PURPOSE:We report our experience with the implementation of a same-day simulation and treatment C-arm linear accelerator (linac)-based stereotactic program for patients with intracranial and extracranial metastatic disease. METHODS:Between May 2021 and October 2023, patients were treated in our same-day program with linac-based SRS/SBRT. Two slots per week were offered. Patients with expedited clinical needs, able to undergo SRS/SBRT simulation and treatment, were considered. Extracranial treatments were required to meet standards for automated intensity modulated radiation therapy (IMRT) optimization. Intracranial treatments were limited to 1-3 lesions and 1-2 isocenters. The day before treatment, the patient needed to be identified, and any diagnostic imaging had to be available for the physician and dosimetrist to discuss the plan. On the day of treatment, simulation was scheduled for 8 AM and treatment at 4 PM by default, with the goal to complete treatment by 6 PM. We analyzed information about each patient's treatment plan and time spent on each step of the workflow. RESULTS:Ninety-seven patients followed our same-day workflow and were included in the analysis. Seventy-five patients received intracranial SRS (57% to 1 lesion), while 22 patients received extracranial treatments (50% to the extremities). Simulation often required additional time to be completed, finishing a median 18 min (IQR 5-40) after the goal end time. The median time between simulation completion and end of the same-day treatment was 7.8 h (IQR 7.4-8.6). Treatment technique and the number of target volumes had a significant impact on planning time. The median treatment end time was 5:13 PM (IQR 4:46 PM-6:01 PM), with 74% ending by 6 PM. CONCLUSIONS:A linac-based program to treat patients with SRS/SBRT in an expedited fashion was established and successfully treated patients in a same-day timeline. Careful selection of planning techniques to limit plan complexity and adding automation in time-consuming parts of the process are crucial when developing expedited workflows.

This work of fiction depicts a scenario in which a faculty member felt they were criticized unfairly and inappropriately for honesty on a faculty survey, which reflected poorly on administration. The faculty member was left struggling with how to respond to conflicting feelings and perception of misaligned goals and mission. Simultaneously, the department chair felt they were blindsided by issues that could have been addressed without the embarrassment of a poor survey. The intended use of this case, through group discussion, self-study, or role-play, is to encourage readers to discuss the situation at hand, inspire professionalism and leadership thinking, and allow the practice of conflict management. Facilitator's notes are available upon request to the MPLA Cases Subcommittee. This case study falls under the scope of and is supported by the Medical Physics Leadership Academy (MPLA), a committee in the American Association of Physicists in Medicine (AAPM).

The American Association of Physicists in Medicine began the Medical Physics Leadership Academy Journal Club in the fall of 2020. The initiative was launched to provide a forum for medical physicists to learn about leadership topics using published material, discuss and reflect on the material, and consider incorporating the discussed skills into their professional practice. This report presents the framework for the MPLA Journal Club program, describes the lessons learned over the last 2 years, summarizes the data collected from attendees, and highlights the roadmap for the program moving forward.

