THE JOURNAL OF NUCLEAR MEDICINE • Vol. 45 • No. 5 • May 2004
http://jnm.snmjournals.org/cgi/reprint/45/5/17N.pdf
Increasing Nuclear Medicine
Residency Training Requirements:
For Better or Worse?
Aproposal has recently been put forward to increase
the duration of the nuclear medicine residency and
implement a 3-tier residency training requirement
beginning in 2005 or 2006. The proposal includes increasing
the length of the nuclear medicine residency from 3 to 4
years (1 basic clinical year [PGY-1] plus 3 years of nuclear
medicine) for medical graduates fresh out of medical school.
Internal medicine physicians will be required to complete 2
years of additional training in nuclear medicine, and radiologists
will be required to complete a fellowship year of
nuclear medicine to be eligible to take the American Board
of Nuclear Medicine (ABNM) examination.
The proposal has the greatest impact on the nuclear
medicine residents who have not completed residency training
in other specialties. Four of the main reasons cited for
increasing the length of training are the perceived needs to:
(a) train residents in new and changing modalities such as
PET/CT, (b) raise the standards of nuclear medicine residents,
(c) make nuclear medicine training more academically
oriented, and (d) increase the respect for nuclear medicine
physicians. Although these are honorable reasons,
many issues must be addressed before these decisions are
finalized.
First, simply increasing the length of residency training
does not guarantee that residents will receive training in new
techniques, in technologies such as PET and CT, or in
innovative research. The requirements are not properly
structured to mandate such training. Moreover, residency
programs with only 1 or 2 residents might actually need to
increase the number of residency slots, because the thirdyear
resident may not be available to perform the same
duties as a first- or second-year resident. The final-year
resident might be in a research or CT rotation, leaving the
clinic without coverage. This will eventually create tensions
and problems within the department. In addition, the new
recommendation does not address the case of a resident
deciding to switch to nuclear medicine after 2 years of
residency training in another specialty. What would be the
requirements in such a situation––2 or 3 years of nuclear
medicine residency?
Some have suggested that 2 years of training in nuclear
medicine after internship are inadequate for nuclear medicine
physicians. This does not seem rational––the majority
of nuclear medicine scans in the United States are currently
being read by general radiologists with only 4–6 months of
training in nuclear medicine. Many nuclear medicine procedures
that were commonly used in the past are no longer in
use. The time spent learning these now outdated procedures
can be diverted to other training, such as PET or PET/CT
experience. Moreover, many nuclear medicine physicians
who were never trained in PET during their own residencies
are currently doing excellent work reading PET scans. This
proves that once a reasonable level of training and experience
is achieved, further knowledge can be built on previous
training and experience.
Second, increasing the length of training with no added
benefit may not increase the quality of the residents, because
it does not make nuclear medicine residency graduates more
marketable for jobs or more advanced training. After the
proposed training requirement increase, a nuclear medicine
residency would require 4 years and a radiology residency
would require 5 years. Most medical students would prefer
to do the radiology residency, because radiology offers more
job opportunities for only slightly longer training. Those
who opt for radiology would be able to read nuclear medicine
scans, along with many other modalities, without additional
training. If the purpose of the extended training requirement
is to attract more and higher quality residents, the
result of this change would not only be poor but would
ultimately be detrimental to nuclear medicine.
Third, although the notion that extending residencies
would provide extra time for research and better prepare
physicians for academic positions is admirable, fellowships
might provide a more practical and beneficial alternative.
Higher professional social status and pay come after a fellowship
year rather than after an additional year of residence.
Young physicians today are confronted by many
issues that were not as evident 5 years ago, such as stringent
Medicare reimbursement rules for residency and the everincreasing
cost of medical school tuition. A year of fellowship
training after residency, allotted exclusively for nuclear
medicine residency graduates, would be a better option.
Fourth, improving the perception of nuclear medicine
among other specialties might be accomplished more effectively
if we try to increase the marketability of nuclear
medicine physicians rather than simply increasing the length
of their training. The reason for the low marketability of both
nuclear medicine residencies and their graduates is not a lack
of training or respect from the physician community but the
limited availability of postresidency employment. The few
jobs available are mostly in academic centers, where
ABNM-certified physicians or radiologists with certification
in nuclear radiology are preferred. The typical nuclear medicine
resident graduating in June will not be able to sit for the
ABNM certification exam until later in the fall, with results
unavailable until December. This keeps the nuclear medicine
residency graduate out of work and training for a
minimum of 6 months. The pass rate of the ABNM certification
examination is lower than those in many other American
Board of Medical Specialties certification examinations,
including that of the American Board of Radiology.
