Tag: nuclear medicine

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How To Be Successful In Nuclear Medicine

successful in nuclear medicine

For the next several weeks (and possibly months), we will start with a new theme: how to be successful in each of your subspecialty rotations. (and of course, today how to be successful in nuclear medicine!) Why should I even bother to tackle this theme? I mean, most residency programs have some guidelines about what residents need to do each month. Well, I can tell you that most of the time, these guidelines are only set up as a way to satisfy the needs of the ACGME and may not be all that relevant to what you need to know. Often, they are very boilerplate and merely copied from one institution to the next. Moreover, these summaries are “oh-so-boring” to read and likely outdated. Additionally, I aim to give this a bit more entertainment value (as I usually do!) and provide some more relevancy to what you actually should do on your rotations. 

To organize this series, I am going to mirror the subspecialty rotations at our institution. At Barnabas (my humble program), we have a mix of modality and organ-based rotations. Now, you may ask, how can this be relevant to your situation if your program arranges your month slightly differently? Well, regardless of how it’s sliced and diced, you can infer many of the same themes at your institution. The information is still here to help you out. These include the books you need to read, how you should learn the material during each year of residency, and the actions to succeed in your rotations.

So, why start with nuclear medicine? Well, for one, it is my area of expertise. And, of course, what better place to start than my home base?

What You Should Read

Hands down, there is one resource that I like the most. It used to be Nuclear Medicine, The Requisites (which is OK). But all that has changed since the newest version of Mettler. (I am an affiliate of Amazon if you decide to click on the links and buy them!) I found Mettler to be comprehensive and reasonable to tackle. It was straightforward to read when I had to study for my recertification examination in nuclear medicine/radiology. Also, it covers most of the nuclear medicine topics. And I believe that is an excellent way to go.

When To Study Topics In Nuclear Medicine

During that first year of nuclear medicine, you need to first start by concentrating on the studies that can kill patients or cause severe morbidity if you miss something. What are these sorts of cases? These include V/Q scans (you don’t want to miss pulmonary emboli). Then, check out myocardial perfusion scans (you don’t want to miss ischemia from a left main coronary artery widow-maker lesion). Go through GI bleeding scans (you don’t want your patients exsanguinating). And finally, read about renal transplant scans (missing dying kidneys).

Then, next, you need to study what is most common when you’ve covered these bases. Of course, what occurs frequently can vary somewhat from institution to institution. But, for the most part, we are talking about bone scans, hepatobiliary scans, infection detection studies (gallium, indium-WBC, and Ceretec-WBC), and iodine scans for thyroid disease. Or perhaps, your institution may specialize in procedures such as parathyroid adenomas (as we do at ours). The bottom line is that you should study what you see most often to communicate intelligently with your attending.

Finally, you should study everything else. And, in nuclear medicine, that can be a lot. But, the core exam will pretty much cover most of nuclear medicine. That includes anything from PET-CTs of all types to DAT SPECT studies to evaluate Parkinson’s disease (or even the rare salivagram!) This order should allow you to be successful in your successive nuclear medicine rotations.

How You Should Learn Nuclear Medicine As A First Through Fourth Year Resident

First Year

Try to sit with your attending as much as possible at the beginning. Get a feel for what your faculty dictates and why. Then, without much further ado, be aggressive and ask to dictate cases as soon as possible on your own. Why? Because you want to convert what your attendings are thinking into a viable and logical report. That is what we do as radiologists. Without this skill, all your learning with be for naught!

Also, try to spend a little bit of time with the technologists. See how they operate the machinery. Check out how the patients undergo stress tests. Watch how the cameras work. All this observation is essential for understanding how technology translates into clinical operations and patient care.

Second and Third Years

During these years, you need to become a bit more independent. Now that you know some of the basics, you should try to pre-dictate cases even before the nuclear medicine attending arrives on the scene. Grab that bone scan and give it a whirl. What’s the worst that can happen? You will miss a few findings and learn something!

Fourth Year

Instead of only concentrating on the less complicated material, try learning the nuts and bolts of some more esoteric studies. Also, be sure to understand how the software works. You might need it at your first job. For instance, ask how your attendings process the PET-FDG brains for quantification. Or, maybe you should try to interpret some of the more arcane PET scans like Amyvid, Axumin, and Dotatate. Bottom line: this is your last chance to learn nuclear medicine before starting your fellowship. Maximize what you know before it is too late. You don’t want to be struggling with nuclear medicine’s nuances when you take your first job if they assign you to tackle that specialty.

