Background
The term “peer review” is frequently used in the medical field. There are journal peer reviews, interdisciplinary departmental reviews, and even multidisciplinary tumor boards. However, professional intradisciplinary peer review, the kind Kate helped formalize through her work on AAPM Medical Physics Practice Guideline 15a1 (“MPPG-15a”), is something different.
As stated originally in AAPM Task Group 1032 (“TG-103”) and reiterated in MPPG-15a, “The purpose of the peer review process…is to enable a collegial exchange of professional ideas and promote a productive critique of the incumbent’s clinical physics program with the aim of enhancing the program while ensuring conformance with regulations, professional guidelines, and established practice patterns.”
“The practice guideline is really focused on professional peer review as an enabler for the individual physicist,” Kate explains. “It’s not about coming in to scold somebody for not doing something. It’s supposed to promote a just culture, being both instructive and collaborative.” Peer review supports professional growth and maintenance of practice quality. It can help to identify gaps in documentation, process, staffing, communication, oversight, regulatory compliance, and clinical integration.
More Than Checking Boxes
The professional field of medical physics has dramatically increased in complexity over time. When the field began roughly 70 years ago, a single physicist could handle an entire workload, including diagnostic imaging, nuclear medicine, and radiation oncology. Now the field has expanded so vastly that even within radiation oncology, physicists often develop subspecialties. It is challenging, if not impossible, for one medical physics professional to keep up with the changing guidelines relevant to every aspect of the field.
External review is especially valuable for solo or small-group practices. MPPG-15a notes that solo practice can make it easier to miss blind spots in one’s own work. Peer review provides an outside perspective and helps align practice with evolving standards.
“At CAMP, we’re blessed to have such a dynamic group,” Kate says. “If I have an MRI question, I have an MRI expert I can call easily. Or I can reach out to a health physicist on our own team with a regulatory question. My work is cross covered by other therapy physicists. However, many physicists don’t have that. They can be very siloed, especially in more rural clinics.”
This isolation presents its own challenges. Physicists learn to do things a certain way, which may have been correct when they were trained. However, without outside input, funding for conferences, or dedicated time to read journal articles, they may continue to do the same things in the same way even as technology and guidelines evolve.
The Ideal External Review
Intradisciplinary, professional peer review is intended to be a quality improvement tool for the medical physics professional, not a punitive audit. It provides a structure in which to continually improve the clinical medical physicist practice, strengthen approaches to patient safety, and support professional development. A good review will ask whether the physicist has adequate tools, time, staffing, processes, institutional support, appropriate policies, and access to leadership, rather than just checking boxes for task completeness.
The ideal peer review is well-structured. Ahead of the review, information will be gathered from the incumbent regarding the site where the review will take place. The scope of review will be agreed upon in writing by both parties and an agenda will be shared ahead of the visit to minimize surprises. Time will be included at the end of the review to generally discuss findings and to provide an opportunity for the incumbent to clarify any outstanding questions. After the review, two formal and confidential reports will be generated; one for the stakeholders and one specifically for the incumbent. The final report should be actionable, distinguishing between required corrective actions, recommended improvements, and general observations about current practices or institutional support.
Peer review is most useful when reviewers have experience relevant to the clinical environment being reviewed and have no conflicts of interest that could compromise objectivity, and it is most successful when it leads to clarity in process, improvement in communication, and sustainability in medical physics support. Peer review should be viewed as a professional safeguard: a structured opportunity for clinical physicists and institutions to take a step back, identify blind spots, and strengthen the systems that support safe, effective patient care.
How CAMP’s Peer Review Program Began
CAMP’s peer review program originated not from a strategic planning session or company mandate, but from a realization within a coverage service that CAMP provided. A solo physicist at a facility had a medical emergency, leaving the clinic without physics coverage or access for weeks. The facility learned about CAMP and called asking for assistance during their physicist’s absence.
“We, of course, offered to help however we could,” Kate recalls. “But when we got there, despite well-intended practices, it was a real challenge to figure out where and how the physicist was documenting processes and QA results without direct communication. This was also in an age of paper, which added another layer of challenge.”
Catherine, a physicist with CAMP at the time, led the coverage effort with Kate’s support, documenting feedback as it came up. When the physicist returned, CAMP scheduled a period of coverage overlap to ask questions that had arisen over the course of their coverage and review gaps that made it difficult to come into the department ‘blind’. “We really wanted to understand processes and provide support in a helpful way, which, though non-traditional in its evolution, became our first professional peer review,” Kate says. They heavily relied on TG-103 recommendations and previous experience with ACR accreditation to generate a peer review report for the physicist and administration.
