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EUropean Training and Education for Medical Physics Experts in Radiology

Final Report Summary - EUTEMPE-RX (EUropean Training and Education for Medical Physics Experts in Radiology)

Executive Summary:
Situation: The core activity of the medical physics expert (MPE), as defined by the EU BSS [1], is to ensure optimal use of ionizing radiation for medical applications and to bring new knowledge and expertise from physics into healthcare. It is essential that these healthcare professionals are trained to the highest level, namely EQF level 8 [2]. Required knowledge, skills and competences (KSCs) for the MPE have been specified in the EC Radiation Protection Report 174 “European Guidelines on Medical Physics Expert” [3]. These Guidelines have developed a harmonized qualification framework and specialization specific Learning Outcomes. While the basic training of medical physicists to EQF level 7 is established in most of the EC Member States, educational tracks for EQF level 8 i.e. the medical physics expert level, the future leaders in the profession, are missing. In many European countries, financial and organizational considerations preclude the development of local training schemes. In addition, in those states where a national scheme is available expertise to cover the more advanced KSCs is not always locally available. In its 2012 EURATOM Fission Training Schemes, the EC has recognized the need for expert training in diagnostic and interventional radiology and decided to support the EUropean Teaching and Education for Medical Physics Experts in Radiology (EUTEMPE-RX). Fourteen partners have worked together to reach excellence in education.

Objective: The main objective of the EUTEMPE-RX project was to provide an education and training scheme that allows the medical physicist in Radiology to reach EQF level 8. The learners that were targeted by the project are medical physicists with typically 2years of practical experience in radiology in hospitals, medical device companies or nuclear authorities, PhD students in radiology physics and biomedical engineers working in radiology. The European training scheme had to address physicists from all over Europe and especially also from the New Member States and even beyond.

Method: The project has developed 12 Modules at EQF level 8, with radiation safety and diagnostic efficacy being prevalent subjects, often called radiation protection and optimization. A purposely developed quality manual guided the project from the approval of the course abstract to the quality survey sent to the participants after the course. Educational workshops were organized to familiarize the teachers with techniques of online teaching, e-learning, interacting with small groups and assessment methods. The course modules used a blended learning scheme: each course aimed at 80 hours of active learning by the participants, divided between a preparation phase at home via online learning and onsite training in the institution of the module leader.

Results: All modules were run as planned, with the quality survey among participants confirming the high level of the courses, the expertise of the teachers and the e-learning preparation phase. The teachers reported that a very motivated group of medical physicists participated in their modules. Teachers have challenged the participants with unique tasks: case studies in medical physics leadership, Monte Carlo simulation of a complete x-ray imaging chain, development of a task specific QA protocol, compilation of optimization plans, simulation tasks with anthropomorphic breast models, etc. Participants undertook practical sessions in modern hospitals and visited a synchrotron facility, a calibration lab, screening organizations, etc. The consortium ratified a sustainability plan to repeat the courses.
Conclusion: The project has realized unique E&T modules for the medical physics expert in diagnostic and interventional radiology. The modules can serve as an example for local course initiatives or for other domains in medical physics

[1] European Commission: COUNCIL DIRECTIVE 2013/59/EURATOM
[2] Recommendation of the EU Parliament (2008/C111/01) on the EU Qualification Framework for LLL
Project Context and Objectives:

Scientific context
Medical exposures represent the largest contribution to manmade radiation exposure in the EU member states. Whereas there is no doubt that medical techniques producing such exposures have improved the health of the EU citizen, the deleterious effects of ionizing radiation must be recognized and the ALARA principle respected. Radiation Protection in Medicine requires justification, dose evaluation and optimization including adherence to DRLs. Our hospitals need a nuclear safety culture. Specific current issues in diagnostic and interventional radiology are:
- A steadily growing trend in the number of exposures for medical applications and large variability in doses per procedure. Patient specific differences may be due to their pathology or anatomy and this tailoring should be done and further stressed in the future (current research projects work at task based imaging). Other differences are due to proper or suboptimal use of equipment and local imaging traditions.
- A growing public awareness of the effects of ionizing radiation particularly when this is used for medical applications and screening
- Growing complexity of medical devices both for assessing the doses and optimizing performance. Task based approaches will increase the need for proper documenting of patient specific quality and dose measures
Following the European BSS of Dec 2013[1], medical physicists are ideally placed to work at these items; this is obvious from the task list published in that Directive and summarized by the European Federation of Organizations for Medical Physics (EFOMP) as ‘work at justified and optimized medical exposures, proactively protecting the patients from unnecessary radiation’. Today, medical physicists (MPs) face huge (scientific and technical) challenges when addressing their tasks.
While selected scientific literature estimates the radiation induced burden on the population from ionizing radiation [4, 5], assessing the effect of suboptimal (technical) quality (and hence sensitivity and specificity) is even more difficult. Actual scientific, evidence based optimization aims to be task based, as opposed to the simplistic ‘proper film blackening’ criterium of the film age a couple of decades ago. Digital imaging, with a computer processing images or enhancing specific features, offers the opportunity to easily quantify image quality features such as noise, but at the same time, the parameter space for testing and optimization became very large. Today while dose monitoring platforms collecting patient dose data are entering our hospitals, quality monitoring is only in an initial phase.
The overall complexity hampers the rapid development and sales of dose reducing options on medical devices, a domain in which Europe had until recently an important role (example: EuroSafe). During recent years there have been many initiatives in the US too, such as ImageGently and ImageWisely.
Nuclear authorities in charge of installing, guiding or supervising nuclear safety in medicine could achieve more results with well trained professionals. Insufficient training of medical physicists in radiology, in medical device companies and in nuclear authorities, on the other hand, may lead to dose escalation, improper use of dose reduction techniques, diagnostic or therapeutic quality that remains unchecked and absent in the scientific arena. The RP174 document [3] has therefore defined several levels of medical physics expertise (Appendix 1 - Fig 1). The Medical Physics Expert (MPE) should be able to face all the challenges in his working place, combining the most advanced levels of knowledge skills and competences at the frontier of his field of work with the most advanced and specialized skills and techniques in medicine and so be able to demonstrate authority.

