The Stereotactic Supervision Dilemma

There is a disparity in resources between large institutions in major metropolitan areas and small rural facilities.  As the physics staffing shortage grinds on and changes the landscape of the profession, smaller rural facilities face hidden challenges as they try and come up with creative solutions. Stereotactic (SRS/SBRT) procedures have become the norm in our field, and physicists have been intimately involved every step of the way as departments have implemented the procedures.  After commissioning SRS/SBRT in a department to assure the accuracy of small field dose, imaging and dose delivery, many departments have physicists do the planning for the procedures as well.  The standard of care is also to have physicists physically present at the machine for the first (or only) fraction of any stereotactic treatment.


In 2017, the AAPM published the practice guidelines AAPM-RSS Medical Physics Practice Guideline 9.a. for SRS-SBRT.  In the report, personal supervision is defined as being present in the room during the performance of the procedure.  The guideline then goes on to define the responsibility of the medical physicist during the first treatment session to “provide personal supervision of the entire session.”


The notes in the practice guideline state, “All treatments must occur under supervision of a QMP.  I addition, a QMP must provide personal supervision at the first treatment, and as needed subsequent treatments,  The personal supervision should include participation in a time-out checklist, assessment of patient immobilization, assessment of adequate imaging parameters, accuracy of respiratory management (if applicable), consultation on excessive or unusual shift requirements during treatment not clearly caused by patient motion on the treatment couch, as well as other patient- or plan specific needs.”


Smaller rural facilities are moving toward more remote and hybrid models for their physics coverage.  This comes from necessity and not desire.  Most facilities will tell you that they would much prefer to have a full-time physicist on-site, but there is a shortage of physicists.  Covid taught us that many physics duties can be done remotely – chart checks, initial plan checks, final checks – even patient-specific QA can be shot by the therapists, or someone trained on-site, and then analyzed by physics remotely.  A physicist can do all their office work remotely and then travel to be on-site once a month to do monthly and annual machine QA.  There are physicists lined up out my door to take on contracts like this.  It is desirable and easily filled, and the cost to the facility often decreases.


The problem for a facility to switch to a hybrid model is that the SRS/SBRT program suffers.  Either the patients must wait to start or not have the adequate physical supervision recommended by the AAPM and RSS.  The AAPM and RSS are very clear in their message that a physicist should be physically present during at least the first fraction of stereotactic treatment.


As with many new procedures, the states are slow to implement national recommendations into the regulations.  So, while physics’ presence may be recommended by all the national governing bodies, few states have written this into their regulations.  For example, in Colorado, the only regulations dealing with SRS/SBRT treatments reference the AAPM issued Task Group 101: Stereotactic Body Radiation Therapy published in 2010.  This document describes every step of the way for the physicist to begin and run a stereotactic program in a department, but it does not mention having the physicist present during treatment.


While state regulations may not absolutely require physics to be physically present during the initial fraction of an SRS/SBRT treatment, the accrediting bodies (ACR, ACRO etc…) do consider it when assessing a department for accreditation.  Accreditation of the department may be tied to insurance reimbursement rates down the road which may ultimately drive the financial need to have full-time physics on-site.


So, what is a rural facility to do?  As departments continue to struggle to find full-time on-site physicists, whether their volumes require it or not, they would love to move to a hybrid model where they can more easily find a long-term solution and reduce costs.  We would love to hear from different people around the country to learn whether your state has the physical presence of a physicist written into the regulations and/or if you have come up with a creative (and most importantly safe) way to solve the stereotactic supervision dilemma.