Nuclear Medicine Residency Curriculum

NMPIT training includes the following:

• Physics
• Mathematics and statistics of nuclear medicine
• Instrumentation and computer science
• Radiation biology and protection
• Radiopharmacy
• Diagnostic nuclear medicine imaging
• Nuclear cardiology
• Single photon emission computed tomography
• Positron emission tomography
• Computed tomography
• Radioimmunoassay
• In vitro radionuclide procedures
• Radioisotope therapy

Non-Imaging Training

NMPITs receive didactic lectures covering the principles and applications of plasma clearance techniques. In addition, practical experience is gained by laboratory rotations during which NMPITs perform analysis under the direction of the in vitro laboratory technologists.

In Vivo Imaging Training

A strong point of the Vanderbilt Nuclear Medicine Residency Program is the close coordination of all imaging modalities. Due to the physical proximity of radiology services and nuclear medicine there is a continuous exchange of information between residents and faculty on the various rotations.

The PET center has been operational at Vanderbilt since 1990 and is integrated into Nuclear Medicine and PACS. The current combined PET-CT instrument demands correlation of the PET image data with CT images for each patient. PACS enhances correlation with other modalities such as MR. Each NMPIT spends 2-4 months in PET each year.

With respect to cardiac imaging, the NMPIT actively participates in the selection of the appropriate radiopharmaceutical, type of study and the actual stressing of the patient as well as in the interpretation of results. The NMPITs are ACLS-trained and involved in the management of cardiac emergencies including EKG interpretation and cardiopulmonary life support. Cath correlation is performed monthly and each NMPIT is exposed to cardiac CTA and MR. Instruction in interpretation of cardiac CTA is available.

Cardiac imaging has benefited from the integration of cardiac PET. Perfusion PET studies are performed using 13N-Ammonia and metabolic studies using 18F-FDG. Quantification of perfusion and metabolism is performed on selected cardiac scans using application of mathematics to tracer kinetics and compartmental modeling.

Therapy Training

As part of the clinical radiation safety and radiobiology lectures, NMPITs receive instruction in the use of unsealed sources. This material covers the use of I-131 in the treatment of hyperthyroidism and thyroid cancer, Lu-177 DOTA-TATE (Lutathera), Strontium-89/Samarium-153/Radium-223 for treatment of painful bone metastases as well as phosphorous-32 in the treatment of polycythemia vera and malignant effusions. Radiation safety specifically covers the precautions to be employed during the administration of large therapeutic doses of these isotopes and in the procedures to be followed in the event of emergency surgery or death of patients containing therapeutic quantities of radionuclides. NMPITs also participate in the treatment of patients with neuroendocrine tumors using Lu-177 DOTA-TATE and the infusion of Y-90 Microspheres for hepatic malignancies.

Radiation Emergencies Training

All individuals working with radionuclides undergo a series of lectures covering the precautions and procedures to be used when handling these materials. As part of the training, safety measures to be followed in the case of minor and major spills and personnel contamination are emphasized. In all instances the radiation safety officer is notified immediately and coordinates the decontamination effort. NMPITs at the institution where the accident occurred are contacted and expected to aid in the survey and cleanup under the direction of the radiation safety officer. Medical management of persons overexposed to ionizing radiation is carried out by staff from Nuclear Medicine, Radiological Sciences and Radiation Oncology as deemed appropriate. Mass casualty situations follow Vanderbilt’s mass casualty plan and may include residents. All radioactive waste is disposed of through the Department of Institutional Safety’s radioactive waste management program.

