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Medical dosimetrists’ perception about the impact of remote treatment planning on

communication and efficiency during the COVID-19 pandemic
Haley Lowe, CMD; Sara Muellerleile, CMD; Scott Stallard, CMD; Nishele Lenards, PhD, CMD,
RT(R)(T), FAAMD; Ashley Hunzeker, MS, CMD; Ashley Fellows, MS, CMD
Medical Dosimetry Program at University of Wisconsin, La Crosse, WI
Abstract
Historically, the medical dosimetry profession has been performed primarily with an in-
clinic setting model promoting communication and efficiency of dosimetry job tasks. However,
the COVID-19 pandemic caused the job to abruptly change to a largely remote treatment
planning environment requiring medical dosimetrists to shift their workflows while trying
to maintain treatment plan quality and safe practices. Researchers developed a fifteen-question
survey that was emailed to certified medical dosimetrists (CMDs) that evaluated the impact
COVID-19 had on communication and efficiently with remote treatment planning. The results
illustrated a shift of CMDs working remotely, with 13.6% (26/190) working remotely prior to
COVID-19 to 77.9% (148/190) after the onset of the pandemic. Seventy-two percent (102/140)
of survey participants did not believe that working remotely caused an increase in re-work due to
breakdowns/limitations in communication, and 42.22% (76/180) stated there was no specific
hindrances to efficiency in remote treatment planning. The nature of the remote treatment
planning shift caused the radiation oncology team to adapt in order to maintain open lines of
communication and provide high quality patient care. Most medical dosimetrists perceived
remote treatment planning to not be a hindrance in efficiency, and was often helpful as there
were less interruptions and more flexibility with remote treatment planning.
Keywords: Remote treatment planning, communication, efficiency, COVID-19, medical
dosimetry
Introduction
The novel coronavirus, COVID-19 was declared a pandemic by the World Health
Organization in March of 2020 causing substantial changes in how the United States operates
and businesses are run. Hospitals and clinics began limiting the number of people going in and
out to mitigate the spread of COVID-19. Society was faced with self-isolation, quarantining, and
social distancing “rules” during this time, and for months to come. While there were not specific
guidelines to follow, a multidisciplinary team in the radiation oncology community convened
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virtually to establish a consensus on next steps regarding radiation therapy treatment during the
early stages of the pandemic. The guidelines regarding staffing were as follows: working
remotely is encouraged – even when it is not medically necessary. 1 Some solutions to reduce on-
site patient-staff interactions included an increase in telehealth consultations and off-site
treatment planning.2 Many cancer centers began remote treatment planning full time; thus,
requiring medical dosimetrists to work from their homes.
At the beginning of the pandemic, Riegel et al3 focused on evaluating the effectiveness
and preparedness of the medical physics and medical dosimetry staff at their clinic. Researchers
found that the medical physics and medical dosimetry groups were able to successfully maintain
high-quality and efficient care for patients while primarily working remotely to minimize risk
and exposure to the coronavirus. The internal study of medical physics and dosimetry stated that
83% found the transition to remote work to be neutral, somewhat easy, or very easy. 3
Additionally 71% of the respondents reported that they were more or just as efficient working
remotely as on site.3
The transition for a majority of medical dosimetrists to work from home was a relatively
sudden shift and change in workflow due to the COVID-19 pandemic. Processes, workflow, and
normal clinic practices have changed substantially, specifically with communication amongst the
radiation oncology team. Departments were required to adapt quickly to provide continued high
quality and efficient care to their patients. A 2020 Radiation Oncology Incident Learning System
(ROILS) report indicated that approximately 1/3 of reported safety events were in direct relation
to treatment planning and, in the midst of the COVID-19 pandemic, a 5% increase in reported
safety compared to 2019 (pre-pandemic).4 Communication has a direct impact on efficiency and
it is probable that these work-flows changed from in-clinic to working remotely. Thus,
communication and efficient workflow amongst team members is of the utmost importance when
treatment planning remotely. With the lack of research regarding the effects of the pandemic on
treatment planning, it is unclear how medical dosimetrists are communicating with other team
members to ensure timely and safe practices.
The problem is that treatment planning was primarily performed in-clinic, but the
COVID-19 pandemic caused the job to suddenly change to a remote treatment planning process
requiring medical dosimetrists to work from home. The pandemic forced many radiation
oncology departments to shift their workflow substantially, while trying to maintain treatment
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plan quality and safe practices. Therefore, the purpose of this study was to investigate
perceptions of medical dosimetrists about the impact of remote treatment planning on
communication and efficiency during the COVID-19 pandemic. Researchers sought to answer:
(Q1) What impact did remote treatment planning have on communication during the COVID-19
pandemic and (Q2) What impact did remote treatment planning have on efficiency during the
COVID-19 pandemic?
Materials and Methods
Instrumentation
A 15-question survey was developed to evaluate perceptions about the impact of remote
treatment planning on communication and efficiency during the COVID-19 pandemic. The
questions were categorized into 4 groups: screening, communication, efficiency, and
demographics. The questions on the survey were designed to answer the study research
