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How Will We Teach and Practice Nuclear Medicine
in the Next Decade in Europe?
Wolfgang Becker
in the next decade, nuclear medicine physicians in
Europe will t r y to guarantee a more homogeneous level
of training and education of their specialty throughout
the continent. In routine nuclear medicine, they will
focus more on the possibilities and availability of positron-emission tomography (PET) and on nuclear medicine therapy. Nuclear medicine physicians will be more
active and interactive with students at the universities
and will offer more lectures and more active training in
the specialty, Nuclear medicine specialists will try to be
even more interactive with clinicians and make their
specialty open and better understandable for other
disciplines. Nuclear medicine physicians will initiate
more cost-benefit studies and more multicenter studies
to prove that their procedures are evidence-based. They
will communicate more intensively with industry for a
better understanding of clinical problems and for development of new useful radiopharmaceuticals. They will
promote their specialty in the public more intensively
and will reasonably explain the risks and benefits of
radionuclide examinations.
Copyright 9 2000 by W.B. Saunders Company
T THE MOMENT, the question of how we will
train and practice nuclear medicine in the next
decade is full of optimism, aims, but also some doubts.
The view to the future is a list of wishes of what a
practicing nuclear medicine physician should do.
Presently, there is no politically structured European policy on nuclear medicine and there are
significant discrepancies between the different European states. It is hard to guess whether competing
imaging modalities will slow down the process of
developing that took place in underequipped countries. But, it appears likely that with the structure of
the scientific society of the European Association
of Nuclear Medicine (EANM) and the professional
organization of the Union of the Medical Specialists/
Section of Nuclear Medicine (UEMS) will stimulate these countries toward major developments in
nuclear medicine. It has to be pointed out that not
all of the geographic European States are members
of the European Community (EC). Each of these
countries has its own way of teaching and practicing medicine and this obviously applies to nuclear
medicine as well (Tables 1 and 2). The act signed
between the EC member states obliges the states to
a mutual recognition of diplomas across the borders. 1 Physicians can now move freely within the
EC (hospitals, university positions, and private
practice) but do not take this opportunity very
often. This has been extended since 1989 to the
countries that have joined the European Union
(EU) and to the countries of the European Free
Trade Agreement (EFTA). It has not yet been
extended to the other European countries, although
this is currently being discussed. To guarantee a
more similar quality of training and practice of
nuclear medicine and all other specialties in Europe, which must be the basis of the political main
aim of free movement of doctors in Europe, the
professional organizations represented by the UEMS
have set up adequate guidelines and established the
European Board of Nuclear Medicine (EBNM).
From the Department of Nuclear Medicine, University of
G6ttingen, Germany.
Address reprint requests to Wolfgang Becker, MD, FRCP,
Department of Nuclear Medicine, University of G6ttingen,
Robert-Koch-Strasse 40, D-37075 GOttingen, Germany.
Copyright 9 2000 by W.B. Saunders Company
0001-2998/00/3003-0006510. 00/0
doi: 10.1053/snuc.2000. 7443
214
TEACHING IN EUROPE AND THE EBNM
As a result of the political discussions and
guidelines, the UEMS considered that some harmonization is necessary in the national training programs and in continuing medical education (CME),
and that minimal standards of quality should be
defined to improve the overall quality of training
and thereby facilitate exchanges of doctors between countries. Therefore, nuclear medicine and
other specialties decided to create European Boards.
One of the most important tasks of these boards has
been to create the tire of "Fellow of the European
Board" as a recognition of quality for young
specialists after having successfully passed a Board
Examination. At the moment, this title is optional
and does not interfere directly with national rules
and regulations for specialized professional exercise. This means that this title is not needed by law
to move as a specialist from one country to another;
this is regulated only by the texts taken from the
European directives or by bilateral intergovemmental agreements. Also, the title gives no legal right to
accreditation as a specialist in any country. This
title is a European recognition of quality, which can
Seminars in Nuclear Medicine, Vol XXX, No 3 (July), 2000: pp 214-219
215
TEACHING AND PRACTICE IN EUROPE
Table 1. Time for Specialization In Nuclear Medicine in Different European Countries
Country
6 years
Austria (A)
5.5 years
Slovakia (SK)
5 years
Belgium (B)
Finland (FIN)
Germany (D)
Greece (GR)
Hungary (H)
Luxemburg (L)
Norway (N)
Poland (PL)
Sweden (S)
Switzerland (CH)
4.5 years
Denmark
4 years
Bulgaria (BG)
Croatia (HR)
Italy
France (F)
Netherlands (NL)
Portugal (P)
Slovenia (SLO)
Spain (E)
United Kingdom (GB)
3 years
Czech Republic (CZ)
Turkey (TR)
No separate speciality of nuclear medicine
Ireland
Estonia
Total
"lqme(y)
Including
6
2 years
Internal medicine, radiology, neurology, or pediatrics
5.5
2.5 years
internal medicine
5
5
5
5
3 months
1 year
2 years
Internal medicine
Radiology or clinical chemistry
Internal medicine or other clinical training
Internal medicine (1 y), radiology (6 mo), cardiology, endocrinology, pediatrics, or oncology (6 mo)
Internal medicine (9 too), radiology (6 mo)
Internal medicine
Radiology or clinical chemistry
Internal medicine and radiology, clinical physiology, or radiology,
or oncology
Clinical training
5
5
5
5
5
5
15 months
2 years
18 months
4.5
30 months
4
4
4
4
4
4
4
4
4
Internal medicine, radiology, oncology, surgery
Radiology
3 semesters Pneumology, rheumatology, radiology, oncology
18 months Internal medicine (1 y), radiology (6 mo)
Cardiology and radiology
21 mo different clinical training and radiology (3 mo)
2 years
Internal medicine~cardiology
General professional training
2 years
3
3
9 months
Specialization in internal medicine or pediatrics is mandatory
internal medicine (6 too), radiology (3 too)
4 years
4 years
Radiology
Radiology
5
1 year
be acquired only after having worked 3 years as a
specialist. This may be helpful in the careers of
some young specialists.
