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Trends in American nuclear medicine training: Past, present, and future
Trends in American Nuclear Medicine Training: Past, Present, and Future Edward B. Silberstein As soon as the capability to produce radioactive atoms was achieved in the 1930s, physician-scientists gravitated as apprentices toward important research centers, such as those at Berkeley, Washington University, and Massachusetts Institute of Technology (M.I.T.)/Massachusetts General Hospital. After World War II, Oak Ridge Associated Universities (ORAU) trained many of the founders of the specialty of nuclear medicine. The initial ORAU preparatory course lasted only 3 weeks. Over the 20 years after World War II, only 100 to 200 physicians had learned radioisotopic techniques and their clinical applications from their older preceptors. The founding of the conjoint Ameri-
can Board of Nuclear Medicine in 1971 (cosponsored by the American Boards of Internal Medicine, Pathology, and Radiology) marked a new era in certifying the quality of graduates of a growing number of nuclear medicine residency programs. Future trends in nuclear medicine education include the following: greater availability of jobs for physicians with board certification in radiology and nuclear medicine; an increased emphasis on training in positron-emission tomography (PET); and recertification and documentation of maintenance of professional competence as certainties. Copyright 9 2000 by W.B. Saunders Company
NQUISITIVE PHYSICIANS in what has become the specialty of nuclear medicine have been traveling to sites of innovation and vision ever since the first radioisotopic studies of human physiology were performed at Harvard by Herman Blumgartt. He used radon from discarded radon tubes to measure blood flow described in a series of 22 articles beginning in 1927. l In 1935, Ernest Lawrence, inventor of the cyclotron, invited his brother, John, to the Radiation Laboratory of the University of California in Berkeley, CA (renamed the Donner Laboratory in 1940), to study the distribution and therapeutic possibilities of P-32. Students such as Drs. Joseph G. Hamilton, Lowell Erf, and Charles Pecher came to Berkeley to contribute further to the clinical uses of P-32 and Sr-89. The first cyclotron built solely for biomedical radioisotope production was dedicated at Washington University, St. Louis, MO, in 1940 with Rockefeller Foundation support. The cyclotron at Massachusetts Institute of Technology (M.I.T.) began producing 1-130 and 1-131 for thyroid disease therapy at Massachusetts General Hospital, also in 1940. Thus, a number of the great academic centers of nuclear medicine began in the United States before World War II. The field of nuclear medicine was in ferment: in 1933 the Handbook of Chemistry and Physics listed 212 stable and 38 radioisotopes, whereas 10 years later, 276 stable and 375 radioisotopes were recorded. Clinically important radioisotopes such as Fe-59, I-131, Co60, and Tc-99m were on that list. ~ The development of the medical uses of radioisotopes, as well as the necessary training programs for the scientists/physicians who would use them,
were slowed by the lack of availability of many tracers, and the great amount of time and money required for such projects. With the involvement of the United States in World War II, beginning December 7, 1941, scarce natural resources of both scientists and radioactive material were directed toward the rapidly organized development of atomic weaponry known as the Manhattan Project, and to other wartime applications of radioisotopes, such as the use of radioactive inert gases to study decompression sickness at the Donner Laboratory. The first atomic bomb was detonated near AIamogordo, NM, July 19, 1945, only 2.5 years after Fermi and his coworkers at the University of Chicago achieved the first self-sustained nuclear chain reaction.