questions: (Q1) What impact does remote treatment planning have on communication during the
COVID-19 pandemic, and (Q2) What impact did remote treatment planning have on efficiency
during the COVID-19 pandemic. The institutional review board (IRB) at the University of
Wisconsin – La Crosse reviewed the project and survey, and was deemed exempt prior to survey
distribution.
Study Validation and Participant Selection
The survey was sent to 10 certified medical dosimetrists (CMDs) as a pilot study as a
measure of validating the study. The pilot study participants were from a variety of clinics across
the country, and of varying ages and experience levels. The results of the pilot survey allowed
the researchers to evaluate the strengths and weaknesses of the survey and correct for any
mistakes prior to distribution. The survey was distributed for participation through the American
Association of Medical Dosimetrists (AAMD) to ‘Full CMD Members’ (n=2600) in an email
sent on August 9, 2021. It was also posted to social media in the ‘AAMD Facebook Group’ to
encourage and promote participation. The survey was active for 2 weeks with a deadline of
August 22, 2021.
Data Collection and Statistical Analyses
The survey was designed using the Qualtrics software program, then distributed to CMDs
through the AAMD. The Qualtrics software provided descriptive statistics for data collection and
allowed researchers to look for statistical relationships between responses to survey questions. A
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Chi-squared statistical analysis was performed to look at the statistical relationships and
association between survey questions and the demographics of the medical dosimetrists.
Results
The response rate of survey completion was 7.3% (190/2600). Prior to the COVID-19
pandemic, 86.32% (164/190) of the participants worked completely on-site, 3.16% (6/190)
worked remotely, and 10.53% (20/190) worked a combination of onsite and remote. After the
onset of COVID-19, the work setting shifted to 22.11% (42/190) on-site, 23.16% (44/190)
remote, and 54.74% (104/190) worked both on-site and remotely.
Medical dosimetrists were asked about their perception of re-work due to limitations and
breakdowns in communication. Results showed that 72.86% (102/140) disagreed with the
statement there was an increase in re-work due to limitations or breakdowns in communication
between remote workers and the rest of the oncology team, while only 10.72% (15/140) agreed
with the statement (Figure 1).
A Chi-squared analysis was performed to determine if a particular age group, experience
level, or type of radiation oncology clinic had a higher or lower association with the statement
about re-work. The test was conducted with a three-by-three contingency table for each
demographic; with a null hypothesis that the 2 categories were independent. In evaluating the
association with age range, years of treatment planning experience, and type of clinic, the chi-
squared test statistic was 3.495 (P-value=0.484), 4.200 (P-value=0.380), and 5.964 (P-
value=0.202) respectively; therefore, no association was discovered.
Due to the nature of the sudden shift in work settings, researchers evaluated changes in
communication processes. The majority of participants, 73.57% (103/140), stated that they
experienced some or significant changes to the communication processes, whereas 26.42%
(37/140) of the participants had no changes in the communication processes. Participants were
asked about the most effective forms of communication to connect with the radiation oncology
team. The varied responses included: email (125/601), phone call (125/601), text messaging
(120/601), employer software application (42/601), screen sharing (89/601), and
carepaths/quality check lists (QCL’s)/digital whiteboards (75/601). Additionally, 42.18%
(62/147) of participants indicated that new policies were implemented at their radiation oncology
clinics specific to how communication occurs, and 27.21% (40/147) of the survey responses
stated that there was an addition of meetings or rounds to assure adequate communication
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amongst the team. When asked about the implementation of new workflow technology, 18.37%
(27/147) of the participants stated there was new technology, such as carepaths in Aria, QCL’s in
Mosaiq, or digital whiteboards to accommodate remote treatment planning.
Researchers also aimed to evaluate the efficiency of treatment planning in a remote
working environment and if there were specific factors that either hindered or aided the
efficiency of remote treatment planning. In the survey, 42.22% (76/180), responded that there
were no specific hindrances to remote treatment planning. The other hindrances to efficiency that
medical dosimetrists experience with remote treatment planning are as follows: a breakdown or
lag time in communication (18%, 32/180), the availability or speed of technology (23%, 42/180),
interruptions (6%, 10/180), and lack of focus (5%, 9/180) (Figure 2). Participants were asked
about factors that aided in the efficiency of treatment planning when working remotely and
responded with flexibility in work hours (62%, 111/180), less interruptions (57%, 102/180),
better focus (48%, 86/180), increased communication connectivity outside of in-person
communication (38%, 68/180), and better technology available at home (16%, 29/180) (Figure
3). Only 3.33% (6/180) of the participants indicated that there were no specific aids to efficiency
while remote planning (Figure 3).
Discussion
Due to the COVID-19 pandemic the medical dosimetry profession shifted from a
predominately on-site work environment to a remote work environment. Results indicated that
approximately 75% of medical dosimetrists did not think that working remotely caused an
increase in re-work due to breakdowns and limitations in communication. One potential
explanation to this result is that the unique communication challenges that arose with remote
planning were combatted with exceptional teamwork, understanding and agility as described by