Dear Editor Methods of electron beam prescribing and treatment planning have evolved. In the past, physicians practiced “the art of electron radiotherapy”: an electron beam treatment would be prescribed based on a physician's clinical training, comfort, and previous experiences. Modern methods apply the concept of “absorbed dose” based on reliable absolute dose calculations and isodose distributions that are displayed in the treatment planning system (TPS). Modern treatment plans are developed to meet target coverage and normal tissue tolerance goals. Despite advances with modern TPSs, some physicians still prescribe electron plans to a standard isodose line (e.g., 80% or 90% isodose relative to the dose at dmax along the central axis), and the medical physicist computes the monitor units using tabulated data. Although the physician's comfort level takes precedence and should be respected, this traditional method cannot entirely be reconciled with clinical (in vivo) measurements or the absorbed dose calculations from accurate algorithms. For example, in the presence of a curved patient surface, the dose to clinically relevant areas has been shown to be different than the dose expected from a simple calculation using tabulated data.1 Accurate dose computation algorithms can be validated against quantitative dosimetry data. Notably, quantitative dose calculation methods are recommended by the American Association of Physicists in Medicine (AAPM).2 These classic rules of thumb, while convenient, are neither quantitative nor practical in many situations. Technical challenges abound for the full quantification of the dosimetric effects of custom skin collimation, but at least the thickness of the collimation can be determined more quantitatively than by using a rule of thumb. TG-25 recommends that clinicians first determine the desired amount of transmission and then choose the appropriate corresponding thickness to achieve that goal—material transmission data must be measured. TG-25 states that “in most cases of external shielding, a transmitted dose value of < = 10% is considered acceptable.”4 The AAPM advises quantitative approaches in other areas of radiotherapy, such as for analysis of couch tops, beam modifiers, internal electron shielding, and immobilization devices.6 Practicality is relevant in custom skin collimation because devices are often fabricated while the patient is waiting in the treatment position. Using less material results in quicker fabrication time. The thickness of the shielding material also affects patient comfort. In the United States, lead sheets can be purchased in thickness increments of 1 or 1.6 mm (1/16th inch). Using the rule-of-thumb methods, either 4.5 or 5.5 mm of lead is needed to collimate a 9 MeV beam (Table 2). However, either 5 or 6 mm (in 1 mm thickness increment) or 4.8 or 6.4 mm (in 1.6 mm thickness increment) need to be placed clinically. The resulting device needed to shield a large area is often quite heavy for the patient. Quantitative data show that a 3 mm thickness of lead can achieve < 10% transmission for a 9 MeV beam (Table 1), suggesting that practical shielding for 9 MeV beam would require about 1/3 less lead than what the rule of thumb prescribes (Table 2). This quantitative approach enables a user to make the skin collimation device faster and lighter. Another argument for adopting the quantitative approach applies when using lead-equivalent materials. These alternative materials, such as leaded vinyl, gamma putty, heat-malleable Matrix, and so forth (Radiation Products Design, Inc., Albertville, MN), offer the practical advantage of being easier to cut and mold than metallic lead sheets. However, a larger thickness of lead-equivalent materials is required for the same shielding effect as lead. For example, 4 mm thick leaded vinyl is equivalent to 1 mm of lead metal for 6 and 9 MeV electron beams (measured by the author, and described by the vendor).7 Using our previous example of a 9 MeV beam, this would result in 18–22 mm thick leaded vinyl (Table 2). Such a thick device does not conform well to skin or clear the limited space under the mounted electron cone at SSD = 100 cm, and it is often too thick to be easily taped onto the skin, especially if it must be placed on a patient's side. If 90% or 95% dose reduction is acceptable by clinicians for the specific case, then the amount of material used can be reduced by about 6–10 mm compared to the “rule-of-thumb” thickness (Table 2). If an even lower dose reduction is clinically acceptable, then the material's thickness and weight can be further decreased and would likely be more practical. Table 1 summarizes the authors’ transmission data for several typical thicknesses of lead or leaded vinyl for 6 and 9 MeV. As the table shows, if the practical limitation is that the clinician wants as much shielding as possible but without a threshold, then lead thickness as low as 1.5 mm can be used for 9 MeV and 1.0 mm can be used for 6 MeV, both achieving more than 40% dose reduction compared to without any lead. Many electron beam radiotherapy cases could benefit from applying the standard of quantitative analysis instead of rules of thumb to custom skin collimation. The benefits include less time needed to create the device, reduced thickness and weight, and lower costs from using less material. If a department were to adopt the use of lead or lead equivalent materials for custom skin collimation, the medical physicist would relay the measured dosimetric data to the physician, who would indicate if a certain thickness of material yields a clinically acceptable shielding result. Dongxu Wang initiated the ideas presented in the document and provided the illustrative data and clinical experience with the materials discussed. Jonathan Polignani provided clinical and literary context, and helped illustrate the relevance of the ideas. Both authors contributed equally to writing the manuscript and both approved the final manuscript. The authors have nothing to report. The authors declare no conflict of interest.

