The Future of Nuclear Medicine.

As I noted in the Wagner Lecture at this year’s Society of Nuclear Medicine and Molecular Imaging Annual Meeting, nuclear medicine (NM) is an ever-changing and rapidly advancing practice in which clinical advances are driven by closely allied efforts in physics, chemistry, biology, and translational research relevant to radiopharmaceutical imaging and therapy. This multidisciplinary intersection of research and practice drives innovation in our specialty. These principles were clearly on broad display at the 2023 Annual Meeting, especially for the combination of molecular imaging diagnostics and radiopharmaceutical therapy (i.e., theranostics). The dynamic nature of NM requires frequent adaptation of our clinical practice and the closely aligned topic of clinical training. This issue of The Journal of Nuclear Medicine includes several contributions that offer opinions on how to address these needs, with an emphasis on the practice of theranostics and on NM training in the United States. Leading the way is a thought-provoking editorial by Michael Graham (1), a former president of the Society of Nuclear Medicine and Molecular Imaging, and 3 invited perspectives that present alternative opinions and additional considerations (2–4). Dr. Graham’s editorial laments that, in the United States, “We are simply not producing very many high-quality academic NM physicians.” He argues that, unlike other countries where NM is a separate and independent practice, the United States allows radiologists with limited training in NM to include NM in their practice. He also raises concerns that, whereas radiologists with specialty NM training are clinically competent and support the practice of NM, they often are not academically inclined. Dr. Graham suggests steps to address these concerns by requiring a minimum of a full year of NM specialty training (versus the current U.S. standard of 4mo) to be certified for NM clinical practice, adding a year to the current U.S. NM residency guidelines to be used for research or additional training in radiopharmaceutical therapy, and a strong informational campaign to attract to the specialty. Dr. Graham argues that these steps are critical to the future of NM in the United States and are urgently needed to avoid having the rest of the NM world “leave us behind.” The 3 accompanying invited perspectives provide some additional data and thoughts on the topic. Segall, Watts, and Frey—leaders in the American Board of Nuclear Medicine (ABNM)—provide data on NM training and certification (2). They note a decline in ACGME-certified NM residencies from 61 in 2006 to 36 in 2022 and an increase in the fraction of foreign trainees in U.S. programs over the same period. Although there has been a relatively stable number of ABNM-certified physicians since 2015, there was a decline in NM residency trainees from a total of 166 in 2008 to a nadir of 74 in 2016 and currently a total of 80. The authors note, however, that the total NM trainee count does not include an increasing number of integrated 16-mo nuclear radiology trainees who are enrolled in diagnostic radiology residency program and go on to certify in NM through the ABNM. This group of trainees accounted for 26% of the certifications in 2022. Overall, there has been an increase in practicing ABNM-certificate holders from an average of 59% since 2015 to 70% in the last 5 y, with a 5% drop in NM certification by trainees holding certificates in specialties other than radiology. The authors were not able to draw conclusions on whether dual radiology–NM training affects whether certificate holders choose to pursue academics versus private practice, noting that a “robust” 43% of current ABNM certificate holders are in self-declared academic practices. A perspective written by Drs. Grady, Mankoff, and Schuster, entitled “Stronger Together—Collaboration Will Only Enhance Patient Care,” offers some opinions and suggestions counter to the Graham editorial (3). The authors note that advancement of NM practice has benefited from the multidisciplinary training of NM physicians and “the breadth of disciplines embraced by the field— clinical imaging and therapy, molecular biology, physics, chemistry, and mathematics.” The authors disagree with Dr. Graham’s premise that NM needs to be a fully independent specialty to be able to thrive in the era of molecular imaging and theranostics. They cite prior examples in which controversy caused by disruptive technology was solved through collaborative development of rigorous common requirements and approaches to training physicians in the new technology. This was the case for hybrid imaging training (e.g., PET/CT), which was jointly addressed by bringing elements of anatomic imaging training (radiology) and molecular imaging training (NM) together and collaborating to set training standards. The authors agree with Dr. Graham on the need for more training in radiopharmaceutical therapy for all NM trainees and call for requiring similar training for physicians in other specialties who contribute other relevant skills and who also practice radiopharmaceutical therapy, such as radiation oncologists. The authors also provide examples of the contributions that dual training in NM and radiology have brought to NM research, as well as important related developments, such as the emergence of formal radiology physician–scientist training programs in the United States—programs that are heavily populated by trainees who ultimately specialize in NM. The authors argue that elevating training requirements for NM imaging and therapy, rather than restricting practice by legislation, is the best way to ensure the future of the specialty in the United States. In a perspective entitled “Redesigned Curricula, Stringent Licensing Criteria, and Integrated Independence are Conditions for a Bright Future for Nuclear Medicine in the United States,” COPYRIGHT 2023 by the Society of Nuclear Medicine andMolecular Imaging. DOI: 10.2967/jnumed.123.266448