Industrial context
Radiation protection and image quality are important parts of new medical devices, in a growing but challenging market of the medical device business. There can only be a net positive impact for these new products if they are subsequently assessed and then used and documented. Following the RP174 document [3] the mission statement of MPEs has been formulated as: “MPEs/ Medical Physics Services will contribute to maintaining and improving the quality, safety and cost-effectiveness of healthcare services through patient-oriented activities requiring expert action, involvement or advice regarding the specification, selection, acceptance testing, commissioning, quality assurance including quality control, and optimized clinical use of medical radiological devices and regarding risks from associated ionizing radiations; all activities will be based on current best evidence or own scientific research when the available evidence is not sufficient. The scope includes risks to volunteers in biomedical research, carers and comforters”. MPEs are often also tasked with the role of the radiation protection expert. Medical physicists in hospitals should collaborate with engineers and scientists in medical device companies.

Societal context
Only a selected group of young professionals choses a profession in nuclear sciences, and in particular medical radiation physics. This is in part due to the limited number of available positions. The result is a lack of inflow, and that will lead to a shortage of trainers and leaders.
Education and training are well known approaches to boost knowledge, skills and competences, and prepare for leadership in the profession. In the RP174 document, KSCs have been listed for the different medical physics professions, from basic training at EQF level 6 and 7 up to the expert level (EQF 8)[2]. It was realized, though, that whilst most EC member States have the basic training for medical physicists implemented, there are no resources to implement the highly specialized training schemes for medical physicist- experts and, in particular, not for the physicists in diagnostic and interventional radiology. Compared to radiotherapy physicists, the number of MPEs in diagnostic and interventional radiology is significantly lower and the specialty is even non-existent in some of the Member States.
New leaders in the specialty will certainly increase the awareness of healthcare professionals of the need for proper dose and healthcare quality. They will motivate and properly train young people, with an overall improved nuclear radiation culture as a result. For properly trained medical physics experts the labor market will enlarge from the local hospital to more responsible positions in (larger) hospitals, to academic centers where they can act as assistant/teacher, to research institutions to start well prepared clinically oriented research studies, to R&D or business development levels in medical device industry and to governmental positions as communicators, decision makers or strategists on radiation protection issues.

Conclusion: The project partners brought together to prepare the EUTEMPE-RX project had discussed the context of the medical physics experts in diagnostic and interventional radiology and shared the situations in their countries. It was obvious that individual countries didn’t have the required expertise to teach all aspects of the MPE at EQF level 8. It was decided to construct a network of excellence, share the expertise and submit the EUTEMPE-RX proposal for support to the EU in the frame of the EURATOM ETFS call. The project started on August 1st, 2013.


Objective 1. To create a network of excellent teaching centers that will prepare high level, dedicated course modules to bring the medical physicist in Diagnostic and Interventional Radiology to the level of the MPE. Quality management techniques had to be applied to prepare effective, efficient, EQF8 based, harmonized education and training programs.
Topics had to help medical physicists to improve their professional activities, and therefore include: leadership, radiobiology for radiological applications, patient dose calculations using Monte Carlo and related techniques, performance evaluation using model observers, new test methods such as using anthropomorphic phantoms, advanced QA protocols, optimization schemes, metrology and radiation protection, and finally dedicated specialized sessions on breast imaging and high dose procedures.
Courses had to embrace as many as possible of the KSCs of the RP174 document for the medical physics expert in radiology.

Objective 2. To set up an Educational and Training platform that answers all challenges related with the knowledge, skills and competences to be achieved by the participants. More in particular, not only knowledge, but more importantly skills and competences had to be taught. It was proposed to maximally use modern teaching methods, such as online teaching, by means of an e-learning platform. We aimed for working in small groups for each module (target of 20 participants) to permit group work assignment, interactive teaching, networking and individually guided project work and discussions.
The e-learning phase should allow harmonization among the participants and minimize the time away from home while learning indispensable parts of knowledge.

Objective 3. To get the courses accredited or act as an example in as many as possible EC Member States. The issue of international harmonization and certification of the EUTEMPE-RX course had to be addressed at the highest political levels using the experience of professional organizations such as EFOMP.. All modules were accredited by EFOMP. Many NMOs accredited the modules and placed them on their websites. HERCA was also approached but unfortunately did not engage.

[1] European Commission: COUNCIL DIRECTIVE 2013/59/EURATOM
[2] Recommendation of the EU Parliament (2008/C111/01) on the EU Qualification Framework for LLL
[4] European Commission: RP154, European Guidance on Estimating Population Doses from Medical X-Ray Procedures ANNEX 1 – DD Report 1 REVIEW OF RECENT NATIONAL SURVEYS OF POPULATION EXPOSURE FROM MEDICAL X-RAYS IN EUROPE
[5] European Commission:

Project Results:
Result 1: the main achievement

The EUTEMPE-RX project has realized 12 course modules at EQF level 8 for medical physicists in diagnostic and interventional radiology. The package of modules covers the great majority of knowledge, skills and competences listed in the RP174 document.
The target number of participants was reached in all modules. Participants came from all over Europe and even beyond.
The teachers have successfully used a common e-learning platform. For each module the online preparation was followed by in depth education and hands-on training (knowledge, skills and competences) during one week face to face.

The time table (Appendix 1 - Table 1) shows next to the timing also all the Module titles, the names of the module leaders and the place. In Appendix 1 - Fig 2 is a group picture: the project partners made up a ‘team of teachers’.

The project was also successfully managed. All milestones were achieved in time and the deliverables were uploaded to the project website of the Commission.

