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  • PROGRAM REQUIREMENTS for RESIDENCY EDUCATION in NUCLEAR MEDICINE 1 I. Introduction 2 3 A. Definition and Scope of the Specialty 4 5 Nuclear medicine is the clinical and laboratory medical specialty that 6 employs the measured nuclear properties of radioactive and stable 7 nuclides for diagnosis, therapy, and research and to evaluate metabolic, 8 physiologic, and pathologic conditions of the body. 9 10 B. Duration and Scope of Education 11 12 1. Length of program. 13 The length of the nuclear medicine residency program is 2 3 years, 14 following 1 year of preparatory clinical residency training (see 15 below). 16 17 2. Admission prerequisites. 18 The length of the nuclear medicine residency program is 2 3 years. 19 However, a minimum of 3 4 years of Graduate Medical Education 20 is necessary to train a physician in the field of nuclear medicine. 21 Before entering a nuclear medicine residency, residents must 22 satisfactorily complete one year of training in an ACGME- 23 accredited or Royal College of Physicians and Surgeons of 24 Canada-accredited or equivalent program that provides broad 25 clinical education, with primary emphasis on the patient and the 26 patient=s clinical problems. Residents should have a sufficiently 27 broad knowledge of medicine to obtain a pertinent history, perform 28 an appropriate physical examination, and arrive at a differential 29 diagnosis. 30 31 3. Description of program format. 32 Residencies in nuclear medicine must teach the basic skills and 33 clinical competence that constitute the foundations of nuclear 34 medicine practice and must provide progressive responsibility for 35 and experience in the application of these principles to the 36 management of clinical problems. Clinical experience must include 37 the opportunity to recommend and plan, conduct, supervise, 38 interpret, and dictate reports for nuclear medicine procedures that 39 are appropriate for the existing clinical problem or condition. 1
  • 40 C. Broad Description of Training Objectives and Goals 41 42 The program must be structured so that the residents’= clinical 43 responsibilities increase progressively during training. At the completion of 44 the training program, residents should be proficient in all areas of clinical 45 nuclear medicine and be able to function independently as nuclear 46 medicine consultants, plan and perform appropriate nuclear medicine 47 procedures, interpret the test results, and formulate a diagnosis and an 48 appropriate differential diagnosis. The residents should be qualified to 49 recommend therapy or further studies. If radionuclide therapy is indicated, 50 they should be capable of assuming responsibility for patient care. 51 Residents should develop a satisfactory level of clinical maturity, 52 judgment, and technical skill that will, on completion of the program, 53 render them capable of the independent practice of nuclear medicine. 54 55 II. Institutions 56 57 A. Sponsoring institution 58 59 One sponsoring institution must assume ultimate responsibility for 60 the program, as described in the Institutional Requirements, and this 61 responsibility extends to resident assignments at all participating 62 institutions. 63 64 B. Participating institutions 65 66 1. Assignment to an institution must be based on a clear 67 educational rationale, integral to the program curriculum, with 68 clearly stated learning activities and objectives. When multiple 69 participating institutions are used, there should be assurance 70 of the continuity of the educational experience. 71 72 Limited outside rotations may be utilized to supplement training in a 73 branch of nuclear medicine, eg, positron emission tomography 74 (PET) or radionuclide therapy, if there is insufficient patient volume 75 in the sponsoring institution. Affiliated institutions should not be so 76 distant as to make it difficult for residents to travel between 77 institutions for participation in clinical responsibilities or didactic 78 activities. 79 Participation by any institution providing 3 months or more of 80 training in the program must be approved by the RRC for Nuclear 81 Medicine, according to criteria similar to those applied to the 82 primary institution. A maximum of 6 months of the 2 3-year nuclear 2
  • 83 medicine program may be spent outside the parent and integrated 84 institutions on rotation to affiliated sites. 85 86 2. Assignment to a participating institution requires a letter of 87 agreement with the sponsoring institution. Such a letter of 88 agreement should: 89 90 a) identify the faculty who will assume both educational 91 and supervisory responsibilities for residents; 92 93 b) specify their responsibilities for teaching, supervision, 94 and formal evaluation for residents, as specified later in 95 this document; 96 97 c) specify the duration and content of the educational 98 experience; and 99 100 d) state the policies and procedures that will govern 101 resident education during the assignment. 102 103 III. PROGRAM PERSONNEL AND RESOURCES 104 105 A. Program Director 106 107 1. There must be a single program director responsible for the 108 program. The person designated with this authority is 109 accountable for the operation of the program. In the event of a 110 change of program director, the program director should 111 promptly notify the executive director of the Residency Review 112 Committee (RRC) through the Accreditation Data System of 113 the Accreditation Council for Graduate Medical Education 114 (ACGME). 115 116 2. The program director, together with the faculty, is responsible 117 for the general administration of the program, and for the 118 establishment and maintenance of a stable educational 119 environment. Adequate lengths of appointment for both the 120 program director and faculty are essential to maintaining such 121 an appropriate continuity of leadership. 122 123 3. Qualifications of the program director are as follows: 124 125 a) The program director must possess the requisite specialty 126 expertise, as well as documented educational and 3
