Abstract
BACKGROUND
Spine stereotactic body radiotherapy (sSBRT) is commonly limited to 1 or 2 vertebral levels given a paucity of efficacy and toxicity data when more than 2 levels are treated.
...OBJECTIVE
To prove our hypothesis that multilevel sSBRT could provide similar rates of local control (LC) (primary endpoint) and toxicity as single-level treatment using the same clinical target, planning target, and planning organ-at-risk volumes.
METHODS
We analyzed consecutive cases of sSBRT treated from 2013 to 2017. Time-to-event outcomes for single-level and multilevel cases were compared using mixed effect Cox models and differences in toxicity rates were evaluated using linear mixed effect models. All models incorporate a patient-level random intercept to account for any within-patient correlation across cases.
RESULTS
There were 101 single-level and 84 multilevel sSBRT cases (2-7 continuous vertebral levels). One-year LC was 95% vs 85%, respectively. After adjusting for baseline covariates, dose delivered, and accounting for within-patient correlation, there was no significant difference in time to local failure (hazard ratio, HR 1.79 0.59-5.4; P = .30). Pain improved in 83.5% of the 139 initially symptomatic tumors. There were no significant differences in grade 2+ acute or late toxicities between single-level and multilevel sSBRT.
CONCLUSION
With rigorous patient immobilization, quality assurance, and image guidance, multilevel sSBRT provides high rates of LC, similar to single-level treatment, without need for larger planning volume margins. Efforts to improve prognostication and case selection for multilevel sSBRT are warranted to ensure that the benefits of improved LC over palliative radiation are justified.
While disparities in the inclusion and advancement of women and minorities in science, technology, engineering, mathematics, and medical fields have been well documented, less work has focused on ...medical physics specifically. In this study, we evaluate historical and current diversity within the medical physics workforce, in cohorts representative of professional advancement (PA) in the field, and within National Institutes of Health (NIH)–funded medical physics research activities.
The 2020 American Association of Physicists in Medicine (AAPM) membership was queried as surrogate for the medical physics workforce. Select subsets of the AAPM membership were queried as surrogate for PA and early career professional advancement (ECPA) in medical physics. Self-reported AAPM-member demographics data representative of study analysis groups were identified and analyzed. Demographic characteristics of the 2020 AAPM membership were compared with those of the PA and ECPA cohorts and United States (US) population. The AAPM-NIH Research Database was appended with principal investigator (PI) demographics data and analyzed to evaluate trends in grant allocation by PI demographic characteristics.
Women, Hispanic/Latinx/Spanish individuals, and individuals reporting a race other than White or Asian alone comprised 50.8%, 18.7%, and 32.4% of the US population, respectively, but only 23.9%, 9.1%, and 7.9% of the 2020 AAPM membership, respectively. In general, representation of women and minorities was further decreased in the PA cohort; however, significantly higher proportions of women (P < .001) and Hispanic/Latinx/Spanish members (P < .05) were observed in the ECPA cohort than the 2020 AAPM membership. Analysis of historical data revealed modest increases in diversity within the AAPM membership since 2002. Across NIH grants awarded to AAPM members between 1985 and 2020, only 9.4%, 5.3%, and 1.7% were awarded to women, Hispanic/Latinx/Spanish, and non-White, non-Asian PIs, respectively.
Diversity within medical physics is limited. Proactive policy should be implemented to ensure diverse, equitable, and inclusive representation within research activities, roles representative of PA, and the profession at large.
New technologies are continuously emerging in radiation oncology. Inherent technological limitations can result in health care disparities in vulnerable patient populations. These limitations must be ...considered for existing and new technologies in the clinic to provide equitable care.
We created a health disparity risk assessment metric inspired by failure mode and effects analysis. We provide sample patient populations and their potential associated disparities, guidelines for clinics and vendors, and example applications of the methodology.
A disparity risk priority number can be calculated from the product of 3 quantifiable metrics: the percentage of patients impacted, the severity of the impact of dosimetric uncertainty or quality of the radiation plan, and the clinical dependence on the evaluated technology. The disparity risk priority number can be used to rank the risk of suboptimal care due to technical limitations when comparing technologies and to plan interventions when technology is shown to have inequitable performance in the patient population of a clinic.
The proposed methodology may simplify the evaluation of how new technology impacts vulnerable populations, help clinics quantify the limitations of their technological resources, and plan appropriate interventions to improve equity in radiation treatments.
Purpose
Medical physics residents (MPRs) will define and shape the future of physics in medicine. We sought to better understand the residency experience, as related to resilience and well‐being, ...through the lens of current MPRs and medical physicists (MPs) working with residents.