Result 2: candidates from Europe, especially from the New Member States, and from beyond

Upfront requirements, put forward in the EC EURATOM call and confirmed during negotiation with the EC, and incorporated as objectives in our project, were:
• increase borderless mobility
• use a train the trainer approach: selected candidates would have leadership qualities and be required to reach EQF level 8
• include gender equality considerations
• organize targeted education for medical physicists in diagnostic and interventional radiology from Europe, and more in particular also from the new Member States. Allowed to welcome also physicists from beyond Europe to increase the international visibility of the project.
Chosen solution:
• Borderless mobility was approached with maximal delivery of KSCs upfront, online:
o The online part of the modules, delivered upfront, allows the participants to prepare themselves. It was the approach that was chosen to maximally cope with differences in KSCs between participants from different member states. Some of the member states do not even train medical physicists in radiology and as a consequence, the basic knowledge can be limited. Yet, it was recognized that these colleagues would benefit a lot from the modules, as in these countries there is an even greater need for new trainers and/or professionals.
o A part of the KSCs at expert level was also delivered upfront. The aim was to minimize classical ex cathedra teaching during the face to face and hence use the face to face phase for hands on learning. Hence, proper video or animated PowerPoint files can be appreciated from at home
o CPD points were awarded for both the online part and the face-to-face
o We organized multicampus education for the face-to-face; different modules were taught in institutes of the module leaders. In the case of MPE01 (what we call the ‘leadership module’) the venue was Prague which is in the centre of Europe and a low cost destination hence making it possible for a maximum number of medical physicists to participate. All this encouraged a European awareness

• Train the trainer approach was realized through
o Small group (around 20 participants) intensive and high level teaching. Our module leaders have produced modules equivalent to 160 EFOMP MPE-CPD points on each specific theme in their respective areas of excellence. This is appropriate training for the trainer
o Having selected participants from as many countries as possible per module and surveying their competence
o Making a lot of teaching material available that the participants could eventually use in their own countries to train others.

• Gender equality via positive discrimination if needed so
o The aspects of gender equality were discussed at every meeting (item on the agenda)
o The project management team attended selected workshops on this theme, to learn about the newest insights
o We chose for online preparation from at home followed by only a week face-to-face. This was inspired by the difficulty of young mothers (and more recently also young fathers) to leave home for a long time. The number of females applying was similar to the number of men.
o In case of equal CV and motivation, priority would be given to females. In practice, we obtained a similar number of female/male without the enforcement of the gender equality positive discrimination

• Selection of participants through
o Careful formulation of requirements for selection, namely
▪ 2y of experience with diagnostic or interventional radiology in a hospital
▪ 2y of experience in a medical device company
▪ 2y of experience in a nuclear safety authority
▪ PhD students in medical radiation physics in radiology
▪ Biomedical engineers in radiology
o A study of applicants’ CVs and motivation letters. Requirements were overruled in selected cases, such as for participants in countries where there is no formal training of medical physics in radiology
o The module leaders did the selection

• Active involvement of stakeholders was realized by
o Selection of representative stakeholders in the scientific advisory board of our project; they were invited to attend the meeting at kick off, after 1y and after 2y, coinciding with the mid-term workshop. Comments and suggestions were discussed during the consortium meetings
o A mid-term workshop open to the public, and organized in a New Member State (Bulgaria), to reach out to stakeholders in these countries
o Inviting the stakeholders to act as external advisers of some modules of interest
o PR activities that aimed from day 1 that participants of different stakeholders would be welcome: working in hospitals, medical device companies, nuclear authorities and PhD students and biomedical engineers working in any of these places in medical physics of radiology

Selection results:
• In Appendix 1 – Fig 3 you can find a geographic distribution of applicants from all over Europe and beyond

• Number of participants
The total number of individual participants was 254. Many participants followed more than 1 module but are counted only once. Target number of participants was between 18 and 24 for all modules, except module 1 that accepted 30. Modules organized during summer found it more difficult to reach their target number. Most modules had 1 or 2 registered participants who did not show up. The effective numbers of attending participants (learners) are given in Appendix – Table 2.
• Geographic distribution of the individual participants
Overall, a good spread of participants was reached (Appendix 1 – Fig 4). The top 3 countries in terms of applicants were Belgium, Italy and Ireland. This is explained by local PR (the project coordinator working in Belgium, 3 course modules taken place in Italy) and combined PR and local physicists (Ireland) who explained to their colleagues about the opportunities of the modules. More targeted PR will be needed for future courses. Countries with a large number of potential participants should be approached like the UK, Netherlands, France, Germany, Switzerland, Austria, etc. It must be stated though that important efforts have been done by EFOMP as well as several of the module leaders and coordinator to reach out to these countries.
• Distribution of participants over the different working domains (stakeholders). The majority of our participants are working in hospitals. Industry remains underrepresented so far. (Appendix 1 – Fig 5)
• Composition of the external experts invited to the Scientific Advisory Board (Appendix 1 – Table 3): it was aimed for representatives of teaching organisations in the nuclear domain, international organizations (IEC, IAEA, ESR, ...) medical device companies, nuclear authorities, ...

Result 3: well steered and documented quality


The project plan of EUTEMPE-RX was ambitious: international, 3 years only, both on line and face to face teaching in 12 places around Europe. From day one, it was realized that a comprehensive quality manual would be needed to streamline the different phases in the project and to achieve a harmonized set of modules.
Quality management aims in the first place to make quality quantifiable and to subsequently allow improvements. It was found crucial for our project to work along quality guidelines.
Creation of the quality manual

During the first consortium meeting, a quality manager and a quality assurance team were appointed. As foreseen in the project proposal, their first aim was to create a quality manual.
The present quality manual has been developed specifically for our project by the quality assurance team, under the guidance of the quality manager: the development of our modules was subsequently based on the principles and procedures that you will find in the quality manual. The consortium partners have been working with the quality assurance team to improve the successive drafts of the quality manual. We are particularly pleased that the scientific advisory board accepted an active role in this too.
The quality manual has guided our activities during the EUTEMPE-RX project. As foreseen in the quality manual, all modules end with a survey sent around to verify the results of a number of objectives put forward in the project plan. This includes an overall evaluation of achieved KSCs and participant’s and stakeholder’s satisfaction.
The quality manual, approved by the consortium meeting and the General Assembly can be found in Appendix 2. The document consists of the following parts: scope and methods, definitions, the EUTEMPE-RX consortium, the definition of quality, the quality management system, and the quality operating procedures with their forms. Typical quality operating procedure forms are part of the quality manual.
Actions to achieve quality
- Module leaders complete the module form (title of the module, teaching team, abstract, elements of the online phase, content of the face-to-face, teaching methods, assessment method, et.), using a template
- Accreditation request is sent to EFOMP, using a SOP
- Material is prepared for online and face to face part (with scientist in coordination team)
- Web conferences (with education & teaching (E&T) team of the KU Leuven)
- Online teaching is started, followed by the face to face phase
- Assessment is done
- Survey the participants for feedback
- Web conference with module leaders, E&T team & educational board
- Sending of assessment results to the participants

Quantified assessment of quality of the course modules

The quality manual describes a survey to be sent to the participants a few days after the assessment. In all cases, more than 70% of the participants completed the survey.

