JNM SPECIAL CONTRIBUTION (DD 5.5.12)SNM/ABNM Joint Position Statement on
Optimizing Training in Nuclear Medicine in the Era of Multimodality and Hybrid
Imaging.
Dominique Delbeke, MD, PhD; Henry D. Royal, MD; Michael M. Graham, MD, PhD; George
M. Segall, MD.
Dominique Delbeke, MD, PhD
Vanderbilt University Medical Center, Nashville, Tennessee
Phone (W): 615-343 7524
E-mail: Dominique.delbeke@vanderbilt.edu
George Segall, MD
VA Palo Alto Health Care System, Palo Alto, California
Stanford University, Stanford, California
Phone (W): 650-858-3945
E-mail: george.segall@va.gov
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Introduction
The emergence of multimodality and hybrid imaging in Nuclear Medicine (NM) has
changed the scope of knowledge required for nuclear medicine physicians. In addition,
molecular imaging (MI) is an evolving field with the developments of new targeted
radiopharmaceuticals and other tracers that will allow identification of patients with specific
characteristics that will benefit from targeted treatments.
The American Board of Nuclear Medicine (ABNM) defines NM as “the medical
specialty that uses the tracer principle, most often with radiopharmaceuticals, to evaluate
molecular, metabolic, physiologic and pathologic conditions of the body for the purposes of
diagnosis, therapy and research” 1. In 2005, a MI summit, sponsored by the Radiology Society
of North America (RSNA) and SNM, recommended the following definition2: “Molecular
imaging techniques directly or indirectly monitor and record the spatiotemporal distribution of
molecular or cellular processes for biochemical, biologic, diagnostic, or therapeutic
applications”. In 2007, the SNM has adopted the following definition for MI 3: “Molecular
imaging is the visualization, characterization, and measurement of biological processes at the
molecular and cellular levels in humans and other living systems. Molecular imaging typically
includes two- or three- dimensional imaging as well as quantification over time. There are
several imaging modalities that can be used for MI, including Positron Emission Tomography
(PET), Single Photon Emission Computed Tomography (SPECT), Magnetic Resonance Imaging
(MRI), Ultrasound (US), Optical Imaging (OI), and potentially others. Molecular imaging agents
are tracers used to visualize, characterize, and measure biological processes in living systems.
Both endogenous molecules and exogenous probes can be molecular imaging agents.” At the
present time, virtually all of the MI procedures that have clinical applications and are available
for patient care use radioactive tracers. In the future, non radioactive tracers may likely become
available for clinical use.
Not all of NM procedures are MI procedures. For example, perfusion imaging of the lungs or
heart is not a molecular procedure because blood flow is not a molecular process.
In order to optimize NM residency training programs of the future, the curriculum needs to
include both anatomical and functional imaging. These issues are arising worldwide and are also
addressed by the European Association of Nuclear Medicine (EANM) 4,5, 6, 7.
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ACR/SNM Task Force I on Nuclear Medicine Training
In 2009, the ACR-SNM Task Force I on Nuclear Medicine Training was convened to
propose recommendations to optimize NM training.
In the United States, there are multiple training pathways in NM that have been summarized in
the report of the ACR-SNM Task Force I on NM Training. This report has been published
simultaneously in the June issue of the Journal of Nuclear Medicine (JNM) and of the Journal of
the American College of Radiology (JACR) 8. These pathways can lead to certification by two
different member boards of the American Board of Medical Specialties (ABMS): the American
Board of Nuclear Medicine (ABNM), and the American Board of Radiology (ABR).
The recommendations of Task Force I are summarized in Table 1 of reference 8. For the
short-term horizon recommendations were to: 1) Harmonize NM residency and NR fellowship
program requirements; 2) Improve robustness of NM training in DR residencies; 3) Improve
robustness of DR training in NM residencies; 4) Encourage 16-month NM pathway within DR
residencies. For the long-term horizon, the recommendation was to develop combined DR and
NM training program for MI specialists.
