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The Current State of Nuclear Medicine and Nuclear Radiology: Workforce Trends, Training Pathways, and Training Program Websites
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Original Investigation
The Current State of Nuclear Medicine and Nuclear Radiology: Workforce Trends, Training Pathways, and Training Program Websites Jack H. Ruddell, BA, Adam E.M. Eltorai, MD, PhD, Oliver Y. Tang, BS, Johanna A. Suskin, BA, Elizabeth H. Dibble, MD, M. Elizabeth Oates, MD, Don C. Yoo, MD
Background: Nuclear medicine (NM) is a multidisciplinary field. Its overlap with nuclear radiology (NR) creates unique training considerations, opportunities, and challenges. Various factors impact the workforce, training needs, and training pathways. This state of flux may be perplexing to prospective NM/NR trainees. Purpose: To evaluate the state of NM/NR training by assessing the (1) workforce trends and job prospects for NM/NR trainees, (2) NM and NR training pathways, and (3) applicant-accessible online presence of training programs. Methods: Workforce trends were analyzed using data collected from the 2017 American College of Radiology Commission on Human Resources Workforce Survey. Information regarding the training pathways leading to board certification(s) for NM and NR physicians were obtained through the American Board of Nuclear Medicine, the American Board of Radiology (ABR), and the Society of Nuclear Medicine and Medical Imaging. Each Accreditation Council for Graduate Medical Education-accredited NM residency or NR fellowship training program’s website was reviewed for 20 content items to assess its comprehensiveness for those seeking information regarding eligibility, applications, training curriculum, and program characteristics. Results: Number of hires for NM/NR physicians has exceeded the projected number of hires from 2014 to 2017. In the last decade, there has been a greater than 25% decrease in the combined number of traditional NM residencies and NR fellowships (79 58 programs) and a greater than 50% decrease in the combined number of NM and NR trainees (173 82 trainees). In 2017, the ABR redesigned its 16-month pathway leading to specialty certification in diagnostic radiology and subspecialty certification in NR. As of March 24, 2019, there are 36 diagnostic radiology or IR residency programs with 64 trainees participating in this redesigned NR pathway. Of the 93.1% (54/58) of traditional Accreditation Council for Graduate Medical Education-accredited NM and NR training programs having websites in the 2017 2018 academic year, the mean number of online criteria met per program was 7.74 § 3.2 of 20 (38.7%). Conclusion: Recruitment into the traditional NM/NR training pathways has been steadily declining, but there has been a renewed interest with the redesigned ABR 16-month pathway. There is a paucity of online information available to prospective NM/NR applicants. In this rapidly evolving and unique field, it is important to streamline NM/NR training and bolster the information accessible to potential NM/NR applicants as they weigh career options. Key Words: Fellowship; Nuclear medicine; Nuclear radiology; Online; Training; Residency; Websites; Work force. © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION Acad Radiol 2019; &:e1–e9 From the Warren Alpert Medical School, Brown University, Providence, Rhode Island (J.H.R., A.E.M.E., O.Y.T., J.A.S.); Division of Nuclear Medicine, Department of Diagnostic Imaging, Warren Alpert Medical School, Brown University, 593 Eddy Street, Providence, RI (E.H.D., D.C.Y.); Department of Radiology, University of Kentucky College of Medicine; Lexington, Kentucky (M.E.O.). Received June 7, 2019; revised September 16, 2019; accepted September 24, 2019. Address correspondence to: D.C.Y. e-mail: [email protected] © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2019.09.026
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he multidisciplinary nature and evolution of nuclear medicine (NM)/nuclear radiology (NR) raise promising prospects for the field but also create substantial challenges for training programs and pathways. Since the establishment of the American Board of Nuclear Medicine (ABNM) in 1971 and the first subspecialty certification from the ABR called “Special Competence in Nuclear Radiology” in 1973, the practice of NM has changed dramatically, with the addition e1
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of new diagnostic radiopharmaceuticals, advanced instrumentation, and parenteral therapies (1). The training pathways for NM physicians have evolved with Accreditation Council for Graduate Medical Education (ACGME) NM program requirements undergoing significant expansion in 2007, currently requiring 3 years of training for residents and offering accelerated curricula for graduates of internal medicine (2 years) or radiology (1 year, akin to a fellowship) residencies (1,2). However, the large variety of training pathways has complicated educational reform, including the development of clinical competencies and the standardization of experience and range of skills for trainees (2,3). NM has also increasingly overlapped with NR, a subspecialty fellowship program also accredited by the ACGME). Despite attempts to increase the number of physicians entering NM/NR by reforming training requirements, the number of physicians achieving board eligibility in NM annually has generally remained between 80 and 100 since 1977 (1,2). Due to the underrepresentation of NM/NR subspecialists among early career radiologists, with only 0.9% undergoing NM/NR training, there have been calls to revamp outreach efforts to medical students, diagnostic radiology (DR) residents, and even interventional radiology (IR) residents (4). Furthermore, while a 2018 assessment of Medicare claims data determined that radiologists primarily subspecializing in NM/NR were more likely to practice in academic and large group practice settings, generally within radiology departments, the workforce prospects of future NM/NR graduates remains less characterized (4). This is critical because the work patterns of NM/NR specialists are remarkably heterogeneous, with one national evaluation quantifying that self-identifying NM/NR physicians spent anywhere between 10% and 90% of their time on NM/NR-specific services (5). Thus, it is paramount to evaluate NM/NR’s future workforce demands and training paradigms. There have been three traditional training pathways to NM/NR practice, with the recent additions of nontraditional fourth and fifth pathways (6 9). The multitude of options offer flexibility to bring physicians into the field of NM/NR from a variety of training backgrounds. However, such an abundance of training pathways, in combination with often disjoint publicly available information regarding their differences, has been described as confusing for physicians and medical students alike (10). Thus, concise clarification and synthesis of pathways is needed. The quality of the online presence of NM/NR programs may play a substantial influential role in enhancing recruitment. One assessment of applicants to IR programs found that they ranked program websites as the single most important source of information, above the advice of mentors and residents/fellows (11). Moreover, 41% of emergency medicine residency applicants chose not to apply to a program because of the quality of its website, highlighting the significant role that online content plays in informing and attracting prospective trainees (12). Online information from NM/NR websites may play a significant role in not only clarifying the dynamic changes in the field and its training pathways, but also in attracting prospective applicants to the discipline altogether. e2
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Consequently, the objective of this study is to evaluate the state of NM/NR training by assessing the (1) workforce trends and job prospects for NM/NR trainees, (2) NM and NR training pathways, and (3) applicant-accessible online presence of training programs. MATERIALS AND METHODS Workforce Trends
Workforce trends were analyzed using published data from the 2017 ACR Commission on Human Resources Workforce Survey (13). The survey was sent to academic department chairs or private practice group leaders in the Practice of Radiology Environment Database. In all, 477 groups (26%) responded, representing 11,056 of 33,659 radiologists (33%) in the United States. Among survey questions asked were the number and subspecialization of radiologists they employed or planned to hire, and whether they employed or managed nonradiologist NM physicians. The survey data were used in this investigation to evaluate percent change in hiring from 2011 to 2016, compare projected and actual hired radiologists, and to evaluate changing subspecialization patterns (particularly those of NM/NR). Training Pathways
An overview of the three traditional and two nontraditional training pathways to NM/NR practice was synthesized using information obtained from the ABNM, ABR, and the Society of Nuclear Medicine and Molecular Imaging (SNMMI). Information regarding changes, updates, and program/applicant trends in the five training pathways for NM/NR physicians were obtained through the ABNM (6,7), ABR (8), and the SNMMI (9). A list of accredited NM and NR programs during the 2017 2018 academic year was obtained from the ACGME’s Accreditation Data System (14,15). Online Presence
Each training program website was investigated by two authors (OYT and JAS, MD candidates) for 20 trainingrelated variables to assess its comprehensiveness for those seeking information regarding applications, training curriculum, and program characteristics (Table 1). A third author (JHR, MD candidate) resolved disagreements in data collection, which affected fewer than 5% of items. The 20 online content items are derived from previous studies of other medical specialties (16 20) and from surveys of residency and fellowship applicants to various specialties identifying the items considered most important by applicants (12,21). Each website was evaluated for how it classified its training program to look for consistency across programs. Programs were classified in the study’s database by size (large was defined as 2 or more positions open for 2018 2019) and whether the program had a separate webpage dedicated specifically for its NM residency or NR fellowship training program.
