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The relationship of nuclear medicine to other diagnostic studies
The Relationship of Nuclear Medicine to Other Diagnostic Studies C. Douglas M a y n a r d
issue of Seminars is devoted to correlative T hisstudies: ultrasound, nuclear medicine, and computed tomography. Over the past few years, with the success of ultrasound procedures (US) and the introduction of computed tomography (CT), there has been much discussion concerning the interrelationships of these techniques with nuclear medicine. A question often heard among nuclear medicine practitioners is, "Where does nuclear medicine now fit?" I would like to address this issue from the position of a nuclear medicine physician and to present some thoughts concerning the problems (or opportunities, depending on how you approach the subject) we all now face in the areas of clinical practice, education, and research because of the rapid growth of new diagnostic procedures. WHERE DOES NUCLEAR MEDICINE BELONG?
For nuclear medicine this is not a new question arising with the development of US and CT but certainly the issue is aggravated by their development. Over the past ten years, nuclear medicine has sought an identity as a speciality. As we survey the country, various practice settings have evolved. Nuclear medicine has in many instances evolved as a separate, independent, functional unit. This has most commonly occurred in large city hospitals and teaching institutions, and in some instances nuclear medicine has achieved departmental status in medical schools. More commonly, however, nuclear medicine has remained a part of a larger, traditional, functioning unit. In many institutions nuclear medicine is a division of the Department of Radiology. This is particularly true in regard to imaging proce-
From the Department of Radiology, Nuclear Medicine Section, Bowman Gray School of Medicine, Winston-Salem, N.C. Address reprint requests to C. Douglas Maynard, M.D., Department of Radiology, Nuclear Medicine Section, Bowman Gray School of Medicine, Winston-Salem, N.C. 27103. 9 1979 by Grune & Stratton, Inc. 0001-2998/79/0901-000250100/0
4
dures and is widely observed in nonteaching hospitals. In some instances, nuclear medicine, both imaging and in vitro studies, is part of the Pathology Department, but more often the in vitro studies are incorporated into the clinical laboratories as part of the Department of Pathology. With the rapid growth in multiple new radioassay procedures, the trend for these tests to be performed as part of the pathologists' or clinical chemistists' domain has accelerated. Nuclear medicine is also occasionally found "housed" in the Department of Medicine in a medical school setting, but this is uncommon in a nonacademic environment. In the past three years, trial combinations with US and CT have also been attempted. The "best" arrangement for nuclear medicine is certainly not evident from surveying what has occurred throughout the country. The specific diagnostic department in which nuclear medicine activities reside within an institution is probably more related to size of the hospital, past history of the institution, prior training of the diagnostic physicians, and internal politics, than any studied appraisal as to where it would function best. Should nuclear medicine units be separate or part of Radiology, Pathology, Internal Medicine, or some other grouping? It certainly is clear that we overlap these other disciplines. Why isn't there a simple answer? Obviously we are dealing with a very complex problem. The nuclear medicine service does not, and should not, function in isolation from other diagnostic services. For years we have attempted to coordinate our activites with other diagnostic services (i.e. radiology, pathology) but the introduction of these two new modalities, ultrasound and computed tomography, have further compounded our problems. How we resolve the day to day clinical interaction of these multiple diagnostic procedures, integrate them into our various training programs, and develop a clinical research program to relate them to patient care, may be as challenging as the very development of the technologies themselves! I would like to present a sample to some of the Seminars in Nuclear Medicine, Vol. IX, No. 1 (January), 1979
OTHER DIAGNOSTIC STUDIES
current problems in the areas of patient care, teaching, and research.
