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The Radiologist and Nuclear Medicine
The purpose of this document is to guide clinical and medical directors and regional
specialty advisors in job planning and at appointment committees.
The paper addresses the challenges of the radiologist working in a nuclear medicine
environment. The range of radiologist input varies from ad hoc sessional reporting (for
example, an hour’s session a day) to committed direct clinical care (DCC) activity within
a formal job plan.
• A radionuclide radiologist has specialty training to satisfy requirements for a diagnostic
licence from the Administration of Radioactive Substances Advisory Committee
(ARSAC) – Certificate of Completion of Training (CCT) Radiology.
• A nuclear medicine physician has specialty training in therapy and diagnostic aspects
of nuclear medicine – CCT Nuclear Medicine.
• A dual-accredited radiologist has therapy and imaging training – CCT Nuclear Medicine
• PET-CT can be reported and directed by an ARSAC certificate holder who has the
appropriate serials on their certificate.
• A non-ARSAC certificate holder can only report PET-CT at the delegation of the local
PET-CT ARSAC certificate holder.
• The Royal College of Radiologists (RCR) will be providing guidance on requirements
for reporting in these cases.
• Only specialty-trained radionuclide radiologists, nuclear medicine physicians, or dual-
accredited radiologists can direct and report PET-CT at present.
Guidance already exists from the Royal College of Physicians (RCP) regarding
consultants who undertake substantial commitments within nuclear medicine
The following guidance assists those departments who have flexible
commitments to nuclear medicine and those departments who wish to dedicate
substantial time to developing the specialty, particularly with the advent of PET-CT
reporting, nuclear cardiology and sentinel node developments.
These recommendations are also of value for appointment committees where there is a
requirement for nuclear medicine service provision. Medical directors and clinical
directors may wish to use dedicated nuclear medicine sessions to form physician posts
rather than radiology posts where deemed suitable for the needs of the trust
The sessional radiologist
Many of the district general hospitals undertaking nuclear medicine procedures have a
radiologist with an ARSAC certificate who carries out reporting in a flexible fashion.
Several of these radiologists are approaching retirement and it is vitally important that
their commitments are recognised in job plans. It may be possible to combine this
aggregate commitment with DCC sessions. However, recognition needs to be made of
the time taken in the attendant administration involved in nuclear medicine, particularly
with respect to ARSAC duties. New appointees should have year 5 radionuclide
radiology subspecialty training or its equivalent.
The radiologist in a smaller single camera department
Many departments working at this level are undertaking a mix of procedures in the range
of 800–1,500 per year.1
This commitment should be recognised in the form of flexible
DCC sessions; for example, combining with other reporting so that when service
commitments increase this can be translated into formal sessions in a more specialist
The radiologist in a larger single camera department
Radiologists in this category will be undertaking around 1,500–2,400 examinations,
which is the recommended guideline for a single gamma camera.1
It is recommended
that they have a minimum of two to three sessions of DCC / supporting professional
activity (SPA). There should be a lead radionuclide radiologist with formal sessional
allocation. Often, workload is divided among more than one ARSAC certificate holder.
The radiologist in a twin camera department
A formal structured job plan should be in place reflecting the precise nature of the
studies such as dedicated cardiac sessions. The radiologist may be involved in reporting
PET-CT examinations and current college (RCP/RCR) guidelines should be
Such departments would be carrying out in the region of the 3,000–4,000
and typically have a lead radiologist accredited in radionuclide radiology.
The radiologist in a large department
Radionuclide radiologists can undertake the imaging component of the workload, but
these departments will also require one or more dual-accredited consultant(s) or nuclear
medicine physician(s) if a comprehensive range of therapy is undertaken (for example,
treatments for thyrotoxicosis; samarium/strontium therapy for prostate and breast
cancer; and MIBG for phaeochromocytoma and neuroblastoma).
Activities are often in excess of 4,800 patients with three cameras.1
have established nuclear cardiology facilities and probably undertake PET-CT reporting.
Job plans for these consultants may follow the guidance for nuclear medicine physician
job plans more closely.
Radionuclide radiology specialty
Radionuclide radiology involves the practice of nuclear medicine combined with the
interpretation of anatomical imaging. The advent of PET-CT and SPECT-CT requires
specialist interpretation and further training. The development of these modalities has
resulted in a restructuring of the radiologist-training programme in recognition of these
The presence of a ‘hub-and-spoke’ model facilitates the exchange of clinical expertise
across a number of departments. Teleradiology allows such image exchange.