Methods and materials
From February–May 2019, we conducted 32, 1‐h, confidential, semi‐structured interviews with MPs either currently enrolled in an accredited residency (n = 16) or currently employed by a department with an accredited residency (n = 16). Interviews centered on the topics of mentorship, work/life integration, and discrimination. Qualitative analysis methods were used to derive key themes from the interview transcripts.
Results
With regard to the medical physics residency experience, four key themes emerged during qualitative analysis: the demanding nature of medical physics residencies, the negative impacts of residency on MPRs during training and beyond, strategies MPRs use to cope with residency stress, and the role of professional societies in addressing residency‐related change.
Conclusions
Residency training is a stress‐inducing time in the path to becoming a board‐certified MP. By uncovering several sources of this stress, we have identified opportunities to support the resiliency and well‐being of MPs in training through recommendations by professional societies, programmatic changes, and interventions at the department and residency program director level for residency programs, as well as strategies that MPRs themselves can use to support well‐being on their career journey.
Head and neck (HN) radiation (RT) treatment planning is complex and resource intensive. Deviations and inconsistent plan quality significantly affect clinical outcomes. We sought to develop a novel ...automated virtual integrative (AVI) knowledge-based planning application to reduce planning time, increase consistency, and improve baseline quality.
An in-house write-enabled script was developed from a library of 668 previously treated HN RT plans. Prospective hazard analysis was performed, and mitigation strategies were implemented before clinical release. The AVI-planner software was retrospectively validated in a cohort of 52 recent HN cases. A physician panel evaluated planning limitations during initial deployment, and feedback was enacted via software refinements. A final second set of plans was generated and evaluated. Kolmogorov-Smirnov test in addition to generalized evaluation metric and weighted experience score were used to compare normal tissue sparing between final AVI planner versus respective clinically treated and historically accepted plans. A t test was used to compare the interactive time, complexity, and monitor units for AVI planner versus manual optimization.
Initially, 86% of plans were acceptable to treat, with 10% minor and 4% major revisions or rejection recommended. Variability was noted in plan quality among HN subsites, with high initial quality for oropharynx and oral cavity plans. Plans needing revisions were comprised of sinonasal, nasopharynx, P-16 negative squamous cell carcinoma unknown primary, or cutaneous primary sites. Normal tissue sparing varied within subsites, but AVI planner significantly lowered mean larynx dose (median, 18.5 vs 19.7 Gy; P < .01) compared with clinical plans. AVI planner significantly reduced interactive optimization time (mean, 2 vs 85 minutes; P < .01).
AVI planner reliably generated clinically acceptable RT plans for oral cavity, salivary, oropharynx, larynx, and hypopharynx cancers. Physician-driven iterative learning processes resulted in favorable evolution in HN RT plan quality with significant time savings and improved consistency using AVI planner.
Studies reveal that most physicians report symptoms of burnout. Less is known about burnout in mid-career medical faculty specifically.ImportanceStudies reveal that most physicians report symptoms of ...burnout. Less is known about burnout in mid-career medical faculty specifically.To characterize burnout and its risk factors, particularly differences by gender, among mid-career medical faculty.ObjectiveTo characterize burnout and its risk factors, particularly differences by gender, among mid-career medical faculty.Between August 2021 and August 2022, a survey was sent to 1430 individuals who received new National Institutes of Health K08 and K23 career development awards from 2006 to 2009. Data were analyzed between June and October 2023.Design, Setting, and ParticipantsBetween August 2021 and August 2022, a survey was sent to 1430 individuals who received new National Institutes of Health K08 and K23 career development awards from 2006 to 2009. Data were analyzed between June and October 2023.Personal and work-related burnout as evaluated using the Copenhagen Burnout Inventory (CBI). The CBI score ranges from 0 to 100, with a score of 50 or higher indicating a high degree of burnout. Multivariable models were used to investigate associations between burnout and participant characteristics, including race and ethnicity, sexual orientation and gender identity, academic rank, work climate, experiences of workplace sexual harassment, sleep hours, work and domestic caregiving time, and time allocation changes in work and domestic work hours compared with before the COVID-19 pandemic. Work climate was evaluated by a general climate