Biomed Imaging Interv J 2006; 2(4):e49
doi: 10.2349/biij.2.4.e49
© 2006 Biomedical Imaging and
Intervention Journal
Editorial
A new world order: training clinicians for a new era in imaging
RJ Hicks, MBBS, MD, FRACP
Centre for Molecular Imaging, The Peter MacCallum Cancer
Centre, Melbourne, Australia
There are three kinds of people: commonplace men, remarkable
men, and lunatics (Mark Twain, Following the Equator).
Over the past 15 years or so I have had the distinction of
being considered a member of each of the categories of humans
identified by the great American humorist, author, and philosopher,
Samuel Clemens (alias Mark Twain). My initial exposure to oncological
PET as a fellow at the University of Michigan in the late 1980s
and early 1990s and the seminal work of Professor Rich Wahl
convinced me of the need to correlate PET images with more detailed
anatomical studies. I was positive about the potential benefits
of a combined device to achieve this end. Consequently, I suggested
to an engineer of GE Medical Systems that his company should
build such a device. His response was that they could not sell
enough PET scanners to make money out of the business, and only
a lunatic would suggest making an even more
expensive device. In 1996, GE made an unsuccessful attempt to
sell its PET business. In retrospect, I am sure that they would
agree that this was one of the most fortuitous business strategy
failures of all time. GE went on to release the first commercial
PET/CT in 2001, followed soon after by Siemens. The latter had
initially pioneered work in this field through the efforts of
Professor David Townsend. Today, PET/CT is the most rapidly
growing imaging modality in the world.
In 1996, coinciding with the nadir of corporate enthusiasm
for PET, I established a PET facility at the Peter MacCallum
Cancer Centre in Australia. This was done without Government
capital or operational funding. The focus of our programme was
to provide a clinical service to cancer patients. Many of my
colleagues considered me a lunatic. PET, they
told me, was a research tool, not a routine clinical imaging
device. It was, they said, unlikely to be an affordable technique
for cancer staging despite encouraging preliminary reports of
its accuracy for this purpose. Despite this, by 1999, we had
installed a second PET scanner. We were performing over 2000
clinical PET studies annually, and I was considered a remarkable
man! As oncologists and imaging specialists became increasingly
aware of the benefits of PET and more and more publications
attested to its accuracy and patient management quality, it
became evident that PET was a revolutionary approach to cancer
evaluation. Modern oncology could not be practiced effectively
without it. Again, I entered the ranks of the commonplace
man since my vision had been self-evident.
When I first heard of the commercial development of hybrid
PET/CT scanners, I was determined to gain access to this technology.
My radiology colleagues, however, questioned the logic of adding
an expensive CT to an already expensive PET scanner that could
only do 10 to 20 scans per day. This appeared to them to be
an incredible waste of a valuable resource when one could simply
compare the PET and the CT images side by side. Nevertheless,
a lunatic again, I persisted and in 2001 installed
the first PET/CT in Australasia and one of the first in the
world. It took little time for my colleagues to realise that
this really was a remarkable advance. Today,
after having used this technology for five years to perform
over 10,000 scans, our clinicians can barely conceive of treating
cancer patients without access to it. Indeed, PET/CT is now
accepted by the clinical community throughout the world as an
important, if not indispensable component of the diagnostic
imaging armamentarium. My view of the imaging world has again
reverted to the mean, and my perspectives are again commonplace.
It is now time, I feel, for me to revert to my lunatic
self. I wish to consider the training of those who will be interpreting
imaging studies in the future. I fear that I may make some statements
that will evoke cries of protest. Nevertheless, I feel compelled
to proceed. Who should be “credentialed” to read a new generation
of hybrid imaging studies that will incorporate exquisite anatomical
detail and previously unimagined molecular biological characterisation?
Debate continues to rage around the world. Some time ago I attended
a debate held at the Academy of Molecular Imaging in Madrid,
Spain, where the nomenclature of hybrid imaging devices was
discussed. Should it be a CT/PET as favoured by radiologists
or PET/CT as supported strenuously by nuclear medicine physicians?
At that time I was on a sabbatical and had performed microarrays
to identify genes that were able to discriminate patients with
oesophageal cancer who did and did not have a metabolic response
to radiotherapy on PET. In the light of this experience, I facetiously
made the suggestion that we should swab all the radiologists
in the room and all the nuclear medicine physicians. From the
collected DNA we would be able to see at which point in evolutionary
history we had differentiated into such fundamentally different
beings and the genes responsible. Perhaps, we could even find
a gene product inhibitor to correct the deficiencies in one
or other group (depending on your own particular bias). My point
was that there is no fundamental difference among us. It is
not nature, but nurture that creates different perspectives
on what is important in imaging.
I recently read a wonderful book by North-American social
anthropologist, Jane Jacobs. Titled “Dark Age Ahead,” this book provides a
contrary view to the more widely held beliefs that the world is most threatened
by ecological disaster due to global warming or global conflict ignited by
religious beliefs. The author proposes what might seem a more prosaic and
insidious forms of decay. Among the several factors she suggests as causing the
gradual decline and the ultimate fall of western society, the one I found most
resonant, was that our society has moved away from education towards credentialing.