The replies to the survey were processed. In a web conference with module leaders, E&T team of the KU Leuven, the coordinator and scientific helper and the educational board, the results of the survey were discussed. The main items were also presented during the consortium meetings. For Module 1, there was only a discussion during the consortium meeting as this was just a couple of days after the face-to-face part.
During the mid-term workshop, half of the modules were accomplished and half were still to come. This was an ideal moment for feedback and sharing of experiences.
An example summary is shown in Appendix 1 - Table 4. There is an overwhelming agreement with the statements put forward. In green we have indicated the top score for the category. A high score (4 and 5) indicated a high level of agreement of the participants with the quality statement that was aimed for.

Result 4: educational achievements

The combination of online teaching and face-to-face was a new experience for most of the teaching teams. Some of the module leaders had experience with Moodle e-learning platforms; others did not. Likewise, it was considered important that the RP174 document was used as a base document for the knowledge, skills & competences (KSCs) and that the large number of these KSCs would be spread in a logical way over the course modules.
Challenges linked to this particular type of teaching included:
• The realization of course modules supporting Life Long Learning
• The new approach to teaching, with online teaching and small group face-to-face (new for most of the teaching teams)
• The creation of a high level course for people with (very) different backgrounds
• The concentration on one topic having participants ranging from those with little prior experience to very experienced people in the group.
The teaching model that would be followed had been decided during the submission phase of the project. It would support Life Long Learning, have a modular approach, include online teaching and face-to-face and aim for EQF level 8.
Regarding Life Long Learning, the following aspects were of particular importance:
• The modular approach of the courses. All modules can be followed independently. We aimed from the beginning to sustain our courses. If this plan is successful, participants will be able to attend modules of choice anytime later ‘in life’
• Absence of any age restrictions upon inscription
• Minimal requirements for participation (2y of practical experience as a medical physicist), without any limit on the maximum number of years. Many more years of experience was gratefully welcomed
• A lot of material developed is made available to the participants on the online platform and during the face-to-face for recapitulation later on
Our approach to introduce the new teaching methods and to serve our particular group of participants and teaching level, has been to organize educational workshops during the consortium meetings. They were led by a team of the Education and Teaching team of the KU Leuven.
An overview of the topics is given below.
Topics of educational workshops during the consortium meetings and the mid-term workshop
1st consortium meeting. Oct 1, 2013 in Leuven. Workshop on Education for MPs in Radiology, Part 1: Setting the scene.
13:30 – 16:00 The Medical Physics Expert (MPE) as in the ‘Guidelines for the MPE’ and in the new BSS
by Carmel Caruana (EFOMP)
Challenges for the MPE
by Peter Sharp (EFOMP)
Lessons learned and opportunities with the Moodle e-learning platform
by Günther Hartmann (EFOMP & Univ. Heidelberg)
The Leuven e-learning platform applied to Module 4.6 ‘From routine QA to advanced QA and performance testing
by Roman Verraest, Anneleen Cosemans & Hilde Bosmans (Leuven)
1st consortium meeting. Oct 1, 2013 in Leuven. Workshop on Education for MPs in RX, Part 2: Assign Knowledge – Skills –Competences of the MPE. Teaching opportunities & practical considerations
9:00 Lessons learned: Implementing ECVET in the nuclear sector
by Michèle Coeck, MELODI & SCK-CEN, the Belgian Nuclear research Institute
9:20 Lessons learned: Teaching and Training in the DoReMi project
by Andrea Ottolenghi, DoReMi & project partner (Pavia)
9:40 Knowledge – skills –competences & a modern teaching platform: example of WP 4.6
by Hilde Bosmans, Anneleen Cosemans, Carmel Caruana (Leuven & EFOMP)
10:00 – 12:00 and from 13:00- 15:00 Discussing the content of all the Modules
15:00 Overview of Module content and summary, by Hilde Bosmans (Leuven)
Kick-off open event to launch the project. With Scientific advisory board present. Sept 30, 2013
18.00 – 18.20 The EURATOM strategy and achievements in Education and Training
by Georges Van Goethem (EC, DG RTD, Energy (EURATOM))
19.10 – 19.40 Novel methods in education in the nuclear sector
by Didier Louvat (ENSTTI Managing Director)
2nd consortium meeting. March 19, 2014 in Leuven.
13:00 – 16:00 The SEKOIA e-learning platform
Introduction and examples. Hands-on workshop
by Roman Verraest (Leuven)

3rd consortium meeting. September 10, 2014 in Athens.
10h -12h Workshop on ‘Assessment’ for teaching courses at EQF level 8
How to activate an audience?
by Saartje Creten & Hilde Creten (Education and Teaching team of Leuven)

3rd scientific advisory board meeting during the consortium meeting. September 11, 2014 in Athens,
Future perspectives: European masters, postgraduate, summer school, etc.
by Saartje Creten & Hilde Creten (Education and Teaching team of Leuven)

4th consortium meeting. March 20, 2015 in Leuven.
14h – 15h Assessment in Module 1. Reflections & lessons learned,
by Carmel Caruana (EFOMP)
15h-16h Educational workshop: more methods of assessment of skills and competences
Saartje Creten & Hilde Creten (Education and Teaching team of Leuven)
16h – 16h30 Getting accredited
Different participants, different expectations, different solutions ?
Curricula, study points & accreditation
Group discussion

5th consortium meeting and mid-term workshop. September 25, 2015 in Sofia
15:30 – 16:00 Challenges and opportunities in teaching knowledge, skills & competences at EQF level 8.
Experience from 5 course modules. Contributions by all 5 module leaders. Hints for the course modules to come
Moderator: Saartje Creten (Leuven)
16:00 – 17:00 Sustainability: which type of modules will we be offering next?
Moderator: Hilde Bosmans (Leuven)

6th consortium meeting. March 20, 2016 in Leuven.
13h30 – 15h30 Requirements for a new e-learning platform in a sustained network
by Saartje Creten (Education and Teaching team of Leuven)

Pictures taken during the educational workshops with the module leaders.
The working during our educational workshops can be appreciated from the pictures in Appendix 1 (Fig6a and Fig 6b).

