1

Radiation therapists’ perspectives about barriers to continuing education in medical

dosimetry
April Hardman, BS, RT(R)(N)(CNMT); Jessica Pagan, BS; RaeLyn Iacobo, MSHS, RT(R)(T)
(MR)(CT), Nishele Lenards, PhD, CMD, RT(R)(T), FAAMD; Ashley Hunzeker, MS, CMD;
Sabrina Zeiler, MS, CMD, RT(T)
Medical Dosimetry Program at University of Wisconsin, La Crosse, WI
Abstract
Historically, the traditional route to becoming a medical dosimetrist has been to complete
on-the-job training (OJT) with the option to sit for the Medical Dosimetry Certification Board
exam (MDCB). In 2017, the MDCB changed the requirements to include a minimum of a
bachelor’s degree and graduation from an accredited medical dosimetry program. With the
elimination of OJT, radiation therapists intending to continue formal education in medical
dosimetry while working were impacted. Previous studies have predicted that a considerable and
continual increase in medical dosimetry graduates will be needed to keep pace with the growing
demand. The purpose of this study was to identify barriers to pursuing an education in medical
dosimetry from the perspectives of radiation therapists. A Qualtrics survey was created to
support the 2 research questions guiding this study. The survey was distributed via email to
10,000 radiation therapy students and registered radiation therapists who hold membership with
the American Society of Radiologic Technologists (ASRT). A total of 650 responses were
received, giving a response rate of 6.5%. Fifteen percent of respondents identified that the most
significant external barrier was the lack of flexibility in school enrollment status (part-time
options). Nineteen percent of the respondents identified that the most significant internal barrier
was the perception of the level of difficulty of medical dosimetry education.
Keywords: medical dosimetrist, radiation therapist, external barrier, internal barrier, education
Introduction
Over the last few decades, the field of radiation oncology has progressed rapidly.
Increasing in both complexity and precision, these technological advancements have enhanced
the treatment planning process but not without added responsibilities of the radiation oncology
team. Initially, a medical physicist performed the planning for the radiation treatment.1 However,
as the job responsibilities began to increase, medical physicists mentored radiation therapists to
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perform treatment planning.2 Eventually, this led to the development of medical dosimetry as a
formalized career.
Historically, the traditional route to become a medical dosimetrist has been to complete
on-the-job training (OJT) with the option to sit for the Medical Dosimetry Certification Board
exam (MDCB). The prerequisites to sit for the MDCB exam required either a minimum of 3
years of OJT or the completion of a formal medical dosimetry program.3 In 2017, the MDCB
changed the requirements to include a minimum of a bachelor’s degree and graduation from an
accredited medical dosimetry program. The MDCB change eliminated the OJT option which
impacted the ability of radiation therapists, who are certified through a separate organization, the
American Registry of Radiologic Technologists (ARRT), to continue formal education in
medical dosimetry while working. In the 2020 American Association of Medical Dosimetrists
(AAMD) survey, 67% of survey respondents held an ARRT certification in Radiation Therapy
(R.T.(T.)).4 Even with the elimination of OJT, the majority of certified medical dosimetrists
(CMDs) in the United States are licensed radiation therapists.
The AAMD 2020 Workforce Study predicts that the number of qualified medical
dosimetrists will not fulfill the workforce demand unless the number of students graduating
accredited programs doubles.4 The survey anticipates that even with an increase in JRCERT
graduates from 170 in 2018 to 225 in 2020, a large continual increase in graduates will be needed
to support the growing demand.4 In order to level this demand, the increase in graduates must
exceed the current rate, and identifying potential barriers that could be preventing this increase
may help to resolve this imminent challenge.
Barriers to post-secondary and higher education is extensively researched in several
fields, but not medical dosimetry. There are several barriers that could impact the number of
students attending post-primary or higher education pathways including low socio-economic
status and ethnic minority backgrounds.5 Researchers evaluated dental hygienists and identified
the major barriers for enrollment as time management, financial issues, work and family
obligations, and program options.6 In the field of nursing, researchers studied the continuation
from an Associate to a Bachelor of Science degree and concluded that the primary concerns of
not continuing their education included costs, lack of time, work and home responsibilities.7
These barriers experienced by allied health professionals can also be applied to radiation
therapists entering a full-time formal education program. Radiation therapists are no longer able
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to work full-time on site while completing OJT; thus, imposing potential loss of income,
insurance, and other benefits. The problem is that barriers for radiation therapists to pursue an
education in medical dosimetry may have a significant impact on future workforce demands. The
purpose of this study was to identify barriers to pursuing an education in medical dosimetry from
the perspectives of radiation therapists. The research questions used to complete this study were
included (Q1) what are the external barriers for radiation therapists to pursuing an education in
medical dosimetry and (Q2) what are the internal barriers for radiation therapists to pursuing an
education in medical dosimetry?
Methods and Materials
Survey Selection
To gain insight about the perceived barriers, a 7-question survey in Qualtrics was created.
The Qualtrics program is a survey tool that allows researchers to generate and quantify
questionnaires for research and statistical analysis. Results of the survey were auto generated and
updated in real-time at the completion of the survey. The survey was estimated to take < 4
minutes to complete. Participants receiving an invitation to participate in the survey were given a
hyperlink within the email that would take them directly to the survey. The questions collected
information on the participants' experience, interest in completing education in medical
dosimetry, internal barriers, and external barriers. 
Study Design
The first 2 questions of the survey assessed the participants' interest in continuing their
education in medical dosimetry. This provided a consensus of interest in the field and eliminated
participants that were not relevant to the research study. The next section of questions focused on
the internal and external barriers to pursuing an education in medical dosimetry. External barriers
correspond to limitations outside of us, including people and the environment around us.8 On the
other hand, internal barriers correspond to limitations inside of us, including: our thinking,
attitude, perceptions, and communication.8 Participants were asked to select the barriers that
applied to them and rank the barriers from most to least significant. The participants gave insight
into the barriers that were perceived to be the most influential in their decision to pursue medical
dosimetry education. The final question, used for correlation to barriers, collected demographic
information pertinent to the experience level and length of time spent in the radiation therapy
profession for each participant.
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Study Validation and Participation Selection Description

