cc radiology physics jun 2011

7/30/2019 CC Radiology Physics JUN 2011

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CORE CURRICULUM FOR MEDICAL PHYSICISTS IN RADIOLOGY

Recommendations from an EFOMP/ESR working group

June 2011

Jacob Geleijns , Leiden University Medical Center, Leiden, The Netherlands

amann Breatnach, Mater Misericordaiae University Hospital, Dublin, Ireland

Alfonso Calzado Cantera, Complutense University of Madrid, Madrid, Spain

John Damilakis, University of Crete, Greece

Philip Dendy, Addenbrookes NHS Trust, Cambridge, United Kingdom

Anthony Evans, University of Leeds, Leeds, United Kingdom

Keith Faulkner, Quality Assurance Reference Centre, Wallsend, United Kingdom

Renato Padovani, S. Maria Hospital, Udine, Italy

Wil Van Der Putten, University Hospital Galway, Galway, Ireland

Lothar Schad, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany

Ronnie Wirestam, Lund University Hospital, Lund, Sweden

Teresa Eudaldo, Santa Creu i Sant Pau Hospital, Barcelona, Spain


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CORE CURRICULUM FOR MEDICAL PHYSICISTS IN RADIOLOGY

I. INTRODUCTION 1

II GENERAL COMPETENCIES 4

Organization 4Professionalism 5

III RADIOLOGY PHYSICS KNOWLEDGE, SKILLS AND COMPETENCIES 6

Fundamental knowledge 7

1. Fundamentals of human anat omy, physiology, and pathology 72. Fundamentals of c l in ical care 83. Pri ncipl es of radiob iology 94. Overview of radiat ion physics 105. Fundamentals of medical imaging 116. St at ist ical met hods 127. Principles of qual i ty management in heal th care 138. General pr inciples of r isk management and safet y in heal th care 159. Evidence based med icine 1610. Informat ion and communicat ion t echnology 17

Applied knowl edge 18

11. Dosim et ry 1812. Medical X-ray im aging 20

12.1 General pr inciples of X-ray imaging and X-ray equipment 2112.2 General project ion radiography 2312.3 Mammography 2412.4 Fluoroscopy 25 12.5 Computed t omography 26

13. Magnetic resonance im aging 2714. Ult rasound im aging 3015. Radiat ion prot ect i on for ionising radiat ion 33

16. Diagnost ic im age display and im age pr ocessing 35

IV RESEARCH PROJECT 36


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I. Intr oduct ion

The ter m Medical Physics Expert ref ers t o a physicist wi t h an appropriate l evel ofexpert ise. This t erm was int roduced in 1997 in the European Counci l Di rect ive97/ 43/ Eurat om on heal th pr otect ion of individuals against t he dangers of ionising radiat ion

in relat ion to m edical exposure [1] . I t had to be t ransposed int o the nat ional legislat i on inal l European countr ies, including t he def ini t ion of t he Medical Physics Expert . However, t herequirem ents for t he Medical Physics Expert wer e impl ement ed di f fer ent l y across Europe.

A new direct ive, the Euratom Basic Safety Standards Direct ive from 2010 (version 24February 2010), gives a more specif ic def init ion of the Medical Physics Expert [2]:

An individual having t he knowledge, t raining and experience to act or give advice onmat t ers relat ing to radiat ion physics appl ied to m edical exposure, w hose compet ence to actis recognised by the competent authori t ies .

The fol lowi ng guidel ines wi t h respect t o competencies and core curr iculum i t ems can beused for t he development of t he local curr iculum f or medical physicist s in radiology. Thecore curr iculum aims at br inging t he medical physicist in radiology up t o the level of aqual i f ied medical physicist . A qual i f ied medi cal physicist is an individual w ho is compet entt o pract ice i ndependent ly and t o regist er as a Medical Physicist , in one or more of t hesubf ield s of m edical physics. To act as an expert furt her experience is required and aninvolvement in a programme for Cont inuing Professional Development is recomm ended [3] .Radiology involves many subspecial t ies, e. g. r adiography, mamm ography, comput edt omography, X-ray guided intervent ions, and paediat r ic radiology but also magnet i cresonance imaging (MRI) and ult rasound imaging. The medi cal physicist in radi ology who isrecognised as a Medical Physics Exper t must have a hi gh level of exper t ise in X-ray im aging.In addi t ion, but depending on local condi t ions, i t may also be desi rable or even requir ed

t hat t he medical physicist in radiology acquires a cert ain level of expert ise in MRI,ul t rasound imaging, and nuclear m edicine. Consequent l y, a t rainee is not expect ed t o coveral l e lement s of t his curr iculum .

The medical physicist in radiologys role is essent ial for enabl ing the pr act ice of safe, st ate-of-t he-art medical im aging. Medical physicist s in radiology are members of t he mul t i -discipl inary cl in ical t eams t hat are responsible f or r adiology services t o pat ient s. Their roleis to provide cr i t ical scient i f ic i nput on t he physical processes and technology that underpinthe whole radiology service. General ly, the medical physicists in radiology design anddevelop t he f ram ework of medical im aging, image processing, image dist r ibut ion, im agest orage, r adiat ion dosimet ry, qual i t y assurance of t he imaging equipment , inf ormat ion andcommunicat ion t echnology (ICT) aspects of t he im aging process, and radiat i on prot ect ion of

t he pat ient and operator. Speci f ical ly, t he medical physicists in radiology provide expertadvice on the development , imp lement at ion and improvement of i maging t echniques andprocesses. They also provide expert input for appl icat ions of medical im aging outside t heradiology department .

Medical physicists in radiology have a leading role in the strategic planning, test ing, safeuse and optimisat ion of advances in medical imaging technologies and techniques. In ordert o acquire and maintain suf f ic ient know ledge and an appropriat e level of compet ence, bothini t ia l and cont i nuing educat ion and t raining are necessary. This core curr iculum for


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medical physicists in radiology is issued joint ly by the European Federat ion of Organisat ionsfor Medical Physics (EFOMP) and the European Society of Radiology (ESR). It providesguidel ines for t he educat ion and t raining of medical physicist wi t hin medical im aging. Theseguidel ines accommodate t he contemporary r equirement s for t he knowledge andcompet ency needs in t his rapidly evolving f ie ld of medicine.

The t wo organisat ions EFOMP and ESR have a long-standing com mi t ment t o im provedcl inical pract ice, science and development and to education and training. EFOMP is anumbr el la organisat ion f or nat ional medical physics organisat ions, wi t h one of i t s mainobj ect ives to harmonise and prom ote t he best pract i ce of m edical physics wi t hin Europe.To accomp lish i t s goals, EFOMP has presented various recomm endat ions and guidel ines in anumb er of Pol icy St at ement s, w hich have been unanim ously adopt ed by EFOMP Memb erOrganisat ions. Pol icy St atem ent No 9, Radiat ion Protect ion of t he Pat ient in Europe: TheTraini ng of t he Medical Physics Exper t in Radiat ion Physics or Radiat ion Technology [3] , i st he EFOMP response t o t he Medical Exposure Dire ct ive, 97/ 43/ Eurat om. Here, EFOMPpresents i ts recommendat ions on the r ole and the compet ence requirement s of t he MedicalPhysics Expert (MPE), as defined in this Direct ive, together with recommendations oneducat ion, t raining and cont inuing prof essional development (CPD). General cr i t er ia f orst ruct ured CPD have been laid down b y EFOMP in Pol icy St at ement No 8, Cont inuingProf essional Development for t he Medical Physicist [4] . CPD is t he planned acquisit i on ofknowledge, exper ience and ski l ls, bot h t echnical and per sonal , requir ed for professionalpract ice t hroughout ones working l i fe. EFOMP recommends that al l m edical physicist s whohave completed t hei r basic educat ion and t raining should be act ively involved in CPD tomaint ain and incr ease compet ence and expert ise af t er qual i f icat ion. The EFOMP approacht o achieve harmonisat ion is to encourage t he est abl ishment of nat ional educat ion andtraining schemes at al l levels in l ine with EFOMP recommendations. Guidel ines for formalEFOMP recognit i on of National Regist rat ion Schemes for Medical Physicists, i ncludi ngmed ical physicist s in radi ology, w ere establ ished in 1995 [5]. EFOMP approval r equir es interaliaclear st atement s of t heoret ical and pract ical compet encies, as wel l as t r aining

programmes consistent with the EFOMP pol icy on training, and a regular renewalmechanism. CPD is now being recommended as the best way t o meet t he requirem ent for arenewal mechanism, and Pol icy St atem ent No. 10 Recommended Guidel ines on Nat ionalScheme s for Cont inuing Prof essional Development of Medical Physicists [6] , and PolicySt ate ment No. 12 The present stat us of Medical Physics Educat ion and Traini ng in Europe.New perspecti ves and EFOMP recom mend at ions [ 7], r ecomm end Nat ional Memb erOrganisat ions t o set up t heir ow n det ai led CPD Scheme. In Pol icy St at ement No.12addit ional recommendations are publ ished by EFOMP on education and training of medicalphysicist s wi t hin t he context of t he current developments in the European Higher Educat ionArea ar ising f rom The Bologna Declarat ion , and w i th a v iew t o fac i l i ta t e t he f reemovement of professionals within Europe. In Pol icy Statement No.11 Guidel ines onProf essional Conduct are publ ished [8].