I
THE ATOMIC ENERGY COMMISSION AND EARLY TRAINING PROGRAMS
Peacetime uses of atomic energy finally received attention when, on August 1, 1946, Harry Truman signed the Atomic Energy Act creating the Atomic Energy Commission (AEC). The first shipment of radioisotopes, a C-14 compound, was sent from Oak Ridge, TN, to Dr. Martin Kamen in St. Louis, August 2, 1946, I because Dr. Kamen had discovered C-14 in Berkeley in 1940. On January 1, 1947, the AEC formally took over the whole Manhattan From University Hospital, CincinnatL OH. Address reprint requests to Edward B. Silberstein, MD, University Hospital~G026 Mont Reid Pavilion, 234 Goodman Street, Cincinnati, 0t145219-2316. Copyright 9 2000 by W.B. Saunders Company 0001-2998/00/3003-0005510.00/0 doi: l O.1053/snuc.2000. 7442
Seminars in Nuclear Medicine, Vol XX• No 3 (July), 2000: pp 209-213
209
210
Project and assumed control of reactor-produced radionuclides. From the AEC facility, H-3, C-14, P-32, S-35, Ca-45, Co-60, Sr-89, and 1-131 were shipped at this time. Early in 1948, through the vision of Dr. Paul C. Aebersold, the AEC approached the Oak Ridge Institute of Nuclear Studies (ORINS), now called Oak Ridge Associated Universities (ORAU), to establish a clinical research facility to study the uses of radioisotopes. A section of the Oak Ridge Hospital was remodeled for this purpose, and students and scientific staff began arriving for training, often on the job, in the summer of 1950 (E. Watson, personal communication, November 1999). Cyrus E. Sturgis, MD, Chairman of the Department of Medicine at the University of Michigan, was one of the visionary academic physicians who had learned of the courses to be given at the AEC Oak Ridge facility to qualify physicians to use radioisotopes. He sent a 33-year-old internist with an interest in thyroid disease, Dr. William H. Beierwaltes, to be 1 of the 5 first civilian trainees at ORINS. He was followed up by Dr. Eugene L. Saenger, Dr. John G. McAfee, and many other luminaries, who called themselves DRIPs (Dabbiers in Radioisotope Procedures) studying at "Bremsstrahlung U." Dr. Beierwaltes subsequently trained Thomas P. Haynie and many other notable nuclear physicians who would later be prominent in education in the specialty. Dr. Frederick J. Bonte received his initial AEC-sponsored training at a 1-day course at the University of Colorado in 1948, supplemented by a fellowship at an "Atoms for Peace" AEC-sponsored laboratory at Western Reserve School o f Medicine (now Case-Western Reserve) run by Dr. Hymer Friedell who had learned radiation medicine at Berkeley. At the Mayo Foundation, a 3-month nuclear medicine training program was offered to radiology fellows beginning in 1954. 2 The master-apprentice model for training was now ready to pass on the theory and practice of nuclear medicine. The Atomic Energy Act of 1954 made the AEC responsible for the safe use of by-product material, ie, reactor-produced radioisotopes. The AEC set up a civilian committee to try to determine safe dosages of radioisotopes and outlines, and, for the first time, the minimum training and experience required for a licensee to use radioactive materials. This led to some complaints that the AEC was
EDWARD B. SILBERSTEIN
acting to restrict the practice of medicine, a tension that still persists almost half a century later. The AEC requirements were divided into basic radioisotope training (physics, mathematics, instrumentation, safety, radiobiology) to be obtained through lectures, readings, and laboratory experiments, and active clinical participation, including patient examinations to determine clinical need, performing the procedure, and adequate follow-up. This course was certified in the medical division of ORINS by the late 1950s to offer what the AEC regarded as a minimal preparatory course. Three 1-week sessions were separated by 1 or 2 months. 3 The first 2 weeks were devoted to basic science, while the third week (a minimum of 30 hours was specified) was spent on the clinical use of 6 of the most common applications of radioisotopes at the time: 1-131 thyroid function and thyroid disease therapy; Cr-51 red cell labeling, Fe-59 ferrokinetics; 1-131 albumin plasma volume; 1-131 triolein absorption; and Co-60 vitamin B-12 absorption (Schilling test). The AEC also noted the importance of knowledge of the use of P-32 for both tumor localization (brain, eye), and treatment of blood diseases, as well as P-32 and Au-198 colloids for malignant effusions.3 Writing in 1957, Dr. Edith Quimby was only able to identify 26 civilian institutions in the United States giving courses in clinical nuclear medicine that were open to others beside their own residents, with a duration of 20 hours to 8 weeks. 4 An exception was the 26-week course at the Bethesda, MD, Naval Hospital open only to the military. About 100 physicians had been trained by July, 1957. 