  • 127 administrative abilities. This includes broad knowledge of, 128 experience with, and commitment to general nuclear 129 medicine, along with sufficient academic and administrative 130 experience to ensure effective implementation of these 131 Program Requirements and sufficient experience 132 participating as an active faculty member in an accredited 133 residency program. 134 135 b) The program director must be certified by the American 136 Board of Nuclear Medicine, or possess qualifications 137 judged to be acceptable by the RRC. 138 139 c) The program director must be appointed in good 140 standing and based at the primary teaching site. 141 142 4. Responsibilities of the program director are as follows: 143 144 a) The program director must oversee and organize the 145 activities of the educational program in all institutions that 146 participate in the program. This includes selecting and 147 supervising the faculty and other program personnel at each 148 participating institution, appointing a local site director and 149 monitoring appropriate resident supervision at all 150 participating institutions. 151 152 b) The program director is responsible for preparing an 153 accurate statistical and narrative description of the 154 program as requested by the RRC, as well as updating 155 annually both program and resident records through the 156 ACGME=s Accreditation Data System. 157 158 c) The program director must ensure the implementation 159 of fair policies, grievance procedures, and due process, 160 as established by the sponsoring institution and in 161 compliance with the Institutional Requirements. 162 d) The program director must seek the prior approval of 163 the RRC for any changes in the program that may 164 significantly alter the educational experience of the 165 residents. Such changes, for example, include: 166 167 (1) the addition or deletion of a participating 168 institution; 169 4
  • 170 (2) a change in the format of the educational 171 program; 172 173 (3) a change in the resident complement. 174 175 On review of a proposal for any such major change in a 176 program, the RRC may determine that a site visit is necessary. 177 178 B. Faculty 179 180 1. At each participating institution, there must be a sufficient number 181 of faculty with documented qualifications to instruct and supervise 182 adequately all residents in the program. 183 184 2. The faculty, furthermore, must devote sufficient time to the 185 educational program to fulfill their supervisory and teaching 186 responsibilities. They must demonstrate a strong interest in the 187 education of residents, and must support the goals and objectives 188 of the educational program of which they are a member. 189 190 3. Qualifications of the physician faculty are as follows: 191 192 a) The physician faculty must possess the requisite specialty 193 expertise and competence in clinical care and teaching, as 194 well as documented educational and administrative abilities 195 and experience in their field. 196 197 b) The physician faculty must be certified by the American 198 Board of Nuclear Medicine, or possess qualifications 199 judged to be acceptable by the RRC. 200 201 c) The physician faculty must be appointed in good 202 standing to the staff of an institution participating in the 203 program. 204 205 4. The responsibility for establishing and maintaining an environment 206 of inquiry and scholarship rests with the faculty, and an active 207 research component must be included within each program. Both 208 faculty and residents must participate actively in scholarly activity. 209 Scholarship is defined as the following: 210 211 a) the scholarship of discovery, as evidenced by peer-reviewed 212 funding or publication of original research in a peer-reviewed 213 journal; 5
  • 214 215 b) the scholarship of dissemination, as evidenced by review 216 articles or chapters in textbooks; 217 218 c) the scholarship of application, as evidenced by the 219 publication or presentation of, for example, case reports or 220 clinical series at local, regional, or national professional and 221 scientific society meetings. 222 223 Complementary to the above scholarship is the regular participation 224 of the teaching staff in clinical discussions, rounds, journal clubs, 225 and research conferences in a manner that promotes a spirit of 226 inquiry and scholarship (eg, the offering of guidance and technical 227 support for residents involved in research such as research design 228 and statistical analysis); and the provision of support for 229 residents= participation, as appropriate, in scholarly activities. 230 231 The faculty as a whole must have demonstrated ongoing participation in 232 such activities during the past 5 years. 233 234 5. Qualifications of the nonphysician faculty are as follows: 235 236 a) Nonphysician faculty must be appropriately qualified in their 237 field. 238 239 b) Nonphysician faculty must possess appropriate institutional 240 appointments. 241 242 C. Other Program Personnel 243 244 Additional necessary professional, technical and clerical personnel 245 must be provided to support the program. 246 247 D. Resources 248 249 The program must ensure that adequate resources (eg, sufficient 250 laboratory space and equipment, computer and statistical 251 consultation services) are available. The institution sponsoring a 252 residency program in nuclear medicine should be of sufficient size and 253 composition to provide an adequate volume and variety of patients for 254 resident training. It must provide sufficient faculty, financial resources, and 255 clinical, research, and library facilities to meet the educational needs of the 256 residents and to enable the program to comply with the requirements for 257 accreditation. 6
  • 258 259 1. Space and Equipment 260 261 The program must provide adequate space, equipment, and other 262 pertinent facilities to ensure an effective educational experience for 263 residents in nuclear medicine and must possess the modern 264 facilities and equipment required to practice nuclear medicine. 265 266 2. Other Specialties 267 268 A nuclear medicine residency program requires the support of 269 services in other specialties, notably medicine, surgery, radiology, 270 pediatrics, and pathology. Training resources should be such that 271 the total number of residents in the institution is large enough to 272 permit peer interaction and intellectual exchange with residents in 273 the nuclear medicine program. 274 275 3. Library 276 277 Residents must have ready access to a major medical library with a 278 representative selection of books and journals related to nuclear 279 medicine, either at the institution where the residents are located or 280 through arrangement with convenient nearby institutions. Library 281 services should include the electronic retrieval of information from 282 medical databases. There must be access to an on-site library or to 283 a collection of appropriate texts and journals in each institution 284 participating in a residency program. On-site libraries and/or 285 collections of texts and journals must be readily available during 286 nights and weekends. Internet access must be readily available. 287 288 IV. Resident Appointments 289 290 A. Eligibility Criteria 291 292 The program director must comply with the criteria for resident eligibility as 293 specified in the Institutional Requirements. 294 295 Programs must demonstrate the ability to recruit and retain qualified 296 residents. Residents should be appointed only when their documented 297 prior experience and attitudes demonstrate the presence of abilities 298 necessary to master successfully the clinical knowledge and skills required 299 of all program graduates. All residents must have demonstrated 300 understanding and facility in using the English language. 301 302 Residents should be reappointed only when their clinical judgment, 7
