This insurance is usually term insurance with a base amount paid by the employer and additional amounts available at extra cost to the employee.

4. Disability Insurance. This employer-provided insurance is usually for a defined dollar amount, which is taxable since it is paid in pre-tax dollars. It may also become effective only in the case of total disability after 90 to 120 days. Depending upon the coverage provided by the employer’s policy, private disability insurance might be necessary. Private disability insurance is less expensive when the physicist is young and healthy, so this option should be thoroughly reviewed early in one’s career. The benefits are generally non-taxable; it remains in effect even with employment changes; and some policies become effective if one cannot practice rather than requiring complete and total disability. These aspects should be discussed with an insurance agent.

5. Vacation, Holidays, and Sick Days (PTO, Paid Time Off). The average number of vacation days according to the 1996 AAPM salary survey was 20. The reported average number of holidays was 9, and sick days were 11.

6. Meeting Allowance. In the past, it has been standard practice for an employer to provide funding for professional meetings. The number of days and the reimbursement should be clarified at the outset, as funding for these types of activities is becoming scarce.

7. Professional Society Membership Fees. This benefit is frequently offered by employers.

8. Malpractice (professional liability) Insurance. Verify the coverage of this employer-provided insurance. One may need to purchase additional private insurance (See Section on Professional Liability Insurance) .

9. Child Care and Elder Care. This may be provided by an employer, usually at additional cost.

10. Parking or Other Transportation Issues.

11. Tuition Reimbursement (individual and family).

12. Profit Sharing and Fund Matching. There are many different types of retirement and pension accounts. Verify the time that it takes to become fully vested, the ability to roll over the vested funds if employment changes, whether the program is fully funded by the employer, and whether one may individually supplement it.

13. Outside Consulting. This may or may not be permitted. Consulting for medical physics services may be handled differently from consulting as an expert witness.

E. Medical Staff Membership

Membership on the medical staff is desirable for medical physicists regardless of the employment arrangement. However, it should be realized that full membership on the medical staff is generally limited to physicians and dentists or is otherwise restricted by state statute or institutional bylaws. In such cases, medical physicists may not be allowed to become full members of the medical staff even if the climate at the facility is otherwise favorable. In many cases, the appropriate membership is entitled, "Associate Staff" or "Professional Staff." This appointment is often accorded to clinical psychologists. This type of membership may not carry the same protection and privileges as full membership. It should also be realized that although full membership on the medical staff does protect an individual from termination from the medical staff, it does not protect the individual from termination by the facility if one is an employee or has a contract with the facility. A physician terminated by a facility may still continue to practice in the area since the physician may bill patients directly for services rendered. Since, at the present time, such billing may not be done by a medical physicist, it is unlikely one could continue to work in the community if terminated by the facility. Membership on the medical staff does affect how medical physicists are viewed by other professionals at the facility and can thus affect the physicist's effectiveness.

F. Credentialing

Credentialing is the process by which an institution confirms that a practitioner is qualified before extending delineated clinical privileges. It should be understood that being credentialed and being on the medical staff are not the same thing. In most institutions credentialing is required of physicians and other members of the medical staff by the medical staff bylaws. However, it is possible for professionals who are not members of the medical staff to also be credentialed. Such groups include clinical psychologists, pharmacists, nurses, technologists and medical physicists.

Physicists who are employees of a facility usually have a job description that may contain a detailed list of services to be performed. However, it may not necessarily list the qualifications of the person performing those duties. If physics services are provided by an individual or group under contract, there is also usually a detailed list of services to be provided. But, again, the qualifications of the person or persons performing the work may not be listed. In addition, job descriptions and contracts represent the understanding of a limited number of parties at a particular time. Thus they do not represent an unending commitment from the institution to utilize only the services of qualified medical physicists. Therefore, regardless of the type of practice arrangement, it is desirable to address documentation of credentials and delineation of clinical privileges in addition to any job description of contract. Failure to do so may leave the facility and/or radiologists without guidance and assurance of competent physics support, and leaves the physicist in a less advantageous position if the institution desires replacement with a less qualified individual.

