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Limited ARSAC licence acquisition for radionuclide radiology

Department of Nuclear Medicine, Pembury Hospital, Tunbridge Wells, Kent, UK

	Abstract

Top Abstract Introduction Method Discussion Conclusion Appendix I Appendix II Appendix III References

 
Radionuclide radiology faces a potentially crippling future manpower shortage. A combination of future retirement, few trainees and many currently unfilled posts threatens to limit future service delivery. The case is made for in-house modular training of existing consultants as the way forward for radionuclide radiology, allowing limited ARSAC licence acquisition. We propose this as a viable solution to the manpower problem in radionuclide radiology.

	Introduction

Top Abstract Introduction Method Discussion Conclusion Appendix I Appendix II Appendix III References

 
Most nuclear medicine examinations in the UK are reported by radionuclide radiologists [1]. Diagnostic radiology in general and radionuclide radiology in particular faces a severe potentially crippling manpower problem. In radionuclide radiology there are many consultant vacancies and unfilled posts around the country, set against a background of too few trainees being trained in the nuclear medicine sub speciality [2]. The current Royal College of Radiology specialist registrar (SpR) training requirement for Nuclear Medicine sub-specialization is 1 year radionuclide radiology (training year 5) and 2 years for full nuclear medicine accreditation (training years 5 and 6). These year 5 and 6 training requirements for ARSAC licence qualification have yet to prove popular with radiology trainees. This has significant manpower implications for District General Hospital (DGH) Nuclear Medicine services. Replacement posts in such departments may be difficult to fill.

In many DGHs the provision of funded Nuclear Medicine sessions is frequently inadequate [3] and often services are provided by a single radionuclide radiologist who is an ARSAC licence holder. It is an ARSAC requirement that the licence is held by the individual, not the department. It follows that, on retirement, unless a new ARSAC licence holder is found, the radionuclide radiology service may be under threat. A significant cohort of radionuclide radiologists is set to retire in the next 10 years [4] and this will have a profoundly adverse effect on service provision.

There are possible solutions to this manpower crisis. The present Radiology SpR training schemes allow sub-specialization training in years 5 and 6. The first and most logical solution is to attract more SpRs into year 5 and 6 training in radionuclide radiology and nuclear medicine. The attractions of positron emission tomography (PET) imaging may bring more trainees into the additional year 6 programs but as yet the trainee numbers are small and can not hope to satisfy the current manpower demand. These low numbers of trainees are unlikely to fill DGH posts especially if alternative posts are available in the larger teaching hospitals and specialist centres.

A centrally based Nuclear Medicine service with peripatetic reporting and tele-radiology with a remote ARSAC licence holder is another potential solution – a hub and spoke system. However in our view the notion of running a department longterm under the auspices of a remote ARSAC holder is unsatisfactory due to quality issues. For example clinical–radiological consultations would be more difficult with the ARSAC licence holder off site and this has been shown to be detrimental to the radiology service [6]. Remote reporting may reduce the radiology input in case discussion at multidisciplinary meetings.

Radiographer/technologist role extension and reporting would also be a means of coping with the service provision but requires supervision. However, Radiographer reporting accuracy has not been fully evaluated and caution is advised [7] and at present this can not be considered a definitive solution.

Another alternative is to train existing consultant radiologists in radionuclide radiology. This is the approach we have adopted. We think that our template for local "in house" modular training of existing consultant radiologists may form the basis for more widespread limited ARSAC licence acquisition and be a viable solution to the manpower problem of radionuclide radiology.

	Method

Top Abstract Introduction Method Discussion Conclusion Appendix I Appendix II Appendix III References

 
Targeted modular "in house" training needs to address the most frequently requested examinations. The training process requires initial observation followed by joint reporting and then a prolonged period of supervised reporting before safe solo reporting can be allowed. If the acquisition of a limited ARSAC licence is the goal of training then the ARSAC licensing authority need to be informed of the intention to train, ideally before the training process starts.

Our department has two gamma cameras performing in excess of 3000 examinations per year with almost 1000 bone scans and 600 lung scans making up the majority of investigations. We perform no therapy procedures. There are five notional contracted radionuclide radiology consultant sessions. We currently have two radionuclide radiologists with individual ARSAC licences out of an establishment of 6.4 whole time equivalent consultant radiologists.

Our training plan for a Consultant radiologist colleague is set out below.

