Nuclear medicine (from A career hot spot: nuclear medicineBMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7096.2 (Published 14 June 1997) Cite this as: BMJ 1997;314:S2-7096
- Liz Prvulovich, senior registrar on behalf of the Council of the British Nuclear Medicine Society
Nuclear medicine provides a varied clinical workload without excessive on call commitments. Senior registrar Liz Prvulovich explains how coming across the specialty was good news for her career.
Like many nuclear medicine specialists, I discovered nuclear medicine quite late in my career while working towards an MD as a research registrar in cardiology. My project used nuclear medicine techniques to examine left ventricular remodelling after myocardial infarction. Four years later and with an MD, I decided to train in nuclear medicine and I have never regretted it. I enjoy all aspects of nuclear medicine but have made use of my cardiac training by developing my interest in nuclear cardiology both clinically and for research. Cardiology on call, with its stream of emergency patients often requiring acute intervention, is, how- ever, a thing of the past.
Limited undergraduate teaching as well as regional differences in the provision and use of nuclear medicine services mean that many junior doctors have only a limited awareness of what nuclear medicine can offer in terms of patient management and as a career. Few actively contemplate a career in nuclear medicine until research projects introduce them to nuclear medicine techniques.
What is nuclear medicine?
Nuclear medicine has held the status of an independent specialty since 1989 and is concerned with the administration of unsealed radioactive substances to patients for diagnosis, therapy, or research. Departments of nuclear medicine exist in most teaching hospitals and within an increasing number of district general hospitals.
The range of nuclear medicine procedures is wide among both adults and children. Examples of common diagnostic procedures include ventilation- perfusion lung scanning for pulmonary embolism, bone scanning in benign and malignant disease, and myocardial perfusion studies in ischaemic heart disease as well as renography in the investigation of renal function and morphology. A recent survey indicated that the number of imaging studies is rising at an annual rate of about 7%. Most patients are dealt with as outpatients; only a few patients require admission for treatment. The most common therapeutic procedure is radioiodine for the treatment of thyrotoxicosis, and others include treatment of thyroid cancer and alleviating bone pain in malignancy.
Attractions of a career in nuclear medicine
Interesting and varied clinical workload
Academic stimulus of work
Huge research potential
Scope to develop a special interest and become a national or international expert
Excellent teaching material
Sociable working hours as few posts have an on call commitment
Liaison with many other disciplines
Ability to develop management skills
No medical takes
The unique ability of nuclear medicine techniques to provide physiological information non-invasively means that its methods are used extensively for research. This research includes using established techniques to assess new drugs or procedures-for instance, left ventricular function studies to assess the cardiotoxicity of chemotherapeutic agents-and also to develop new radiopharmaceuticals and procedures for assessment and therapy in specific disease processes. Examples of these include cerebral blood flow studies as well as receptor and antibody imaging. Positron emission tomography has been used in research for 20 years and is now making the transition into clinical practice in oncology, cardiology, and neurology.
Potential drawbacks of a career in nuclear medicine
Recommendation to take MSc course in nuclear medicine
Few junior doctors for consultant support
Relative isolation from medical colleagues in singlehanded departments
Service led specialty
One of the less glamorous specialties
What do nuclear medicine specialists do?
Nuclear medicine specialists are responsible for providing the clinical services outlined above and must hold a Department of Health certificate that allows them to administer radioactive substances. Applications for certificates are currently assessed on the basis of experience and training but future requirements will probably be more stringent and allied to appropriate higher medical training. Specific duties of nuclear medicine specialists include the selection, supervision, and reporting of diagnostic investigations, assessing patients for treatment, and providing appropriate follow up as well as the usual triad of audit, research, and teaching. History taking and examination of patients as they pass through the department ensures that detailed clinical information is available for reporting. Many consultants are also heads of departments and so have managerial roles and are budget holders. The precise range of responsibilities varies because of a number of factors, including the size and type of the hospital served, and its commitment to research and teaching.