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TABLE 1. List of 20 Training-Related Website Variables Assessed for Each Accreditation Council for Graduate Medical Education-Accredited NM and NR Program’s Website. Online Variables Alumni listing Application information for International Medical Graduates Application requirements Away rotation descriptions Call responsibilities Case log Current residents/fellows Didactic schedule Faculty listing Hospital information
Number of positions available Number of residents/fellows
Program coordinator contact information Program director contact information Research done at institution Rotation scheduling Salary and benefits Specified NM/NR faculty Social information Technology description
The 20 online variables were compared by ACGME classification of NM vs. NR, program size, and separate webpage status using Mann-Whitney U tests, considering a p value < 0.05 as indicative of significance. The Association of American Medical Colleges (AAMC) Careers in Medicine website was also accessed to evaluate what information medical students are exposed to regarding NM/NR careers when accessing the specialty information website. RESULTS Workforce Trends
Annual hiring of all radiologists rose by 47.9% from 1239 in 2011 to 1833 in 2016 (Fig 1). Growth in hiring outpaced
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projected values based on the ACR survey estimates in 2014 (1114 projected vs. 1393 hired), in 2015 (1323 projected vs. 1707 hired), and in 2016 (1688 projected vs. 1830 hired). This held true for NM/NR specifically: 23 projected vs. 46 hired in 2014, 30 projected vs. 51 hired in 2015, and 51 projected vs. 62 hired in 2016. There has been increasing subspecialization within radiology, with generalists comprising 35.2% of all radiologists in 2012, 12.8% in 2015, and 10.4% in 2017 (Fig 2). Between 2012 and 2017, the greatest increases in the radiology workforce were seen in general interventional (8.4% 12.7%) and neuroradiology (7.7% 12.5%). By 2017, the nuclear subspecialty accounted for 4.5% of radiologists compared to 3.3% in 2012 (Fig 2).
Training Pathways—Overview
The first traditional training pathway to NM/NR practice is 3 years of ACGME-accredited NM-specific training following 1 year of postgraduate medical education. The second involves 2 years of ACGME-accredited NM-specific training following 2 or more years of postgraduate medical education. These two pathways currently lead to eligibility only for certification through the ABNM. The third pathway entails completion of an ACGME-accredited DR residency, followed by a 1-year ACGME-accredited fellowship in NR leading to certifications in DR and NR through The American Board of Radiology (ABR); such a graduate might also meet the eligibility requirements for ABNM certification. There are two newer nontraditional NM/NR pathways. The first new pathway was established when the ABR introduced a 16-month pathway leading to certifications in DR and NR in 2010 which was substantially redesigned it in 2017.
Figure 1. 2017 American College of Radiology Survey Results: Hiring/projection trends from 2011 to 2017.
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Figure 2. 2017 American College of Radiology Survey Results: current radiology workforce by subspecialty from 2012 to 2017.
From 2010 to 2016, only ACGME-accredited DR programs with companion ACGME-accredited NM/NR programs were qualified to participate, restricting adoption and limiting enrollment (22). Of the 16 months, four were DR core training, followed by an additional 12 months specifically in NM/NR. Starting in 2017, the ACGME-accredited DR program need not be paired with a NM/NR program—4 months are still dedicated to DR core NM/NR training, but only 8 of the additional 12 months need to be specifically in NM/NR given that up to 4 months can be dedicated to NM/NR/ molecular imaging-related training (recognizing the correlative aspects in practice). In this redesign, any sequence of the 16 months is allowed at any time during the 48-month DR residency, in contrast to the original pathway. The second new nontraditional pathway is a comprehensive integrated 5-year DR/NM/NR program applied directly from medical school through the national resident matching program (NRMP). The curriculum is along the lines of 36 months of DR and 24 months of NR/NM. Each component is individually ACGME-accredited. Training Pathways—Current Trends
For the three traditional training pathways to NM/NR practice, there has been a decrease in the combined number of e4
ACGME-accredited NM/NR programs and the number of corresponding residents/fellows from 2007 to 2018. In 2007 2008, there were 79 programs with a combined total of 173 trainees. However, by 2017 2018, those combined numbers had decreased to 58 programs (26.6% decrease) and 82 trainees (52.6% decrease). Though these combined numbers have declined over the last 11 years, the field of NM/ NR has undergone an evolution in its training pathways, particularly with efforts to integrate DR and NM/NR (23). For the newer nontraditional NM/NR pathways, the redesigned ABR 16 month allows any ACGME-accredited DR or IR program to accommodate the ABR 16-month pathway for its trainees. As of March 24, 2019, there are 36 DR or IR residency programs participating and 64 trainees enrolled (Table 2). At present, this new pathway is recognized by the ABR, but not by the ABNM although graduates might meet the criteria to sit for the ABNM examination. The redesigned pathway has a few more stringent requirements than the original pathway. Positron emission tomography/computed tomography (PET/CT) and single photon emission/CT (SPECT/CT) are now mandated. In the original pathway, as per core DR training, only three low-dosage and three high-dosage radioactive iodine (RAI) therapies were required, but the redesigned pathway requires 15 RAI and five parenteral therapies (Table 3). The integrated 5-year
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TABLE 2. DR Residencies Currently Participating in the Redesigned 2017 ABR Pathway. DR Residencies Participating in Redesigned Pathway Baylor University Medical Center Bryn Mawr Hospital Case Western Reserve/University Hospital of Cleveland Cleveland Clinic Foundation Drexel University College of Medicine/Hahnemann University Hospital Duke University Georgetown University Hartford Hospital Indiana University School of Medicine Loma Linda University Louisiana State University Shreveport Program Mallinckrodt/Washington University/Barnes-Jewish Hospital/St. Louis Children’s Hospital Consortium Massachusetts General Hospital/Harvard Medical School Mayo Clinic College of Medicine (Arizona) Program Mayo School of Graduate Medical Education (Jacksonville) Mayo School of Graduate Medical Education (Rochester) Medical College of Wisconsin (affiliated) Medical University of South Carolina Mt. Sinai Medical Center of Florida
New York Presbyterian Hospital (Columbia Campus) Pennsylvania Hospital of the University of Pennsylvania Health System Rutgers-Robert Wood Johnson Medical School St. Joseph’s Hospital & Medical Center St. Vincent’s Medical Center Staten Island University Hospital SUNY Upstate (Syracuse) Medical University University of Alabama Medical Center University of California (San Diego) University of California (San Francisco) University of Kentucky College of Medicine University of Michigan University of Pennsylvania University of Tennessee at Knoxville University of Vermont University of Wisconsin Wake Forest University School of Medicine West Virginia University
The University of Pennsylvania has an IR program participating in the redesigned 16-month pathway.
TABLE 3. American Board of Radiology (ABR) 16-Month pathway to Nuclear Radiology (NR) Certification (2010 vs. 2017).
Application Curriculum
Original (2010)
Redesigned (2017)
➢ Only ACGME-accredited DR programs with accredited NR/NM program ➢ 4 DR-core NR/NM months ➢ 12 NR/NM months ➢ Up to 2 NR/NM months in PGY1/pre-R1 may count toward the 16 (10 consecutive months mandatory)
➢ ACGME-accredited DR or IR programs with or without NR/NM program ➢ 4 DR-core NR/NM months ➢ 8 additional NR/NM months ➢ 4 NR/NM/molecular imaging (MI)-related months ➢ Up to 2 NR/NM months in PGY1/pre-R1 may count toward the 16 (any sequence allowed) ➢ Mandated ➢ Core DR therapies and additional therapies (15 oral RAI and 5 parenteral) ➢ ABR
PET/CT and SPECT/CT Therapies
➢ Not mandated ➢ Core DR (3 + 3 RAI)
Certification
➢ ABR
ACGME, Accreditation Council for Graduate Medical Education; NM, nuclear medicine; DR, diagnostic radiology; IR, interventional radiology; PGY, postgraduate year; RAI, radioactive iodine.
