Multimodality Imaging Training Curriculum

Éamann Breatnach,  Tom Nunan, Wolfram H. Knapp
(*Last Revision 18.5.2010)

Multimodality Training Curriculum

The publication in June 2007 of White Paper in Multimodality Imaging marked the recognition by both ESR and EANM of the importance of coordinating future work practices to incorporate multimodality imaging.  The white paper outlined principles and an approach to cooperation between both societies in response to issues raised by the recent development of hybrid imaging with both positron emission tomography (PET) and single photon emission computed tomography (SPECT). Progress from this agreed position requires formulation of common training structures. A curriculum which ensures the optimal use of complex modalities in patient care will be necessary to promote development of high expertise in integrated imaging. One of the major differences in the two specialties is that traditionally, radiology has essentially been based on morphology and nuclear medicine studies on function. The advent of hybrid imaging necessitates a dual approach so that the specialists have the required skills.
 
Though this curriculum must be practical and economically feasible, it is the responsibility of both ESR and EANM to work towards the highest quality of patient care by ensuring an adequate knowledge base in the efficient use of complex technology.  Such an outline could also potentially form the basis for future curricula in other hybrid imaging e.g. PET and MRI.

PART 1
Training Issues
 1. As outlined in the white paper on multimodality imaging, any training in each specialty  must be  comprehensive, and not based exclusively on a single technique extracted from  the partner specialty.  Hybrid training should incorporate broad based knowledge of the  core principle of both specialties  including clinical experience, communication skills, patient safety issues, etc.
 2.   In the interests of best patient care, it is essential that an in-depth understanding of the
       potential and applications of both radiology and nuclear medicine be attained for best
       practice hybrid image interpretation.
 3. Training in radiology or nuclear medicine complementary to the base specialty should only take place  in recognised training departments fully accredited by the appropriate national or European authority  for the relevant specialty.
 4. During the crossover training the programme should allow to maintain the acquired competences in the primary specialty for both radiologists and nuclear medicine specialists, in accordance with the requirements of local rules and regulations.

 5. A two year period of training in the complementary specialty subsequent to the base specialisation in either radiology or nuclear medicine is recommended. The practical incorporation and training of this will vary from country to country, but it is recommended that a period of circa 18 months be dedicated to cross-sectional imaging techniques of the complementary specialty, i.e., to PET and SPECT for radiologists and CT and MRT for nuclear physicians.
This would allow for a 6 month period to be used in acquiring additional knowledge of the core principles of the complementary specialty.  It is recommended that national authorities would allow 12 months of training in the complementary specialty to be recognised as part of the training in the base specialty  for accreditation purposes. This time structure would allow for completion of full specialisation plus competency in multimodality imaging within a period of 6 years. A common trunk approach to training is not supported by this curriculum. 
6. Neurological and cardiac hybrid imaging are not included in this core curriculum. Due to their specialised nature, it is anticipated that dedicated training will be required.

7.  The competencies achieved through this process are specifically in the areas of SPECT/CT and PET/CT, but it is anticipated that this outline may form a structured basis for similar training in evolving hybrid imaging techniques.

 Principles of Training in Hybrid Imaging

1.   Clinical Specialty
 Cross over training should incorporate broad based knowledge of the core clinical principles. Many of these will be common to both specialties such as clinical orientation to include knowledge of the disease under investigation and the most appropriate imaging test for the clinical situation, communications skills, patient safety issues, resuscitation techniques.

2. An emphasis on, and evidence of, attendance and participation in multidisciplinary meetings is of particular importance in multimodality training and will enhance an integrated understanding of both specialties.  Trainees must also record actual clinical presentations at such multidisciplinary and tumour board meetings.

3. For training in hybrid imaging particular emphasis should be placed on an understanding of the appropriateness of various imaging modalities in specific clinical settings.  These skills should include choice of most appropriate imaging test or combination of tests to provide meaningful and relevant answers to the clinical issues and questions,  balancing the pro's and con's (clinical accuracy, radiation dose, availability, costs, etc) of the different tests.

4. In order not to interfere with current training programmes is it important that numbers from each core specialty undertaking this programme should be balanced.  It is recommended that there be a 1:1 exchange of trainees across the two specialities. While it is the goal of both societies that a single doctor will sign off on PET/CT and / or SPECT/CT imaging reports it is recognised that there will be complex clinical situations where a dual read will remain best practice.

5.  Administration and management
Knowledge of the principles of administration and management applied to a clinical department  with multidisciplinary staff and high-cost equipment is required.

6. Research and Evidence Based Medicine
The promotion of personal research is necessary.  It is assumed that basic instruction in the critical reading of medical literature, experimental design and biostatistics, to include focussed literature search, literature appraisal and application as applied to a diagnostic test will have been acquired during training in the home specialty. As well as an understanding of uncertainty, error and principles of audit on radiology and nuclear medicine trainees should also remain cognizant of the possible medico legal implication of the interpretations they make. Trainees should be encouraged to undertake either a research project, or possibly experience a period of dedicated research secondment during their training. This should ideally have an application to hybrid imaging.
 
7.    Continuous Assessment
The methods of assessment and appraisal will vary from country to country, but a regular dialogue between trainer and trainee is desirable to monitor progress and  to rectify early any weaknesses that may be manifest. Formal written / oral examination and / or a scientific thesis may be required in some countries during or at the end of this period of training. It is recommended that a log-book of clinical radiological activities and nuclear medicine activities should be maintained during the training period. Such a log-book might include the number of clinical examinations performed. By this means  principle of nuclear medicine or radiology training i.e. number of examinations performed (vide supra) can be incorporated in hybrid training. It is recommended that personal guidance and continuous assessment should be provided by a nominated tutor.

 8. Core Knowledge
Core knowledge of anatomy, cell biology, genetics, physiology, and the physical basis of all imaging modalities and patient safety must remain central in the educational model.  Trainees should be familiar with and competent in the management of acutely ill patients within the department
 
9. Communication Skills and Clinical Decision Making
Radiologists and nuclear medicine physicians are clinical specialists. Direct patient contact is an increasing component of radiologic and nuclear medicine practice. Learned principles of communication skills with patients should include the ability to explain tests and procedures to be performed, including hazards and benefits, the obtaining of  informed patient consent, and the explanation of examination results to patients when  appropriate. Principles of communication skills with clinicians should include competence in clinically relevant report formulation, an appreciation of the need to urgently transmit unexpected findings determining immediate patient management, and an ability to place examination results in a clinical and multidisciplinary context.                
 
10.  Clinical Conferencing
Attendance at clinical conferences and multidisciplinary meetings is an essential component of the training process. This will enhance the trainees knowledge of the diseases under investigation and also improve communication skills.

11. Health Economics 
 The complex technology involved in hybrid imaging is inherently costly and
 training in SPECT PET CT must include an understanding of the principles of cost  effectiveness, cost benefit analysis and how this relates to the various clinical scenarios addressed.

An understanding of the principles of sensitivity/specificity, cost effectiveness, cost-benefit analysis and how this relates to the various clinical scenarios is required. A knowledge of methods of database search and an understanding of the process of performing a meta-analysis are also necessary.