The survey was tested for validity with an initial pilot study population of 70 participants.
A pilot study is a smaller sized test of the survey that is to be used on a larger scale.9 The
fundamental purpose of conducting a pilot study is to examine the feasibility of an approach that
is intended to ultimately be used in a larger scale study.9 The pilot population consisted of
radiation therapy students and registered radiation therapists employed in the field. The number
of responses for this pilot study was 35 responses. The pilot sample size was based on the
pragmatics of recruitment and the necessities for examining feasibility.9 The response window
was open for 10 days with a reminder email sent on day 5. A total of 35/70 responses were
received, giving a response rate of 50%. Once the pilot survey was completed, the results were
analyzed to determine if any refinements were necessary for source documentation, informed
consent procedures, or data collection tools.9 No modifications were necessary.
Data Collection
The survey was distributed to 10,000 radiation therapy students and registered radiation
therapists who hold membership with the American Society of Radiologic Technologists
(ASRT). The ASRT is a national organization for medical imaging, radiation therapy
professionals, and students. The nationwide outreach of ASRT allowed for a diverse population
to be used for a randomized final distribution of surveys. Qualified participants were emailed a
descriptive introduction about the purposes of the research survey. There was a statement of
implied consent and contact information for questions and concerns regarding involvement in the
study. The study was anonymized and allowed for a 16-day window of completion. The survey
was distributed on September 15, 2021, and completed on October 1, 2021, with a final reminder
of completion issued to all participants on the final day of the survey window.
Statistical Analyses
The researchers designed and used a survey with a mixed method approach of multiple-
choice questions measured with a Likert Scale for order and ranking. Open-ended responses
were used for choices not mentioned in the listed options. Data analyses were completed using
Qualtrics with descriptive statistics and thematic analysis for the open-ended responses.
Results
A total of 650/10,000 responses were received, resulting in a response rate of 6.5%.
From these responses, 408/650 respondents answered they did experience barriers to continuing
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their education in medical dosimetry (Table 1). Out of the respondents, 242/650 were not eligible
to complete the survey due to lack of interest in medical dosimetry; therefore, 408/650 eligible
respondents completed the survey. The demographic information recorded was based on years of
experience. The respondents who confirmed they had barriers to continuing their education
(68.1%, 278/408) indicated 5+ years of experience. Only 31.9% (130/408) had < 5 years of
experience (Table 2).
Out of 14 external barrier categories in the questionnaire, 59.8% (244/408) of the
respondents identified that the most significant external barrier was the lack of flexibility in
school enrollment status (part-time options). The second most significant external barrier was
loss of employment (income and benefits) which was identified by 55.6% (227/408) of the
respondents. Lastly, the third most significant external barrier identified by 53.2% (217/408) of
the respondents was lack of financial support (e.g., scholarships, loans) (Figure 1).
Out of 9 internal barrier categories in the questionnaire, 35.0% (143/408) of the
respondents identified that the most significant internal barrier was the perception of the level of
difficulty of medical dosimetry education. The second most significant internal barrier was the
lack of confidence in succeeding, which was identified by 23.0% (94/408) of the respondents.
Finally, the third most significant internal barrier was the perception that there would be
insufficient support from faculty, as identified by 21.3% (87/408) of the respondents. Only
31.4%, (128/408) of the respondents identified that they did not have any internal barriers
(Figure 2).
Amongst the 80 open-ended responses, a common theme mentioned by 15% (12/80), was
the perception that increased use of Artificial intelligence (AI) would decrease the number of