Nuclear medicine was recognized as an autonomous specialty at the European level by the same
European Directive. ~A minimal training time of 4
years is imposed on National Training Programs.
Table 2. Countries Where in Vitro Diagnostic
With Radioimmunoassays Are Not Part
of Nuclear Medicine Training
Denmark
Finland
France
The Netherlands
Norway
Slovenia
Spain
Sweden
Other SpecialtyTraining
internal medicine (6 rno), surgery (6 mo), general practice (6 too),
other clinical training (12 mo)
The major goal of the European Board is to
independently define European standards of quality
in the fields of CME and specialized medical
training in nuclear medicine and to control their
observance with the overall objective of improving
the level of knowledge and ability of European
nuclear medicine specialists. CME has become
increasingly important to both general practitioners
and specialists and the main role of the EBNM is to
provide accreditation of educational events of sufficient standards. At the moment, this is practiced in
close cooperation with the European School of
Nuclear Medicine. Basically, a system of European
Credit Points has been created and the points will
be attributed according not only to the duration of
the lectures but also to the program quality, practical demonstrations, and final evaluations. For events
WOLFGANG BECKER
216
organized at a national level, a guest monitor from
another country will be requested to attend.
Table 3. Countries Where Radioimmunoassays Are
Performed Only by Nuclear Medicine Specialists
AIMS FOR TEACHING NUCLEAR MEDICINE IN
THE FUTURE
Bulgaria
Czech Republic
Greece
Slovakia
For specialized training in nuclear medicine,
harmonization between European nations seems to
be the best way to improve and ensure quality. In
this respect, 4 major features have to be considered:
1. A common European syllabus, established by
the EANM committee on Education, must be
established. 2 This is updated at regular intervals to be state of the art. This syllabus should
be used by all European countries as soon as
changes in the medical training are under
discussion.
2. The European School of Nuclear Medicine
should be more powerful and offer more
seminars, self-education programs, distance
learning, and self-assessment programs. A
minimal number of Credit points per year for
participation in CME should become obligatory in all European countries.
3. An accreditation of European training centers
must occur, which is difficult to address and
will be implemented progressively. This
should improve the quality of training all over
Europe. The quality of nuclear medicine has
to be significantly improved and it should be
guaranteed that only well-trained nuclear
medicine specialists will perform nuclear
medicine.
4. The European Board Examination, which
regularly takes place at the annual conference
of EANM since 1996 in Copenhagen should
be required. The Fellowship of the Board
should be taken into account more often when
doctors apply for permanent positions.
PRACTICE OF NUCLEAR MEDICINE IN
EUROPE
According to the different training situation in
different European countries the practice of nuclear
medicine is also different. The whole field of
nuclear medicine could be described as in vitro
nuclear medicine, in vivo nuclear medicine, and
radionuclide therapy. In vitro diagnostic nuclear
medicine is also performed by other specialties,
just as biochemists, clinical chemists, endocrinologists, and others. Only in some countries is it a
predominant nuclear medicine procedure (Table 3).
The trend away from in vitro testing in nuclear
medicine is obvious in most of the European
countries.
Radionuclide therapy is also performed by a lot
of other specialists in different countries (Table 4).
Also, in diagnostic nuclear medicine other specialists perform nuclear medicine, especially radiologists. A questionnaire last year in Europe 3
showed that a variety of different specialists run
nuclear medicine departments and are responsible
for patient care (Table 5). But it is important to
mention that not all procedures are performed in
hospitals, there are only some countries where
nuclear medicine is not performed in private practice (Table 6).
The location of nuclear medicine departments all
over Europe is shown in Table 7. The nuclear
medicine departments all over Europe are different
and range from 1 to 15 per 1 million inhabitants. 3 In
these institutions, an average number of 10 to 20
procedures per 1,000 inhabitants were performed.
