News

June 2005

Background Information on Role Development of the Nuclear Medicine Practitioner

As nuclear medicine technology matures as a profession, an expanded scope of practice is under consideration. According to a study undertaken in 2000 (Pickett, Waterstram-Rich, Turner, 2000) nuclear medicine technologists (NMT) expressed a high level of interest in an advanced practice career pathway. Technologists also indicated they were already performing many tasks outside accepted practice guidelines and were doing so without the benefit of formalized training. Such activity puts the technologist, the physician, the institution, and most importantly, the patient, at risk for an adverse event.

Work place characteristics have also changed over time with nuclear medicine procedures performed in a variety of clinical settings. Nuclear medicine technologists may work in areas with little physician coverage and make medical decisions outside their area of expertise. As increasingly more procedures are performed by other medical specialists, particularly cardiology and oncology, technologists who work for these specialists are often required to demonstrate a certain amount of medical expertise to compensate for that which is lacking among the specialists but would have been present with a nuclear medicine physician.

The fact that many technologists have significant work experience represents a unique opportunity for professional growth. Nuclear medicine technologists possess a shared bond with medical imaging physicians. They speak a common language and share a deep understanding of medical imaging. Talented NMTs would be ideal candidates for a role in providing advanced nuclear medicine services similar to that of a physician assistant or nurse practitioner. They would have the added advantage of being able to administer radiopharmaceuticals, a task often prohibited by PAs or nurse practitioners in licensure states. But without the proper education and training, NMTs lack the regulatory underpinnings of other physician extenders.

To address the aforementioned situation, the Society of Nuclear Medicine Technologist Section (SNMTS) recently completed a physician survey for input as to how such a middle level provider, or Nuclear Medicine Practitioner (NMP), might function and how physicians view this development. The survey, which was completed in April 2005, revealed an overall positive impression by physicians regarding role development of an NMP. In general it is anticipated that NMPs will be required to demonstrate a high level of autonomy, technical sophistication in addition to advanced clinical knowledge and strong critical thinking and decision-making skills. They will be highly capable and motivated professionals, comfortable with the sciences, seeking increased education at the Master’s degree level.

Results from Physician Survey April 2005

The Technologist Section of the Society of Nuclear Medicine (SNMTS) conducted a survey to explore the possibility of creating a middle level provider of nuclear medicine services (Appendix I). The survey questionnaire was developed by Sage Computing, Inc staff in consultation with the SNM staff members and using draft questions approved by the SNM staff and committee members. SNM had conducted a pilot survey in 2004 and items from that study were used as the basis of the current survey.

The questionnaire administered by Sage was mailed to 1,500 physicians. These potential respondents were selected based on a random number assigned to each person and are representative of a larger universe of 2,700 individual society members from ASNC, ACNP, and ACR. Mailing addresses were provided by SNP; almost every state was represented in the sample, as well as Puerto Rico. The overall response rate was 24.7%.

Demographics of Respondents
Survey respondents were asked to report their specialty area and could select up to six areas alone or in combination. Forty-five percent reported expertise in the area of cardiology and 34.3% reported nuclear medicine (ABNM). One-quarter (25.6%) reported a specialty in internal medicine (ABIM) and 13.1% reported their specialty as radiology.

Survey respondents were asked how long they have been practicing nuclear medicine. One third reported practicing more than 20 years. The average of all responses was approximately 14 years of experience in nuclear medicine. Only one in five respondents reported that their institution had a nuclear medicine residency program. When asked if they had ever worked with a physician assistant (PA) or nurse practitioner (NP), the vast majority said yes (71.4%).

Proposed Tasks of NMP
Survey respondents were asked their opinion about the usefulness of an NMP in performing various tasks. The survey instrument used a Likert scale of 1 through 5, with 5 representing “very useful” and 1 representing “not very useful.” The option of “Not applicable” was available for each question as well.

Overall, 72.5% of the respondents thought an NMP would be very useful (5 on Likert scale) or useful (4 on Likert scale) in performing exercise stress tests; 50.7% thought it be useful if the NMP could read an ECG; and 83% thought having the NMP be ACLS certified would be useful or very useful.

Eighty-two percent thought they would be very useful or useful in obtaining informed consent; 74% were of the opinion that an NMP would be very useful or useful for taking clinical histories before and/or after imaging procedures. Only 16% thought an NMP would be useful in administering radiopharmaceuticals intrathecally or intraperitoneally; most thought this task was either not applicable (33.2%) or not very useful (27.6%).

When queried about the value of an NMP administering the radiopharmaceutical for sentinel node imaging, 42% agreed that it would be useful or very useful; 30% indicated this was not applicable to their practice.