ACR/SNM Task Force II on Nuclear Medicine Training
In May 2011, the ACR-SNM Task Force II on Nuclear Medicine Training was charged
with building on the work and recommendations of Task Force I, to create meaningful and
practical residency training programs that will address the current needs for nuclear imaging and
therapy, as well as look to the future of MI. Task Force II was co-chaired by M. Elizabeth Oates,
MD from ACR and Dominique Delbeke, MD from SNM. The task force II had 16 members,
two of each of the following organizations: the American College of Radiology, (ACR), the
Society of Nuclear Medicine (SNM), the American Board of Radiology (ABR), the American
Board of Nuclear Medicine (ABNM), the Radiology Residency Review Committee (DR RRC),
the Nuclear Medicine Residency Review Committee NM RRC), Association of Program
Directors in Radiology (APDR) and Nuclear Medicine Program Directors Association
(NMPDA) that belong to the SNM Academic Council. The NM participants on the task force
included, from the SNM, George M. Segall, MD, and Dominique Delbeke, MD (co-chair of the
ACR/SNM Task Force on Combined Training Programs); from the ABNM, Kirk A. Frey, MD,
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and Eric M. Rohren, MD; from the NM-RRC, Christopher J. Palestro, MD, and Donald A.
Podoloff, MD; from the NMPDA, Daniel Lee, MD, and Darlene F. Metter, MD.
Over the summer of 2011, preliminary ideas were shared between task force members but
the task force did not meet as a group due to logistical scheduling issues. In September 2011, the
DR participants of task force II proposed a draft of guiding principles and two models for
combined training in DR and NM, a 4-year and a 5-year model of clinical curriculum. These
recommendations of the DR participants of Task Force II have been published on-line by JACR
in January 2012 9. The 4-year model includes two options: The fundamental option of 4 years of
DR including the four core months of NM; and the advanced option taking advantage of the
recent changes in the DR-RRC and the ABR and permitting up to 16 months in one subspecialty,
NM for the purpose of NM training. The 5-year model included three years in DR (including or
not the four months of core NM), two additional years in NM 9.
Despite the apparent agreement of taskforce I, the NM participants of Task Force II
recognized that there were differing interpretations of the TFI short-term recommendations. For
the NM participants, the recommendation to harmonize NM residency and NR fellowship
program requirements meant unifying these residencies under the NM-RRC whereas the DR
participants interpreted harmonization as creating two equal but separate residency programs.
Recommendations 2 and 3 were not addressed. The DR participants of TFII focused on the
combined program (recommendation 4) and advocated to entrust the oversight of combined
training programs to the DR-RRC.
SNM leadership attempted several times, without success, to set up meeting with ACR
leadership to try to resolve these complex and interconnected issues. Therefore, SNM, ABNM,
and NM-RRC decided to withdraw from participation to the ACR/SNM Task Force II. The SNM
leadership continues to be willing to meet with ACR leadership to resolve differences of opinion.
Existing/Traditional NM residency training pathways
The SNM and ABNM have recognized the importance of requiring more training in
anatomic imaging for NM residents. In July 2007, the residency training in NM was lengthened
from 2 years to 3 years in order to accommodate more training in anatomic imaging. Six months
of training in anatomic imaging are now required. Several alternative NM training pathways
exist: 1) two years of NM if a physician is eligible for another specialty board; 2) one year of
NM if a physician is eligible for the ABR; 3) residents enrolled in a radiology resident training
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program are eligible for ABNM certification after completing 16 months of training in an
ACGME accredited NM program during their 4 years of radiology training (recommended as 4year combined DR and NM program). The three years NM training is appropriate for physicians
who will dedicate their career to academia and research. The two years NM training is
appropriate for clinicians who want to be able to lead NM in their clinical specialty.
ACGME and National Resident Match Program (NRMP): Combined Residency Training
Combined programs are addressed on the ACGME website 10 (see the left-menu Search
function for Programs with Combined Specialty Tracks). According to ACGME, “Combined
training consists of a coherent educational experience in two or more closely related specialties
or subspecialties available for selected individuals. The educational plan for combined training is
approved by the specialty board of each of the specialties to assure that resident physicians
completing combined training are eligible for board certification in each of the component
specialties. Each specialty or subspecialty program is separately accredited by ACGME through
its respective specialty review committee. The duration of combined training is longer than any
one of its component specialty programs standing alone, and shorter than all of its component
specialty programs together”. The ACGME is no longer considering accreditation of combined
residency programs as a single program 9. However, ACGME will assign a program number that
allows institutions to enroll residency positions of combined programs on the NRMP. This can
apply to both the 4-year and 5-year combined training model as residents can formally transfer to
other programs with appropriate documentation.
