Physics and Imaging in Radiation Oncology 19 (2021) 25–32 Contents lists available at ScienceDirect Physics and Imaging in Radiation Oncology journal homepage: www.sciencedirect.com/journal/physics-and-imaging-in-radiation-oncology Professional practice changes in radiotherapy physics during the COVID-19 pandemic Jenny Bertholet a, b, *, 1, Marianne C. Aznar a, c, d, 1, Cristina Garibaldi a, e, David Thwaites a, f, g, Eduard Gershkevitsh a, h, Daniela Thorwarth a, i, 3, Dirk Verellen a, j, Ben Heijmen a, k, Coen Hurkmans a, l, Ludvig Muren a, m, 3, Kathrine Røe Redalen a, n, Frank-André Siebert a, o, Marco Schwarz a, p, Wouter Van Elmpt a, q, Dietmar Georg a, r, Nuria Jornet a, s, 2, Catharine H. Clark a, t, u, v, 2 a European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium b Division of Medical Radiation Physics, Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland c Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, The Christie NHS Foundation Trust, Manchester, UK d Nuffield Department of Population Health, University of Oxford, Oxford, UK e Unit of Radiation Research, IEO European Institute of Oncology, IRCCS, Milano, Italy f Institute of Medical Physics, School of Physics, University of Sydney, Sydney, Australia g Medical Physics, Leeds Institute of Cancer and Pathology, School of Medicine, Leeds University, Leeds, UK h North Estonia Medical Centre, Tallinn, Estonia i Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Germany j Iridium Network, Antwerp University (Faculty of Medicine and Health Sciences), Antwerp, Belgium k Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands l Catharina Hospital, Department of Radiation Oncology, Eindhoven, The Netherlands m Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark n Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway o Clinic of Radiotherapy, University Hospital of Schleswig-Holstein, Campus Kiel, Germany p Proton Therapy Department, Trento Hospital, TIFPA-INFN, Trento, Italy q Department of Radiation Oncology (MAASTRO), GROW – School for Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands r Division Medical Radiation Physics, Department of Radiation Oncology, Medical University of Vienna, AKH Wien, Austria s Servei de Radiofísica i Radioprotecció, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain t Department of Radiotherapy Physics, University College London Hospital, UK u Department of Medical Physics and Bioengineering, University College London, UK v National Physical Laboratory, London, UK A R T I C L E I N F O A B S T R A C T Keywords: Background and purpose: The COVID-19 pandemic has imposed changes in radiotherapy (RT) departments COVID-19 worldwide. Medical physicists (MPs) are key healthcare professionals in maintaining safe and effective RT. This SARS-CoV-2 study reports on MPs experience during the first pandemic peak and explores the consequences on their work. Radiotherapy Methods: A 39-question survey on changes in departmental and clinical practice and on the impact for the future Medical Physics was sent to the global MP community. A total of 433 responses were analysed by professional role and by country Treatment planning Quality assurance clustered on the daily infection numbers. Results: The impact of COVID-19 was bigger in countries with high daily infection rate. The majority of MPs worked in alternation at home/on-site. Among practice changes, implementation and/or increased use of hypofractionation was the most common (47% of the respondents). Sixteen percent of respondents modified patient-specific quality assurance (QA), 21% reduced machine QA, and 25% moved machine QA to weekends/ * Corresponding author. E-mail address: jenny.bertholet@insel.ch (J. Bertholet). 1 Joint first authors. 2 Joint last authors. 3 Dr. Ludvig Muren and Dr. Daniela Thorwarth, co-authors of this paper, are Editor-in-Chief of Physics & Imaging in Radiation Oncology. The editorial process for this manuscript was managed independently from Dr. Muren and Dr. Thorwarth and the manuscript was subject to the Journal’s usual peer-review process. https://doi.org/10.1016/j.phro.2021.06.002 Received 20 April 2021; Received in revised form 29 May 2021; Accepted 12 June 2021 Available online 22 June 2021 2405-6316/© 2021 The Authors. Published by Elsevier B.V. on behalf of European Society of Radiotherapy & Oncology. