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The Radiologist and Nuclear Medicine

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  • 1. THE ROYAL COLLEGE OF RADIOLOGISTS TEL: 020 7636 4432 38 PORTLAND PLACE FAX: 020 7323 3100 LONDON W1B 1JQ A Charity registered with the Charity Commission No. 211540 VAT Registration No. 706 9665 05 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. Clarification • 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 and Radiology. • 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. Historical perspective Guidance already exists from the Royal College of Physicians (RCP) regarding consultants who undertake substantial commitments within nuclear medicine departments.1 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
  • 2. 2 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 job plan. 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 implemented.2 Such departments would be carrying out in the region of the 3,000–4,000 examinations1 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 These departments have established nuclear cardiology facilities and probably undertake PET-CT reporting.
  • 3. 3 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 requirements. Clinical networks The presence of a ‘hub-and-spoke’ model facilitates the exchange of clinical expertise across a number of departments. Teleradiology allows such image exchange. Standards 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 lung cancer.6 In addition, the NICE technology appraisal on myocardial perfusion scintigraphy has identified some guidelines for its appropriate use.7 Job planning The time allocation for procedures is shown in Table 1.
  • 4. 4 Table 1. Time allocation per procedure Procedure Time required Non-training environment In a training environment 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 studies 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. • Research 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
  • 5. 5 and research procedures. This, and their expertise in radiation protection of the patient, often requires their participation on committees such as radiation protection and research ethics.1 • 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 Workforce requirements 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.
  • 6. 6 Appendix 1 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 for 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.
  • 7. 7 Appendix 2 PET-CT2,9 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) PAs/week Note scanner provision/1.5 million 1,200/year * Based on 50 weeks per year after allowing for Bank Holidays.
  • 8. 8 Appendix 3 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 It is 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 cancer 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.
  • 9. 9 References 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. http://www.eanm.org/scientific_info/guidelines/guidelines_intro.php?navId=54 (last accessed 28/2/07) 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 28/2/07) 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. http://info.cancerresearchuk.org/images/publicationspdfs/factsheet_breast_feb2004.pdf (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. Acknowledgements 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- Committee. 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

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