Patient Care The articles in this journal illustrate that the newer imaging procedures may be either complementray or competitive. When complementary, such as radionuclide liver imaging with abdominal ultrasound, a system must be devised within the institution to allow efficient and effective use of the information derived from each modality. When competitive, such as computed tomography of the head versus radionuclide brain imaging, proper planning to adjust personnel changes, equipment and space reguirements, etc., must be accomplished. Although currently this topic is discussed mainly in relationship to imaging techniques, it is by no means restricted to these tests. The effect of the T-4 on evaluation of Thyroid functions, and the need to correlate stress testing with thallium cardiac studies clearly demonstrates that more is involved in the problem than imaging procedures alone. In our rapidly advancing technology, the competitive and complementary nature of the test changes quickly. The accepted test today for a particular problem may be a radionuclide study, tomorrow an ultrasound procedure, later, yet another approach. The need to develop a means to effectively evaluate these changes in efficacy and to affect them within an institution is apparent. It often is necessary to perform tests in a particular sequence so that when the diagnosis is made, no further unnecessary tests need be performed. An example would be the combination of intravenous urography, radionuclide renal imaging, ultrasound, and computed tomography studies of renal mass. On occasion, a single examination provides the necessary diagnosis, but at other times a combination of tests is perferred. A systematic approach must be developed to allow for proper patient flow from test to test as required by the situation. This is difficult even when the various tests are performed in the same department, and when they must be accomplished in many separate units the problem of proper scheduling is further compounded. We certainly do not want to get into a strict "cookbook" approach to problems,
5
so a mechanism that allows considerable flexibility but functions efficiently is needed. Inefficient management. Multiple independent units within an institution tend to promote a duplication of personnel, i.e. hospital managers, secretaries, attendants, blood collectors; duplication of equipment, i.e., automatic film processors, and duplication of space needs, i.e., waiting rooms.
Space requirements and equipment needs+ Each unit vies for space and equipment. The decision as to how the available space is used, or capital equipment money is spent, is usually made by the dean, hospital administration, or some institutional committee. The support of an individual is often highly political. With the increasing problem of financing capital equipment, competition for funds will accelerate. Some way of establishing priorities among the laboratory service directors is required. Self-referral. As multiple diagnostic units evolve within an institution the clinician often participates in the diagnostic procedures. When this occurs, the problem of self-referral must be addressed. This is a complex issue since often the only individual qualified to interpret a procedure within a particular institution is the patient's own primary physician. A means also must be established to determine who within a diagnostic unit is competent to participate. From an administrative standpoint, the criteria of allowing a person to participate just because he is qualified must be questioned. Multiple participation often leads to an inefficient operation. Certainly, problems other than those mentioned are created by the multiplicity of diagnostic units. These problems vary in each institution, depending on its size, type (teaching or nonteaching), and the composition of these units.
Education The complexities of educational programs have likewise increased greatly with the development of these new technologies. Currently in nuclear medicine, there are multiple routes to certification in the field. The American Board of Radiology examines candidates in nuclear medicine as a part of their training in diagnostic radiology. This Board also affords a certificate acknowledging special competence in nuclear
6
radiology after an additional year's training. The American Board of Pathology offers a certificate in nuclear pathology following a year of specialized training. The American Board of Nuclear Medicine is a conjoint board supported by the American Board of Radiology, the American Board of Internal Medicine, the American Board of Pathology, and the Society of Nuclear Medicine, allowing individuals to be certified primarily in nuclear medicine. The coordination of individuals within the multiple tracts within an institution is becoming more and more complex. With the introduction of ultrasound and computed tomography, working out proper exposure for all the trainees, with their various needs, as part of their training programs and desires, as part of their future job expectations, is complicated. With the techniques housed in independent units, the design and implementation of the various training programs requires a proper relationship between the various institutional units. When a radiology resident's nuclear medicine exposure is in an independent nuclear medicine facility, or a nuclear medicine resident desires exposure to ultrasound, etc., a cooperative spirit must exist between these organizations. Providing adequate patient case loads for training in these specialized areas is also becoming a problem for some programs. The same difficulties exist among nuclear medicine technology training programs. Currently, miltiple tracks for certifying technologists are in existence or in the process of being developed. Exams are given by The American Registry of Radiologic Technologists, the American Society of Clinical Pathologists, and the Nuclear Medicine Technology Certifying Board, established primarily by the Technology Section of the Society of Nuclear Medicine. Adequate training programs to teach technology students from various disciplines the intricacies of both in vivo and in vitro studies will require the same cooperation as that for training programs for nuclear medicine residents. To date the most difficult aspect has been related to obtaining adequate in-vitro training for nuclear medicine technologists when these procedures are performed primarily in pathology departments with little relationship to the imaging section. Likewise, teaching medical students to apply nuclear medicine tests clinically, and to interre-
C. DOUGLAS MAYNARD
