Letter Postgraduate Training in a Low- and Middle-income Country: Sharing Experience from a Joint Commission International Accreditation-accredited University Hospital Madam d Our team of residents and faculty of radiation oncology, Aga Khan University, read the article published in your journal with interest [1]. Pakistan, like other low- and middle-income (LMI) countries, needs modern equipment and trained pro- fessionals [2]. We are working in a tertiary referral university hospital and our programme is regularly reviewed by internal and external audit systems, including the Joint Commission In- ternational Accreditation (JCIA). We are continuously taking steps through audits for training evaluation [3]. Radiation oncology is a quality conscious discipline. Doctors, physicists and radiation therapy technologists (RTT) are integral and crucial components of this service. However, like many countries, in Pakistan they are not getting the deserved recognition as health care providers. In the absence of robust regulatory systems pertaining to continuing medical education and practice privilege docu- mentation, we strongly recommend peer-reviewed, site- specialised practice [4]. We involve our postgraduates in quality initiatives, like clinical quality indicators, and they are active participants of site-specific tumour boards [5]. We believe and work on pre-defined learning objectives, which are helping us to achieve international postgraduate training standards. We have developed our syllabus as recommended by the In- ternational Atomic Energy Agency for LMI countries [6]. We are carrying out end of term briefing sessions to review the progress of structured training. In order to overcome a shortage of qualified teachers in our country, monthly activities are organised for all trainees in the city, in which learning objective-based interactive learning sessions are conducted by qualified faculty of ra- diation (oncologist/physicist) on a voluntary basis. This strategy is also helping us to develop collegiality among colleagues of other cancer units. Regular web-based ses- sions from qualified foreign consultants are also part of this activity. We have also developed training programmes for the training of physicists and RTTs. In our opinion, radiation oncology is mainly based on the expertise of three personnel: oncologists, physicists and RTTs. Although a lack of equipment is evident, without the expertise of these three professionals, even the availability of machines cannot benefit the patients. The inclusion of quality and ethical practice should be considered as an in- tegral part of structured curriculum. Thus, training is of critical importance and constant efforts are required in or- der to improve cancer services in LMI countries. M.U. Karim*, A. Nadeem Abbasi, N. Ali, A. Hafiz, B.M. Qureshi, B. Mir Section Radiation Oncology, Department of Oncology, Aga Khan University Hospital, Karachi, Pakistan * Author for correspondence. E-mail address: karim_mk31@hotmail.com References [1] Eriksen JG. Postgraduate education in radiation oncology in low- and middle-income countries. Clin Oncol 2017;29(2): 129e134. [2] Nadeem Abbasi A, Muhammad W, Hussain A. Implementation of quality medical physics training in a low-middle income countrydsharing experience from a tertiary care JCIA- accredited university hospital. J Appl Clin Med Phys 2016; 17(6):454e456. [3] http://www.jointcommissioninternational.org/about-jci/jci- accredited-organizations/?c¼Pakistan. [4] Abbasi AN, Karim MU, Qureshi BM, Hafiz A, Ali N. Comment on: Are we training the next generation of proficient radiation oncologists, or just better examination candidates? J Med Im- aging Radiat Oncol 2017;61(1):156. [5] Abbasi AN. Cancer management is a multidisciplinary team work. J Coll Physicians Surg Pak 2011;21:259e261 . [6] https://www.iaea.org/newscenter/news/syllabus-developed- radiation-oncologists. Contents lists available at ScienceDirect Clinical Oncology journal homepage: www.clinicaloncologyonline.net http://dx.doi.org/10.1016/j.clon.2017.05.006 0936-6555/Ó 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. Clinical Oncology xxx (2017) 1 Please cite this article in press as: Karim MU, et al., Postgraduate Training in a Low- and Middle-income Country: Sharing Experience from a Joint Commission International Accreditation-accredited University Hospital, Clinical Oncology (2017), http://dx.doi.org/10.1016/j.clon.2017.05.006