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). J. Bertholet et al. Physics and Imaging in Radiation Oncology 19 (2021) 25–32 evenings. The perception of trust in leadership and team unity was reversed between management MPs (towards increased trust and unity) and clinical MPs (towards a decrease). Changes such as home-working and increased use of hypofractionation were welcomed. However, some MPs were concerned about pressure to keep negative changes (e.g. weekend work). Conclusion: COVID-19 affected MPs through changes in practice and QA procedures but also in terms of trust in leadership and team unity. Some changes were welcomed but others caused worries for the future. This report forms the basis, from a medical physics perspective, to evaluate long-lasting changes within a multi-disciplinary setting. 1. Introduction (management vs clinical MP) where relevant. From this study we can infer how to adapt to future crises, but also integrate potentially positive The outbreak of the Severe Acute Respiratory Syndrome CoronaVirus changes to keep for the future. 2 (SARS-CoV-2) causing Coronavirus disease 2019 (COVID-19) is an extreme event with complex spread-dynamics [1]. The crisis has pro­ 2. Materials and methods duced different infection rates and strain levels on the healthcare sys­ tems of different countries. Radiotherapy (RT) has been recognized as an A web-based questionnaire (Supplementary material A.I) was essential non-elective treatment for many tumour entities [2,3]. Cancer distributed to ESTRO’s physics members via e-mail (2500 recipients) patients are at increased risk of COVID-19-related complications [4]. and the broader medical physics community via social media. It con­ Although RT services continued, important changes were implemented tained 39 questions on demographics (questions 1–12), department rapidly to enhance patient and staff protection against infection, organisation (13–20), changes in practice (21–31), morale and mental including treatment delay or RT schedule alterations [2,3,5–12]. This health (32–33) and expected future impacts (34–38), with an open text- also affected medical physicists (MPs), who are key healthcare pro­ box for further comment(s). Responses were collected anonymously fessionals in sustaining safe, effective, and efficient RT under constraints from June 18 to September 24, 2020. of social distancing and national/regional pandemic-related guidelines Of the 489 responses received, 50 with no information beyond the [13]. demographics and 6 from non-MP professionals were excluded. Results In addition to legal requirements for MPs presence at the hospital, from the 433 respondents were analysed overall, as well as by profes­ which may differ internationally, Whitaker et al. distinguished four sional group and country cluster, where relevant. types of tasks from a practical standpoint [14]. First, direct patient- The largest professional groups were clinical MPs (N = 298, 69%) facing tasks, such as brachytherapy, first fraction verification for com­ and head of medical physics/management (hereafter “management plex treatments and in-vivo dosimetry represent a small but vital portion MPs”, N = 110, 25%). Fifteen research/academic physicists (3%) and 10 of the workload requiring MPs on-site during treatment hours. Second, with other or non-specified roles (2%) were only included in the overall some measurement-based quality assurance (QA) requires on-site pres­ analysis. ence but can be performed out of treatment hours. Third, treatment Countries were divided into clusters according to the daily number of planning-related, quality management, and administrative tasks can infections [1], with cluster A (N = 222, 51%) containing Italy, Spain, often be done remotely. Fourth, project planning, education, training UK, USA, that were generally most affected by the pandemic. Cluster B and research can often be performed remotely or potentially postponed (N = 156, 36%) contained countries such as Belgium, the Netherlands, for clinical staff. Switzerland. Cluster C (N = 45, 10%) contained countries with low daily Researchers that mostly