late them to all the other diagnostic studies, is not accomplished easily with the fragmentation of diagnostic units. Certainly, we must provide a forum where we can demonstrate a practical approach to the use of multiple diagnostic studies in a clinical problem. Correlative conferences between units can achieve this to some degree, but don't we need to demonstrate their dayto-day interrelationship? Can this be effectively accomplished with fragmentation of services? The future success of our field will be dependent on ending this fragmentation. Research Obviously, many hospitals that have the problem of multiple service units do not conduct research activities, so I will not belabor this issue. It appears, however, that some of the most difficult problems we face in the next five or ten years are in the area of clinical research, trying to compare, as in the articles in this journal, the various new diagnostic techniques to determine where they should be employed, in what sequence they should be performed, and how the information can best be summated to give the answer to the clinical problem at hand, Many factors make these clinical comparisons difficult. Are the instruments used up to the current state of the art? Are the diagnostic physicians of relatively equal ability in their fields? Are the tests performed within an adequate time frame for comparison? These comparisons are essential, and when performed as a team effort, very valuable; when not, they may be useless. The clinical comparison is vital to the future of our field, and without a united effort we cannot possibly achieve our goals. Separate units make this success unlikely. Another problem in clinical correlation is the determination of at what point a technique moves from the realm of clinical research to become an applicable, clinically practicle procedure, and who should finance the interim stage: the hospital, the patient, private foundations, federal grants, or the manufacturers? We are currently experiencing this phenomenon in relationship to whole body CT studies, and there is no apparent solution in sight. SOLUTIONS
I am certain that there will be many who feel that what has been presented is not much differ-
OTHER DIAGNOSTIC STUDIES
ent than problems we have encountered in the past. To some degree this is certainly true. However, rapidly advancing technology and the cost of diagnostic procedures make the problems associated with the development of multiple diagnostic units within an institution more apparent and more real. How can we better interrelate the clinical tests within an institution for the purpose of better patient care, improved educational programs, and correlative clinical research? Apparently no one has the answer, but a number of solutions have been discussed and there are trial attempts at some hospitals currently.
Imaging Division There are several experiments in the area of imaging. The amalgamation of ultrasound, nuclear medicine, and computed tomography into a single diagnostic division, often referred to as "specialized" imaging, has occurred at several institutions. Other institutions are in the process of developing departments of imaging that are an extension of the concept of specialized imaging divisions. These are mainly expansions or renamings of the Department of Radiology. These moves to amalgamate all the administrative aspects of the diagnostic imaging techniques certainly are a step in the right direction, and if properly organized they can allow for the daily correlation or clinical imaging tests, training or medical personnel, and development of interdisciplinary clinical research protocols. Will correlation of the imaging tests be enough in the future? Does the cardiac unit that performs the stress ECG need to be administratively more closely tied to nuclear medicine unit that performs the thallium cardiac studies? Do the in-vitro thyroid studies and thyroid imaging procedures (radionuclide and ultrasound) need to be performed by the same unit? What about echocardiography and ECG; cerebral emission CT, cerebral angiography, and xenon cerebral blood flow measurements, and on and on? It would appear that perhaps the interrelationship of diagnostic studies is not just in imaging. Could it be that a different administrative structure would be best? One approach would be directed at organ systems similar to a diagnostic cardiac unit that
7
in some fashion adequately amalgamates all these tests into one administrative unit. Perhaps the ultimate could be that all diagnostic procedures within an institution could be administered under a single unit, the Division of Diagnostic Studies, made up of a number of smaller divisions arranged to fit the functional needs of that particular institution. The administration of this unit would be responsible for the overall management of the diagnostic unit; would determine space allocations, equipment purchases and personnel needs, and would determine the need to introduce new techniques and a plan for implementation. In teaching hospitals, it would also be responsible for coordination of all the teaching programs and would participate in institutional research decisions. Perhaps with time this unit could become a true consultative service for diagnostic studies so that the clinician would refer a clinical problem to be studies instead of ordering a series of tests to be performed. Obviously there is no easy answer to the many problems created by the vast number of useful diagnostic procedures now available to us. The complexities vary directly with the size of the institution (small community hospitals have far less problems than do the large teaching hospitals); the number of diversity of studies available; the administrative units already operational, and the missions of the institutions (i.e., teaching versus research, etc.). Nuclear medicine is only a part of the whole. Its future success, however, is directly related to its functioning as an integral part within this large, growing, diagnostic area. Our studies represent a superb combination of function and structure and will continue to be a vital part of an integrated diagnostic approach. All of us, however, regardless of our specialty background, must address this complex issue if we are engaged in a diagnostic technical discipline. Certainly no single solution will suffice, but we must all take part in examining the issue. How should diagnostic tests be integrated within an institution to provide the best patient care, allow excellence in educating a wide variety of health care personnel, and stimulate research? The answer to this question is obviously pertinent to the future of the field of nuclear medicine.