Credentialing decisions rest with the institution's governing board. However, the criteria for credentialing are usually developed by the medical staff in consultation with the chiefs of departments. In many cases, state licensure and certification by an appropriate board (such as the American Board of Radiology) is sufficient by itself. For a medical physicist, the criteria might include minimum educational requirements as well. A sample application for credentialing is given in Appendix B.

Clinical privilege delineation also varies widely among institutions. In some cases, privileges are broadly defined. For example, a radiologist might ask for the privilege to practice diagnostic radiology (as opposed to therapeutic radiology). On the other hand there is a trend toward more specific delineation of privileges. For example, extending diagnostic radiology privileges for conventional imaging, MRI, interventional mammography, ultrasound, etc. In almost all cases, however, the list of clinical privileges is much less detailed than a job description.

The process of developing a list of clinical privileges for a specific professional position usually is carried out at the departmental level. In institutions that do not already have clinical privileges defined, physicists are advised to initiate discussions with the departmental chair. The actual form of the resultant document will depend on circumstances, but the sample in Appendix B can be used as a guide.

IV. WRITTEN AGREEMENTS

A. General

Regardless of the type of practice arrangement, a written agreement is highly recommended and extremely advantageous. The document should spell out the agreements of the contract including the services to be provided, the remuneration to be received, the conditions of employment or contract, the minimum duration of the agreement, and the grounds and process for termination. People and circumstances change with time, especially in the current managed care environment. A written contract serves as the basic reference document to define and clarify existing commitments and also serves as a foundation from which new relationships and new understandings can be built. A written agreement is also an excellent vehicle to define, during negotiations, the roles and expectations of both parties. Without such a document, too much is subject to the memory, interpretation and assumptions of each party.

The type of written document will vary depending upon the type of practice. The provisions listed in Section IV-C may or may not be included in every document, but they should at least be addressed in the thought process. The exact chronology and details of any negotiation process depend upon the particular situation, the competition for the contract or position, the personalities involved, etc. In some cases, a standard contract or employment agreement may be the only document offered. The hospital or group may or may not allow changes to this "standard," but any questions or reservations should be clarified during the negotiation phase. In other situations, especially as a private consultant, the medical physicist may be able to offer a previously drawn personal contract to the client.

B. Legal Advice

1. General. The medical physicist should seek competent legal advice at the very beginning of the negotiation process. It is necessary not only to ensure that the resulting document is lawful and binding, but it is also necessary to have a legal advisor with one’s best interests as the primary goal. The lawyers for hospitals and other groups are protecting their clients, not the physicist. The final contract, which results from negotiations, is, hopefully, a compromise between the two parties. Even if the medical physicist is offered a "take-it-or-leave-it" proposition, a personal lawyer can advise the physicist of potential pitfalls, risks, and liabilities and the lawyer can be a valuable negotiating voice for the medical physicists.

2. Selecting an attorney. When selecting an attorney, first:

a. Determine what type of legal assistance is necessary. Most local bar associations offer a referral service, which can be of some initial help.

b. Gather a list of candidates.

c. Prepare questions and interview each candidate.

3. Fees. The "flat fee" or set charge for these types of services is a common fee arrangement. This is the easiest charge to check and compare, simply call several lawyers and determine their fees for this work. Hourly rates are the most common type of fee. Rates vary greatly, and charging is performed by the attorney for each hour spent reviewing the contract and each hour spent reviewing it with the physicist. Hourly attorneys often require a "retainer" (i.e., a down payment), and if the attorney spends less time than the retainer, a refund is in order. Contingency fee arrangements are not a normal mode of payment for this type of work. A consulting medical physicist will most likely encounter instances when a contract review by a qualified attorney is desired. It is therefore in one’s best interest to find an attorney who can be relied upon for ongoing advice and with whom a comfortable relationship can be developed.