The ABNM also should be aware that general radiologists
with nuclear medicine training of 4–6 months are eligible to
read any nuclear medicine scan with no additional certification
or training. Prospective employers prefer radiologists
over nuclear medicine physicians, because the radiologists
can read many other modalities in addition to nuclear medicine
scans. The ABNM should take these factors into consideration
and make the passing criteria of its certification
examination less stringent.
The major limiting factor for the marketability of the
nuclear medicine residency is the job market that confronts
residency graduates. The big question is whether the increase
in training requirements will be the solution it is
expected to be or the beginning of the end of the existence
of nuclear medicine as an independent specialty. If the job
situation and the demand for nuclear medicine physicians
remain the same, it will be very hard to recruit quality
residents to 4-year nuclear medicine residency programs.
Many residents recruited are likely to be medical graduates
from other countries, some of whom are willing to accept
any residency to satisfy visa requirements. Even this source
of recruitment could dry up when these students realize that
there is no future for nuclear medicine physicians in the
United States. Many residency programs would eventually
be forced to close. This will have a tremendous effect on the
field of nuclear medicine and the development of molecular
imaging. Nuclear medicine technologists, physicists, and
scientists depend on nuclear medicine physicians for guidance
in clinical matters. Subsequent development could be
hindered in other sectors of nuclear medicine, including the
basic sciences, leading the United States to fall behind other
developed countries in the field––a situation that may already
have occurred, as evidenced by increasing percentages
of nuclear medicine–related articles in U.S. journals authored
by individuals working outside the country.
Physicians trained in internal medicine have many other
subspecialties from which to choose for additional fellowship
training. Because most of these fellowships are for 2
years, many internists will prefer to be trained in another
internal medicine subspecialty rather than in nuclear medicine.
In the present situation, they will be more marketable
after a fellowship in an internal medicine subspecialty. The
number of internists deciding to do further training in nuclear
medicine will be far fewer than the number of residency
spots available.
One alternative to the proposed changes in residency
training requirements is to have an integrated 3-year program
for medical students straight out of medical school,
similar to the residency programs offered in obstetrics and
gynecology. The first year could be a PGY-1 year, with 9
months of basic clinical training integrated into a 2-year
nuclear medicine residency. If all integrated nuclear medicine
programs participated in the National Resident Matching
Program or similar matching programs and if medical
students were made aware of such an opportunity, recruitment
would be easier. The feasibility of making nuclear
medicine residency a training program with an integrated
PGY-1 should be actively considered. It also carries the
advantage of getting higher quality applicants, especially
because radiology residencies have recently become extremely
competitive in the match. Physicians trained in other
specialties but wanting to pursue a career in nuclear medicine
need not be required to do the integrated clinical year.
They could do 1 or 2 years of additional nuclear medicine
training, depending on their previous graduate medical education.
The other alternative is to create fellowship positions
designated exclusively for nuclear medicine residency
graduates, with emphases on research, oncology, PET, and
CT training.
The existence of nuclear medicine as an independent
specialty is now at a crossroads. It is time to either revive its
independence or become a subspecialty. The major challenge
is to attract quality residents and produce excellent
nuclear medicine physicians for the future. The SNM Young
Professional Committee, representing residents and recent
graduates, believes that simply increasing the length of training
without a thorough consideration of the issues raised
here will be detrimental to the future of nuclear medicine.
The SNM and other professional organizations should
work closely with professional bodies such as the American
Medical Association to increase awareness of nuclear medicine
as a separate specialty among the medical fraternity
and, most important, among referring physicians and the
public. In most other specialties, the present trend is to hire
and grant clinical privileges to board-certified or boardeligible
physicians. It is surprising that this is not the case in
nuclear medicine. Instead, it does not seem to matter who is
better trained but who is most influential in getting these
privileges. The ABNM, as the certifying body, should emphasize
that physicians who are board eligible or board
certified in nuclear medicine are the most competent professionals
for reading nuclear medicine scans, including cardiac,
PET, and PET/CT images. It will take a concerted
effort and cooperation from many individuals, other specialties,
many professional organizations, and involved committees
to achieve this goal.
Aju Thomas, MD, Board Member
Kelly H. Pham, DO, Co-Chair
Gina Caravaglia, DO, Co-Chair
SNM Young Professionals Committee