It is a legal requirement that all procedures are carried out in accordance with written
procedures and protocols, and these are usually derived from national (from the British
Nuclear Medicine Society [BNMS]) or European guidelines.3,4
Single-handed specialists working independently cannot easily fulfil the requirements of
clinical governance. A minimum of 0.4 whole-time consultant overlap within single-
handed practices is encouraged to avoid clinical isolation. In some cases, this may be
achieved by ensuring that the practitioner rotates to another unit as part of their weekly
commitment or another practitioner rotates in to the unit if that is more appropriate to the
caseload. The potential role of telemedicine links with larger centres is being explored as
a means of sharing experience and opinions between departments, and to allow a wider
audit of performance than currently possible.1
The training standards for doctors working in the subspecialty of radionuclide radiology
have been specified in the appropriate curriculum documents.5
• National Institute for Health and Clinical Excellence (NICE) guidelines
The appropriate use of nuclear medicine services in specific circumstances has been
referred to in NICE guidelines into the management of specific diseases; for example, in
In addition, the NICE technology appraisal on myocardial perfusion
scintigraphy has identified some guidelines for its appropriate use.7
The time allocation for procedures is shown in Table 1.
Table 1. Time allocation per procedure
Procedure Time required
In a training
Routine non-imaging studies, planar imaging
and bone densitometry
10 mins 13 mins
Tomographic imaging 15 mins 20 mins
Complex procedures and image co-registration
30 mins 40 mins
PET-CT (single report). Correlation may
require review of previous cross-sectional
imaging – see below
40 mins 50 mins
Stressing prior to cardiac imaging, including
prior assessment and advice on drug therapy
25 mins 30 mins
Review of other imaging modalities 10 mins 15 mins
The PET-CT reporting times are in the context of an integrated service. If the reporting
element is outsourced then the time will be shorter, but account should be taken of the
time required in the host trust to collate images into the clinical cortex, protocol and
select cases, as well as participate and prepare for MDTs. Extra resources would be
needed to administer the service overall.
Continuing medical education (CME)
Radiologists should ensure that they undertake CME accreditation in proportion to the
nuclear medicine activities they supervise and report. This is particularly true of mixed
sessions of radiology and nuclear medicine.
Nuclear medicine techniques are used extensively in medical research. All consultants
are expected to take an active interest in research, although the time commitment to this
activity will vary according to individual interest and hospital type.
• Local management duties
Many consultants have managerial duties as heads of department and budget holders
and undertake appraisals of medical staff. Protected time is necessary for departmental
and directorate meetings. Clinical service directors may have responsibility for service
planning, requiring additional time allocation. Radionuclide radiologist consultants have
unique legal responsibilities with respect to ARSAC certification for diagnostic, therapy
and research procedures. This, and their expertise in radiation protection of the patient,
often requires their participation on committees such as radiation protection and
• Regional and national work
Adequate provision for local and off-site managerial duties and committee work should
be included in the job plan. Depending on the frequency, this may be included as a
weekly programmed activity (PA) if necessary, but agreement on how this leave for
external duties will be handled should be included in the job plan.1
The workload of radionuclide radiologists covers a broad spectrum, ranging from routine
reporting to complex SPECT-CT, PET-CT imaging and in some cases radionuclide
therapy. Adequate time must be incorporated into the job plan for correlative imaging.
Workload estimates must balance the time element required for procedures grouped by
type and allow for variations between consultants.
Myocardial perfusion scintigraphy (MPS)
The NICE report on myocardial perfusion scintigraphy7
suggests that the UK should be
working towards providing 4,000 MPS studies per year per million population, compared
with only 1,200 per year in 2000. This means that we need capacity for an additional
2,800 MPS studies per year per million population. As the calculation below shows,8
a department serving a population of 250,000, this would require an additional 2.3 PAs
of consultant time. Using this figure, 1,260 clinical hours per whole-time equivalent
(WTE) consultant are required.