have type-4 tasks were most likely to work case numbers, with most responses from Norway and New Zealand (see from home while clinical MPs needed to work on-site and/or on shift supplementary material A.II for details). Ten responses were not [13–15]. Management MPs were involved in decision making and included in any cluster, but only in the overall analysis, because either liaising between hospital administration and clinical staff [9]. Thus, MPs country was not indicated or was not included in the analysis of [1]. The may have had widely diverse experiences during COVID-19 due to majority (68%) of responses came from Europe followed by US/Canada different roles and responsibilities. (16%), New Zealand and Australia (7%), Asia and Middle East (7%), Most RT service changes were aimed at limiting patient presence at Latin America and Africa (~1% each). the hospital (e.g. RT postponement when clinically supported, or Demographics for clusters A and B were homogeneous (Supple­ hypofractionation) and to limit interaction between team-members (e.g. mentary Table A.III). shift work) [2,5–10,16–18]. These were considered a “contingency No response was mandatory and the number of responses per standard of care” in an “early pandemic scenario” while more drastic country were uneven. Therefore, no statistical analysis between sub- resource shortages and patient triage were anticipated in a “second groups could be performed. (later) pandemic scenario” [19,20]. MPs have less patient contact than radiation oncologists, radiation therapists (RTTs) and nurses. They 3. Results perform many “behind the scenes” tasks, e.g. planning and patient- specific QA (PSQA), easily overlooked when establishing guidelines 3.1. Organisation of the department limiting patient contact. Whereas new publications are exploring the aftermath and lessons learned for future clinical practice [18,21–23] (Cluster) A-respondents were the most tested for COVID-19, and had with potentially more patient-centric research and streamlined admin­ the highest rates of positive/suspected patients and related treatment istrative and regulatory procedures [24], the impact for MPs is unclear. interruption (Table 1). The corresponding test rates and positive test This study presents a global survey of MPs experience during the first rates were lower for B and lowest for C-respondents. A-respondents were pandemic wave (March-June 2020). We aim to understand the different more likely to be tested for COVID-19 after the first crisis peak, while B- challenges faced by MPs in different roles and countries and the po­ respondents were more often tested before or at the crisis peak. tential impact for future practice. Results were analysed for three The proportion of respondents working at home or on location was country clusters based on daily number of infections in order to link the similar across clusters (Supplementary Fig. 1). Only a third of clinical spread-dynamic and early/late pandemic scenarios to changes in med­ MPs worked fully on-site. ical physics practice. Results are also reported by professional role Thirty percent of A-respondents reported that there was no 26 J. Bertholet et al. Physics and Imaging in Radiation Oncology 19 (2021) 25–32 Table 1 Table 2 Infection situation in the department by country cluster and overall. Organisation of the department by country cluster and overall. By clustera A (N = B (N = C (N = Overall (N By clustera A (N = B (N = C (N = Overall (N 222) 156) 45) = 433) 222) 156) 45) = 433) Were you tested for COVID-19 How well prepared was the (e.g. blood, nose/mouth department for the COVID-19 swab)? (Q9/10) emergency? (Q13) No 104 88 36 234 (54%) Some contingency plan, but we 132 93 21 253 (58%) (47%) (56%) (80%) had to develop the plan further (59%) (60%) (47%) Yes, at the start of the crisis 11 24 4 (9%) 40 (9%) as we went along (5%) (15%) Well-developed contingency 44 46 13 105 (24%) b Yes, at the peak of the crisis 29 27 3 (7%) 62 (14%) plan (20%) (29%) (29%) (13%) (17%) No contingency plan 44 15 7 67 (15%) Yes, after the peak of the crisis 78 17 2 (4%) 97 (22%) (30%) (10%) (16%) (35%) (11%) Other 1b 2 (1%)c 1 4 (<1%) (2%)d Was any patient COVID-positive No response 1 0 3 (7%) 4 (<1%) (or suspected) treated