The Basics Of How To Be Successful In Nuclear Medicine

Let’s be honest. Nuclear medicine is not the most formidable rotation of all. (A little biased coming from a nuclear guy!) Or, what I mean is that you are usually not worked to the bone. However, it certainly has its challenges.

To summarize, I would concentrate on those studies that have the most clinical impact first, dictate soon after starting, spend some time with the technologists, and be somewhat aggressive and attempt to preview and dictate studies when you are ready. This targeted approach is how I would proceed if I were starting anew. These guidelines can give you a bit of a boost when starting out and give you the tools to be successful in nuclear medicine. Go for it!

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Is Nuclear Medicine A Dying Field?

dying field

Question About Nuclear Medicine As A Dying Field:

Hi Dr. Julius!

What is the future of nuclear radiology? I have seen some programs that offer dual certification pathways within their DR residencies. Is that worth it? I’ve also heard it’s a bit of a dying field, thoughts?

Also, is therapeutic nuclear radiology becoming a feasible pathway for radiology grads? On paper, it sounds fantastic to use radionucleotides to not only diagnose but also treat patients.

Thank you!

Answer:

Once again, an excellent question from one of my readers!

Well, I have a lot of opinions on this topic since I am first and foremost a nuclear radiologist. And I am happy to share them with you!

Nuclear Medicine History/Background

You first have to start by understanding the history of the specialty. Nuclear medicine is one of the oldest subspecialties in radiology. It came about before ultrasound and was once the only other high tech modality for radiologists other than x-rays. So, back in the old days, probably around 50 years ago or so, a lot of really smart radiologist went into the field. And, at that time, the area was distinct from the rest of the radiology field. So, they formed a separate board society and training programs “unattached” to radiology residency in addition to a fellowship after residency. Fast forward to our time, and you have a bit of a mess. Most applicants to nuclear medicine would prefer to get into radiology because you can do so much more. You have much better job prospects because the radiology training is so much more diverse.

The Split

But, this current organization of two separate radiology and nuclear medicine creates a problem. Generally, the folks that are only nuclear medicine need more to do than just reading nuclear medicine studies during the daytime. Most practices do not have enough work to support a nuclear radiologist. So, enter the new dichotomy. There are those nuclear medicine physicians who train primarily in radiology that, in general, prefer to do the diagnostic radiology work along with diagnostic nuclear medicine. And then, some are only nuclear medicine trained that need to create a new livelihood for themselves. And one of those areas is the realm of nuclear medicine treatment. In general, right now, these procedures do not pay well and are very time-consuming. However, these nuclear medicine physicians provide an essential service by administering the radioactive pharmaceuticals and following up the patients over time.

I believe in the future; the specialty will split into these two entities- diagnostics and treatment- because of the current mechanics of reimbursement and what procedures that nuclear medicine docs and nuclear radiologists can perform.

Is Nuclear Medicine A Dying Field?

Finally, to complete the answer to your question, diagnostic and therapeutic nuclear medicine are very active in research and new radiopharmaceuticals coming in for clinical use. So, nuclear medicine is certainly not a dying field. But, who performs what is changing. Of course, there is some overlap. For instance, I perform radioactive iodine treatments and do pretty much all diagnostics. But, I don’t do any of the Lutithera or Xofigo treatments or others available to the public. And, there are all variations in between. Nevertheless, nuclear medicine is an excellent specialty for someone who wants an exciting radiology subspecialty and likes to practice general radiology (Which is what I do!)

That is my long-winded answer to your question (I could have even gone on for longer but had to stop somewhere!)

Dr. Barry Julius

By the way, for those of you interested in a book for nuclear medicine, I would highly recommend the Mettler book. I used it to study for my recertification examination! (I am an Amazon affiliate and receive a commission)

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The Frustrations Of Starting Residency With Nuclear Medicine

nuclear medicine

Order matters. And when you are starting in a radiology residency, it makes the most sense to learn subjects logically to get the most out of your first year. First, start with rotations that overlap most radiology topics. Then, afterward, get a bit more specific and esoteric. Right? However, as often is the case, many chief residents and program directors only have so many open slots to fill the rotation schedule. And all of them need to get filled. One of those residents has to begin with nuclear medicine. Maybe that person is you.