DR/NM/NR program is limited in availability, with only Stanford University, University of California (Davis), and Johns Hopkins University currently participating. Online Presence
Ninety-three percent (54/58) of ACGME-accredited NM and NR programs contained websites and were included for online content analysis. The mean number of positions per program open to applicants in 2018 2019 was 1.37 § 1.02, while the total number of NM/NR residents/fellows per program across training years in 2017 2018 was 1.63 § 1.7. Thirteen of 54 (24%) had 2 or more positions open for 2018 2019 and were
classified as large. The ACGME classified 39 as “nuclear medicine” and 15 as “nuclear radiology.” Twenty-three programs’ websites described their programs as a residency, 22 as a fellowship, and 9 as having both options. Twenty programs described themselves as having multiple length-of-training options. Six programs were self-described “joint programs.” However, of all 54 programs self-specifying their program type, there were 11 distinct responses for a program’s self-identified title (Table 4). There were only 22 programs that had a unique webpage for their training program which was separate from their DR department website (with exception of University of California, Los Angeles (UCLA), all of the NM departments are divisions or sections with Radiology departments). e5
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TABLE 4. Different Self-identified Titles of NM/NR Programs, Verbatim. Self-identified Title of Program Nuclear Medicine Residency Nuclear Medicine Fellowship Nuclear Radiology Fellowship Nuclear Medicine Residency and Fellowship Nuclear Radiology/Nuclear Medicine Fellowship Nuclear Medicine/Diagnostic Radiology Combined Residency Nuclear Medicine Diagnostic Radiology and Nuclear Medicine Residency Nuclear Medicine and Molecular Imaging Training Nuclear Medicine: Molecular Imaging and Therapeutics Fellowship Joint Program in Nuclear Medicine (JPNM) Residency
26 10 9 2 1 1 1 1 1 1 1
Of the 54 training program websites evaluated, the mean number of online criteria met per program was 7.74 § 3.2 of 20 (38.7%). The maximum score for a single program was 15/ 20 (75%). The items most commonly accessible from program websites included program coordinator contact (83%), description of technology covered in curriculum (74%), and application requirements (72%) (Fig 3). Least commonly found on
program websites were a description of away rotation opportunities (2%), a sample log of cases by residents/fellows (13%), a listing of alumni (13%), information on social events for trainees or social events open to the community (20%), and expected salary and benefits (22%). Only 6 of the 20 online content criteria were found on over 50% of program websites, whereas 11 criteria were found on only a third or less. Large programs were associated with a significantly greater measure of online comprehensiveness compared to small programs (9.31 § 3.0 vs. 7.24 § 3.1 of 20; p = 0.038) (Table 5). Additionally, training programs that had dedicated websites separate from the department website were also associated with a significantly greater number of online comprehensiveness measures (10.0 § 2.2 vs. 6.19 § 2.8 of 20; p < 0.001). Though websites of programs classified as NM had greater comprehensiveness than those classified as NR, this difference was not statistically significant. Furthermore, on the AAMC Careers in Medicine specialty information website, a comprehensive overview of “nuclear medicine” with salary information was observed, whereas “nuclear radiology” was listed but with little to no information on the subspecialty. Furthermore, “nuclear medicine” was designated as having a “3-year length of training” whereas “nuclear radiology” was designated as having a “1-year length of training” with no further information.
Figure 3. Percent of NM and NR program websites with specified content (n = 54).
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TABLE 5. Twenty Online Criteria: Mean number and Percentage of Criteria Met by Programs (N = 54), by ACGME NM or NR Classification, Program Size, and Separate Webpage Status. Mean Percent Criteria Met All programs (N = 54) 39% NM vs. NR NM (n = 37) 40% NR (n = 17) 35% Program size Small (n = 41) 36% Large (n = 13) 47% Separate webpage No (n = 32) 31% Yes (n = 22) 50%
Mean Number Criteria Met
p Value
7.74 (3.2) 8.14 (3.3) 6.88 (2.8)
0.219
7.24 (3.1) 9.31 (3.0)
0.038
6.19 (2.8) 10.0 (2.2)
<0.001
DISCUSSION This study evaluates workforce trends, training pathways, and information available online for prospective applicants and medical students interested in a career in NM/NR. The challenges facing NM/NR may be rooted in limited medical student exposure to NM/NR (24 26). Consequently, previous evaluations on the state of NM/NR have called for more intensive exposure and recruitment of medical students and early-stage radiology residents (24). Efforts from the Alliance of Medical Student Educators in Radiology have included formalizing objectives for medical school radiology curricula to include NM didactics (25) as well as including the practice of NM in a longitudinally integrated radiology course during the second half of medical school (26). Such endeavors are important for attracting outstanding trainees to presently unfilled positions in training programs. Prospective NM/NR trainees share significant concerns about their future after training, including job prospects as well as financial and subspecialty viability (27 29). Similar to an earlier analysis of heterogeneous work patterns for NMtrained physicians (5), surveyed NM/NR physicians reported that they spent nearly half of full-time work on work outside of NM/NR, with considerable variability by practice type. However, these factors should not mask a potentially improving market for NM/NR physicians with growth in hiring outpacing ACR projections from 2014 to 2016 and with increasing demand for specialized PET/CT imaging (30). Nevertheless, the gap between ACR projections and actual hiring of NM/NR physicians has also decreased slightly over the time period, suggesting that this growth may be potentially slowing due to factors like shrinking numbers of newly trained NM/NR physicians. However, future studies should reexamine hiring trends in the context of NM and NR certificates issued once the first graduates of the 2017 redesigned pathway are eligible to sit for examinations to provide a better picture of NM/NR physicians entering the workforce.
Accordingly, the low proportion of NM/NR subspecialists among early-career radiologists has raised concerns of shifting subspecialty interests away from NM/NR among more recently-trained radiologists (4). Our study corroborates this trend, demonstrating 26.6% and 52.6% decreases over the past decade in the number of NM/NR programs and trainees, respectively. Furthermore, an estimated 46% of NM residency positions are unfilled annually (31), and 65% of NR fellowship spots went unfilled in the 2015-2016 academic year (32). Future investigations may be directed toward documenting proportions of NM residency graduates that went on to pursue additional NM training, opted for DR training, or were hired for NM-specific positions to provide medical students a realistic picture of what opting for NM-only training might hold. Our evaluation of the NM/NR specialty’s training outlook assessed the 2017 ABR 16-month pathway. This redesigned training model may address concerns medical students have about training in NM/NR. For example, despite exposure to radionuclide therapies that previously distinguished NM from NR and DR training, an insufficient focus on therapies has been cited as a factor behind the decline of NM programs (10). The introduction of additional RAI and parenteral therapies through this redesigned pathway may push back on this perception. This is an important change given the growth of therapeutic radiopharmaceuticals and theragnostics. The improved ability to accommodate a traditional fellowship or more research experience may also make NM/NR training more attractive to trainees. There has been rapid growth in the redesigned 2017 ABR pathway since its inception, with 64 trainees enrolled from 36 participating programs. Greater collaboration of stakeholders, particularly the ABNM and ABR, leading the training of NM/NR physicians will be important for the future of NM/NR. Approximately half of ABNM diplomates certified from 2001 to 2016 were also certified in DR by the ABR (9). As NM/NR continues to evolve and boundaries with similar specialties and subspecialties are increasingly blurred, there have been concerns raised that NM/NR may face substantial conflicts with other medical disciplines over training and the techniques that fall within NM/NR’s domain (10). Nevertheless, steps have been taken to rectify this divide, such as the ABNM’s recent encouragement of dual certification in NM and DR to improve trainees’ employment options as well as greater collaboration between NM and Radiology professional societies, notably the SNMMI and ACR (9). Continued intersociety cooperation for objectives, such as bolstering exposure and recruitment through initiatives like the Alliance of Medical Student Educators in Radiology, will be necessary to address the specialty’s ongoing challenges. An evaluation of 54 NM and NR websites using 20 commonly-utilized or specialty-specific content variables demonstrated significant heterogeneity and shortcomings in programs’ online presence, with programs only meeting an average of 38.7% online criteria and over half of criteria present on less than 33% of websites. These findings are comparable to those of previous evaluations of certain other e7
