Practice Guidelines for Medical Physics

Law, rules and regulations, not Guidelines, specify the requirements for practice and violating them constitutes professional misconduct. Not adhering to this Guideline may be interpreted as professional misconduct only if the conduct also violates pertinent law, rules and regulations, some citations of which are listed at the end of this Guideline.

Title and Scope of Practice | Exemptions to Medical Physics License Requirements

Title and Scope of Practice

Under Article 166 of the Education Law, Medical Physics is both a title and scope of practice protected profession, which means that only a person licensed under Article 166 can use the title “Professional Medical Physicist” and only such a person may perform the medical physics functions specified in the Education Law. The functions and/or activities described within the Medical Physics’ scope of practice may only be performed by a Professional Medical Physicist (PMP) who holds a valid license and current registration. The Medical Physics’ “scope of practice” is defined in two separate parts of the Education Law. Education Law §8702 contains the general scope of practice provisions for Medical Physics, and Education Law §8701(2)(a) through (d) contains the scope of practice provisions for the four Medical Physics Specialty Areas.

Education Law §8702 defines the Practice of Medical Physics as follows:

The use and application of accepted principles and protocols of physics in a clinical setting to assure the correct quality, quantity and placement of radiation during the performance of a radiological procedure, so as to protect the patient and other persons from harmful, excessive or misapplied radiation. Such practice shall include, but is not necessarily limited to:

  1. radiation beam calibration and characterization;
  2. oversight and responsibility for patient radiation dose measurement, calculation and reporting1;
  3. oversight and responsibility for quality control (QC);
  4. instrument specification;
  5. optimization of image quality;
  6. acceptance testing;
  7. shielding design;
  8. protection analysis on radiation emitting equipment and radio-pharmaceuticals; and
  9. consultation with a physician to assure accurate radiation dosage and application to a specific patient.
1 Examples include, but are not limited to, review of radiation oncology treatment plans and physics chart checks; and, for imaging studies, the estimation of absorbed dose.

Education Law §8701(2)(a) through (d) define the four Medical Physics Specialty Areas as follows:

Diagnostic radiological physics means the branch of medical physics relating to the diagnostic application of radiation, the analysis and interpretation of image quality, performance measurements and the calibration of equipment associated with the production and use of such radiation, the analysis and interpretation of measurements associated with patient doses and exposures, and the radiation safety aspects associated with the production and use of such radiation.

Medical health physics means the branch of medical physics pertaining to the radiation safety aspects of the use of radiation for both diagnostic and therapeutic purposes, and the use of equipment to perform appropriate radiation measurements.

Medical nuclear physics means the branch of medical physics pertaining to the therapeutic and diagnostic application of radionuclides, excluding those used in sealed sources for therapeutic purposes, the analysis and interpretation of performance measurements associated with radiation imaging equipment and performance oversight of radionuclide calibration equipment associated with the production and use of radionuclides, the analysis and interpretation of measurements and calculations associated with patient organ doses, and the radiation safety aspects associated with the production and use of such radionuclides.

Therapeutic radiological physics or radiation oncology physics means the branch of medical physics relating to the therapeutic application of radiation, the analysis and interpretation of radiation equipment performance measurements and the calibration of equipment associated with the production and use of such radiation, the analysis and interpretation of measurements associated with patient doses, and the radiation safety aspects associated with the production and use of such radiation.

Note: Preparing Draft Reports of any activities related to the Scope of Practice of Medical Physics is not considered the practice of medical physics. However, the PMP must sign and accept responsibility for all reports pertaining to Scope of Practice activities.


Exemptions to Medical Physics License Requirements

Service Engineers | Radiologic or Imaging Technicians | Oversight and Supervision | Limited Permits

As stated in Education Law §8707:

Nothing in Article 166 shall be construed to affect, prevent, or in any manner expand or limit the authority of any person otherwise authorized by law or regulation to practice any function of a medical physicist, or any department or agency authorized by law or regulation to regulate the use of radiation, nor prohibit the repair or calibration of any test equipment used by professional medical physicists by any person otherwise allowed to do so under state or federal law, nor serve to limit radiologic and/or imaging technicians or any individual otherwise authorized by law or regulation from performing QC measurements or obtaining QC data, nor serve to limit a service engineer in the repair of radiation producing equipment nor an installation engineer in the installation of radiation producing equipment.

The law exempts selected personnel performing specified activities from medical physics license requirements:

Service engineers:

  1. Repair or calibration of any test equipment used by professional medical physicists;
  2. Repair of radiation producing equipment; and/or
  3. Installation of radiation producing equipment.