The performance of a linear accelerator (Linac) depends on the integrity of its x-ray target. The sudden failure of its target not only breaks down the Linac but also could contribute significant disruptions to patient care. This work is to develop a predicative quality assurance (QA) method using Statistical Process Control (SPC) and AutoRegressive Integrated Moving Average (ARIMA) modeling to identify the risk of target failure before it occurs. In the past years, we observed two incidents of target failure among our Linacs. Retrospectively, we collected past daily QA data (from both open fields and enhanced dynamic wedge (EDW) measurements) and analyzed its historical trend using methods of SPC and ARIMA. SPC is a technique that monitors process performance based on statistical analysis. ARIMA is a time-series forecasting algorithm that can be used to estimate future values based on its past pattern. Both have been evaluated for predictive QA in radiotherapy. Application of SPC on open beam QA data would not yield an early warning signal to the pending target failures. However, when the same SPC methodology applies to EDW measurements, the control limits were breached a couple of weeks before the target failed. EDW mechanism introduces nonuniform magnification factors over its wedge-directed beam profiles and is responsible for the sensitivity of its profile to changing beam properties induced by a degrading target. Further extension of the warning period may be possible by using ARIMA modeling. Predicative QA for EDW daily data using SPC and ARIMA methods may provide an early QA warning to incoming Linac target failure.

Smart manufacturing is a popular concept for smarter decision-making and more efficient production. Although distributed methods for data management and processing in smart manufacturing have many advantages such as low cost of adaptation and convenience for local database, some methods are hard to manage variable data sources and discover proper range of data for smart decision-making. Therefore, Dataspace is considered in this article to be a feasible and effective method. From the relation-defined perspective of utilisation of industrial Big Data, the contribution is a novel industrial Dataspace design with static structure and working flow paths for smart manufacturing. In design, the industrial Dataspace platform has been proposed to accommodate smart manufacturing characteristics with the intelligence of pay-as-you-go, like harnessing distributed heterogenous data from industrial enterprises, understanding industrial data by ontology or knowledge, corelating the data with smart applications, and enabling related decisions. A further analytical case in Surface Mounting Technology manufacturing of welding procedure is provided to illustrate the execution of customisation, focused and related decision support, and system evolution within industrial Dataspace.

This work of fiction is part of a case study series developed by the Medical Physics Leadership Academy (MPLA). It is intended to facilitate the discussion of how students and advisors can better communicate expectations and navigate difficult conversations. In this case, a fourth-year Ph.D. student Emma learns that her advisor Dr. So is leaving the institution and has not arranged to bring any students with him. As Emma and Dr. So meet to discuss Emma's next steps, the conversation reveals misunderstandings and miscommunications of expectations, including a specific publication requirement for graduation from Dr. So. Having just learned of Dr. So's publication requirement, Emma realizes that graduating before the lab shuts down is not feasible. The intended use of this case, through group discussion or self-study, is to encourage readers to discuss the situation at hand and inspire professionalism and leadership thinking. This case study falls under the scope of and is supported by the MPLA, a committee in the American Association of Physicists in Medicine (AAPM).

This work of fiction is part of a case study series developed by the Medical Physics Leadership Academy (MPLA). It is intended to facilitate the discussion of the managerial and leadership challenges faced by a clinical medical physicist. In this case, a physicist David used to work in a clinic where he thrived and felt like a leader, despite not having the title. After a job change, he is now officially the "Lead Physicist" at a hospital newly affiliated with a large academic healthcare system. He believes he will be equally successful. Yet he struggles to bring about changes and get buy-in from coworkers. In the end, he feels like giving up and considers changing his job. This case is in the scenario of Problem Diagnosis.i The intended use of this case, through group discussion or self-study, is to encourage readers to perform a comprehensive analysis that identifies the root cause of the problem. This case study falls under the scope of and is supported by the MPLA, a committee in the American Association of Physicists in Medicine (AAPM).