  • 303 medical knowledge, history-taking, professional attitudes, moral and 304 ethical behavior, and clinical performance are documented to be entirely 305 satisfactory. 306 307 B. Number of Residents 308 309 The number of residents should be determined by the adequacy of 310 resources for resident education such as variety and volume of patients 311 and related clinical material available for education, faculty-resident ratio, 312 institutional funding, and the quality of faculty teaching. At the time of the 313 program=s regular review, the RRC will assess the continued adequacy of 314 the program=s resources for the current number of residents. 315 316 C. Resident Transfers 317 318 To determine the appropriate level of education for residents who 319 are transferring from another residency program, the program 320 director must receive written verification of the previous educational 321 experiences and a statement regarding the performance evaluation 322 of the transferring resident prior to their acceptance into the 323 program. A program director is required to provide verification of 324 residency education for residents who may leave the program prior 325 to completion of their education. 326 327 D. Appointment of Fellows and Other Students 328 329 The appointment of fellows and other specialty residents must not 330 dilute or detract from the educational opportunities of the regularly 331 appointed nuclear medicine residents. 332 333 V. PROGRAM CURRICULUM 334 335 A. Program Design 336 337 1. Format 338 339 The program design and sequencing of educational experiences 340 will be approved by the RRC as part of the review process. 341 342 2. Goals and Objectives 343 344 The program must possess a written statement that outlines its 345 educational goals with respect to the knowledge, skills, and other 346 attributes of residents for each major assignment and for each level 8
  • 347 of the program. This statement must be distributed to residents and 348 faculty, and must be reviewed with residents prior to their 349 assignments. 350 351 B. Specialty Curriculum 352 353 1. Basic Science Content 354 355 Study of the basic sciences that constitute the foundation for clinical 356 nuclear medicine must be part of the resident=s education. This is 357 most effectively accomplished through a combination of formal 358 didactic lectures and discussion of these topics in conferences. 359 The program director must develop a formal didactic schedule that 360 indicates the specific date and time of each lecture, the topic of the 361 lecture, the faculty individual presenting the lecture, and the 362 duration of the lecture. This schedule must incorporate each of the 363 elements of basic science detailed below, and the program director 364 must provide written documentation of this schedule as part of the 365 information submitted to the RRC for its review of the program. 366 The schedule must be current for each academic year. Visiting 367 faculty and residents may provide some of the lectures. 368 369 The training program must provide didactic instruction in the 370 following areas: 371 372 a) Physics: structure of matter, modes of radioactive decay, 373 particle and photon emissions, and interactions of radiation 374 with matter. 375 376 b) Instrumentation: principles of instrumentation used in 377 detection, measurement, and imaging of radioactivity with 378 special emphasis on gamma cameras, including SPECT and 379 PET devices, and associated electronic instrumentation and 380 computers employed in image production and display. 381 Instruction must be provided in the instrumentation principles 382 involved in magnetic resonance imaging and multi-slice 383 computed tomography. 384 385 c) Mathematics, statistics, and computer sciences: probability 386 distributions; medical decision making; basic aspects of 387 computer structure, function, programming, and processing; 388 applications of mathematics to tracer kinetics; 389 compartmental modeling; and quantification of physiologic 390 processes. 391 9
  • 392 d) Radiation biology and protection: biological effects of ionizing 393 radiation, means of reducing radiation exposure, calculation 394 of the radiation dose, evaluation of radiation overexposure, 395 medical management of persons overexposed to ionizing 396 radiation, management and disposal of radioactive 397 substances, and establishment of radiation safety programs 398 in accordance with federal and state regulations. 399 400 e) Radiopharmaceuticals: reactor, cyclotron, and generator 401 production of radionuclides; radiochemistry; 402 pharmacokinetics; and formulation of radiopharmaceuticals. 403 Specifically, instruction should include the chemistry of 404 byproduct materials for medical use; ordering and unpacking 405 radioactive materials safely and performing the related 406 radiation surveys; calibrating instruments used to determine 407 the activity of dosages and performing checks for proper 408 operation of survey meters; calculating and safely preparing 409 patient or human research subject dosages; using 410 administrative controls to prevent a medical event involving 411 the use of unsealed byproduct material; using procedures to 412 contain spilled byproduct material safely and using proper 413 decontamination procedures; eluting generator systems 414 appropriate for preparation of radioactive drugs for imaging 415 and localization studies or that need a written directive; 416 measuring and testing the eluate for radionuclide purity, and 417 processing the eluate with reagent kits to prepare labeled 418 radioactive drugs; and administering dosages of radioactive 419 drugs for uptake, dilution, excretion, and imaging and 420 localization studies. 421 422 An essential part of the training program is continuing extensive 423 instruction in the relevant basic sciences. This should include 424 formal lectures and formal labs, with an appropriate balance of time 425 allocated to the major subject areas, which must include physical 426 science and instrumentation; radiobiology and radiation protection; 427 mathematics; radiopharmaceutical chemistry; and computer 428 science. Instruction in the basic sciences should not be limited to 429 only didactic sessions. The resident's activities also should include 430 laboratory experience and regular contact with basic scientists in 431 their clinical adjunctive roles. 432 433 An aggregate of at least 100 hours per year should be devoted to basic 434 science instruction, i.e., formal lectures and formal labs. An appropriate 435 balance of time should be allocated to the major subject areas, which 436 must include physical science and instrumentation: 50 hours per year; 10