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specialties, including 37% 40% for plastic surgery (19), 46% for otolaryngology (18), and 46% 49% for neurosurgery (17). This result was comparable to earlier estimations of website comprehensiveness for NM residencies at 32% (31). However, it is notable that the content level of NM and NR program websites lagged behind that of websites for DR programs, which contained an average of 61% of content variables (16). While Plas et al. found no difference in website comprehensiveness when classifying programs by location or Doximity ranking (31), we found that larger program websites contain more content. This observation parallels the findings of studies for several other specialties and most likely reflects the greater resources larger programs have to invest into their online presence (17 19,33). Programs with a separate page for online information were also more comprehensive with more space for detail. Nevertheless, there is substantial room for improvement of online content, particularly regarding items such as listing of types of cases covered by residents/fellows, alumni information, salary and benefits, and listing of current trainees. The paucity of NM- and NR-related info from overarching umbrella organizations, including the AAMC, also highlights the need to increase representation of NM/NR information in central sources for interested medical students. Improving the accessibility and completeness of online information may represent a low-resource and efficient way for NM/NR programs to augment recruitment. While the 2017 ACR Commission on Human Resources Workforce Survey provides useful insight into radiology hiring projections and trends, it is limited by the response rate to accurately represent one third of US radiologists. Data distinguishing the number and demographics (e.g., US vs. international medical graduate) of trainees in the five separate pathways is not publicly available, though availability of such data could have provided useful context in this study. While most nuclear cardiology studies are now read by cardiologists (34), detailed information about the associated demand for NM/NR physicians based on percent of nuclear cardiology read by cardiologists over time is beyond the scope of this paper. Our analysis of online content for NM and NR programs faces some potential limitations. First, there is no strictly objective method of selection for the 20 website content variables that were used to quantify website comprehensiveness. However, the present study not only utilized variables that have been studied in the majority of earlier online content studies for other specialties (11,17 21), but also evaluated content variables of special interest to NM and NR applicants, such as technology and treatment modalities included in the curriculum. Moreover, data collection on online content variables may have yielded different results on comprehensiveness if conducted by different authors. However, there was high agreement between the two authors collecting data for the present study, with a mediating third author finding and resolving disparities in less than 5% of items. Finally, not all items may hold equal value to prospective trainees; nevertheless, this would not affect the primary e8
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purpose of this section of the investigation, which was to identify specific areas for improvement. The present study found decreasing NM/NR recruitment into the traditional pathways and increasing participation in the redesigned ABR 16-month pathway. Furthermore, we documented three areas with importance regarding the progression of NM/NR and education of future trainees: an increase in unfilled workforce positions, expansion in training pathways for NM/NR certification, and a paucity of online information available to prospective applicants, particularly with respect to what types of cases trainees may expect to manage and a listing program alumni and their respective placements following training. Despite a steady hiring progression, NM/NR faces potential stagnation if the number of applications and training programs continue to decline (22). In this rapidly evolving field, it is imperative to champion NM/NR training and bolster the information accessible to potential NM/NR applicants as they weigh career options. DISCLOSURE No funding was received for this work. REFERENCES 1. Graham MM, Metter DF. Evolution of nuclear medicine training: past, present, and future. J Nucl Med 2007; 48(2):257–268. 2. Arevalo-Perez J, Paris M, Graham MM, Osborne JR. A Perspective of the Future of Nuclear Medicine Training and Certification. Semin Nucl Med 2016; 46(1):88–96. doi:10.1053/j.semnuclmed.2015.10.003. 3. Guiberteau MJ, Graham MM. ACR-SNM Task Force on Nuclear Medicine Training: report of the task force. J Nucl Med 2011; 526:998–1002. doi:10.2967/jnumed.111.092171. 4. Rosenkrantz AB, Wang W, Hughes DR, Duszak Jr. R. Generalist versus Subspecialist Characteristics of the U.S. Radiologist Workforce. Radiology 2018; 286(3):929–937. doi:10.1148/radiol.2017171684. 5. Balthazar P, Schuster DM, Grady EE, Rosenkrantz AB, Duszak Jr. R. Current Clinical Practice Patterns of Self-Identified Nuclear Medicine Specialists. AJR Am J Roentgenol 2018; 211(5):978–985. doi:10.2214/ AJR.18.20005. 6. Training Requirements for the ABNM Certifying Examination. The American Board of Nuclear Medicine (ABNM). https://www.abnm.org/index. php/exam/training-requirements/. February 17, 2015. Accessed January 10, 2019. 7. DR Certified Requirements. The American Board of Nuclear Medicine (ABNM). https://www.abnm.org/index.php/dr-certified-requirements/. 2019. Accessed January 10, 2019. 8. Nuclear Radiology: Requirements and Registration. American Board of Radiology. https://www.theabr.org/diagnostic-radiology/subspecialties/ nuclear-radiology/requirements-registration. January 31, 2019. Accessed January 31, 2019. 9. Segall GM, Grady EE, Fair JR, Ghesani MV, Gordon L. Nuclear Medicine Training in the United States. J Nucl Med 2017; 58(11):1733–1734. doi:10.2967/jnumed.117.200857. 10. Mankoff D, Pryma DA. Nuclear Medicine Training: What Now? J Nucl Med 2017; 58(10):1536–1538. doi:10.2967/jnumed.117.190132. 11. DePietro DM, Kiefer RM, Redmond JW, Hoffmann JC, Trerotola SO, Nadolski GJ. The 2017 Integrated IR Residency Match: Results of a National Survey of Applicants and Program Directors. J Vasc Interv Radiol 2018; 29(1):114–124. doi:10.1016/j.jvir.2017.09.009. 12. Gaeta TJ, Birkhahn RH, Lamont D, Banga N, Bove JJ. Aspects of residency programs' web sites important to student applicants. Acad Emerg Med 2005; 12(1):89–92. doi:10.1197/j.aem.2004.08.047. 13. Bluth EI, Bansal S, Bender CE. The 2017 ACR Commission on Human Resources Workforce Survey. J Am Coll Radiol 2017; 14(12):1613–1619. doi:10.1016/j.jacr.2017.06.012.
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14. List of Programs by Specialty: Nuclear Medicine Programs, Academic Year 2017-2018. Accreditation Council for Graduate Medical Education (ACGME). https://apps.acgme.org/ads/Public/Reports/Report/1. 2018. Accessed January 15, 2018. 15. List of Programs by Specialty: Nuclear Radiology Programs, Academic Year 2017-2018. Accreditation Council for Graduate Medical Education (ACGME). https://apps.acgme.org/ads/Public/Reports/Report/1. 2018. Accessed January 15, 2018. 16. Hansberry DR, Bornstein J, Agarwal N, McClure KE, Deshmukh SP, Long S. An Assessment of Radiology Residency Program Websites. J Am Coll Radiol 2018; 15(4):663–666. doi:10.1016/j.jacr.2017.11.010. 17. Skovrlj B, Silvestre J, Ibeh C, Abbatematteo JM, Mocco J. Neurosurgery Residency Websites: A Critical Evaluation. World Neurosurg 2015; 84 (3):727–733. doi:10.1016/j.wneu.2015.04.051. 18. Svider PF, Gupta A, Johnson AP, Zuliani G, Shkoukani MA, Eloy JA, et al. Evaluation of otolaryngology residency program websites. JAMA Otolaryngol Head Neck Surg 2014; 140(10):956–960. doi:10.1001/ jamaoto.2014.1714. 19. Silvestre J, Tomlinson-Hansen S, Fosnot J, Taylor JA. Plastic surgery residency websites: a critical analysis of accessibility and content. Ann Plast Surg 2014; 72(3):265–269. doi:10.1097/SAP.0000000000000125. 20. Ruddell JH, Eltorai AEM, Mark AS, Raman S, Sams CM. What’s missing? An analysis of pediatric radiology fellowship website utility and recruitment potential. Pediatr Radiol 2019; 49(6):723–726. doi:10.1007/ s00247-019-04381-w. 21. Chu LF, Young CA, Zamora AK, Lowe D, Hoang DB, Pearl RG, et al. Selfreported information needs of anesthesia residency applicants and analysis of applicant-related web sites resources at 131 United States training programs. Anesth Analg 2011; 112(2):430–439. doi:10.1213/ ANE.0b013e3182027a94. 22. Oates ME, Guiberteau MJ. Adoption of the 16-month American Board of Radiology pathway to dual board certifications in nuclear radiology and/ or nuclear medicine for diagnostic radiology residents. Acad Radiol 2014; 21(10):1348–1356. doi:10.1016/j.acra.2014.05.015. 23. Oates ME. Integrated residency training pathways of the future: diagnostic radiology, nuclear radiology, nuclear medicine, and molecular imaging. J Am Coll Radiol 2012; 9(4):239–244. doi:10.1016/j.jacr.2011.12.017.
