An International Perspective on the Medical Physicist and Radiation Therapist Workforce:

In 2015, the Lancet Oncology Commission published “Expanding Global Access to Radiotherapy.”¹ With the issue, it stated that “Radiotherapy is a critical and inseparable component of comprehensive cancer treatment ... [and that] … worldwide access to radiotherapy is unacceptably low.” Workforce deficit was identified as one barrier to the use of radiation therapy. The Commission made an urgent call to recruit and train specialized professionals across the radiation oncology (RO) disciplines. They also recommended population-based benchmarks of one RO medical physicist (MP) per 300-500 people and one radiation therapist (RT) for 100-150 people.

Nine years on, this article explores the changing workforce landscape as it relates to MPs and RTs in parts of the world outside North America. In examining the topic through a global lens, we cannot provide a comprehensive review of the workforce across individual jurisdictions and countries. Rather we hope to provide food for thought around the impact on workforce and training driven by evolving radiation therapy technologies and RO evidence-base, as well as adaptations to the education environment and professional scope of practice, to name just a few developments in our field. We highlight the evidence and provide illustrative examples from both professions and from diverse parts of the world, in particular, those familiar to our global authorship panel. We discuss ongoing challenges and potential solutions.

Developments influencing our workforce

Several key trends affect the entire RO workforce, maybe especially so for MPs and RTs. Increasing automation of labor-intensive tasks, including contouring, planning and treatment verification, can improve workflow and substantially decrease workforce demands.² This automation, increasingly underpinned by artificial intelligence (AI), can increase consistency and help eliminate human error. However, ever advancing technology also increases complexity and requirements for equipment commissioning, quality assurance and risk analysis to ensure safe clinical use. Staff need to be equipped with knowledge in computing/AI to maximize benefits from these advances. Achieving this goal requires a well-structured curriculum and additional training.³ Professor Sandra Turner is a Radiation Oncologist at the Sydney West Radiation Oncology Network and Clinical Professor at the University of Sydney, Australia. She is Clinical Lead of Professional Development across the Western Sydney Local Health District and has strong interests in medical education and radiation therapy advocacy.

Global connectivity through virtual platforms, often incorporating AI, can also improve access to and standardization/quality of education and training required of the modern MP and RT workforce. The COVID-19 pandemic brought a paradigm shift in education, making remote learning vastly more accessible.^{4, 5} The imperative for virtual training brought with it more sophisticated learning platforms, and accelerated attempts to deliver online education at scale.

The global evidence-based movement toward moderate- and ultra-hypofractionation for many cancers provides an opportunity to alleviate workforce (and patient) burden by reducing average treatment visits. In turn, this may allow patients greater access to radiation therapy services and reduced health care costs. However, treatment accuracy requirements for higher dose per fraction treatments increases workforce competency and technology requirements. Where feasible, the benefits of these technologies should be embraced.

A global snapshot of radiation therapist and medical physics workforce issues

Workforce shortages for RTs are reported in high- and low- to middle-income countries alike.⁶ Workforce gaps can be directly attributed to a deficit in educational programs for RTs in many regions.⁷ In the Asia Pacific, a paucity of educational experts to teach RTs exists.⁸ In Sub-Saharan Africa, the RT workforce is so heavily depleted that a >200% increase is needed if cancer patients are to access RT in facilities with functioning equipment.⁹ Many African countries have no radiation therapy facilities at all or equipment lies dormant due to workforce gaps. For example, in Nigeria, equipment is being purchased and new centers are opening despite there being no national RT training program.

In Western Europe, many RTs are leaving the profession due to limited opportunities for career advancement.¹⁰ Out-of-date pay structures, limited career pathways, inadequate training positions and low remuneration are leading to low recruitment, career dissatisfaction, RT staff shortages and loss of staff even in high income countries such as Australia, New Zealand and Ireland.

For MPs, the field presents a diverse and dynamic landscape, reflecting different regions’ varied health care systems, economic resources, educational structures and available technologies. As the demand for MPs continues to rise, particularly for RO MPs, there are also significant workforce challenges, alongside opportunities for growth and development.

Across Asia for example, the quality, length and content of postgraduate MP training programs vary significantly.¹¹ As a result, major differences are seen in the qualifications and accreditation arrangements for MPs. To illustrate this point, in Indonesia for instance, there are two discrete levels of MPs, “Associate MP” and “Clinically Qualified MP” (CQMP). Associate MPs play a limited role, e.g., relating to simple equipment/techniques. A CQMP must be present for the use of advanced techniques and devices.¹²

Scope of practice and training variations affect both professional groups. In some countries, including in Europe and Asia, RTs are not (or have only very recently been) given status as a recognized profession. In other, even high-income countries, RTs do not treat patients, this role being substituted by nurses or generic “radiographers” with limited specific expertise. RT practice scope also varies widely from either a planning/dosimetrist role, or a patient treatment role, or both roles combined. In the latter case, frequent rotations between planning/dosimetrist and machine roles may impact growth in expertise in complex planning tasks, for example, as well as job satisfaction through attaining subspecialty roles.

Similarly, scarcity of trained dosimetrists, or RTs competent in planning, impacts heavily on the MPs’ role and patient throughput. In Malaysia for example, MPs are still in charge of all treatment planning creating a huge burden on their workforce compared to other regions.^{13, 14}

Improving training quality and workforce retention

The many variations described above underscore the importance of attempts to standardize education, training and accreditation activities to ensure consistent quality and competency among graduates in both professions. Education focusing on enhancing leadership capability of all RO professionals fosters confidence in championing positive change across the world.¹⁵

There are numerous organizations and collaborations worldwide working to support RT and MP education and practice quality. For MPs, the International Organization for Medical Physics provides a pathway for programs to seek accreditation and ensure recommended standards are met. In European Union (EU) countries guidelines are being developed (under EU-REST) to address inconsistencies in recognition and training of MPs.¹⁶

The International Atomic Energy Agency (IAEA) has a strong focus on closing the education gap for RTs and MPs especially among lower- and middle-income countries. The IAEA supports education and training of RTs and MPs through fellowships, curriculum development, workshops, and virtual education platforms including real-time virtual tumor boards and conference streaming. Initiatives include AMPLE (Advanced Medical Physics Learning Environment), AFRONET (African RO Network tumor board),¹⁷and APRONET (Asia Pacific RO Network). Global competency-based certification of education may alleviate the shortage of trained RO professionals, however, systematic implementation on the ground remains a challenge.

Efforts to enhance career progression pathways and specialist RT roles in some regions go some way to ensuring workforce remain engaged and appropriately remunerated. In Western Europe for example, there is the opportunity for Ministries of Health to sanction advanced and consultant RT practitioner roles. These have been proven to improve job satisfaction and workforce efficiency.¹⁸ Recruitment ventures aimed at high schools and universities will remain important to increase awareness of these specialized health professional roles.

Take home messages

There is no doubt that the MP and RT workforces are under strain across much of the world. Efforts to catch up and keep pace of workforce requirements will remain a constant challenge as radiation therapy utilization escalates in line with global cancer cases. Being smart and agile in sharing education opportunities and international collaborations to recognize commonalities and prevent redundancy will be vital. Clearly training will continue to require tailoring to local needs. Taking advantage of developments in our field that have potential to reduce workforce burden, improve training and create efficiencies will be paramount. All the while, our goal will remain to optimize patients’ access to high-quality modern radiation therapy.

Acknowledgement - thanks to Helen Ball for her background research in writing this article.