Conclusions from the educational workshops
(1) Assessment
• The assessment should fit in the 5 or 6 days’ face-to-face phase of each module.
• Individual projects are an ideal way to assess at EQF level 8. Multiple choice exams have to be avoided.
• The participants will normally not be given a second chance to pass the module if they failed the first exam but they are welcome to re-attend the module.
• The pass grades are: pass, merit and distinction. This is done to motivate the participants.

(2) E-learning platform
• The same e-learning platform had to be used by all module leaders, upfront and for some modules also intensely after the face-to-face (module 3 and module 7).
• Functionality was found not to be sufficiently satisfactory, but it was possible to produce attractive material.
• In the sustained network activities, a Moodle platform will be used.
• Examples can be found in Appendix 4.
(3) Teaching techniques
• The use of different educational techniques encourages active participation of the participants. As a result, several module leaders have been very creative.
• The following teaching methods have been included (example: see Appendix 5)
- Inclusion of practical sessions, and in particular group tasks, in x-ray rooms,
- Visits to laboratories,
- Interviews with experts,
- Skype sessions with overseas teachers,
- Quizzes,
- Have participants present results from group discussions, or own experiences,
- Case studies
- Movies,
- Different teachers teaching, with different background (example: anatomo-pathologists, communication specialists, etc.)
- Brain storm sessions, ...

From an educational point of view, our course modules were unique for 2 main reasons: (1) the use of different teaching and assessment methods, and (2) the high level interactive teaching aiming to address KSCs that are relevant for the daily challenges with x-ray imaging. As a result of this, the module leaders obtained unique achievements with the participants in terms of improved professional skills; some of which are touching areas of active clinically oriented research or can be considered as entrance for a future job in clinically oriented research. The teachers worked with the participants at:
• case studies in medical physics leadership
• understanding radiobiology
• Monte Carlo simulation of a complete x-ray imaging chain
• (new) task specific QA protocols for new but also older modalities
• performing experiments in state-of-the-art laboratories
• (new) optimization plans for digital imaging
• scientific questions solved with the simulation of anthropomorphic breast models
• individualized dose calculation (using Monte Carlo techniques, for pregnant patients, pregnant staff and children)
• practical protocols for monitoring high dose (interventional) procedures
• trouble shooting experiences
• the use of emerging figures of merit such as model observers and critical evaluation on how to use them
• a true understanding of uncertainties in dose measurements, etc.
We encouraged our participants to let us know of research papers that they published with the material or KSCs obtained during a module. We report already the following scientific contributions by three of the participants:
(1) S. Rodriguez, N Marshall, L Struelens, H Bosmans. Validation study of the thorax phantom ‘Lungman’ for optimization purposes. Abstract submitted for the SPIE conference in Orlando, 2017 and largely based on the KSCs achieved during Module 3.
(2) Yanka Baneva, Lesley Cockmartin, Hilde Bosmans, Nicholas Marshall, Giovanni Mettivier, Paolo Russo, Kristina Bliznakova, ‘Evaluation of breast software model for x-ray 2D and 3D mammography imaging’ presented at the 1st EMPC in Athens, Sept 1-4, 2016, largely based on the KSCs achieved during Module 5.
(3) A. Kuchcinska “Developing future Medical Physics leaders: a participant’s perspective on EUTEMPE-RX leadership module MPE01” at the 1st EMPC in Athens, Sept 2, 2016

Most module leaders were very enthusiastic about the results that were obtained with the participants and the positive attitude of the participants during the modules. These positive impressions of the teachers were then compared with some of the results of the quality survey completed by the participants. In this paragraph, we select the questions that show the appreciation of the participants with the content of the modules, the level at which education is provided and the professional applicability of the KSCs.
In a survey sent out after the course module, the participants have scored the following criteria, on a scale from 1 (poor) to 5 (excellent)
• Criterion 1: This level of the module helped me achieve EQF level 8 in the areas covered by the module
• Criterion 2: Participation in this module enabled me to develop learning goals relevant to my professional objectives
• Criterion 3: The study materials (online work, articles, hand-outs, face-to-face presentations, etc.) were sufficient for me to master the learning goals.
• Criterion 4 The assessment (e.g. paper, examination, exercises, etc.) allowed me to show my level of achieved knowledge/skills/competences.
Appendix 1 - Table 5 shows the mean score for the different modules for these 5 questions. The scores were overall very high.
Result 5: the practical organisation of harmonized course modules

One of the fundamental objectives of the project was to organize harmonized courses that together would make up a teaching packet leading to the recognition of medical physics experts. Harmonization has different aspects, of which the practical organization is a big part as this is the first thing the public, the participants and other stakeholders see.
Organization of the course modules was an anticipated challenge due to (1) the multi campus approach, (2) a new consortium that did not know each other very well at the start, (3) the start from scratch of a big undertaking, (4) the small groups of participants expecting an individualized approach, etc.
The grant of the EC covered the participant fees, and not the travel and accommodation of the participants. It was decided, during our meetings, with our EC project officer present, that we would not charge the participants anything for the practicalities of attending the course. Travel and hotel costs were, however, to be covered by the participants themselves. Due to the limited financial situation of some of the participants, we could not work with professional congress organizers as these were deemed too expensive.
The practical organization of the courses was streamlined by the organizational committee that was confirmed in its role during the first consortium meeting.
The main measures were:
• Making practical organization of the modules an item on the agenda of all consortium meetings, maximally triggering discussions between partners , sharing experience, ...
• Making a welcome page with practical information of the course an obligatory part of the e-learning platform
• Distributing a document with practical instructions to all module leaders (see appendix 6). This document includes many practical arrangements, hints and tricks, for the online phase and the face-to-face, how to cover the costs of invited speakers, a timeline, etc.
• A harmonized website with uniform information about the site and the global approach of practical arrangements, applying to all.
In the quality survey sent after the face-to-face part (appendix 3), the participants were invited to reply to the following questions:
Question 1. Should the module be organized in the future in the same location?
(If not, where should it take place?)
• Question 2. Is there a need for such a module to be organized in your country?
Appendix 1 - Table 6 shows the results in terms of number of participants answering and percentages of positive answers to the two questions. From the results, it can be confirmed that the large majority of participants have appreciated the locations used by the module leaders. It must be said that some of the courses cannot be given in other places as it they are linked to unique equipment or computer infrastructure being available. In some modules, the participants agree with the location chosen by the module leader for the courses, but would also look forward to having the module also organized in their country (example module 6, module 7 and module 10).
Most modules had an official dinner and other social events organized during the face-to-face part. This was considered an important part of the module by most of the participants. We will make it an obligatory part of future editions of the project. Informal meetings are great opportunities to get to know the peers, building networks, etc.,

