Introduction and overview: Clive Baldock, moderator

In 2020, the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) consulted its members regarding developing an ACPSEM position with regards to registration through the Australian Health Practitioner Regulation Agency (AHPRA) [1]. At that time, responses to the ACPSEM discussion document indicated definitive support from Australian respondents for pursuing AHPRA registration. However, the opposite view was strongly held from New Zealand respondents with regards to registration through the equivalent New Zealand vehicle – the Health Practitioners Competence Assurance Act (HPCAA) Annual Certificate of Competence.

In this Topical Debate, Robin Hill and Cathy Barbagallo discuss whether in Australia, professional registration for qualified medical physicists should be mandated through AHPRAFootnote 1.

Robin Hill works at the Chris O’Brien Lifehouse in Sydney, Australia where he is the Head of Research and Education in Radiation Oncology Medical Physics and an Adjunct Senior Lecturer in the School of Physics at the University of Sydney. Robin’s first interest in kilovoltage x-ray beams came about from the opportunity to complete an Honours project at the University of Adelaide under the guidance of Professor Alun Beddoe. This was followed by an MSc in Medical and Health Physics which led to moving to Sydney to work as a clinical radiotherapy physicist. His interest in kilovoltage x-ray beams continued when he subsequently undertook research into his PhD through the University of Sydney for which he graduated in 2012. This work led to the publication of the review paper Advances in kilovoltage x-ray beam dosimetry in Physics in Medicine and Biology [2]. While his interest covers different aspects of clinical radiation oncology and medical physics, he continues to engage in research in kilovoltage x-ray beam dosimetry. He is a member of the IAEA (International Atomic Energy Agency) working group updating the chapters in the TRS398 Code of Practice relevant to kilovoltage x-ray beams and a member of the editorial board of Biomedical Physics and Engineering Express.

Arguing against the proposition is Cathy Barbagallo, celebrating an impressive three decades of dedicated service in the dynamic field of radiation oncology this year. Whilst completing her Master of Applied Science degree at Queensland University of Technology (QUT) she began working at the Queensland Radium Institute (QRI) Mater Centre, now known as ROPART (Princess Alexandra Hospital - Radiation Oncology Raymond Terrace). During this time, she assumed responsibility for the manually after-loaded Iridium brachytherapy program and played an integral role in the newly developed I-125 choroidal melanoma seed program.

In 2002, Cathy’s journey led her to Victoria, where she joined Radiation Oncology Victoria (ROV), with her time divided between treatment centres in Footscray and Ballarat. Her role evolved, and she took charge of implementing the ACPSEM Training, Education, and Assessment Program (TEAP) training program (V2.0) at ROV. Her dedication to education was evident, and in 2015, she embarked on a new chapter as a full-time lecturer at Royal Melbourne Institute of Technology (RMIT) for undergraduate radiation therapists and postgraduate medical physicists. She continued in her role as an ACPSEM assessor for Radiation Oncology Medical Physics (ROMP) registrars.

February 2017 marked a pivotal moment as Cathy assumed the role of Victorian Preceptor, overseeing the development and growth of ROMP registrars, based at the Alfred Hospital. Her tenure witnessed her guiding numerous registrars on their transformative TEAP journeys, providing unwavering training, assessment, and invaluable guidance.

In her most recent chapter, since 2018, Cathy Barbagallo has assumed the role of a national ACPSEM ROMP Training Coordinator, where she has been instrumental in reshaping the curriculum for training and offering steadfast support to ROMP registrars. She provides valuable supervisor training and most recently is working with educational consultants to enhance training methodologies within the landscape of medical physics.

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For the proposition: Robin Hill

Opening statement

In an article published by Forbes, Ben Zimmerman presents the case on why “The Most Dangerous Phrase In Business: We’ve Always Done It This Way” [3]. In this article, he discusses businesses that are now defunct due to not being able to adapt to change. One good example of this is Blockbuster Video which has now disappeared. Some of us would remember the Saturday night tradition of going to the Blockbuster store and finding a movie to watch on either DVD or even VHS tape! Blockbuster has long disappeared while the various streaming services are worth billions of dollars. While hindsight is always good, it would be interesting to know what the board of Blockbuster considered when streaming services were first proposed while the company was doing just fine.

To date, the medical physics profession in Australia and New Zealand has been very successful in developing professional standards for training, education, certification and registration. In many cases, this has been world leading. Much of this has been collectively from the work of the ACPSEM in addition to great effort by so many medical physicists. In the past few years, there have been proposals put forward that that medical physicists should come under the umbrella of Australian Health Practitioner Regulation Agency (AHPRA). The primary role for AHPRA is found on their website “to ensure that Australia’s registered health practitioners are suitably trained, qualified and safe to practise” [4].

One could well argue that we already do this by having medical physicists who are suitably trained, qualified and are safe to practice. The ACPSEM has invested considerable resources so that all three requirements are successfully met for clinical medical physicists. Many would say that the ACPSEM training program and certification is the best in the world! The question then arises, if our current system of training and ongoing need to practice safely works well, then why change it?

One is entitled to ask why we should move our registration program into AHPRA which may bring additional cost, new work burdens and may involves processes that have not necessarily been designed for medical physicists?

I believe the answer lies within some of the fundamental work of medical physicists which is to engage in audits for clinical programs. Whether that be in radiation oncology, radiology or nuclear medicine, the importance of an audit is to check what is done and to see if it can be done better [5,6,7]. The same can be said for Australian Council on Healthcare Standards (ACHS) audits which are hospital-wide and performed every few years by independent assessors [8]. We may have the best equipment, suitably qualified and experienced staff as well as robust quality management systems. However, we can still learn new things and make room for improvement by engaging in external audits.