C. Specific Provisions

The following list covers the majority of topics that should be incorporated into a written agreement. Item 1 applies primarily to an institutional practice as a professional service contractor, and also applies to most employment contracts. Items 2-9 describe a few extra specifics, which apply to an employment contract, and Items 10-13 apply to specific private practice situations.

1. Services, Scope of Work, and Standards. The services to be provided, the scope of work, and the standards by which the work is accomplished should be identified. In order to properly bid for any contract, the scope of work and time involved definitely need to be identified. Accurately estimating the time involved and the staffing required to fulfill the obligations of the contract is very important. Overextending resources will invariably lead to insufficient coverage and an inability to meet standards. Questions such as the following need to be addressed:

a. What equipment and facilities are to be covered by the medical physicist?

b. How will adjustments to the contract be made if additional equipment or facilities are added in the future?

c. For radiation oncology, what is the patient load to be covered? At what point (number of new patients, or daily patient load) will adjustments to the contract be made to allow for additional manpower?

d. What standards will be followed? This could be fairly broad, such as providing professional medical physics support consistent with the facilities and equipment available and the standards established by the medical physics community and the American College of Radiology. Selection and strict compliance with these standards are subject to the professional judgement of the medical physicist (i.e., what calibration protocol does one choose to follow, how should a specific test be conducted, and what tolerance levels are acceptable). If the contract includes specific AAPM task group reports, NCRP reports, state or federal regulations, etc., the medical physicist must be careful to include the right to exercise professional judgement whenever necessary. In some cases, such as compliance with state regulations, there is no option; however, an option should be maintained whenever possible. The professional medical physicist should only agree to provide those services for which the physicist is deemed qualified. These medical physics services should be maintained in such a manner that a department or group would be eligible for accreditation by appropriate review agencies such as the ACR. The physicist should have copies of, or access to, any documents referenced in the contract. The physicist should read and be familiar with all references (e.g., hospital bylaws).

e. What clinical coverage (i.e., presence in the clinic) must be provided? When can equipment calibration and maintenance be performed? If the institution has a heavy workload, wants physics coverage during the entire workday, and equipment calibration and testing can only be performed during non-clinical hours, then more than 1 FTE is probably needed. Also, is coverage required during vacation, illness, or continuing medical education? If it is only required that the physicist be available via pager, for example, then the amount of time allowed away from the clinic should be defined (e.g., four weeks vacation, eight holidays, two weeks illness).

f. What physics resources (FTEs) will be required to adequately provide the contracted services?

g. What physics support personnel will be provided by the hospital? What are the staffing levels that will be provided and maintained? The institution should agree to employ only those individuals who meet the standards of training and experience agreed upon jointly by the physicist, radiologist or radiation oncologist, and administrator. The physicist should have the authority to set the standards and qualifications required for any jobs involving medical physics or medical physics support.

2. Remuneration. When determining fees for service, the medical physicist in private practice should consider the following expenses involved in providing services and conducting business. As an employee, many of these items are usually provided by the employer and may be overlooked by the medical physicist just entering private practice. If the medical physicist is negotiating an institutional contract, equipment and office expenses may be provided by the institution as part of the contract. Multi-year contracts should have an annual inflation adjustment included. If this is not possible, then the initial cost of the contract should take the duration of the contract and subsequent inflation into consideration. The following expenses should be considered:

a. Office Expenses

i. Secretarial Support (salary and benefits)

ii. Office Equipment (typewriter, computer system, telephone, copy machine, cellular phone, pager)

iii. Office Equipment Usage Fees (maintenance, repair, and replacement)

iv. Office Supplies (paper, postage, computer software, etc.)