24. Harolds JA, Novelline RA, Guiberteau MJ, Metter D, Oates ME. Jobs and new initiatives in nuclear medicine education. J Nucl Med 2011; 52 (3):17N–23N. 25. Alliance of Medical Student Educators in Radiology (AMSER). AMSER Learning Objectives for a Medical School Radiology Curriculum. Association of University Radiologists (AUR), 2018 https://www.aur.org/uploadedFiles/Alliances/AMSER/AMSER-Learning-Objectives-Listed-by-Subject(1).pdf Accessed February 2, 2019. 26. Hall TR. Longitudinal Integration of a Radiology Course in the Clinical Continuum. Association of University Radiologists, 2013 https://www.aur.org/ WorkArea/DownloadAsset.aspx?id=1237 Accessed February 2, 2019. 27. Harolds JA, Oates ME, Metter DF, Guiberteau MJ. Are nuclear medicine residents prepared for employment? A survey-informed perspective. J Am Coll Radiol 2014; 11(3):221–224. doi:10.1016/j.jacr.2013.07.010. 28. Osborne JR, Beylergil V, Samitt C, Graham MM. Roundtable on the Future of Nuclear Medicine Training. J Nucl Med 2015; 56(12):1966– 1969. doi:10.2967/jnumed.115.165621. 29. Harolds JA, Guiberteau MJ, Metter DF, Oates ME. Career prospects for graduating nuclear medicine residents: survey of nuclear medicine program directors. J Am Coll Radiol 2013; 10(8):593–598. doi:10.1016/j. jacr.2013.02.018. 30. Harolds JA, Metter D, Oates ME, Guiberteau MJ. CT training of nuclear medicine residents in the United States, 2013-2014. J Am Coll Radiol 2015; 12(1):59–62. doi:10.1016/j.jacr.2014.08.006. 31. Plas TLV, Novin SA, Yi PH. How comprehensive are nuclear medicine residency websites? World J Nucl Med 2018; 17(4):223–227. doi:10.4103/wjnm.WJNM_67_17. 32. Harolds JA, Guiberteau MJ, Oates ME. Recruitment Into a Combined Radiology/Nuclear Medicine Subspecialty. J Am Coll Radiol 2017; 14 (1):122–124. doi:10.1016/j.jacr.2016.06.033. 33. Silvestre J, Guzman JZ, Skovrlj B, Overley SC, Cho SK, Qureshi SA, et al. The Internet as a communication tool for orthopedic spine fellowships in the United States. Spine J 2015; 15(4):655–661. doi:10.1016/j. spinee.2014.11.024. 34. Guiberteau MJ, Oates ME. Counterpoint: Nuclear Medicine’s Decline: Radiology Is the Solution, Not the Problem. J Am Coll Radiol 2018; 15(3 Pt A):387–389. doi:10.1016/j.jacr.2017.11.029.
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Original Investigation
The Current State of Nuclear Medicine and Nuclear Radiology: Workforce Trends, Training Pathways, and Training Program Websites Jack H. Ruddell, BA, Adam E.M. Eltorai, MD, PhD, Oliver Y. Tang, BS, Johanna A. Suskin, BA, Elizabeth H. Dibble, MD, M. Elizabeth Oates, MD, Don C. Yoo, MD
Background: Nuclear medicine (NM) is a multidisciplinary field. Its overlap with nuclear radiology (NR) creates unique training considerations, opportunities, and challenges. Various factors impact the workforce, training needs, and training pathways. This state of flux may be perplexing to prospective NM/NR trainees. Purpose: To evaluate the state of NM/NR training by assessing the (1) workforce trends and job prospects for NM/NR trainees, (2) NM and NR training pathways, and (3) applicant-accessible online presence of training programs. Methods: Workforce trends were analyzed using data collected from the 2017 American College of Radiology Commission on Human Resources Workforce Survey. Information regarding the training pathways leading to board certification(s) for NM and NR physicians were obtained through the American Board of Nuclear Medicine, the American Board of Radiology (ABR), and the Society of Nuclear Medicine and Medical Imaging. Each Accreditation Council for Graduate Medical Education-accredited NM residency or NR fellowship training program’s website was reviewed for 20 content items to assess its comprehensiveness for those seeking information regarding eligibility, applications, training curriculum, and program characteristics. Results: Number of hires for NM/NR physicians has exceeded the projected number of hires from 2014 to 2017. In the last decade, there has been a greater than 25% decrease in the combined number of traditional NM residencies and NR fellowships (79 58 programs) and a greater than 50% decrease in the combined number of NM and NR trainees (173 82 trainees). In 2017, the ABR redesigned its 16-month pathway leading to specialty certification in diagnostic radiology and subspecialty certification in NR. As of March 24, 2019, there are 36 diagnostic radiology or IR residency programs with 64 trainees participating in this redesigned NR pathway. Of the 93.1% (54/58) of traditional Accreditation Council for Graduate Medical Education-accredited NM and NR training programs having websites in the 2017 2018 academic year, the mean number of online criteria met per program was 7.74 § 3.2 of 20 (38.7%). Conclusion: Recruitment into the traditional NM/NR training pathways has been steadily declining, but there has been a renewed interest with the redesigned ABR 16-month pathway. There is a paucity of online information available to prospective NM/NR applicants. In this rapidly evolving and unique field, it is important to streamline NM/NR training and bolster the information accessible to potential NM/NR applicants as they weigh career options. Key Words: Fellowship; Nuclear medicine; Nuclear radiology; Online; Training; Residency; Websites; Work force. © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION Acad Radiol 2019; &:e1–e9 From the Warren Alpert Medical School, Brown University, Providence, Rhode Island (J.H.R., A.E.M.E., O.Y.T., J.A.S.); Division of Nuclear Medicine, Department of Diagnostic Imaging, Warren Alpert Medical School, Brown University, 593 Eddy Street, Providence, RI (E.H.D., D.C.Y.); Department of Radiology, University of Kentucky College of Medicine; Lexington, Kentucky (M.E.O.). Received June 7, 2019; revised September 16, 2019; accepted September 24, 2019. Address correspondence to: D.C.Y. e-mail: [email protected] © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2019.09.026
T
he multidisciplinary nature and evolution of nuclear medicine (NM)/nuclear radiology (NR) raise promising prospects for the field but also create substantial challenges for training programs and pathways. Since the establishment of the American Board of Nuclear Medicine (ABNM) in 1971 and the first subspecialty certification from the ABR called “Special Competence in Nuclear Radiology” in 1973, the practice of NM has changed dramatically, with the addition e1
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of new diagnostic radiopharmaceuticals, advanced instrumentation, and parenteral therapies (1). The training pathways for NM physicians have evolved with Accreditation Council for Graduate Medical Education (ACGME) NM program requirements undergoing significant expansion in 2007, currently requiring 3 years of training for residents and offering accelerated curricula for graduates of internal medicine (2 years) or radiology (1 year, akin to a fellowship) residencies (1,2). However, the large variety of training pathways has complicated educational reform, including the development of clinical competencies and the standardization of experience and range of skills for trainees (2,3). NM has also increasingly overlapped with NR, a subspecialty fellowship program also accredited by the ACGME). Despite attempts to increase the number of physicians entering NM/NR by reforming training requirements, the number of physicians achieving board eligibility in NM annually has generally remained between 80 and 100 since 1977 (1,2). Due to the underrepresentation of NM/NR subspecialists among early career radiologists, with only 0.9% undergoing NM/NR training, there have been calls to revamp outreach efforts to medical students, diagnostic radiology (DR) residents, and even interventional radiology (IR) residents (4). Furthermore, while a 2018 assessment of Medicare claims data determined that radiologists primarily subspecializing in NM/NR were more likely to practice in academic and large group practice settings, generally within radiology departments, the workforce prospects of future NM/NR graduates remains less characterized (4). This is critical because the work patterns of NM/NR specialists are remarkably heterogeneous, with one national evaluation quantifying that self-identifying NM/NR physicians spent anywhere between 10% and 90% of their time on NM/NR-specific services (5). Thus, it is paramount to evaluate NM/NR’s future workforce demands and training paradigms. There have been three traditional training pathways to NM/NR practice, with the recent additions of nontraditional fourth and fifth pathways (6 9). The multitude of options offer flexibility to bring physicians into the field of NM/NR from a variety of training backgrounds. However, such an abundance of training pathways, in combination with often disjoint publicly available information regarding their differences, has been described as confusing for physicians and medical students alike (10). Thus, concise clarification and synthesis of pathways is needed. The quality of the online presence of NM/NR programs may play a substantial influential role in enhancing recruitment. One assessment of applicants to IR programs found that they ranked program websites as the single most important source of information, above the advice of mentors and residents/fellows (11). Moreover, 41% of emergency medicine residency applicants chose not to apply to a program because of the quality of its website, highlighting the significant role that online content plays in informing and attracting prospective trainees (12). Online information from NM/NR websites may play a significant role in not only clarifying the dynamic changes in the field and its training pathways, but also in attracting prospective applicants to the discipline altogether. e2
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Consequently, the objective of this study is to evaluate the state of NM/NR training by assessing the (1) workforce trends and job prospects for NM/NR trainees, (2) NM and NR training pathways, and (3) applicant-accessible online presence of training programs. MATERIALS AND METHODS Workforce Trends