Anderson et al.5 Communication shifted and medical dosimetrists relied on numerous forms of
communication to work with the radiation oncology team, such as phone calls, workplace chats,
screen sharing, teleconferencing, and email. Additionally, survey responses indicated that teams
had to change policies based on the way communication occurred and some required
supplemental communications such as meetings or rounds. The Peter MacCallum Cancer Centre
in Australia implemented bi-daily huddles to aid in the communication with the ‘work from
home’ members of the team.5 Previous research has shown that radiation oncology clinics can
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thrive with remote treatment planning as long as there is a focus on maintaining open lines of
communication.5
With regard to efficiency, most of the participants agreed that working remotely
permitted less interruptions (57%) and better focus (48%) on treatment planning compared to
working on-site. Oftentimes, on-site medical dosimetrists are interrupted from treatment
planning to participate in CT Simulations, evaluate treatment setups and immobilization devices,
help with moving a patient, or general day-to-day tasks. 6 Of those that were surveyed,
approximately 27% noted that flexibility in work hours aided in efficiency of treatment planning.
Additionally, several of the participants noted the lack of commute time while working remotely
allowed for more time to be spent on treatment planning.
In radiation oncology there is a push to increase efficiency of patient care while also
improving the quality; therefore, value in evaluating the efficiencies and inefficiencies within the
treatment planning process.7 Researchers also evaluated hindrances to efficiency with remote
treatment planning. While 42% of participants did not agree that working remotely was a
hindrance to the efficiency of treatment planning, a hindrance that was noted was the lack of
availability or speed of technology (23%) when working remotely. The remote work
environment allowed for less interruptions (57%) and better focus (48%) of the medical
dosimetrist. As noted in Blumberg et al8, the physical environment (improved lighting, reduction
in noise, etc.) can increase the safety of treatment planning. Work environment, whether remote
or on-site plays a role in how efficiently one is able to adequately complete a job.
Conclusion
The purpose of this study was to investigate perceptions of medical dosimetrists about the
impact of remote treatment planning on communication and efficiency during the COVID-19
pandemic. This pandemic introduced the onset of predominantly remote treatment planning in
the medical dosimetry profession. Transitioning to a remote work environment, medical
dosimetrists adapted to changes in communication. Since in-person communication amongst the
radiation oncology team became more limited, communication processes shifted for the majority
of the respondents and almost half of participants indicated that new policies regarding
communication were implemented in their clinics. Nearly half of participants disagreed that
working remotely had any hindrances to the efficiency of treatment planning. Participants agreed
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that, while working remotely, there were less interruptions which resulted in better focus on
treatment planning.
A limitation of the study is that only AAMD ‘Full CMD’ members were invited to
participate in the study and resulted in a low response rate to the survey. Further research could
include a larger population and an increase in respondents. Another possibility for further
research could include evaluating how other members of the radiation oncology team perceived
communication and efficiency changes during the pandemic. Finally, additional research could
be carried out to determine if working remotely is sustainable for medical dosimetrists post-
pandemic.
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Acknowledgements
We would like to acknowledge University of Wisconsin – La Crosse Statistical
Consulting Center and Dr. Elfessi for assisting with the statistical analyses of data. However, any
errors in statistics or interpretation of the data are the sole responsibility of the authors.
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References
1. Simcock R, Thomas TV, Estes C, et al. COVID-19: Global radiation oncology's targeted
response for pandemic preparedness. Clin Transl Radiat Oncol. 2020; 20:55-68.
http://doi.org/10.1016/j.ctro.2020.03.009.
2. Horsely PJ, Back M, Lamoury G, Porter B, Booth J, Eade TN. Radiation Oncology during
Covid-19: Strategies to avoid compromised care. Asia Pac J Clin Oncol. 2021 Feb;17(1):24-
28. doi: 10.1111/ajco.13456.
3. Riegel AC, Chou H, Baker J, Antone J, Potters L, Yijian C. Development and execution of a
pandemic preparedness plan: Therapeutic medical physics and radiation dosimetry during the
COVID-19 crisis. J Appl Clin Med Phys. 2020;21(9):259-265.
http://doi.org/10.1002/acm2.12971.
4. American Society for Radiation Oncology. Radiation oncology incident learning system:
aggregate data report quarter 4, 2020: Patient Safety Work Product.
http://www.astro.org/ASTRO/media/ASTRO/Patient%20Care%20and%20Research/P
DFs/ROILS_2020_Q4.pdf. Updated 2021. Accessed May 1, 2021.
5. Anderson N, Thompson K, et al. Planning for a pandemic: Mitigating risk to radiation
therapy service delivery in the Covid-19 era. J Med Radiat Sci. 2020 Sep;67(3):243-248. doi:
10.1002/jmrs.406.
6. AAMD. General Job Description. April, 2020. Accessed November 9,
2021. https://www.medicaldosimetry.org/about/job-description/.
7. Batumalai V, Jameson MG, et al. Cautiously Optimistic: A survey of radiation oncology
professionals’ perceptions of automation in radiotherapy planning. Tech Innov Patient
Support Radiat Oncol. 2020 Nov 17;16:58-64. doi: 10.1016/j.tipsro.2020.10.003.
8. Blumberg AL, Burns RA, Cagle SW, et al. Safety Is No Accident: A framework for quality
radiation oncology care. American Society for Radiation Oncology; 2012.
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Figures

