Twenty Years of the Malaysian Association of Medical Physics:
Looking Back to Move Forwards
H. M. Zin ABSTRACT
The Malaysian Association of Medical Physics (MAMP) was set up in the year 2000 to promote and further develop the field that was relatively new in Malaysia. The article briefly summarises key developments in medical physics since the first discovery of x-rays in 1895. The resulted rapid progress in the field was also highlighted and related to the pace of development in Malaysia.
Key activities organised by MAMP were also addressed. The international practices related to the field and the profession were highlighted and compared to the current status in Malaysia. Although the field has progressed well in the country, there are several gaps identified to further improve the field and the profession in Malaysia.
Keywords: Medical physics; professional practice; education and training; history; regulation Oncological and Radiological Science Cluster, Advanced Medical
and Dental Institute, Universiti Sains Malaysia, Bertam 13200 Kepala Batas, Pulau Pinang, Malaysia
*Corresponding Author: H. M. Zin Email: [email protected] Tel: 604-5622468 Fax: 604-5622551
Received: 9 December 2020
Accepted for publication: 26 January 2021
Publisher: Malaysian Association of Medical Physics (MAMP) http://www.mamp.org.my/
https://www.facebook.com/MedicalPhysicsMalaysia
INTRODUCTION
The Malaysian Association of Medical Physics (MAMP) was established and registered at the Registrar of Society Malaysia on 4th Feb 2000. Dr. Saion Salikin and Dr.
Noriah Jamal were the founding President and the Secretary of MAMP, respectively. The association was set up to promote and further develop medical physics in Malaysia, including matters related to applications of radiation in diagnostic imaging, nuclear medicine and radiotherapy including radiation safety, training, research and development, and consultation. MAMP was also intended to develop certification standards, training schemes, an accreditation system, a registration system and training, qualification and experience being required to perform the very specialised procedures. These aims are listed in clause 3 of the MAMP constitution, a constitution produced when the association was founded in 2000. The founding of MAMP preceded global recognition in 2008 of the profession of Medical Physicist by the International Labour Organisation (ILO) under the International Standard Classification of Occupations (ISCO). Medical physics is now firmly recognised as a science and engineering profession under ISCO based on the International Organisation of Medical Physics (IOMP) Guidance on ISCO-08. The establishment of MAMP is part of a national effort in terms of developing systems within which the profession can be recognised, also ensuring competency of the profession. Besides MAMP, several other organisations such as the Institut Fizik Malaysia (IFM) is also contributing to the development through the Medical Physics Subgroup of IFM.
This year MAMP is 20 years old. Year 2020 has been an unprecedented year. The majority of MAMP members are millennials, growing up in the late eighties and early nineties when the country envisioned “Wawasan (vision) 2020”. The expectation of the technological advancement
and mass adoption of automation and robotic technologies are now much wider and more pronounced. These envisioned elements of future technology have started to alter our daily lives in many ways.
Crystal ball gazing into what ahead is a tricky task, but the progress already made in the field and the profession can give some clues to the rate of progression in the future. The agile future also seeks one to adapt to the coming changes as well as preparing to explore newer technologies and adapting the existing roles to the changing needs (Ng 2008). Prof. Dr. Ng Kwan Hoong, the recipient of the Marie Sklodowska-Curie Award in 2018, has posed the following questions that will still remain relevant after 2020.
“How would medical physicists fit into this changing scenario? Are we prepared to explore the newer technologies? How are our curricular adapting to the changing needs?”
In order for medical physics in Malaysia to move forward and prepare for the future, perhaps we can take some time to look back at the historical development of the field and possibly learn from the past. This paper will introduce the field and the profession, highlight important related historical global events related to the field’s development, before concluding on the areas to move forward.
“The further you can look back, the further you can look forward.” — Winston Churchill
as quoted in “The Last Lion: Winston Spencer Churchill:
Visions of Glory, 1874-1932” (William Manchester 1984).
PHYSICIST IN MEDICINE
Medical physicist is a health professional involved in assessing and treating illness together with a multidisciplinary team of medical specialists (oncologists, radiologists, nuclear medicine specialists, neurologists, urologists and many others), and radiation technologists (radiographers and radiation therapists). The medical fields that the medical physicists are often involved in are radiation oncology, diagnostic radiology, and nuclear medicine. The medical physicist has an important role in protecting patients and healthcare workers from potential radiation hazards. They are involved with the commissioning, calibration, safe operation and quality assurance of medical imaging and radiation therapy systems. Improper use of radiation contributes to potential radiation side effects and death that was seen not only in the early days of radiation use but also recently (Lindell 1996).