Workforce trends were analyzed using published data from the 2017 ACR Commission on Human Resources Workforce Survey (13). The survey was sent to academic department chairs or private practice group leaders in the Practice of Radiology Environment Database. In all, 477 groups (26%) responded, representing 11,056 of 33,659 radiologists (33%) in the United States. Among survey questions asked were the number and subspecialization of radiologists they employed or planned to hire, and whether they employed or managed nonradiologist NM physicians. The survey data were used in this investigation to evaluate percent change in hiring from 2011 to 2016, compare projected and actual hired radiologists, and to evaluate changing subspecialization patterns (particularly those of NM/NR). Training Pathways
An overview of the three traditional and two nontraditional training pathways to NM/NR practice was synthesized using information obtained from the ABNM, ABR, and the Society of Nuclear Medicine and Molecular Imaging (SNMMI). Information regarding changes, updates, and program/applicant trends in the five training pathways for NM/NR physicians were obtained through the ABNM (6,7), ABR (8), and the SNMMI (9). A list of accredited NM and NR programs during the 2017 2018 academic year was obtained from the ACGME’s Accreditation Data System (14,15). Online Presence
Each training program website was investigated by two authors (OYT and JAS, MD candidates) for 20 trainingrelated variables to assess its comprehensiveness for those seeking information regarding applications, training curriculum, and program characteristics (Table 1). A third author (JHR, MD candidate) resolved disagreements in data collection, which affected fewer than 5% of items. The 20 online content items are derived from previous studies of other medical specialties (16 20) and from surveys of residency and fellowship applicants to various specialties identifying the items considered most important by applicants (12,21). Each website was evaluated for how it classified its training program to look for consistency across programs. Programs were classified in the study’s database by size (large was defined as 2 or more positions open for 2018 2019) and whether the program had a separate webpage dedicated specifically for its NM residency or NR fellowship training program.
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TABLE 1. List of 20 Training-Related Website Variables Assessed for Each Accreditation Council for Graduate Medical Education-Accredited NM and NR Program’s Website. Online Variables Alumni listing Application information for International Medical Graduates Application requirements Away rotation descriptions Call responsibilities Case log Current residents/fellows Didactic schedule Faculty listing Hospital information
Number of positions available Number of residents/fellows
Program coordinator contact information Program director contact information Research done at institution Rotation scheduling Salary and benefits Specified NM/NR faculty Social information Technology description
The 20 online variables were compared by ACGME classification of NM vs. NR, program size, and separate webpage status using Mann-Whitney U tests, considering a p value < 0.05 as indicative of significance. The Association of American Medical Colleges (AAMC) Careers in Medicine website was also accessed to evaluate what information medical students are exposed to regarding NM/NR careers when accessing the specialty information website. RESULTS Workforce Trends
Annual hiring of all radiologists rose by 47.9% from 1239 in 2011 to 1833 in 2016 (Fig 1). Growth in hiring outpaced
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projected values based on the ACR survey estimates in 2014 (1114 projected vs. 1393 hired), in 2015 (1323 projected vs. 1707 hired), and in 2016 (1688 projected vs. 1830 hired). This held true for NM/NR specifically: 23 projected vs. 46 hired in 2014, 30 projected vs. 51 hired in 2015, and 51 projected vs. 62 hired in 2016. There has been increasing subspecialization within radiology, with generalists comprising 35.2% of all radiologists in 2012, 12.8% in 2015, and 10.4% in 2017 (Fig 2). Between 2012 and 2017, the greatest increases in the radiology workforce were seen in general interventional (8.4% 12.7%) and neuroradiology (7.7% 12.5%). By 2017, the nuclear subspecialty accounted for 4.5% of radiologists compared to 3.3% in 2012 (Fig 2).
Training Pathways—Overview
The first traditional training pathway to NM/NR practice is 3 years of ACGME-accredited NM-specific training following 1 year of postgraduate medical education. The second involves 2 years of ACGME-accredited NM-specific training following 2 or more years of postgraduate medical education. These two pathways currently lead to eligibility only for certification through the ABNM. The third pathway entails completion of an ACGME-accredited DR residency, followed by a 1-year ACGME-accredited fellowship in NR leading to certifications in DR and NR through The American Board of Radiology (ABR); such a graduate might also meet the eligibility requirements for ABNM certification. There are two newer nontraditional NM/NR pathways. The first new pathway was established when the ABR introduced a 16-month pathway leading to certifications in DR and NR in 2010 which was substantially redesigned it in 2017.
Figure 1. 2017 American College of Radiology Survey Results: Hiring/projection trends from 2011 to 2017.
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Figure 2. 2017 American College of Radiology Survey Results: current radiology workforce by subspecialty from 2012 to 2017.
From 2010 to 2016, only ACGME-accredited DR programs with companion ACGME-accredited NM/NR programs were qualified to participate, restricting adoption and limiting enrollment (22). Of the 16 months, four were DR core training, followed by an additional 12 months specifically in NM/NR. Starting in 2017, the ACGME-accredited DR program need not be paired with a NM/NR program—4 months are still dedicated to DR core NM/NR training, but only 8 of the additional 12 months need to be specifically in NM/NR given that up to 4 months can be dedicated to NM/NR/ molecular imaging-related training (recognizing the correlative aspects in practice). In this redesign, any sequence of the 16 months is allowed at any time during the 48-month DR residency, in contrast to the original pathway. The second new nontraditional pathway is a comprehensive integrated 5-year DR/NM/NR program applied directly from medical school through the national resident matching program (NRMP). The curriculum is along the lines of 36 months of DR and 24 months of NR/NM. Each component is individually ACGME-accredited. Training Pathways—Current Trends
For the three traditional training pathways to NM/NR practice, there has been a decrease in the combined number of e4
ACGME-accredited NM/NR programs and the number of corresponding residents/fellows from 2007 to 2018. In 2007 2008, there were 79 programs with a combined total of 173 trainees. However, by 2017 2018, those combined numbers had decreased to 58 programs (26.6% decrease) and 82 trainees (52.6% decrease). Though these combined numbers have declined over the last 11 years, the field of NM/ NR has undergone an evolution in its training pathways, particularly with efforts to integrate DR and NM/NR (23). For the newer nontraditional NM/NR pathways, the redesigned ABR 16 month allows any ACGME-accredited DR or IR program to accommodate the ABR 16-month pathway for its trainees. As of March 24, 2019, there are 36 DR or IR residency programs participating and 64 trainees enrolled (Table 2). At present, this new pathway is recognized by the ABR, but not by the ABNM although graduates might meet the criteria to sit for the ABNM examination. The redesigned pathway has a few more stringent requirements than the original pathway. Positron emission tomography/computed tomography (PET/CT) and single photon emission/CT (SPECT/CT) are now mandated. In the original pathway, as per core DR training, only three low-dosage and three high-dosage radioactive iodine (RAI) therapies were required, but the redesigned pathway requires 15 RAI and five parenteral therapies (Table 3). The integrated 5-year
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TABLE 2. DR Residencies Currently Participating in the Redesigned 2017 ABR Pathway. DR Residencies Participating in Redesigned Pathway Baylor University Medical Center Bryn Mawr Hospital Case Western Reserve/University Hospital of Cleveland Cleveland Clinic Foundation Drexel University College of Medicine/Hahnemann University Hospital Duke University Georgetown University Hartford Hospital Indiana University School of Medicine Loma Linda University Louisiana State University Shreveport Program Mallinckrodt/Washington University/Barnes-Jewish Hospital/St. Louis Children’s Hospital Consortium Massachusetts General Hospital/Harvard Medical School Mayo Clinic College of Medicine (Arizona) Program Mayo School of Graduate Medical Education (Jacksonville) Mayo School of Graduate Medical Education (Rochester) Medical College of Wisconsin (affiliated) Medical University of South Carolina Mt. Sinai Medical Center of Florida
New York Presbyterian Hospital (Columbia Campus) Pennsylvania Hospital of the University of Pennsylvania Health System Rutgers-Robert Wood Johnson Medical School St. Joseph’s Hospital & Medical Center St. Vincent’s Medical Center Staten Island University Hospital SUNY Upstate (Syracuse) Medical University University of Alabama Medical Center University of California (San Diego) University of California (San Francisco) University of Kentucky College of Medicine University of Michigan University of Pennsylvania University of Tennessee at Knoxville University of Vermont University of Wisconsin Wake Forest University School of Medicine West Virginia University
The University of Pennsylvania has an IR program participating in the redesigned 16-month pathway.