Three questions were asked regarding NMP interpretation of images. When asked if an NMP should evaluate images and provide a preliminary diagnosis, 20% said this would be very useful and the same percentage said it would not very useful. Overall, 35% did not seem to favor this task (task rated as 1 or 2) while 38% did (task rated as 4 or 5); 18% were undecided. When asked whether the NMP should evaluate images and simply indicate whether they were normal or abnormal, slightly more seemed to be in favor of this task but many respondents remained opposed. Thirty-one percent rated this task as a 1 or a 2 (not very useful or not useful) and 43% rated the task as a 4 or 5 (useful or very useful). More ambiguity appeared for the task of the NMP evaluating images and providing a technical report or preliminary diagnosis to the radiologist. The largest number (23%) rated this task as a 3; 34% thought this task was not particularly useful (1 or 2) and 35% thought the task was useful or very useful (4 or 5).

In response to the question about an NMP ordering interventional pharmaceuticals according to protocol, 62% thought this was useful or very useful. Forty-six percent believed it would be useful or very useful for an NMP to order complimentary diagnostic procedures.

Interest appeared to be strong regarding the role of an NMP in therapeutic procedures. Forty six percent said it would be useful or very useful for the NMP to review requests and examine patients prior to therapy procedures and monitory post-therapy patients. Nearly one fifth of the respondents indicated this task was not applicable in their practices.

Value of an NMP
Respondents were asked to rate a series of opinions about NMPs based on the question: “Please provide your opinion on the role or value of an NMP.” When asked if “NMPs would provide technologists with opportunity for advancement,” 60.8% reported yes (likely or very likely), while only 12.0% responded not very likely. Similarly, when asked if “an NMP would free up a radiologist, NM physician, or cardiologist to do other things”, 53.0% reported yes (likely or very likely) and only 15.9% said not very likely.

The response to the question “An NMP would potentially decrease the need for ancillary personnel”, one half of respondents said yes (likely or very likely). This is somewhat inconsistent with the results of a previous question, where only a quarter of respondents said they were unlikely to hire a nurse/PA if a highly skilled technologist were on staff.

Asked if “An NMP would improve efficiency especially in very busy departments”, 61.6% of all respondents agreed (very likely or likely) while only one in 10 said it’s very unlikely. Thirty-six percent of respondents agreed that “An NMP could make the specialty of NM more powerful”, but 24.1% dissented with that opinion. On the operational matter “Better and more prompt service could be offered to patients with an NMP”, almost half (47.7%) agreed it’s likely or very likely: only 15.3% disagreed with that statement about an increase in service promptness.

Physicians were also asked if an NMP would offer a greater level of direct patient contact. Half agreed and 15% did not agree. Nearly half of all responses (48.7%) indicated that “an NMP would improve departmental quality and management efficiency”, substantiated by only 14.5% who disagreed that it’s not very likely. As for whether “An NMP would be helpful when direct physician presence was not possible”, almost 64% agreed (likely or very likely) while only 12% did not agree. Lastly in this series of opinions, respondents were asked their opinion on “An NMP would be helpful considering shortage of radiologists and NM physicians”, and 42.6% agreed it’s likely to very likely while 21.9% said it was not very likely.

Other Roles of the NMP
Respondents were asked to register their opinions on a series of seven sub-questions about the importance of the role and capabilities of an NMP. Overall, when presented with these statements about NMPs, the majority always rated the role and capabilities as important to very important, (and generally a small minority did not agree). That indicates that if an NMP were present, they would need to have the capabilities and play a significant role in supporting or carrying out lab management, coding and billing procedures, accreditation processes and research. Following are details of the findings for each area.

First, they were asked if “An NMP should be proficient in department or lab management”. More than 70% said that is important or very important. Only 12.4% said not important or not very important. Next they were asked to rate the importance of the statement, “An NMP should be capable of helping a lab receive accreditation.” Over 76% agreed; and only 10% disagreed.

Respondents were presented with the statement, “An NMP should be capable of conducting or assisting with research projects.” Sixty-three percent agreed and only 13% did not agree. When physicians were asked to respond to “An NMP should be very familiar with therapeutic procedures,” 72.8% said it was very important to important, while only 11.5% did not rate it as important.

Asked about whether “An NMP should be familiar with billing and coding issues,” a little more than half (53.6%) agreed it is very important or at least important, and one in five (20.1%) said it was not important.

Education and Training
Stating their opinions on “An NMP should be trained and educated at the master's level,” 52.3% respondents ranked that as important (or very) and a total of 21.1% were of the opposite opinion. Finally, physician respondents were asked their opinion on whether “An NMP should be trained and educated in a manner similar to a PA.” A majority of 71.2% agreed it is at least important; only a total of 11% rated it as not (or not very) important.

Variations Among Physician Respondents
Some basic factors characterizing the physician respondents to the survey could affect their responses. For example, physicians with an NM residency program at their institution might experience more academic type clinical settings and practice patterns and therefore might view the role of an NMP differently than a physician with no local NM residency. The responses were analyzed by the following variables: (1) specialty area of respondent, (2) nuclear medicine residency at the institution, (3) prior experience with a PA or NP, and (4) years of practicing nuclear medicine.

