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NUCLEAR MEDICINE RESIDENCY TRAINING PROGRAM

 

Introduction

•is designed to provide a learning environment such that the resident will gain sufficient knowledge and expertise to be able to practice all aspects of the specialty
•specific educational objectives regarding individual portions of the program are in place to help ensure, with regular feedback mechanisms, that adequate teaching is obtained
•contains a variety of experiences in general, cardiac, pediatric and therapeutic nuclear medicine, as well as in bone mineral densitometry, in vivo non-imaging and in vitro nuclear medicine
•residents have access to a wide variety of patients ranging from those that are acutely ill to those being investigated on an outpatient basis.  This allows adequate experience in the selection of appropriate techniques and interpretation of studies under a variety of urgent emergency and ambulatory conditions
•responsibility is graduated throughout the program so that the resident will be acting at the level of a consultant at the end of training
•consultants act as teachers and role models giving guidance to the residents
•the functions of the program are closely allied to the requirements of the Royal College of Physicians and Surgeons of Canada for training and examination in nuclear medicine
The Residency Training Committee ensures the provision of educational resources, objectives and adequacy of training. 

General Outline

•the Royal College of Physicians and Surgeons of Canada require five years of approved residency training
•the overall period must include three core years of comprehensive nuclear medicine residency training
•for details of the requirements, please see "Objectives of Training and Specialty Training Requirements in Nuclear Medicine" which is published by the Royal College of Physicians and Surgeons of Canada

Narrative Description of the Program

•during the three years of comprehensive training in Nuclear Medicine, residents spend four weeks functioning as a “nuclear medicine technologist” usually at University and Victoria Hospital. Hands on radiopharmacy is incorporated into this rotation and it includes preparation of radiopharmaceuticals, quality control, dose calibration, record keeping, etc.
•In vitro technical work (including technical performance of GFR studies, radiolabelling of white blood cells, radiolabelling of red blood cells, etc) is usually performed at University Hospital and radiolabeling of therapy tracers (ie.octreotide) is performed at Victoria Hospital
For those residents without prior formal training in Radiology, the minimum training requirements must include:

•six months of cross-sectional imaging relevant to Nuclear Medicine including head, chest, and body CT
•this rotation is usually performed at all three sites and is geared towards giving the resident a meaningful exposure to general diagnostic radiology especially as it relates to aiding in the interpretation of nuclear medicine procedure
 
For those residents with prior Radiology training, the minimum training requirements must include:

•candidates will be required to complete a minimum of five years of training including PGY1 year, two years of training in an accredited Diagnostic Radiology program and two years of Nuclear Medicine training
•at least 18 months of the Diagnostic Radiology training must precede the Nuclear Medicine training
Content and Sequence of Training

2.     Content and Sequence of Training

Entry from PGY-1/CARMS STREAM

Program
Year

Content and Sequence of Rotations
Number of Months (or 4-week blocks)

 

1

2

3

4

5

6

7

8

9

10

11

12

13

First

INT MED

CARD

MED ONC

ENDO

NEPH

NEURO

GEN
SUR

URO

ER

PATHO

PED
-ER

Elec
tive

Elec
tive

Second

Clin NM-A

Clin NM-A

Clin NM-A

Clin NM-B

Clin NM-B

Clin NM-B

Clin
NM-C

Clin
NM-C

Clin
NM-C

Clin
NM-TX

Radio
phar/
Tech

Elec
tive

Elec
tive

Third

Clin NM

Clin NM

Ped NM

Nuc-Card

Nuc-Card

Elec
tive

Elec
tive

Cross
ectional

Cross
ectional

Cross
ectional

Cross
ectional

Cross
ectional

Cross
ectional

Fourth

Clin NM

Clin NM

Clin NM-TX

PET-CT

PET-CT

PET-
CT

PET
-CT

Nuc-
Card

Nuc-
Card

Elec
tive

Elec
tive

Elec
tive

Elective

Fifth

Clin NM

Clin NM

Clin NM

Clin NM

Nuc-Card

Nuc-Card

Clin
NM

Clin
NM

Clin
NM

Clin
NM

IntM,
Res,
Sub
specialty

IntM,
Res,
Sub
specialty

IntM,
Res,
Sub
specialty

Re-enrty from Radiology and Dual certification stream

Program year

Content and Sequence of Rotations
Number of four week blocks

 

1

2

3

4

5

6

7

8

9

10

11

12

13

First

Clinical Nuclear
Medicine Hospital A

Nuc
Card

Clinical Nuclear
Medicine Hospital B

Nuc Ther

Clinical NM Hospital C

Second

Radiophrm
/Tech

Nuc Ther

Nuc
Card

PET/CT

Clin NM Hospital A

Nuc
Peds

Clinical NM
Hospital B

 

