NMC Guidelines for Competency-Based Training Programme For MD Nuclear Medicine

The National Medical Commission (NMC) has released Guidelines For Competency Based Postgraduate Training Programme For MD In Nuclear Medicine

The purpose of PG education is to create specialists who would provide high quality health care and advance the cause of science through research & training.

Nuclear medicine is a multi-disciplinary practice and the training of medical doctors is critical to the performance of a Nuclear Medicine department. Successful post graduate students are awarded a final certificate, degree or diploma that is recognized by the government, local health authority and hospital employer as an assurance of specialist competence in Nuclear Medicine. Post graduate training programme in Nuclear Medicine consists of an integrated training course of three years duration and would enable the post graduate student to practice nuclear medicine safely.

The purpose of this document is to provide teachers and learners illustrative guidelines to achieve defined outcomes through learning and assessment. This document was prepared by various subject-content specialists. The Reconciliation Board of the Academic Committee has attempted to render uniformity without compromise to purpose and content of the document. Compromise in purity of syntax has been made in order to preserve the purpose and content. This has necessitated retention of "domains of learning" under the heading "competencies".

SUBJECT SPECIFIC LEARNING OBJECTIVES

The objective of the programme is to enable the post graduate student s to perform Nuclear Medicine practice, teaching and research independently and fulfill the manpower needs of ever expanding new branch of diagnostic and therapeutic medicine.

Post Graduate Training will consist of Theoretical and Practical Training:

SUBJECT SPECIFIC COMPETENCIES

By the end of the course, the student should have acquired knowledge (cognitive domain), professionalism (affective domain) and skills (psychomotor domain) as given below:

A. Cognitive domain

1. Should have knowledge of basic principles of radiation physics and its subsequent applications.

2. Should have knowledge of radiation protection principles.

3. Safe handling of radionuclides and their disposal.

4. Should have knowledge of International Commission for Radiological Protection (ICRP) and National Regulatory guidelines pertaining to nuclear medicine practice.

5. Should have knowledge of diagnostic tests, interpretation of results and pitfalls.

6. Good clinical practice of therapeutic nuclear medicine and dosimetry.

7. Should be able to conduct clinical research and write a thesis/dissertation under supervision.

8. Should develop good working relationship with user specialties and handling inter-specialty referrals

B. Affective domain:

1. Should be able to function as a part of a team, develop an attitude of cooperation with colleagues, and interact with the patient and the clinician or other colleagues to provide the best possible diagnosis or opinion.

2. Always adopt ethical principles and maintain proper etiquette in dealings with patients, relatives and other health personnel and to respect the rights of the patient including the right to information and second opinion.

3. Develop communication skills to word reports and professional opinion as well as to interact with patients, relatives, peers and paramedical staff, and for effective teaching.

C. Psychomotor domain

At the end of the course, the student should have acquired the following skills:

A) Basic Sciences Experiment:

1. Practicals related to Physics, Instrumentation and its quality Control.

2. Preparation of radiopharmaceuticals and their quality control.

3. Detection of contamination in various workplaces.

4. Characterization of unknown isotopes.

5. Management of accidental spillage.

B) Clinical Experiment:

1. GFR Estimation.

2. Esophageal transit time.

3. Gastric emptying time.

4. Renal transplant evaluation.

5. Determination of Ejection Fraction and RWMA (wall motion).

Course contents:

Syllabus

The syllabus is divided into the following four parts:

1. Basic Science aspects of Radiation Physics and its application to diagnostic/ therapeutic Nuclear Medicine

2. Diagnostic Nuclear Medicine and its applications

3. Therapeutic Nuclear Medicine and its applications

4. Recent Advances in Nuclear Medicine

At the end of the course, the student should have acquired knowledge in the following:

Part I: Basic Science related to Nuclear Medicine

1.1 Radiation Physics and Instrumentation

a. Structure of atom, Natural and artificial radioactivity.

b. Modes of Radioactive decay.

c. Interaction of radiation with matter.

d. Principles of radiation detection and detectors.

e. Basic principles of production of radionuclides by reactors and cyclotrons.

f. Nuclear Medicine Instrumentation including Gamma Cameras, Single Photon Computed Tomography (SPECT), Positron Emission Tomography (PET), Hybrid Imaging Systems like SPECT/CT, PET/CT and PET/MR

g. Counting Systems: Well counters, liquid scintillation counters, spectrometers, Radioactive Iodine Uptake (RAIU) probe and radiation monitoring devices.

h. Quality control of Nuclear Instruments, as in (f and g).

i. Collimation of radiation detectors and the characteristics of various collimators, their response to point, line and plane sources.

j. Electronic instruments, such as pulse amplifiers, pulse height analyzer, count rate meters and computer interfaces including gating devices.

k. Software and hardware fusion technology, Digital Imaging and Communications in Medicine (DICOM) technology and Picture Archiving and Communication System (PACS).