TABLE 3. American Board of Radiology (ABR) 16-Month pathway to Nuclear Radiology (NR) Certification (2010 vs. 2017).
Application Curriculum
Original (2010)
Redesigned (2017)
➢ Only ACGME-accredited DR programs with accredited NR/NM program ➢ 4 DR-core NR/NM months ➢ 12 NR/NM months ➢ Up to 2 NR/NM months in PGY1/pre-R1 may count toward the 16 (10 consecutive months mandatory)
➢ ACGME-accredited DR or IR programs with or without NR/NM program ➢ 4 DR-core NR/NM months ➢ 8 additional NR/NM months ➢ 4 NR/NM/molecular imaging (MI)-related months ➢ Up to 2 NR/NM months in PGY1/pre-R1 may count toward the 16 (any sequence allowed) ➢ Mandated ➢ Core DR therapies and additional therapies (15 oral RAI and 5 parenteral) ➢ ABR
PET/CT and SPECT/CT Therapies
➢ Not mandated ➢ Core DR (3 + 3 RAI)
Certification
➢ ABR
ACGME, Accreditation Council for Graduate Medical Education; NM, nuclear medicine; DR, diagnostic radiology; IR, interventional radiology; PGY, postgraduate year; RAI, radioactive iodine.
DR/NM/NR program is limited in availability, with only Stanford University, University of California (Davis), and Johns Hopkins University currently participating. Online Presence
Ninety-three percent (54/58) of ACGME-accredited NM and NR programs contained websites and were included for online content analysis. The mean number of positions per program open to applicants in 2018 2019 was 1.37 § 1.02, while the total number of NM/NR residents/fellows per program across training years in 2017 2018 was 1.63 § 1.7. Thirteen of 54 (24%) had 2 or more positions open for 2018 2019 and were
classified as large. The ACGME classified 39 as “nuclear medicine” and 15 as “nuclear radiology.” Twenty-three programs’ websites described their programs as a residency, 22 as a fellowship, and 9 as having both options. Twenty programs described themselves as having multiple length-of-training options. Six programs were self-described “joint programs.” However, of all 54 programs self-specifying their program type, there were 11 distinct responses for a program’s self-identified title (Table 4). There were only 22 programs that had a unique webpage for their training program which was separate from their DR department website (with exception of University of California, Los Angeles (UCLA), all of the NM departments are divisions or sections with Radiology departments). e5
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TABLE 4. Different Self-identified Titles of NM/NR Programs, Verbatim. Self-identified Title of Program Nuclear Medicine Residency Nuclear Medicine Fellowship Nuclear Radiology Fellowship Nuclear Medicine Residency and Fellowship Nuclear Radiology/Nuclear Medicine Fellowship Nuclear Medicine/Diagnostic Radiology Combined Residency Nuclear Medicine Diagnostic Radiology and Nuclear Medicine Residency Nuclear Medicine and Molecular Imaging Training Nuclear Medicine: Molecular Imaging and Therapeutics Fellowship Joint Program in Nuclear Medicine (JPNM) Residency
26 10 9 2 1 1 1 1 1 1 1
Of the 54 training program websites evaluated, the mean number of online criteria met per program was 7.74 § 3.2 of 20 (38.7%). The maximum score for a single program was 15/ 20 (75%). The items most commonly accessible from program websites included program coordinator contact (83%), description of technology covered in curriculum (74%), and application requirements (72%) (Fig 3). Least commonly found on
program websites were a description of away rotation opportunities (2%), a sample log of cases by residents/fellows (13%), a listing of alumni (13%), information on social events for trainees or social events open to the community (20%), and expected salary and benefits (22%). Only 6 of the 20 online content criteria were found on over 50% of program websites, whereas 11 criteria were found on only a third or less. Large programs were associated with a significantly greater measure of online comprehensiveness compared to small programs (9.31 § 3.0 vs. 7.24 § 3.1 of 20; p = 0.038) (Table 5). Additionally, training programs that had dedicated websites separate from the department website were also associated with a significantly greater number of online comprehensiveness measures (10.0 § 2.2 vs. 6.19 § 2.8 of 20; p < 0.001). Though websites of programs classified as NM had greater comprehensiveness than those classified as NR, this difference was not statistically significant. Furthermore, on the AAMC Careers in Medicine specialty information website, a comprehensive overview of “nuclear medicine” with salary information was observed, whereas “nuclear radiology” was listed but with little to no information on the subspecialty. Furthermore, “nuclear medicine” was designated as having a “3-year length of training” whereas “nuclear radiology” was designated as having a “1-year length of training” with no further information.
Figure 3. Percent of NM and NR program websites with specified content (n = 54).
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TABLE 5. Twenty Online Criteria: Mean number and Percentage of Criteria Met by Programs (N = 54), by ACGME NM or NR Classification, Program Size, and Separate Webpage Status. Mean Percent Criteria Met All programs (N = 54) 39% NM vs. NR NM (n = 37) 40% NR (n = 17) 35% Program size Small (n = 41) 36% Large (n = 13) 47% Separate webpage No (n = 32) 31% Yes (n = 22) 50%
Mean Number Criteria Met
p Value
7.74 (3.2) 8.14 (3.3) 6.88 (2.8)
0.219
7.24 (3.1) 9.31 (3.0)
0.038
6.19 (2.8) 10.0 (2.2)
<0.001
DISCUSSION This study evaluates workforce trends, training pathways, and information available online for prospective applicants and medical students interested in a career in NM/NR. The challenges facing NM/NR may be rooted in limited medical student exposure to NM/NR (24 26). Consequently, previous evaluations on the state of NM/NR have called for more intensive exposure and recruitment of medical students and early-stage radiology residents (24). Efforts from the Alliance of Medical Student Educators in Radiology have included formalizing objectives for medical school radiology curricula to include NM didactics (25) as well as including the practice of NM in a longitudinally integrated radiology course during the second half of medical school (26). Such endeavors are important for attracting outstanding trainees to presently unfilled positions in training programs. Prospective NM/NR trainees share significant concerns about their future after training, including job prospects as well as financial and subspecialty viability (27 29). Similar to an earlier analysis of heterogeneous work patterns for NMtrained physicians (5), surveyed NM/NR physicians reported that they spent nearly half of full-time work on work outside of NM/NR, with considerable variability by practice type. However, these factors should not mask a potentially improving market for NM/NR physicians with growth in hiring outpacing ACR projections from 2014 to 2016 and with increasing demand for specialized PET/CT imaging (30). Nevertheless, the gap between ACR projections and actual hiring of NM/NR physicians has also decreased slightly over the time period, suggesting that this growth may be potentially slowing due to factors like shrinking numbers of newly trained NM/NR physicians. However, future studies should reexamine hiring trends in the context of NM and NR certificates issued once the first graduates of the 2017 redesigned pathway are eligible to sit for examinations to provide a better picture of NM/NR physicians entering the workforce.