  • 437 radiobiology and radiation protection: 15 hours per year; mathematics and 438 statistics: 10 hours per year; radiopharmaceutical chemistry: 15 hours per 439 year; computer science: 10 hours per year. 440 441 2. Didactic Clinical Content 442 443 There must be didactic instruction in both diagnostic imaging and 444 non-imaging nuclear medicine applications and therapeutic 445 applications. The instruction must be well organized, thoughtfully 446 integrated, and carried out on a regularly scheduled basis. The 447 program director must develop a formal didactic schedule that 448 indicates the specific date and time of each lecture, the topic of the 449 lecture, the faculty individual presenting the lecture and the duration 450 of the lecture. This schedule must incorporate each of the elements 451 of the clinical specialty detailed below, and the program director 452 must provide written documentation of this schedule to the RRC for 453 its review of the program. Visiting faculty and residents may provide 454 some of the lectures. The schedule must be current for each 455 academic year. 456 Instruction must include the following areas: 457 458 a) Diagnostic use of radiopharmaceuticals: clinical indications, 459 technical performance, and interpretation of in vivo imaging 460 of the body organs and systems, using external detectors 461 and scintillation cameras, including SPECT and PET and 462 correlation of nuclear medicine procedures with other 463 pertinent imaging modalities such as plain film radiography, 464 angiography, computed tomography, bone densitometry, 465 ultrasonography, and magnetic resonance imaging. 466 467 b) Exercise and pharmacologic stress testing: the 468 pharmacology of cardio active drugs; physiologic gating 469 techniques; patient monitoring during interventional 470 procedures; management of cardiac emergencies, including 471 electrocardiographic interpretation and cardiopulmonary life 472 support; and correlation of nuclear medicine procedures with 473 other pertinent imaging modalities such as angiography, 474 computed tomography, bone density measurement, 475 ultrasonography, and magnetic resonance imaging. 476 477 c) Non-imaging studies: training and experience in the 478 application of a variety of non-imaging procedures, including 479 instruction in the principles of immunology; preparation of 480 radiolabeled antibodies; uptake measurements; in-vitro 481 studies including Schilling test, glomerular filtration rate, red 11
  • 482 blood cell mass and plasma volume, and breath tests. 483 484 d) Therapeutic uses of unsealed radiopharmaceuticals: patient 485 selection and management, including dose administration 486 and dosimetry, radiation toxicity, and radiation protection 487 considerations in the treatment of metastatic cancer and 488 bone pain, primary neoplasms, solid tumors, and malignant 489 effusions; and the treatment of hematologic, endocrine, and 490 metabolic disorders 491 492 e) Fundamentals of the operation of a positron tomography 493 imaging center, including medical cyclotron operation for 494 production of PET radionuclides such as fluorodeoxyglucose 495 (FDG), experience in PET radiopharmaceutical synthesis, 496 and image acquisition and processing. 497 498 f) Quality management and improvement: principles of quality 499 management and performance improvement, efficacy 500 assessment, and compliance with pertinent regulations of 501 the Nuclear Regulatory Commission and the Joint 502 Commission on the Accreditation of Healthcare 503 Organizations 504 505 3. Conferences and Seminars 506 507 All residents must participate in regularly scheduled clinical nuclear 508 medicine conferences and seminars and interdisciplinary 509 conferences, in which the resident is responsible for presenting 510 case materials and discussing the relevant theoretical and practical 511 issues. There should be active resident participation in well- 512 structured seminars and journal clubs that review the pertinent 513 literature with respect to current clinical problems and that include 514 discussion of additional topics to supplement the didactic 515 curriculum. 516 517 a) Clinical interpretation conference 518 All residents must participate in regularly scheduled, usually 519 daily, procedure interpretation and review conferences. The 520 program must provide the resident with the opportunity to 521 gain progressively independent responsibility for review, 522 technical approval and acceptance, and interpretation and 523 dictation of consultative reports on completed nuclear 524 medicine procedures. 525 526 b) Teaching files 12
  • 527 Teaching case files involving diagnostic and therapeutic 528 nuclear medicine procedures should cover the full spectrum 529 of clinical applications; they should be indexed, coded with 530 correlative and follow-up data, and readily accessible for 531 resident use. There must be a mechanism for maintaining 532 case records and treatment results to facilitate patient follow- 533 up and to provide teaching material. 534 Electronic availability of teaching files is acceptable as a 535 substitute or enhancement of on-site teaching case files. 536 537 4. Clinical Curriculum Content 538 539 The residency program in nuclear medicine should include the 540 diagnostic, therapeutic, and investigational uses of radionuclides. It 541 should be of sufficient breadth to ensure that all residents become 542 thoroughly acquainted with current nuclear medicine diagnostic and 543 therapeutic applications. The training experience should ensure 544 ample opportunity to attain sequentially increasing competence in 545 selecting the most appropriate nuclear medicine studies for the 546 patient, performing these studies in the technically correct manner, 547 interpreting the information obtained, correlating this information 548 with other diagnostic studies, and treating and following up the 549 patient who receives radionuclide therapy. Under adequate faculty 550 supervision, the resident should participate directly in the 551 performance of imaging studies, non-imaging measurements and 552 assays, and therapeutic procedures. 