in your department? (Q11) Did you divide the team? (Q14/ Yes 152 85 11 251 (58%) 15) (68%) (54%) (24%) Yes split but not alternate (one 23 21 4 (9%) 52 (12%) No 47 51 23 127 (29%) group at home) (10%) (13%) (21%) (33%) (51%) Yes split and alternate between 117 72 34 227 (52%) I don’t know 22 20 11 54 (12%) work/home (53%) (46%) (76%) (10%) (13%) (24%) No, no split 56 38 4 (9%) 100 (23%) No response 1 0 0 1 (<1%) (25%) (24%) Did any patient have their Other (see text for description) 26 24 3 (7%) 53 (12%) treatment interrupted because (12%) (15%) of confirmed/suspected No response 0 1 0 1 (<1%) COVID-19 infection? (Q12) (<1%) Yes 99 57 13 172 (40%) (45%) (37%) (29%) Did you divide the department No 75 61 19 162 (37%) into clean/at risk areas? (34%) (39%) (42%) (Q16) I don’t know 47 38 13 98 (23%) Yes 79 55 12 148 (34%) (21%) (24%) (29%) (36%) (35%) (27%) No response 1 0 0 1 (<1%) No 130 85 27 249 (57%) a (59%) (54%) (60%) Ten responses are not associated with any cluster (see supplementary ma­ Other (see text for description) 11 (5%) 13 (8%) 4 (9%) 29 (7%) terial A.II). No response 2 3 (2%) 2 (4%) 7 (2%) b this question referred to the first peak of the crisis (March–June 2020). (<1%) contingency plan to handle the COVID-19 situation while for B and C- Did you have the means to work remotely in planning? (Q17) respondents this was 10% and 16%, respectively (Table 2). No, we did not get remote 30 45 13 92 (21%) Three-quarters of respondents indicated some form of team splitting, connection (14%) (29%) (29%) mostly implemented by alternating people at home or at work with Yes, we got it as soon the 48 21 6 76 (17%) daily, weekly, or less frequently, early/late shifts. For small departments emergency started (22%) (13%) (13%) with 1–2 treatment units, 30% of respondents indicated there was no Yes, we already had it 90 63 22 180 (41%) (41%) (40%) (49%) team splitting. This number was 23%, 16% and 21% for departments Yes, we got it but not 43 16 4 (9%) 63 (14%) with 3–6 units, 7–10 units or 10 or more units respectively. Some other immediately (19%) (10%) arrangements, aimed at minimizing contact at work, included groups Other 9 (4%) 10 (6%) 0 19 (4%) on-site without contact or people working at home whenever possible. No response 2 1 0 3 (<1%) (<1%) (<1%) For just over half of the respondents, departments were not split into at risk/clean areas (Table 2). However, about a third of respondents’ Was the physics personnel departments, relatively homogeneous across clusters, were split. screened daily for COVID “Other” solutions involved having one COVID-linac or treating at-risk symptoms? (Q18) patients at the end of the day. Yes 84 85 12 185 (43%) Although remote access for planning was similar across the clusters (38%) (54%) (27%) No 138 70 29 247 (57%) (40%) before the pandemic, access increased more for A-respondents (62%) (45%) (64%) than for B and C-respondents during the pandemic. No response 0 1 4 (9%) 1 (<1%) Access to personal protective equipment (PPE) was similar across (<1%) clusters (Table 2). Yet 13 A-respondents and eight B-respondents re­ ported explicitly having no, or insufficient, equipment. Eight B-re­ Which personal protective equipment was available spondents reported no such need because contact could be avoided. from the hospital for MPs at Some reported having specialized equipment (visor, high filtration the peak of the crisis? (Q19) masks) for brachytherapy. Gloves 131 85 30 254 (58%) The percentage of physics staff staying away due to being infected (59%) (54%) (67%) was highest in cluster A and lowest in C (Table 2). The percentage FFP2/N95 mask 44 38 6 92 (21%) (20%) (24%) (13%) staying away due to quarantine was higher than for infection, and Surgical mask 190 101 28 329 (76%) cluster A had the highest rates. Other common reasons to stay away were (86%) (65%) (62%) risk factors or pregnancy (self or relative, 49 respondents), child-care Protective glasses 4 (9%) 59 (14%) (13), suspected infection/awaiting test results (8) or travel (self or (continued on next page) 27 J. Bertholet et al. Physics and Imaging in Radiation Oncology 19 (2021) 25–32 Table 2 (continued ) relative, 6). Two respondents reported that staff remained at home By clustera A (N = B (N = C (N = Overall (N because of pandemic-related anxiety or distress. 