Nuclear medicine is an evolving field of medicine that has undergone major changes in the last few years. Specific new areas that residents must now master include PET, sentinel node mapping, radioimmunotherapy, and correlative image interpretation with coregistered CT or MRI images. All these aspects of nuclear medicine have been in existence for several years but have only recently become part of the standard clinical repertoire that every nuclear medicine physician must be able to do well. Nuclear medicine physicians act as advisors to other physicians who provide direct care for the patient. As advisors it is essential that they are well trained and able to effectively optimize patient care.
When they finish training, most nuclear medicine residents currently have a broad experience in the field but are not fully capable of stepping into the role of physician advisor. Many take an additional fellowship year in PET. The others continue to learn on the job and gradually mature into capable physicians.
The major goal in extending the nuclear medicine residency program is to give the residents more experience, particularly in the new areas identified previously, as well as in nuclear cardiology. This will ensure that they will be adequately trained to confidently advise their fellow physicians when they finish training and begin their post-training careers.
Background
When originally founded in 1971, the American Board of Nuclear Medicine (ABNM) was a joint board with representation from internal medicine, pathology, and radiology. It became an independent entity in 1976. The requirement for entry into a nuclear medicine residency position was initially 2 years of postgraduate residency training. In 1990, the ABNM voted to decrease the entry requirement to 1 year of postgraduate training, usually an internal medicine or rotating internship. Since the beginning, the nuclear medicine portion of the training has been for 2 years. The only exceptions are for individuals who have completed training in radiology. These physicians can train for 1 year in a nuclear medicine program to become board eligible for ABNM.
Nuclear medicine and preventive medicine are the only secondary specialties in medicine with such short training programs. Preventive medicine is very different, with a requirement for a year of nonclinical academic training, which usually extends longer to a master's in public health degree. Internal medicine, family medicine, pediatrics, and emergency medicine all are 3-year programs.
Nuclear medicine training in other countries is considerably longer than that in the United States. In Canada, the requirement is 1 year of internship followed by 4 years. Three of those years must be in nuclear medicine. In the United Kingdom, the requirement is 2 years of general clinical experience followed by 4 years of nuclear medicine. In Australia, 3 years of clinical experience are followed by 2 years of nuclear medicine. After this training, the residents are strongly encouraged to spend an additional year of training outside the country.
Throughout the world, training in nuclear medicine is more rigorous than in the United States. This is definitely having an impact on US. productivity in the field. The relative numbers of publications by U.S. nuclear medicine physicians versus those from other countries is dropping. Many U.S. academic nuclear medicine physicians have been trained outside the United States, and their numbers are increasing.
Other Specialties Involved with Nuclear Medicine
Radiology. Radiology residents are required to train for 6 months in nuclear medicine, although this is rarely achieved. More typically, they spend 4-5 months in nuclear medicine rotations and receive credit for lectures and on-call experience for the remaining time. Once they have completed their training in radiology, they are allowed to practice nuclear medicine as well as radiology. Those who are interested in gaining more expertise can take a fellowship year in nuclear radiology. They are then eligible to take a certifying examination and receive a CAQ certificate in nuclear radiology. Alternatively, they can take a residency year in nuclear medicine to become eligible to take the ABNM examination and become board qualified.
Cardiology. Cardiology fellows who wish to practice nuclear cardiology (myocardial perfusion imaging and first-pass and gated blood pool imaging) are required to obtain 200 hours of training in basic concepts in nuclear medicine, including 50 hours of radiation safety training. They must also document involvement with 300 myocardial perfusion studies. Many of these fellows take a certifying examination given by the American Society of Nuclear Cardiology (ASNC). A small number take the 2-- year nuclear medicine residency program and become board certified by the ABNM.
Endocrinology. The major interest of endocrinologists in nuclear medicine has been in thyroid disease, particularly Grave's disease and thyroid cancer. Nuclear medicine studies are used in diagnosis of these diseases, and high-dose radioiodine is used for therapy. Other areas of interest include octreotide imaging of carcinoid and other neuroendocrine tumors, adrenal imaging, and parathyroid imaging. A small number of endocrinologists are licensed to treat patients with high-dose radioiodine. Training requirements to do this are determined by the Nuclear Regulatory Commission (NRC) and are currently 200 hours of study in basic concepts and radiation safety, along with participation in 30 thyroid treatments.
Radiation oncology. Radiation oncologists treat patients with external beam radiotherapy or with encapsulated sources placed within the body. Nuclear medicine physicians treat patients with unencapsulated radioactive agents. In some areas, this differentiation is becoming blurred. In many rural areas, most of the radioiodine therapy is done by radiation oncologists. They also often direct therapy with ^sup 82^Sr or ^sup 153^Sm for skeletal metastatic pain and are likely to be involved in therapy with radiolabeled antibodies as they become available. The training they receive as part of the radiation oncology residency program qualifies them in the eyes of the NRC to perform these therapies.
Mechanism for Making the Transition
Additional program requirements must be carefully defined. These should include experience in PET, lymphatic mapping, radic,immunotherapy, and correlative imaging. Specific numbers of studies required should be defined. Arrangements should be made for residents to spend at least 4 months in a radiology CT-MRI rotation to become competent in correlative imaging.
Once agreement has been reached and a start date for the 3-year program has been fixed, all residents entering a nuclear medicine residency program after that date would be required to be trained for 3 years to be board eligible. Residents who entered a program before that date would continue to be board eligible after 2 years but would be encouraged to continue for a third year.
The board examination would be modified to test applicants in the new areas beginning 3 years after the start date.
In recognition of the complex nature of our relationship with radiology, we probably have to allow radiologists, who have completed 4 years of training in an American Counsel of Graduate Medical Education-- approved program and are American Board of Radiology board eligible to train for 1 year in a nuclear medicine program to be ABNM board eligible. In anticipation of changes in the radiology training requirements, a resident who has trained for 1 clinical year and 2 years in radiology would be required to train for 2 years in nuclear medicine. Anyone else would need 1 clinical year and 3 years in nuclear medicine.
Impact and Implications
The major impact would be to improve the training of nuclear medicine physicians. This would result in more optimal use of nuclear medicine in both diagnosis and therapy. U.S. nuclear medicine physicians would be trained to a level similar to that in the rest of the world, which is certainly not the case currently. It is likely this improved training would attract more high-quality residents into nuclear medicine. Together with the better training, this would ensure continuation of innovation in the field.
The major impact would be seen in the specialty of radiology. The current arrangement whereby radiologists practice nuclear medicine after minimal training of 4-5 months is not optimal. Although some radiologists have taken the effort to obtain additional training, many have not. This results in low-quality nuclear medicine, decreased referrals for studies, and inappropriate underutilization. It is part of a much larger issue: how much training in nuclear medicine should a radiologist have to be able to competently supervise and interpret nuclear medicine studies? This issue will be resolved only by joint discussion between the ABNM and ABR and with the RRCs of radiology and nuclear medicine.
The impact in other specialties should be minimal. The NRC defines how much basic physics and radiation safety training is necessary to handle radionuclides and administer them to humans. Training requirements in nuclear cardiology are largely defined by ASNC, although ABNM could propose an explicit 2-year program for cardiologists.
This proposed change to 3 years of training should have little impact on endocrinology or radiation oncology, except to provide them with much better trained nuclear medicine colleagues.