v. Office Space Rental, Utilities and Insurance

vii. Internet Service

b. Professional Services

i. Accountant

ii. Lawyer

iii. Locum Tenens (as extra staff or for absences during vacation, illness, professional meetings and seminars)

c. Medical Physics Equipment (purchase, calibration, repair, and replacement)

d. Continuing Education (meetings, seminars, books, journals)

e. Automobile Expenses (purchase or lease, maintenance, replacement, insurance, parking)

f. Meals and Entertainment (meals away from home, entertaining current and potential clients)

g. Travel (airfare, lodging, rental car, etc.)

h. Malpractice Insurance

i. Taxes (self-employed social security, Medicare, income taxes)

j. Benefits (medical insurance, disability insurance, retirement or profit sharing)

k. Salary

3. Authority and Supervision. It is important to establish the line of accountability and authority for the medical physicist. For example, the radiation oncology physicist shall be accountable directly to the medical director of radiation oncology. Where the physicist is employed in a setting that precludes reporting to the medical director on administrative matters, the physicist should be administratively accountable to the appropriate senior administrator. In addition, the radiation oncology physicist shall direct the radiation oncology physics program, including the technical direction of medical dosimetrists, therapy equipment engineers, and other physics support staff personnel. In situations where the medical dosimetrists and/or other physics support staff personnel are hospital employees and the radiation oncology physicist is under a professional services contract, the authority of the medical physicist must be clearly defined. The medical physicist should be responsible for the evaluation of such individuals and for making recommendations directly to senior level management for the hiring, firing, and disciplining of medical physics support staff. Changes in department directors or chief therapists may create authority problems and conflicts if the physicist’s supervisory and management role is not clearly defined.

4. Equipment Requirements, Replacements, Upgrades. The availability of modern equipment is essential for the practice of medical physics. It is in this area that the physicist’s professional administration is essential. If the medical physicist does not provide equipment, the written agreement should state that the hospital will furnish all of the necessary equipment, facilities and funding required for the effective and proper practice of medical physics. It should specify in detail the mechanism by which the need for new or replacement equipment will be determined and the procedures to follow in budgeting, purchasing, and amortizing. The written agreement should also specify that the medical physicist is an integral part of the team that selects all major diagnostic and/or therapeutic radiology equipment and accessory devices.

5. Maintenance. The medical physicist should be the focal point for all equipment maintenance. The written contract should specify that the hospital will maintain and repair its equipment and facilities to a mutually agreed standard. The facility will also provide and maintain utilities, service, and physical upkeep of the physics office and laboratories.

6. Exclusivity. The medical physicist should insure that exclusive rights to provide medical physics services to the area of specialty are delegated to them. If the institution has an open staff arrangement with the physicians, major confusion would exist if each physician wanted to utilize his or her own physicist. This situation would be inefficient and create major confusion within the department or institution.

Separate contracts and physics support for different specialty areas are viable (e.g., separate physicists for diagnostic radiology and radiation oncology);

however, responsibilities in overlapping areas such as radiation safety should be clearly defined.

7. Intellectual Property. Identification and clarification of intellectual property is important and should be defined. Considerations include the definition of intellectual property, ownership of intellectual property and the final ownership in case of termination.

8. Contract Terms and Renewals. Ideally, it would be beneficial to have a contract automatically renew after a specified time period unless either party gives ample notice (e.g., six months or 90 days) that the contract is to be terminated or re-negotiated.

9. Professional Liability Insurance. Considerable thought should be given to one’s professional liability (medical malpractice) coverage. Many patients may be adversely affected by a single misadventure.

Most likely, the full-time employee is provided coverage by the employer, but every medical physicist should carefully review that liability coverage and its possible limitations. It may be in one’s best interest to invest in further personal coverage.

The non-employee medical physicist will usually find it imperative to purchase coverage, as many hospitals require that independent contractors provide their own personal liability coverage, often specifying the limits themselves.