The Europ ean Societ y of Radiology (ESR) r epre sent s the m edical specialt y of Radiologyt hroughout Europe. In the St atut es of t he ESR t he t erm radiology m eans diagnost ic andint ervent ional radiology, bi omedical and molecular im aging . A radiologist is a qual i f iedmedical pr act i t ioner who has undergone appropri ate post graduat e t raining in diagnost ic andint ervent ional radiology. The Society is dedicated t o promot ing and developing t he highestst andards of r adiology and relat ed sciences in Europe. Among other goals, t he Societ y aimst o (a) prom ote radiology and associated di scipl ines through educat ion, r esearch, qual i t y ofservice, management ski l ls, socio-economic responsibi l i ty and ethical principles in research


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and safe radiological pract ice, (b) provide r adiologist s wi t h a broad range of high-qual i t yeducat ional m ateri als and (c) harm onise and standardise t eaching and examinat ionprogrammes t o provide equivalent t raining for radiologist s and other staf f working inradi ology depart ment s in European count rie s. ESR can be regarded as a prim e provid er f orexquisi t e t eaching and plays an ever increasing role in t he educat ion of radiologist s inEurope and Worldw ide. Medical physicist s have always been at t he for efront of t he

develop ment of r adiology. ESR and EFOMP are scient i f ic or ganisat ions wit h a shared int erestin and com mon goals for t he advance of m edical im aging. ESR seeks t o foster great ercooperat ion among radi ologist s and me mber s of EFOMP. Educati on and t rainin g should b erecognised as the m ain process by which societ ies can reach t hei r f u l lest potent ial .Est abl ishing and promot ing educat ional act iv i t ies between radiologist s and m edicalphysicist s wi l l maximise t echnological progress and pat ient benef i t .

[ 1] Counci l Di rect ive 97/ 43/ Euratom of 30 June 1997 on heal th pr otect ion of individualsagainst t he dangers of ionising radiat ion in relat ion t o medical exposure. Of f ic ialJournal of t he European Communi t ies; 9 July 1977:22. No. L 190

[ 2] Draft Eurat om Basic Safet y St andards Dire ct ive Version 24 Februar y 2010 (f inal)[ 3] EFOMP Policy St at ement No. 9: Radiat ion Prot ect ion of t he Pat ient in Europe: The

Traini ng of t he Medical Physics Exper t in Radiat ion Physics or Radiat ion Technol ogy.Physica Medi ca 1999; XV (3): 149-153

[ 4] EFOMP Policy St at ement No. 8: Cont inuing Professional Developm ent for t he MedicalPhysicist. Physica Medica 1998; XIV (2): 81-83

[ 5] EFOMP Policy St at ement No. 6: Recommend ed guidel ines of National Regist rat ionSchemes for Medical Physicists. Physica Medica 1995; XI (4): 157-159

[ 6] EFOMP Policy St at emen t No. 10: Recomm ended Guidel ines on Nati onal Schemes f orContinuing Professional Development of Medical Physicists. Physica Medica 2001; XVII(2) 97-101.

[ 7] EFOMP Policy St at ement No. 12: The pr esent st atus of Medical Physics Educat ion andTraini ng in Europe. New per spect ives and EFOMP recomm endat ions. Physica Medica

2010; (26) 1-5.[ 8] EFOMP Policy St at ement No. 11: Guidel ines on Prof essional Conduct and Procedures t oBe Implem ent ed in t he Event of Al leged Misconduct . Physica Medica 2003; (19) 227-229.


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II. GENERAL COMPETENCIES

Organisation

Introduction

The medical physicist in radiology is a member of a mul t i -discipl inary t eam t hat includesradi ologist s, m edical ph ysicists in radiology, r egist ered t echnologist s in r adiography (RTR s),comput er scient i st s, assist ant medical t echnicians, nurses, administ rator s, hospi t almanagement and other health care professionals. The medical physicist in radiology mustbe ab le to work t ogether w i th t he mul t i -d iscip l inary t eam in t he c l in ica l appl icat ion ofmedical im aging and part ic ipates in the organising and st ruct uring of t he medical im agingprocess.

Competences:

Demonst rat e an underst anding of t he organisat ion of local and nat ional heal t h care Demonst rat e an awareness of t rends in heal th care Abi l i t y t o work e f fect ive ly, in t erms of t ime and equipment , as a sta f f member in a

medical team

Abi l i ty t o manage workl oad and to provide ef fect ive input t o a t eam Demonst rat e an underst anding of t he required t echnological inf rast ruct ure for a

radiology department and an awareness of how to establ ish the necessaryint eract i ons wi t h other discipl ines wi t hin the hospi t al (e.g. nuclear medicine;radiot herapy; cardiology; surgery; and other medical special t ies that apply medicalimaging)

Abil i ty to organise specif ied aspects of the routine radiology physics service Abi l i ty t o part ic ipat e in netw orks for r esearch and development


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Professionalism

Introduction

The medical physicist in radiology should ensure t hat t he wel l -being, int erest s and digni ty

of pat ients are promot ed and safeguarded at al l t imes. The m edical physicist in radiologyt akes care t hat pract ices in t he hospi t al do not const i t ute an unnecessary hazard t o anyperson. The medical physicist in radiology must be able t o communicat e in an ef f ic ient andunambiguous way, wi t h a variet y of heal t hcare prof essionals, t o ensure t he safe andaccurate pr ovision of heal th care services. This includes the accurate communicat ion ofin format ion w i t h in t he rad iology department and wi th o ther hospi ta l sta f f . Inc identa l l y i tmay also be necessary to give information to patients and answer their questions. As aheal th care professional t he role of t he medical physicist in radiology impl ies certain socialact ions that have consequences for t he pat ient , t he heal th care organisat ion and societ y.

Competences:

Know t heir own l im i t at ions of knowledge and compet ency Demonst rat e an underst anding of t he role of t he medical physicist s in radiology

wi t hin the heal t h care syst em

Understand relevant nat ional professional codes and the need t o work w i t hin t hem Demonst rat e an underst anding of , and be able to act w i t hin, relevant nat ional

legislat i on and int ernat ional r egulat ions and guidel ines

Demonst rat e an underst anding and correct use of medical t erminology Discuss technical and cl inical aspects of medical imaging with medical staff Discuss general aspects of medical imaging with patients and the general publ ic Abi l i t y t o prepare wr i t t en mater ia l in t he form of notes, r epor ts and sc ient i f i c papers Demonstrate the abi l i ty to work in mul t id iscipl inary team Abi l i ty t o part ic ipate i n t he process of s i te planning and room design Abi l i ty t o part ic ip ate in t he tender p rocess for m edical imaging syst ems, and t o

part ic ipate in select i on procedures

Abi l i ty t o work wi t hin the f ramew ork of cross-discipl inary research col laborat ion toimpr ove the rout ine cl in ical service

Demonst rat e t he abi l i t y t o act according to best use of r esources in t he int erest oft he pat ient and society

Have the abi l i t y to t ake adequate act ion in response to incident s Show considerat ion for another per sons ethical , cul t ural or moral i ssues


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III. RADIOLOGY PHYSICS KNOWLEDGE, SKILLS AND COMPETENCIES

The f ie ld of m edical imaging is a dynamic, fast evolving discipl ine w i t h const antdevelopment, int roduct ion and implementat ion of new advanced imaging and minimalinvasive t reatm ent t echnologies. Because of t hei r key role i n t his process, medicalphysicist s in radiology requir e broad scient i f ic int erests and need t o const ant ly learn andacquire new knowledge. An excel lent knowledge of radiat i on physics, X-ray im aging,dosimetry, and radiat ion protect ion remains the central competence, but competences mayalso be requi red w it h regard t o magneti c resonance im aging (MRI), ult rasound imaging (US),and nuclear medicine (NM). Interdiscipl inary knowledge is needed for involvement inappl icat ion and development of new hybrid im aging technologies.

The medical physicist s in radiology have to demonstrat e and apply t hei r knowl edge incl in ical pract ice thr ough ski l ls and appropriat e at t i t ude. The fol low ing sect ions providemore det ai l on the required areas of core knowledge and required competencies for t hemedical physicist in radiology.