1.2 Mathematics, Statistics and Computer Sciences.

a. Basic Mathematical concepts, counting statistics, probability distribution, Baysian and McNemmar statistics, parametric and non- parametric statistics.

b. Compartmental analysis and mathematical models of physiologic systems.

c. Basic aspects of computer structure, function and programming.

d. Computer applications with emphasis on digital image acquisition, analysis, processing and enhancement, tomographic reconstruction, display and recordings of findings.

e. Fundamental of filters, their applications and uses.

1.3 Radiation Biology

a. The biological effects of radiation exposure with emphasis on the effects of low level exposure.

b. Methods of reducing unnecessary radiation exposure to patients, personnel and environment.

c. ICRP recommendations and their amendments from time to time and other international recommendations, environmental regulations- regarding limits of radiation exposure, handling of radioactive patients, transport of radioactivity material and disposal of radioactive wastes.

d. The diagnosis, evaluation and treatment of radiation over exposure in any form.

Part 2: Diagnostic Nuclear Medicine

2.1 Radiopharmaceuticals

The chemical, physical and biological properties of radiopharmaceuticals used in Nuclear Medicine investigations; production, Quality Control and Regulations of hospital based-Nuclear Pharmacy.

The emphasis will be on:

a. Physical and chemical characteristics of radionuclide used in diagnostic Nuclear Medicine

b. Criteria for selection of radionuclide for diagnostic purposes

c. Biological behavior of radiopharmaceuticals

d. Quality control

e. Mechanism of localization

f. Positron Emitting radionuclides, target reactions and their radiopharmaceuticals chemistry, various synthetic modules.

g. Specific topics on Radiopharmaceuticals: Bone seeking, hepatobiliary, brain and cerebrospinal fluid (CSF), renal, thyroid, parathyroid, infection imaging, Tumor Seeking, cardiac imaging etc.

h. Good Manufacturing Practice (GMP) and Laws pertaining to in-house manufacturing of Radiopharmaceuticals.

i. Radiopharmaceuticals for Research.

2.2 In vivo Diagnostic Imaging

a. General clinical indications for organ imaging; normal and altered anatomy, physiology, biochemistry and metabolism of various organs. Must learn the technical aspects of performing the procedures including proper patient preparation and patient management before, during and after the procedure.

b. In vivo imaging and/or functional studies including brain Single Photon Emission Computed Tomography (SPECT), tracing of cerebrospinal fluid pathways, thyroid imaging, salivary glands, lungs, heart, gastrointestinal, hepatobiliary system, spleen, kidney, prostate, adrenal, bone and joints, bone marrow evaluation etc.

c. The use of physiologic gating techniques for functional studies and patient monitoring during intervention, both physical exercise and using pharmacological stress agents

d. Cellular kinetics, absorption and excretion analysis, nuclear hematology and metabolic balance studies using radiotracers.

e. Comparative analysis of Nuclear Medicine procedures with X-ray, Ultrasound, Echo, MRI, CT and angiography etc.

f. Nuclear Cardiology: Stress and redistribution studies using Thallium201 and other technetium-based myocardial perfusion agents; myocardial viability, Gated SPECT studies, etc.

g. Positron Emission Tomography (PET): All indications for use of PET imaging in oncology, cardiology, neurosciences and psychiatric disorders.

2.3 In vitro Studies

a. Principles of Radioimmunoassay (RIA), quality control and data analysis for various hormones and drugs assays.

b. Glomerular Filtration Rate (GFR) estimation, Red Cell Survival, Red Cell Mass using chromium and C14 urea Breath test.

Part 3: Therapeutic Nuclear Medicine

3.1 Principles of Internal Dosimetry: Calculation of the radiation dose from internally administered radionuclide

3.2 Characteristics of Radionuclides/Radiopharmaceuticals for radionuclide therapy

3.3 Radiation protection in therapeutic set up: Design of Isolation ward as per the norms of Atomic Energy Regulatory Board (AERB)

3.4 Principles of OPD and in-door therapy administration

3.5 Therapy in thyroid disorders; benign thyroid diseases, aetiology of hyperthyroidism, various modalities of treatment and follow up strategy, long-term outcome and various national and international regulations pertaining to therapeutic administration of radionuclides.

