As molecular imaging emerges from the cocoon of nuclear medicine, fueled by changes that have made it a vital technique for diagnosing disease and predicting and monitoring treatment response, training for physicians and technologists has made its way to the forefront for many education programs around the United States. Individual programs are modifying their curriculum to incorporate molecular imaging training.
As PET/CT and SPECT/CT take hold and studies prove their clinical strength, the approach to diagnosis and evaluation of the patient also is changing. According to Michael Graham, PhD, MD, director of nuclear medicine, at the University of Iowa and vice-president elect of the Society of Nuclear Medicine (SNM), this change in approach is driving the surge in interest in molecular imaging and the focus on formalizing training and education requirements.
“There seems to be a growing recognition about the importance of molecular imaging principles, particularly in personalizing both diagnosis and treatment,” Graham notes. “But, ultimately, it is the treatment.”
Right now, interest in molecular imaging is focused on the nuclear medicine department, although additional interested groups include oncology, gynecology and gastroenterology, the latter of which use various optical imaging methodologies.
“Nuke med has been doing MI all along except it was not called that,” he says. “A lot of what we train residents in can be called molecular imaging—it includes training on how it localizes, metabolizes and more—we just have never labeled it before.”
Graham says that formalizing molecular imaging training will be the next iteration of nuclear medicine training residency program requirements.
Currently, according to SNM, the average residency program in nuclear medicine takes three years to train qualified physicians in the diagnostic and therapeutic use of radioactive pharmaceuticals. Residents are required to have one or more years of preparatory training and two or more years of nuclear medicine residency training in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Diagnostic imaging consultation and nuclear medicine facility management are emphasized in the two-year program. Training also includes research experience, therapy with unsealed sources, and tomographic imaging with SPECT or PET radioisotopes.
“It is quite possible for molecular imaging training for physicians to move to a four-year program due to the increased complexity of molecular imaging,” Graham says. In the next iteration of training requirements, it is difficult to put a number on specific hours for a molecular imaging program because it is not yet a separate clinical entity. “You cannot exactly have a rotation for it,” he adds. “The program would include didactic sessions, the principles, the lab sessions and maybe data analysis, but it is still kind of nebulous—however, we are working our way forward.”
The path to formalized molecular imaging training is not completely free of obstacles. With radiologists more involved in image interpretation and with shifting reimbursement issues—physicians being paid less to do more—what is happening in the academic realm is that radiology faculty are becoming more clinically oriented and less focused on research.
In light of these issues, the field is beginning to see a shortage of full-time nuclear medicine physicians, and needless to say, growth is slow. “Since the early 1970s, we have been averaging about 70 to 80 people a year—an annual average of board certified nuclear medicine physicians that is simply not enough to sustain the field,” according to Graham.
“Radiologists, with more clinical appointments instead of academic appointments, are not expected to do research—just the clinical work of image interpretation,” says Graham. “They are not providing the research that we need to move the nuclear medicine field forward.”
Building technologist skills
Training in molecular imaging is not only being formalized for physicians, but for technologists as well. Many programs are trying to incorporate new courses focused on molecular imaging into the standard two-year nuclear medicine curriculum.
According to Mark Wallenmeyer, CNMT, RT (N), the president-elect of the SNM Tech Section, there are several different approaches that SNM plans to suggest as requirements for nuclear medicine programs. SNM has suggested extensive pre-professional requirements for technologists before they enter a nuclear medicine program which include two semesters each of physics, chemistry and anatomy and physiology, as well as suggested coursework in biology, biochemistry and microbiology.
Once a technologist is in a professional curriculum, other imaging modalities, such as CT or MRI, are incorporated. “The move right now is to PET/CT, so we are trying to get this new curriculum into facilities so any new tech who is graduating will have the extensive training, both pre-professional and professional, in these areas,” Wallenmeyer says.
As PET/CT and SPECT/CT become more prevalent, the goal is to get technologists licensed and certified to perform each procedure. The difficulty with this endeavor is that each state has a different law specifying who can perform what exam. Currently, the Consistency, Accuracy, Responsibility and Excellence in Medical Imaging and Radiation Therapy (CARE) bill has been proposed which would require personnel performing the technical components of medical imaging and radiation therapy to meet federal education and credentialing standards in order to participate in federal health programs.
“We are trying to get states to recognize that these are molecular imaging procedures and we need to have one person, not two, performing these procedures,” Wallenmeyer notes.
The SNM Tech Section has proposed that by 2015, all new technologists entering the field will need to have a Baccalaureate degree. “Molecular imaging techs are looking at information on a cellular level, so the pre-professional requirements will play a role in how the radioisotopes are used, how they perform, how they emit radiation—all of which will just lay the foundation for a successful student going into their professional curriculum,” he concludes.
Training in practice
The Northwestern Memorial Hospital School of Nuclear Medicine Technology, which provides students with a comprehensive body of knowledge and clinical experiences, already is part of a four-year bachelor’s degree program with affiliated colleges and universities in the Chicago area. Each year, approximately 20,000 imaging procedures and more than 5,000 cardiac stress imaging procedures are performed by the nuclear medicine and nuclear cardiology departments.
The program accepts 12 students per year, who complete their pre-requisite course work in the sciences at one of the affiliated colleges or universities. This extensive workload, which includes many hours in biology, chemistry, genetics and organic chemistry, leads to the didactic portion of molecular imaging training. The fourth year of the bachelor’s degree program has more clinical work, according to Program Director Nancy McDonald, CNMT.
“In our program, we get more into the specifics of nuclear physics, pathophysiology, and a little bit of molecular biology and immunology,” McDonald explains. “Students are in class two full days [in their fourth year] and in clinicals the other three.”
On clinical days, students receive training on PET, PET/CT and SPECT scanners to ensure their capability to meet competency requirements on certification board exams.
The American Society of Radiologic Technologists (ASRT) has added a PET/CT curriculum that programs are supposed to begin adopting. Additionally, students now have to be trained in CT, and cross-sectional anatomy has been added as well as lectures on contrast media and patient reactions to contrast media.
Students in the Northwestern Memorial Hospital program also can participate in a new addition to the program—simulated training of a patient’s reaction to contrast agent.
“Luckily, we have the facilities and the manpower to add more training and curriculum as needed, thanks to our relationship with our other NM Academy accredited schools and hospital departments,” McDonald says.
As more requirements and curriculum are added to molecular imaging training programs down the road, more advanced levels of training are needed that entry-level technologists currently are not getting, she adds. “Technologists entering the field with molecular imaging training will need more training in the cellular sciences, technical training such as advanced life-support training, and additional clinical training that should probably continue once a tech is hired, to develop expertise in multiple areas,” she says.