The introduction of positron emission tomography/computed tomography (CT), single photon-emission CT/CT, and software packages for multimodality imaging has accelerated the need for nuclear medicine physicians to obtain more training in cross-sectional imaging, especially in CT. In recent years, the Nuclear Regulatory Commission, the Accreditation Council for Graduate Medical Education, the American Board of Radiology, and the American Board of Nuclear Medicine have promulgated new rules and regulations. In addition, the Society of Nuclear Medicine, the American College of Radiology, and the American College of Cardiology Foundation have crafted new guidelines and training requirements. All these changes have consequences for the education of physicians in nuclear medicine. Self-referral and concerns about radiation exposure from nuclear medicine examinations and CT are also affecting the education of physicians practicing nuclear medicine. The authors examine the impact of these developments on training and certification in nuclear medicine and suggest another pathway to train some nuclear medicine physicians.
Computed tomography (CT) has excellent spatial resolution but is not always a good predictor of tissue behavior. For many tumors, whole-body positron emission tomography (PET) has several advantages over regional CT, including illustrating areas of pathology on the basis of abnormal metabolism before a lesion is evident anatomically, better staging, quicker assessment of the response to therapy, and imaging the whole body to discover areas where abnormalities were unexpected. With PET, it is often possible to predict if an enlarged node is likely to contain a significant number of malignant cells within it or to be a benign node or a node that has had the malignant cells within it destroyed by therapy. Combined modalities such as PET/CT and single photon-emission CT (SPECT)/CT have resulted in better diagnostic tools than each modality alone because there is better anatomic localization and accuracy of diagnosis. Other uses of 2-[ 18 F]fluoro-2-deoxyglucose PET/CT include evaluating a solitary pulmonary nodule, radiation therapy planning, infection or inflammation studies, cardiac imaging, predicting the response of tumors to chemotherapy, and neurologic imaging ( ).
PET/CT is currently one of the fastest growing imaging techniques. Furthermore, there are numerous radiopharmaceuticals other than 2-[ 18 F]fluoro-2-deoxyglucose that can be used in PET ( ). It is believed that there will soon be commercially available PET/magnetic resonance (MR) units ( ). Images of the brain using simultaneous PET/MR have been produced ( ). Many believe that there is tremendous potential for PET/MR ( ). Even if this expected development does not find widespread application, the growth of MR alone, and multimodality fusion software, will stimulate more study of MR by nuclear medicine physicians in the future. Instrumentation and software advances will require that nuclear medicine physicians learn more about cross-sectional imaging and that radiologists learn more about nuclear medicine ( ).
Board and Accreditation Council for Graduate Medical Education requirements
Changes by the Nuclear Medicine Residency Review Committee that became effective in July 2007 included a requirement that, for those who are doing 2- or 3-year residencies in nuclear medicine, there be “a minimum of 4 months of CT experience that may be combined with a rotation that includes PET-CT or SPECT-CT, although rotation on a CT service is desirable for part of the training.” Those who have already fulfilled the requirements of a radiology residency are excused from this requirement ( ). For a nuclear medicine resident to have a dedicated rotation in CT will require cooperation from the radiology department of his or her program’s institution ( ). In the coming years, there will be a need to require more training in molecular imaging, both clinically and in research ( ).
Completing a nuclear radiology fellowship program is no longer sufficient for eligibility for taking the American Board of Nuclear Medicine (ABNM) examination, unless the nuclear radiology program is also certified as a nuclear medicine residency program. This is because of the different requirements of nuclear radiology and nuclear medicine residency programs in therapy ( ).
There is a rarely used pathway to ABNM eligibility with the American Board of Internal Medicine. For this, a candidate must take 2.5 years of internal medicine and 1.5 years of nuclear medicine and obtain preapproval from the ABNM ( ).