Therapy in thyroid disorders; aetiopathology, classification and diagnosis of thyroid nodules and malignancies- various modalities of treatment and follow-up strategies, long-term outcome and various national and international regulations pertaining to therapeutic administration of radionuclides.

3.6 Bone pain palliation using various radionuclides such as P32, Sr89, Y90, Sm153, Ra223, Lu177 etc.

3.7 Radiosynevectomy

3.8 Radiopeptide therapy and Radioconjugate therapy

3.9 Radioimmunotherapy

3.10 Locoregional internal radiation therapy

3.11 Research agents in radionuclide therapy

Part 4: Recent Advances in Nuclear Medicine

Covering all aspects of the following areas:

4.1 Instrumentation

4.2 Radiopharmaceuticals

4.3 Diagnostic procedures

4.4 Therapeutic procedures

TEACHING AND LEARNING METHODS

Teaching methodology should consist of:

1. Didactic lectures in Physics related to Nuclear Medicine, radiopharmacy, radioisotopes techniques, instrumentation, data processing and quality control.

2. Participation in the daily routine work of the department including work rounds of patients admitted for radionuclide therapy.

3. The postgraduate students shall be required to participate in the teaching and training programme of undergraduate students and interns.

4. Presentation of cases in the reporting sessions of the department.

5. Log book: Log book will be maintained meticulously to record all training done and Log books shall be checked and assessed periodically by the faculty members imparting the training.

6. A postgraduate student of a postgraduate degree course in broad specialities/super specialities would be required to present one poster presentation, to read one paper at a national/state conference and to present one research paper which should be published/accepted for publication/sent for publication during the period of his postgraduate studies so as to make him eligible to appear at the postgraduate degree examination.

7. Active participation in the combined clinical meetings with other departments for case discussions.

8. Regular participation in department journal clubs, Seminars and other periodical CME programmes.

9. Participation in the Seminars and CME programme of allied departments.

10. Department should encourage e-learning activities.

11. Rotation:

Apprenticeship/Rotation in:

a) Radio-diagnosis 03 months [CT 2 mo and MR 1 mo]

b) Cardiac stress lab 02 months

c) Immunoassay lab 01 month

During the training programme, patient safety is of paramount importance; therefore, skills are to be learnt initially on the models, later to be performed under supervision followed by performing independently; for this purpose, provision of skills laboratories in medical colleges is mandatory.

The year-wise schedule of training would be as follows:

Year 1

(a) Scientific principles:

• Basic physics and mathematics,

• Instrumentation,

• Principles of computing,

• Basic radiation biology and radiation protection,

• Basic radiopharmacy and radiochemistry,

• Principles of tracer technology.

(b) Clinical Nuclear Medicine:

• Diagnostic: Normal and abnormal appearances of images, mode of pharmaceutical uptake; normal variants and common artifacts in bone, heart, lung, kidney, brain, thyroid, tumour and infection images.

• Therapeutic: Basic principles of radionuclide therapy; treatment of hyperthyroidism, thyroid cancer and metastatic bone pain.

• Principles of radiation protection: ALARA (as low as reasonably achievable) ALARP (as low as reasonably practicable).

Year 2

(a) Requirements of Year 1 in greater depth:

• Tracer kinetics;

• Computing and image processing;

• Radiobiology including the biological effects of high and low level radiation;

• Linear hypothesis and the threshold hypothesis of the biological response to low level radiation;

• The effective dose equivalent and the calculation of radiation dose from radiopharmaceuticals.

(b) Radiopharmacy:

• Properties of commonly used diagnostic and therapeutic radiopharmaceuticals;

• Production of radionuclides by reactors, cyclotrons and radionuclide generators;

• Quality assurance and quality control of radiopharmaceuticals.

Year 3

(a) Requirements of Year 2 in greater depth:

• Principles of radiology including ultrasound, computerized tomography and magnetic resonance imaging.

• Co-registration of nuclear medicine images and those from other imaging techniques.

• Diagnostic: special investigations in cardiology, lung disease, gastroenterology, hepato-biliary diseases, nephro-urology, neurology and psychiatry, endocrinology, haematology, oncology and infection.

(b) Therapeutic applications:

• Treatment of bone metastases, neural crest tumors, prostate malignancies, solid malignancies;

• Use of radionuclide monoclonal antibodies and radionuclide labeled peptides for tumor therapy.

(c) Further practice and experience of work accomplished in years 1 to 3:

• Legal and regulatory requirements,

• Audit,

• Departmental management,

• Research techniques and evaluation,

• Teaching and training.