553 554 Residents must be provided structured opportunities to (a) learn the 555 indications, contraindications, complications, and limitations of 556 specific procedures; (b) develop technical proficiency in performing 557 these procedures; (c) learn to interpret the results of these 558 procedures; and (d) dictate reports and communicate results 559 promptly and appropriately. The program must provide adequate 560 opportunity for residents to participate in and personally perform 561 and analyze a broad range of common clinical nuclear medicine 562 procedures. This must include experience in each of the following 563 categories: 564 565 a) Musculoskeletal studies, including bone scanning for benign 566 and malignant disease, and bone densitometry. 567 568 b) Myocardial perfusion imaging procedures performed with 569 radioactive perfusion agents in association with treadmill and 570 pharmacologic stress (planar and tomographic, including 571 gated tomographic imaging). Specific applications should 13
  • 572 include patient monitoring, with special emphasis on 573 electrocardiographic interpretation, cardiopulmonary 574 resuscitation during interventional pharmacologic or exercise 575 stress tests, pharmacology of cardio active drugs, and 576 hands-on experience with performance of the stress 577 procedure (exercise and pharmacologic agents) for a 578 minimum of 50 patients. Program directors must be able to 579 document the experience of residents in this area, eg, with 580 logbooks. 581 582 c) Radionuclide ventriculography performed with ECG gating 583 for evaluation of ventricular performance. The experience 584 should include first pass and equilibrium studies and 585 calculation of ventricular performance parameters, eg, 586 ejection fraction and regional wall motion assessment. 587 588 d) Endocrinologic studies, including thyroid, parathyroid, and 589 adrenal imaging, along with octreotide and other receptor- 590 based imaging studies. Thyroid studies should include 591 measurement of iodine uptake and dosimetry calculations for 592 radio-iodine therapy. 593 594 e) Gastrointestinal studies of the salivary glands, esophagus, 595 stomach, and liver, both reticuloendothelial function and the 596 biliary system. This also includes studies of gastrointestinal 597 bleeding, Meckel diverticulum, and C14 urea breath testing. 598 599 f) Hematologic studies, including red cell and plasma volume, 600 splenic sequestration, hemangioma studies, labeled 601 granulocytes for infection, thrombus imaging, bone marrow 602 imaging, and B12 absorption studies. 603 604 g) Oncology studies, involving gallium, thallium, sestamibi, 605 antibodies, peptides, fluorodeoxyglucose (FDG), and other 606 agents as they become available. Oncology experience 607 should include all the common malignancies of the brain, 608 head and neck, thyroid, breast, lung, liver, colon, kidney, 609 bladder and prostate. It should also involve lymphoma, 610 leukemia, melanoma, and musculoskeletal tumors. Hands- 611 on experience with lymphoscintigraphy is very important. 612 613 h) Neurologic studies, including cerebral perfusion with both 614 single photon emission computed tomography (SPECT) and 615 positron emission tomography (PET), cerebral metabolism 616 with FDG, and cisternography. This experience should 14
  • 617 include studies of stroke, dementia, epilepsy, brain death 618 and cerebrospinal fluid dynamics. 619 620 i) Pulmonary studies of perfusion and ventilation performed 621 with radiolabeled macroaggregates and radioactive gas or 622 aerosols used in the diagnosis of pulmonary embolus, as 623 well as for quantitative assessment of perfusion and 624 ventilation. 625 626 j) Genitourinary tract imaging, including renal perfusion and 627 function procedures, clearance methods, renal scintigraphy 628 with pharmacologic interventions, renal transplant 629 evaluation, and vesicoureteral reflux., and scrotal and 630 testicular imaging. 631 632 k) Therapeutic administration of radiopharmaceuticals, to 633 include patient selection and understanding and calculation 634 of the administered dose. Specific applications should 635 include radioiodine in hyperthyroidism (minimum of 10 636 cases) and thyroid carcinoma (minimum of 5 cases), 637 radiolabeled antibodies (minimum of 3 cases) and may 638 include radio-phosphorus (soluble) in polycythemia vera and 639 other myeloproliferative disorders, radiocolloids for therapy, 640 radionuclides for painful bone disease, and radioligand 641 therapy. Program directors must be able to document the 642 experience of residents in this area, including patient follow- 643 up, eg, with logbooks. 644 645 l) PET imaging of the heart, including studies of myocardial 646 perfusion and myocardial viability. 647 648 m) PET imaging of the brain, including studies of dementia, 649 epilepsy, and brain tumors. 650 651 n) PET imaging in oncology, including studies of tumors of the 652 lung, head and neck, esophagus, colon, thyroid, and breast, 653 as well as melanoma, lymphoma, and other tumors as the 654 indications become established. 655 656 o) Co-registration and image fusion of SPECT and PET images 657 with computed tomography (CT) and magnetic resonance 658 imaging (MRI) studies. If the program cannot provide 659 sufficient clinical experience in PET imaging, supplemental 660 clinical training or at least didactic instruction should be 661 made available. 15
  • 662 663 p) Anatomic imaging of brain, head and neck, thorax, 664 abdomen, and pelvis with CT and/or MRI to be able to 665 effectively correlate understand the correlation between 666 anatomic and functional imaging. This experience can be 667 combined with a rotation that includes PET-CT or SPECT- 668 CT and should include a minimum of 500 CT studies. The 669 experience should emphasize reviewing CT images 670 associated with PET-CT or SPECT-CT studies. The resident 671 should acquire sufficient experience with such studies under 672 the supervision of qualified faculty to be able to accurately 673 correlate the CTs associated with the PET-CT or SPECT-CT 674 studies. There must be a minimum of 12 weeks of rotations 675 on CT and/or MRI services. It should include a minimum of 676 500 CT cases. This participation should include reviewing 677 images as well as dictations of reports. This requirement 678 does not apply to residents who have completed training in 679 Diagnostic Radiology and are board-eligible or board- 680 certified by the American Board of Radiology. 