issue of Seminars is devoted to correlative T hisstudies: ultrasound, nuclear medicine, and computed tomography. Over the past few years, with the success of ultrasound procedures (US) and the introduction of computed tomography (CT), there has been much discussion concerning the interrelationships of these techniques with nuclear medicine. A question often heard among nuclear medicine practitioners is, "Where does nuclear medicine now fit?" I would like to address this issue from the position of a nuclear medicine physician and to present some thoughts concerning the problems (or opportunities, depending on how you approach the subject) we all now face in the areas of clinical practice, education, and research because of the rapid growth of new diagnostic procedures. WHERE DOES NUCLEAR MEDICINE BELONG?
For nuclear medicine this is not a new question arising with the development of US and CT but certainly the issue is aggravated by their development. Over the past ten years, nuclear medicine has sought an identity as a speciality. As we survey the country, various practice settings have evolved. Nuclear medicine has in many instances evolved as a separate, independent, functional unit. This has most commonly occurred in large city hospitals and teaching institutions, and in some instances nuclear medicine has achieved departmental status in medical schools. More commonly, however, nuclear medicine has remained a part of a larger, traditional, functioning unit. In many institutions nuclear medicine is a division of the Department of Radiology. This is particularly true in regard to imaging proce-
From the Department of Radiology, Nuclear Medicine Section, Bowman Gray School of Medicine, Winston-Salem, N.C. Address reprint requests to C. Douglas Maynard, M.D., Department of Radiology, Nuclear Medicine Section, Bowman Gray School of Medicine, Winston-Salem, N.C. 27103. 9 1979 by Grune & Stratton, Inc. 0001-2998/79/0901-000250100/0
4
dures and is widely observed in nonteaching hospitals. In some instances, nuclear medicine, both imaging and in vitro studies, is part of the Pathology Department, but more often the in vitro studies are incorporated into the clinical laboratories as part of the Department of Pathology. With the rapid growth in multiple new radioassay procedures, the trend for these tests to be performed as part of the pathologists' or clinical chemistists' domain has accelerated. Nuclear medicine is also occasionally found "housed" in the Department of Medicine in a medical school setting, but this is uncommon in a nonacademic environment. In the past three years, trial combinations with US and CT have also been attempted. The "best" arrangement for nuclear medicine is certainly not evident from surveying what has occurred throughout the country. The specific diagnostic department in which nuclear medicine activities reside within an institution is probably more related to size of the hospital, past history of the institution, prior training of the diagnostic physicians, and internal politics, than any studied appraisal as to where it would function best. Should nuclear medicine units be separate or part of Radiology, Pathology, Internal Medicine, or some other grouping? It certainly is clear that we overlap these other disciplines. Why isn't there a simple answer? Obviously we are dealing with a very complex problem. The nuclear medicine service does not, and should not, function in isolation from other diagnostic services. For years we have attempted to coordinate our activites with other diagnostic services (i.e. radiology, pathology) but the introduction of these two new modalities, ultrasound and computed tomography, have further compounded our problems. How we resolve the day to day clinical interaction of these multiple diagnostic procedures, integrate them into our various training programs, and develop a clinical research program to relate them to patient care, may be as challenging as the very development of the technologies themselves! I would like to present a sample to some of the Seminars in Nuclear Medicine, Vol. IX, No. 1 (January), 1979
OTHER DIAGNOSTIC STUDIES
current problems in the areas of patient care, teaching, and research.
