Consultant physicians working with patients - Royal College of ...

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2 Specialties Nuclear medicineNuclear medicineDr John Buscombe MBBS MD FRCP FRCR Consultant physician nuclear medicineDr Sabina Dizdarevic MD MSc FRCP Consultant in nuclear medicineProfessor Val Lewington BM MSc FRCP FRCR Professor of nuclear medicineDr Brian Neilly MBChB MD FRCP FRCR Consultant physicianDr Liz Prvulovich MD FRCP FASNC FEBNM Consultant physician nuclear medicineDr Andrew Scarsbrook BMedSci BMBS FRCR Nuclear medicine physician1 Description of the specialtyNuclear medicine uses radioactive materials fordiagnosis, treatment and research. Nuclear medicineinvestigations detect early physiological changes thatoccur in response to disease, and provide uniquefunctional information to diagnose and support themanagement of patients of all ages in many medicalareas including oncology, cardiology, nephrourology,orthopaedics, rheumatology and neuropsychiatry.Increasingly, nuclear medicine data are fusedwith anatomical scans to improve the specificityand sensitivity of complementary imagingmodalities.The range of diagnostic nuclear medicine investigationsis expanding rapidly. Tracers based on receptor-specificligands, monoclonal antibodies and small peptides arenow available for tissue characterisation at a molecularlevel, contributing to the investigation of movementdisorders, schizophrenia, Alzheimer’s disease, theunstable coronary plaque and thromboembolicdisease.Advances in tumour targeting have led to a parallelexpansion in unsealed source therapy usinghigh-activity, radiolabelled drugs for cancer treatment.2 Organisation of the service and patternsof referralNuclear medicine services are hospital based, withadditional provision of positron emissionimaging–computed tomography (PET-CT) in someareas via mobile scanners. Service delivery varies to suitlocal population size, casemix and degree ofcentralisation. 1,2 Small departments undertaking alimited range of diagnostic investigations follow anoutpatient clinic model and are often sited withinradiology departments. Large units offering acomprehensive range of diagnostic procedures, bonedensitometry, outpatient clinics and radionuclidetherapy require day-care and dedicated inpatientfacilities.Diagnostic nuclear medicine procedures are performedeither by specialist nuclear medicine practitioners or bymultiple individual practitioners responsible for specificservice components allied to their main specialty.Examples of the latter include system-specificradiologists and cardiologists. Where the service isfragmented, it is essential to have at least one specialisttrained to Certificate of Completion of Training (CCT)level (or on the specialist register) in nuclear medicineto ensure consistent development across the fullspectrum of nuclear medicine practice.Diagnostic services are required in most acute hospitals.Service configuration usually follows a ‘hub-and-spoke’design, linking large teaching hospital centres withsmaller, local departments. Specialist services andinpatient facilities are provided in the central unit andconsultants may undertake sessions in central andoutreach hospitals. Nuclear medicine consultants withparticular expertise in cardiology, oncology, PET-CTand radionuclide therapy provide advice and receivetertiary referrals from other centres.3 Working with patients: patient-centredcarePatient preference is central to service delivery.However, due to legal constraints all proceduresinvolving radiation exposure must be justified and oftenthe need to order the required radiopharmaceuticals,which may not be available every day, means that theseC○ Royal College of Physicians 2013 181
Consultant physicians working with patientsscans are often planned in advance. However, someunits have limited instant access to some tests such aslung scintigraphy. Direct access to services without areferral from a medical or IR(ME)R-approvedpractitioner is, therefore, inappropriate for bothpractical and safety reasons.The majority of diagnostic nuclear medicineinvestigations are undertaken as outpatient procedures,whereas high-activity radionuclide therapy may requireinpatient admission for between 1 and 7 nights in asingle room with separate washing and toilet facilities.Written information is required for all procedures andis, ideally, developed in collaboration with patientrepresentatives. The Joint Specialty Committee forNuclear Medicine and the British Nuclear MedicineSociety have developed central information resourcesfor patients and their carers. The significance of testresults and potential implications for management areusually discussed with patients by their referringclinician.4 Interspecialty and interdisciplinaryliaisonMultidisciplinary team workingNon-medical personnel are essential to routine nuclearmedicine service provision. The skill mix varies betweendepartments but will usually include physicists andother clinical scientists, medical technical practitioners,radiographers, radiopharmacists and nuclear medicinenurse specialists. Play specialists and cardiac technicianscontribute to specialist services in centres with a highpaediatric or cardiac workload. Provision of a medicalphysics expert and a radiation protection adviser is alegal requirement.Nuclear medicine clinicians liaise closely with mostother specialties and are often core members of cancermultidisciplinary team (MDT) meetings. Review ofnuclear medicine imaging should be undertaken byappropriately trained specialists who are able to provideadvice reflecting new information arising from MDTdiscussions. The Royal College of Physicians (RCP) haspublished new guidance for nuclear medicinephysicians working within MDTs.Most nuclear medicine specialists undertakeradionuclide therapy and many are the lead clinicians injoint clinics managing benign and malignant disease.5 Delivering a high-quality serviceA high-quality service is patient centred and producesaccurate results in a timely manner in accordance withexplicit service standards. Nuclear medicine servicesshould be led by a specialist trained to CCT level (or onthe specialist register), or equivalent, in nuclearmedicine. Service quality is jeopardised in hospitalswhere there is no sessional commitment to nuclearmedicine, particularly if a small nuclear medicinecaseload is divided between a large numbers ofconsultants, diluting individual experience. The nuclearmedicine physician liaises closely with scientists andclinical colleagues to ensure that new evidence-basedtechniques are introduced safely.Reciprocal rota commitments with colleagues in otherunits are recommended to avoid professional isolationfor consultants working single-handedly. Telemedicinelinks improve communication between large andsmaller departments and facilitate audit but are not asubstitute for local clinical involvement. Scan readingand issuing reports is only part of the role of the nuclearmedicine specialist. As many of the studies performedare not well known by the general medical professionproviding an expert opinion and guidance is alsoessential.The facilities required to deliver a high-quality serviceinclude: dedicated patient waiting areas to separate patientswho have received radiopharmaceuticals frompatients and carers not receiving them separate area for administration ofradiopharmaceuticals dedicated toilet facilities which will need to complywith trust’s disabled access and personal dignityrequirements examination rooms and quiet counselling room fordiscussion with any patient, including any pregnantand breastfeeding women, appropriate to thecasemix secure radiopharmaceutical storage area area for image analysis data-reporting room educational and library area separate paediatric waiting or play area, asappropriate cardiac stressing facility – this may be shared withcardiology if it is organisationally more appropriate182 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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2 Specialties HaematologyHaematolog
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