According to the International Atomic Energy Agency (IAEA), a clinically qualified medical physicist must have a university degree in physics, engineering and equivalent physical science, followed by an appropriate academic qualification in medical physics at the postgraduate level. The physicist must also undergoes structured clinical in-service training undertaken in a hospital before they can be considered competent to practice (IAEA 2013). The IAEA has emphasised that the holder of a university degree in medical physics without the required hospital training cannot be considered to be clinically qualified.
Besides the clinical role that is usually referred to when the role of the medical physicist is defined, a medical physicist may also have wider roles, in research, education and administration, the proportion varying depending on the work location. The roles may heavily involve clinical contributions, particularly if the medical physicist works in a hospital whereas one would have to do more research, and academic roles if the medical physicist works in an academic setting.
125 YEARS OF GLOCAL DEVELOPMENT SINCE 1895
The discovery of x-rays by Wilhelm Conrad Röntgen in November 1895 instantly revolutionised the field of medicine. Within two years of the discovery, the technology was brought to the Perak state by a group of photography enthusiast (Khoo 1971). The chairman of the Perak Amateur Photographic Society, Mr Wray demonstrated a Roentgen ray apparatus to reveal via x-ray imaging the bony details of a pomfret fish (Bradley
& Wells 2014). Also shown was the fractured hand of a person who had suffered an accident several months earlier. Soon after, the state received an x-ray apparatus, the first one in the Far East. By the year 1927, it was recorded that five sets of new X-ray equipment had been installed in KL, Ipoh and Seremban (Wastie 1994).
It was exciting, for the first time allowing one to see through the body instead of having to rely on indirect diagnosis and evidence of successful treatment. Because of the immense usefulness, the radiation technology was quickly adopted worldwide. Thus said, the adoption was done rather hastily without fully knowing the potential danger from inappropriate use. Many early records of the application reported that operators of the apparatus suffered from severe dermatitis and mutilation from the overexposure to radiation (Lindell 1996).
In 1896, soon after the discovery of x-rays and very early examples of their use, Henri Becquerel made a further serendipitous discovery, that of radioactivity, working with the element uranium. This was followed by Marie and Pierre Curie and the discovery of radium in
1898. In 1934, Irene Curie and Federic Joliot discovered an artificial way of producing radioactivity. These discoveries have led to many associated applications not only in medicine but also in consumer products. Some of the inappropriate uses also lead to potential adverse effects.
Further understanding of these different types of radiation by the physicist has ushered in a new era of radiation based medical diagnosis and treatment, thereby, giving rise to the modern medical physics profession.
Medical physicists bridge applied physics and medicine to better interpret the radiation science and technology for use in medicine. They became more involved with the more sophisticated development of the radiation technology, that lead to the setup of relevant department in the hospitals lead by physicist.
One of the early ‘medical physics’ departments, named the Electrical and Radiotherapeutic Department, was setup in London at the Free Cancer Hospital Research Institute in 1910, now the Royal Marsden Hospital (Brunning & Dukes 1965). The Department was led by one of the pioneers in medical physics, C.
E. S. Philips. Subsequently, W. V. Mayneord become the Director of the Physics Department and Professor of Physics as Applied to Medicine. This set a path to the new era of radiation-based medical diagnosis and treatment, thereby giving rise to the modern medical physics profession.
In Malaysia, the use of radiation for therapeutic purposes began in 1950 when Kuala Lumpur Hospital acquired kilovoltage x-ray machines in phases (Abd.
Aziz Tajuddin & Bradley 1995). The involvement of a physicist was recorded in Malaysia when the hospital had the first local consultant radiotherapist serving the department in 1960 (Lim 2006). Soon after, in 1968, the Institute of Radiotherapy, Oncology and Nuclear Medicine of Kuala Lumpur Hospital was established with a Betatron machine of 5-43 MeV and two 6 MV linear accelerators (Lim 2006). The physicist post was officially created by the Malaysian Ministry of Health (MOH) in 1974 as well as a physics laboratory within the Institute to support the medical physics services, including dosimetry and later on in the late 1980s computerised treatment planning. Further modernisation of the institute’s radiotherapy services was made through introduction of two new linear accelerators in 1997 and 2001, the latter being supported by a three-dimensional (3D) treatment planning system and digital simulator. In the nineties, the radiotherapy services with modern linear accelerators expanded across other parts of Malaysia.
Northern services were established through several private centres in Ipoh and Penang and in East Malaysia at a public hospital facility in Sarawak. In 1995, the first academic institution that established a radiotherapy and oncology division was Universiti Sains Malaysia
Hospital (HUSM). Their modern radiotherapy service started with a PRIMUS Siemens linear accelerator capable of 3D conformal radiotherapy and x-knife radiosurgery in the year 2001. Around the same time, the University Hospital KL (now University Malaya Medical Centre (UMMC)) also began a modern radiotherapy service under several oncologists and medical physicists.