NMPIT Expectations:

1. NMPIT is expected to be familiar with and to follow all policies of the Handbook, the Dept. of Radiology, Radiation Safety and VUMC.
2. NMPIT is ultimately responsible for the coverage of the services at VUH, VCH and VAMC.
3. NMPIT with the Radiology Chief Resident is responsible for the supervision of the radiology residents on the service, including coordination of coverage for the service(s).
4. NMPIT is ultimately responsible for assuring that all cardiac patients at VUH and VAMC are stressed in a timely manner.
5. NMPIT is expected to attend the weekly VA NM conference, the monthly cath correlation conference, the PET/CT conference (Thursday, 8 a.m.), the monthly VUH QA meetings, quarterly Journal Club, and nuclear medicine/cardiology conferences (noon, etc.), and all of the physics lectures. NMPIT is strongly encouraged to attend the Department of Radiology daily noon conferences, the Radiology Grand Rounds, and the monthly nuclear medicine research conferences.
6. NMPIT is responsible for the organization on a timely basis of the VAMC weekly conference, the noon conferences, and journal clubs. Presenters for journal clubs are expected to prepare PowerPoint presentations and know the appropriate background material. All attendees are expected to critically read the assigned articles prior to the meeting.
7. NMPIT is encouraged to join the Society of Nuclear Medicine and subscribe to and read the Journal of Nuclear Medicine. (Resources: Residents)
8. NMPIT is expected to participate in a research project and to present abstracts and/or posters at SNM, RSNA or SECSNM; the publication of at least one abstract per year is expected.
9. NMPIT will be responsible for teaching the nuclear medicine technology students including didactic presentations and to make presentations to the medical students as the need arises.
10. Vacations must be coordinated with the NM Program Director and the VA Chief as well as with the other NMPITs and with the Radiology Chief Residents. Only one NMPIT at a time should be scheduled to be away. In general, vacation time is not permitted the last week of June, the first week of July, or the week of RSNA/SNM/SECSNM annual meetings. There are Departmental policies regarding vacation time and meeting participation. Senior NMPITs will have priority in June.
11. NMPIT is expected to take the ABNM exams and/or the ABR special competency exams; there is an in-service nuclear medicine exam each January which is mandatory, the results of which will be part of the written evaluations for each NMPIT.
12. NMPIT is expected to spend time with the technologists and with the radiopharmacists early in the year as per the manual; NMPIT should be able to process SPECT and PET/CT studies by the end of December.

Knowledge-Based Objectives:

At the end of the residency, the NMPIT should be able to:

1. Demonstrate sufficient knowledge of medicine and apply this knowledge to nuclear medicine and radiological studies in a clinical context to generate meaningful differential diagnoses.
2. Demonstrate knowledge of the principles of research design and implementation.
3. Understand how nuclear medicine and radiologic equipment can be used to generate appropriate and diagnostic images.
4. Demonstrate knowledge of the levels of ionizing radiation related to specific imaging procedures and employ measures to minimize radiation dose to the patient.
5. Demonstrate the ability to use the Internet as an educational instrument to expand medical knowledge.
6. Demonstrate knowledge of issues of impairment (i.e. physical, mental and alcohol and substance abuse), obligations for impaired physician reporting, and resources and options for care of self-impairment or impaired colleagues.
7. Demonstrate an understanding of broad principles of biomedical ethics.
8. Demonstrate principles of confidentiality with all information transmitted during a patient encounter.
9. Demonstrate knowledge of regulatory issues pertaining to the use of human subjects in research.
10. Demonstrate the ability to design cost-effective care plans based on knowledge of best practices.
11. Demonstrate knowledge of the sources of financing for U.S. health care including Medicare, Medicaid, the Veteran’s Affairs and Department of Defense, public health systems, employer-based private health plans, and patient’s own funds.
12. Demonstrate knowledge of basic health care reimbursement methods.
13. Demonstrate knowledge of the regulatory environment including state licensing authority, state and local public health rules and regulations, and regulatory agencies such as Centers for Medicaid and Medicare Services (CMS) and Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).
14. Demonstrate knowledge of basic practice management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision and management of staff.

