JNM: Molecular imaging demands redesign of nuclear medicine education
For nearly 40 years, residents have had to decide between one of two tracks for nuclear medicine training, a fragmented and outdated system that, thanks to shifts toward healthcare reform and molecular imaging, must be reconciled, according to a joint Society of Nuclear Medicine (SNM) and American College of Radiology (ACR) task force article published in the June issue of The Journal of Nuclear Medicine.

Medical school graduates seeking training in nuclear medicine can obtain certification via two routes, with multiple pathways. The first, conferred by the American Board of Radiology (ABR), is in nuclear radiology; the second, under the American Board of Nuclear Medicine (ABNM), certifies residents in nuclear medicine.

This schism, which took place in 1973, has resulted in varying standards and qualities of education in both nuclear medicine and diagnostic radiology, not to mention turf issues, between the two specialties. Although persisting for four decades, with radiologists interpreting the bulk of noncardiac nuclear medicine images accompanied by a decline in nuclear medicine training for diagnostic radiologists, the ACR-SNM Task Force on Nuclear Medicine Training concluded that enough is enough.

“This trend of decreasing general nuclear medicine training in diagnostic radiology residencies has become a cause for concern,” wrote Milton J. Guiberteau, MD, from the department of radiology at St. Joseph Medical Center in Houston, and Michael M. Graham, MD, PhD, from the department of radiology at the University of Iowa College of Medicine in Iowa City.

“The recognition of the strengths inherent in combined anatomic and functional imaging, as well as new skills required for molecular imaging, have prompted a reassessment of the optimal skills needed for imagers of the future. And because of healthcare reform and economic pressures, the implications for physician training in nuclear medicine for radiologists and nonradiologists alike have become increasingly clear and pressing.”

As hybrid anatomic and functional imaging modalities like PET/CT and SPECT/CT have cemented their roles in radiology and nuclear medicine, training for the latter has been extended by a year to incorporate experience with CT. Full use of continuing technological advancements, like the recent approval of PET/MR and an expanding radiopharmaceutical cabinet for molecular imaging, require a new approach to training.

Citing “general agreement” among members of the task force that nuclear medicine physicians need additional training in anatomic and functional imaging to reach full competence in molecular imaging, the group envisioned that “most molecular imaging will be practiced by physicians who are dual certified by the ABR and the ABNM.”

Topping the task force’s recommendations was a call for a fully integrated radiology and nuclear medicine training program. This residency would consist of a minimum three years in diagnostic radiology and two years in nuclear medicine and result in dual certification.

The task force also emphasized that the length of nuclear medicine training programs needs to be extended to account for hybrid imaging. “Beginning July 1, 2011, the training requirements in nuclear medicine will mandate 4 to 6 months of training in CT, during which time it is possible to acquire experience in the interpretation of 500 CT cases. This amount of training is regarded as minimal and will not be sufficient if MRI becomes a necessary part of the training,” Guiberteau and Graham argued.

Because four-year residencies in radiology require just four months of nuclear medicine training, the task force insisted that radiology residents who plan to practice substantial nuclear medicine should undergo additional training in the field. The group looked to the coming restructuring of radiology residency programs to make this possible.

“Harmonizing or even equalizing the curricula for the nuclear radiology fellowship with the one-year nuclear medicine residency available to physicians who are board certified in diagnostic radiology is desirable,” Guiberteau and Graham continued. Moreover, the authors relayed the task force recommendation that fellowships in molecular imaging be introduced.

“Given the well-developed cultures that have evolved around the current training pathways, residency review committees and certifying boards and the substantial territorial investments in ownership by both radiology and nuclear medicine, community-wide acceptance of a new paradigm of compromise and cooperation will be a critical step going forward,” the authors concluded. At the core of these calls for reform, they stressed, is better patient care.