There are more questions in the quality survey that are linked with the practical organization. We selected the following items from the list, all of them also scored with a mark from 1 (I fully disagree) to 5 (I fully agree):
• Criterion A: The learning goals of this module (found on the description page of the module) were clear to me.
• Criterion B: The module leader(s) and presenters had a good command of the subject matter of the course
• Criterion C: The module leader(s) answered my questions promptly.
• Criterion D: The upfront communication on practicalities (e.g. organizational aspects, online work, face-to-face sessions, course material, assessment, etc.) was sufficient.
• Criterion E: The knowledge, skills and competences supported by this module match with those expected by my employer.
The results are shown in Appendix 1 - Table 7. The scores are overall again very high. It must be stated that criterion E was not scored by the employer but by the participant. Some stated indeed that they don’t know.
Result 6: a new nuclear safety culture in the European hospitals

The project had claimed to improve the nuclear safety culture in the hospitals. This was achieved in different ways:

• The organization of workshops on aspects of nuclear safety during the consortium meetings
• The incorporation of aspects directly linked with nuclear safety in our modules
• Attending scientific presentations on nuclear safety and report to the consortium: make it an item on the agenda
(1) Several workshops on aspects of nuclear safety culture were organized to make the module leaders aware of the importance to discuss these aspects with their participants.
The topics were put on the agenda of the consortium meetings. During the mid-term workshop, open to the public and with our scientific advisory board present, nuclear safety (the basic rules), the related challenges in hospitals and what medical physicists can do at it, was the theme of the morning program. This has led to underlining the importance of educating medical physicists at a sufficiently high level.
Kick-off meeting in Leuven, Sept 30, 2013
18.00 – 18.20 The EURATOM strategy and achievements in Education and Training
by Georges Van Goethem (EC, DG RTD, Energy (EURATOM))
19.10 – 19.40 Novel methods in education in the nuclear sector
by Didier Louvat (ENSTTI Managing Director)
2nd Consortium meeting in Leuven, March 20, 2014
13:00 – 14:00 Synergy between nuclear research and education in EURATOM programmes, with emphasis on safety culture
by Georges Van Goethem
3rd Consortium meeting in Athens, September 10, 2014
16:00 – 17:00 Nuclear safety in hospitals. Discussion based upon the scientific paper “Developing the radiation protection safety culture in the UK”, P Cole, R Hallard, J Broughton, R Coates, J Croft, K Davies, I Devine, C Lewis, P Marsden, A Marsh, R McGeary, P Riley, A Rogers, H Rycraft and A Shaw J. Radiol. Prot. 34 (2014) 469–484
Discussion moderated by Hilde Bosmans

Mid-term workshop in Sofia, Bulgaria, September 25, 2015
1. Nuclear Safety in Hospitals & the EC reply
9.15 – 9.45 Nuclear radiation safety and the difficult extrapolation towards the medical world
by Jan Bens, director of the Federal Agency of Nuclear Control (BE) & former Deputy Director, WANO Paris
9.45 -10.15 What is a medical physics expert (MPE) following the (European) BSS? (Future) role of the MPE in diagnostic and interventional radiology
by John Damilakis (MPE in Crete, EUTEMPE-RX project partner and EFOMP’s president)
10.15 – 10:45 EUTEMPE-RX: objectives, work plan & current realizations & a message on ‘nuclear safety culture’,
by Hilde Bosmans, on behalf of Georges Van Goethem (EC project officer)
2. Research and Innovation in radiation protection & medical physics
11.20 – 11.40 Radiation protection in radiology: one of today’s challenges
by Peter Vock (on behalf of the European Society of Radiology)
11.40 – 12:00 Dose to the patient: role and responsibility of the manufacturer
by Rémy Klausz, GE HealthCare, FR
12.00 – 12:20 Where medical physics expertise can make the difference: interventional radiology
by Michael Grass, Philips Research, DE
12.20 – 12:40 Medical physics expertise in regulatory can promote active radiation protection initiatives (STUK, Finland, as an example)
by Paula Toroi (medical physics expert in STUK, FI)
12.40 – 13:00 Summary: today’s challenges and the need for networking to ‘driving technology to advance healthcare – proactively protecting patients’ (motto of the MPE)
by Peter Sharp, EFOMP’s past president
(2) All modules embraced the aim to go for a nuclear safety culture in radiology departments. The following overview summarizes the most obvious contributions. The course programs can be scrutinized for more detailed information.
• Module 1 prepared a new generation of medical physicists to take leadership roles in the diagnostic and interventional radiology physics. These people must give a voice to patient safety and take part in decision making related to the justified and optimized use of radiation. They have to work at structural solutions for incidence and accident reporting.
• Module 2: provided a high level course on radiation biology applied to diagnostic and interventional radiology
• Module 3: taught how to apply Monte Carlo techniques to solve advanced x-ray radiation situations
• Module 4: prepared the present generation of physicists for the challenges of emerging advanced x-ray techniques
• Module 5: applied anthropomorphic phantom modelling to improve dosimetry and quality of imaging in general (justification)
• Module 6: taught how Quality Assurance should be performed to control all parts of the imaging chain and how measured data can be used to learn about the use of radiation
• Module 7: instructed how to optimize the use of radiation in x-ray imaging
• Module 8: applied the newest analysis techniques (model observers) to optimize CT imaging, responsible for the largest contribution of man made radiation
• Module 9: optimized breast cancer population screening, which is of particular importance because it is applied on a large group of healthy females.
• Module 10: set up protocols to make high dose interventional procedures safer
• Module 11: studied dosimetry to sensitive groups in detail: pregnant patients, pregnant staff and children
• Module 12: offers better insight in radiation protection and the measures to ensure a safer working environment and proper calibration of instruments.
Overall results of the project:
The application of the new insights gained with the specific modules would lead to a significantly improved situation in the hospitals. There are now more physicists with advanced knowledge of medical physics and radiobiology at work in European hospitals, where they take leadership in the justification and dose optimization discussions. We plan to send a next survey to the participants 1year after the finish of the last module to ask for concrete examples.