222) 156) 45) = 433) 29 23 3.2. Changes in practice (13%) (15%) Visor 23 25 9 60 (14%) This section is based on 411 responses. The most widely imple­ (10%) (16%) (20%) Other (see text) 38 34 3 (7%) 62 (14%) mented change was increased use or implementation of hypofractiona­ (17%) (22%) tion (193 responses, 47%, Fig. 1). This was more prevalent in cluster A (54%) and in large-volume centres (4000+patients/year, 70%). What proportion of your Decreased gating use and increased simultaneous integrated boost (SIB) physics staff had to stay away use was reported by 11% of respondents. Overall, 156 (38%) re­ from the department for spondents implemented no changes in techniques (15% for large- COVID-related reasons? (Q20) volume centres). Due to being infected themselves In addition, 16 respondents observed a reduction in RT and 11 None 129 104 34 275 (63%) mentioned postponing prostate RT with longer hormone treatment (58%) (67%) (76%) instead. Fifty-six (14%) respondents (37 from cluster A) observed a <10% 42 21 3 (7%) 66 (15%) (19%) (13%) workload increase, including 13 where RT was given instead of surgery 10–25% 19 (9%) 9 (6%) 1 (2%) 29 (7%) and/or chemotherapy. Six had more head and neck referrals; five had 25–50% 6 (3%) 5 (3%) 0 11 (3%) additional data collection or reporting; and four reported increased >50% 0 3 (2%) 0 3 (<1%) workloads due to initial replanning or additional QA for hypofractio­ No response/do not know 26 14 (9%) 7(16%) 49 (12%) nated treatments. (12%) PSQA and machine QA procedures were changed/reduced by 16% Due to going into isolation (e.g. and 21% of respondents respectively (Table 3). For 25%, QA was moved household member infected/ infection suspected) to weekend or evenings to limit interactions. Others often did QA None 99 82 22 210 (48%) “whenever possible”. (45%) (53%) (49%) Overall, 49% of respondents did not need changes to compensate for <10% 60 30 11 101 (23%) extra time for cleaning/sterilizing rooms after treating COVID-positive (27%) (19%) (24%) patients, while 17% and 18% extended working hours and reduced 10–25% 33 22 5 60 (14%) (15%) (14%) (11%) patient numbers, respectively (Table 3). Thirteen respondents indicated 25–50% 9 (4%) 6 (4%) 1 (2%) 17 (4%) that no COVID-positive/suspected patients had been treated in their >50% 1 3 (2%) 2 (4%) 6 (1%) department. Twelve reported that the reduced patient numbers (<1%) compensated for the extra cleaning time. No response/do not know 20 13 (8%) 4 (9%) 39 (9%) (90%) Most respondents reported that treatment unit technical support was available (Supplementary Table A.IV). Preventive maintenance was a Ten responses are not associated with any cluster (see supplementary ma­ cancelled for 30% of A-respondents, 22% of B and 27% of C. Re­ terial A.II). b placements of the high-dose rate/pulsed-dose rate afterloader sources Describes a quick adaption to COVID-19. c were generally carried out as planned. One had no plan initially, then developing their approach then hospital-wide plan in place. One had a plan before the emergency started. Some MPs participated in COVID-related research initiatives: 49 d Well-developed department plan but hospital-wide plan lagged behind. respondents reported that MPs helped design databases, 48 collected data (e.g. cone-beam CT), 15 participated in radiomics studies, eight investigated low-dose RT as COVID-19 treatment, four wrote papers on their experience and one investigated mask sterilization. Fig. 1. Changes in treatment technique (Q21) overall (red box), by country cluster (left of the dotted line) and by centre size in patients treated per year (right of the dotted line). Ten responses not associated to any cluster and 25 responses without an answer for the number of patients treated per year are only included in the “Overall” group. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) 28 J. Bertholet et al. Physics and Imaging in Radiation Oncology 19 (2021) 25–32 Table 3 more respondents noted an increase, rather than a decrease, in trust Changes in QA practice and time required to sterilise the linac room by country between team members (Fig. 2). For management MPs, responses indi­ cluster and overall. cated an increased feeling of team unity and trust in leadership. How­ By clustera A (N = B (N = C (N = Overall (N ever, for clinical MPs, the tendency was reversed. 