SNM/ABNM Recommendations for Combined Training in Diagnostic Radiology and
Nuclear Medicine
The most efficient way to move forward with combined training is for DR and NM to
work together, instead of having DR take over the entire effort of directing the combined training
programs. Such a plan would take advantages of the considerable strengths of both existing
specialties, and should result in MI physicians with balanced and strong training in both areas.
Medical specialties are defined by their core knowledge. ABNM was created in 1971 and
was the first conjoint board of the ABMS. The conjoint board was sponsored by the American
Board of Internal Medicine (ABIM, therapies), the American Board of Pathology (ABP,
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radioimmunoassay) and ABR (diagnostic imaging) and the SNM based on the recommendation
of the Liaison Committee for Specialty Boards, the ABMS and the Council on Medical
Education of the AMA. It became an independent medical specialty board in 1985. The
justification for recognizing NM as an independent medical specialty is that the core knowledge
required for the practice of NM is very different than the core knowledge required for the
practice of DR. The core knowledge in NM is centered on tracer principle, most often with
radioactive tracers, to study physiologic, biochemical, and molecular processes in space and
time. The ABNM has recently published a statement on NM professional competency and scope
of practice 11. NM training programs embrace the complete spectrum of the practice of NM,
including general diagnostic procedures, radionuclide therapies, and cardiac imaging. Residency
programs in NM are robust and have trained the majority of NM physician in practice for the
past 40 years. There are 54 ACGME-accredited NM resident training programs and there are
currently 158 on-duty residents12. Each NM program graduates an average of two residents per
year, for a total stable number of about 100 residents per year taking the ABNM examination.
The ABR began offering its own certificate of competence in NR in 1973. NR was
established as a subset of NM that only included nuclear diagnostic imaging. Fellowship
programs in NR have been created that lead to eligibility for subspecialty certification in NR by
the ABR, physicians must have ABR certification in diagnostic radiology and have an additional
year of fellowship training in NR in one of the 19 ACGME-accredited NR training programs.
There are currently 15 on-duty residents12. This training pathway includes a total of 16 months in
NR, four months during radiology residency plus 12 must during fellowship. In 2011, the ABR
created a second pathway for subspecialty certification in NR consisting of 16 months of training
in NR or NM during 4 years of radiology residency, of which 10 months must be consecutive.
A significant difference between NM and NR is the amount of training required for
therapy with radiopharmaceuticals as described in the article on Credentialing and Delineation of
Privileges for Therapeutic Procedures Using Radiopharmaceuticals 13. The ABNM, SNM,
ACNM and NM RRC have challenged the addition of radionuclide therapy to the DR program
requirements and are challenging the proposed changes to the NR program requirements which
make NR essentially a duplicate of NM program requirements. Duplication of training
requirements will stimulate competition for the pool of potential trainees instead of encouraging
collaboration. The larger number of NM residency programs compared to NR, the longer track
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records of experience and expertise of NM professionals with the entire scope of NM procedure
makes NM RRC a natural choice to have oversight over NM training in the future.
From the history of NM for the past 40 years, it is obvious that the core knowledge of
NM and therapy using radiopharmaceuticals has been in the hands of NM professionals. The
research and progress in NM have been led by leaders in NM. Research and progress in nonnuclear MI is the result of the combined efforts of leaders in MRI, US, and NM applying the
tracer principle to other technologies. An example is research taking advantage of multimodality
imaging (bioluminescence and positron emission) with PET radiopharmaceuticals such as 18FFDG for sentinel lymph node detection. Another example is research studies using dual-labeling
of biomarkers with both nuclear and optical tracers.
DR considers NM as a subspecialty that should not require more specialized training than
any other subspecialty, other than compliance with the Nuclear Regulatory Commission (NRC)
regulations. However, there are other subspecialties of DR for which specific training is
mandated by legislation, such as mammography that has to be in compliance with the
Mammography Quality Standards Act (MQSA)14, 15.
With that background in mind, the oversight of combined training has to be under a joint
effort of both the DR-RRC and NM-RRC, especially for advanced training that includes more
scholar projects for the trainees and role-modeling of faculty for future imager-scientists. The
NM rotations of any combined program (except for the 4 months of core rotations in NM for DR
trainees) should be placed under the direct oversight of the NM-RRC and NM program directors.
As ninety percent of the MI procedures that have clinical applications and are available for
patient care are PET and SPECT, MI rotations should be under the authority of the NM program
director and as applicable, the NR or other subspecialty of DR program director, for example
MRI.