4 Thus, until about 1960, physicians learned the medical application of isotopes primarily in preceptorships with the clinical investigators who had pioneered in developing these techniques, but there was a need for many more well-trained individuals. In 1961 the American Board of Radiology introduced a special examination in nuclear medicine. 5 However, no true formal training program yet existed, and there were no recognized standards of nuclear medicine education and practice. An article in the Journal of Nuclear Medicine in 1965 noted that more than 30 training centers offered postgraduate studies in nuclear medicine. This same article wrestled with issues of nuclear medicine curriculum but had difficulty designing a clinical nuclear medicine rotation beyond radioiso-
AMERICAN NUCLEAR MEDICINE TRAINING
topic therapy. The investigator defined nuclear medicine as a "liaison specialty uniting the fundamental sciences to the clinical specialties through the use of radiation methodology.'5 The concept of a liaison specialty raised the question of ownership of this methodology, which would remain an issue for the next 20 years. In the late 1960s the Veterans Administration (VA) established a limited number of nuclear medicine fellowships throughout the United States after covening an expert committee, chaired by Dr. Joseph Ross, to study the issue. The VA has continued to provide strong support to nuclear medicine training, funding some portion of almost half of the U.S. training programs. THE RESIDENCY REVIEW COMMITTEE OF ACCREDITATION COUNCIL ON GRADUATE MEDICAL EDUCATION
The Residency Review Committee (RRC) in nuclear medicine of the Accreditation Council on Graduate Medical Education (ACGME) has been the group responsible for accreditation of nuclear medicine training programs since its formation in 1972. In 1974, the first 26 nuclear medicine residency programs were approved out of 91 applicants. The RRC was required to have equal representation from the American Board of Nuclear Medicine (ABNM) and the American Medical Association. The RRC reviews all residency programs to determine that the program content, institutional support facilities, faculty, and curriculum satisfy the educational requirements that make the resident eligible to take the specialty Board examination. The nuclear medicine residency is a 2-year program that must now follow up a year of preparatory clinical training. In 1974 the first 26 residency programs were approved. By 1985 the nuclear medicine RRC had raised the number to 92 programs. Fifteen years later the number had fallen to 70 residency programs. THE ABNM In the mid-1960s, the Brookhaven National Laboratory Division of Medicine and Biology presented 3 programs to inform and bring together the academic community and the 3 specialty certifying Boards of Internal Medicine, Pathology and Radiology, the major users of radioisotopes. These educational efforts stressed the clinical importance
211
of diagnostic and therapeutic uses of available radionuclides. Pathology and radiology representatives immediately expressed a desire to establish specialty certification in nuclear medicine, although those from internal medicine were not very interested initially, and the other 2 specialties could not agree as to which should set up the certification requirements and examination. 6,7 In 1967 representatives of the American Board of Radiology approached the SNM about working together to establish a certifying examination in nuclear medicine. Eventually Drs John and Ernest Lawrence helped convince the leadership of the American Board of Internal Medicine (ABIM) to join in a conjoint Board of the American Board of Radiology (ABR), American Board of Pathology (ABP), and ABIM, partially supported with staff and facilities by the SNM. Approval by the American Board of Medical Specialties (ABMS) came May 22, 1971, with final incorporation of the ABNM on July 28, 1971. The initial ABNM blueprint required that all policies and activities of the conjoint ABNM be approved by all 3 sponsors, and that any candidate for certification had to be approved first by 1 of the 3 sponsoring Boards. This was an administrative quagmire. Other problematic issues arose when the ABR and ABP both requested that the Liaison Committee of Specialty Boards permit them to issue some certificates in Nuclear Medicine on the basis of special qualifications, but without an examination. After much debate, and to avoid a major schism, the ABR and ABP were allowed by the ABMS on May 31, 1972, to issue subspecialty certifications in Nuclear Radiology and Radioisotopic Pathology respectively, in cooperation with the conjoint Board. 6,7 Dr. Joseph Ross, the first Executive Director of the ABNM, was instrumental in the many meetings required to give the ABNM life and bring the Board through these controversies. Over the next 13 years the many requirements of conjoint Board status became quite onerous, and in 1985 ABMS granted the ABNM primary Board status. The ABNM has remained an independent financially solvent organization, taking its place as 1 of the 24 member Boards of the ABMS. The first statement of the "Components of Professional Competence of Nuclear Medicine Physicians" was published in 1971; nuclear medicine was only the second specialty to do so. 6 Revisions and expansions of these Components have been