214) 143) 44) = 411) Over 70% of respondents, over all professional groups, reported that Did you change patient specific working from home had become more acceptable and 48% reported that QA? (Q22) flexible working had become more acceptable. Forty percent of re­ No, we continued the same way 181 121 37 346 (84%) spondents reported the use of new online tools. Sixty-eight percent of (85%) (85%) (84%) respondents would like home-working to remain after the pandemic and Reduction of pre-treatment QA 15 (7%) 4 (3%) 2 (5%) 23 (6%) Reduction or stopped in-vivo 7 (3%) 3 (2%) 0 10 (2%) a slightly lower number believes that is likely (Fig. 3). Regarding clinical dosimetry (diodes) practice, there is some interest in keeping more hypofractionation after Increase use of EPID or other 7 (3%) 5 (3%) 1 15 (4%) the pandemic and a similar number said that is likely. Generally, wishes online in-vivo QA and likeliness for changes was evaluated slightly higher by management Increase use of remote 5 (2%) 2 (1%) 1 8 (2%) automatic PSQA MPs than by clinical MPs. Some respondents noted other things they Other 13 (6%) 8 (6%) 3 (7%) 24 (6%) would like to remain: paperless clinics (9), online meetings (6), flexible working (5) and more online conferences or exams (5). Few respondents Did you change the tests for treatment unit QA? (Q23/24) (45 overall, 11%) hope that no changes will remain after the pandemic. No, we did not change 176 111 33 326 (79%) The majority of respondents (83%) were not concerned about pres­ (82%) (78%) (75%) sure to keep changes made to cope with increased workload, but 48 Yes, we stopped yearly/ 12 (6%) 6 (4%) 4 (9%) 23 (6%) (12%) had concerns (14% of management, 12% of clinical MPs). Among quarterly tests these, 21 mentioned pressure for out-of-hours work (week-end, eve­ Yes, we reduced tests frequency 14 (7%) 12 4 (9%) 32 (8%) (8%) nings). Seven were concerned about increased workloads or less time/ Yes, we reduced the number of 14 (7%) 6 (4%) 0 22 (5%) staff for the same amount of work. tests Finally, other comments shared at the end of the survey generally Did you change the time for indicated a willingness to learn and reflect on the changes necessitated treatment unit QA? (Q25) by COVID-19. Some wrote that they were proud of their team and We kept the same machine QA 135 99 30 269 (65%) management and of how they had been well prepared. In contrast, slots (68%) (69%) (68%) others were disappointed in management and/or felt unheard. Uned­ We moved QA to a different slot 59 30 10 103 (25%) (28%) (21%) (23%) ited, anonymous comments are available in supplementary material A. Other 14 (7%) 4 (3%) 1 (2%) 20 (5%) IV. No response 6 (3%) 10 3 (7%) 19 (5%) (7%) 4. Discussion To compensate for the extra time needed to sterilise the We report on the experience of 433 MPs from 40 countries world­ linac room, after treating a wide during the early stage of the COVID-19 pandemic. Overall, they COVID patient, RT/MP services needed to (Q29): observed substantial changes in working situations and their in­ Extend working hours 28 34 4 (9%) 68 (17%) stitution’s clinical practice. Shift working with weekly alternation at- (13%) (24%) home/on-site with minimal contact and the use of PPE was frequently Reduce the number of patients 45 18 7 72 (18%) adopted to limit the infection risk for clinical MPs. treated (21%) (13%) (16%) No changes 99 73 26 203 (49%) Countries were grouped in clusters based on COVID-19 data up to (46%) (51%) (59%) April 12, 2020 [1] while responses were collected between June- Other (see text) 42 15 5 62 (15) September 2020. The cluster-based analysis may be biased with (20%) (10%) (11%) certain countries or centres being over-represented. Moreover, because Acronyms: EPID: electronic portal imaging device. the situation is highly dynamic, this survey should be considered a a 10 responses are not associated with any cluster (see supplementary material snapshot in time. Different pandemic stages have been identified as A.II). “early pandemic scenario” aiming for contingency standard of care and “late pandemic scenario” anticipating