Fundamental knowledge (sect ions 1 to 10) should be acquired by al l medical physicists thatare t rained in radiology physics. Appl ied knowl edge wi t h regard t o dosimet ry, m edical X-rayimaging, and radiat i on prot ect i on should also be acquired by al l medical p hysicist s (sect ion11 (dosimet ry), 12 (Medical X-ray im aging), and 15 (Radiat ion pr otect ion f or ionisingradiat ion)). The requirem ent t o acquire appl ied knowledge in the f ie ld of magnet icresonance imaging, ultrasound imaging, or nuclear medicine imaging may depend on localcondi t ions.


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FUNDAMENTAL KNOWLEDGE

1. Fundamentals of human anatomy, physiology, and pathology

Short descript ion

Basic understanding and knowledge of human anatomy, physiology and pathology isrequired t o underst and the cl in ical aspects of medi cal imaging. I t is also a pre-r equsi t e forcommunicat ion and exchange of pat ient-, d iagnosis-, and disease-relat ed inf ormat ion.Likewise, basic knowledge of human anatomy, physiology and pathology is essential tounderstand the advantages and drawbacks of dif ferent imaging modali t ies and is,as such, aprerequisi t for opt imizat ion of imaging and radiat ion protect ion.

Competences

Abi l i ty t o part ic ipate, at a basic level , in discussions on cl in ical aspects of m edicalimaging in a mul t id iscipl inary cl in ical envi ronment

Abi l i ty t o recognise basic anatomical and pat hological st ruct ures of t he human bodyin m edical im ages, w it h an emphasis on st at ic and dynami c 2D and 3D visual izat ion ofanat omical and pathological st ruct ures

Demonst rat e an underst anding of how physiology interact s wi t h medical i magingCore curr iculum i tems

General knowledge of nomenclatur e in anat omy Knowledge of human anatom y General knowl edge of pat hology General knowledge of physiology Appearance of anatom y and pathology in medical images The ef f ect of physiology on medical images


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2. Fundamentals of cl inical care

Short descript ion

Medical physicist s in radiology work as a part of a int erdiscipl inary t eam of refer r ingphysicians, radiologists, and radiographers. A basic understanding of cl inical care, includingt he f undamentals of diseases and t rauma; of diagnosis and t reatm ent ; of screening andfol low up, is required.

The medical physicist in radiology should underst and the st ruct ure of t he management ofboth t he hospi ta l and t he rad iology depart ment to be ab le to par t i c ipat e in i t . The medica lphysicist in radiology should acquire basic knowledge of the organisat ion and managementof t he heal th care syst em and of t he relevant guidel ines and recommendat ions f r omnat ional or int ernat ional or ganisat ions. The medical physicist in r adiology should be fami l iarwi t h ethical issues in heal t h care and wi t h the role of t he medical ethics commit t ee.

Competences

Demonstrate a basic understanding of trauma and the development of diseases, aswell as their diagnosis and fol low up

Demonstrate a basic understanding of screening programs Demonstrate knowledge of various options for diagnosis and treatment Demonstr ate an understanding of t he posi t ion of t he medical physicist in radiologys

own inst i t ut i on as part of t he local and nat ional heal th care syst ems,

Demonst rat e knowledge of t he development of m edical physics and the appl icat ionsof m edical physics in heal t h care

Apply ethical considerat ions in medical p ract iceCore curriculum items:

Basic introduction to major diseases including their signs and symptoms Basic int r oduct ion t o t rauma General pri ncipl es of di agnosis General pr inciples of im age guided t r eatm ent , f or example in surgery, int ervent ional

radiology, radiot herapy and cardiology

General pr inciples of populat ion screening General pr inciples of f ol low up General overview of t he appl icat ion of medical physics in c l in ical care Overview of medical uses of ionising radiat ion in medical imaging (X-ray, nuclear

medicine)

Overview of med ical uses of non-i onising radiat ion in m edical i maging (MRI,ultrasound imaging)

Nat ional and local heal t h care syst em, global v iew of other European syst ems Guidel ines and recommendat ions relat ed to cl i n ical care f rom nat ional and

int ernat i onal organisat ions

General et hical considerat ions in m edical pract ice and in biomedi cal research Principles of m anagement as appl ied t o hospi t al depart ment s and research proj ects


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3. Principles of radiobiology

Short descript ion

Act iv i t ies of m edical physicist s in radiology require b asic knowledge in t he f ie ld of

radi obiology. Princip les of r adiobiol ogy are the b asis for risk assessment in radi ology.Special knowledge of radiobiology is required to assess the effect of radiat ion exposure forspecial groups l ike chi ldr en and pregnant w omen. Special knowledge on det erminist icradiobiological effects (t issue reactions) is required for risk assessment in patients thatdevelop such ef fect s. For proper r i sk management wi t h regard t o pat ient s, st af f , andgeneral publ ic expert ise should thus be acquired bot h for lat e and acut e radiat ion ef f ects.

Competences

Abi l i ty t o apply r adiobiological knowl edge for achieving proper r isk assessment indiagnost ic im aging and in im age guided int ervent ions

Abi l i ty t o use radiobiology t o st imulat e opt i misat ion of t he appl icat ion of ionisingradiat i on in diagnost ic r adiology

Contr ibut e appropri ate radiobiological knowledge f or t he assessment of possibleharm in case incident s wi t h relat ively high exposures t hat m ay occur f or occupat ionalexposures as wel l as for cl ini cal exposures of p at i ent s

Core curr iculum i tems

Fundamentals of cel lu lar and molecular bi ology The physical and biological background to t he ef f ect of ionising radiat i on on l iv ing

cel ls

The response of t issues t o radiat ion at a molecular, cel lu lar and macroscopic level Radiobiology for humans in general , and for chi ldren and t he fet us in part icular Models of r adiat ion induced cancer and herid i t ary r isks


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4. Overview of radiation physics

Short descript ion

The medical physicist in r adiology should have a high expert ise in f undamental radiat i onphysics in order to understand how ionising radiat ion is appl ied in medical imaging. Goodknowledge of radiat i on physics is also essent ial for achieving opt im al radiat ion prot ect ion ofpat ient s, staf f , and general publ ic. Relevant descript ions of t he di f f erent sources of ionisingradiat i on as appl ied in d i f f erent imaging modal i t ies, including X-ray im aging and nuclearmedicine, should be included. Of great import ance is t he knowledge of t he physics ofint eract ion of di f f erent t ypes of radiat ion wi t h mat t er and t issues, as i t form s t he basis forunderstanding the advantages and l imits of various imaging techniques. Knowledge of theresponse of various det ector mat erials to di f f erent variet i es of ionising radiat i on providesinsight in t he (potent ial ) perform ance of det ector s. Final ly, good knowledge of radiat ionphysics is required for p roper appl icat ion of r adiat ion dosimet ry.

Competences and skil ls

Abi l i ty t o speci fy t he di f f erent mechanisms of generat ion of i onizing radiat ion,including radioact ive d ecay

Abi l i ty t o recognise the di f fer ence bet ween t he physical interact ions of indi rect lyand di rect ly ionising radiat ion

Abi l i ty t o describe di f fer ent mechanisms of energy loss of various type of radiat i ont hrough various media

Abi l i ty t o describe quant i t at ively radiat ion f ie lds appl ied in radiology


Atomic st r ucture Electromagnet ic and part iculate radiat ion Ionising and non-ionising radiat ion Quantum nature of electromagnet ic radiat ion Principles of X-ray generat ion and the X-ray spectrum Radioact iv i t y and radiat ion sources Interact ion of phot ons (X-rays, gamm a-rays) w i t h mat t er and t issues Scat t er ing and at t enuat ion of a photon beam in m at t er and t issues Interact ion of charged part ic les wi t h mat t er and t issues


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5. Fundamentals of medical imaging

Short descript ion

As a special ist in the appl icat ion of medical physics in radiology, the medical physicist inradiology must acquire a high degree of knowledge about t he fundament al models andmechanisms of medical i mage form at ion and im age display, of reconst ruct ion andpost processing; and about fundament al aspects of observer perfor mance and hum an imagepercept ion.


Abi l i ty t o apply t he theory of im age form at ion t o advice on the select i on of the m ostappropriate imaging modal i ty

Abi l i ty t o apply the t heory of image form at ion t o achieve the most opt imal imageacquisi t ion prot ocol

Abi l i ty t o apply theory of image reconst ruct ion and post processing to achieve opt im alimage qual i ty f or a speci f ic c l in ical t ask

Abi l i t y t o apply the t heory o f observer per formance to t he opt im izat ion of m edicalimaging

Abi l i t y t o apply the t heory o f human image percept ion t o the opt im izat ion of imagereading

Abi l i ty t o advise on the implem entat ion and appl icat ion of syst ems for comput eraided diagnosis


Fourie r analysis Image form at ion and image qual i t y Reconst ruct ion algori t hms Vision and perception Visual isat ion of medical images Image display Image processing Quant i t at ive image analysis St at ist ics of t he im aging process Image registrat ion and image fusion Computer aided diagnosis


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6. Statistical methods

Short descript ion

Rout ine w ork in a radiology depart ment of t en requires t he use of st at ist ics in medicine,including radiology. Medical physicist s are f requent ly involved in t echnical and cl in icalst udies; in p art icular in designing, analyzing and int erpret ing the experim ental approachand processing the dat a. Therefor e, m edical physicist s have to be t rained in t hefundament als of stat i st ical met hods.