212
EDWARD B. SILBERSTEIN
published in 1981 and 1994, 8 with a current revision to be completed in the year 2000. This last revision will add vital aspects of medical ethics, and be brought into conformity with general criteria on physician competence being set forth by the ABMS: (1) medical knowledge, (2) patient care, (3) interpersonal communication skills, (4) professionalism, (5) practice-based learning and improvement, and (6) systems-based practice. In 1999 the ABNM finalized joint efforts with both the ABR and ABIM to collaborate more closely in a variety of efforts. An ABR-certified radiologist who enters a Nuclear Radiology fellowship in which there is also an existing ABNMaccredited residency (true of 15 of 28 Radiology fellowship programs) may now sit for the ABNM certificate Board examination. If the candidate passes, he/she receives both an ABNM certificate and the ABR subspecialty certificate. The ABNM and ABIM have agreed on a 4-year combined residency that will lead to certification by both Boards. Discussions are proceeding with at least one other ABMS-member Board toward forming yet another joint program. FUTURE TRENDS IN NUCLEAR MEDICINE EDUCATION AND TRAINING
There is always some hazard in predicting the future, but certain trends have become apparent that we who practice Nuclear Medicine need to be aware of: 1. There will be fewer jobs for nuclear medicine physicians who do not have ABR certification. The reimbursement policies of managed care have led to a need for imaging specialists who not only read scintigraphs but also can interpret the information provided by x-ray, magnetic resonance, computed tomography (CT), and ultrasound techniques. With computer programs for image registration blending nuclear and CT images now a clinical reality, and equipment available that can perform simultaneous transmission (CT) and single photon emission computed tomography (SPECT), the need for physicians trained in the interpretation of both techniques is obvious. In addition, more cardiologists are acquiring the training needed to read myocardial perfusion and wall motion images. A decrease in the number of full-time positions available for physicians practicing only nuclear medicine has led to a reduction in the
2.
3.
4.
5.
6.
number of nuclear medicine residencies, from 92 in 1985 to 70 at the beginning of 2000. However, more radiologists have become aware of the need for greater expertise in dealing with the complexities of modem nuclear medicine, The result has been no change in the number of candidates taking the ABNM certifying examination because there has simultaneously been an increase in ABRcertified candidates with an additional year of nuclear medicine training who are now sitting for the examination. The emphasis on positron emission tomography (PET), both in residency programs and on the ABNM examination, is likely to increase because third-party reimbursement allows PET to assume an even greater clinical role. Joint training programs, with input from ABR, ABIM, and other ABMS-member Boards, will become more popular, especially if reimbursement issues with the federal Health Care Finance Administration can be solved for full funding of the nuclear medicine year. Recertification for all candidates who received ABNM-certification in 1992 or later will remain mandatory. The recertification process will eventually involve all practitioners of nuclear medicine in some way because the ABMS responds to the demands of the public for documentation of continuing clinical competence among practitioners who once passed an ABMSmember certifying examination and have subsequently been in practice for over 10 years. Some of the components of this assessment of continuing competence have been mentioned earlier. There will continue to be a need for outstanding training programs in nuclear medicine, and a higher percentage of trainees seeking admission to such programs will have had previous extensive postgraduate education. ACKNOWLEDGMENTS
The author wishes to express his gratitude to William H. Beierwaltes, MD, William H. Blahd, MD, Frederick J. Bonte, MD, Thomas P. Hayne, MD, John G. McAfee, MD, Eugene L. Saenger, MD, and Evelyn E. Watson for graciously providing a wonderful historical perspective on this topic.