more drastic resource shortages 3.3. Morale and mental health and patient triage [19,20]. A-countries had typically reached the latter stage early, while C-countries mostly remained in the early stage at the This section is based on 410 responses. To keep the team united survey time and could learn from A-countries experience. This differ­ during the pandemic, 282 (69%) respondents used email, 199 (49%) ence in burden on healthcare systems was reflected in the department texting groups, 108 (26%) voice-only teleconference, 195 (48%) video- infection situation and organisation (Tables 1 and 2). A-respondents had conferencing, 143 (35%) communication and collaboration platforms, the highest numbers of infected staff or those staying away from the and 124 (30%) on-site face-to-face meetings. department and the most infected/suspected patients. They were also Additionally, 20 respondents reported virtual social interactions. most tested for COVID-19 but typically after the first peak, likely due to Fifteen respondents reported that staff had supported each other (as a shortage of tests early in the pandemic, e.g. as reported in Spain [9]. personal initiative). Four wrote that the lack of support had been hard on Conversely, B-respondents were more often tested at the crisis start or them, while seven indicated there was no need for any support. Eight peak (Table 1). Access to PPE at the first crisis peak for A-respondents people mentioned increased flexibility in working time, six that there was similar to other clusters. However, thirteen A-respondents reported was some kind of support, and six mentioned psychological support having no or insufficient hospital-provided PPE, consistent with re­ available at various levels. ported PPE shortages [2,3], while some B-respondents reported not needing PPE because contact could be avoided. Having little patient contact, MPs might have had low priority for PPE access despite the risk 3.4. Future impact of infection among colleagues. There was little difference in change of practice between clusters This section is based on 406 responses. Over all professional groups, (Fig. 1, Table 3). Nevertheless, the most common change, 29 J. Bertholet et al. Physics and Imaging in Radiation Oncology 19 (2021) 25–32 Fig. 2. Changes observed in working environment by professional group and overall. For a same colour, darker shades indicate an increase in unity/trust whereas a lighter shade indicates a decrease. Fig. 3. Changes in practice for the future that respondents wish to keep (in dark shades) and how likely they are to remain (light shades). Results are presented overall in the red box and for management and clinical MPs on the left and right of the dotted line respectively. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) implementation or increased use of hypofractionation (47% overall), planned hypofractionation implementation or paperless clinics, were was more predominant in cluster A (54%). The increase was markedly accelerated by the pandemic. more common in centres with large patient numbers and it has been Certain medical physics tasks can, in principle, be performed proposed extensively to reduce the patient presence in the hospital [12]. remotely (e.g. treatment planning) or on-site outside of treatment hours However, hypofractionation use is country-dependent [17,25] and for (e.g. machine QA) [14]. Indeed, remote planning access was already centres not yet applying it, implementation represents significant work, available before COVID-19 for about 40% of respondents. However, not easy to carry out under pressure [12]. Concerns around its level of 14% of A-respondents and 29% of B and C-respondents had not yet got evidence have also been raised which may have prevented wider remote planning access during COVID-19. Khan et al. claim that the bulk implementation [12,20]. Despite its advantages, hypofractionation may of planning and plan checking could be performed remotely without involve increased MPs workload, from PSQA, first fraction verification, quality loss [13], even if not supported by data. Although technically and initial replanning at implementation. Others reported that already feasible, it has a cost and may be complicated