Basic template for ARSAC licence accreditation training

1. Select an appropriate radiologist with basic FRCR level Nuclear Medicine training.
   
2. Obtain ARSAC licensing information, regulations and application forms.
   
3. Notify ARSAC of intention to train.
   
4. Specify the range of investigations in which training will take place. (This will be determined by local requirements and localised specialist interest).
   
5. Determine from ARSAC the required type and number of examinations likely to be necessary for certification.
   
6. Introduce a background reading curriculum.
   
7. Commence observational training including re-familiarization with safety procedures, equipment and radiopharmacy.
   
8. Follow this with joint simultaneous reporting.
   
9. Followed by supervised reporting in which each individual report is double-read and either sanctioned or jointly reviewed before becoming definitive.
   
10. Perform an internal audit assessing interobserver and intraobserver variation, e.g. ventilation and perfusion lung scanning for the diagnosis of acute pulmonary embolism.
    
11. Focus continuing medical education (CME) on radionuclide radiology meetings.
    

Our trainee was a general consultant radiologist with 5 years consultant experience. He had no formal post fellowship training in nuclear medicine or radionuclide radiology, but had appropriate FRCR teaching and hospital training in nuclear medicine.

At the start of the training program the trainee was given the department teaching file to review and a relevant reading and reference list (Appendices I and II). There are now some good websites which can provide a valuable supplement to training (Appendix III).

Our structured in house modular training commenced with a 1 month review of basic sciences and policies and procedures in the radiopharmaceutical laboratory with special emphasis on safety. During the induction period our trainee became familiar with the departmental facilities and protocols including hardware, software, scanning routines and location of emergency equipment and emergency procedures. While this was concentrated in a 1 month period, much of it was repeated over the ensuing 18 months. The reporting component of training comprised 3 months observation and joint reporting followed by 15 months of supervised reporting. All reports were reviewed by one of the existing ARSAC licence holders and were either sanctioned or jointly re-reviewed before becoming definitive. 1500 bone scans and 700 lung scans were reported by the trainee during the training period. This may well be in excess of the minimum requirements which ARSAC may demand.

During lung scan assessment we performed our own in-house audit of interobserver lung scan reporting, finding complete concordance in 25 out of 30 reports with five cases reassessed. None of these cases had more than 1 level of probability difference between observers which is acceptable, within published levels of discordance [5].

	Discussion

Top Abstract Introduction Method Discussion Conclusion Appendix I Appendix II Appendix III References

 
We considered it was important to obtain the trainee's agreement at the outset to attend a minimum of three recognized (CME.CPD supported) radionuclide meetings, of which at least two would have a high clinical content. In our case we requested additional attendance at one "safety bias" meeting and the acquisition of a current Acute Life Support certificate. We strongly urged the trainee to join the British Nuclear Medicine Society and include the additional Nuclear Medicine training in the Job Plan Review at formal annual appraisal.

When the training programme is successfully completed to the trainer's satisfaction an application to the Department of Health for a limited ARSAC licence may be submitted. The structured "in house" modular training should then be found acceptable.

There are obvious advantages to this training programme. Each radionuclide radiologist has an ARSAC licence covering their particular sphere of activity. There is year round flexibility and uninterrupted local provision of the nuclear medicine service. We now have sufficient ARSAC licence holders within our department to ensure that the legal basis of the nuclear medicine service will continue in spite of any single future retirement.

"In house" training is not without its problems. For the trainers there is a large time commitment which may be unbudgeted and uncontracted as in our case. No formal assessment of the trainer abilities was obtained but both had been providing a nuclear medicine service for 20 years and 15 years. No formal external inspection of the training site and program was performed. In future we think it desirable for some liaison with local teaching hospitals or for several DGH to participate together and obtain some form of site accreditation. We would certainly encourage more formal assessment of such sites. Given the time commitment involved in training and the European working time directive, there may also have to be some redistribution of both the trainee's and trainer's workloads.

Our department is part of a recognized radiology Specialist Registrar Training scheme which is externally accredited and the trainers are experienced in teaching radionuclide imaging. If a department is not part of an SpR training scheme then individuals may feel unable to train another consultant colleague.