This development of services based in the academic institutions provided the path for training of relevant professionals in the fields locally and further expansion of the field in Malaysia. In particular, there are two long- standing MSc Medical Physics programmes in Malaysia, one at Universiti Sains Malaysia (USM) and the other at University of Malaya (UM) (the latter being recognised by the United Kingdom (UK) Institute of Physics and Engineering in Medicine (IPEM), please see below.
2020 STATUS
Fast forward to the present, MAMP has grown in terms of the membership number and the scale and the frequency of the activities organised. The committees were elected at the Annual General Meeting (AGM) of the society.
Former MAMP presidents were Dr. Saion Salikin (2000-2005) and Dr. Wan Ahmad Kamil Wan Abdullah (2006-2018). In 2013, MAMP became affiliated to the Asia-Oceania Federation of Medical Physics (AFOMP) under the International Organisation of Medical Physics (IOMP). MAMP has actively involved in organising activities related to medical physics and the professions such as bi-annual conferences, workshops on clinical practice, academic training, and seminars on latest update in the field. The events are often organised in partnership with relevant organisations in Malaysia such as the IFM, the College of Radiology Malaysia and the Malaysian Oncological Society. The bi-annual conference known as the National Seminar on Medical Physics was renamed the International Seminar on Medical Physics (ISMP) on the 10th anniversary to recognise the diversity of the nationality of the conference speakers and attendees in previous conferences. Table 1 summarises the details of the conferences organised by MAMP in the last 10 years. Photo 1 shows the participants from ISMP 2016.
In terms of the programmes to train medical physicists in the country, there are two Master programmes in medical physics, as previously mentioned, with one IPEM accredited (Azlan et al. 2020). The master programmes in Medical Physics were established in USM in 1995 followed by in UM in 1998. Starting in the year 2010, Malaysia introduced the pilot clinical training programmes through an IAEA funded training scheme.
The clinical training programme is now running the second cycle of the scheme involving those currently practicing.
TABLE 1 Summary of MAMP conferences organised since year 2012 Conference Details
(Name, Date, Venue) Theme Highlights
8th National Seminar on Medical Physics 2012; 19 December 2012; Sunway Hotel Seberang Jaya, Penang
Advances in Imaging and Radiotherapy 41 attendees, 11 oral, 12 posters presentations
All accepted extended abstracts were published in a conference proceeding.
9th National Seminar on Medical Physics 2014; 5 April 2014; Marriott Hotel Putrajaya
Advances in Multidisciplinary Research and Clinical Practice 65 attendees, 17 oral and 12 posters resentations
22 manuscripts were published in Proceedings of NSMP 2014, Journal of Physics Conference Series, Volume 546, 2014
10th International Seminar on Medical Physics 2016; 27-28 August 2016; Bayview Hotel Penang
Fostering Medical Physics Research and Clinical Practice for Better Healthcare”
300 attendees, 28 oral and 22 poster presentations
41 manuscripts were published in Proceedings of ISMP 2016, Journal of Physics Conference Series, Volume 851, 2017
11th International Seminar on Medical Physics 2019; 7-8 November 2019; Istana Hotel, Kuala Lumpur
Medical Physics: Together We Make an Impact
Over 100 attendees, 24 posters and 28 oral presentations
33 manuscripts were published in Proceedings of ISMP 2019, Journal of Physics Conference Series, Volume 1497, 2019
There are 35 centres in Malaysia offering radiological diagnosis and radiotherapy services nationwide, where seven are in public hospitals, 24 in private medical centres and four in university hospitals. Seventy-seven per cent of MPs in Malaysia are working in public hospitals, while the rest are in private medical centres and industrial companies (Wong et al. 2019). The number of linac provides for greater than one linac per million population in Malaysia (Zubizarreta et al. 2017) Although, the number seems to be within the recommended ratio for a nation, the linacs are more concentrated in the central region than the rest of Malaysia (Yahya et al.
2019). Many Malaysians outside the central region have to travel far, two to ten times further (40 km to over 200 km) compared to those in the central region (less than 20 km). Radiotherapy typically requires daily out-patient treatment for a period of a month, and thus this can be an obstacle for those patients far
from the centre, a matter that should perhaps deserve attention to resolve the disparity.
A relatively recent survey sample of 106 respondents has provided a summary of the distribution of medical physicists in Malaysia (Wong et al. 2019).
Two-thirds of the respondents have a postgraduate degree in Medical Physics, with very few formally certified and that too by professional medical physics organisations abroad. This highlights a gap in the profession, showing that despite a good educational system no national bridge exists in the form of formal training programme to properly prepare the graduates for entry into the workforce. However, given that majority of the workforce are below 40 years of age, the prospect for improving the status quo to fulfil the international requirements of having a postgraduate degree and structured clinical training is bright. The number of medical physicists in the country is now estimated at over 300 people.