by cyber-security and 30 J. Bertholet et al. Physics and Imaging in Radiation Oncology 19 (2021) 25–32 data-privacy perspectives [26,27]. Adequate equipment (e.g. computer resource shortage are expected in the short term but should be based on hardware, fast internet connection) may be required for efficient and international consensus. comfortable home-working for MPs. A full health and safety assessment The challenge, looking ahead post-pandemic, is to optimize resource- for home-working environments should be considered, as Whitaker et al. use while maintaining treatment quality and safety and ensure an recommend [14], if it becomes routine practice. equitable workload and sustainable working conditions for all pro­ Concerning on-site QA tasks, 16% and 21% of respondents changed fessions. This task should include all stakeholders and further qualitative PSQA and reduced machine QA, respectively (Table 3). A quarter of assessment via focus groups and/or new surveys to capture the evolution respondents moved QA to different times, often weekend or evening. of clinical practice and COVID-19′ s long-lasting effects. As previous re­ These changes align with Khan et al. who reported prioritisation of QA ports considered the lessons learned from the oncologists [24] or RTTs tasks and moving QA to evenings/weekends or early morning before [18] perspective, we hope that this report can constitute a basis to start first patient [13]. However, it is necessary to establish clear guidelines this multi-disciplinary assessment from the medical physics perspective. prioritising QA tasks/test frequency in the case of resource shortage. In conclusion, MPs have reported a large impact of COVID-19 on Within the interdisciplinary team, the workload involved in hypo­ their work, depending on the number of daily infections in their country. fractionation implementation and PSQA should be accounted for when This caused changes in practice such as increased use/implementation recommending regimen alteration, especially in emergency situations. of hypofractionation and reorganisation of machine and patient-specific Multiple reports have warned of expected increased workloads post- QA. The impact of these changes on team unity and trust in leadership pandemic from deferred referrals and patient treatments [9,13,28,29]. has been perceived differently by management and clinical MPs. For MPs, postponed QA and equipment servicing may also contribute to Although some changes were welcomed, there were also personal sac­ substantial workload increases [13]. Among respondents, there was rifices. We hope this data will help reflect on the impact of this evolution clear interest in increasing working flexibility and home-working which on MPs for future crisis scenarios but also in regular practice. may help in handling this backlog [13]. Although some changes such as the implementation of hypofractionation and home-working were Declaration of Competing Interest welcomed, personal sacrifices were also reported. Twelve percent of respondents were concerned about pressure to maintain increased or The authors declare that they have no known competing financial out-of-hours workloads. Management MPs were as concerned as clinical interests or personal relationships that could have appeared to influence MPs, indicating that this pressure may come from higher in the the work reported in this paper. department or hospital management. Interestingly, respondents indicated overall that there had been Acknowledgement increased trust between team members (Fig. 2), but the tendencies regarding trust in leadership and team unity were reversed between We acknowledge all the respondents of the survey for their detailed management MPs (towards increased trust and unity) and clinical MPs answers and for openly sharing their experience. We thank the ESTRO (towards a decrease). This contradiction is concerning given that the office for technical support. perception of being valued by the supervisor was related to decreased burnout-risk among MPs [30] and trust in leadership rests on a fragile Appendix A. Supplementary data balance of mutual trust and transparent communication [31,32]. 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