Nuclear Medicine

Educational Purpose: The purpose of this rotation is to train fellows in the various aspects of nuclear cardiology needed for the practice of consultative cardiology.  During the rotation, the fellows are expected to participate in all aspects of nuclear testing including development of a basic understanding of nuclear physics, the safe handling of radionuclides, preparation of radionuclide tracers, calibration and maintenance of nuclear equipment, image acquisition, and methods of quality control.  Fellows will gain a thorough understanding of the indications for specific nuclear cardiology tests including (but not limited to) myocardial perfusion SPECT imaging, viability testing, myocardial PET imaging, and radionuclide ventriculography.  They will be trained on image acquisition, reconstruction, analysis, and image interpretation including recognition of artifacts.  Emphasis will also be placed on achieving competence in stress testing including understanding the principles of patient selection, performance, monitoring, interpretation, and reporting of exercise and pharmacological stress testing.

Integration of risk factors, clinical symptoms and stress testing to allow appropriate application of the resultant diagnostic information for clinical management is paramount.  Fellows will become well versed in the clinical application of nuclear cardiology to the care of patients with cardiovascular disease and risk factors.  Correlation of nuclear cardiology results with other diagnostic modalities will be emphasized.  Fellows will also be expected to communicate information, verbally when necessary, to the physician requesting the nuclear service, and deal with him/her on a professional level.

Overall Goals & Competency-Based Learning Objectives: 
Ability to obtain a complete medical history, perform a careful and accurate examination with a cardiology focus for the optimal performance of stress test and nuclear cardiology (COMPETANCIES: patient care, medical knowledge)
Learn proper techniques of performing nuclear procedures (including chemical procedures) and understand nuclear physics and radiation safety including nuclear safety for patients and health care workeres (COMPETANCIES: patient care, medical knowledge, systems based practice)
Learn how to risk stratify and mange patients after being evaluated by cardiac stress test and nuclear cardiovascular procedures and understand how to correlate other imaging modalities and nuclear studies (COMPETANCIES: patient care, medical knowledge)
Ability to perform all procedures with emphasis on patient comfort and safety (COMPETANCIES: patient care, interpersonal skills and communication)
Ability to manage complications from stress test and nuclear studies, including nuclear decontamination procedures (COMPETANCIES: Patient safely, medical knowledge, system based practice)
Understand the newest basic science concepts and mechanisms in nuclear cardiology and become familiar with current medical literature, clinical trials, and evidence based medicine in nuclear cardiology (COMPETANCIES: medical knowledge)
Master the nuclear evaluation of patients with coronary artery disease, including reversible ischemia and myocardial viability (COMPETANCIES: medical knowledge, patient care)
Communicate effectively the risk and benefits of the procedure to the patient before obtaining consent for the procedure (COMPETANCIES: patient care, interpersonal skills and communication, systems based practice)
Provide professional presentation of nuclear findings to patient and family members in a compassionate and informative manner with appreciation of cultural, spiritual and social context of wellness and illness. Provide complete and accurate report to consulting physicians and care teams (COMPETANCIES: patient care, interpersonal skills and communication, professionalism, systems based practice)
Understand and utilize the multidisciplinary resources necessary to perform nuclear studies and  collaborate with other members of the health care team to assure comprehensive cardiac care (COMPETANCIES: patient care, interpersonal skills and communication, professionalism, practice-based learning and improvement)
Knowing when to ask for help and advice from senior fellows and attending physicians (COMPETANCIES: medical knowledge, professionalism, practice-based learning and improvement)

Goals & Objectives by PGY Level: 
PGY 4: 
1. Ability to risk stratify patients after being evaluated by cardiac stress test and nuclear cardiovascular procedures. 
2. Introduction to the preparation of Radionuclide Tracers and Safety in Handling Radionuclides 
3. Introduction to calibration and maintenance of Nuclear Equipment, Image acquisition , Data Processing, Radiation Safety, and Image Interpretation
4. Interpret and understand the clinical data, including the history, exam, resting and stress EKGs and exercise data, reviewing and discussing them with the attending. 
5. Understand the sensitivity, specificity, and accuracy in the interpretation of these tests 
6. Learn basic operation and quality control of gamma cameras and computers. 
7. Understand principles of patient selection, performance, monitoring, interpretation, and reporting of exercise and pharmacological stress testing. 
8. Learn how to acquire, reconstruct and analyze radionuclide ventriculograms and perfusion images. 
9. Interpret at least 100 nuclear cardiology studies, to correlate the results with other clinical parameters, and to assess the impact of the study on subsequent clinical management. 
10. Ability to manage complications from stress test and nuclear studies, including nuclear decontamination procedures.