Accordingly, the low proportion of NM/NR subspecialists among early-career radiologists has raised concerns of shifting subspecialty interests away from NM/NR among more recently-trained radiologists (4). Our study corroborates this trend, demonstrating 26.6% and 52.6% decreases over the past decade in the number of NM/NR programs and trainees, respectively. Furthermore, an estimated 46% of NM residency positions are unfilled annually (31), and 65% of NR fellowship spots went unfilled in the 2015-2016 academic year (32). Future investigations may be directed toward documenting proportions of NM residency graduates that went on to pursue additional NM training, opted for DR training, or were hired for NM-specific positions to provide medical students a realistic picture of what opting for NM-only training might hold. Our evaluation of the NM/NR specialty’s training outlook assessed the 2017 ABR 16-month pathway. This redesigned training model may address concerns medical students have about training in NM/NR. For example, despite exposure to radionuclide therapies that previously distinguished NM from NR and DR training, an insufficient focus on therapies has been cited as a factor behind the decline of NM programs (10). The introduction of additional RAI and parenteral therapies through this redesigned pathway may push back on this perception. This is an important change given the growth of therapeutic radiopharmaceuticals and theragnostics. The improved ability to accommodate a traditional fellowship or more research experience may also make NM/NR training more attractive to trainees. There has been rapid growth in the redesigned 2017 ABR pathway since its inception, with 64 trainees enrolled from 36 participating programs. Greater collaboration of stakeholders, particularly the ABNM and ABR, leading the training of NM/NR physicians will be important for the future of NM/NR. Approximately half of ABNM diplomates certified from 2001 to 2016 were also certified in DR by the ABR (9). As NM/NR continues to evolve and boundaries with similar specialties and subspecialties are increasingly blurred, there have been concerns raised that NM/NR may face substantial conflicts with other medical disciplines over training and the techniques that fall within NM/NR’s domain (10). Nevertheless, steps have been taken to rectify this divide, such as the ABNM’s recent encouragement of dual certification in NM and DR to improve trainees’ employment options as well as greater collaboration between NM and Radiology professional societies, notably the SNMMI and ACR (9). Continued intersociety cooperation for objectives, such as bolstering exposure and recruitment through initiatives like the Alliance of Medical Student Educators in Radiology, will be necessary to address the specialty’s ongoing challenges. An evaluation of 54 NM and NR websites using 20 commonly-utilized or specialty-specific content variables demonstrated significant heterogeneity and shortcomings in programs’ online presence, with programs only meeting an average of 38.7% online criteria and over half of criteria present on less than 33% of websites. These findings are comparable to those of previous evaluations of certain other e7
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specialties, including 37% 40% for plastic surgery (19), 46% for otolaryngology (18), and 46% 49% for neurosurgery (17). This result was comparable to earlier estimations of website comprehensiveness for NM residencies at 32% (31). However, it is notable that the content level of NM and NR program websites lagged behind that of websites for DR programs, which contained an average of 61% of content variables (16). While Plas et al. found no difference in website comprehensiveness when classifying programs by location or Doximity ranking (31), we found that larger program websites contain more content. This observation parallels the findings of studies for several other specialties and most likely reflects the greater resources larger programs have to invest into their online presence (17 19,33). Programs with a separate page for online information were also more comprehensive with more space for detail. Nevertheless, there is substantial room for improvement of online content, particularly regarding items such as listing of types of cases covered by residents/fellows, alumni information, salary and benefits, and listing of current trainees. The paucity of NM- and NR-related info from overarching umbrella organizations, including the AAMC, also highlights the need to increase representation of NM/NR information in central sources for interested medical students. Improving the accessibility and completeness of online information may represent a low-resource and efficient way for NM/NR programs to augment recruitment. While the 2017 ACR Commission on Human Resources Workforce Survey provides useful insight into radiology hiring projections and trends, it is limited by the response rate to accurately represent one third of US radiologists. Data distinguishing the number and demographics (e.g., US vs. international medical graduate) of trainees in the five separate pathways is not publicly available, though availability of such data could have provided useful context in this study. While most nuclear cardiology studies are now read by cardiologists (34), detailed information about the associated demand for NM/NR physicians based on percent of nuclear cardiology read by cardiologists over time is beyond the scope of this paper. Our analysis of online content for NM and NR programs faces some potential limitations. First, there is no strictly objective method of selection for the 20 website content variables that were used to quantify website comprehensiveness. However, the present study not only utilized variables that have been studied in the majority of earlier online content studies for other specialties (11,17 21), but also evaluated content variables of special interest to NM and NR applicants, such as technology and treatment modalities included in the curriculum. Moreover, data collection on online content variables may have yielded different results on comprehensiveness if conducted by different authors. However, there was high agreement between the two authors collecting data for the present study, with a mediating third author finding and resolving disparities in less than 5% of items. Finally, not all items may hold equal value to prospective trainees; nevertheless, this would not affect the primary e8
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purpose of this section of the investigation, which was to identify specific areas for improvement. The present study found decreasing NM/NR recruitment into the traditional pathways and increasing participation in the redesigned ABR 16-month pathway. Furthermore, we documented three areas with importance regarding the progression of NM/NR and education of future trainees: an increase in unfilled workforce positions, expansion in training pathways for NM/NR certification, and a paucity of online information available to prospective applicants, particularly with respect to what types of cases trainees may expect to manage and a listing program alumni and their respective placements following training. Despite a steady hiring progression, NM/NR faces potential stagnation if the number of applications and training programs continue to decline (22). In this rapidly evolving field, it is imperative to champion NM/NR training and bolster the information accessible to potential NM/NR applicants as they weigh career options. DISCLOSURE No funding was received for this work. REFERENCES 1. Graham MM, Metter DF. Evolution of nuclear medicine training: past, present, and future. J Nucl Med 2007; 48(2):257–268. 2. Arevalo-Perez J, Paris M, Graham MM, Osborne JR. A Perspective of the Future of Nuclear Medicine Training and Certification. Semin Nucl Med 2016; 46(1):88–96. doi:10.1053/j.semnuclmed.2015.10.003. 3. Guiberteau MJ, Graham MM. ACR-SNM Task Force on Nuclear Medicine Training: report of the task force. J Nucl Med 2011; 526:998–1002. doi:10.2967/jnumed.111.092171. 4. Rosenkrantz AB, Wang W, Hughes DR, Duszak Jr. R. Generalist versus Subspecialist Characteristics of the U.S. Radiologist Workforce. Radiology 2018; 286(3):929–937. doi:10.1148/radiol.2017171684. 5. Balthazar P, Schuster DM, Grady EE, Rosenkrantz AB, Duszak Jr. R. Current Clinical Practice Patterns of Self-Identified Nuclear Medicine Specialists. AJR Am J Roentgenol 2018; 211(5):978–985. doi:10.2214/ AJR.18.20005. 6. Training Requirements for the ABNM Certifying Examination. The American Board of Nuclear Medicine (ABNM). https://www.abnm.org/index. php/exam/training-requirements/. February 17, 2015. Accessed January 10, 2019. 7. DR Certified Requirements. The American Board of Nuclear Medicine (ABNM). https://www.abnm.org/index.php/dr-certified-requirements/. 2019. Accessed January 10, 2019. 8. Nuclear Radiology: Requirements and Registration. American Board of Radiology. https://www.theabr.org/diagnostic-radiology/subspecialties/ nuclear-radiology/requirements-registration. January 31, 2019. Accessed January 31, 2019. 9. Segall GM, Grady EE, Fair JR, Ghesani MV, Gordon L. Nuclear Medicine Training in the United States. J Nucl Med 2017; 58(11):1733–1734. doi:10.2967/jnumed.117.200857. 10. Mankoff D, Pryma DA. Nuclear Medicine Training: What Now? J Nucl Med 2017; 58(10):1536–1538. doi:10.2967/jnumed.117.190132. 11. DePietro DM, Kiefer RM, Redmond JW, Hoffmann JC, Trerotola SO, Nadolski GJ. The 2017 Integrated IR Residency Match: Results of a National Survey of Applicants and Program Directors. J Vasc Interv Radiol 2018; 29(1):114–124. doi:10.1016/j.jvir.2017.09.009. 12. Gaeta TJ, Birkhahn RH, Lamont D, Banga N, Bove JJ. Aspects of residency programs' web sites important to student applicants. Acad Emerg Med 2005; 12(1):89–92. doi:10.1197/j.aem.2004.08.047. 13. Bluth EI, Bansal S, Bender CE. The 2017 ACR Commission on Human Resources Workforce Survey. J Am Coll Radiol 2017; 14(12):1613–1619. doi:10.1016/j.jacr.2017.06.012.
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THE CURRENT STATE OF NUCLEAR MEDICINE AND NR
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