Competences

Abi l i ty t o demonst rat e the underst anding of t he fundament als of biost at ist ics Abi l t y t o per form common sta t ist i ca l t est s Abi l i ty t o est imat e measurement uncertaint ies and thei r categories Abi l i ty t o apply comput at ional t echniques and dedicated sof t ware packages for

stat ist ical data analysis Abi l i ty t o analyse and interpr ete st at ist ical resul t s Abi l i ty t o set t olerances and act ion levels


Descript ive st at ist ics Probabi l i ty dist r ibut ions General pr inciples and appl icat ion of stat i st ical t est s St udy d esign and pow er analysis Random and systematic errors Error propagat ion Uncert ainty analysis Regression and corr elat ion Tolerance and act ion levels Receiver operat ing charact erist ic curves


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7. Principles of quality management in health care

Short descript ion

Qual i t y m anagement requires an organisat ional st ruct ure where responsibi l i t ies,

procedures, processes and resources are clearly def ined. I t should be supported by theradiology depart ment m anagement in order t o work ef f ect ively and should be ascomprehensive as is required t o meet t he overal l qual i t y obj ect i ves. I t must have a cleardef ini t ion of i t s scope and of al l t he qual i ty standards t o be met and requires col laborat ionbet ween al l mem bers of t he radiology team. The qual i t y syst em must incorporat ecompl iance wi t h al l the requirem ents of nat i onal legislat i on, accredi tat ion and requires t hedevelopment of a formal wri t ten qual i ty assurance program that detai ls the qual i tyassurance pol ic ies and pr ocedures, qual i ty contr ol t est s, f r equencies, t olerances, act ioncri t er ia, r equired records and personnel .

The Quali t y Assurance ( QA) pr ocess in r adiology invol ves al l st eps of t he diagnost ic pr ocess

f rom image request and just i f i cat ion of the examinat ion to equipment per formance, andimage reading and strorage.

Competences:

Abi l i t y t o par t i c ipate in qual i t y m anagement and fac il i t a te qual i t y improvement Abi l i ty t o def ine qual i t y object ives and to measure and improve ef fect ive qual i ty

per formance

Abi l i ty t o def ine and apply contr ol tests, f requencies, t olerances, and act ion cr i t er ia Abi l i ty t o demonst rat e knowledge of nat ional and internat i onal legislat i on and

recommendat ions for q ual i t y assurance

Abi l i ty t o perform qual i t y cont rol on diagnost ic imaging modal i t ies Abi l i ty t o part ic ipate in c l in ical audi t s in radiology departm ents Abi l i ty t o set speci f icat ions, m easure perf ormance, compare w i t h speci f icat ions,

and, as required, adjust t he process t o meet speci f icat ions in accordance wi t h therecommendat ions and st andards ( including documentat ion and t r aining of ot herprofessionals)

Demonst rat e knowledge of nat ional and inter nat ional recomm endat ions and localprot ocols for q ual i ty m anagement

Abi l i ty t o impl ement EU Direct ives, nat ional r egulat ions and guidel ines andrecomm endat ions f r om nat i onal and int ernat i onal organisat ions

Demonst rat e knowledge of equipm ent management Demonst rat e underst anding of wr i t t en procedures of a depart ment al qual i t y

management system


Basic aspects of p lanning and management Qual i ty, qual i ty assurance and qual i ty cont rol Qual i ty st andards Assessment of qual i t y


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Qual i ty management syst ems, r ecords, and im provement of qual i t y Nat ional and int ernat ional recomm endat ions and local prot ocols for qual i t y

management

Qual i ty procedures and t est s on imaging modal i t ies Clini cal audit processes


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8. General pr inciples of r isk management and safety in healt h care

Short descript ion

Medical imaging is essential in cl inical care and involves advanced and complex instrumentst hat r equire a high level of safet y and const ant qual i t y impr ovement. Ensuring safet y inmedical im aging is a dynamic process t hat should cont inuously be im proved and modi f ied t omeet t he evolving needs and demands of t he hospi t al envi ronment . The medical physicistwi l l provide speci f ic inf ormat ion wi t h regard t o r isk management and safet y in radiological -, e lect romagnet ic-, and ul t rasound imaging. Medical physicist s must be f ami l iar wi t h suchhazards and necessary pr ecaut ions. They should have a suff icient appreci at ion of be stpract ice concerned wi th safety and r isk management to be able to contr ibute, faci l i tate,impl ement and impr ove safet y management syst ems.

Competences:

Abi l i ty t o use r isk assessment and incident invest igat ion t o impr ove the qual i typrogram

Abi l i ty t o evaluate and prevent t he r isks of a given procedure or pr otocol Abi l i ty t o prevent invest igat e, and evaluat e incidents in a radiology departm ent and

implement correct ive act ions

Abi l i ty t o evaluat e whet her service agreement s and sof t ware updat es of r adiologyequipment are adequat e to ensure pat ient safet y

Abi l i t y t o evaluate e f f ect ive safety per f ormance Abi l i ty t o manage and plan for em ergency si t uat ions Abil i ty to assess human factors and safety-related behaviour Abi l i ty t o increase t he safet y aspects that are r elated t o medical physics for t he

pat ient undergoing diagnost ic and (m inimal) invasive image guided t reatm entprocedures

Abi l i ty t o ident i fy and manage the r isks associated w i t h medical im agingCore curr iculum i tems

Def ini t ion and measurement of r isk Assessment and quant i f icat ion of r isk Risk management Human r isk percept ion Elect r ical , e lect ro-magnet ic, m agnet i c, and ul t r asound safet y Mechanical safet y Principles of radiat ion prot ect ion f or ionising radiat i on and non-ionising radiat ion Tools for risk assessment such as Failure Mode Analysis; Effect Analysis; and Root

Cause Analysis


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9. Evidence based medicine

Short descript ion

Evidence based medicine general ly requires a mul t id iscipl inary ef f ort t hat int egratesmedical , social , economic and et hical issues relat ed t o t he use of c l in ical care and m edicalt echnology in a syst emat ic, t ransparent , unbiased and robust manner. I ts aim is t heform ulat ion of safe, ef f ect ive heal t h pol ic ies t hat are pat i ent f ocused but t hat also seekopt imal economical and societ al value.

Competences:

Demonst rat e an underst anding of t he basic met hodology empl oyed in heal t htechnology assessment

Abi l i t y t o per form a system at ic rev iew of t he l i tera t ure to eva luate t he c l in ica lef f ect iveness of a new technology or t echnique

Abi l i ty t o assess t he ef f icacy of a new t echnology/ t echnique To be famil iar with the standards for report ing of diagnostic accuracy (STARD,

Quadas)

To be fami l iar wi t h t he goal and principles of t he Cochrane Col laborat i on Abi l i ty t o apply experiment al outcomes to evidence based medicine approaches

Core Curr iculum i tems

General aspects of heal t h t echnology assessment Design and implem entat ion of c l in ical t r ia ls Inter nat ional classif icat ion of diseases (ICD) Principles of systematic review


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10. Information and communication technology

Short descript ion

There is a need for the medical physicist in radiology to have an understanding of

Informat ion and Communicat ion Technology (ICT). The cont emporary r adiology depart menthas a number of comput er syst ems which are used t o manage and del iver highly compl exradiology services. The need t o safely t ransfer, archive, and ret yr ieve dat a across a numberof software and hardware interfaces is essential. I t is not necessary for medical physicistst o become expert s in ICT, however t hey are requir ed to work ef fect ively wi t h ITprofessionals from inside and outside the hospital organisat ion.