So, from the mouth of a nuclear radiologist to you, why can beginning with nuclear medicine be such a frustrating specialty rotation? Well, let me give you some reasons why starting with this subspecialty can be formidable. And, then I will provide you with the information you need to resolve the issue!

Reasons Why Starting With This Subspecialty Can Be So Frustrating 

Some Nuclear Medicine Attendings Are Not Radiologists

Sometimes, especially in highly academic facilities, nuclear medicine attendings are strictly nuclear medicine trained. These attendings live and breathe a different world than the nuclear radiologist. They can’t take an overnight call as a typical radiologist would do. And, their perspective is very different from a radiologist. Not to say that they are not good doctors. But instead, you may not learn on that first rotation what you need to know to succeed in a radiology residency. Starting off the block in this situation can make your transition to radiology residency that much more difficult.

Lots of Cases Are Off the Beaten Path

In many nuclear medicine departments, most studies have less to do with the rest of radiology. For instance, many facilities perform an overwhelming number of cardiac myocardial perfusion scans. Sure, there is critical information on these studies. But, on-call, you may be very unlikely to see a cardiac perfusion case at nighttime. Or, you will catch lots of other more esoteric sorts of studies like gastric emptying to salivagrams. Although essential, learning these studies do not help much when you are taking cases at noon conference.

Need To Study Information Only Relevant To Nuclear Medicine

Finally, in nuclear medicine, you will need to learn lots of information only applicable to nuclear medicine. Learning about the dosage of radiopharmaceuticals will probably not help you much elsewhere in radiology. And, understanding radiopharmaceutical biodistribution, although critical to grasp the pathophysiology of a disease, in reality, will not go a long way toward helping you read a CT scan. This information takes time to learn and may replace the time you could discover other radiology topics. 

How To Resolve The Issues That Come With Starting With Nuclear Medicine

When starting residency on a nuclear medicine rotation, regardless of whether your faculty is nuclear medicine only or a radiologist, make sure to look at nuclear medicine with the lens of how what you see on rotation does overlap with other subspecialties. Even the lowly salivagram has some features that you may find on other imaging modalities. In this case, look at the neck CT and MRI. Check out the anatomy of what you see on the salivagram, such as parotid atrophy, inflammation, or stones. Or, for the cardiac studies, make sure to learn about the angiograms, the cardiac MRI, and the CT scan findings as well. If you stay isolated in your learning and thinking, you will find nuclear medicine more frustrating.

Also, make sure to start learning those areas that you need to know for an independent call. Understanding the relevancy will make it seem like what you are learning has more real-world applications. Check out hepatobiliary scans, V/Q scans, and GI bleeding studies first to increase relevancy. Learning to interpret these studies will have easily observable influences upon patient management. It will make you feel all the more relevant when you are first starting.

Finally, seek mentors and fellow residents who have been in a similar boat to you when you are starting. You are not the one who has had this issue. Other residents have done very well even after starting with nuclear medicine as a first rotation.

Nuclear Medicine Doesn’t Have To Be So Frustrating On That First Rotation!

Well, there you have it. You may not be starting as central to all of radiology as you might have liked. But, you can create an experience that is worthy of a great month. Just follow some of the steps I listed and above, and you will learn a lot and have an excellent experience!

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Patient 0- A Mystery Wrapped In An Engima

Today I am going to try something completely new- a case study as a blog. Typically, I have not attempted to make the focus of this blog individual case studies. But, this case touched upon so many interesting medical, ethical, political, and professional issues that I felt that it was worthy of its own post. So, let me give you some background on patient 0 and allow me to explain.

The Background On Patient 0

A fairly young patient arrives at our emergency department after entering the country by plane, 3 days prior to admission. She claims to have worsening right upper quadrant pain exacerbated by eating. In addition, she states that she never had any imaging studies either here in this country or from her home country. After “examining” patient 0, the emergency physician decides to order a hepatobiliary scan to exclude cholecystitis. So, the patient comes to our nuclear medicine department for the study. Initially, we take a prelim scout image prior to injecting the radiopharmaceutical and this is what we see:

 

A technologist looks at the study and determines that maybe there was some contamination and repeats the image again after cleaning the table. Here is the image again!!!

 

Panic!!!

No change… Uh oh, where is this activity coming from? She just flew in from a foreign country and claims to have had no tests after entering the United States. The physicist is subsequently called down to interview the patient. Here are some of the questions and answers:

Physicist: “Are you sure you did not receive any medical tests since arriving in the United States?”