elements scale assessing elements such as friendliness, respect, and collegiality, and a diversity, equity, and inclusion climate elements scale assessing elements such as homogeneity, sexism, and homophobia; higher scores indicated a more favorable view of the climate.Main Outcomes and MeasuresPersonal and work-related burnout as evaluated using the Copenhagen Burnout Inventory (CBI). The CBI score ranges from 0 to 100, with a score of 50 or higher indicating a high degree of burnout. Multivariable models were used to investigate associations between burnout and participant characteristics, including race and ethnicity, sexual orientation and gender identity, academic rank, work climate, experiences of workplace sexual harassment, sleep hours, work and domestic caregiving time, and time allocation changes in work and domestic work hours compared with before the COVID-19 pandemic. Work climate was evaluated by a general climate elements scale assessing elements such as friendliness, respect, and collegiality, and a diversity, equity, and inclusion climate elements scale assessing elements such as homogeneity, sexism, and homophobia; higher scores indicated a more favorable view of the climate.In all, 1430 surveys were sent, 926 candidates responded (65% response rate), and the analytic cohort was limited to the 841 respondents who were still in academic medicine (50.7% men). Burnout was significantly more common for women than men (mean SD CBI personal scores, 46.6 19.4 vs 37.5 17.2; P < .001; mean SD CBI work-related scores, 43.7 20.4 vs 34.6 19.7; P < .001). In multivariable models, personal burnout was significantly more likely for women (adjusted odds ratio AOR, 2.29 95% CI, 1.54-3.41; P < .001) and with more weekly hours of patient care (AOR, 1.07 95% CI, 1.00-1.15 for each 5-hour increase; P = .04). Personal burnout was less likely with more nightly sleep hours (AOR, 0.68 95% CI, 0.56-0.81 for each 1-hour increase; P < .001) and with an improved general work climate rating (AOR, 0.64 95% CI, 0.48-0.85 for each 1-point increase in general work climate scale score; P = .002). Work-related burnout was also significantly more likely for women than men (AOR, 1.77 95% CI, 1.17-2.69; P = .007). Greater work-related burnout was associated with an increase of 8 or more work hours per week compared with before the COVID-19 pandemic (AOR, 1.87 95% CI, 1.13-3.08; P = .01), more weekly hours of patient care (AOR, 1.11 95% CI, 1.03-1.19 for each 5-hour increase; P = .007), and a workplace sexual harassment experience in the past 2 years (AOR, 1.71 95% CI, 1.11-2.62; P = .01). Work-related burnout was significantly less likely with more nightly sleep hours (AOR, 0.80 95% CI, 0.66-0.96 for each 1-hour increase; P = .02) and with an improved general work climate rating (AOR, 0.49; 95% CI, 0.36-0.65 for each 1-point increase in general work climate scale score; P < .001).ResultsIn all, 1430 surveys were sent, 926 candidates responded (65% response rate), and the analytic cohort was limited to the 841 respondents who were still in academic medicine (50.7% men). Burnout was significantly more common for women than men (mean SD CBI personal scores, 46.6 19.4 vs 37.5 17.2; P < .001; mean SD CBI work-related scores, 43.7 20.4 vs 34.6 19.7; P < .001). In multivariable models, personal burnout was significantly more likely for women (adjusted odds ratio AOR, 2.29 95% CI, 1.54-3.41; P < .001) and with more weekly hours of patient care (AOR, 1.07 95% CI, 1.00-1.15 for each 5-hour increase; P = .04). Personal burnout was less likely with more nightly sleep hours (AOR, 0.68 95% CI, 0.56-0.81 for each 1-hour increase; P < .001) and with an improved general work climate rating (AOR, 0.64 95% CI, 0.48-0.85 for each 1-point increase in general work climate scale score; P = .002). Work-related burnout was also significantly more likely for women than men (AOR, 1.77 95% CI, 1.17-2.69; P = .007). Greater work-related burnout was associated with an increase of 8 or more work hours per week compared with before the COVID-19 pandemic (AOR, 1.87 95% CI, 1.13-3.08; P = .01), more weekly hours of patient care (AOR, 1.11 95% CI, 1.03-1.19 for each 5-hour increase; P = .007), and a workplace sexual harassment experience in the past 2 years (AOR, 1.71 95% CI, 1.11-2.62; P = .01). Work-related burnout was significantly less likely with more nightly sleep hours (AOR, 0.80 95% CI, 0.66-0.96 for each 1-hour increase; P = .02) and with an improved general work climate rating (AOR, 0.49; 95% CI, 0.36-0.65 for each 1-point increase in general work climate scale score; P < .001).This survey study of K grant awardees revealed substantial rates of burnout among mid-career medical faculty, and burnout rates differed by gender. Evidence-based interventions are needed to realize the benefits of workforce diversity and vitality.Conclusions and RelevanceThis survey study of K grant awardees revealed substantial rates of burnout among mid-career medical faculty, and burnout rates differed by gender. Evidence-based interventions are needed to realize the benefits of workforce diversity and vitality.