Competencies

Abil i ty to understand and discuss ICT concepts with other healthcare professionals Abi l i ty t o underst and and discuss heal thcare dat a connect iv i ty st andards wi t h

col leagues f r om ot her discipl ines t o faci l i t ate t he integrat ion of general syst emswi t h in rad iology depart ments

Demonst rat e a understanding of hardw are conf igurat ion, operat ing syst ems andtypical sof tware appl icat ions

To underst and t he basic concept s in heal th inf ormat ics such as t he unique pat ientindent i f ier , t he medi cal recor d and disease coding such as ICD10

To understand basic princip les of comm unicat ion st andards in medici ne such as HL7,SNOMED, IHE

To understand the DICOM standard for medical image communication To understand basic concepts of Patient Administrat ion Systems, the Electronic

Patient Record and Order Communication Systems

To be aware of pr ivacy issues relat ed t o electr onic pat ient inform at ion syst ems To understand ICT inf rastr uct ure f or a r adiology depart ment (RIS, PACS) To under st and safet y and r isk relat ed issues associat ed t o ICT

Core Curr iculum i tems

Operat ion of the maj or components of comput ers, The principles of comp ut er net wor ks (LAN, WAN) Data exchange formats and standards (DICOM, PACS, and others as required) Hardw are that is required t o support heal th inf ormat ics syst ems Risk issues associat ed w it h ICT


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APPLIED KNOWLEDGE

11. Dosimet ry

Short descript ion

Dose assessment is an imp ort ant t ask of t he med ical physicist in radiol ogy. The concept ofabsorbed dose and kerm a in part icular, and dosimet r ic quant i t ies and uni ts in generalshould be wel l understood. The medical physicist in radiology should be fam i l iar w i t h t hepr inc ip le o f t he ca l ibrat ion chain f rom pr imary standard to f ie ld inst r ument , andunderst and the physics and technologies of t he di f f erent dosimet ry det ectors.Det erminat ion of t he absorbed dose in t he prim ary and scat t ered X-ray beam is animport ant issue.

The medical physicist in r adiology should be fami l iar w i t h the di f fer ent pr act icalmeasurement s or comput at ional syst ems that can be used for pat ient , occupat i onal , andenvironment al dosimet ry of X-rays and underst and thei r advantages and l imi t at ions in ordert o be able t o select t he most appr opriat e syst em for each dosimet r ic problem .

Competences:

Demonst rat e a good underst anding of t he basic dosimet r ic q uant i t ies and uni t s andfundament a l concepts

Demostr ate k nowl edge of t he dosim et ric syst ems (syst ems based on ionisat ions in air ,t hermo luminescence dosimet ry (TLD); semi-conductor ; f i lm, opt i cal st imulat ed

luminescence (OSL), scint i l lat ion) Abi l i ty t o ident i f y and select t he appropiate dosimet ry syst em for various

appl icat ions

Abi l i ty t o perfor m m easurement s wi t h several dosimet ry syst em Demonst rat e knowledge of dosimet r ic standards and t r aceabi l i t y Demonstarte an understanding of the cal ibrat ion systems and methods used in

radiology

Abi l i ty t o select appropiate phant oms for t he dosimet ry of di agnost ic X-ray beams Abi l ty t o ident i f y and properly apply the dosimet r ic t echniques speci f ic f or radiology

equipment

Abi l i ty t o perfor m pat ient dosimet ry in r adiology, including dose assessment for t hefe tus


Basic quant i t ies, i . e. phot on f luence and photon f luence rat e, energy f luence andenergy f luence r ate, kerma and absorbed dose

Prim ary measurement s, i . e. ionisat ion in ai r as t he prim ary radiat ion standard, m eanenergy required t o create an ion pair, cavi t y theory, t he Bragg-Gray principle,conversion of char ge to absorbed dose


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Secondary measurement s, i . e. chemi cal ef f ects (oxidat ion of f errous to fer r ic ions),biochemical changes, biological changes

The ionisat ion chamber Relat ionship bet ween ex posure and absorbed dose Conversion of absorbed dose in air t o absorbed d ose in anot her m edium Other detectors, i .e. scint i l lat ion detectors, thermoluminescent dosemeters, opt ical

st imulat ed luminescence, semiconductor detect ors, phot ographic f i lm andradiochromic f i lm

Phantoms and phantom mat erials for dosimetr y in diagnost ic X-ray beams Principles of dose m easurement for speci f ic imaging modal i t ies and impl icat ions for

pat ients

Basic cl inical pat ient dose indicators (dose area product, entrance skin dose) Dose indicators for the detector (absorbed dose and absorbed dose rate on the

de tec to r )

Detect or dose requir ement in proj ect ion radiography (speed class (f i l m-screen),speed index (CR and DR)

Dose im mam mography, absorbed dose in glandular t issue Pat ient dose in diagnost ic f luoroscopy and in int ervent i onal radiology (entr ance dose,

dose in the intervent ional reference point )

Pat ient dose in comput ed t omography (computed t omography dose index, doselength product )

Dose assessment for t he f oet us Dose measurement s in qual i t y assessment of eq uipm ent


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12. Medical X-ray imaging

Short descript ion

X-ray imaging is t he most widespread appl icat ion of m edical imaging. I t can be perform edin m any ways, for di f f erent c l in ical appl icat i ons, and by various medical pr ofessionals. X-rayimaging is essent ial in t he heal t h care syst em, but necessi t ates cert ain radiat ion exposureof t he pat ient , and somet imes exposure of w orkers and general publ ic. The appl icat ion ofX-rays in medi cal imaging is st r ict ly regulated; t his is to ensure t hat appr opriate measuresfor r adiat ion prot ect i on are implement ed. Medical X-ray imaging varies f r om generalproj ect ion r adiography, t o 3D visual isat ions; f r om st at ic i maging t o dynamic imaging; f romdent al appl icat ions to w hole body CT. Medical X-ray imaging is of t en associated w i t h t heradiology departm ent , but is also rout inely appl ied in depart ment s such as cardiology,radiot herapy and urology. Sytem s for m edical X-ray imaging are inst al led in emergencyrooms, and mobile systems for X-ray imaging are often used in operat ing rooms.

This chapter l ist s compet encies and core curr iculum i t ems for medical X-ray imaging, t hef i r st sect ion l ist s generic comp etencies and curr iculum i t ems for X-ray equipment and X-rayimaging; t he fol l owing sect ions provide speci f ic addi t ional compet encies and curr iculumit ems for t he hardware and the im age acquisi t ion in general proj ect ion r adiography,mamm ography, f luoroscopy, and comput ed tom ography.


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12.1 General pr inciples of X-ray equipment and X-ray imaging

Competences

Basic pr incipl es

To become acquainted w i t h t he physical components of X-ray imaging equipment(high vol t age generat or, X-ray tube, t ube cool ing, f lat f i l ter s and shaped f i l t ers,co l l imator , detector , ant i scat ter gr ids, operator console , pat ient support ,computer, display, workstat ion)

Understand the physical principles underlying X-ray imaging systemsImage acquisit ion, image processing and image reconstruct ion

Underst and t he ef f ect on image form at ion of basic X-ray int eract ion processes in t hebody

Underst and the modes of operat i on of di f f erent im age receptors Understand t he im age acquisi t ion prot ocols, preprocessing of image data, image

reconstruct ion principles, and postprocessing of images Abi l i ty t o operate the X-ray uni ts at a basic level , pr im ari ly for qual i t y cont rol , but

also for i mage qual i t y assessment and dosim et ry

Acquire general knowledge about t he di f f erent image acquisi t ion prot ocols used t operf orm t he most comm on types of c l in ical examinat ions

Image qual i t y ( including artef acts)

Abi l i ty t o assess image qual i ty f rom m easurement s wi t h t est obj ects and wi t h humanobservers

Demonst rat e awareness t hat di f ferent requirem ents for image qual i t y apply tospeci f ic c l in ical t asks

To be fami l iar w i t h the ef fect on image qual i t y when changing imaging andreconstruct ion parameters The know how t o opt i mise protocols for X-ray imaging Abi l i ty t o recognise and analyse im age art efact s

Safet y and st andards

Abl i ty t o evaluate t he local appl icat ions of law s, r egulat ions, r ecommendat ions andst andards relat ed t o X-ray safet y

To provide pract ical safet y-relat ed guidel ines, incident -report ing rout ines andeducat ional mat erial for al l per sonnel

Clinical aspects

To understand t he pat ient 's perspect ive in t he ent i re pr ocess of X-ray examinat ions To become f ami l iar w i t h images f r om rout ine X-ray examinat ions (proj ect ion

radiography, m ammography, f luoroscopy, X-ray guided int ervent i ons, com put edt omography, t omosynthesis)

To recognise basic norm al anatom y as wel l as pat hology in t he imagesCore curr iculum i tems


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Basic pr incipl es

X-ray tubes for di f ferent appl icat ions Component s of t he X-ray t ube X-ray generators and t iming of the X-ray exposure Opt imisat ion of the design of t he X-ray tube and generat or for di f ferent appl icat ions

in medical im aging

X-ray imaging geometry Beam l im i t ing devices Relat i ve import ance of photoelect r ic and Compt on ef fect at di f f erent X-ray energies

in di f f erent t issues

Reduct i on of scat t ered radiat ion K-shell energies and absorpt ion edges in radiol ogy Performance requirements of imaging receptors especial ly resolut ion and sensit ivi ty Cri t ical comparison of di f f erent analogue and digi t al receptor s Operat ion of X-ray im aging syst ems

Image acquisit ion, image processing and image reconstruct ion

Image acquisi t ion pr otocols Pre- and post processing of di gital im ages Image reconst ruct ion principles