10. Outside Professional Activities and Non-Competition Clauses. The opportunity to become involved in many professional outside activities such as professional societies, teaching, research, and additional consulting will present itself. For the private consulting physicist, these activities may not present a contractual problem unless there is a non-competition clause in their contract with the institution, which restricts additional consulting. If the institution requires a non-competition clause, wherein one is restricted from providing physics services to the institution’s competitors, it is recommended that a distance limitation (e.g., 100 miles) to this restriction be defined. Before accepting any additional work, the medical physicist should verify that he or she is not overextending his/her resources and is still able to meet existing commitments.

It is suggested that verbiage such as "full-time" be avoided in a contract or at least that the term "full-time" defined. Secretarial support for professional society activities should be identified if this involvement is important to the physicist.

11. Termination. The exact conditions under which a contract may be terminated must be fully defined. In situations where it is stated that the contract may be terminated "for cause," "cause" should be specifically defined. For example, cause may be defined as fraud, embezzlement, gross misconduct or felony conviction. The effective date of termination must also be stated. A five-year contract that may be terminated within 30 days is really a 30-day contract. It is beneficial to define who has the authority to approve termination, and it is recommended that such a decision must be a unanimous decision between, at least, the medical director and CEO or the appropriate senior vice president. It is also recommended that any act or failure to act is identified in writing and that the medical physicist be given at least 30 days to correct or remedy such act.

It should also be stipulated if tail-end malpractice endorsements are required upon termination, who such insurance should cover (i.e. institution, physicist, or both), and who is responsible for payment of such coverage.

12. Amendments. Any written agreement should have provisions for amendments. It should be explicitly stated that all amendments should be clearly stated, must be in writing, and must be signed by both parties. Failure to approve a proposed amendment should not be grounds for termination of the contract.

13. Miscellaneous. The medical physicist should be entitled to any benefits or perquisites afforded other medical staff.

V. RELATIONSHIPS

A. Relations with Physicists

Medical physicists should treat each other in a professional manner. They should compete only on the quality of service.

B. Relations with Radiologists and Radiation Oncologists

The medical physicist is a colleague of the radiologist and radiation oncologist.

Physicists should provide accurate, up-to-date information to their physician colleagues. If the physicist believes that a patient is not receiving proper care, this should be discussed with the radiologist or radiation oncologist, and, if necessary, with other professionals and the administration of the facility. At no time should the physicist interfere with the doctor-patient relationship.

C. Relations with Physicians Outside of Radiation Medicine

The medical physicist should be considered a health professional by physicians. The physicist should assist these physicians whenever possible.

The physicist should avoid taking sides in disputes among physicians and should remain as impartial as possible. At no time should a physicist undermine the patient's confidence in any physician

D. Relations with Regulatory Agencies

Physicists frequently deal with federal and state regulators, and in many cases are the primary contact with such agencies. At all times the physicist should conduct himself or herself in a professional manner, and should act as an advocate for the client without acting in any way illegally, dishonestly or unethically. If the physicist becomes aware of violations of federal or state regulations, it is necessary to report them; but this should never be done without the knowledge of the employer or client. The responsible physician and then the facility administration should be notified, and appropriate action taken at this level first. There are statutes in existence to protect so-called "whistle-blowers," so that if the medical physicist must report a violation against the facility, the facility, legally, may not take punitive action.

E. Relations with Patients

The medical physicist should provide services in such a way that maximum benefit to the patient is obtained. The physicist should limit activities to competent practice areas. In dealing with patients, the physicist should provide identification as a medical physicist, and should, if appropriate, indicate education, training and experience. The medical physicist must not offer medical advice to the patient.

F. Relations with the Public

The medical physicist is an expert in this chosen profession and should be available to the community to provide expert opinion. At all times the physicist should conduct activities professionally, and should base his or her statements on scientific principles and fact. To avoid damage to one’s reputation, as well as to medical physicists as a whole, the individual physicist should not comment on areas with which the physicist is not thoroughly familiar.

Appendix C - Retirement Plans

Useful Links

ACR Guide to Medical Physics Professional Practice