681 682 q) Experience in radiation oncology and medical oncology. 683 This is essential because of the increasing close interaction 684 with these specialties. The experience can consist of one 685 month rotations or an equivalent experience through 686 participation in patient management conferences and clinics. 687 688 689 5. On-Call Experience 690 691 In addition, each resident must be given the experience of being 692 on-call and assuming the responsibility for providing consultative 693 activities for procedures performed on an emergency basis. 694 695 6. Patient Population Requirements 696 697 While the number of procedures may vary from one training 698 program to another, a well-designed program will perform at least 699 4,000 common nuclear medicine imaging procedures annually, a 700 wide variety of non-imaging procedures, and at least 15 701 radionuclide therapeutic procedures annually. Imaging procedures 702 should be distributed over the entire spectrum of nuclear medicine 703 practice, including the pediatric age group. A minimum of 100 704 pediatric nuclear medicine cases should be available annually. 705 Resident rotations to hospitals with a large pediatric caseload 706 should be considered if the number of pediatric studies in the 16
  • 707 primary institution averages fewer than 100 per year. 708 709 7. Patient Management 710 711 The program must provide the residents with experience in direct 712 and progressively responsible patient management as they 713 advance through training. This training must culminate in sufficient 714 independent responsibility for clinical decision making to ensure 715 that the graduating resident has achieved the ability to function 716 independently and in a proficient manner in all nuclear medicine 717 consultative areas. 718 719 8. Other 720 721 The residents must be provided training in both basic life-support 722 and advanced cardiac life-support. 723 724 C. Residents= Scholarly Activities 725 726 Each program must provide an opportunity for residents to 727 participate in research or other scholarly activities, and residents 728 must participate actively in such activities. 729 730 D. ACGME Competencies 731 732 The residency program must require that its residents obtain 733 competence in the six areas listed below to the level expected of a 734 new practitioner. Programs must define the specific knowledge, 735 skills, behaviors, and attitudes required and provide educational 736 experiences as needed in order for their residents to demonstrate 737 the following: 738 739 1. Patient care that is compassionate, appropriate, and effective 740 for the treatment of health problems and the promotion of 741 health. 742 743 Residents are expected to: 744 745 a) Obtain information about the patient related to the requested 746 test or therapy using patient interview, chart and computer 747 data base review, physical examination, and contact with the 748 referring physician. 749 750 b) Select appropriate procedures or therapy based on the 17
  • 751 referring physician=s request and the patient=s history. This 752 involves selection of the appropriate radiopharmaceutical, 753 dose, imaging technique, data analysis, and image 754 presentation. It also includes review of image quality, 755 defining the need for additional images and correlation with 756 other imaging studies such as x-rays, CT, MRI, or 757 ultrasound. 758 759 c) Communicate results promptly and clearly to the referring 760 physician or other appropriate health care workers. This 761 communication should include clear and succinct dictation of 762 the results. 763 764 d) Conduct therapeutic procedures. Therapeutic procedures 765 must be done in consultation with an attending physician 766 who is a licensed user of radioactive material. These 767 procedures should include dose calculation, patient identity 768 verification, explanation of informed consent, documentation 769 of pregnancy status, counseling of patients and their families 770 on radiation safety issues, and scheduling follow-up after 771 therapy. 772 773 e) Maintain records (logs) of participation in nuclear cardiology 774 pharmacologic and exercise studies and in all types of 775 therapy procedures. 776 777 2. Medical knowledge about established and evolving 778 biomedical, clinical, and cognate (eg, epidemiological and 779 social-behavioral) sciences and the application of this 780 knowledge to patient care. 781 782 Residents should closely follow scientific progress in nuclear 783 medicine and learn to incorporate it effectively for modifying and 784 improving diagnostic and therapeutic procedures. Residents are 785 expected to: 786 787 a) Become familiar with and regularly read the major journals in 788 nuclear medicine. During the residency this will involve 789 regular participation in journal club. 790 791 b) Use computer technology including internet web sites and 792 CDROM teaching disks. 793 794 c) Participate in the annual in-service examination. 18
  • 795 796 d) Know and comply with radiation safety rules and regulations, 797 including NRC and/or agreement state rules, local 798 regulations, and the ALARA (as low as reasonably 799 achievable) principles for personal radiation protection. 800 801 e) Understand and use QC (quality control) procedures for 802 imaging devices, laboratory instrumentation, and 803 radiopharmaceuticals. 804 805 3. Practice-based learning and improvement that involves 806 investigation and evaluation of their own patient care, 807 appraisal and assimilation of scientific evidence, and 808 improvements in patient care. 809 810 Residents must develop and continuously improve skills in 811 obtaining medical knowledge using new techniques as they develop 812 in information technology. This includes: 813 814 a) Using the internet and computer data bases to search for 815 patient information, disease, and technique information. 816 Residents should also be familiar with viewing and 817 manipulating images with the computer, both locally and 818 remotely. 819 820 b) Residents should improve their understanding of diseases 821 and patient care by attending inter-specialty conferences, 822 correlative conferences, mortality and morbidity conferences, 823 and utilization conferences. 824 825 c) Patient follow-up is essential for determining the accuracy of 826 study interpretation. Residents should regularly obtain such 827 follow-up information and correlate the clinical findings with 828 their study interpretation. 829 830 4. Interpersonal and communication skills that result in effective 831 information exchange and collaboration with patients, their 832 families, and other health professionals. Residents must 833 communicate clearly and effectively and work well with each of the 834 following groups: 835 836 a) Patients and their families. 837 b) Physicians in nuclear medicine and radiology. 838 c) Referring physicians from other specialties. 19