Despite increasing evidence and recognition of persistent gender disparities in academic medicine, qualitative data detailing the association of gender-based experiences with career progression ...remain sparse, particularly at the mid- to senior-career stage.
To investigate the role gender has played in everyday professional experiences of mid- to senior-career women clinician-scientists and their perceptions of gender-related barriers experienced across their careers.
In this qualitative study, a total of 60 of 159 invited clinician-scientists who received National Institutes of Health K08 or K23 awards between 2006 and 2009 and responded to a survey in 2021 agreed to participate. Invitees were selected using random, purposive sampling to support sample heterogeneity. Semistructured in-depth interviews were conducted January to May 2022. For this study, interviews from 31 women were analyzed using the framework approach to thematic analysis. Data analyses were performed between August and October 2023.
Descriptive themes of participant experiences of gender and gender-based barriers in academic medicine.
A total of 31 women clinician-scientists (8 identifying as Asian 25.8%, 14 identifying as White 45.2%, and 9 identifying as members of a minority group underrepresented in medicine 29.0%; 14 aged 40-49 years 45.2% and 14 aged 50-59 years 45.2%) were included. Among them, 17 participants (54.8%) had children who required adult supervision or care, 7 participants (22.6%) had children who did not require supervision or care, and 6 participants (19.4%) did not have children. There were 4 dominant themes identified within participant experiences in academic medicine: the mental burden of gendered expectations at work and home, inequitable treatment of women in bureaucratic processes, subtle and less subtle professional exclusion of women, and value of communities built on shared identities, experiences, and solidarity.
This study found that women perceived the institution of academic medicine as a male-centric system misaligned with the needs of women, with associated feelings of exclusion, disillusionment, and loss of trust in their institutions. Findings suggest that the confluence of domestic obligations and unaccommodating institutional environments may make it difficult for women clinician-scientists to achieve established timelines of career progression and productivity; these findings may have long-term implications for the well-being and retention of women in academic medicine.
To generate an understanding of the primary concerns facing medical physicists regarding integration of a demanding technical career with their personal lives.
In 2019, we recruited 32 medical ...physics residents, faculty, and staff via emails to US medical physics residency program directors to participate in a 1-hour, semistructured interview that elicited their thoughts on several topics, including work–life integration. Standard techniques of qualitative thematic analysis were used to generate the research findings.
Of the participants, 50% were women and 69% were non-Hispanic White individuals, with a mean (SD) age of 37.5 (7.4) years. They were evenly split between residents and faculty or staff. Participant responses centered around 5 primary themes: the gendered distribution of household responsibilities, the effect of career or work on home and family life, the effect of family on career or work, support and strategies for reconciling work–life conflicts, and the role of professional societies in addressing work–life integration. Participants expressed concern about the effect of heavy workloads on home life, with female respondents more likely to report carrying the majority of the household burden.
Medical physicists experience challenges in managing work–life conflict amid a diverse array of personal and professional responsibilities. Further investigations are needed to quantitatively assess the division of work and household labor by gender in medical physics, particularly after the outbreak of the COVID-19 pandemic, but this study's qualitative findings suggest that the profession should consider ways to address root causes of work–life conflict to promote the future success and well-being of all medical physicists, and perhaps women in particular.
Due to a gap in published guidance, we describe our robust cycle of in-house clinical software development and implementation, which has been used for years to facilitate the safe treatment of all ...patients in our clinics.
Our software development and implementation cycle requires clarity in communication, clearly defined roles, thorough commissioning, and regular feedback. Cycle phases include design requirements and use cases, development, physics evaluation testing, clinical evaluation testing, and full clinical release. Software requirements, release notes, test suites, and a commissioning report are created and independently reviewed before clinical use. Software deemed to be high-risk, such as those that are writable to a database, incorporate the use of a formal, team-based hazard analysis. Incident learning is used to both guide initial development and improvements as well as to monitor the safe use of the software.
Our standard process builds in transparency and establishes high expectations in the development and use of custom software to support patient care. Since moving to a commercial planning system platform in 2013, we have applied our team-based software release process to 16 programs related to scripting in the treatment planning system for the clinic.
The principles and methodology described here can be implemented in a range of practice settings regardless of whether or not dedicated resources are available for software development. In addition to teamwork with defined roles, documentation, and use of incident learning, we strongly recommend having a written policy on the process, using phased testing, and incorporating independent oversight and approval before use for patient care. This rigorous process ensures continuous monitoring for and mitigatation of any high risk hazards.
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