Additional work to meet expansion in myocardial perfusion scans
Additional MPS per 250,000 population 700/year
Additional MPS studies per week* 14/week
Consultant time for stressing 25 mins
Consultant time for reporting 15 mins
Total consultant time for each MPS study 40 mins
Total consultant time for additional MPS 9.3 hr/week
Clinical PAs required 2.3 PAs
* Based on 50 weeks per year after allowing for Bank Holidays.
Additional work to meet expansion in PET-CT
PET-CT scans per 1.5 million population 1,200/year
PET-CT scans per week (1.5 million)* 24
Consultant time for each PET-CT scan 40–50 mins
Total consultant time for PET-CT scans 24 x 50 mins
Additional DCC required
(For double reporting RCR/RCP)
Approx six (12)
Note scanner provision/1.5 million 1,200/year
* Based on 50 weeks per year after allowing for Bank Holidays.
Sentinel node localisation
Sentinel node localisation is currently indicated for breast cancer. Additional potential
indications include melanoma, vulval carcinoma etc.
There were 40,470 new cases of breast cancer in the UK in the year 2000.10,11
assumed that approximately two-thirds of these cases might benefit from sentinel node
localisation and that a negligible number were performed in 2000. The calculation below
shows that, for a department serving a population of 250,000, this would require an
additional 0.3 PAs of clinical time. This equates to a total of 11 WTE consultants for the
whole of the UK.
Additional work to meet expansion in sentinel node (SN) localisation for breast
New breast cancer cases in UK 40,470/year
Breast cancer cases per 250,000 population 169/year
Cases likely to benefit from SN localisation 113/year
SN studies per week* 2.3/week
Consultant time for each SN study 30 mins
Total consultant time for SN studies 1.1 hr/week
Clinical PAs required 0.3 PAs
* Based on 50 weeks per year after allowing for Bank Holidays.
The radionuclide radiologist’s job plan will vary according to the case mix, an individual’s
areas of special expertise and the amount of specialist scientific support. Where there is
more than one consultant in a department, it would be expected that would be flexibility
in the job plan for rotation of sessions as required. This will facilitate maintenance of
competence in less frequently performed procedures and allow cross-cover
arrangements to be in place.
1. Royal College of Physicians. Nuclear medicine. In: Consultant Physicians Working
with Patients, 3rd edn. London: RCP, 2005: 223–235.
2. The Royal College of Radiologists. PET-CT in the UK. A strategy for development and
integration of a leading edge technology within routine clinical practice. London: The
Royal College of Radiologists, 2005.
3. British Nuclear Medicine Society. Clinical procedure guidelines;
http://www.bnms.org.uk/guidelines.htm (last accessed 28/2/07)
4. European Association of Nuclear Medicine. Scientific guidelines.
5. The Royal College of Radiologists. Structured training in clinical radiology, Appendix:
curricula for sub-speciality training. London: The Royal College of Radiologists, 2006.
6. National Collaborating Centre for Acute Care. Diagnosis and treatment of lung cancer.
London: National Collaborating Centre for Acute Care, 2005.
7. National Institute for Clinical Excellence. Myocardial perfusion scintigraphy for the
diagnosis and management of angina and myocardial infarction. NICE Technology
Appraisal 73. London: NICE, 2003. www.nice.org.uk/TA073guidance (last accessed
8. Anagnostopoulos C, Harbinson M, Kelion A, Kundley K, et al. Procedure guidelines
for radionuclide myocardial perfusion imaging. Heart 2004; 90(Suppl 1): i1–i10.
9. Intercollegiate Standing Committee on Nuclear Medicine. Positron emission
tomography. A strategy for provision in the UK. London: RCP, 2003.
10. Cancer Research UK. Breast Cancer Care – February 2004.
(last accessed 28/2/07)
11. British Nuclear Medicine Society. British Nuclear Medicine Generic Quality
Guidelines for the Provision of Radionuclide Diagnostic Services. London: BNMS, 2005.
Particular thanks go to Dr Rosie Allan, Professor Jon Hill and Dr Giles Maskell.
I would also like to acknowledge the valuable contributions from the RCR Radionuclide
Radiology Sub-Committee, the Joint RCR/RCP Intercollegiate Standing Sub-Committee
on Nuclear Medicine (ICSC) and the British Medical Association’s Radiology Sub-
Dr Gill Markham
Dean & Vice-President
Faculty of Clinical Radiology
BFCR(07)5 Approved by the Board of the Faculty of Clinical Radiology 2 March 2007