	Conclusion

Top Abstract Introduction Method Discussion Conclusion Appendix I Appendix II Appendix III References

 
Using the above template we have demonstrated that it is feasible for a general radiologist to obtain a limited ARSAC licence by "in house" modular training. This template could be improved and used as a means for existing providers of radionuclide radiology services to solve the anticipated manpower problems. "In house" training of colleagues in specific areas of radionuclide radiology seems the only way to ensure future continuity of the service.

	Appendix I

Top Abstract Introduction Method Discussion Conclusion Appendix I Appendix II Appendix III References

 
Background reading and reference books

• Murray IPC, Ell PJ. Relevant chapters on Lung and bone scintigraphy. Nuclear medicine and clinical diagnosis and treatment. (2nd edn) Churchill Livingstone 2000 – Section 1 & 6.
  
• Datz L. Gamuts in nuclear medicine (3rd edn). St Louis, MO: Mosby, 1995.
  
• Fogelman I, Maisey M. An atlas of clinical nuclear medicine. Martin Dunitz, 1988.
  
• Thrall JJ, Ziessman A. Nuclear medicine – the requistes (2nd edn). St Louis, MO: Mosby, 2001.
  
• Holder LE, Fogelman I, Collier BD. Atlas of planar and SPECT bone scanning (2nd edn). Martin Duntz, 2000.
  
• Relevant Journals. Our departmental library contains Nuclear Medicine Communications, the Journal of Nuclear Medicine and Seminars in Nuclear Medicine as well as the major radiological journals
  

	Appendix II

Top Abstract Introduction Method Discussion Conclusion Appendix I Appendix II Appendix III References

 
Important lung scanning seminal papers and reviews

• The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA 1990;263:2753–9.
  
• Worsley DF, Alavi A. Radionuclide imaging of acute pulmonary embolism. Radiol Clin North Am 2001;39:1032–52.
  
• Ralph DD. Pulmonary embolism. The implications of prospective investigation of pulmonary embolism diagnosis. Radiol Clin North Am 1994:32:679–87.
  
• Gottschalk A, Stein PD, Goodman LR, Sostman HD. Overview of prospective investigation of pulmonary embolism diagnosis II. Semin Nucl Med 2002;32:173–82.
  
• Freeman LM, Krynycki B, Zuckier LS: Enhanced lung scan diagnosis of pulmonary embolism with the use of ancillary scintographic findings and chemical correlation. Semin Nucl Med 2001;31:143–57.
  

	Appendix III

Top Abstract Introduction Method Discussion Conclusion Appendix I Appendix II Appendix III References

 
Useful websites

• Mallinckrodt Institute of Radiology Nuclear Medicine Teaching File http://gamma.wustl.edu (accessed 11 March 2005).
  
• Harvard Medical School Joint Programme in Nuclear Medicine Electronic Learning Resources. www.jpnm.org (accessed 11 March 2005).
  

	Acknowledgments

 
Based on a presentation to the British Nuclear Medicine Society Annual Meeting in Manchester, April 2002.

Received for publication March 26, 2004. Revision received November 29, 2004. Accepted for publication January 13, 2005.

	References

Top Abstract Introduction Method Discussion Conclusion Appendix I Appendix II Appendix III References

 

1. McCready R. Diagnostic radiologists in nuclear medicine. Clin Radiol 1990;42:225.[Medline]
2. Robinson P. Obtaining departmental accreditation for training in radionuclide radiology. Royal College of Radiologists Newsletter 2001;64:11–2.
3. Conry BG, Burwood RJ. Radionuclide radiology directed nuclear medicine services in district general hospitals in south Thames. Br J Radiol 2001;74:715–9.[Abstract/Free Full Text]
4. Robinson P. Nuclear medicine and radiology – bridging the gaps. Royal College of Radiologists Newsletter 2001;65:11–2.
5. Bateman NT, Coakley AJ, Croft DN, Lejall JR. Ventilation-perfusion lung scans for pulmonary emboli. Accuracy of reporting. Eur J Nucl Med 1977;2:201–3.[Medline]
6. Dalla Palma L, Stacul F, Meduri S, Geiting JTe. Relationships between radiologists and clinicians: results from three surveys. Clin Radiol 2000;55:602–5.[Medline]
7. Svasti-Salee D, Flanagan JJ, Conry BG, Wetton CW, Akehurst S. The reliability of radiographer based interpretation in acute reporting of VQ scans: a prospective assessment. Nucl Med Commun 2004;25:408. (Presented at the spring meeting of the BNMS 2004.)

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