I 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) 
Abstract
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 additional 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 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. Even with the elimination of OJT, the majority of certified
medical dosimetrists (CMDs) in the United States are licensed radiation therapists. 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 While the MDCB eligibility
changes, added challenges for medical dosimetrists to become certified, it is only one of the
driving factors controlling the supply of medical dosimetry professionals.4
As of 2021, there are only 15 accredited programs that offer formal education and
training for medical dosimetry.5 Eight of the available programs offer a bachelor’s or master’s
degree.5 With the limited number of programs available, there becomes a finite number of
I 2

students that can graduate from these programs and enter the workforce; thus, impacting the
demand for more medical dosimetrists.
According to the AAMD Education & Research Foundation, the competition for student
acceptance into Joint Review Committee on Education in Radiologic Technology (JRCERT)
accredited medical dosimetry programs is high.6 In 2009, one program reported 99 applicants for
16 positions.6 Though the number of applicants to this program was significant, barriers still
exist in pursuing higher education. 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
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.7 Researchers evaluated dental hygienists and identified
the major barriers for enrollment as time management, financial issues, work and family
obligations, and program options.8 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.9
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
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
I 3

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 less than 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.10 On the
other hand, internal barriers correspond to limitations inside of us, including: our thinking,
attitude, perceptions, and communication.10 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 go to medical
dosimetry school. 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.
Study Validation and Participation Selection Description
The survey was tested for validity with an initial pilot study population of 70 participants.
The pilot population consisted of radiation therapy students and registered radiation therapists
employed in the field. The accepted number of responses for this pilot study was a minimum of
15 responses. 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%. From these responses,
21/35 respondents answered they had barriers to continuing their education in medical
dosimetry. The other 14 responders were automatically taken to the end of the survey since the
participants answered that their disinterest in continuing education in medical dosimetry was not
related to any barriers. This gives a survey completion rate of 60% from the 35 responders who
I 4

took the survey. Once the pilot survey was completed, the results were analyzed to ensure that
the survey was comprehensive and free of errors.
Data Collection
The survey was then 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 Analysis
The survey used a mixed method approach of multiple-choice questions, Likert Scale for
order and ranking, and open-ended responses for choices not mentioned in the options. Data
analysis was completed using Qualtrics and consisted of frequencies and percentages to describe
the findings of the survey. Additional analysis were required for text-entry responses.
Results
For this study, a total of 10,000 email surveys were distributed to members of ASRT who
identified as radiation therapists or radiation therapy students. A total of 650/10,000 responses
were received, giving a response rate of 6.5%. From these responses, 408/650 respondents
answered they had barriers to continuing their education in medical dosimetry. The other
242/650 responders were automatically taken to the end of the survey since the participants
answered that their disinterest in continuing education in medical dosimetry was not related to
any barriers. This gives a survey completion rate of 62.7% from the 650 responders who took the
survey.
The demographic information recorded was based on years of experience. A majority of
the respondents who confirmed that they had barriers to continuing their education in medical
dosimetry (n= 278) indicated 5+ years of experience, with only (n= 130) having 0-5 years of
I 5

experience. Therefore, 68% of the responders who completed the survey were experienced
therapists.
Out of 14 external barrier categories in the questionnaire, the majority of respondents
identified that their top 3 external barriers were: lack of flexibility in school enrollment status
(part-time options), loss of employment (income and benefits), and lack of financial support
(e.g., scholarships, loans). The most significant external barrier identified was a lack of
flexibility in school enrollment status (part-time options), which was selected the most (n=244).
This barrier was picked by 15.07% of the responders. The second most significant external
barrier selected by 14.02% (n=227) of the responders was loss of employment (income and
benefits). Lastly, the third most significant external barrier identified by 13.4% (n=217) of the
responders was lack of financial support (e.g., scholarships, loans).
Out of 9 internal barrier categories in the questionnaire, 19.09% (n=143) of the
responders identified that the most significant internal barrier was the perception of the difficulty
level of medical dosimetry education. The second most significant internal barrier was the lack
of confidence in succeeding, which was identified by 12.55% (n=94) of the responders. Finally,
the third most significant internal barrier was the perception that there would be insufficient
support from faculty, picked by 11.62% (n=87) of the responders. (n=128) 17% of the
responders identified that they did not have any internal barriers.
Discussion
Due to the voluntary participation in this survey, researchers were unable to conclude
whether the demographics represent the field of radiation therapy as a whole. Results from this
study showed that 68% (n=278) of respondents were therapists with 5 or more years of
experience, 32% (n=130) of respondents were therapist with 0-5 years of experience. This
demographic only reflects the survey’s participants who were members of the ASRT and may
not represent the true demographic population of radiation therapy.
In response to research question (Q1) what are the external barriers for radiation
therapists to pursuing an education in medical dosimetry: lack of flexible in school enrollment
status (part-time options), loss of employment (income and benefits), and lack of financial
support (e.g., scholarships, loans) were the top 3 answers. Respondents (n=10) indicated in the
text entry choices that they feared artificial intelligence might replace future medical dosimetry
positions. Although, there is limited recent research amongst allied health professionals and
I 6

barriers to school, this response reflected similar responses in prior research on other allied
health professionals and nursing.8,9
In response to research question (Q2) what are the internal barriers for radiation
therapists to pursuing an education in medical dosimetry: the perception of the difficulty level of
medical dosimetry education, the lack of confidence in succeeding, and the perception that there
would be insufficient support from faculty were the top 3 internal barriers. In addition to this,
(n=128) 17% of the responders identified that they did not have any internal barriers. These
results imply that there are more significant external barriers than internal barriers for pursuing
an education in medical dosimetry. This may or may not be consistent with other research as
there is little recent research available on internal barriers to attending school for allied health
professionals.
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.
Researchers in this study revealed that the participants' most significant barrier to
pursuing an education in medical dosimetry was the lack of flexibility in school enrollment
status. In addition, there is a perception of the level of difficulty of medical dosimetry education
that might be impacting the study population and their decision to pursue an education in
medical dosimetry. Overall, data indicates that potential medical dosimetry students are more
impacted by external barriers. By addressing and alleviating some of these external barriers, it
would open up the potential for additional applications to medical dosimetry school. It is clear
that there is a demand for an alternative enrollment option. This will allow students the
possibility to work while in the program, support financial needs, and keep benefits.
Limitations and Recommendations
There were several limitations to this study. The study relied on email distribution
without verifying that recipients had active email addresses. Another limitation was the time
limit for the survey data collection of only 2 weeks. Future research might be conducted to
expand the inclusion criteria to other potential student populations and therapists that do not
I 7

belong to the ASRT. Additional research may also be conducted on the barriers to setting up
clinical sites. This demographic only reflects the survey’s participants who were members of the
ASRT and may not represent the true demographic population of radiation therapy. Furthermore,
research may be needed to verify statistical relationships existing between gender and age in
relationships with these barriers.
 I 8

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. Joint Review Committee on Education in Radiologic Technology.
https://portal.jrcertaccreditation.org/accredited-educational-programs/search. Accessed June 21,
2021.
6. Announcements. AAMD Education & Research Foundation/ AAPM Medical Dosimetry
Accreditation Grant Program.
https://aapm.org/announcements/AAMDFoundationAccreditationGrant.asp. Accessed May 5,
2021.
7. 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.
8. 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.
9. 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.
 I 9

10. 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.
I 10

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)  

I 11
I 12

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.) 
I 13

(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+