dosimetrists being employed in departments in the future. While the AI theme was significant
amongst the text entry responses, it was not indicted enough to out rank the existing selections
from either the internal or external barriers. Another common text-entry response 11.3% (9/80)
included concerns for the requirement of a bachelor’s degree to sit for the MDCB exam. The
remaining responses were related to the barriers already listed in the survey.
Discussion
The most significant external barriers identified by participants in this study suggested
that financial reasons were a major factor preventing them from pursing further education in
medical dosimetry. Student loan debt in the United States has reached 1.3 trillion collectively.10
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In 2018, by the time graduates completed their undergraduate degrees, their average estimated
debt was approximately $29,900.10 Student loan debt has an impact on the lives of graduates and
their choices for continuation of schooling, family formation and home ownership.10 Having a
large amount of debt from undergraduate education is often further compounded when seeking
an additional degree. Additionally, the dependent health insurance age cutoff limits benefit
coverage options to those older than 26, which could impact many potential students. Therefore,
both entry level and experienced radiation therapists may encounter significant financial burdens
and concerns when faced with student loan debt and loss of benefits due to continuing their
education in medical dosimetry.
In addition to the cost of completing the degree, the financial strain of leaving
employment adds to the burden of pursing a medical dosimetry degree. Medical dosimetry
programs that require 1 to 2 years of full-time enrollment recommend that radiation therapists
not retain employment to keep up with curriculum demands and abide by accreditation standards.
The loss of income and benefits can be impractical for many. In this study, financial concerns
were rated as a significant barrier and could prevent potential students from pursuing an
education in medical dosimetry. The results of this study support the need for medical dosimetry
programs to consider an accessible and flexible pathway to medical dosimetry education. The
availability of part-time programs or earned stipends could be influential for students to help
offset the medical dosimetry program costs and alleviate some of the financial barriers
preventing potential students from pursing a degree in medical dosimetry.
Intrinsic barriers are more difficult to modify as they are unique to the individual, despite
commonalities among peers. Intrinsic barriers often need to be resolved by the individual alone,
although support from faculty and peers is beneficial. The internal barriers impacting the
participants’ decisions to pursue a medial dosimetry degree were selected by 43.8% of the entry
level radiation therapist respondents. The top 3 internal barriers of this study (perception of the
level of difficulty of medical dosimetry education, lack of confidence in succeeding, and the
perception that there would be insufficient support from faculty) are consistent with Gorczyca11
in which entry-level nurses expressed anxiety around academic expectations and performance
based on stressful times experienced in undergraduate studies. In the Gorczyca11 study, the
participants expressed a disinterest in returning to engage in academic endeavors and did not feel
ready to continue their education towards a higher degree due to lack of expertise and
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experience. In correlation with the Gorczya11 study, entry level radiation therapists (n=130)
identified lacking confidence in successfully completing a medical dosimetry program as a
barrier (28.5%, 37/130) more frequently than experienced radiation therapists (n=278, 20.5%,
57/278).
Overall, the results of this study indicate that external barriers are more prominent than
internal barriers for radiation therapists in their pursuit of an education in medical dosimetry. The
current study results are promising as external barriers lend easier to modifications on a large
scale. After the elimination of on-the-job training, the medical dosimetry profession was
impacted by a declining number of eligible board examinees, of which many were radiation