This guide provides a framework and general steps for writing a case study for the Medical Physics Leadership Academy (MPLA).1, 2 This guide may be used as part of the Request for Proposal (RFP) for case studies in AAPM leadership-themed sessions. Consideration of the case category and learning objectives should be maintained while developing the case synopsis, case study and facilitators guide. A case synopsis is a high-level summary of the case study. An example of a case synopsis is given in Exhibit 1 in Supplemental Materials. The following components should be included: setting, including information about technology or organizational structure when needed to understand the case; plot, an explanation of the situation; discussion points; and characters, including job titles, personality, beliefs, and concerns. Remember that your case study is a work of fiction. Even when inspired by a real-life event, names of characters, locations, and institutions should all be invented. (You may use actual product and vendor names if doing so will not influence the discussion.) Developing a synopsis will help you evaluate the appropriateness of your setting, plot, and characters before writing the case study. The example synopsis in Exhibit 1 allowed the authors to identify a lack of diversity in the characters and rework them in order to reach a broader audience. It also allowed them to eliminate characters that took focus away from the learning objectives. Outlining discussion points in your synopsis will help determine what details to include in your final version. In this example, the author wanted readers to identify IT and billing as potential factors in decision-making, and identifying these factors as discussion points enabled the authors to allude to them in the final version of MPLA Case 1: Implementing Cone-Beam CT in a Community Hospital.2 without explicitly stating them. An effective case study should not have clear, black-and-white solutions, but should inspire discussion and the consideration of multiple competing factors. A good synopsis will help you with writing the case, as well as assist reviewers of your submission. An MPLA case should be no more than 2,500 words, roughly four to five single-spaced pages using 12-point font size. A reader should be able to finish the case study within 15-20 minutes to accommodate sufficient discussion time if such a case is used in a typical hour-long meeting or discussion session. For those without much experience in creative writing, seek help from expert writers and literary enthusiasts. “MPLA Case 1: Implementing Cone Beam CT in a Community Hospital”2 was written with the assistance of an English and creative writing major who worked from the case synopsis and professional case studies (non-medical physics) as models. Seek help from experts when writing about non-medical physics areas. For example, a case study about purchasing new equipment may require assistance in obtaining and presenting realistic financial and budgetary data. The facilitator's guide is a teaching note that guides instructors on how to use your case study to facilitate discussion. It should be written in parallel with the case study and stay consistent to the scenario case study defined in Step 1. See Sample Facilitator's Guide for “MPLA Case 1. Implementing Cone Beam CT in a Community Hospital”2 for a model of how to write a facilitator's guide. The MPLA Cases Subcommittee will publish a guide on writing a facilitator guide. Your case study needs to be relatable and discussion-worthy. Revisit step 1 to ensure your case study retains its real-life essence while clearly advancing your learning objectives. Seek feedback on whether desired discussion points arise naturally from your case study presentation. The MPLA Cases Subcommittee offers some support for reviewing and revising new case studies. Please reach out to the Subcommittee if you have any questions. Our contact information can be found from AAPM's website. Thank you for contributing to the MPLA's mission and have fun writing! Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

This work of fiction is part of a case series by the Medical Physics Leadership Academy (MPLA) demonstrating the use of case studies as an educational method for the development of professionalism, leadership, and communication skills within the medical physics community A facilitator's or self‐study guide is available. Please contact the MPLA Cases Subcommittee (https://www.aapm.org/org/structure/ default.asp?committee_code=MPLACA) for access.