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Professional society influences on Nuclear Medicine education
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
The impact of the Nuclear Regulatory Commission on Nuclear Medicine education
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Table 1
Code of Federal Regulations, Title 10, Sections Defining Training Requirements for the Medical Use of Byproduct Material
Section ⁎ Description 35.190 Uptake and dilution studies (nonimaging procedures) 35.290 Diagnostic imaging (general nuclear medicine and positron emission tomography) 35.390 Therapeutic procedures (includes 35.392, 35.394, and 35.396) 35.392 Oral 131 I therapy ≤1.22 GBq (33 mCi) 35.394 Oral 131 I therapy >1.22 GBq (33 mCi) 35.396 Parenteral radioisotope therapy 35.490 Radiation therapy
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Table 2
NRC, ABNM, and ABR Training Requirements ⁎ for Nuclear Medicine
NRC Code Description Clinical (h) Basic Science (h) Board Certification ABNM ABR 35.190 Uptake, dilution, excretion 60 8 Yes Yes † 35.290 Imaging and localization 700 80 Yes Yes 35.390 Radiotherapy (including 35.392, 35.394, and 35.396) 700 200 Yes No 35.392 131 I ≤33 mCi 700 80 Yes Yes 35.394 131 I >33 mCi 700 80 Yes Yes 35.396 Parenteral radiotherapy 700 200 Yes No
ABNM, American Board of Nuclear Medicine; ABR, American Board of Radiology; NRC, Nuclear Regulatory Commission.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Radiation exposure concerns
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Economic effects
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Current status of the training programs
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Prospects
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Conclusions
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Acknowledgments
Get Radiology Tree app to read full this article<
References
1. Henkin R.E., Bova D., Dillehay G.L., Kareshi S.M., Halama J.R., Wagner R.H.: Nuclear medicine.2nd ed.2006.MosbySt. Louis, MO
2. Von Schulthess G.K.: Molecular anatomic imaging: PET-CT and SPECT-CT integrated modality imaging.2nd ed.2007.Lippincott, Williams & WilkinsPhiladelphia, PA
3. Ziessman H.A., O’Malley J.P., Thrall J.H.: Nuclear medicine: the requisites.3rd ed.2006.Mosby ElsevierPhiladelphia, PA
4. Mettler FA, Guiberteau MJ. Essentials of nuclear medicine imaging. 5th ed. Philadelphia, PA: Saunders Elsevier.
5. Valk P.E., Delbeke D., Bailey D.L., Townsend D.W.: Positron emission tomography: clinical practice.2006.SpringerNew York
6. Margolis D.J., Hoffman J.M., Herfkens R.J., et. al.: Molecular imaging techniques in body imaging. Radiology 2007; 245: pp. 333-356.
7. Nomori H., Kosaka N., Watanabe K., et. al.: 11 C-acetate positron emission tomography imaging for lung adenocarcinoma 1 to 3 cm in size with ground-glass opacity images on computed tomography. Ann Thorac Surg 2005; 80: pp. 2020-2025.
8. Ho C.L., Yu S.C.H., Yeung D.W.C.: 11 C-acetate PET imaging in hepatocellular carcinoma and other liver masses. J Nucl Med 2003; 44: pp. 213-221.
9. Ponde D.E., Dence C.S., Oyama N., et. al.: 18 F-fluoroacetate: a potential acetate analog for prostate tumor imaging—in vivo evaluation of 18 F-fluoroacetate versus 11 C-acetate. J Nucl Med 2007; 48: pp. 420-428.
10. Shields A.F., Grierson J.R., Dohmen B.M., et. al.: Imaging proliferation in vivo with [F-18] FLT and positron emission tomography. Nat Med 1998; 4: pp. 1334-1336.
11. Yousem D.M., Beauchamp N.J.: Radiology business practice: how to succeed.2008.Saunders ElsevierPhiladelphia, PA
12. Cherry S.R.: The 2006 Henry N. Wagner Lecture: of mice and men (and positrons)—advances in PET imaging technology. J Nucl Med 2006; 47: pp. 1735-1745.