Peer Review for the Group Practice
TG-103 was primarily focused on a peer review for the practicing solo medical physicist. When Kate joined the effort to update TG-103 into MPPG-15a, one challenge was addressing how group practices should handle peer review. While noting that an external peer review can still benefit professionals in a group practice setting, MPPG-15a also outlines a process by which professionals in a group setting can establish a professional peer review process amongst the team. Four standards were developed for continually reviewing processes internally within the group. While these might look different for different medical physics and dosimetry groups, Kate describes how CAMP approaches each of these standards, below.
1. Documented Process
CAMP doesn’t rely solely on informal communication channels such as emails or hallway conversations for peer review. They have a formal peer review policy that details exactly how they implement the other three standards for each specialty within their practice (therapy physics, diagnostic & nuclear medicine physics, health physics, and medical dosimetry).
2. Regular Interdisciplinary Meetings
CAMP holds monthly meetings for its therapy team, diagnostic team, and radiation safety team. They utilize a tool called Asana to build a working agenda, document attendance, take notes, and assign due outs. “It’s important to us to have collaborative meetings,” Kate says. “All team members are encouraged to add agenda items, share ideas, and take point on projects that are born out of discussion, whether they are seasoned CAMPers or new to the group.” CAMP also includes a section in its monthly therapy meeting to review any incidents that have been reported at a facility (through processes such as RO-ILs) that may provide learning opportunities impacting other facilities, which has proven a valuable tool as well.
3. Built-in Review of Processes
A rotation of responsibilities ensures multiple checks and balances to prevent errors. CAMP uses a color-coded spreadsheet for monthly QA to track who did which testing and when. Residents performing QA are assigned a different LINAC each month. This ensures that various individuals check the machines for different QA aspects and demonstrates cross coverage visually. Having the same person inspect the same machine every month could lead to the same error being repeated.
For smaller sites where a physicist works more independently, CAMP gets creative. PTO coverage becomes an opportunity for different eyes on the QA and chart checks. One of the most innovative aspects of the program is their approach to annual QA, an effort which Kiernan McCullough spearheaded in 2020. Every month during their subspecialty meeting, the entire team reviews a different component of annual QA. In March, everyone tests their MLCs. In January, everyone does imaging QA.
“Everybody at every site is performing the same tests at the same time very thoroughly,” Kate explains. “Then we can come back with the results and look across our fleet and say, ‘Hey, this one’s an outlier. Why is that?’ or we can make updates or changes to a process collaboratively.” This also allows the CAMP physicist who often operates more independently to review linac QA alongside the team.
Kate recalls an instance early in her career where a physicist colleague reviewed a patient chart during a first weekly check and noticed something she’d missed on an initial review: a previous treatment was in very close proximity to the current treatment, resulting in a high dose to the spinal cord. A necessary dose accumulation had been missed due to incorrect documentation, but by incorporating a built in review of processes, an error was corrected and Kate learned a valuable lesson that has propagated through her career in how she approaches chart review. While not a formal peer review, a review from a peer within her group was both valuable and instructive to Kate, not to mention beneficial to patient care.
4. External Review
Some form of external input should be taken by the group. “The most straightforward way to accomplish this,” Kate explains, “is through an accreditation process such as APEx or ACR.” If accreditation is not an option, the group needs to demonstrate a process for bringing outside information and review back to the group at large, such as through conference attendance or journal club meetings. CAMP utilizes all of these approaches, with both ACR and APEx accreditations at client facilities, journal club meeting participation, and designated time for conference attendees to share what they learned with the rest of the group.
Real Impact
The outcomes of peer review can range from minor suggestions to significant changes for the incumbent being reviewed. CAMP has provided feedback on QA documentation, updates to more current guidance, encouraging policy creation or establishing clear tolerances. “It may or may not be directly patient care related,” Kate notes. “Sometimes it’s documentation or regulation oriented, but you’re saving them a future lawsuit or billing audit.”
Other times, the impact is about efficiency and support. One of the most valuable aspects of peer review is being that extra outside voice for the incumbent to the administration, supporting the physicist who requires specific equipment, funding for conferences, appropriate staffing, or other financial or administrative support.
“We learn from those we review, too,” Kate emphasizes. “That’s one of the things about peer review: you’re there, you’re talking through processes, you’re asking questions. While we often have input and feedback to give, we also end up saying, ‘Oh, you do it this way. I never heard of that before, but that’s still valid and makes for an interesting approach.'” The collaboration from a peer, particularly for the physicist who doesn’t have a regular sounding board, is where the benefit of a formal peer review shines through.
When Things Get Complicated
In an ideal world, a physicist would realize they could use some support and would ask their administration for a formal professional peer review. Administration would agree, a reviewer would arrive and provide helpful feedback. Then they would return in a few years, and everything would be productive and efficient.