  • 839 d) Nuclear medicine technologists. 840 e) Other health care workers throughout the institution. 841 842 5. Professionalism, as manifested through a commitment to 843 carrying out professional responsibilities, adherence to ethical 844 principles, and sensitivity to a diverse patient population. 845 Residents are expected to always behave in a professional manner. 846 This includes: 847 848 a) Consistent demonstration of completely ethical behavior. 849 850 b) Respect for the dignity of patients and all members of the 851 medical team. 852 853 c) There should be no discrimination based on age, ethnicity, 854 gender, disability, or sexual orientation. 855 856 d) Residents should be responsive to patients= needs by 857 demonstrating integrity, honesty, compassion, and 858 commitment. 859 860 e) Residents should always respect the patient=s privacy and 861 autonomy. 862 863 6. Systems-based practice, as manifested by actions that 864 demonstrate an awareness of and responsiveness to the 865 larger context and system of health care and the ability to 866 effectively call on system resources to provide care that is of 867 optimal value. 868 This involves learning to work in a variety of heath care settings 869 and understanding the inter-relationship with other health care 870 professionals. Specifically, residents should be aware of: 871 872 a) Work conditions in hospitals, out-patient clinics, diagnostic 873 centers, and private practice settings. 874 875 b) Resource allocation and methods directed towards 876 controlling health care costs such as Diagnostic Related 877 Groups (DRGs), APC, and pre-certification by medical 878 insurers. 879 880 c) The concept of providing optimal patient care by selecting 881 the most cost-effective procedures and using or 882 recommending other diagnostic tests that might complement 20
  • 883 the nuclear medicine procedures. This also involves 884 awareness of the relevant risk-benefit considerations. 885 886 d) Basic financial and business skills to function effectively in 887 current health care delivery systems. This includes an 888 understanding and knowledge of coding, procedure charges, 889 billing practices, and reimbursement mechanisms. 890 891 892 VI. Resident Duty Hours and the Working Environment 893 894 Providing residents with a sound academic and clinical education 895 must be carefully planned and balanced with concerns for patient 896 safety and resident well-being. Each program must ensure that the 897 learning objectives of the program are not compromised by 898 excessive reliance on residents to fulfill service obligations. Didactic 899 and clinical education must have priority in the allotment of 900 residents= time and energies. Duty hour assignments must 901 recognize that faculty and residents collectively have responsibility 902 for the safety and welfare of patients. 903 904 A. Supervision of Residents 905 906 1. All patient care must be supervised by qualified faculty. The 907 program director must ensure, direct, and document adequate 908 supervision of residents at all times. Residents must be 909 provided with rapid, reliable systems for communicating with 910 supervising faculty. 911 912 2. Faculty schedules must be structured to provide residents 913 with continuous supervision and consultation. 914 915 3. Faculty and residents must be educated to recognize the signs 916 of fatigue and adopt and apply policies to prevent and 917 counteract the potential negative effects. 918 919 B. Duty Hours 920 921 1. Duty hours are defined as all clinical and academic activities 922 related to the residency program, ie, patient care (both 923 inpatient and outpatient), administrative duties related to 924 patient care, the provision for transfer of patient care, time 925 spent in-house during call activities, and scheduled academic 926 activities such as conferences. Duty hours do not include 21
  • 927 reading and preparation time spent away from the duty site. 928 929 2. Duty hours must be limited to 80 hours per week, averaged 930 over a four-week period, inclusive of all in-house call activities. 931 932 3. Residents must be provided with 1 day in 7 free from all 933 educational and clinical responsibilities, averaged over a 4- 934 week period, inclusive of call. One day is defined as one 935 continuous 24-hour period free from all clinical, educational, 936 and administrative activities. 937 938 4. Adequate time for rest and personal activities must be 939 provided. This should consist of a 10 hour time period 940 provided between all daily duty periods, and after in-house 941 call. 942 943 C. On-Call Activities 944 945 The objective of on-call activities is to provide residents with 946 continuity of patient care experiences throughout a 24-hour period. 947 In-house call is defined as those duty hours beyond the normal work 948 day, when residents are required to be immediately available in the 949 assigned institution. 950 951 1. In-house call must occur no more frequently than every third 952 night, averaged over a four-week period. 953 954 2. Continuous on-site duty, including in-house call, must not 955 exceed 24 consecutive hours. Residents may remain on duty 956 for up to 6 additional hours to participate in didactic activities, 957 transfer care of patients, conduct outpatient clinics and 958 maintain continuity of medical and surgical care. 959 960 3. No new patients may be accepted after 24 hours of continuous 961 duty. A new patient is defined as any patient for whom the 962 resident has not previously provided care. 963 964 4. At-home call (pager call) is defined as call taken from outside 965 the assigned institution. 966 967 a) The frequency of at-home call is not subject to the every 968 third night limitation. However, at-home call must not 969 be so frequent as to preclude rest and reasonable 970 personal time for each resident. Residents taking at- 22