13. Schlemmer H, Pichler BJ, Claussen CD. Simultaneous MR/PET for brain imaging: first patient scans. Presented at: 54th Annual Meeting of the Society of Nuclear Medicine; Washington, DC; June 2–6, 2007.
14. Zaidi H., Mawlawi O.: Simultaneous PET/MR will replace PET/CT as the molecular multimodality imaging platform of choice. Med Phys 2007; 34: pp. 1525-1528.
15. Coleman R.E., Delbeke D., Guiberteau M.J., et. al.: Concurrent PET/CT with an integrated imaging system: intersociety dialogue from the Joint Working Group of the American College of Radiology, the Society of Nuclear Medicine and the Society of Computed Body Tomography and Magnetic Resonance. J Nucl Med 2005; 46: pp. 1225-1239.
16. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in nuclear medicine. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/200nuclearmedicine07012007.pdf . Accessed October 25, 2008.
17. Harolds JA, Dunnick NR, Smith GT, Baker SR. Panel discussion on controversies and problem solving in nuclear medicine training. Presented at: Annual meeting of the Association of University Radiologists; Denver, CO; April 25, 2007.
18. Graham M.M., Metter D.F.: Evolution of nuclear medicine training: past, present, and future. J Nucl Med 2007; 48: pp. 257-268.
19. Henry R. Report of the ABNM to the Academic Council. Presented at: Annual meeting of the Society of Nuclear Medicine; New Orleans, LA; June 15, 2008.
20. Accreditation Council for Graduate Medical Education. ACGME program requirements for fellowship education in the subspecialties of internal medicine. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/141pr707_ims.pdf . Accessed May 13, 2008.
21. Certification Board of Nuclear Cardiology. Home page. Available at: http://www.cbnc.org/theexam/eligibility_us.cfm . Accessed on October 24, 2008.
22. Cerqueira M.D., Berman D.S., Di Carli M.F., et. al.: Task Force 5: training in nuclear cardiology. J Am Coll Cardiol 2006; 47: pp. 898-904.
23. Beller G.A., Bonow R.O., Fuster V.: ACCF 2006 update for training in adult cardiovascular medicine (focused update of the 2002 COCATS 2 training statement). J Am Coll Cardiol 2006; 47: pp. 894-897.
24. Budoff M.J., Achenbach S., Fayad Z., et. al.: Task Force 12: training in advanced cardiovascular imaging (computed tomography). J Am Coll Cardiol 2006; 47: pp. 915-920.
25. Pohost G.M., Kim R.J., Kramer C.M., Manning W.J.: Task Force 12: training in advanced cardiovascular imaging (cardiovascular magnetic resonance [CMR]). J Am Coll Cardiol 2006; 47: pp. 910-914.
26. American Board of Radiology. Diagnostic radiology: nuclear training for diagnostic radiologists. Available at: http://www.theabr.org/DR_Pri_NUCTraining.htm . Accessed October 25, 2008.
27. American Board of Radiology. Diagnostic radiology: requirements. Available at: http://www.theabr.org/DR_Pri_Req.htm . Accessed October 25, 2008.
28. American Board of Radiology. Overview of ABR changes: the exam of the future. Available at: http://www.theabr.org/Images/Overview_changes.pdf . Accessed October 25, 2008.
29. American Board of Radiology. Frequently asked questions about ABR’s new core and certifying examinations in diagnostic radiology. Available at: http://www.theabr.org/faq_ic_1.pdf . Accessed October 25, 2008.
30. American Board of Radiology. Transforming the ABR’s diagnostic radiology qualifying and certifying examinations. Available at: http://www.theabr.org/Images/becker_ic_present_1.pdf . Accessed October 25, 2008.