PGY 5: 
1.   Continue to build upon learning objectives in PGY-4 year.
2.   Interpret at least a total of 300 nuclear cardiology studies, including correlation with cardiac catheterization, and assess the impact of the study on subsequent clinical management

PGY 6: 
1.   Continue to build upon learning objectives in PGY-4 and 5 and develop at minimum at level 2 training in Nuclear Cardiology
2.   Master the nuclear evaluation of patients with coronary artery disease, including reversible ischemia and myocardial viability.

Mix of Disease: Fellows will be exposed to a variety of patients during the nuclear cardiology rotation.  Exercise testing will expose fellows to patients undergoing evaluation of functional capacity, ischemia, arrhythmias, and efficacy of medical therapy.  Stress testing and nuclear imaging will provide exposure to patients with known or suspected coronary artery disease, cardiomyopathies, and patients undergoing pre-operative evaluation.  Patients will be over the age of 18 years old.  The gender mix will be balanced at UMH; however, patients at the VAMC will be mostly male.  Exposure to pregnant patients will be limited on this rotation due to radiation safety concerns.

Teaching Methods:
Patient-Centered Teaching/Learning: Fellows will receive direct instruction from the attending physician in the stress and nuclear reading areas with additional instruction in certain procedures by qualified technicians on service.  Fellows are expected to identify knowledge gaps and search for answers to their questions on a routine basis.   
Conferences/Didactic Learning:  Fellows are expected to attend the Division of Cardiology Fellows’ Core Curriculum Lectures given throughout the academic year in addition to the departmental Grand Rounds.  The Thursday Imaging Lecture Series will cover a variety of topics in nuclear cardiology.

Procedures:  Fellows will participate in all procedures associated with nuclear cardiology including exercise and pharmacologic stress testing, calibration and maintenance of nuclear equipment, image acquisition, and methods of quality control.

Pathologic Material/Educational Resources:  
The fellows will review EKGs, chest X-rays, cardiac catheterizations, CT scans, stress tests and echocardiograms as indicated by the patient’s cardiac condition.  
Up to Date: http://www.uptodate.com/home/index.html
PubMed: www.ncbi.nlm.nih.gov/pubmed/ 

Text books:  Cardiology textbooks are available in the Hospital Library and the Calder Medical Library.
o Nuclear Medicine: The Basics, 2004 by Ramesh Chandra
o Principles and Practice of Nuclear Medicine, 2nd edition, 1995, by Early and Sodee for radiation physics instruction
o For clinical nuclear cardiology, the following texts are suggested: Nuclear Cardiology: Practical Applications, by Heller and Hendel or Nuclear Cardiology: Technical Applications by Heller, Mann, and Hendel.
o Other useful texts include those by Beller and Zaret, Iskandrian, or Gerson.
Institutional access for http://www.cardiosource.org  and CardiosourcePlus with ACCSAP7.

Evaluations: Fellows will be evaluated by their supervising attending physician(s) using a competency-based system on New Innovation.  Feedback will be provided during and at the end of the rotation.

Supervision Policy: Direct/Indirect with direct supervision immediately available.

Team Structure:
Supervising Attending 
1-2 Cardiology Fellow(s)
Various support staff including nuclear technologists and ARNPs

Attending Responsibilities:
Supervises and assumes ultimate responsibility for the performance and interpretation of all nuclear cardiology imaging modalities
Responsible for providing verbal and written feedback to the fellow

Fellow Responsibilities:
Perform both exercise and pharmacologic stress tests along with the support staff
o Obtain consent from the patient prior to performing the test
o Interpret the results of the EKG portion of the exam and provide a preliminary reading that will be reviewed by the supervision attending and placed in the medical record.
Interpret the results of the nuclear imaging test and provide a preliminary reading that will be reviewed with the attending physician for accuracy prior to reporting in the medical record
Communicate abnormal results to the referring physician (and the patient when appropriate) and provide a suggested plan of care 
Determine appropriateness of all patients referred for nuclear cardiology imaging
Assist the nuclear technologist in methods of quality control as described in the educational purpose and goals
Responsible for keeping a log of all procedures/studies in New Innovations
Attends all divisional conferences
Attends assigned Cardiology Clinics
Completes a written evaluation of the attending
Comments