Evolving practice in global healthcare: Remote physics support for low- and middle-income countries.

The COVID-19 pandemic has disrupted traditional onsite support for radiotherapy clinics in low- and middle-income countries (LMIC). Clinics there have struggled to commission new techniques and receive onsite training for their staff. We sought to evaluate whether an offsite approach could fill this gap at a clinic in Jordan by requesting a clinical audit and attempting to commission volumetric modulated arc therapy (VMAT). Over 13 months, a consultant provided remote support for a radiotherapy center that had already obtained treatment equipment and licenses. The consultant began by conducting a virtual audit, using a remote login to the center's R&V and TPS, to identify any gaps in the clinical workflow. Suggestions for improving the clinical workflow were proposed, and change implementation was tracked through emails, social media apps, and video conferencing. An extensive table outlined the commissioning process, including all measurements to be done. Social media apps and shared documents were used to track measurements and analysis. The lack of person-to-person interaction in this new remote-support ecosystem created conflicts; we have highlighted some of these, as well as their resolution and the lessons learned from them. The virtual audit identified gaps categorized as machine QA, treatment plan review, and treatment delivery processes. Following the implementation of the proposals, motion management was added, and machine QA became more comprehensive. VMAT was commissioned using the reports of the AAPM and the IAEA. The main challenges for remote support were time difference, establishing an appropriate form and frequency of communication, tone of voice used in messages, and buy-in from local staff. This evolving practice will enable medical physicists to use modern, multimodal remote communication pathways to effectively transfer knowledge to centers in LMICs. The audit-proposal-improvement pathway for remote support can be incorporated to help others while avoiding the pitfalls we faced.