2.86%
7.86%

16.43%

54.29%

18.57%

significantly agree somewhat agree neither agree or disagree

somewhat disagree significantly disagree

Figure 1. Results from survey question #5: state your level of agreement—there was an increase
in re-work due to limitations or breakdowns in communication between remote workers and the
rest of the oncology team.

No specific hindrances to efficiency

76
while remote planning

Other, please explain 12

Lack of focus 9

Interruptions 10

Avaliability or speed of technology 41

Breakdown or lag time in communication 32

0 10 20 30 40 50 60 70 80

Figure 2. Results from survey question #8: please identify hindrances to efficiency of remote
treatment planning (choose all that apply).
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No specific aids to efficiency while remote

planning 6
Other, please explain
17
Better focus
86
Less interruptions
102
Better technology at home
29
Increased communication connectivity
outside of in-person (i.e. text/email) 68
Flexibility in work hours (completing work
at times ideal to the dosimetrist) 111

0 20 40 60 80 100 120
Figure 3. Results from survey question #10: please identify aids to efficiency of remote
treatment planning (choose all that apply).
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Appendix A

Survey on Communication and Efficiency During COVID-19 in Medical Dosimetry

Introduction

Medical Dosimetry Professional,

The purpose of our research is to investigate perceptions of medical dosimetrists about

the impact of remote treatment planning on communication and efficiency during the
COVID-19 pandemic.

