DOS 518 - Week 3 Discussion
What does this mean for on-the-job training (OJT) in the near future? Even though MDCB prevents OJT individuals from taking the exam in 2017, if the CARE Bill does not pass, do you foresee OJT continuing if it's not against the law? Why or why not?
Initial Post: The CARE Act
The Consistency, Accuracy, Responsibility, and Excellence in Medical Imaging and Radiation Therapy Act of 2011 (and 2012, and 2013...) or "CARE Act" for short, is an attempt "to amend the Public Health Service Act and title XVIII of the Social Security Act to make the provision of technical services for medical imaging examinations and radiation therapy treatments safer, more accurate, and less costly."1 The primary goal of the bill is to force all personnel involved in the technical component of either medical imaging and radiation therapy to be certified by an appropriate certification body for their line of work.
This bill has come up before both houses of Congress several times:
House: H.R.3652 (111th Congress)
Sponsor: Rep. Barrow, John [D-GA-12] (Introduced 09/25/2009)
Latest action: 09/29/2009 Referred to the Subcommittee on Health.
Senate: S.3737 (111th Congress)
Sponsor: Sen. Enzi, Michael B. [R-WY] (Introduced 08/05/2010)
Latest action: 08/05/2010 Read twice and referred to the Committee on Health, Education, Labor, and Pensions.
House: H.R.2104 (112th Congress)
Sponsor: Rep. Whitfield, Ed [R-KY-1] (Introduced 06/02/2011)
Latest action: 06/06/2011 Referred to the Subcommittee on Health.
Senate: S.3338 (112th Congress)
Sponsor: Sen. Enzi, Michael B. [R-WY] (Introduced 06/25/2012)
Latest action: 06/25/2012 Read twice and referred to the Committee on Health, Education, Labor, and Pensions.
House: H.R.1146 (113th Congress)
Sponsor: Rep. Whitfield, Ed [R-KY-1] (Introduced 03/13/2013)
Latest action: 04/11/2013 Referred to the Subcommittee on Health.
Senate: S.642 (113th Congress)
Sponsor: Sen. Enzi, Michael B. [R-WY] (Introduced 03/21/2013)
Latest action: 03/21/2013 Read twice and referred to the Committee on Health, Education, Labor, and Pensions.
When a bill is referred to committee, that effectively means it has been killed.
The 114th Congress started their service in January 2015 and as of today, the CARE Act has not yet been re-introduced to either chamber of Congress.
The are several problems with the bill, such as failure to make a clear case for how mandated certification will result in improvements in safety, accuracy, and cost. It sounds good on paper, but this is relying on knee-jerk "of course it will!" reactions rather than laying out a clear cause and effect case. In theory, certification should guarantee a minimum level of competency, but it does not take into account the differences between entry level exams such as those for radiation therapy and advanced level certification exams such as those for dosimetry or physics.2 This is an important distinction that is glossed over in the bill, saying that industry experts will be consulted to determine the appropriate level of certification.1 Under this system, certified new people would effectively have more value than noncertified people of any experience level. I would rather be treated by an uncertified therapist with 15 years of experience than a certified therapist fresh out of school.
The reduced cost assumption is based on overly simplistic reasoning. The idea is that higher skilled staff will make fewer errors, resulting in fewer repeated procedures, thus saving costs. It does not consider the added costs of a new layer of federal bureaucracy to manage this process, the cost of seeking certification, and the salary premium that may be demanded by staff once these career tracks become more elite with higher barriers to entry. The wording does not explain why the high skill must come from certification and not extensive training. It also doesn't account for the possibility that a low-skilled person with exquisite attention to detail may follow instructions better than a high skilled person whose attention tends to drift. In scenarios where creative thinking is required, a broad base of training is extremely valuable, but out of the box thinking is not appropriate for every situation.
Another problem with the bill that more directly related to us is that the bill does not mention medical dosimetry at all. It is implied under the umbrella term "radiation therapy" but it is never explicitly stated. This is a quibble over wording, but another issue that more directly affects students like us is the section stating "Individuals enrolled in a nuclear medicine, radiation therapy, or medical physicist training or certification program as of the date the Secretary publishes the list of approved certification organizations shall have 6 months from the date of completion of the training program to become fully qualified as required under paragraph (1)". Everyone in our program who does not yet have a CMD would be unable to fulfill this requirement, because we are going to miss the application deadline for the February 2016 CMD exam and will have to wait until 8 months after graduation before we can take the test. If any of us fail, we will be further out of compliance, and with a failure rate of around 50%, that could affect a lot of us.2
This bill is well-intentioned but it seems to be doomed to failure because of its vagueness. Luckily, industry seems to be making headway in the direction of quality improvement on its own, without relying on a potentially cumbersome umbrella law to force a one-size-fits-all rule across two broad disciplines with many subspecialties. I do not have enough experience to speak for areas other than dosimetry, but in my browsing of available dosimetry jobs, I see that just about every job description says that the applicant must already be certified, or be board eligible and pass board exams with 3 years of starting. This is likely because of high levels of advocacy activity at national conferences and among thought-leaders in the dosimetry profession. Luckily these ideas are easily propagated by HR people who look at other postings and copy/paste the requirements into their own job descriptions. However we got here, we have now come to the point where anyone posting a dosimetry job that does not mention certification would get odd looks.
I think that this grassroots way of effectively forcing a certification process without actually forcing it is a much more reasonable mechanism with fewer unforeseen consequences. It allows dosimetry and all of the other disciplines to seek quality improvement in their own ways.
On the job training (OJT) is likely to remain an option for new dosimetrists for a long time going into the future. Some rural areas or areas that are underserved by medical professionals may not have the option of bringing in a certified staff member and may rely on training an in-house candidate through OJT. The CARE Act thought of this too, and allowed the possibility of an exemption for exactly this scenario.1 I see no harm in allowing OJT at a local level, but trainees will have to beware, because it will severely limit their marketability if they should ever want to move to another institution. In this way, market forces, not legislation, will promote accredited education programs and certification.
In a perfect world, I think that both work experience AND accredited education are needed. Our program, which includes both, will prepare us better than either would individually. Unfortunately, market forces can cut both ways, and the shorter a program is, the more appealing it might be to applicants. The shortest programs may not leave candidates fully prepared, but the certification examinations can act as a gatekeeper to make sure that students are learning what they need. Longer programs can distinguish themselves with accreditation and high pass rates among graduates.
- Consistency, Accuracy, Responsibility, and Excellence in Medical Imaging and Radiation Therapy Act of 2013, S 642, 113th Cong (2013).
- Lenards, N. Accreditation, Certification & Professional Organizations. [SoftChalk]. LaCrosse, WI: UW-L Medical Dosimetry Program; July 14, 2015.