AMERICAN NUCLEAR MEDICINE TRAINING
213 REFERENCES
1. Brucer M: AChronology of Nuclear Medicine 1600-1989. St. Louis, MO, Heritage Publications, 1990, p 496 2. Childs DS: Training of residents in radioisotopes. JAMA 159:541-544, 1955 3. Knisely RM: Training for clinical use of radioisotopes: Qualification courses. J Nucl Med 1:239-250, 1960 4. Quimby EH: Training programs in clinical use of radioactive isotopes. AJR Am J Roentgenol 79:138-141, 1958
5. Steinberg J: Nuclear medicine and medical education. J Nucl Med 6:691-698, 1965 6. Ross JF: A history of the American Board of Nuclear Medicine. Semin Nucl Med 26:191-193, 1996 7. Ross JF: The American Board of Nuclear Medicine, Inc; Fifteen years of growth and progress. J Nucl Med 27:861-862, 1986 8. American Board of Nuclear Medicine: Components of professional competence of Nuclear Medicine Physicians. J Nucl Med 35:1234-1235, 1994
can Board of Nuclear Medicine in 1971 (cosponsored by the American Boards of Internal Medicine, Pathology, and Radiology) marked a new era in certifying the quality of graduates of a growing number of nuclear medicine residency programs. Future trends in nuclear medicine education include the following: greater availability of jobs for physicians with board certification in radiology and nuclear medicine; an increased emphasis on training in positron-emission tomography (PET); and recertification and documentation of maintenance of professional competence as certainties. Copyright 9 2000 by W.B. Saunders Company
NQUISITIVE PHYSICIANS in what has become the specialty of nuclear medicine have been traveling to sites of innovation and vision ever since the first radioisotopic studies of human physiology were performed at Harvard by Herman Blumgartt. He used radon from discarded radon tubes to measure blood flow described in a series of 22 articles beginning in 1927. l In 1935, Ernest Lawrence, inventor of the cyclotron, invited his brother, John, to the Radiation Laboratory of the University of California in Berkeley, CA (renamed the Donner Laboratory in 1940), to study the distribution and therapeutic possibilities of P-32. Students such as Drs. Joseph G. Hamilton, Lowell Erf, and Charles Pecher came to Berkeley to contribute further to the clinical uses of P-32 and Sr-89. The first cyclotron built solely for biomedical radioisotope production was dedicated at Washington University, St. Louis, MO, in 1940 with Rockefeller Foundation support. The cyclotron at Massachusetts Institute of Technology (M.I.T.) began producing 1-130 and 1-131 for thyroid disease therapy at Massachusetts General Hospital, also in 1940. Thus, a number of the great academic centers of nuclear medicine began in the United States before World War II. The field of nuclear medicine was in ferment: in 1933 the Handbook of Chemistry and Physics listed 212 stable and 38 radioisotopes, whereas 10 years later, 276 stable and 375 radioisotopes were recorded. Clinically important radioisotopes such as Fe-59, I-131, Co60, and Tc-99m were on that list. ~ The development of the medical uses of radioisotopes, as well as the necessary training programs for the scientists/physicians who would use them,
were slowed by the lack of availability of many tracers, and the great amount of time and money required for such projects. With the involvement of the United States in World War II, beginning December 7, 1941, scarce natural resources of both scientists and radioactive material were directed toward the rapidly organized development of atomic weaponry known as the Manhattan Project, and to other wartime applications of radioisotopes, such as the use of radioactive inert gases to study decompression sickness at the Donner Laboratory. The first atomic bomb was detonated near AIamogordo, NM, July 19, 1945, only 2.5 years after Fermi and his coworkers at the University of Chicago achieved the first self-sustained nuclear chain reaction.