Routes of entry
Trainees are drawn from all of the medical specialties, including cardiology, respiratory medicine, and nephrology, as well as from radiology. The specialty attracts as many women as men, and women are well represented at senior level in the profession.
Training in nuclear medicine starts as a specialist registrar; there are no senior house officer posts. Recruitment to specialist registrar posts is therefore based on an assessment of personality as well as progression through a medical career to date, but applicants are not expected to have prior experience of nuclear medicine.
Nuclear medicine introduced specialist registrars in January 1997. From that date, UK applicants for higher medical training in nuclear medicine have had to have completed a minimum of two years' general professional training in approved posts and either obtained membership of the Royal College of Physicians (MRCP) or Fellowship of the Royal College of Radiologists (FRCR). Overseas graduates who competefor higher medical training posts must provide evidence of equivalent knowledge, training, and experience. Training is supervised by the Joint Committee on Higher Medical Training and its Specialist Advisory Committee in Nuclear Medicine.
Higher medical training in nuclear medicine lasts for up to four years depending on previous experience and leads to the award of a certificate of completion of specialist training (CCST). A relevant research period may contribute up to 12 months towards the total duration of higher medical training. Radiologists entering with FRCR may be exempt for up to two years of the training programme, but will need to do at least two years' whole time equivalent of clinical training in an approved programme. Flexible training is possible.
Ideally, both physicians and radiologists would take the approved MSc course in nuclear medicine provided by the University of London during training. The MSc can accommodate up to 20 students and provides instruction in the clinical, scientific, and legal aspects of the specialty covering the core curriculum for higher medical training in nuclear medicine. Trainees attend the MSc part time over two years and the cost is £1270 annually. Lectures are provided in modular blocks to enable trainees from outside London to attend; practicals and tutorials are provided locally. The MSc examination currently comprises two written papers and two vivas which cover scientific principles and clinical nuclear medicine as well dissertation. The pass rate is usually about 80%.
A survey of nuclear medicine in the UK in 1993 indicated that there were about 130 whole time equivalent clinicians performing nuclear medicine in the UK. This breaks down into approximately 30 nuclear medicine physicians with the remainder being made up from radiologists providing nuclear medicine services. Although nuclear medicine has only 16 specialist registrar posts, there is a shortage of properly trained doctors wanting to undertake higher medical training in nuclear medicine, and recruitment to existing training posts has been difficult. The recent granting of manpower approval for additional training posts is likely only to exacerbate this problem unless recruitment into the speciality can be stimulated.
Senior house officers interested in a career in nuclear medicine may apply to the British Nuclear Medicine Society for funding towards a two week attachment in a nuclear medicine department designed to permit a more informed career choice. Further details are available from the society at the address below.
What are characteristics of someone who would enjoy nuclear medicine?
Nuclear medicine specialists work as part of a multidisciplinary team which includes physicists, radiopharmacists, nurses, radiographers, and technicians so communication skills and a healthy respect for each team member's contribution to the provision of a high quality service is essential. Doctors who enjoy patient contact but prefer not to maintain responsibility for large numbers of inpatients or have the stress of medical takes and an on call commitment may enjoy nuclear medicine with its regular working hours, largely outpatient workload, and limited or absent on call commitment.
For those who enjoy the stimulus of research and academic work, nuclear medicine offers many opportunities, though these do generally have to be combined with significant clinical workloads. The broad range of procedures in nuclear medicine makes it possible for individuals to pursue their clinical interests and develop existing expertise whatever their medical background and there is scope for motivated individuals to develop into either national or international experts. Finally, those with a strong medical grounding and an inquiring mind will enjoy the varied clinical workload and the daily challenge of providing optimal quality studies.
The British Nuclear Medicine Society
1 Wimpole Street
London W1M 8AA
Specialist advisory committee for nuclear medicine
(for advice about training and courses)
Chairman: Dr A J Coakley
Royal College of Physicians
St Andrews Place
London NW1 4LE
Tel: 0171 935 1174
Fax: 0171 487 4156