Image qual i t y ( including artef acts)

Basic aspects of image qual i ty (spatial resolut ion and contrast, contrast to noiserat io, point spread funct ion, modulat ion t ransfer funct ion, noise power spectrum,detect ive quantum ef f ic iency, noise equivalent quanta, contrast-detai l curve)

Physical m easurement of image qual i ty Assessment of i mage qual i t y using human observer s Dif f erences in im age qual i t y for di f f erent X-ray imaging syst ems Opt imisat ion of c l i n ical prot ocols for X-ray imaging Image artefacts for X-ray imaging systems

Safet y and st andards

Laws, r egulat ions, r ecommendat ions and st andards relat ed t o X-ray imaging Accept ance and const ancy t est s of X-ray im aging syst ems

Clinical aspects

General overview of c l in ical appl icat i ons of X-ray im aging General understanding of c l in ical im ages General understanding of c l in ical requirements wi th regard to image qual i ty in X-ray

imaging


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12.2 General projection radiography

Competences

Hardware To demonst rat e awareness of di f ferent designs of general proj ect ion r adiography

syst ems, l ike t able- and w al l -bucky syst ems, general r adiography out side t he buckysystem, mobile systems for general radiography, chest radiography systems,radiography systems for chi ldren

To demonst rat e awareness of det ector syst ems for general r adiography, i .e. screenf i l m radiography, comput ed radiography, and digi tal radiography

To be able t o advice on t he purchase and use of t he most appropri ate generalproj ect ion radiography uni t for a speci f ic c l in ical appl icat i on

Image acquisit ion

To underst and common i mage acquisi t ion paramet ers for X-ray imaging To underst and principles of pr oj ect ion r adiography To demonst r a te f ami l iar i t y w i th spec ial r equi rements for pediat r i c pro j ect ion

radiography

To demonst rate awareness of t he appl icat ion of radiost ereomet r ic analysis imaging Dual energy im aging, i ncludi ng dual energy X-ray absorpt iomet ry (DXA)


Hardware

Project ion radiography imaging systems (general system, chest system, paediatricsyst em, mobi le system , t able syst em, wal l st and)

Detect or design f or pr oj ect ion radiography im aging syst emsImage acquisit ion and p ost processing

Modes of oper at ion of proj ect ion radiography imaging syst ems Acquisi t ion parameters ( tube vo l tage, f i l t ra t ion, tube current , exposure t ime,

automat ic exposure control , col l imat ion)

Digit al im age pre- and post-pr ocessing


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12.3 Mammography

Competences

Hardware To demonstrate awareness of the designs of mammography systems, including

systems for image guided stereotact ic biopsy

To demonst rat e awareness of di f ferent detect or syst ems for m ammography, i . e.screen f i lm mamm ography, mamm ography wi t h computed r adiography plates, anddigi ta l m ammography wi th f la t panel detectors

To be able to advice on the purchase and use of a mammography unitImage acquisit ion and p ost processing

To underst and common im age acquisi t ion paramet ers for mam mography To demonstrate fami l iar i ty wi th special requirements for mammography compared to

general proj ect ion radiography

To underst and the ef f ect of compression in mamm ography To demonst rat e fami l iar i t y wi t h computer aided diagnosis in mamm ography To demonst rat e fami l i ar i t y wi t h image guided biopsies To demonst rat e fami l i ar i t y wi t h tomosynt hesis in mamm ography


Hardware

Mamm ography imaging syst ems (mamm ography, t omosynthesis) Detector design for mammography imaging systems

Image acquisit ion and p ost processing

Modes of oper at ion of proj ect ion radiography imaging syst ems Acquis i t ion parameters ( tube vo l tage, f i l t ra t ion, tube current , exposure t ime,

automat ic exposure cont ro l , co l l imat ion, magni f i cat ion, pro ject ion mammographyand t omosynthesis)

Digital image pre- and post-processing, reconstruct ion of tomosynthesis acquisit ions Stereotact ic biopsy


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12.4 Fluoroscopy

Competences

Hardware Demonstrate awareness of dif ferent designs of f luoroscopy systems, l ike f luoroscopy

uni ts wi t h one or tw o C arms, wi t h under- or over-t able X-ray tubes, or mobi le Carms

To demonst rat e awareness of di f fer ent det ector syst ems t hat can be incorporated inf luoroscopy syst ems, l ike an im age intensi f ier, or di f ferent t ypes of f lat p aneldetector

To be able to advice on t he purchase and use of t he most appropriat e f l uoroscopyuni t f or a speci f ic c l in ical appl icat i on

Image acquisit ion and p ost processing

To underst and common acquisi t ion paramet ers for im aging wi t h a f l uoroscopy uni t Demonstr ate aw areness t hat d i f f erent acquisi t ion paramet ers should be used f or

di f ferent c l in ical tasks

To underst and the di f fer ent acquisi t ion modes of a f l uoroscopy uni t To understand stat ic and dynamic 2D imaging To underst and st at ic 3D imaging wi t h a f luoroscopy uni t (cone beam CT) To demonst rat e fami l iar i t y wi t h special requirement s for f luoroscopy of chi ldren To become fami l iar w i t h contrast enhanced f luoroscopy st udies To be aware of special requirement s wi t h regard to radiat ion protect ion in

f luoroscopy, and part icular ly in X-ray guided intervent ions

To be aware of the possible occurrence of skin effects at high skin dosesCore curr iculum i tems

Hardware

Fluor oscopy im aging syst ems (diagnost ic f luor oscopy, f l uoroscopy guidedinterventions, mobile f l luoroscopy systems, bi-plane systems)

Detector design for f luoroscopy imaging systemsImage acquisit ion and p ost processing

Modes of operat ion of f luoroscopy systems (continuous and pulsed f luoroscopy,automat ic br ightness contr ol , h igh dose rat e f l uoroscopy, digi t al spot imaging, di gi tal

subt ract ion angiography, c ine runs, last image hold, cone beam CT wi t h f luoroscopyunits)

Image acquisi t ion parameters (tube vol tage, f i l t rat ion, tube current , exposure t ime,col l imat ion (f ie ld size), magni f icat ion)

Contr ast enhancement in f luoroscopy Digit al im age pre- and post-pr ocessing Overview of pract ices wi t h possible hi gh skin dose


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12.5 Comput ed tomography (CT)

Competences

Hardware To demonst rat e awareness of di f f erent designs of comput ed t omography syst ems,

l ike mul t isl ice CT, dual source CT, and volum et ric CT scanners; CT scanners fordiagnostic imaging and for radiotherapy planning, cone beam CT scanners

To demonst rate awareness of di f ferent modes of operat ion of CT scanners To be able to advice on t he purchase and use of t he most appropriat e comput ed

t omography syst eem f or a speci f ic c l in ical appl icat ion

Image acquisi t ion and r econst ruct ion

To underst and common acquisi t ion paramet ers for CT imaging To understand CT image reconstruct ion To under st and stat ic 2D and 3D acquisit ions in CT To under st and dynam ic 2D and 3D acquisit ions in CT To demonst rat e fami l iar i t y wi t h special requirement s for pediat r ic CT imaging To demonst rat e fami l iar i t y wi t h special requirement s for quant i t at ive imaging in CT To become acquainted wi t h contr ast enhanced studies in CT To be aware of special requir ement s wi t h regard t o radiat ion prot ect ion in CT,

part icular ly in peadiat r ic CT and CT guided intervent ions

Dual ener gy imagingCore curr iculum i tems

Hardware Computed tomography imaging systems (general CT scanner, radiotherapy planning

CT scanner, cone beam CT scanner)

Detect or design for com put ed t omography imaging syst ems (curved CT det ector , f latpanel det ector)

Image acquisi t ion and r econst ruct ion

Basic pr inciples of computed tomography reconstruct ion (f i l tered back project ion,i terat ive reconstruct ion, beam hardening correct ion, noise reduct ion, correct ion forphoton st arvat ion)

Modes of operat ion of CT systems (axial, hel ical, and volumetric acquisit ion andreconstruct ion, dynamic acquisi t ion and reconstruct ion (CT f luoroscopy), CT

radiograph, bolus tracking, prospective triggering (ECG), retrospective gating (ECG,respirat ory), CT per fusion)

Acquis i t ion parameters ( tube vo l tage, bow t ie f i l te r , tube current , ro ta t ion t ime,tube current modulat ion, scanned f ie ld of v iew, s l ice thickness, beam col l imat ion,over beam ing, over scanning)

Contr ast enhancement in comput ed tom ography CT guided inter vent ions CT in hybr id im aging syst ems


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13. Magnet ic resonance imaging