(3) Attending scientific presentations on nuclear safety and report to the consortium: make it an item on the agenda
• EFOMP is partner in ENETRAP, allowing cross fertilization with teaching in the nuclear domain
• Hilde Bosmans participated on behalf of EUTEMPE-RX in MELODI meeting (Brussels, Oct 8 – 10, 2013)
• Hilde Bosmans participated on behalf of EUTEMPE-RX in OPERRA-COMET Call Launch Meeting , January 20-21, 2014
• Hilde Bosmans participated (as an observer, on behalf of EUTEMPE-RX) in the 1st NUSHARE meeting (Brussels, March13-14, 2014)

Result 7: steps forward to accreditation at European level

The EUTEMPE- RX project can be seen as a professional initiative to facilitate the certification process for MPEs and thus contributing to the requirements of Directive 2013/59/Euratom for the MPE [1]. It is a professional initiative that aims at the attestation of professional competence in Diagnostic and Interventional Radiology at the MPE level.
At the EUTEMPE-RX Consortium Meeting of March 2014, it was decided to ask the European Federation of Organisations for Medical Physics (EFOMP) to explore the feasibility of establishing two new boards:
• A high level accreditation board which would be external to EFOMP for medical physics programmes and learning modules at the MPE level (EQF level 8)
• Examination board for the attestation and certification of MPEs that should then facilitate the recognition of participants as MPEs by the relevant national competent authorities
Accreditation bodies can use the guidelines presented in the EC guidelines on the Medical Physics Expert [2] to evaluate the content of education and training programmes in medical physics offered by organisations such as professional and scientific societies, etc.
It is important to establish criteria for “mutual recognition” between EU Member States. If effective mutual recognition is to be achieved then there must be a good degree of commonality with respect to the key elements of, and criteria applied to, the various national schemes. Challenge:
• Ensure sufficient flexibility for European Union Member States to establish systems for MPE recognition that can be readily accommodated within their national infrastructures, but also to
• Ensure a degree of commonality sufficient to facilitate mutual recognition of the MPE between European Union Member States.
(1) The European Board for Accreditation in Medical Physics - EBAMP
The EFOMP/EUTEMPE-RX working group completed the draft documents setting up EBAMP in May 2014. The EBAMP Quality Manual, setting out its operational procedures and protocols, was presented to the EFOMP Officers for their comments and suggestions for improvement and subsequently sent to the EFOMP National Member Organisations and the EUTEMPE-RX partners for their comments and suggestions for improvement. The final documents were approved by the EFOMP Council at its meeting in Marburg, Germany in September 2015. EBAMP is operational since Athens, Sept 1st, 2016.
(2) EFOMP Examination Board - EEB
In parallel with the preparation of the documentation for the setting up of EBAMP, the Working Group has prepared the draft documentation for the set-up of the EFOMP Examination Board. The same procedure for comments was followed and the final documentation was approved by the EFOMP Council by postal ballot on the 10th of April 2016.
The realizations of EBAMP and EEB represent a success story of the EUTEMPE-RX project. The activities of these 2 organisations could obviously be expanded beyond the EUTEMPE-RX course modules. EBAMP could develop from the accreditation of CPDs to accredit entire university undergraduate and post graduate programmes for medical physics. The EEB could expand its Diploma and Certificate for MPEs in diagnostic and interventional radiology to other disciplines of medical physics, such as Radiation Oncology, Nuclear Medicine, non-ionising radiation (e.g. MR and ultrasound).

Potential Impact:
Impact, including socio-economic impact and societal implications

Socio-economic impact

The present project has produced teaching courses at EQF level 8 for medical physicists working in diagnostic and interventional radiology and aiming to reach the expert level. Medical physicists working in hospitals, companies providing QA services, medical device companies and universities have attended the modules. Most of the participants passed the exams, with merit or distinction. Participants have also confirmed the courses to be at the appropriate level. They have met their expectations and those of their employers. We therefore conclude that knowledge, skills and competences have improved. Likewise, the teaching teams have created these new courses and their experience, as well as their teaching material, is now stronger and available to the European and the international communities.
The following impact can be expected:
• The participants have been trained in a train the trainer approach. They are now able to contribute to teaching opportunities in their respective countries
• The participants have been trained in specific modules. They have acquired specific skills, like Monte Carlo simulation, patient specific dose calculations, taking the lead in making QA protocol, Etc. They can now apply these skills in their work place.
• Other modules may have triggered an interest in clinically oriented research. We expect a net benefit on the number and the quality level of doctorate projects.
It is too early to know how many changes in jobs have occurred as the result of one or more course modules. It is planned to send a last survey one year after the end of the modules. All respondents to the first quality survey had confirmed they were happy to complete a next survey.

Societal impact

Module 1 has aimed to increase leadership in medical physics applied to diagnostic and interventional radiology and the profession. This will ultimately lead in technology being used more optimally in healthcare.
The first reason to organize these courses had been the concern with high population radiation doses to patients in diagnostic and interventional radiology and the concerns about diagnostic efficacy (sensitivity and specificity). These concerns were the leitmotiv of the modules and are generally summarized in 2 words: dose and quality. A relatively large group of 254 participants has focused on these aspects, has made new plans, has now more techniques or KSCs to apply locally. In this sense, the geographical spread of the country of origin of our participants is of major importance. This is reinforced by the fact that participants have been able to work during the modules at projects of local importance. Examples are module 3 (the choice of a simulation exercise), module 6 (the choice of task based application for which a QA protocol had to be compiled), module 7 (the proposal of a new optimization plan for a modality of choice, etc.). Module leaders have guided many of these projects even beyond the course module.
The major impact, that is however difficult to measure, is expected to come from medical physicist s doing their job now significantly better, are more motivated and address more, if not all, of the challenges they face with new KSCs. The expected result is that also research and development will improve. As always, increased research requires improved teaching. In the future, the scientific work that occurs in the team of participants will be tracked. Module leaders or other centres in search for PhD students may find potential candidates in the group of participants.