Vendor-provided commercialized equipment and software are well accepted in the medical physics profession, since they are designed to free up physicists’ time, improve workflow efficiency, and provide higher accuracy and precision. There have been clear lines dividing three parties, at least in the field of radiation oncology: patients, health care providers, and medical device suppliers. Medical physicists (and dosimetrists) are part of the health care providers group. One of their main duties, as defined by IAEA (International Atomic Energy Agency), is “mainly related to the safety and performance of related equipment and computer systems”.1 Therefore, any financial relationship between medical physicists and medical device vendors should be clearly disclosed to avoid conflicts of interest (COI). However, in recent years, vendors of radiotherapy equipment and software are increasingly engaged in directly providing radiotherapy physics services to the clinic. This includes not only vendor-sponsored equipment commissioning but also vendor-employed dosimetrists conducting treatment planning (i.e., “software as a service” or “oncology as a service”) for radiation oncologists through its business subsidiaries.2 The vertical integration of technical services, traditionally provided separately by vendors and clinical medical physicists or dosimetrists, may lead to unavoidable conflicts of interest and thus this parallel/opposed debate on the following opinion statement: Vendor-provided clinical physics services are a disservice to patients and the medical physics profession. Parallel to this opinion is Dongxu Wang1 1 Views and opinions expressed here are this author’s alone, and do not represent those of Memorial Sloan Kettering Cancer Center. Dongxu Wang discloses the following Conflict of Interest: the author is a beneficiary of an intellectual property licensed to Ion Beam Applications, S.A. . Dongxu Wang received his PhD in Medical Physics from University of Wisconsin-Madison in 2011. After graduate school, he joined the University of Iowa Hospitals and Clinics as an Assistant Professor in Medical Physics. At the University of Iowa, he studied part-time and received his Master’s degree in Business Administration (MBA) in 2019. He is now Associate Attending Physicist at Memorial Sloan Kettering Cancer Center. Dr. Wang’s earlier expertise and focus were in proton therapy and proton imaging. Recently he became an active member of the Medical Physics Leadership Academy (MPLA), with a particular interest in using the case study method to advance the leadership and professionalism education for medical physicists. Opposed to this opinion is Per Halvorsen. Mr. Halvorsen is the Chief Physicist for the Lahey division in Radiation Oncology at Beth Israel Lahey Health in suburban Boston. He received his MS degree in Radiological Medical Physics from the University of Kentucky in 1990 and was certified by the American Board of Radiology in 1995. He has been a member of the American Association of Physicists in Medicine (AAPM) for nearly 30 yr and has been an active volunteer in professional societies, chairing the AAPM Professional Council and serving on the Board of Directors. He has authored numerous peer-reviewed manuscripts, recently as the chair of the Medical Physics Practice Guideline for Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT) and as a member of the ASTRO–ASCO–AUA Evidence-Based Guideline for Hypo-fractionated Prostate treatment. He is a volunteer surveyor for the American College of Radiology (ACR) and served many years on its accreditation program oversight committee. He is Deputy Editor-in-Chief of the JACMP, and a Fellow of the ACR and AAPM. Medical physicists and medical dosimetrists add clinical values to cancer care. Some of our services, such as treatment planning and special physics consults, are billable and therefore adding financial values as well. Driven by financial interests, as a corporate would rightfully do, some vendors want to provide medical physics and medical dosimetry services as an extension of their technical product. Serious concerns have already been raised regarding regulatory ambiguity and ethical dilemma with vendors’ involvement into routine clinical practice, as a disservice to patients and to our profession, and eventually to their core business. Radiotherapy physicists, as health care providers who are independent from medical device vendors, assume the responsibility of ensuring an FDA-cleared device is at least safe and effective. It is a key to understand that radiotherapy devices, categorized as Class II, are not subjective to extensive testing and clinical trial before FDA 510(K) clearance. Vendors certainly do not want to assume this additional liability in the first place. Any physicists who have been the early users of a newly developed radiotherapy equipment can attest to the pain and effort, despite the joy and satisfaction, in all kinds of troubleshooting for a new, advanced but complicated technology. It is important to note that not all such troubleshooting is for trivial or non-harmful flaws; rather, some of those may be significant enough to cause harm or even death to a patient, if they had not been caught by a diligent and experienced clinical physicist. A vendor-employed physicist or dosimetrist may be potentially liable for medical device defects. For example, if a dosimetrist employed and trained by a treatment planning system (TPS) vendor made a mistake in dose calculation due to a software design bug in the same TPS, is that a professional error or medical device error? With “software as service” being the business concept, is there still a boundary between a medical device and professional service? We can see two extreme outcomes with this situation. The dosimetrist alone can serve as a scapegoat, to avoid hurting sales of the TPS software. Or, the regulator may scrutinize the medical device vendor as an entirety. Heightened regulation will destroy the current entrepreneurial environment where cancer-curing technology advances fast. At present, most clinical physicists are employed by hospitals and their main duties are caring for patients. Medical physicists sometimes help vendors improve their products in commissioning and troubleshooting a new device. Had the physicists been employed by the machine vendor, who do they serve or report to? Some of the common vendor practices would be otherwise stroking serious COI concerns. A significant portion of workflow improvement or troubleshooting for a new device may take place during the treatment of a real patient, since anything unexpected can happen. And this highly depends on the physicists who are responsible for testing and commissioning the device. Now if the medical physicist is an extension of the vendor, this whole troubleshooting process could be undisclosed and patients might suffer from a nonconsented clinical trial of a prematurely engineered medical device. The prospect of medical physics being an extension of a medical device vendor’s service brings up entangled and conflicted interests. The divided professional loyalty by medical physicists is likely viewed as detriments to the best patient care. This endangers medical physics profession as medical physicists may no longer be considered the trustworthy partners of clinicians or the radiation safety gatekeepers for patients. The credibility of medical physics as an independent, board-certified healthcare profession will be at risk. Imagine a physician practice owned by a pharmaceutical company; I will think twice before seeing a doctor there, if ever. First, I should clarify that I am personally ambivalent about this topic, but the topic merits a robust debate without the distraction of focusing on any particular vendor, so I volunteered to articulate the opposing view. I am ready for the eggs. My current employer is a not-for-profit regional health system, but I previously served as Vice President for Medical Physics for a national for-profit radiation oncology service provider. In preparing for this debate, I also spoke with several physicist colleagues who are currently or were previously employed by one of the national equipment vendors. Two comments in particular stuck with me: “As a profession we’re defined by both the top and the bottom” (the latter referring to physicians in rural communities who have witnessed the effects of poor radiotherapy services) and “The whole reason we have this option is because there’s a need. Any solution needs to be weighed against the option of not addressing the need.” As a profession, I believe we should recognize three uncomfortable truths: I will address each of these points, and posit that vendor-provided clinical physics services can, when rendered in the right way, be part of the solution. A recent study describes the disparity in access to cancer care in the United States.3 Approximately 60 million Americans live in areas considered rural by the United States Census Bureau,4 and outcomes are generally worse for this patient population.5 My vendor-employed colleagues assert, and my personal experience confirms, that clinical physics coverage is considerably more variable, and more sparse overall, in such rural settings. It is not uncommon that centers rely on a medical physicist who visits the center once per month (usually outside clinical hours) to perform minimal regulatory compliance work without any opportunity for collaboration with the full clinical team to understand and improve their processes. A recent publication in the Red Journal substantiates the second uncomfortable truth: the quality of clinical radiotherapy physics services is too variable. Kearns and colleagues reported that nearly one in five institutions were found to have errors in their TPS models, and on average, a generic reference model had better accuracy than the institution’s TPS beam model.6 Perhaps most uncomfortable is the risk that a