therapists. Eliminating the external barriers faced by radiation therapists when applying to
medical dosimetry programs could be beneficial. However, this does not increase the number of
available programs or medical dosimetry educators, which are also factors that could contribute
to a potential workforce shortage.4 With programmatic accreditation of medical dosimetry
programs, addressing the barriers for radiation therapists may provide more enrollment options
for individuals with knowledge of radiation oncology and could prove to be fruitful for the
medical dosimetry profession.
Conclusion
The medical dosimetry field is rapidly evolving, and the need for medical dosimetrists is
expected to increase. Perceived barriers for radiation therapists to pursue an education in medical
dosimetry may have a significant impact on future workforce demands. The purpose of this study
was to identify barriers to pursing an education in medical dosimetry from the perspectives of
radiation therapists. Generally, financial barriers and lack of flexibility in enrollment options
were the main external barriers to pursuing medical dosimetry education. In addition, there is a
perception of the level of difficulty of medical dosimetry education that might be impacting
radiation therapists. The findings from this study may help to decrease barriers for radiation
therapists in the near future.
A limitation of this study was the lack of survey respondents. A low response rate does
not provide conclusive evidence of whether the results represent a majority of radiation
therapists. Future research should be conducted to expand the inclusion criteria to radiation
therapists that are not ASRT members to represent the true demographic population of radiation
therapists.
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References
1. Robinson GF, Mobile K, Yu Y. The radiation oncology workforce: A focus on medical
dosimetry. Med Dosim. 2014;39(2):197-200. http://doi.org/10.1016/j.meddos.2014.02.001.
2. Cagle S, Sullivan C. The Changing Face of The Medical Dosimetrist: How This Will Affect
Your Department. In: AAMD Annual Meeting; 2015. (PPT Presentation).
https://www.roswellpark.org/sites/default/files/changing-face-medical-dosimetrist.pdf.
3. Pusey D, Smith L, Zeman EM, Adams R. A history and overview of the certification exam
for medical dosimetrists. Med Dosim. 2005;30(2):92-96.
http://doi.org/10.1016/j.meddos.2005.03.001.
4. American Association of Medical Dosimetrists. 2020 AAMD Workforce Study Reports.
Salary and Workforce Surveys - American Association of Medical Dosimetrists.
https://www.medicaldosimetry.org/publications/salary-and-workforce-surveys/. Updated
June 1, 2021. Accessed June 21, 2021.
5. Vandelannote I, Demanet J. Unravelling socioeconomic school composition effects on higher
education enrollment: the role of students’ individual and shared feelings of futility and self-
efficacy. Soc Psychol Educ. 2021;24(1):169-193. https://doi.org/10.1007/s11218-021-09608-
z.
6. Smith AN, Boyd LD, Rogers CM, Le Jeune RC. Self-perceptions of value, barriers, and
motivations for graduate education among dental hygienists. J Dent Educ. 2016;80(9):1033-
1040. http://doi.org/10.1002/j.0022-0337.2016.80.9.tb06185.x.
7. Sabio C. Associate degree nursing students’ perceived barriers to baccalaureate nursing
education and intentions to enroll in a baccalaureate-only nursing environment. Teach Learn
Nurs. 2019;14(1):9-14. http://doi.org/10.1016/j.teln.2018.08.004.
8. Internal and external barriers to effective communication: And how to overcome them!
https://www.seekhle.com/2018/07/barriers-to-effective-communication.html. Updated July 7,
2018. Accessed July 26, 2021.
9. Leon AC, Davis LL, Kraemer HC. The role and interpretation of pilot studies in clinical
research. J Psychiatr Res. 2011; 45(5):626-629.
http://dx.doi.org/10.1016/j.jpsychires.2010.10. 008.
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10. Velez E, Cominole M, Bentz A. Debt burden after college: the effect of student loan debt on
graduates’ employment, additional schooling, family formation, and home ownership. Educ
Econ. 2018;27(2):186-206. https://doi.org/10.1080/09645292.2018.1541167.
11. Gorczyca C. Factors influencing the pursuit of graduate education in registered nurses:
exploring the motivations and barriers. [Thesis]. Vancouver, Canada: The university of
British Columbia; 2013.
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Figures