By having the medical physics profession registered within AHPRA, we could learn to do things in a new way. It means that ACPSEM can use its resources for other activities in supporting its members. It can also ensure that we don’t become like Blockbuster. Therefore, I believe that the benefits of joining AHRPA are many for the medical physics profession in Australia.

Against the proposition: Cathy Barbagallo

Opening statement

Medical physicists are a diverse group of professionals united in the management of radiation in a health context. Our work is both clinical and research driven, with significant overlap with academic institutions. Representation and regulation of our work has been managed in part by ACPSEM, our professional body, but also by the legislative requirements of our geography, and indeed by international regulations [9].

As scientists, we do not sit readily within the role of “health practitioner”. Medical physicists of any specialty do not determine the outcome or treatment of a patient. We do not make clinical decision decisions as implied by the title of “health practitioner,” but we do form part of the infrastructure. We provide the data and facilitate the equipment, as well as ensuring maintenance of standards and quality, but this does not equate to a clinical decision, as we do not provide the context around how it is applied.

AHRPA membership does not provide representation for its members but is a public register of practitioners. It does not provide specialist knowledge, facilities, expertise in training or assessment to its membership. It does not provide indemnity insurance, professional development opportunities, and does not consider members who have trained overseas for equivalence. Not insignificantly, there is the financial burden of joining an additional organisation.

Another major issue for us professionally is the inclusion of members from New Zealand. The affiliation with AHPRA would necessarily divide us ‘across the ditch’ with a different government body acting in each country.

ACPSEM represents members from both countries, with a single purpose. But even within one country, with the aim to remove state-based differences in a range of clinical disciplines, AHPRA falls short. While it claims to manage professionals nationally and provide a forum for patients; it does not provide this latter service in New South Wales or Queensland in Australia. Indeed, in many ways, we share more in common with a United States-based medical physicist than we might with a local podiatrist or midwife all represented by AHPRA [10].

The ACPSEM has as part of its vison and purpose the setting of the professional standards that underpin our certification and registrations, as well as advocating for us as a profession and including research and clinical practice as equal parts of our practice. The ACPSEM already has a well-established and rigorous process for assessing suitable academic training, as well as clinical departments for ongoing clinical training. Our professional training via TEAP, as part of ACPSEM, is respected and recognised as both diverse, and high quality [11, 12].

The ACPSEM has a register of qualified professionals, and to retain on the register involves undertaking continuing professional development (CPD) activities. CPD tasks are undertaken over a three-year period in a range of focussed areas. The range of tasks on the current CPD list encompass all areas in which a medical physicist may work and can demonstrate life-long learning with an implication of currency of standards and information. Importantly, there is no mandatory inclusion of clinical workload. The Medical Radiation Practitioner’s Board (MRPB), within AHPRA, includes mandatory demonstration of clinical practice. Will those members who primarily work in management, education, or indeed, part-time, find themselves unregistered despite valuable contributions to the field because they have not undertaken routine quality assurance (QA) recently? Indeed, it does beg the question of what constitutes “clinical practice” when technology is constantly evolving, so too does our clinical role [13].

As professionals, we are often most critical of ourselves – let us continue to self-regulate to the high standards we have already set.

For the proposition: Robin Hill

Rebuttal statement

My esteemed colleague has made very good points on the positive outcomes of having medical physicists registered within the ACPSEM. We should all be happy with what has been achieved through world class training programs, certification and registration. Given this success, any changes to this should be a positive step forward.

Firstly, I would suggest that many medical physicists would be considered health practitioners. Our work contributes towards the outcome and treatment of patients. We are not prescribing the radiation dose or indicating what volume inside MRI scans may be a tumour. However, some medical physicists are involved in leading or assisting in clinical trials by which clinical decisions are made. Providing scientific guidance in such clinical activities like theranostics or advanced brachytherapy are all part of the treatment of a patient. Further, these clinical trials or advanced therapies could not (and should not) be performed without the active involvement of a medical physicist.

The second aspect is that the ACPSEM has put in significant resources towards those three key areas of training, registration and certification. However, the resources of the ACPSEM is limited and also relies on significant good will from a large cohort of professional volunteers. But at some stage, we should review what are the key activities that the ACPSEM should focus on with those resources. As such, using the AHPRA processes for registration for example could make good financial sense.

Finally, as medical physicists, we can get very comfortable with processes and become resistant to change. This is not to say that what we do now is wrong. But things can be better. Imagine in radiotherapy if we still relied on reference dosimetry using exposure-based calibrations, did not have protocols to guide small field dosimetry and we only used pencil beam algorithms for treatment planning [6, 13,14,15,16]. It is not that these were completely wrong, but now we have much greater knowledge.

Given these points, let us move to having our profession regulated to the high standards as set by AHRPA.

Against the proposition: Cathy Barbagallo

Rebuttal statement

It is anecdotal that many medical physicists are slow to change, and indeed, the wheels of research and development can often move glacially towards clinical implementation. That said, the onus of many facets of our work relies on us checking and checking again, ensuring that we have made a decision that is to the best of our ability, with all the current facts. As the field of our work changes, so too must medical physicists grow, adapt and pivot to accommodate.

Unlike Blockbuster, Netflix is a story of pivoting and growth. Launched in 1997 as a mail-out rental DVD service, it adopted the streaming service model in 2007 as its customer base changed. By August 2008, after a database corruption, the entire company pivoted to a streaming-only model. From there, they moved to production and development, spawning a whole new aspect to their business. The company is essentially doing what they have always done, providing entertainment to people in their own homes, but modified their model to keep ahead of the curve and determining their own future.

Let us take the opportunity to look at external regulation squarely and decide how we would like our profession to continue to grow. We should look to our counterparts who have been incorporated into the AHPRA model and decide whether their members have benefited from this or not. Until then, administration and registration by a body of peers is the best way forward.