This survey is composed of multiple choice and ranking order questions that should take
<5 minutes.

Thank you for taking the time to participate in this short but valuable survey.

Screening Questions

1) Prior to the Covid-19 pandemic (March 2020), specify your work setting.

a. Worked completely on site

b. Worked completely remote

c. Worked a combination of on site and remote

2) After the Covid-19 pandemic (March 2020), specify your work setting.

a. Worked completely remote

b. Worked completely on site

c. Worked a combination of on site and remote

(Q1) What impact did remote treatment planning have on communication during the
COVID-19 pandemic?

3) What forms of communication were effective in connecting with your radiation

oncology team while working remotely during the pandemic? (Choose all that apply)

a. Email

b. Phone call

c. Text
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d. Employer app

e. Screen share, GoToMeeting, etc.

f. Carepath, QCL, digital whiteboard etc.

g. Other (please specify)

4) Please rank the previously selected methods of communication from most (1) to least
effective below. (use the drag and drop feature to order your choices)

a. Options here will only be those that were selected from Q3 with drag and drop
feature to order the choices

5) State your level of agreement: There was an increase in re-work due to limitations or
breakdowns in communication between remote workers and the rest of the oncology
team.

a. Significantly agree

b. Somewhat agree

c. Neither agree nor disagree

d. Somewhat disagree

e. Significantly disagree

6) State the level of changes in communication processes since the start of the COVID-19
pandemic (March 2020) due to increased remote treatment planners.

a. There were significant changes

b. There were some changes

c. There were no changes to the communication processes already in place

7) Please identify the changes made to communication processes to accommodate for

remote treatment planners. (Choose all that apply)

a. Implementation of new workflow software/technology (carepath, QCL, digital

whiteboard, etc.)

b. New policies related specifically to how communication occurs (email, phone,

GoToMeeting/screen share, etc.)
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c. Addition of meetings or rounds to ensure adequate communication amongst

team members

d. Other (please specify)

(Q2) What impact did remote treatment planning have on efficiency during the COVID-
19 pandemic?

8) Please identify hindrances to efficiency of remote treatment planning. (Choose all that
apply)

a. Breakdown or lag time in communication

b. Availability or speed of technology

c. Interruptions

d. Lack of focus

e. Other, please explain (text box)

f. No specific hindrances to efficiency while remote planning

9) Please rank the previously selected methods of efficiency of remote planning from
most (1) to least effective below. (use the drag and drop feature to order your choices)

a. Only options selected from question 8 will be available. Drag and drop feature
to order choices. Question is skipped if option “f” was chosen in Q8.

10) Please identify aids to efficiency of remote treatment planning. (Choose all that
apply)

a. Flexibility in work hours (completing work at times ideal to the dosimetrist)

b. Increased communication connectivity outside of in-person (i.e., text/email)

c. Better technology at home

d. Less interruptions

e. Better focus

f. Other, please explain (text box)

g. No specific aids to efficiency while remote planning

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11) Please rank the previously selected aids in efficiency of remote planning from most
(1) to least effective below. (use the drag and drop feature to order your choices)

a. Only options selected from question 10 will be available. Drag and drop feature
to order choices. Question is skipped if option “g” was chosen in Q10.

12) The efficiency of daily medical dosimetry tasks with remote planning (compared to
working on-site) is...

a. Significantly more productive

b. Somewhat more productive

c. The same

d. Somewhat less productive

e. Significantly less productive

Demographic Questions

13) Identify your age range.

a. 20-29

b. 30-39

c. 40-49

d. 50-59

e. 60+

14) How many years of treatment planning experience do you have?

a. 1-5 years

b. 6-10 years

c. 11-15 years

d. 16-20 years

e. 21 years +

15) What type of clinic are you employed with?

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a. Academic Center

b. Community Hospital

c. Private Practice

d. Industry

Closing statement

We thank you for your time spent taking this survey. Your response has been recorded.