PHOTO 1 Participants of the ISMP 2016
In terms of national recognition, the Atomic Energy Licensing Act (Basic Safety Radiation Protection) Regulations 2010 recognised the field of medical physics as a field of specialisation involving the use and application of physics in medicine (Atomic Energy Licensing (Basic Safety Radiation Protection) Regulation 2010; Atomic Energy Licensing Act 1984). The regulation specifies that quality assurance of diagnostic and therapeutic uses of radiation is conducted by or under the supervision of a qualified expert in medical physics. The regulation interprets that the qualified expert means an individual who by virtue of certification by any authority or society or professional licensee, or by virtue of his academic qualifications and experience, is duly recognised by the Board as having the expertise in a relevant field of specialisation. Recently, the Allied Health Professions (AHP) or Act 774 was gazetted on 1st. of July 2020 to regulate the practice of allied health practitioners including medical physicist in Malaysia (Allied Health Professions Act 2016), intended to ensure the safety and wellbeing of the public through the establishment of the Malaysian Allied Health Professions Council (MAHPC). The MAHPC was established to protect public interest by ensuring practitioners are registered and competent to practise; to determine and regulate the standards of practice, conduct training; and maintaining the registers. Registration of the allied health practitioners is expected to begin in 2021. The development in official recognition of the profession can stimulate further development in the qualification and competency required for the medical physicist to practice in a healthcare setting.
AFTER 2020
Globally, since 2008 the medical physicist profession and their roles has been recognised by the ILO and medical physics is accepted as modern applied branch of physics. Medical physics is growing in importance both as science and as a profession, driven by the technological developments of society in general and medicine in particular. Medical physicists are expected to have the education and specialist training in the concepts and techniques of applying physics in medicine, besides, being clinically competent to practice in the medical physics field (IAEA 2013). The roles of the medical physicists in these areas are important and must be recognised and well-regulated because of the possible impact of the work involved on human health.
The concentration of medical physicists in Malaysia is above the average for a developing country, but the distribution and the roles can be strengthened. Medical
physics education and clinical training programmes have difficulties in meeting the demand for producing well educated and well-trained medical physicists.
The two existing postgraduate programmes are well organised with one of the programmes internationally accredited, but the clinical training aspect is still under development and not standardised (Ng et al.
2021). Therefore, continuous education, research and development are crucial in maintaining the competency of the existing workforce. Another big challenge is the distribution of health care facilities, affected to a certain degree by the health care financing model in the country (Rasiah et al. 2009). This in particular affects the accessibility of patients from outside of the central region.
Now MAMP is at an intersection of rapid progress in the field that is backed by a recognition system in Malaysia. The association was founded in a different setting in which there was no national recognition of the profession, unlike a good number of developed countries during that time. Hence, the aims and objectives of MAMP in the constitution are also to address issues on recognition and certification. The profession has currently been recognised by the AHP Act and will soon become a new healthcare profession that will be regulated. Now the focus on associated efforts related to the field and profession development can be intensified. This endeavour would need support from the medical physicists especially those from the clinical service settings that currently make up only about a quarter of MAMP membership. Strategic initiatives from the academic and health care sectors are important to ensure that the efforts result in multiple impacts that will match to internationally recommended practice. At the same time, the field must also be wary of the possible volatile and disruptive global changes from the rapid development of future technology that will be affecting the field. This would need concerted efforts from all the stakeholders.
ACKNOWLEDGMENT
The author who currently serves as the President of MAMP 2019-2020 would like to thank fellow committee members for their contributions to the field throughout the term. Special subcommittees were established to drive strategic causes related to the profession and field development.
MAMP committee members 2019-2020 1. Dr. Mohd Hafiz Mohd Zin, President
2. Dr Rafidah Zainon: Vice President, SIG in lonising Imaging
3. Assoc Prof. Dr. Noramaliza Mohd Noor: Secretary 4. Dr. Husaini Salleh: Treasurer, Finance & Business
Planning
5. Dr. Rozilawati Ahmad: Assistant Secretary, Media
& Public Engagement
6. Assoc. Prof. Dr. Ahmad Taufek Abdul Rahman:
Research and Innovation
7. Assoc. Prof. Dr. Ahmad Nazlim Yusoff: Publication 8. Ms. Mahzom Pawanchek: Profession, Clinical
Practice and Accreditation
9. Dr. Noor Diyana Osman: Membership
10. Dr. Noriah Jamal: SIG in Radiation Protection 11. Dr. Nur Hartini Mohd Taib: SIG in Non-ionising
Imaging
12. Assoc. Prof. Dr. Ung Ngie Min: Education, Training and Resources
The author also would like to acknowledge the support from other organisations in Malaysia including the Medical Physics Division of IFM, Persatuan Pegawai Sains Fizik Kementerian Kesihatan Malaysia (KKM) (PERFEKS), the Malaysian Nuclear Agency and major public and private institutions that have contributed to the field and professional developments in Malaysia.
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