solo physicist may fall into a “protective bubble.” I worked as a solo physicist many years ago, and the experience was a strong motivation for AAPM Report 807 which, in turn, led to the TG-103 report recommending peer review for physicists in solo practice.8 A small hospital or clinic employing a solo physicist has few points of reference for evaluating their clinical physics needs, and a friendly, helpful, and ever-present solo physicist may develop a “walk on water” aura among the clinical and administrative colleagues. Consequently, it may be difficult for the physicist to explain their limitations with respect to commissioning new technology or commencing a new clinical service. So, how could vendor-provided clinical physics service be part of the solution to these concerns? First, the major vendors have a significant footprint in the radiation oncology community and may be able to pool resources (both human and technology) to serve rural clinics in a manner that no single clinic or health system could match. Second, the major vendors benefit from a large database of similar systems and employ standardized processes and reporting tools to compare every center’s systems to their national database to protect against outliers. Third, working as part of a larger team ensures that peer review is an integral component of the medical physics service. Finally, physicists working for a major vendor have access to shared tools that may not be otherwise accessible to a small center. What about conflicts of interest? Vendor-employed clinical physicists face an inherent conflict of interest which must be actively managed. COI can occur in any employment model,9 but the vendor-employed model presents some obvious potential COI, particularly during acceptance testing and commissioning of new equipment manufactured by that vendor. Standardized reporting tools can help in this regard (so an individual physicist cannot gloss over unfavorable details), as can comparison of local data to a large aggregate data pool (to confirm equipment and local physicist performance). Finally, local clinic authority via a clear governance model can play a constructive role, such as the medical director having final say on satisfaction with the clinical physics services and having those services benchmarked against relevant AAPM reports and ACR-AAPM Technical Standards. And last but not least, every physicist is personally responsible for living up to the Principles in AAPM Code of Ethics,10 regardless of their employment model. Our vendor-employed colleagues are competent, committed clinical physicists who care about their professional reputations. Similarly, these vendors have every incentive to safeguard their company’s reputation. In this respect, all parties are incentivized to perform to the expected professional standards. We have significant challenges with access to care and consistent quality of clinical physics services in the United States. The specific employment model is not the root cause of our most pressing challenges. I appreciate Mr. Halvorsen’s insights regarding the disparities of clinical physics in rural areas. I share his wish that the vendors may help fulfill the needs for consistent and available medical physics services. Unfortunately, I do not think it will work out that way, by design or by chance, because the underlying causes for these two problems will not be addressed. Access of medical physics services in rural area: Through my former state university appointments, I had the privilege to have served a handful of Midwest community hospitals, all being single-Linac operations and each requiring no more than 0.6 FTE (full-time equivalent) physicist. Indeed, medical physicists are sparser than the geographic distribution of linear accelerators themselves. I do not think a vendor can sell more physics FTE to a community practice than the current level, nor is a vendor willing to dedicate more physicists than what is worth it in the contract. More importantly, the logistical and supply–demand challenge of hiring and staffing physicists in the vast, sparsely populated rural area is almost insurmountable. As I often heard in those days, “small places are small because people don’t move there.” This challenge will not diminish just because a vendor is now providing the service, so long the service is still onsite. In fact, it can make the situation worse, now that a physicist is no longer vendor neutral. The staffing of field service engineers (FSE) from vendors is of good reference. I knew of a FSE who covered a 300-mile area stretching along the Mississippi River, and once waited 5 h during daytime for his arrival to fix a down Linac. As bad as he felt about the long delay of timely service, unfortunately, it might just be the vendor’s good business model concerning profitability vs service level. Consistent quality of medical physics services: I concur with Mr. Halvorsen that on vendor’s platform, data collection and quality control will be a lot easier. Consistent medical dosimetry and medical physics services should be expected. This might lead to higher quality as well, if the consistent standard is set high. However, medicine is a multifactorial endeavor; there is a general lack of direct evidence that any particular technical standard leads to discernable clinical outcome. This leaves plenty of room for interpretation for a range of acceptable technical specifications, and the possible justification for not having to achieve the best specification. This is likely to happen when profitability-to-effort ratio is concerned, as the business metric is much easier to establish and quantify. For example, if the vendor’s new vision is to simplify Linac commissioning by spot checking and to complete the whole process within two business days by skipping 3D water tank scanning, a vendor-hired physicist will have to align his or her practice with the organizational direction. I do not see it possible for this vendor-employed physicist to insist on a full range of beam data collection, occupying the company’s sparse (sounds familiar?) resource including the traveling installer, just to double check and independently confirm, as physicists are supposed to do. I do not disagree with Mr. Halvorsen that a well-designed governance model might mitigate some of the conflict-of-interest concerns with vendor-employed clinical physicists. Yet, this practice places medical physicists as the service branch of a medical device company, not as independent practitioners in healthcare. This alters the nature of our profession as we know it. Conflict of interest sounds theoretical and manageable until one’s paycheck is at stake. Dr. Wang argues that vendor-provided clinical physics services are subject to regulatory ambiguity — that professional services will be conflated with equipment performance, potentially leading to increased regulation which “will destroy the current entrepreneurial environment where cancer-curing technology advances fast.” I do not find this argument compelling. First, the regulators are quite adept at distinguishing between equipment safety and professional practice and maintain a firewall against unduly imposing on the practice of medicine. Second, the equipment vendors are keenly aware of the regulatory and legal environments (likely more so than most hospital-employed clinical physicists) and would take prudent measures to protect their business from such risks. Practicing in accordance with nationally recognized practice standards and recommendations is arguably one of the most effective approaches in that regard. I share Dr. Wang’s concerns regarding the ethical dilemma of loyalty to the patient and one’s employer. This is a “healthy tension” faced by all clinical physicists regardless of their employment model, although I agree it may be felt more acutely when the clinical physicist is employed by the manufacturer of the equipment used in the clinic. The AAPM Code of Ethics10 clearly states that our primary obligation is to the safety and welfare of the patient. Principle I states “Members must hold as paramount the best interests of the patient under all circumstances”, and Principle X states “Members are professionally responsible and accountable for their practice, attitudes, and actions, including inactions and omissions.” Dr. Wang mentioned that early troubleshooting for a new device often involves clinical physicists who are commissioning the equipment for use in their clinics. If such clinical physicists are employed by the equipment manufacturer, their paramount priority remains the best interests of the patient — and they may in fact be able to more effectively pursue troubleshooting and improvement of such new devices as they will have direct access to their colleagues on the product development team. As I stated earlier, the quality of clinical radiotherapy physics services is demonstrably more variable than it should be.6 That may be partly due to the prevalence of isolated practices without the benefit of working with a larger team of physicists who can share expertise, tools, and information. There are many models of group practice, of course, health systems and consulting groups being two examples. There is no inherent reason why a vendor-owned physics group practice would be an inferior model for clinical physics services. To address the concern about potential COI with vendor-provided clinical physics services, the hospital contracting for such services should insist on local clinic authority via a clear governance model and on having those services benchmarked against relevant AAPM reports and ACR–AAPM technical standards. The uncomfortable truth is that, despite all our wealth as a society, we have significant challenges with access to care and consistent quality of clinical physics services in the United States. I do not believe that the specific employment model represents one of our most pressing challenges.