Resident Graded Responsibility

•consultations with clinicians are required of residents throughout the period of training but expectations of the standard to be achieved are related to the seniority of the trainee
•in the Nuclear Medicine Program, each of the hospitals functions with a staff physician assigned either on a daily or weekly basis to a specific activity within the department
•the residents are assigned to this supervisory staff physician who in turn oversees the activities of the resident and through this daily interpersonal contact allowing the staff physician to provide a graded responsibility to the residents
•residents are required to present regularly at weekly inter-hospital clinical rounds, seminars and other teaching sessions throughout the year and the subjects assigned and the standard of presentation given are related to resident seniority and experience
•because of the variability and background that may exist upon entrance into the nuclear medicine program, it is necessary to review the requirements of each trainee individually and to tailor his or her experience accordingly. This is done through discussions with the individual and through the resident program committee
•the Program Director in conjunction with input from the chief resident (who is usually a senior resident) is responsible for scheduling and the detailed organization of weekly didactic teaching sessions and seminars and the Thursday afternoon didactic clinical sessions
•the chief resident acts as a liaison addressing any issues of concern that the residents have with the program director
•There are no hospital regulations that interfere with appropriate graded responsibility

On-call Duties of Residents

•residents are expected to provide on call service during their various clinical rotations.
•an integrated on call coverage exists within the city
•residents are on call over a four-day block extending from Friday at 5 p.m. and ending Tuesday at 8 a.m. and provide this coverage in out of hospital, typically one and not more than 2 weekends per month
•call during the week also occurs; the sum of all call never exceeds 1 in 4.
•the resident is expected to be on first call with backup always provided by a staff nuclear medicine physician
•remote access of cases is provided by electronic means, allowing some work to be done from home.
•the university adheres to the PAIRO Agreement, which regulates resident duties

Physical Facilities for Teaching

University Hospital

•there are 4 dual head SPECT gamma cameras (one with SPECT-CT capability) and a thyroid uptake probe at this site
•has a dedicated consulting room/film reading room with two imaging computers that are connected to all of the gamma cameras by Ethernet
•the residents/consultant can review studies collected on any of the gamma cameras
•all of the gamma cameras at University Hospital are computerized
•a small teaching file is present
•unique to University Hospital is a collection of 3,000 reprints located in over 120 binders organized by topic
•these labeled binders have an alphabetical list of the first authors located at the front of the binder
•there are alphabetical dividers in each binder
•the resident can browse a topic in a binder and retrieve classic papers
•there is computer access available to Medline databases as well as teaching files and self directed quiz cases by visiting bookmarked educational sites

St. Joseph’s Hospital

• there are 3 dual head SPECT gamma cameras (one with SPECT-CT capability) and a thyroid uptake probe at this site
•provides a large reading, interview and consultation area for residents
•individual staff teaching materials is available to residents in the form of personal libraries and teaching files
•there is computer access available to Medline databases as well as teaching files and self directed quiz cases by visiting bookmarked educational sites

Victoria Hospital

• there are 5 dual head SPECT gamma cameras (3 with SPECT-CT capability), one single head SPECT gamma camera and a thyroid uptake probe at this site
•is the largest site with the most number of gamma cameras
•teaching files exist primarily on slides and tapes within the department and additional files are available in consultants’ offices
•a large teaching file is available in the Nuclear Medicine Department at Victoria Hospital, which contains many pediatric cases
•a seminar room in Diagnostic Radiology has been booked for all of the nuclear medicine resident teaching seminars as well as a large room for inter-hospital rounds
•there is a separate room for fellows and residents, equipped with computers for scholarly activities such as research and self studying. Within this room there is a large screen hooked up to the computers for teaching activities
•there is computer access available to Medline databases as well as teaching files and self directed quiz cases by visiting bookmarked educational sites

Other Imaging and Related Modalities

•each of the residents in the program who has not already had training in an approved program in diagnostic radiology must spend a minimum of six months of cross-sectional imaging relevant to Nuclear Medicine
•in addition to this, the complimentary use of diagnostic radiology and nuclear medicine and the correlation of the findings of one with those of the other are encouraged as a daily practice throughout residency training
•all available radiologic investigations are normally reviewed as part of the reporting process in nuclear medicine studies
•this often involves correlation of nuclear medicine studies with computed tomography and ultrasonography results
•this is facilitated by the fact that several faculty members hold certifications in other specialties in addition to nuclear medicine
•at each hospital, diagnostic radiology and nuclear medicine share the same computer information system including the integration of patient data, reports and imaging studies that have been performed
•these are readily accessible and can be integrated into the interpretation of nuclear medicine studies
•at St. Joseph’s Hospital, PET/CT imaging is part of the Department of Nuclear Medicine
•there is a 64 slice CT scanner within the department used for both diagnostic and research purposes

Oral Examinations

•three to four times per year, a one-hour mock oral examination is given to each resident
•the mock oral examination follows the Royal College format
•immediate verbal feedback is given to the resident at the end of the examination