I
THE ATOMIC ENERGY COMMISSION AND EARLY TRAINING PROGRAMS
Peacetime uses of atomic energy finally received attention when, on August 1, 1946, Harry Truman signed the Atomic Energy Act creating the Atomic Energy Commission (AEC). The first shipment of radioisotopes, a C-14 compound, was sent from Oak Ridge, TN, to Dr. Martin Kamen in St. Louis, August 2, 1946, I because Dr. Kamen had discovered C-14 in Berkeley in 1940. On January 1, 1947, the AEC formally took over the whole Manhattan From University Hospital, CincinnatL OH. Address reprint requests to Edward B. Silberstein, MD, University Hospital~G026 Mont Reid Pavilion, 234 Goodman Street, Cincinnati, 0t145219-2316. Copyright 9 2000 by W.B. Saunders Company 0001-2998/00/3003-0005510.00/0 doi: l O.1053/snuc.2000. 7442
Seminars in Nuclear Medicine, Vol XX• No 3 (July), 2000: pp 209-213
209
210
Project and assumed control of reactor-produced radionuclides. From the AEC facility, H-3, C-14, P-32, S-35, Ca-45, Co-60, Sr-89, and 1-131 were shipped at this time. Early in 1948, through the vision of Dr. Paul C. Aebersold, the AEC approached the Oak Ridge Institute of Nuclear Studies (ORINS), now called Oak Ridge Associated Universities (ORAU), to establish a clinical research facility to study the uses of radioisotopes. A section of the Oak Ridge Hospital was remodeled for this purpose, and students and scientific staff began arriving for training, often on the job, in the summer of 1950 (E. Watson, personal communication, November 1999). Cyrus E. Sturgis, MD, Chairman of the Department of Medicine at the University of Michigan, was one of the visionary academic physicians who had learned of the courses to be given at the AEC Oak Ridge facility to qualify physicians to use radioisotopes. He sent a 33-year-old internist with an interest in thyroid disease, Dr. William H. Beierwaltes, to be 1 of the 5 first civilian trainees at ORINS. He was followed up by Dr. Eugene L. Saenger, Dr. John G. McAfee, and many other luminaries, who called themselves DRIPs (Dabbiers in Radioisotope Procedures) studying at "Bremsstrahlung U." Dr. Beierwaltes subsequently trained Thomas P. Haynie and many other notable nuclear physicians who would later be prominent in education in the specialty. Dr. Frederick J. Bonte received his initial AEC-sponsored training at a 1-day course at the University of Colorado in 1948, supplemented by a fellowship at an "Atoms for Peace" AEC-sponsored laboratory at Western Reserve School o f Medicine (now Case-Western Reserve) run by Dr. Hymer Friedell who had learned radiation medicine at Berkeley. At the Mayo Foundation, a 3-month nuclear medicine training program was offered to radiology fellows beginning in 1954. 2 The master-apprentice model for training was now ready to pass on the theory and practice of nuclear medicine. The Atomic Energy Act of 1954 made the AEC responsible for the safe use of by-product material, ie, reactor-produced radioisotopes. The AEC set up a civilian committee to try to determine safe dosages of radioisotopes and outlines, and, for the first time, the minimum training and experience required for a licensee to use radioactive materials. This led to some complaints that the AEC was
EDWARD B. SILBERSTEIN
acting to restrict the practice of medicine, a tension that still persists almost half a century later. The AEC requirements were divided into basic radioisotope training (physics, mathematics, instrumentation, safety, radiobiology) to be obtained through lectures, readings, and laboratory experiments, and active clinical participation, including patient examinations to determine clinical need, performing the procedure, and adequate follow-up. This course was certified in the medical division of ORINS by the late 1950s to offer what the AEC regarded as a minimal preparatory course. Three 1-week sessions were separated by 1 or 2 months. 3 The first 2 weeks were devoted to basic science, while the third week (a minimum of 30 hours was specified) was spent on the clinical use of 6 of the most common applications of radioisotopes at the time: 1-131 thyroid function and thyroid disease therapy; Cr-51 red cell labeling, Fe-59 ferrokinetics; 1-131 albumin plasma volume; 1-131 triolein absorption; and Co-60 vitamin B-12 absorption (Schilling test). The AEC also noted the importance of knowledge of the use of P-32 for both tumor localization (brain, eye), and treatment of blood diseases, as well as P-32 and Au-198 colloids for malignant effusions.3 Writing in 1957, Dr. Edith Quimby was only able to identify 26 civilian institutions in the United States giving courses in clinical nuclear medicine that were open to others beside their own residents, with a duration of 20 hours to 8 weeks. 4 An exception was the 26-week course at the Bethesda, MD, Naval Hospital open only to the military. About 100 physicians had been trained by July, 1957. 4 Thus, until about 1960, physicians learned the medical application of isotopes primarily in preceptorships with the clinical investigators who had pioneered in developing these techniques, but there was a need for many more well-trained individuals. In 1961 the American Board of Radiology introduced a special examination in nuclear medicine. 5 However, no true formal training program yet existed, and there were no recognized standards of nuclear medicine education and practice. An article in the Journal of Nuclear Medicine in 1965 noted that more than 30 training centers offered postgraduate studies in nuclear medicine. This same article wrestled with issues of nuclear medicine curriculum but had difficulty designing a clinical nuclear medicine rotation beyond radioiso-