Main dissemination activities

A big effort has been spent to disseminate the existence of the project in order to ensure a sufficient number of participants during the project duration. This was in line with the PR plan that had been produced and crucial for the project as we wanted to reach out to all professionals, also the colleagues not regularly attending professional meetings. The project has been presented at more than 30 conferences. During the European Conference of Medical Physics in 2014, more than half of modules leaders were invited to present their module during their invited speech. Leaflets and other related information were distributed to about 580 participants of the Conference.
A peer reviewed paper has been produced after the European meeting in Athens, September 2014:
• Bosmans H, Bliznakova K, Padovani R, Christofides S, Van Peteghem N, Tsapaki V, Caruana CJ, Vassileva J. EUTEMPE-RX, an EC supported FP7 project for the training and education of medical physics experts in radiology. Radiat Prot Dosimetry. 2015 Jul;165(1-4):518-22.

Exploitation of results

Sustainability plan

Work package 5 aimed to produce a sustainability plan. During the mid-term workshop in Sofia (Sept 2015) and during the 5th (March 2016) and 6th consortium meetings (June 2016) in Leuven, the sustainability of the project has been discussed in extenso. A plan has been accomplished indeed. Five phases can be considered: (1) deciding on the type of activity in the continued effort, (2) the proposal of a new structure for future actions, (3) the creation of a memorandum of understanding between the actual partners, (4) the realization of an agenda with a concrete plan for repetition of the courses and (5) the plans for future development of the modules.

During the mid-term workshop, several possible common activities for the current consortium have been discussed. This included:
• Stay with online and face-to-face courses, but with different implementations:
▪ To repeat the modules as is, with the actual 2 yearly frequency
▪ To repeat the modules as is, but annually
▪ Repeat some of the modules in other places
▪ Make courses on the same theme, but at EQF level 6 or 7
▪ Translate into the languages of some of the larger EC Member states
▪ Apply for EC funding to translate the modules into Russian or Chinese

• Explore other types of online teaching
▪ Increase the online phase and reduce (or even eliminate) the face-to-face part
▪ Make a club in which we give access to all online material and occasionally organize face-to-face sessions
▪ Switch to distance learning
▪ Make a MOOC

• Prioritize other missing courses for MPEs in radiology, such as ultrasound, MRI, image processing, 3D image reconstruction, ...
• Expand the current modules with modules for MPEs in other domains, such as nuclear medicine and radiation oncology

It was decided
1. to repeat the modules as they have been given once during the project, in the same location every 2 years. Registration fees would be put to a minimum
2. to keep meeting with the consortium for a further harmonized approach
3. to discuss new teaching methods (such as the creation of a MOOC) during the consortium meetings. The future directions may be determined by the number of participants in the successive round of the modules.
4. to support a new consortium that would apply for EC funding in the other domains
5. to set up a structure that would allow to easily expand the actual EUTEMPE-RX modules with modules in related domains
Two documents have been compiled: (1) a Memorandum of understanding and (2) a sustainability document that describes the working and quality monitoring during sustained activities.
The Memorandum of Understanding is included in Appendix 7. The EUTEMPE-RX partners have signed it to express their wish to continue the operation of EUTEMPE-Network after the end of the EUTEMPE-RX project. The name ‘EUTEMPE-Net’ was approved by the consortium, to cover more than RX.

The sustainability document outlines the new structure, in which there is place for new schools, for nuclear medicine, radiation oncology and others. Educational support, that was essential during this first round of modules, cannot be engaged at the same level due to absence of funding.

In order to sustain the activities, the following actions have been taken:

1. A new e-learning platform (Moodle) has been purchased and made operational
2. The website is being renewed and a new webmaster has been recruited
3. The new course scheme has been finalized (Appendix 1 -Fig 8)
4. Fees have been calculated
5. First e-mail announcements have been sent around
6. The new set of courses has already been shown in different conferences
7. A leaflet has been created with the course overview
8. Some module leaders have created their own leaflet for publicity reasons
9. Contacts for the organization of webinars for PR have been initiated with IOP.

Hilde Bosmans is the first project coordinator of the new network and is also partner in subsequent EC project applications that aim to find funding for the new schools. The KU Leuven will not charge the project for her current activities.
The University Hospital in Leuven supports the prolonged project with secretarial support (against a minimal cost) and offers scientific support during 2 years by means of covering the personnel costs of a physicist, 50FTE, during 2 years. This was acknowledged by the partners in the project.

List of Websites:

The E&T program that has been worked out will be continued by the EUTEMPE-Net.

Coordinator of the continued project is Prof Hilde Bosmans.

Hilde Bosmans
Department of radiology
University Hospitals Leuven
Herestraat 49
BE 3000 Leuven
Tel: + 32 16 34 37 51
Fax: + 32 16 34 37 69
Secr: + 32 16 34 37 80 & + 32 16 34 37 82

Secretarial support for the project (inscriptions etc)
Patricia Adriaens and Herlinde Raymakers
Department of radiology
University Hospitals Leuven
Herestraat 49
BE 3000 Leuven
Tel: + 32 16 34 37 40
e-mail :
e-mail :
e-mail :

Scientific support for the project
Hanne Van Coetsem
Department of radiology
University Hospitals Leuven
Herestraat 49
BE 3000 Leuven
Tel: + 32 16 34 90 63

A leaflet has been produced that will be used for the first to come PR activities (see Appendix 8). Some module leaders have also produced their leaflet. This activity will be more streamlined in the future to increase harmonization.

A power point presentation has been made that can serve as a template for (local) future presentations of the project (See Appendix 9). The template has been used twice already (by Hilde Bosmans) to introduce the new series of course modules, namely at the AAPM meeting in Washington (August 1, 2016) and at the 1st ECMP in Athens, September 1st, 2016.