What exactly does that mean? She argues, that education is open-ended,
expansive, and unrestricted in its vision. It empowers the recipient to look
beyond intellectual horizons, to imagine new ways of interacting with the world,
and to build a system of thought and investigation that will expand
possibilities into the future. Credentialing, on the other hand, is about
defining what someone is capable of doing. It restricts endeavour and
constrains perspectives. It limits opportunities for intellectual evolution and
enquiry. Another important tenet of her book is that there has been a loss of
self-regulation of the professions. She points out that ethical standards and
maintenance of competence are no longer being an internalised character trait of
professionals, but have to be regulated by external bodies. This is akin to
having a police force to detect and punish crime on the assumption that it will
occur. Accreditation Boards and credentialing bodies that are divorced from
involvement in the field they purport to supervise run the risk of
administering the law but not justice, conformity but not excellence.
How does this apply to imaging? In my view, PET/CT or CT/PET
offers the medical community a great challenge; one that can degenerate into a
battle for turf or one that can lead to a new era in imaging. In some parts of
the world, this emerging modality is either controlled exclusively by
radiologists or nuclear medicine physicians. In others, small subgroups within
each of these specialty groups require further training to be credentialed. In Australia,
for example, nuclear medicine physicians or radiologists with accreditation in
both fields can apply for accreditation as a PET scan reader only if they spend
a minimum of 20 working days in an approved training facility and review 300
cases under supervision. There is currently no provision for nuclear medicine
physicians to gain accreditation to read the CT component, short of five years’
training in radiology. Therefore, the reader may ask, who should read PET/CT
scans, radiologists or nuclear medicine physicians? My answer is neither and
both! PET/CT is just one among a growing range of technologies that will blur
the boundaries of structural and molecular imaging. We already have SPECT/CT, and
prototype PET/MRI devices are being tested. A range of functional imaging
techniques and new tracers will extend the range of information of MRI beyond
anatomical detail. In addition, optical imaging is also entering the realms of
clinical application.
I believe we need to focus on an entirely different skill
set compared with the existing one in radiology or nuclear medicine, if we are
to embrace and maximise the potential of these emerging modalities. Towards
this end, I suggest we focus on a modular educational process that would enable
practitioners to acquire the specific skill sets pertinent to their work
environment. In the course of my work, I have noted the immense contribution of
cardiologists towards nuclear cardiology, cardiac MRI and, more recently,
multi-detector CT cardiac imaging.. Neurologists have made a significant
contribution towards neurologic SPECT and PET, and I believe that oncologists
are doing the same in terms of oncologic PET/CT. I feel strongly that the
success of our programme has been underpinned by my emphasis both on the need
to learn about oncological principles and current treatment paradigms and to
actively engage medical, surgical, and radiation oncologists in our programme to
report oncological PET adequately. Consequently, I assert that we should
rejoice in clinicians crossing specialty boundaries to bring new perspectives,
unique skill sets, and differing knowledge bases to the practice of imaging. Does
an oncologist or radiation oncologist wanting to use PET/CT for radiation
treatment planning have need to learn the nuances of obstetric ultrasound to do
so? Should an epileptologist wanting to compare PET and MRI results with
volumetric EEG be limited to getting opinions from imaging specialists who
spend the vast majority of their day looking at chest X-rays? For that matter, do
nuclear medicine physicians need to undergo a complete radiology training
programme or radiologists a complete nuclear medicine training programme to
read that component of a PET/CT that they are currently not credentialed to do?
My answer is an unequivocal no! Rather, I suggest that we initiate training
programmes that would enable development of specific modality expertise. All
imaging specialists require a core skill set including knowledge of radiation
safety and the physics of imaging. Apart from this, however, I believe there
should be greater flexibility for clinicians to choose components from an
increasingly complex array of techniques. We should encourage and recognise the
efforts of trainees to gain clinical experience pertinent to their practice of
imaging and imaging attachments for clinicians who will integrate this
information into patient management. Many of my trainees over the years have
come from clinical specialties, and I have encouraged others to also enter
clinical training programmes. These trainees now practice a mix of clinical and
imaging work and do both with greater insight and expertise than if they had
constrained their training to one field.
Let us break down the hegemony of “learned colleges.” Let us
not be ruled by bureaucrats. Let us develop a new way of training
the imaging specialist of the future, to ensure a diversity
and plurality of skills. Vive la révolution!
Received 20 September 2006; accepted
24 September 2006
Correspondence: Centre for Molecular Imaging, The
Peter MacCallum Cancer Centre, St. Andrews Place, East Melbourne,
VIC 3002, Australia. Tel.: +613 9656 1111; Fax: +613 9656
1400; E-mail: rod.hicks@petermac.org
(Rodney Hicks).
Please cite as: Hicks RJ,
A new world order: training clinicians for a new era in imaging, Biomed Imaging Interv J 2006; 2(4):e49
<URL: http://www.biij.org/2006/4/e49/>
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