Figure 1. Distribution of external barriers experienced by survey respondents (n = 408) who

answered that they had an interest in continuing their education in medical dosimetry.
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Figure 2. Distribution of internal barriers experienced by survey respondents (n = 408) who

answered that they had an interest in continuing their education in medical dosimetry.
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Tables
Table 1. Distribution of responses (n = 650) to the question on the likelihood of considering
medical dosimetry education. Respondents who answered unlikely or very unlikely were not
eligible to participate in the survey.

Number (N) Percentage (%)

How likely are you considering futhering your education in a medical
dosimetry program?

Extremley Likley 104/650 16.0%

Likely 79/650 12.2%
Undecided 140/650 21.5%
Unlikely 157/650 24.2%
Very Unlikely 170/650 26.2%

Table 2. Distribution of respondents (n = 408) in response to a demographic question at the end

of the survey regarding years of experience working in radiation therapy.

Number (N) Percentage (%)

Demographics: How many years of radiation therapy experience do you
have? (post-graduation)

0-5 130/408 31.9%

5+ 278/408 68.1%
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Appendix A
Survey Introduction

Dear Radiation Therapists,

As medical dosimetry graduate students at the University of Wisconsin La Crosse, we invite you
to complete this survey regarding barriers to continuing education in Medical Dosimetry from
the perspective of radiation therapists. We are reaching out to you because you have been
identified as a radiation therapist or are currently enrolled in a radiation therapy program.
Barriers for radiation therapists to pursue an education in medical dosimetry may
significantly impact future workforce demands. The researchers of this study aim
to identify barriers that contribute to radiation therapists not enrolling in medical dosimetry
programs.  

This survey is composed of 7 questions. Completing this survey should take < 4 minutes. The
survey is anonymous, and your identity will remain confidential. Your participation is
completely voluntary. Clicking on the survey link implies consent to participate in the study.

If you have any questions or concerns, please contact our research advisor, Nishele Lenards, at
nlenards@uwlax.edu.

This survey is best suited for completion on a desktop, as some of the questions may not be
mobile friendly. Please click here; or copy and paste this URL into your internet
browser:https://uwlax.ca1.qualtrics.com/jfe/form/SV_ai99mueJRqHakAu

We thank you in advance for your participation.  

If you decide to participate in this survey, please submit the survey before (deadline date).  

Thank you,  

RaeLyn Debner (debner4390@uwlax.edu)  

April Hardman (hardman5150@uwlax.edu)  

Jessica Pagan (pagan7749@uwlax.edu)  

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Appendix B

Questions and Answers to Barriers of Radiation Therapists to pursuing education in Medical

Dosimetry. We greatly appreciate your participation in this survey. This survey should take <4
minutes to complete.
Survey Questions   
1. How likely are you considering furthering your education in a medical
dosimetry program?      
a. Extremely Likely   (skips to #3)  
b. Likely    (skips to #3) 
c. Undecided    (skips to #3) 
d. Unlikely (skips to #2) 
e. Very Unlikely (skips to #2) 
2. Based on your prior answer, is your decision to not further education in medical
dosimetry due to challenges or barriers you may have encountered?  
a. Yes (skip to #3) 
b. No (this choice will auto exit survey with a custom message: “Thank you
for participating in the survey. There are no additional questions applicable to
you”) 

(Q1) What are the external barriers to pursing an education in medical dosimetry for
radiation therapists?  
3. External barriers correspond to limitations outside of us, including people and
environment around us. Please identify the external barriers that would prevent you from
going to medical dosimetry school.  
 Lack of clinical sites in preferred location    
 Lack of familiarity in the program applications    
 Lack of financial support (e.g. scholarships, loans)  
 Loss of employment (income and benefits)    
 Length of most medical dosimetry programs    
 Lack of patient interaction    
 Ergonomic: too much sitting    
 Difficulty of the board exam  
 Lack of flexibility in school enrollment status (part-time options) 
 Lack of flexible schooling format (hybrid or online options) 
 Personal responsibilities    
 Job responsibilities in medical dosimetry  
 Other (please specify) [text entry box]  
 There are no external barriers (skip to question #5) 
4.  If applicable, please rank your prior choices of external barriers from most significant (1)
to least significant.  (Use the drag and drop feature to order your choices) 
(This question will carry forward their choices from #3 and allow them to order only those
they selected in #3.) 
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(Q2) What are the internal barriers to pursing an education in medical dosimetry for
radiation therapists? 
5.  Internal barriers correspond to limitations inside of us, including: our thinking,
attitude, perceptions, and communication. Please identify the internal barriers that would
prevent you from going to medical dosimetry school. 
 Lack of confidence in succeeding   
 Preference to obtain more work experience.    
 Perception about the difficulty level of medical dosimetry education    
 Perception that the job will be boring     
 Perception that I am not in an ideal age range 
 Perception that there would be insufficient support from faculty 
 Perception that job will be stressful 
 Other (please specify) [text entry box] 
 There are no internal barriers (skip to question #7) 
6. If applicable, please rank your prior choices of internal barriers from most significant (1)
to least significant.  (Use the drag and drop feature to order your choices) 
(This question will carry forward their choices from #5 and allow them to order only those
they selected in #5.) 
7.  Demographics: How many years of Radiation Therapy Experience do you have? (post-
graduation)    
a. 0-5    
b. 5+