Cardiac pacemakers are among the top 10 most frequently implanted medical devices in the United States.1 Radiation therapy (RT) can have adverse effects on the performance of cardiac pacemakers. As opposed to a standard subcutaneous pacemaker on the upper chest, we sometimes encounter a leadless pacemaker implanted in the right ventricle of the heart. A leadless pacemaker has the same function as a regular pacemaker but is much smaller in size and has no leads. A Micra AV dual-chamber pacemaker transcatheter leadless pacemaker is 95% smaller than typical pacemakers (Fig.

As a series of industrial Internet platforms have been launched, manufacturing facilities in the physical world, although distributed in different enterprises, are interconnected in the form of manufacturing services (MSs) in cyberspace. In this context, it makes possible for on-demand sharing of MSs as well as corresponding cross-enterprise collaboration. However, many dynamic uncertainties of both MSs and the submitted demands occur unpredictably, which seriously hinders the platforms' applications. To cope with the problem of MSs scheduling with supply-demand dual dynamic uncertainties, a three-stage approach based on an evolutionary hypernetwork model is proposed. In which, six of nine kinds of dynamic events and eighteen specific conditions are considered, and an event-condition-act mechanism is designed to guide local/global rescheduling if needed. Experimental results show the effectiveness of the proposed approach, as well as the potential of a platform employing the approach in response to different dynamic events in its application.