Technical Skills:

At the end of the residency, the NMPIT should be able to:

1. Actively participate in preparing and moderating multi-disciplinary conferences.
2. Provide a clear and informative written radiologic report including a precise diagnosis whenever possible, a differential diagnosis when appropriate, and recommended follow- up or additional studies when appropriate.
3. Provide direct communication to the referring physician or appropriate clinical personnel when interpretation reveals an urgent or unexpected finding and document this communication in the radiologic report.
4. Demonstrate effective skills of face-to-face listening and speaking with physicians, patients, patient’s families and support personnel.
5. Demonstrate appropriate telephone communication skills.
6. Demonstrate skills in obtaining informed consent, including effective communication to patients of the procedure, alternatives and possible complications.
7. Counsel patients concerning preparation for diagnostic testing.
8. Demonstrate the ability to use all relevant information resources to acquire evidence- based data, including electronic patient information systems.
9. Analyze practice experience and perform practice-based improvement in cognitive knowledge, observational skills, formulating a synthesis and impression, and procedural skills.
10. Demonstrate critical assessment of the scientific literature.
11. Demonstrate knowledge of and apply the principles of evidence-based medicine in practice.
12. Facilitate the learning of students, peers and other health care professionals.
13. Demonstrate positive work habits, including punctuality and professional appearance.

Decision Making/Value Judgment Skills:

At the end of the residency, the NMPIT should be able to:

1. Participate as an active member of the nuclear medicine team by communicating face-to- face with clinicians, answering the telephone, providing consultations, problem solving and decision-making.
2. Act as the contact person for technologists and nurses in managing patient and imaging issues; oversee diagnostic imaging to ensure adequacy of studies performed.
3. Develop a diagnostic plan based upon the clinical questions and relevant clinical, radiologic, and pathologic information.
4. Use multiple sources, including information technology to optimize life-long learning and support patient care decisions.
5. Actively participate in departmental or institutional quality assurance (QA)/quality improvement (QI) activities with faculty supervision.
6. Demonstrate altruism (putting the interests of patients and others above own self- interest).
7. Demonstrate compassion: be understanding and respectful of the patients, patient families, and staff and physicians caring for patients.
8. Demonstrate excellence: perform responsibilities at the highest level and continue active learning throughout one’s career.
9. Be honest with patients and all members of the health care team.
10. Demonstrate honor and integrity: avoid conflicts of interest when accepting gifts from patients or vendors.
11. Interact with others without discriminating on the basis of religious, ethnic, sexual or educational differences and without employing sexual or other types of harassment.

Credentialing for Cardiovascular Nuclear Medicine/Cardiac PET/CT

For Cardiovascular Nuclear Medicine/Cardiac PET/CT, successful completion of the American Board of Nuclear Medicine or American Board of Cardiology with 12 months training in an accredited Nuclear Cardiology program, or American Board of Radiology.

Candidates must have educational experience in the following areas:

1. Physical Science: Structure of matter, modes of radioactive decay, particle and photon emissions, and interactions of radiation with matter
2. Instrumentation: Principles of instrumentation used in detection, measurement and imaging of radioactivity with special emphasis on gamma cameras, including single photon and positron emission tomographic devices, and associated electronic instrumentation and computers employed in image production and display
3. Mathematics, Statistics and Computer Sciences: Probability distributions, medical decision making, basic aspects of computer structure, function, programming and processing, applications of mathematics to tracer kinetics, compartmental modeling, and quantification of physiologic processes
4. Radiation Biology and Protection: Biological effects of ionizing radiation, means of reducing radiation exposures, calculation of the radiation dose, evaluation of radiation overexposure, medical management of persons overexposed to ionizing radiation, management and disposal of radioactive substances, and establishment of radiation safety programs in accordance with federal and state regulations.
5. Radiopharmaceuticals: Reactor, cyclotron and generator production of radionuclides, radiochemistry, pharmacokinetics and formulation of radiopharmaceuticals.
6. Quality Assurance: Principles of quality assurance, efficacy assessment and compliance with NRC and JCAHO regulations.

Procedures under this credentialing include the selection of the appropriate studies, performance, supervision and interpretation of:

1. Myocardial perfusion scintigraphy using different SPECT and PET/CT radiopharmaceuticals
2. Myocardial infarct avid imaging
3. Cardiac blood pool imaging with the gated equilibrium technique
4. Cardiac blood pool imaging with the first pass technique
5. Cardiac flow imaging (angiocardiography) for cardiac valvular disease and intracardiac and great vessels shunts
6. Vascular flow imaging (peripheral angiography)
7. Venous thrombosis imaging (venography)
8. Iodine-123-MIBG imaging
9. Cardiac amyloid imaging using Tc99m-Pyrophosphate