  • 971 home call must be provided with 1 day in 7 completely 972 free from all educational and clinical responsibilities, 973 averaged over a 4-week period. 974 975 b) When residents are called into the hospital from home, 976 the hours residents spend in-house are counted toward 977 the 80-hour limit. 978 979 c) The program director and the faculty must monitor the 980 demands of at-home call in their program, and make 981 scheduling adjustments as necessary to mitigate 982 excessive service demands and/or fatigue. 983 984 D. Moonlighting 985 986 1. Because residency education is a full-time endeavor, the 987 program director must ensure that moonlighting does not 988 interfere with the ability of the resident to achieve the goals 989 and objectives of the educational program. 990 991 2. The program director must comply with the sponsoring 992 institution=s written policies and procedures regarding 993 moonlighting, in compliance with the Institutional 994 Requirements. 995 996 3. Any hours a resident works for compensation at the 997 sponsoring institution or any of the sponsor=s primary clinical 998 sites must be considered part of the 80-hour weekly limit on 999 duty hours. This refers to the practice of internal 1000 moonlighting. 1001 1002 E. Oversight 1003 1004 1. Each program must have written policies and procedures 1005 consistent with the Institutional and Program Requirements 1006 for resident duty hours and the working environment. These 1007 policies must be distributed to the residents and the faculty. 1008 Duty hours must be monitored with a frequency sufficient to 1009 ensure an appropriate balance between education and service. 1010 1011 2. Back-up support systems must be provided when patient care 1012 responsibilities are unusually difficult or prolonged, or if 1013 unexpected circumstances create resident fatigue sufficient to 1014 jeopardize patient care. 23
  • 1015 1016 F. Duty Hours Exception 1017 1018 The RRC for Nuclear Medicine will not consider requests for 1019 exceptions to the limit to 80 hours per week, averaged 1020 monthly. 1021 1022 1023 VII. Evaluation 1024 1025 A. Resident 1026 1027 1. Formative Evaluation 1028 The faculty must evaluate in a timely manner the residents 1029 whom they supervise. In addition, the residency program 1030 must demonstrate that it has an effective mechanism for 1031 assessing resident performance throughout the program, and 1032 for utilizing the results to improve resident performance. 1033 a) Assessment should include the use of methods that 1034 produce an accurate assessment of residents= 1035 competence in patient care, medical knowledge, 1036 practice-based learning and improvement, interpersonal 1037 and communication skills, professionalism, and 1038 systems-based practice. 1039 1040 b) Assessment should include the regular and timely 1041 performance feedback to residents that includes at least 1042 semiannual written evaluations. Such evaluations are to 1043 be communicated to each resident in a timely manner, 1044 and maintained in a record that is accessible to each 1045 resident. 1046 1047 c) Assessment should include the use of assessment 1048 results, including evaluation by faculty, patients, peers, 1049 self, and other professional staff, to achieve progressive 1050 improvements in residents= competence and 1051 performance. 1052 1053 2. Final Evaluation 1054 1055 The program director must provide a final evaluation for each 1056 resident who completes the program. This evaluation must 1057 include a review of the resident=s performance during the final 1058 period of education, and should verify that the resident has 24
  • 1059 demonstrated sufficient professional ability to practice 1060 competently and independently. The final evaluation must be 1061 part of the resident=s permanent record maintained by the 1062 institution. 1063 1064 B. Faculty 1065 1066 The performance of faculty must be evaluated by the program no 1067 less frequently than at the midpoint of the accreditation cycle, and 1068 again prior to the next site visit. The evaluations should include a 1069 review of their teaching abilities, commitment to the educational 1070 program, clinical knowledge, and scholarly activities. This 1071 evaluation must include annual written confidential evaluations by 1072 residents. 1073 1074 C. Program Evaluation 1075 1076 The educational effectiveness of a program must be evaluated at 1077 least annually in a systematic manner. 1078 1079 1. Representative program personnel (i.e., at least the program 1080 director, representative faculty, and one resident) must be 1081 organized to review program goals and objectives, and the 1082 effectiveness with which they are achieved. The group must 1083 conduct a formal documented meeting at least annually for 1084 this purpose. In the evaluation process, the group must take 1085 into consideration written comments from the faculty, the 1086 most recent report of the GMEC of the sponsoring institution, 1087 and the residents= confidential written evaluations. If 1088 deficiencies are found, the group should prepare an explicit 1089 plan of action, which should be approved by the faculty and 1090 documented in the minutes of the meeting. 1091 1092 2. The program should use resident performance and outcome 1093 assessment in its evaluation of the educational effectiveness of the 1094 residency program. Performance of program graduates on the 1095 certification examination should be used as one measure of 1096 evaluating program effectiveness. The program should maintain a 1097 process for using assessment results together with other program 1098 evaluation results to improve the residency program. 1099 1100 3. Performance of program graduates on the certification examination 1101 should be used as one measure of evaluating program 1102 effectiveness. As part of the overall evaluation of the program, the 25
  • 1103 RRC will take into consideration the information provided by the 1104 ABNM regarding resident performance over the most recent 5-year 1105 period. 1106 1107 VIII. Experimentation and Innovation 1108 Since responsible innovation and experimentation are essential to 1109 improving professional education, experimental projects along sound 1110 educational principles are encouraged. Requests for experimentation or 1111 innovative projects that may deviate from the program requirements must 1112 be approved in advance by the RRC, and must include the educational 1113 rationale and a method of evaluation. The sponsoring institution and 1114 program are jointly responsible for the quality of education offered to 1115 residents for the duration of such a project. 1116 1117 IX. Certification 1118 1119 Residents who plan to seek certification by the American Board of Nuclear 1120 Medicine should communicate with the office of that Board regarding the full 1121 requirements for certification. 1122 1123 1124 1125 ACGME: 6/02Effective Date: January 1, 2003 1126 Common Requirements/Duty Hours Requirements: ACGME approved & effective 1127 7/1/03 1128 1129 H:nmDraftscommonreqjsa.doc 1130 26