Patient Care The articles in this journal illustrate that the newer imaging procedures may be either complementray or competitive. When complementary, such as radionuclide liver imaging with abdominal ultrasound, a system must be devised within the institution to allow efficient and effective use of the information derived from each modality. When competitive, such as computed tomography of the head versus radionuclide brain imaging, proper planning to adjust personnel changes, equipment and space reguirements, etc., must be accomplished. Although currently this topic is discussed mainly in relationship to imaging techniques, it is by no means restricted to these tests. The effect of the T-4 on evaluation of Thyroid functions, and the need to correlate stress testing with thallium cardiac studies clearly demonstrates that more is involved in the problem than imaging procedures alone. In our rapidly advancing technology, the competitive and complementary nature of the test changes quickly. The accepted test today for a particular problem may be a radionuclide study, tomorrow an ultrasound procedure, later, yet another approach. The need to develop a means to effectively evaluate these changes in efficacy and to affect them within an institution is apparent. It often is necessary to perform tests in a particular sequence so that when the diagnosis is made, no further unnecessary tests need be performed. An example would be the combination of intravenous urography, radionuclide renal imaging, ultrasound, and computed tomography studies of renal mass. On occasion, a single examination provides the necessary diagnosis, but at other times a combination of tests is perferred. A systematic approach must be developed to allow for proper patient flow from test to test as required by the situation. This is difficult even when the various tests are performed in the same department, and when they must be accomplished in many separate units the problem of proper scheduling is further compounded. We certainly do not want to get into a strict "cookbook" approach to problems,
5
so a mechanism that allows considerable flexibility but functions efficiently is needed. Inefficient management. Multiple independent units within an institution tend to promote a duplication of personnel, i.e. hospital managers, secretaries, attendants, blood collectors; duplication of equipment, i.e., automatic film processors, and duplication of space needs, i.e., waiting rooms.
Space requirements and equipment needs+ Each unit vies for space and equipment. The decision as to how the available space is used, or capital equipment money is spent, is usually made by the dean, hospital administration, or some institutional committee. The support of an individual is often highly political. With the increasing problem of financing capital equipment, competition for funds will accelerate. Some way of establishing priorities among the laboratory service directors is required. Self-referral. As multiple diagnostic units evolve within an institution the clinician often participates in the diagnostic procedures. When this occurs, the problem of self-referral must be addressed. This is a complex issue since often the only individual qualified to interpret a procedure within a particular institution is the patient's own primary physician. A means also must be established to determine who within a diagnostic unit is competent to participate. From an administrative standpoint, the criteria of allowing a person to participate just because he is qualified must be questioned. Multiple participation often leads to an inefficient operation. Certainly, problems other than those mentioned are created by the multiplicity of diagnostic units. These problems vary in each institution, depending on its size, type (teaching or nonteaching), and the composition of these units.
Education The complexities of educational programs have likewise increased greatly with the development of these new technologies. Currently in nuclear medicine, there are multiple routes to certification in the field. The American Board of Radiology examines candidates in nuclear medicine as a part of their training in diagnostic radiology. This Board also affords a certificate acknowledging special competence in nuclear
6
radiology after an additional year's training. The American Board of Pathology offers a certificate in nuclear pathology following a year of specialized training. The American Board of Nuclear Medicine is a conjoint board supported by the American Board of Radiology, the American Board of Internal Medicine, the American Board of Pathology, and the Society of Nuclear Medicine, allowing individuals to be certified primarily in nuclear medicine. The coordination of individuals within the multiple tracts within an institution is becoming more and more complex. With the introduction of ultrasound and computed tomography, working out proper exposure for all the trainees, with their various needs, as part of their training programs and desires, as part of their future job expectations, is complicated. With the techniques housed in independent units, the design and implementation of the various training programs requires a proper relationship between the various institutional units. When a radiology resident's nuclear medicine exposure is in an independent nuclear medicine facility, or a nuclear medicine resident desires exposure to ultrasound, etc., a cooperative spirit must exist between these organizations. Providing adequate patient case loads for training in these specialized areas is also becoming a problem for some programs. The same difficulties exist among nuclear medicine technology training programs. Currently, miltiple tracks for certifying technologists are in existence or in the process of being developed. Exams are given by The American Registry of Radiologic Technologists, the American Society of Clinical Pathologists, and the Nuclear Medicine Technology Certifying Board, established primarily by the Technology Section of the Society of Nuclear Medicine. Adequate training programs to teach technology students from various disciplines the intricacies of both in vivo and in vitro studies will require the same cooperation as that for training programs for nuclear medicine residents. To date the most difficult aspect has been related to obtaining adequate in-vitro training for nuclear medicine technologists when these procedures are performed primarily in pathology departments with little relationship to the imaging section. Likewise, teaching medical students to apply nuclear medicine tests clinically, and to interre-
C. DOUGLAS MAYNARD