This work of fiction re-enacts a scenario in which a medical physics resident was not able to address a physics call during patient simulation and was criticized by the supervising faculty physicist in front of the team and the patient. The resident and the faculty agreed to meet afterwards to debrief the situation, in the hope of establishing a better working relationship. The intended use of this case, through group discussion, self-study, or role-play, is to encourage readers to discuss the situation at hand, inspire professionalism and leadership thinking, and allow the practice of conflict management. Facilitator's notes are available upon request to the MPLA Cases Subcommittee. This case study falls under the scope of and is supported by the Medical Physics Leadership Academy (MPLA), a committee in the American Association of Physicists in Medicine (AAPM).

This fictional case describes the challenging situation for a junior physicist, who joined her hometown's cancer center as a solo physicist after graduating from residency. She is concerned about providing optimal patient care as well as improving her work/life balance. She wonders how to move forward. The intended use of the case study, in either a facilitated learning session or self-study, is to inspire the readers to discuss the situation, analyze the institutional and personal factors, apply relevant leadership skills, and propose action plans. This case study falls under the scope of, and is supported by, the Medical Physics Leadership Academy (MPLA). A sample facilitator's guide or self-study guide is available upon request to the MPLA Cases Subcommittee.

This fictional case describes a managerial situation of implementing cone-beam computed tomography faced by a solo medical physicist in a rural community hospital. The intended use of the case study, in either a facilitated learning session or self-study, is to inspire the readers to discuss the situation, analyze the institutional and personal factors, apply relevant leadership skills, and propose action plans. This case study falls under the scope of, and is supported by, the Medical Physics Leadership Academy (MPLA). A sample facilitator's guide or self-study guide is included in the manuscript for reference by users of this case study.