Patient: “No…”

Physicist: “Did you receive any medical tests when you were in your home country?”

Patient: “Yes, I got an injection of something in my arm to relieve my pain.”

Physicist: “What was that injection?”

Patient: “I don’t know. Pain medication?”

Physicist: “Did you eat anything unusual?”

Patient: “I ate a regular light breakfast and lunch.”

So, the physicist calls over the radiology manager of the department and myself, the nuclear medicine physician of the day. Given the absence of a clear history of radiopharmaceutical administration, he becomes concerned that either patient may have ingested radioactivity from a contaminated source or the patient may have had an exposure something that is highly radioactive. Exposure to a dirty bomb??? We all begin to sweat profusely.

What would you do next?

Calmer Heads Prevail

So, the physicist takes at the Geiger counter and notes that the radioactivity coming from the patient is less than 0.1 mR/hr at 1 meter. Whew, at least we know that the patient is not a danger to the personnel in our department.

Now, how would you deal with this situation???

Well, we decided to change the primary photopeaks of the camera to determine the most likely Kev of the gamma rays emanating from the patient. Theoretically, if the radioactivity was from a nuclear plant or other unusual sources, the patient would not have a photopeak coming from the typical photopeaks for medical imaging. So, we tried imaging with photopeaks at I-131 and thallium. Neither of these photopeaks matched the images coming from the camera. (counts were lower and images were blurred) The best photopeak with the most resolution and counts was from the Tc-99m photopeak, shown in the images above. At least, we were now fairly sure that the radioactivity was from a medical source.

What Next?

Given a large amount of uptake in the belly and the discovery that patient 0 was not a medical hazard to staff and patients, we decided to send the patient back to the emergency department. Since there was too much uptake in the abdomen, we could not run a hepatobiliary scan and recommended the patient receive a different test. (Patient ended up getting an MRCP showing numerous stones in  a dilated CBD and had an ERCP to remove the stones).

Implications, Politics, And Ethics

Let’s go back a bit. I stated before that patient 0 reported to have recently traveled from a foreign country. How would it have been possible for patient 0 to get to this country with this amount of gamma rays coming from her abdomen? If the patient truly traveled from her home country several days ago, wouldn’t the radiation have been detected at the airport? Would she really be in this country at this point? Probably not.

But, no detectors are foolproof. Sometimes, a detector could not be functioning properly or can malfunction. But, does that still likely explain the patient’s radioactivity? Unlikely. Why? Since technetium 99m half life is 6 hours, and the patient states she traveled to this country 3 days ago, would she really have this amount radiotracer left in the large bowel? No.

So then, what is really is going on here? Personally, I think that she received a medical dosage of a radiopharmaceutical, possibly for a hepatobiliary scan, after arriving in the United States. And then, she likely left the other facility to come to our hospital, maybe against medical advice. That begs the question. Why?

Immigration Policy Issues

My first thoughts: Could she be here at our hospital because she feared deportation back to her home country? Was she a medical tourist who was hoping to get better treatment in our country? I’m not sure of the real answer to why she was here.

But, the real question in my mind. Are we going to see more of this type of situation in the future? With new and stricter immigration policies, more patients may decide that they cannot tell the truth about their prior imaging because of the real or imagined fears of deportation. I think this has the potential to be the proverbial “tip of the iceberg”. We may see more cases like this in the future.

Our Ethical Obligations

First and foremost, as physicians, we are obliged to serve our medical duty to the public and ensure that we do no harm to others. In this case, we accomplished that once we figured out that the radiation dose and exposures were not harmful to other people.  However, in my mind, many questions still remain about this case, especially what are our ethical obligations if she was exposed to a non-medical radioactive source. How would we have handled that situation? Who would we have notified next? Do we follow the regular channels of just contacting the Radiation Safety Officer. Or do we also get in touch with the patient’s relatives, the police, the nuclear regulatory commission, or the FBI…

Bottom Line

Fortunately for us, we averted a potentially scary situation. But, it really makes you think about all the potential outcomes of a radioactive patient 0 scenario. What about next time?

Comments From You

I would love to hear what you, the reader, think about this case since it makes for a great discussion. Would you have done anything differently? What are your thoughts about a patient such as this that could potentially arrive at your institution?