When asked, “How useful would it be if the NMP could perform the following tasks?” the cardiology specialists reported much less usefulness for the four tasks: order complementary diagnostic procedures; review requests and examine patients prior to procedures; monitor post-therapy patients; and especially, perform bladder catheterization. However, on the other questions regarding the role and value of an NMP and NMP capabilities, the responses were nearly the same without regard to any respondent specialty. Most response frequencies were only a few to several percent different between cardiology and non-cardiology NM practitioners.

The data were analyzed to assess whether physicians responded differently depending on whether or not their institution had a nuclear medicine residency program. There were some important differences in responses that were statistically significant at 95% level of confidence. When asked, “How useful would it be if the nuclear medicine practitioner could perform the following tasks?” physicians with residencies rated as “very useful” much more frequently for five tasks (of 16 tasks), as did respondents at institutions without residencies. Those areas were: administer radiopharmaceuticals intrathecally or intraperitoneally, administer radiopharmaceutical for sentinel node imaging, perform bladder catheterizations, review requests and examine patients prior to therapy procedures, and monitor post-therapy patients.

The responses to the question, “Please provide your opinion on the role or value of a NMP” differed significantly depending on whether a residency program was present. Respondents with residency programs were more likely to respond “very likely” than those at institutions without residency programs on these important factors: NMPs would provide technologists with opportunity for advancement, an NMP would free up a radiologist, NM physician or cardiologist to do other things, and an NMP would improve efficiency. In addition, respondents with residency programs reported that it would be very important that an NMP be trained and educated at the master's degree level.

The survey data were further analyzed for differences between respondents who had worked with a PA or NP and those who had not. For most questions, the two groups’ responses were much the same, but there were some notable differences. As for NMPs performing tasks, physicians that had worked with a PA or NP rated as very much more useful the capability of the NMP to perform exercise stress tests and read ECGs. When rating the role and importance of NMP capabilities, physicians who worked with PAs or NPs rated four of seven areas as very important, at a more than 10% higher rate than physicians who had not worked with PAs or NPs. These areas were: lab management; lab accreditation; conducting or assisting with research projects; and familiarity with therapeutic procedures. This indicates that those who worked with a PA or NP place more weight on their staff having greater capabilities.

When responses were analyzed for differences due to the number of years of practice, there were no statistically significant differences. Regardless of the length of service, physicians’ responses to questions were much the same, whether the question was about NMP roles, value or capabilities.

Education of the NMP

Nuclear Medicine Practitioners would be educated at the master’s degree level and most likely after several years of experience. The rationale for the master’s degree is that this level of education is now mandatory for the NMP counterparts in the healthcare arena, the nurse practitioner and the physician assistant. According to the physician survey, a strong interest was expressed both in the master’s degree level of education as well as following a PA educational model. Regulatory requirements [Medicare]also require a master’s degree for certain privileges.

Also according to the physician survey, prior experience as a nuclear medicine technologist is viewed as essential. Forty-three percent of the responders felt that two or three years of experience was necessary before training to become an NMP and 41% thought five or more years was important.

Technologists who reported a high level of interest in an advanced practice career pathway in the 2000 study indicated educational programs should be configured so that they could be completed while technologists remain employed. In fact, current employment settings will most likely be crucial for educating and training the NMP. New educational models should be explored, including online education and part time tracks. Tracks should be developed in cooperation with existing Radiologist Assistant (RA) programs for the dual credentialed where applicable, which means nuclear medicine accreditation bodies should collaborate with the radiology professionals. Institutional consortia should be considered as a means of conserving scarce resources.

Next Steps

After appropriate review and approval by the SNM and SNMTS Leadership, a model curriculum and associated competencies will be developed. Key stakeholders in the process will include accreditation and credentialing bodies. External bodies to the Society of Nuclear Medicine, including other medical and professional associations, as well as regulatory groups, will also play a key role in further defining the knowledge, skills, and privileges of the NMP.

Summary and Proposed Action Item

The concept of middle level provider of nuclear medicine services, referred in this paper as a Nuclear Medicine Practitioner (NMP), is supported by two studies of technologists and physicians. It is anticipated that the NMP would have attributes parallel to a physician assistant with roles and functions to be defined by advanced clinical competency beyond the technologist level. This new clinical role offers an opportunity for significant career advancement for technologists and would result in nuclear medicine services that are more cost effective and efficient.

Be it Resolved, that the SNM supports the establishment of a middle level provider in nuclear medicine known as the nuclear medicine practitioner.

Pickett, M.W., Waterstram-Rich, K.M., & Turner, L.W. (2000). The future of nuclear medicine technology: Are we ready for advanced practice? Journal of Nuclear Medicine Technology, 28, 280-286

1. American Law Report (ALR)
2. Cornell Law website www.cornell.edu
3. Appendix I: Physician Survey for Nuclear Medicine Practitioner (NMP)