31. Dunnick NR, Becker G, Anderson PO. American Board of Radiology: From “binge and purge” to life-long-learning. Available at: http://www.theabr.org/Images/dunnick_ic_present_1.pdf . Accessed October 25, 2008.
32. American Board of Radiology. Available at: http://www.theabr.org/Images/strife/abrreport_future08.pdf .
33. Baker S.R.: The oral boards: why radiology has it wrong and why it must be changed now. J Am Coll Radiol 2008; 5: pp. 5-9.
34. Delbeke D., Coleman R.E., Guiberteau M.J., et. al.: Procedure guideline for tumor imaging with 18 F-FDG PET/CT 1.0. J Nucl Med 2006; 47: pp. 885-895.
35. Delbeke D., Coleman R.E., Guiberteau M.J., et. al.: Procedure guideline for SPECT/CT imaging 1.0. J Nucl Med 2006; 47: pp. 1227-1234.
36. American College of Radiology. ACR practice guideline for performing FDG-PET/CT in oncology. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/nuc_med/fdg_pet_ct.aspx . Accessed on October 25, 2008.
37. Society of Nuclear Medicine. Home page. Available at: http://www.molecularimagingcenter.org/index.cfm?PageID=7165&RPID=10 . Accessed on October 25, 2008.
38. Molecular Imaging Center of Excellence Task Force meeting. Presented at: Annual meeting of the Society of Nuclear Medicine; New Orleans, LA; June 15, 2008.
39. Nuclear Medicine Program Directors’ revised survey results. Distributed June 15, 2008.
40. Molecular Imaging Center of Excellence Task Force. Nuclear medicine curriculum resource compendium—preview. Available at: http://www.molecularimagingcenter.org/docs/Compendium_Final_5_30_08.pdf . Accessed on October 25, 2008.
41. Harolds J.A., Graham M., Maurer A., Guiberteau M.J., Miller T., Vydareny K.: Recent changes in nuclear medicine/radiology training and certification requirements. Acad Radiol 2006; 13: pp. 1405-1409.
42. Nuclear Regulatory Commission. Medical uses licensee toolkit. Available at: http://www.nrc.gov/materials/miau/med-use-toolkit.html . Accessed on October 25, 2008.
43. Mettler FA. Magnitude of radiation uses and doses in the United States: NCRP Scientific Committee 6-2 analysis of medical exposures. Presented at: Advances in Radiation Protection in Medicine; April 16, 2007.
44. White paper addresses increased radiation dosage. ACR Bull 2007; 62: pp. 5.
45. Amis E.S., Butler P.F., Applegate K.E., et. al.: American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol 2007; 4: pp. 272-284.
46. Pierce D.A., Preston D.L.: Radiation-induced cancer risks at low doses among atomic bomb survivors. Radiat Res 2000; 154: pp. 178-186.
47. Berrington de Gonzalez A., Darby S.: Risk of cancer from diagnostic x-rays: estimates for the UK and 14 other countries. Lancet 2004; 363: pp. 345-351.
48. Brenner D.J., Hall E.J.: Computed tomography—an increasing source of radiation exposure. N Engl J Med 2007; 357: pp. 2277-2284.
49. Brenner D.L., Doll R., Goodhead D.T., et. al.: Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A 2003; 100: pp. 13761-13766.
50. Gilbert E.S.: Invited commentary: studies of workers exposed to low doses of radiation. Am J Epidemiol 2001; 153: pp. 319-322.
51. Mezrich R.: Are CT scans carcinogenic?. J Am Coll Radiol 2008; 5: pp. 691-693.
52. Karatzis E.N., Danias P.G.: Exposure to ionizing radiation from cardiovascular imaging and therapeutic procedures may be a considerable unrecognized risk for subsequent cancer development. J Am Coll Radiol 2008; 5: pp. 694-695.
53. Smith A.B., Dillon W.P., Lau B.C., et. al.: Radiation dose reduction strategy for CT protocols: successful implementation in neuroradiology section. Radiology 2008; 247: pp. 499-506.
