A career in nuclear medicine

John Frank explains why nuclear medicine has become a major imaging specialty, crucial to both diagnosis and therapy, and offers a guide to becoming a part of it

Nuclear medicine is the branch of imaging that uses radio-isotopes to study the physiology and metabolism of the body (rather than the anatomy shown by x rays, computed tomography (CT), ultrasound, and magnetic resonance imaging (MRI)). Nuclear medicine today is the exciting development of the early 20th century pioneering work of, among others, Rutherford, the Curies, and Lawrence, who built the first cyclotron in 1933. With all the new isotopes and radiopharmaceuticals we now have available, there is huge scope for advances in the field. If you are the sort of person who would enjoy the challenge of working in a rapidly developing multicraft specialty, then you may well be a candidate for a national training number (NTN) in nuclear medicine. It also helps to be computer literate. There have been many recent advances in nuclear medicine, but without doubt the most exciting is the development of positron emission tomography (PET) imaging, and in particular PET/CT. This has revolutionised oncological imaging, and ideally no major cancer centre should be without PET.

Today, nuclear medicine encompasses a wide range of investigations and treatments.

Nuclear medicine, being essentially physiological, correlates well with all other forms of imaging, which are mainly anatomical. We can show the activity of disease rather than the anatomical appearance. For example, in Crohn's disease the barium enema will show what the bowel looks like, but the labelled white cell scan will show the extent of activity. It's a vital tool for the clinician. There is therefore a huge interaction with the rest of imaging, the clinicians and the oncologists. Box 1 shows a typical week in nuclear medicine.

Nuclear medicine treatment

You can also become involved in the therapeutic aspects of nuclear medicine, both curative as in the treatment of thyrotoxi-cosis with ¹³¹I, neuroendocrine tumours with yttrium and ¹³¹I, and palliative as in the administration of strontium or samarium to alleviate pain from bone metastases. In many centres, treatment of thyrotoxicosis with radio-iodine is the preferred option, and has excellent results. Nuclear medicine treatment offers the possibility to target neuroendocrine tumours, such as carcinoid, selectively and research is continuing to label specific monoclonal antibodies to various tumours both for diagnosis and treatment.

Nuclear medicine scans can be either static or dynamic, thus showing differing aspects of the body's function (box 2).

There is no doubt that the future lies with PET scanning. PET uses ¹⁸F labelled fluoro-deoxyglucose, a glucose analogue, to map the metabolic function of cells. This, when combined with modern CT, gives a most powerful weapon in the staging of malignancy.

PET is also useful in cardiac imaging to define hibernating myocardium, and in neurological imaging, particularly of dementia.

Job appeal and satisfaction

For all the reasons I have given, nuclear medicine can be a very satisfying career (box 3)

The satisfaction often comes from clarifying a diagnosis which is not clear clinically, such as pulmonary embolism. Your images alter the patient's treatment for the better. Nothing beats letters of thanks from patients you have helped or cured.

Training in the United Kingdom

A licence from the Administration of Radioactive Substances Advisory Committee (ARSAC) is required before any nuclear medicine investigations can be performed, and to obtain one, you must show you've been properly trained in nuclear medicine. ARSAC is a governmental body that ensures that your training will be adequate to allow the minister of health to issue you a licence to administer radioactive substances. This indicates that you are a suitable person to run and control a nuclear medicine department, and also meet the criteria of the IR(ME)R regulations. (IR(ME)R are the new ionising radiation (medical exposure) regulations, and they place an onus on the referrer to justify exposing the patient to ionising radiation and on the nuclear medicine specialist to ensure that not only is the test requested the correct one, but that previous imaging is appropriate and has been acted on.)

Although currently there are relatively few funded NTNs, more are being created all the time, especially in conjunction with radiology, where the subspecialty training in years 5 and 6 now allows trainees to specialise in nuclear medicine. There are two pathways to train in nuclear medicine. Both may lead to the certificate of completion of specialist training (CCST) in nuclear medicine.

Radiologists with FRCR

The first training pathway, aimed at radiologists who hold the FRCR, is to dedicate year 5 of the specialist registrar training scheme to nuclear medicine. This will allow the radiology registrar to obtain recognition in radionuclide radiology but does not lead to a CCST in nuclear medicine. It does, of course, count towards the CCST in radiology. Year 5 work covers all aspects of nuclear medicine imaging with the exception of PET. For dual accreditation, doctors need to spend year 6 in nuclear medicine, and during this year they will experience in vitro work, PET, and treatment for both benign and malignant disease. If you take the two year option you will finish with dual accreditation in radiology and nuclear medicine, and can also study for the MSc in nuclear medicine during years 5 and 6. At the moment this course, which is part time over two years, is run from King's College in London. Year 5 is run under the auspices of the Royal College of Radiologists, but year 6 is controlled by the Royal College of Physicians of London.

Doctors with MRCP

The second pathway, aimed at doctors who already hold the membership of the Royal College of Physicians (MRCP), takes four years and is made up of theory and clinical work based at an accredited centre. As well as diagnostic work, the course also covers laboratory work, PET, and treatment with unsealed sources, for both benign and malignant disease. The CCST is awarded at the completion of training, and this allows the acquisition of an ARSAC, both for diagnostic and some treatment work. This whole course is run under the aegis of the Royal College of Physicians of London. During the four years, you can also study for the MSc in nuclear medicine.

If you are a radiology trainee who wishes to be considered for further training in nuclear medicine, you will need to discuss this with the consultants in nuclear medicine and your college tutor so that you can be assessed for suitability for year 5 training. If during this year you decide that you would like dual accreditation and so do year 6, you will need to discuss this further with the nuclear medicine consultants. You must also look out for advertisements in the BMJ, as under current regulations the year 6 posts must be advertised nationally, and an assessor from the Royal College of Physicians sits on the interview panel.

If you are a doctor who wishes to specialise in nuclear medicine, then you should discuss the prospects of training in nuclear medicine with your local nuclear medicine consultants and your RCP tutor, and also look for the advertisements for posts in the BMJ. The British Nuclear Medicine Society (www.bnms.org.uk/) website, where details of all the trainee posts and NTN status is recorded, is of great help to all potential trainees.

Career prospects

These are good. The Intercollegiate Standing Committee on Nuclear Medicine carried out a survey, which was published earlier this year and indicates that 100-120 consultants with training in nuclear medicine will need to be replaced over the next 10 years. In addition, as more departments expand and the provision of PET and CT/PET becomes a greater possibility, new posts will be created.

There are two main types of consultant in nuclear medicine. If you are a physician trained consultant, you will mainly work in larger centres, either purely in nuclear medicine or also with some general medical responsibility. If you are a radiology trained consultant, and have just done year 5 in nuclear medicine so that you are eligible for an ARSAC licence, you would be a radio-nuclide radiologist with a CCST in radiology. You would tend to work in district general hospitals as a radiologist but also have responsibility for all the nuclear medicine there. You would probably only devote four sessions per week to nuclear medicine. If, though, you have done year 6 as well and have dual accreditation, then it is more likely that you would work in a larger hospital, where the nuclear medicine department is separate from radiology, and spend most of your time in nuclear medicine, with only a couple of sessions a week in radiology.

The future

This is bright and good for nuclear medicine specialists. Without doubt, the future is CT/PET, as cancer and oncology enjoy a high priority. Nuclear medicine can and does have a vital role in both diagnosis and therapy, and you can be part of it.

Plan to visit your local nuclear medicine department, talk to the staff there, and see if you have what it takes.