Written Examinations

•a written physics and radiopharmacy examination is given at the end of each of these respective courses, marked and the answers and results discussed with the residents by the appropriate basic scientists
•a written examination in a short answer format simulating the Royal College examination and requiring approximately 3 hours is given once per year to the residents
•questions cover the broad area of nuclear medicine, are marked in an informal manner, and answers and results discussed with the residents
•all nuclear medicine residents (with the exception those in the basic clinical year) are enrolled in the practice examination ministered by the American College of Nuclear Medicine on an annual basis

Evaluation of Clinical Studies
 
•clinical skills of the residents are evaluated on a daily basis
•the residents are responsible for supervising all clinical studies within the department. This includes:
◦supervising the study and ensuring adequate images are obtained
•a staff nuclear medicine physician reviews each case with the resident 
◦the standard format utilized is for the resident to present the findings on the appropriate image to the staff physician
•discussion of the case may ensue.  In this way, the supervising staff physician directly evaluates clinical skills on a daily basis
•Finally, physicians have direct opportunities to supervise and then observe the skills of residents in the performance of various procedures such as shunt studies, cardiac stress testing, etc. as well as physical examination on patients particularly with regards to thyroid disease

Evaluation of Communication Skills

•the communication skills of a resident in nuclear medicine must be both verbal and written
•the residents dictate all the cases, which they have reviewed with the staff physician
•the appropriate staff physician prior to the reports leaving the nuclear medicine department approves these written reports
•in this way, feedback can be given to the resident with regards to the quality of their written reports on studies and faculty have a direct opportunity to continuously evaluate resident performance in this area

Verbal communication skills

•are evaluated less frequently but still on a daily basis
•there are many opportunities for residents to discuss cases with visiting medical staff, residents, or interns from the various referring services when they present themselves in the nuclear medicine department to review a case, or by phone
•in many circumstances, a staff physician may well be nearby or present at this time and in this way, the verbal communication skills of the resident can be directly evaluated, comments made when appropriate as well as suggestions to improve these skills where necessary

Assessment of Attitudes

•because of the close nature of the relationship between the staff physicians in the Department of Nuclear Medicine and the resident assigned to each service, a close working relationship develops
•it is in this manner that the faculty develops a good sense of the attitudes of the various residents.  When appropriate, these attitudes are discussed within the context of the Residency Program Committee
•if there are perceived problems, they may also be discussed directly by supervising faculty with the Program Director

In-Training Evaluation System

•every month, each resident within the program is formally evaluated. 
•a standard in-training evaluation form specific for the rotation is utilized
•the consultant at each institution is responsible for performing the in-training evaluation or for ensuring that one of the other faculty members at his institution performs this evaluation
•the faculty member performing the evaluation seeks opinion from the other members within his own department prior to completing the evaluation report
•the in-training evaluation report is discussed with the resident prior to being forwarded to the Program Director
•where it is felt that specific objectives have not been reached, these are discussed with the resident and a suggested course of remedial action is outlined.
•the Program Director reviews all evaluations prior to placing such evaluations within the resident's file
•finally, at each Residency Program Committee meeting, the performance of each resident within the program is discussed

Resident Progress

•a close relationship between residents and faculty does exist
•the Program Director maintains an open door policy and is available at any time to discuss resident progress or problems
•the Program Director is regularly involved in some of the teaching
•the progress of the residents is evaluated at each meeting of the Residency Training Committee
•if any problem is perceived, the Program Director or a designate (if more appropriate) is required to give feedback, advice, or council to the resident
•at least once per year and more often if there are difficulties, the Program Director will meet with each resident within the program to discuss their progress, future plans (career counseling) and difficulties (stress counseling)

Remediation

•when resident weaknesses are identified, the site supervisor at the institution discusses these where the resident is based
•suggestions for improvement can be made and a timetable for follow-up reassessment instituted
•when such weaknesses are significant, these are discussed by the supervisor with the Program Director and the Residency Program Committee
•this may result in a more formal course of remediation being laid out with goals and deadlines being established
When residents are deemed not to be meeting the required levels of knowledge or ability, this is recognized as a major difficulty. 
•the situation is discussed with the resident by both the site supervisor and/or the Program Director to ascertain any possible extenuating circumstances
•where necessary, direct offers of assistance may be made to the resident and may include such avenues as counseling or involvement in a learning disabilities program administered through the university for advanced students
•specific goals and objectives for achieving the required levels of knowledge are outlined and deadlines established
•such discussions, goals and deadlines are placed in writing and delivered to the resident with signed acknowledgement of receipt
•should such actions fail to improve the performance of the resident, the performance will be discussed with the Associate Dean of Postgraduate Education, UWO, and a final notice given to the resident in accordance with established postgraduate program policy, UWO
•fortunately, such circumstances are extremely rare due to our ability to attract very good residents from the start

Final In-Training Evaluation Report (FITER)

•the final in-training evaluation report is completed by the Program Director after consulting with the entire faculty supervising the resident in the final year of training
•this is generally performed by circulating copies to all clinical members of the Committee for completion with the final report representing an overall average of the various evaluations
• where there are significant discrepancies, a meeting of the faculty may be necessary to assign a final grading

 

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