SNM/ABNM Recommendations for Levels of Training in Diagnostic Radiology and
Nuclear Medicine
The levels of training approach has been described and implemented in cardiac imaging
during the Core Cardiology Training Symposium (COCATS) and have been last revised in 2006
for Nuclear Cardiology16. Training of residents/fellows in nuclear cardiology is divided into
three levels: 1) General (Level one, minimum of 2 months) makes trainee acquainted with the
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field; Specialized (Level two, minimum of 4 months) provides trainee with expertise to practice
the field; Advanced (Level three, minimum of 12 months) provides training sufficient to be the
director of a laboratory or pursue an academic career.
This approach has also been suggested by the “External Stakeholders Working Group” of
the SNM 2020 Task Force appointed early in 2011. The purpose of the SNM 2020 task force was
to bring together a broad cross section of health care professionals to discuss the future of the
NM profession and make recommendations that will serve as guiding principles to meet the
challenges for the profession and the field. The external stakeholder’s group worked under the
co-chairmanship of Milton Guiberteau for radiology and Robert Hendel for cardiology. There
were seven additional members, all leaders in radiology or cardiology. The SNM 2020 task force
working groups met on September 16, 2011 in McClean, Virginia to present their reports. One of
the recommendations of the external stakeholders working group was to consider collaborative
designated levels of clinical practice, such as a three tiered level for training in NM, as in
cardiology. Level one would indicate knowledge of the field and an ability to order tests and
perform certain procedures. Level two would signify a practitioner able to order, perform and
interpret nuclear medicine studies. Level three would be a reserved designation for someone with
knowledge and experience to serve as laboratory “director". The external stakeholder group also
mentioned that specifying organ or system and multimodality/hybrid imaging competency may
be useful designations (Personnel communication: Report of the SNM 20/20 Task Force,
External Stakeholder Working Group, Co-Chairs: Milton Guiberteau and Robert Hendel;
Working Group Members: Timothy Bateman; Burton Drayer, N. Reed Dunnick, Douglas
Maynard, Barbara Joyce McNeil, James Min, James Thrall).
The NM participants from task force II propose the following definitions for levels of
training in DR and NM:
1) Basic training (level one): a minimum of 2 months which give the ability to recommend
procedures and perform and interpret selected procedures. Specialized training (level
two): a minimum of 16 months in NM or 3 years in DR which gives the ability to order,
perform and interpret NM or DR procedures respectively.
2) Advanced training (level 3): a minimum of 36 months in NM (excluding the 4 core
months of NM during DR residency) or 48 months in DR which give the ability to be a
laboratory director.
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For combined training, the level in each specialty can be given. For example after
completion of a residency in radiology, the trainee would be level three in DR and level one in
NM, as there is a 4 months core training in NM17. After completion of a residency in NM, the
trainee would be level three in NM and level one in DR, as Effective July 1, 2011, residents in
NM must have a minimum of six months of CT experience, including a minimum of four months
in a diagnostic radiology CT service18. A 5-year combined training with 3 years in DR and 2
years in NM, the trainee would be level two in DR and in NM.
This approach is also designed to stimulate excellence in the field, promote patient safety
and quality of patient care. Level one trainee would practice under the responsibility of a level
two or three trainee who can be off-site as this is now possible with teleradiology.
Summary
Nuclear medicine physicians and diagnostic radiologists of the future will need more
training in anatomic and functional respectively. After the report of the ACR/SNM Task Force I
on NM training8, SNM and ACR have appointed the ACR/SNM Task Force II on Nuclear
Medicine training. A 4-year and 5-year curriculum model has been proposed by the DR
participants of the task force with global oversight by the DR RRC9. The NM participants have
withdrawn participation because of disagreement about the global oversight by DR-RRC. The
NM participants to ACR/SNM Task Force II conclude the following about the proposals from
the DR participants from the ACR/SNM task force II on NM training:
1. There is agreement about the goals for training future imagers.
2. There is agreement about the structure of the clinical curriculum models proposed (4-year
and 5-year model) and dual eligibility for ABR and ABNM.
3. There is agreement about the desirability of a single maintenance of certification (MOC)
process by the ABR and ABNM.
4. There is disagreement about the oversight. The oversight of combined training has to be
under a joint effort of both the DR RRC and NM RRC as the large experience and
expertise in NM resides with NM professionals and track records of training in all aspects
of NM and resides in NM RRC.
5. The existing training pathways in NM continue to exist.
6. Levels of training should be adopted.
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