But Kate’s honest about the fact that not all situations are ideal. “It may be a case where the administration has requested a formal peer review and the incumbent is less cooperative, or the incumbent wants a review but can’t acquire financial support from administration and has to get creative.” In one instance, a solo physicist requested CAMP leave feedback after covering his PTO. While not a “formal” professional peer review in the traditional sense, this allowed the solo physicist to take outside suggestions without costing the center more than the regular short term coverage costs.
The biggest fear that peer reviewers have? Walking in and discovering a serious problem, such as a calibration that’s been dramatically off, resulting in widespread patient mistreatment.
“We actually haven’t had that happen yet,” Kate says. “We’ve identified gaps, given a lot of feedback, but luckily so far there hasn’t been a major reportable event uncovered.”
Kate has talked with other physicists in the field who have encountered serious issues during peer reviews. In that case, the question becomes: what should you do when you’ve uncovered negligence in what’s supposed to be a confidential process?
“At the end of the day, we have a responsibility to the patient,” Kate says simply. “If there is a mistreatment, if there’s something reportable, that’s going to trump confidentiality. It’s uncomfortable. But you have to do what’s right for patient care and bring the issue up to the appropriate parties in a respectful and productive manner.” There is a need to balance guidance in the AAPM Code of Ethics3, which highlights that the interests of the patient are paramount, with the professional peer review process.
The Diagnostic Imaging Gap
If there’s an area that can be expanded upon for professional peer review, it’s the adoption of a process for diagnostic imaging and nuclear medicine colleagues.
“Professional peer review is certainly better established in radiation oncology than in other medical physics specialties, and I would like to see it more embraced in diagnostic imaging,” Kate says. Diagnostic imaging physicists are inherently more independent, often traveling between clinics and not often in the same office or department regularly.
They’re also already heavily regulated. Including state inspections and MQSA reviews, there’s already a lot of oversight. “But that’s not the same thing as having an independent review of your practice by a peer in the field,” Kate emphasizes. “There’s nobody coming in and saying, ‘Why do you set your phantom up like that?’ or ‘Are you getting the support you need from your administration?’ It’s more likely regulatory checkboxes that may or may not be directly relevant to practice as a QMP.”
The ACR’s DICOE program is a move in the right direction, with a physicist providing the review instead of a regulator. But true professional peer review, a colleague coming alongside to support professional development and providing confidential feedback in a non-punitive way directly to the incumbent, is still underutilized in diagnostic imaging and nuclear medicine physics.
Advice for the Isolated Physicist
For the solo physicist operating on his or her own, it is important to read MPPG-15a and understand that there is an established process in place intended to support you. If you are maintaining or working toward accreditation through ACR or APEx, peer review is required for the medical physicist. Bring MPPG-15a to your administration and request support for a formal peer review in accordance with the AAPM practice guideline.
If you aren’t able to secure a formal peer review, you can also be creative. “It doesn’t have to be CAMP or another established peer reviewer,” says Kate. “Many physicists trade off with other solo physicists. Reach out to a colleague to trade reviews: you review their program and they review yours. Utilize the spreadsheet templates in MPPG-15a. It could even be done remotely.”
Sometimes CAMP has worked peer review into PTO coverage, which may be more easily approved by administration. As clinical coverage allows over the course of PTO, the covering physicist can review QA documentation, policies, and processes and follow up with the incumbent upon return. The point is to find a way to get outside eyes on your program and approach as a professional.
“The goal is to have an outside perspective from a respected peer, to have a fresh set of eyes that might catch something you’ve overlooked,” emphasizes Kate.
References
For detailed information about performing or requesting a professional peer review, please review MPPG-15a directly. Supplemental resources are also included with MPPG-15a for the peer review process. Peer review should always be handled in a professional and ethical manner and the AAPM Code of Ethics is an important resource as well.
- Halvorsen PH, Baydush AH, Buckey CR, et al. AAPM Medical Physics Practice Guideline 15.A: Peer review in clinical physics. J Appl Clin Med Phys. 2023;24:e14151. doi:10.1002/acm2.14151
- Halvorsen, P.H., Das, I.J., Fraser, M., Freedman, D.J., Rice, R.E., III, Ibbott, G.S., Parsai, E.I., Robin, T.T., Jr. and Thomadsen, B.R. (2005), AAPM Task Group 103 report on peer review in clinical radiation oncology physics. Journal of Applied Clinical Medical Physics, 6: 50-64. https://doi.org/10.1120/jacmp.v6i4.2142
- American Association of Physicists in Medicine. AAPM Code of Ethics. AAPM Policy No. 2564. Published November 19, 2020. Accessed January 21, 2026. https://www.aapm.org/org/policies/details.asp?id=2564¤t=true
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Last updated: June 2026