AMERICAN NUCLEAR MEDICINE TRAINING
topic therapy. The investigator defined nuclear medicine as a "liaison specialty uniting the fundamental sciences to the clinical specialties through the use of radiation methodology.'5 The concept of a liaison specialty raised the question of ownership of this methodology, which would remain an issue for the next 20 years. In the late 1960s the Veterans Administration (VA) established a limited number of nuclear medicine fellowships throughout the United States after covening an expert committee, chaired by Dr. Joseph Ross, to study the issue. The VA has continued to provide strong support to nuclear medicine training, funding some portion of almost half of the U.S. training programs. THE RESIDENCY REVIEW COMMITTEE OF ACCREDITATION COUNCIL ON GRADUATE MEDICAL EDUCATION
The Residency Review Committee (RRC) in nuclear medicine of the Accreditation Council on Graduate Medical Education (ACGME) has been the group responsible for accreditation of nuclear medicine training programs since its formation in 1972. In 1974, the first 26 nuclear medicine residency programs were approved out of 91 applicants. The RRC was required to have equal representation from the American Board of Nuclear Medicine (ABNM) and the American Medical Association. The RRC reviews all residency programs to determine that the program content, institutional support facilities, faculty, and curriculum satisfy the educational requirements that make the resident eligible to take the specialty Board examination. The nuclear medicine residency is a 2-year program that must now follow up a year of preparatory clinical training. In 1974 the first 26 residency programs were approved. By 1985 the nuclear medicine RRC had raised the number to 92 programs. Fifteen years later the number had fallen to 70 residency programs. THE ABNM In the mid-1960s, the Brookhaven National Laboratory Division of Medicine and Biology presented 3 programs to inform and bring together the academic community and the 3 specialty certifying Boards of Internal Medicine, Pathology and Radiology, the major users of radioisotopes. These educational efforts stressed the clinical importance
211
of diagnostic and therapeutic uses of available radionuclides. Pathology and radiology representatives immediately expressed a desire to establish specialty certification in nuclear medicine, although those from internal medicine were not very interested initially, and the other 2 specialties could not agree as to which should set up the certification requirements and examination. 6,7 In 1967 representatives of the American Board of Radiology approached the SNM about working together to establish a certifying examination in nuclear medicine. Eventually Drs John and Ernest Lawrence helped convince the leadership of the American Board of Internal Medicine (ABIM) to join in a conjoint Board of the American Board of Radiology (ABR), American Board of Pathology (ABP), and ABIM, partially supported with staff and facilities by the SNM. Approval by the American Board of Medical Specialties (ABMS) came May 22, 1971, with final incorporation of the ABNM on July 28, 1971. The initial ABNM blueprint required that all policies and activities of the conjoint ABNM be approved by all 3 sponsors, and that any candidate for certification had to be approved first by 1 of the 3 sponsoring Boards. This was an administrative quagmire. Other problematic issues arose when the ABR and ABP both requested that the Liaison Committee of Specialty Boards permit them to issue some certificates in Nuclear Medicine on the basis of special qualifications, but without an examination. After much debate, and to avoid a major schism, the ABR and ABP were allowed by the ABMS on May 31, 1972, to issue subspecialty certifications in Nuclear Radiology and Radioisotopic Pathology respectively, in cooperation with the conjoint Board. 6,7 Dr. Joseph Ross, the first Executive Director of the ABNM, was instrumental in the many meetings required to give the ABNM life and bring the Board through these controversies. Over the next 13 years the many requirements of conjoint Board status became quite onerous, and in 1985 ABMS granted the ABNM primary Board status. The ABNM has remained an independent financially solvent organization, taking its place as 1 of the 24 member Boards of the ABMS. The first statement of the "Components of Professional Competence of Nuclear Medicine Physicians" was published in 1971; nuclear medicine was only the second specialty to do so. 6 Revisions and expansions of these Components have been
212
EDWARD B. SILBERSTEIN