Short descript ion

Magnetic resonance imaging (MRI) is an advanced med ical im aging t echnique w hich hasshown r apid t echnical developm ent during t he last decades. MRI has proven part icular lyuseful f or morp hological imaging of t he brain and spine, due t o excel lent sof t t issuecontr ast , but is becoming increasingly import ant also in cardiac, abdominal ,musculoskelet al and neur ofunct ional im aging appl icat ions. In addi t i on, m agnet ic resonancespect roscopy (MRS) is a promising tool f or in vi vo st udies of me t abol ic changes. The i mageacquisi t ion is based on t he combined use of a st at ic m agnet ic f ie ld , wi t h superimp osedt ime-varying magnet i c f ie ld gradients, and pulsed radiof requency (RF) elect romagnet icf ie ld s. MRI is characterised by the abi l i t y t o provide a mul t i t ude of im age contr ast feat ures,impl ying t hat each cl in ical appl icat ion requires careful opt imisat ion of the employedimaging prot ocol . Ident i f icat ion and reduct ion of im age art efact s is also of considerableimportance for opt imal image qual i ty. MRI safety issues include pract ical hazards, such asferr omagnet ic obj ects act ing as project i les, awareness of biophysical aspects ofelectromagnetic f ields, assessment of associated physiological effects and appropriate riskassessment for st af f and pat ient s. In t his sect ion, compet encies and core curr i culum i t emsfor MRI and MRS are l i st ed, includ ing hardw are, image acquisit i on, p ost -pr ocessingprocedures, image qual i ty, cl inical appl icat ions and safety issues.


Basic pr incip les

To become acquainted w i t h the operat ion of MRI uni ts, t he sof t ware user int erfaceand surrounding equipment

Subst ant ial exp ert ise in al l aspect s of t he qual i t y assurance ( QA) of MRI unit sHardware

To demonstr ate awareness of comm ercial ly avai lable m agnet designs and f ie ldst rengt hs, r adiof requen cy (RF) syst ems and gradient syst ems

To measure st at ic-f ie ld levels in t he vic ini ty of t he MR uni t (e.g. , t o map anddel ineate t he 0.5 mT contour)

To be able t o select appropriat e RF coi lsImage acquisit ion

To perform basic imaging, including posit ioning, pulse-sequence select ion and imagedisplay

To underst and the import ance of basic scanner paramet ers (echo t im e, repet i t iont im e, inversion t ime, f l ip angle , f ie ld o f v iew, mat r ix size etc . ) for image qual i t y ,acquisi t ion t ime and contr ast behaviour using spin-echo, gradient -echo and inversion-recover y pulse sequences

To demonst rate f ami l iar i t y wi t h fast and advanced pulse sequences, w i t h respect t oimage qual i t y and contr ast f eatures

To demonstrate fami l iar i ty wi th paral le l imaging techniques To understand f low effects and become acquainted with MR angiography (MRA)


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To become acquainted with pulse sequences, protocols and post-processing tools forperfusion and diffusion MRI, functional MRI and MR spectroscopy (MRS)

To be aware of special r equirement s associated w i t h MRI-guided int ervent ionsImage qual i t y ( including artef acts)

To deter mine signal t o noise rat io (SNR) f rom phantom measurement s, demonst rat ingawareness of r elevant noise dist r ibut ions, and to predict t he ef f ect on SNR whenchanging various imaging parameters

To be able to ident i fy and reduce common MRI art efact sSafet y and st andards

To evaluat e t he local appl icat i ons of l aws, regulat ions, recomm endat ions andst andards relat ed t o MR safet y

To maintain relevant emergency routines and basic MR compatibi l i ty assessment To provide pract ical safet y-relat ed guidel ines, incident -report ing rout ines and

educat ional mat erial for al l per sonnel

Clinical aspects To underst and t he pat ient 's perspect i ve in t he ent i re p rocess of an MRI examinat ion To become fami l iar w i t h t he employed imaging prot ocol and the resul t ing images for

routine MRI examinations (normal anatomy as well as pathology)

Core curri culum it ems

Basic nuclear magnetic resonance principles

Electro-magnet ic Spins in the st at ic m agnet ic f ie ld (B0) (prot on, phosphor) Larmor f requency Exci t at ion radiof requency f ie ld (B1) The format ion of t he sp in / grad ient echo Int r insic and ext r insic MRI contrast p arameter s Relaxat ion m echanisms (T1, T2, T2*)Hardware

The stat ic magnetic f ield subsystem The radi ofr equency f ield subsyst em ( coi l de sign and RF shield ing) The gradient f ie ld subsyst em (amp l i t udes, r ise t imes, slew rat e and eddy current

ef fects)

Basic image formation

Spatial encoding in three dimensions using l inear magnetic f ield gradients and thepropert ies of k-space

Convent ional pul se sequences (spin echo, gradient echo, i nversion recovery) Fast imaging techniques (echo-planar imaging, fast spin-echo)Int roduct ion t o special t echniques, sequences and appl icat ions

Paral lel imaging St eady-stat e fr ee pr ecession sequences


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Motion compensation Flow quant i f icat ion MR angiography (MRA), p erf usion and dif fusion im aging Funct ional MR im aging (BOLD-f MRI) MR spect ro scopy (MRS)Image qual i t y, f actors inf luencing image cont rast Signal-to-noise ratio (SNR) Spatial resolut ion Acquisi t ion t imeImage qual i ty, common artefacts

Motion art efact Aliasing Metal and suscept i bi l i t y art efact Chemical shi f t art efact Truncat ion artefactImage qual i ty, system-related issues

B0 inhomogenei ty B1 inhomogenei ty RF distort ions and coi l problems Ghost ing (not ascribed t o mot ion)Contrast agents

Basic mechanisms Image contr ast ef f ects of paramagnet ic and ferr omagnet i c contrast agents Hyperpolar ised subst ancesSafet y and st andards

Guidel ines Pract i cal hazards (proj ect i les, implant s, heat ing, acoust ic noise) Physiological ef f ects related t o electr omagnet ic f ie lds Safe use of cont rast agentsInt roduct ion to cl in ical appl icat ions of MR


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14. Ult rasound imaging

Short descript ion

Ultr asound imaging is a modal i t y t hat pr ovides essent i al inform at ion in t he detect ion anddi f f erent iat i on of disease using non-ionizing radiat ion. Ul t r asonography is rout inely used notonly in radiology but also in departments such as gynecology, obstetrics, cardiology andemergency medicine. Medical physicists in radiology must have a broad scienti f ic knowledgeof physics and technology related t o medical ul t rasound. They have to be f ami l iar w i t h t heperf ormance evaluat ion m et hods of ul t rasound syst ems including acceptance t est ing androut ine qual i ty contr ol t est ing. Moreover, t hey must know t he principles of ul t rasoundsafet y and the relevant regulat ions. This knowledge wi l l a l low t hem t o design and perfor ma qual i ty assurance program of ul t rasound equipment , opt imise performance and apply theALARA princip les in cl in ical pr act i ce.


Basic pr incipl es

Substant ial exper t ise in al l aspects of t he oper at ion and qual i t y assurance (QA) oful t rasound imaging uni t s

Fami l iar i t y wi t h al l pr incipal modes of operat ion i .e. A-mode, B-mode, M-mode,Pulsed Doppler , Colour Doppler

Abi l i ty t o select t he appropriat e t ransducers for gray-scale or Doppler imaging andunderst and t he ef f ect of ul t r asound imaging paramet ers such as f r equency, overal lgain, t ime gain compensat ion, focusing on image qual i t y

Abi l i ty t o measure or comput e dist ance, area and volume comput at ions is import antand the t r ainee must become f ami l iar wi t h images f r om rout ine examinat ions.

Image qual i t y

Abi l i ty t o opt im ise image qual i t y in c l in ical images Abi l i ty t o ident i f y and explain image art efact s. A pictor ial r ecord containing an

i l lust rat ed descript ion of di f ferent art efact s should be col lected and is a usefulconf i rm at ion of exper ience

Safety

The trainee must understand and recognise general aspects of safety in ultrasoundimaging

Abi l i ty t o interp ret and use the acoust ical output indices i .e. t hermal index andmechanical index

Core curr iculum items

Basic pr incipl es

Wave equat ion, harmonic solut ion and non-l inear solut ions. Basic paramet ers (pressure, displacement , densi t y, part ic le veloci t y; Int ensi t y and

pow er; speed of sound in soft t issue, gas and bone; acoustic i mp edance)


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Interact ions of ul t rasound wi t h t issue

Absorpt ion, f requency dependence Scat t er single and mul t ip le scat t er ing and relat ionship t o w avelengt h Reflect ion, behaviour at interfaces angular dependence Refract ion

Single elem ent t ransducers

Piezo-electr ic ef f ect Transducers resonance, bandwidth, backing and matching Near and far f ie ld beam pat t erns Pulsed operat ion, duty f actor Focusing aperture

Arrays

Linear arrays (design principles, side lobes; electronic focusing; transmit beamform ing; receive f ocusing; apodisat ion and dynamic apert ure; curvi - l inear arr ays)