late them to all the other diagnostic studies, is not accomplished easily with the fragmentation of diagnostic units. Certainly, we must provide a forum where we can demonstrate a practical approach to the use of multiple diagnostic studies in a clinical problem. Correlative conferences between units can achieve this to some degree, but don't we need to demonstrate their dayto-day interrelationship? Can this be effectively accomplished with fragmentation of services? The future success of our field will be dependent on ending this fragmentation. Research Obviously, many hospitals that have the problem of multiple service units do not conduct research activities, so I will not belabor this issue. It appears, however, that some of the most difficult problems we face in the next five or ten years are in the area of clinical research, trying to compare, as in the articles in this journal, the various new diagnostic techniques to determine where they should be employed, in what sequence they should be performed, and how the information can best be summated to give the answer to the clinical problem at hand, Many factors make these clinical comparisons difficult. Are the instruments used up to the current state of the art? Are the diagnostic physicians of relatively equal ability in their fields? Are the tests performed within an adequate time frame for comparison? These comparisons are essential, and when performed as a team effort, very valuable; when not, they may be useless. The clinical comparison is vital to the future of our field, and without a united effort we cannot possibly achieve our goals. Separate units make this success unlikely. Another problem in clinical correlation is the determination of at what point a technique moves from the realm of clinical research to become an applicable, clinically practicle procedure, and who should finance the interim stage: the hospital, the patient, private foundations, federal grants, or the manufacturers? We are currently experiencing this phenomenon in relationship to whole body CT studies, and there is no apparent solution in sight. SOLUTIONS
I am certain that there will be many who feel that what has been presented is not much differ-
OTHER DIAGNOSTIC STUDIES
ent than problems we have encountered in the past. To some degree this is certainly true. However, rapidly advancing technology and the cost of diagnostic procedures make the problems associated with the development of multiple diagnostic units within an institution more apparent and more real. How can we better interrelate the clinical tests within an institution for the purpose of better patient care, improved educational programs, and correlative clinical research? Apparently no one has the answer, but a number of solutions have been discussed and there are trial attempts at some hospitals currently.
Imaging Division There are several experiments in the area of imaging. The amalgamation of ultrasound, nuclear medicine, and computed tomography into a single diagnostic division, often referred to as "specialized" imaging, has occurred at several institutions. Other institutions are in the process of developing departments of imaging that are an extension of the concept of specialized imaging divisions. These are mainly expansions or renamings of the Department of Radiology. These moves to amalgamate all the administrative aspects of the diagnostic imaging techniques certainly are a step in the right direction, and if properly organized they can allow for the daily correlation or clinical imaging tests, training or medical personnel, and development of interdisciplinary clinical research protocols. Will correlation of the imaging tests be enough in the future? Does the cardiac unit that performs the stress ECG need to be administratively more closely tied to nuclear medicine unit that performs the thallium cardiac studies? Do the in-vitro thyroid studies and thyroid imaging procedures (radionuclide and ultrasound) need to be performed by the same unit? What about echocardiography and ECG; cerebral emission CT, cerebral angiography, and xenon cerebral blood flow measurements, and on and on? It would appear that perhaps the interrelationship of diagnostic studies is not just in imaging. Could it be that a different administrative structure would be best? One approach would be directed at organ systems similar to a diagnostic cardiac unit that
7
in some fashion adequately amalgamates all these tests into one administrative unit. Perhaps the ultimate could be that all diagnostic procedures within an institution could be administered under a single unit, the Division of Diagnostic Studies, made up of a number of smaller divisions arranged to fit the functional needs of that particular institution. The administration of this unit would be responsible for the overall management of the diagnostic unit; would determine space allocations, equipment purchases and personnel needs, and would determine the need to introduce new techniques and a plan for implementation. In teaching hospitals, it would also be responsible for coordination of all the teaching programs and would participate in institutional research decisions. Perhaps with time this unit could become a true consultative service for diagnostic studies so that the clinician would refer a clinical problem to be studies instead of ordering a series of tests to be performed. Obviously there is no easy answer to the many problems created by the vast number of useful diagnostic procedures now available to us. The complexities vary directly with the size of the institution (small community hospitals have far less problems than do the large teaching hospitals); the number of diversity of studies available; the administrative units already operational, and the missions of the institutions (i.e., teaching versus research, etc.). Nuclear medicine is only a part of the whole. Its future success, however, is directly related to its functioning as an integral part within this large, growing, diagnostic area. Our studies represent a superb combination of function and structure and will continue to be a vital part of an integrated diagnostic approach. All of us, however, regardless of our specialty background, must address this complex issue if we are engaged in a diagnostic technical discipline. Certainly no single solution will suffice, but we must all take part in examining the issue. How should diagnostic tests be integrated within an institution to provide the best patient care, allow excellence in educating a wide variety of health care personnel, and stimulate research? The answer to this question is obviously pertinent to the future of the field of nuclear medicine.