Practical training

The post graduate students are obliged to play an active 'in-service' role in the practice of Nuclear Medicine to familiarize themselves with all the techniques required as a nuclear medicine practitioner, such as:

• Protocols of in vivo and therapeutic procedures;

• Data acquisition and processing with various equipments, quality control of instruments and labeled agents;

• Interventional procedures, including physiological, pharmacological, and mental stress for diagnostic application, and all therapeutic interventions;

• In vitro protocols and procedures, if appropriate.

Since post graduate students will take on the responsibilities of a nuclear physician, they must pass a qualifying test that covers both theoretical knowledge and practical abilities in the daily practice of nuclear medicine.

ASSESSMENT

FORMATIVE ASSESSMENT, during the training programme

Formative assessment should be continual and should assess medical knowledge, patient care, procedural & academic skills, interpersonal skills, professionalism, self directed learning and ability to practice in the system.

General Principles

Internal Assessment should be frequent, cover all domains of learning and used to provide feedback to improve learning; it should also cover professionalism and communication skills. The Internal Assessment should be conducted in theory and practical/clinical examination.

Quarterly assessment during the MD training should be based on:

1. Journal based / recent advances learning

2. Patient based /Laboratory or Skill based learning

3. Self directed learning and teaching

4. Departmental and interdepartmental learning activity

5. External and Outreach Activities / CMEs

The student to be assessed periodically as per categories listed in postgraduate student appraisal form (Annexure I).

SUMMATIVE ASSESSMENT, i.e., namely assessment at the end of the training

The summative examination would be carried out as per the Rules given in POSTGRADUATE MEDICAL EDUCATION REGULATIONS, 2000.

Post Graduate Examination will be in three parts:

1. Thesis:

Every post graduate student shall carry out work on an assigned research project under the guidance of a recognised Post Graduate Teacher, the result of which shall be written up and submitted in the form of a Thesis. Work for writing the Thesis is aimed at contributing to the development of a spirit of enquiry, besides exposing the post graduate student to the techniques of research, critical analysis, acquaintance with the latest advances in medical science and the manner of identifying and consulting available literature.

Thesis shall be submitted at least six months before the Theory and Clinical / Practical examination. The thesis shall be examined by a minimum of three examiners; one internal and two external examiners, who shall not be the examiners for Theory and Clinical examination. A post graduate student shall be allowed to appear for the Theory and Practical/Clinical examination only after the acceptance of the Thesis by the examiners.

2. Theory Examination:

The examinations shall be organised on the basis of 'Grading'or 'Marking system' to evaluate and to certify post graduate student's level of knowledge, skill and competence at the end of the training. Obtaining a minimum of 50% marks in 'Theory' as well as 'Practical' separately shall be mandatory for passing examination as a whole. The examination for M.D. shall be held at the end of 3rd academic year. An academic term shall mean six month's training period.

There will be 4 theory papers:

Paper I: Basic Sciences related to Nuclear Medicine

Paper II: Diagnostic Nuclear Medicine

Paper III: Therapeutic Nuclear Medicine

Paper IV: Recent advances in Nuclear Medicine

3. Practical/Clinical and Oral Examination

Practical examination shall consist of carrying out special investigative techniques for diagnosis and therapy. Oral examination shall be comprehensive enough to test the post graduate student's overall knowledge of the subject.

There shall be:

1. One long case and two short cases.

2. Two practicals consisting of one in basic science and one in clinical science.

3. Spots

4. Oral/viva-voce examination & scan reading

Recommended Reading: Books (latest edition)

1. Neuro PET, by Herholz

2. Molecular anatomic Imaging, by Von Schulthess

3. Principles and Practice of Nuclear Medicine ,by Paul, J. Early, D. Bruce Sodee

4. Diagnostic Nuclear Medicine, by Sandler and Gottchalk

5. Nuclear Medicine in Clinical Diagnosis and Treatment, by Ell and Gambhir

6. Positron Emission Tomography, by Valk, Bailey, Townsend

7. Practical FDG Imaging A teaching File, by Debelke, Martin, Patton, Sandler.

8. Functional Cerebral SPECT and PE Imaging

9. CT and MR Imaging of the whole body, Haaga, Lanzieri, Gilkeson

10. Multidetector CT : Principle Techniques and Clinical Applications, by Fishman Jeffrey Normal Lymph node Topography

11. CT atlas, by Richter Feyerabind

Journals

03-05 international Journals and 02 national (all indexed) journals