Phased array (off axis focusing; mult i-frequency imaging; 1.5 and 2D arrays)Gray scale im aging

Pulse-echo principle: pulse repet i t ion f r equency; gain, t ime gain compensat ion mode operat ion mode operat ion M-mode Demodulat ion Compression Frame rate Display and archivin g Pre- and post pr ocessing Harmonic Imaging 3D and 4D techniq ues

Doppler techniques;

Doppler equat ion Continuous Wave principle detect ion and origin of spectrum Spectral analysis and display Pulsed Doppl er ali asing Colour Dopple r Power Doppler

Spect ral i ndices e.g. Pulsat i l i t y Index, Resist ance Index

Image Quali ty

Spatial resolut ion (axial , lateral, sl ice thickness) Contrast resolut ion and dynamic range; Artef acts (propagat ion artef acts e.g. shadowing, reverberat ion, f l ar ing) Mirror image, beam w idth ar t e facts Side lobe


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Contrast Agents

Blood pool cont rast agents Microbubbles, resonance, non-l inear behaviour Inert gas bubbles

Safety

Mechanisms of int eract ion (t hermal , cavi tat ions, m icro-st reaming) Biological ef f ects (molecular, cel lu lar, animal , human) Waveform indices (t hermal index, mechanical index) Safe operat ing levels Legislat i on (nat ional and int ernat ional)

Quality Assurance

Tissue m imicking phantoms Measurement prot ocols Out put measurement (hydrophones and power balances) Doppler perf orm ance assessment Recording and f i le archiving

Cl inical appl i cat ions

Obst et ri cs and gynaecology Cardiac Abdominal smal l body part s (breast , t est es, t hyroid) Musculo-skeletal Paediatr ic Vascular


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15. Radiation protection for ionising radiat ion

Short descript ion

The accept ance by society of t he r isks associated w i t h radiat ion is condi t ional on t he

benef i t s t o be gained f r om t he use of r adiat ion. Nonetheless, t he r isks must be minim isedby t he appl icat ion of radiat i on safet y st andards.Medical physicists in radiology should have a broad scienti f ic knowledge of radiat ionprot ect ion. They have to be prepared t o address t he needs of prot ect ing the pat ient ,personnel and the general publ ic in t he radiology depart ment . They have t o know t hephysical and biological ef fect s of radiat ion for exposed individuals, t he relevantregulat ions, m et hods of compl i ance and record keeping. This knowledge wi l l a l low t hem t oassess t he radiat ion ri sk and opt im ise med ical exp osures. They w il l apply t he ALARA anddose l im i t at ion pr inciples in the design of radiology faci l i t ies and imaging prot ocols.

Competences and skills:

Apply general pr incipl es of r adiat ion pr otect ion and r isk management Implement radiat ion prot ect i on principles and r isk management in radiology Assess the effect iveness of radiat ion protect ion measures Apply t he concept of j ust i f icat ion to medical exposures Optimise medical exposures in radiology Assessment of r adiat ion ef fect s on humans in general , and on chi ldren and t he fet us

in part icular

Implement t he concept of diagnost ic ref erence levels in radiology Veri fy that radiat ion protect ion and r isk management is in compl iance wi th

guidel ines, di rect ives, and legislat ion ( including dose l im i t s where appl icable)

Perf orm radiat ion surveys of areas by using model s and dose measurement s Perform shielding calculat ions for planned or modi f ied X-ray rooms (radiography;

mamm ography; CT; f l uoroscopy; operat ion rooms; and emergency rooms)

Design and perfor m sui t able experim ent s t o check shielding calculat ions Supervise occupational dosimetry and the use of personal dosimeters Opt imise radiat ion protect ion in high dose or high r isk pract ices (Intervent ional

radiology; CT; Heal th screening programmes; I rradiat ion of chi ldren, neonates or t hefetus; Genet ic predisposi t ion for detr imental radiat ion ef fects)

Conduct cr i t ical examinat ions ( inter locks, warning systems, safety design featuresand barriers)

Advise on personal protect ive equipment , including protect ive garments, and f ixedand mobile shielding devices

Demonst rat e fami l iar i ty w i t h ethical aspects of biomedical research wi t h regard t oaspect s of r adiat ion prot ect ion of pat ient s and volunteers in biomedical research


Scient i f ic basis of r adiat ion prot ect ion Quant i t ies and uni ts in radiat ion prot ect ion Basic pr inciples of dose l i mi t at ion


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Just i f icat ion, opt imisat ion, and t he ALARA principle Dose l im i t s (workers, populat ion) Internat ional and nat ional recomm endat ions st andards and regulat ions Safety design of medical X-ray instal lat ions Radiat ion effects in radiology on the embryo and foetus, leukaemogenesis and

carcinogenesis, genet ic and somat ic hazards for exposed individual s and populat ions;

Genet ic r isk fact ors Radiat ion moni t or ing Classif icat ion of areas Personal dose monit oring Administ rat ion and organisat ion of radiat ion protect ion. Nat ional and inter nat ional

rul es and organisat ions

Management of radiat ion safety, including hazard assessment, contingency plans; Accidents in radiology, act ions t o t ake in t he event of a radiat ion accident Responsibi l i t ies and dut ies of al l w orkers that are involved in radiat ion pr otect ion Occupat ional exposure and occupat ional dosimet ry quant i t ies and met hods Medical exposure and pat ient dosimet ry quant i t ies and met hods Diagnostic reference levels Operat ional parameter s af fect ing pat ient dose and image qual i t y Public exposure High entrance skin dose appl icat ions Potent ial exposure and emer gency plans Shield ing calculat ions and assessment of shield ing (general radi ology, CT,

f luor oscopy, int ervent ional radiology, mamm ography)

Opt imizat ion of radiat ion prot ect ion (pat i ents, st af f and general publ ic) byopt i misat ion of pr act ices, pr ocedures and acquisi t ion prot ocols


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16. Diagnostic image display and image processing

Short descript ion

For t he purpose of im age reading and image review, t he medical im ages are predomi nant lydisplayed on moni t ors. The syst ems for im age reading, and t he image reading i tsel f , areof t en integrat ed in the radiology and hospi t al inform at ion and communicat ion t echnology(ICT) systems. The qual i ty and qual i ty control of these monitors is essential for ensuringgood perf ormance of a radiology depart ment . The medical physicist in radiology should beable t o advise on t he appl icat ion of c l in ical images, b oth f or v isual izat ion andquant i f icat ion purposes.


Give advise on t he select ion of a syst em f or im age display and im age processing Discuss dif fer ent t ypes of pr ocessing of cl i nical im ages Abl i ty t o explain m ethods of i mage processing on cl in ical im ages Abl i ty t o dist inguish bet ween di f fer ent appl icat ions of i mage display syst ems Abl i ty t o coordinate t he acceptance and const ancy test ing of im age display syst ems


Knowledge of the hardware for image display and image processing Knowledge of the software for image display and image processing Requirements for image display and image processing systems for dif ferent cl inical

appl icat ions

Measurement of t he perfor mance of im age displays Integrat ion of syst ems for im age display and image processing Clini cal appl i cat ions of im age processing Accept ance and const ancy t est s of d iagnost ic im age display syst ems


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IV RESEARCH PROJECT

Short descript ion

The medical physicist plays a key role in t he development and advancement of t he f ie ld of

radiology and in st rengthening of t he research act iv i t ies in t he medical physics communi t y.To prepare t he medical physicist for t his responsibi l i t y, one or more short , focused researchproj ects should be undert aken at some st age during t he t raining programme, ei t her as afu l l - t ime act iv i t y w i t h in a wel l -def ined per iod or on par t - t ime basis over a pro longed t imeperiod (e.g. part of t he pract ical t raining period). Such proj ects wi l l a lso resul t in thet rainee acquir ing advanced compet encies for f rom di f ferent part s of t he syl labus.

The proj ect should be per form ed under supervision of a t rained medical physicist , i t shouldbe wel l s t ructured and a lso l im i t ed in scope, in order t o f i t w i t h in the g iven t im e f rame.The topic of t he research proj ect should be relevant for radiology physics and pract ice,t ypical ly i t would l i e wi t hin t he cl in ical and appl ied side of t he span of radiology physics

research.

The project should resul t i n a wr i t t en report , ideal ly in the form of a manuscript sui t ablefor submission t o a medical physics or radiology journal . Al ternat ively, i t could resul t in oneor m ore short er report s, based on speci f ic problems arising in t he t rainee's departm ent .

Competencies and skil ls

Abi l i ty t o plan, prepare and perform d i f f erent phases of a research project Abi l i ty t o acquire f i r st -hand experience in proper scient i f ic evaluat ion, of both ow n

and publ ished dat a

Abi l i ty t o prepare a scient i f ic manuscript for publ icat ion

cc radiology physics jun 2011

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