54. Treves S.T., Davis R.T., Fahey F.H.: Administered radiopharmaceutical doses in children: a survey of 13 pediatric hospitals in North America. J Nucl Med 2008; 49: pp. 1024-1027.
55. Stzelcyk J.J., Damilakis J., Marx M.V., Macura K.J.: Facts and controversies about radiation exposure, part 1: controlling unnecessary radiation exposures. J Am Coll Radiol 2006; 3: pp. 924-931.
56. Stzelcyk J.J., Damilakis J., Marx M.V., Macura K.J.: Facts and controversies about radiation exposure, part 2: low-level exposures and cancer risk. J Am Coll Radiol 2007; 4: pp. 32-39.
57. Hendee W.R.: An opportunity for radiology. Radiology 2006; 238: pp. 389-394.
58. DeMaria A.N.: Self-referral in cardiology. J Am Coll Cardiol 2004; 43: pp. 1500-1501.
59. Levin D.C., Parker L., Intenzo C.M., Sunshine J.H.: Recent rapid increase in utilization of radionuclide myocardial perfusion imaging and related procedures: 1996-1998 practice patterns. Radiology 2002; 222: pp. 144-148.
60. Levin D.C., Intenzo C.M., Rao V.M., et. al.: Comparison of recent utilization trends in radionuclide myocardial perfusion imaging among radiologists and cardiologists. J Am Coll Radiol 2005; 2: pp. 821-824.
61. Levin D.C., Rao V.M.: Turf wars in radiology: the overutilization of imaging resulting from self-referral. J Am Coll Radiol 2004; 1: pp. 169-172.
62. Hillman B.J., Olson G.T., Sunshine J.H., et. al.: Physicians’ utilization and charges for outpatient diagnostic imaging in a Medicare population. JAMA 1992; 268: pp. 2050-2054.
63. Shortsleeve M., Herring W.: The impact of self-referral on radiology residency training programs. J Am Coll Radiol 2003; 2: pp. 415-417.
64. Moser J.W.: Getting at the facts on imaging utilization growth. J Am Coll Radiol 2005; 2: pp. 720-724.
65. Levin D., Rao V.: Turf wars in radiology: privileging and site accreditation programs—what they have accomplished for commercial health plans. J Am Coll Radiol 2003; 3: pp. 534-536.
66. Levin D., Rao V.: Turf wars in radiology: possible remedies for self-referral that could be taken by federal or state governments and payers. J Am Coll Radiol 2004; 1: pp. 806-810.
67. Armstrong D. Medicare moves to cut “self referral” practice. The Wall Street Journal. September 12, 2007:B1.
68. Franc BL, Jacene H, Barnes L, et al. Trends in nuclear medicine physician recruitment. Presented at: Annual meeting of the Association of University Radiologists; Austin, TX; April 5–8, 2006.
69. Metter D. Nuclear Medicine RRC: the who, what, how, and why. Presented at: Annual meeting of the Society of Nuclear Medicine; New Orleans, LA; June 17, 2008.
70. Fleming M. Preparing for a residency site review. Presented at: Annual meeting of the Society of Nuclear Medicine; New Orleans, LA; June 17, 2008.
71. Lucas R.G., Jacene H., Harolds J., Barnes L., Maurer A.: Nuclear medicine training for radiology residents: needs assessment survey. Acad Radiol 2007; 14: pp. 301-305.
72. Graham MM. The continuing evolution of nuclear medicine training: past, present, and future. Presented at: Annual meeting of the Society of Nuclear Medicine; New Orleans, LA; June 16, 2008.
73. National Resident Matching Program. Results and data: 2007 main residency match. Available at: http://nrmp.org/data/resultsanddata2008.pdf . Accessed on October 25, 2008.
74. Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/420_diagnostic_radiology_07 01 2008.pdf. Accessed on October 25, 2008.