published in 1981 and 1994, 8 with a current revision to be completed in the year 2000. This last revision will add vital aspects of medical ethics, and be brought into conformity with general criteria on physician competence being set forth by the ABMS: (1) medical knowledge, (2) patient care, (3) interpersonal communication skills, (4) professionalism, (5) practice-based learning and improvement, and (6) systems-based practice. In 1999 the ABNM finalized joint efforts with both the ABR and ABIM to collaborate more closely in a variety of efforts. An ABR-certified radiologist who enters a Nuclear Radiology fellowship in which there is also an existing ABNMaccredited residency (true of 15 of 28 Radiology fellowship programs) may now sit for the ABNM certificate Board examination. If the candidate passes, he/she receives both an ABNM certificate and the ABR subspecialty certificate. The ABNM and ABIM have agreed on a 4-year combined residency that will lead to certification by both Boards. Discussions are proceeding with at least one other ABMS-member Board toward forming yet another joint program. FUTURE TRENDS IN NUCLEAR MEDICINE EDUCATION AND TRAINING
There is always some hazard in predicting the future, but certain trends have become apparent that we who practice Nuclear Medicine need to be aware of: 1. There will be fewer jobs for nuclear medicine physicians who do not have ABR certification. The reimbursement policies of managed care have led to a need for imaging specialists who not only read scintigraphs but also can interpret the information provided by x-ray, magnetic resonance, computed tomography (CT), and ultrasound techniques. With computer programs for image registration blending nuclear and CT images now a clinical reality, and equipment available that can perform simultaneous transmission (CT) and single photon emission computed tomography (SPECT), the need for physicians trained in the interpretation of both techniques is obvious. In addition, more cardiologists are acquiring the training needed to read myocardial perfusion and wall motion images. A decrease in the number of full-time positions available for physicians practicing only nuclear medicine has led to a reduction in the
2.
3.
4.
5.
6.
number of nuclear medicine residencies, from 92 in 1985 to 70 at the beginning of 2000. However, more radiologists have become aware of the need for greater expertise in dealing with the complexities of modem nuclear medicine, The result has been no change in the number of candidates taking the ABNM certifying examination because there has simultaneously been an increase in ABRcertified candidates with an additional year of nuclear medicine training who are now sitting for the examination. The emphasis on positron emission tomography (PET), both in residency programs and on the ABNM examination, is likely to increase because third-party reimbursement allows PET to assume an even greater clinical role. Joint training programs, with input from ABR, ABIM, and other ABMS-member Boards, will become more popular, especially if reimbursement issues with the federal Health Care Finance Administration can be solved for full funding of the nuclear medicine year. Recertification for all candidates who received ABNM-certification in 1992 or later will remain mandatory. The recertification process will eventually involve all practitioners of nuclear medicine in some way because the ABMS responds to the demands of the public for documentation of continuing clinical competence among practitioners who once passed an ABMSmember certifying examination and have subsequently been in practice for over 10 years. Some of the components of this assessment of continuing competence have been mentioned earlier. There will continue to be a need for outstanding training programs in nuclear medicine, and a higher percentage of trainees seeking admission to such programs will have had previous extensive postgraduate education. ACKNOWLEDGMENTS
The author wishes to express his gratitude to William H. Beierwaltes, MD, William H. Blahd, MD, Frederick J. Bonte, MD, Thomas P. Hayne, MD, John G. McAfee, MD, Eugene L. Saenger, MD, and Evelyn E. Watson for graciously providing a wonderful historical perspective on this topic.
AMERICAN NUCLEAR MEDICINE TRAINING
213 REFERENCES
1. Brucer M: AChronology of Nuclear Medicine 1600-1989. St. Louis, MO, Heritage Publications, 1990, p 496 2. Childs DS: Training of residents in radioisotopes. JAMA 159:541-544, 1955 3. Knisely RM: Training for clinical use of radioisotopes: Qualification courses. J Nucl Med 1:239-250, 1960 4. Quimby EH: Training programs in clinical use of radioactive isotopes. AJR Am J Roentgenol 79:138-141, 1958
5. Steinberg J: Nuclear medicine and medical education. J Nucl Med 6:691-698, 1965 6. Ross JF: A history of the American Board of Nuclear Medicine. Semin Nucl Med 26:191-193, 1996 7. Ross JF: The American Board of Nuclear Medicine, Inc; Fifteen years of growth and progress. J Nucl Med 27:861-862, 1986 8. American Board of Nuclear Medicine: Components of professional competence of Nuclear Medicine Physicians. J Nucl Med 35:1234-1235, 1994