Note: Performing QC measurements or obtaining QC data is not among the exempted activities permitted to be performed by a service engineer, given the safety imperative of having an independent, properly trained person (the PMP) double check the service person. However, a service or installation engineer is not prohibited from making any measurements necessary for the repair or installation of radiation producing equipment within the scope of the manufacturer’s repair or installation procedures or protocols.

Radiologic or imaging technicians2:

  1. Performing QC measurements; and/or
  2. Obtaining QC data.

Note: The PMP should exercise ‘general oversight’ of a radiologic or imaging technician leading to the PMP accepting responsibility for the medical physics-related work done by the radiologic or imaging technician performing QC measurements or acquiring QC data.

2 The term “radiologic or imaging technicians” includes Radiological Technologists and may include other personnel. These individuals may only perform QC measurements or obtain QC data under the oversight of a PMP. Radiologic technologists are licensed by the New York State Department of Health (NYSDOH) and are supervised by a practictioner as defined in Article 35 of Part 89.

Oversight and Supervision:

The PMP assumes full professional responsibility for QC measurements or QC data performed under his or her supervision and oversight.

General Oversight — Performing QC measurements or obtaining QC data is done under a PMP’s overall direction and control, but the PMP’s physical presence is not required during these activities. If the PMP and the individual under General Oversight are not employed by the same entity, a written Oversight Agreement should be executed by all parties to assure the required level of oversight is maintained. Under General Oversight the PMP should be available to address questions as needed, deliver training of the personnel who actually perform the procedure. Assuring proper calibration, maintenance of the necessary equipment and supplies are the continuing responsibility of the PMP.

Specifically, the PMP providing general oversight should review, approve, and manage the QC Program in Radiation Therapy, Diagnostic Radiology, and Nuclear Medicine by doing the following:

  1. Specifying what QC tests are to be performed;
  2. Specifying the frequency of each QC test;
  3. Specifying the method and procedure to be used for each QC test;
  4. Specifying and approve the test equipment to be used for each QC test;
  5. Specify and approving the qualifications of individuals performing QC testing or acquiring QC data;
  6. Specifying the range that would be acceptable for each QC test result and the course of action, should the result be out of that range;
  7. Specifying the range of results that would constitute a Critical Failure, and require the “radiologic or imaging technician” who is acquiring the QC data to immediately notify the Radiation Safety Officer (RSO) or practictioner, advising that facility management should cease using the equipment, and to promptly notify the the PMP;
  8. Signing the written report. If other personnel performed QC measurements or acquired QC data, include the name(s) and credentials; and
  9. Accepting responsibility for the report as if the measurements or QC data were acquired by him or herself.

“Direct and immediate supervision” means the continuous physical presence of the supervisor during the performance of activities that are within the scope of practice of medical physics as defined in Education Law §§8702 and 8701(2)(a) through (d), and is only specifically required for limited permitees performing scope of practice activities.

Individuals with the following qualifications may acquire QC data only under the general oversight of the PMP.

  1. Licensed Radiological Technologists (Radiographer, Nuclear Medicine Technologist, or Radiation Therapist); and
  2. Individuals holding a Limited Permit in the appropriate specialty area of Medical Physics.

Note: The PMP should exercise Individuals authorized by the PMP may serve as “radiologic and/or imaging technicians” to collect QC data only if the PMP documents the nine items listed above in the facility QC manual, along with the qualifications of the individual acquiring the QC data. In addition to exercising general oversight, the PMP must reauthorize any such individual by personally observing him or her, at recommended intervals of 12 months or less. This reauthorization should document the individual’s current, demonstrated competency to perform each QC task for which he or she is authorized. It should be noted that this process only enables the authorized individuals to collect data exclusively for the authorizing PMP and does not constitute an unrestricted authority to collect QC data for other PMP’s.

Limited Permits

Education Law §8706(1)(a) and (b) authorizes the Department to issue a limited permit to an individual who has fulfilled all the requirements for a license as a PMP except those relating to examination or experience; or a medical physics student enrolled in a graduate or post-graduate curriculum approved by the Department.

Without exception, individuals practicing medical physics under a limited permit must be under the direct and immediate supervision of a PMP, and only practice in the specialty area of such PMP.

Although obtaining QC data is not within the protected scope of practice for the profession of medical physics, limited permittees may perform QC measurements or acquire QC data under the general oversight of a PMP.

All employers must assure that direct and immediate supervision (for scope of practice activities) and general oversight (for obtaining of QC data) is available when hiring an individual with a limited permit.

Last Updated: March 6, 2018