Leading in this field is Belgium, with the highest
number of institutions and investigations (70 per
1,000 inhabitants). 3 The number of gamma cameras
is quite different in the European countries. In total,
Germany has about 1,500, Great Britain has 380,
Italy has 370, and France has 330 gamma cameras,
and so forth.4 The situation changes per million
inhabitants. Taking this into account, Belgium is
the leading country followed up by Germany, The
Netherlands, Greece, and s o f o r t h . 4 With these
cameras, the number of scintigraphies performed
Table 4. Countries Where Radionuclide Therapy Is Performed
by Someone Other Than Nuclear Medicine Specialists
Country
SpecialityPerforming
RadionuclideTherapy
Bulgaria
Denmark
Finland
Poland
Sweden
United Kingdom
Radiotherapy
Nuclear medicine and oncology
Oncology and others
Oncology and endocrinology
Oncology
Oncology and endocrinology
TEACHING AND PRACTICE IN EUROPE
217
Table 5. The Heads of Nuclear Medicine Departments
Specialization
Frequency
Nuclear medicine specialist
Radiologist
Other medical doctors
Physiologist
Physicist
Chemist
Others
69.2%
21.6%
3%
2.6%
2.3%
0.6%
0.6%
Table 7. Distribution of Nuclear Medicine
Departments in Europe
Location
Frequency
Public hospitals
University hospitals
Private hospitals
Private practice
Diagnostic center
Other
37%
29%
18%
10%
5%
1%
Data from Askienazy. 4
per year are highest in Germany, followed up by
France, Italy, and Great Britain. The numbers of
scintigraphies per 1,000 inhabitants are highest in
Belgium, followed up by The Netherlands, Greece,
Germany, and so forth.4 Positron-emission tomography (PET) in Europe varies much more than
conventional imaging (Table 8). There are countries without a single PET machine, whereas in
Germany, 67 PET scanners are available.
The 1998 questionnaire 3 pointed out that cardiology and oncology are the most important areas of
interest for nuclear medicine. New opportunities
for the future are new radiopharmaceuticals, if
available, and PET. Both innovations have a high
impact on patient management. PET is a challenge,
but is also expensive and cannot be the only
direction in which nuclear medicine has to develop
because then nuclear medicine will suffer in a lot of
countries where the number of PET scanners is
zero or very limited and no access for the general
public is guaranteed. So we also need other nonPET radiopharmaceuticals with a high diagnostic
potential but also a therapeutic potential.
AIMS FOR PRACTICING NUCLEAR MEDICINE
IN THE FUTURE
In the normal medical education of students,
nuclear medicine is not well represented, so there is
Table 6. Countries Where Nuclear Medicine Is Not
in Private Practice
Belgium (nearly not)
Bulgaria
Czech Republic
Denmark
Finland
Luxemburg
Norway
Slovenia
Slovakia
Sweden
United Kingdom
a range of 2 to 15 hours in different countries in the
pregraduate medical curriculum. This leads to an
underrepresentation of nuclear medicine knowledge of students. The interest in this specialty is
low, so in total we have only a small number of
nuclear medicine physicians. The consequence is
that, besides budgetary limitations, in all clinical
conferences in which clinicians and radiologists are
well represented, it is only sometimes possible to
participate and explain nuclear medicine images,
discuss them with the clinicians, and offer nuclear
medicine examinations as solutions for the clinical
problem.
Nuclear medicine physicians should work together more closely with other imaging modalities,
make their images available for others, and impleTable 8. Number of Dedicated PET Scanners per Country
Country
Number of
PETScanners
Germany
Austria
Belgium
United Kingdom
Italy
Spain
the Netherlands
Denmark
Finland
Sweden
Switzerland
Czech Republic
France
Hungary
Bulgaria
Croatia
Greece
Ireland
Luxemburg
Norway
Poland
Slovakia
Slovenia
67
9
8
6
5
5
3
2
2
2
2
1
1
1
0
0 (but coincidence camera)
O
0
0
0 (but coincidence camera)
0
0
0
218
ment their images in combined systems (image
fusion, and so forth).
The limited representation of nuclear medicine
physicians also leads to a smaller number of good
clinical studies because sometimes the clinical
problems are really not known by the nuclear
medicine physician or because a lack of manpower
applications for grants or multicenter studies can
not be organized. This is one of the reasons that
nuclear medicine studies on cost benefit are only
rarely available and that nuclear medicine procedures cannot be found in studies of evidence-based
medicine.
Not only in the public, but also among medical
students, nuclear medicine is not attractive because
we deal with radioactivity, patients are sent back to
their hospital rooms as radioactive and every single
study with radiopharmaceuticals is regulated.
The small numbers of nuclear medicine physicians and the different structures with somewhat
low numbers of nuclear medicine procedures lowers the potential income, especially for radiopharmaceutical companies, so that they are not willing
to invest in the development of new radiopharmaceuticals. This again limits the horizon for the
future. A lot of new radiopharmaceuticals in the
past have had a limited indication in a dedicated
number of patients (gastroenteropancreatic tumors)
and are on one hand excellent, but on the other
hand do not earn the money other pharmaceuticals
do. A lot of other new developments of the past
years were produced by radiopharrnaceutical companies because certain molecules were available,
were good candidates for labeling, and were pushed
forward without interaction to the user. This missing interaction has to be improved. At the moment,
the scope broadens because PET activities are very
successful and seem to solve a lot of clinical
questions and because nonradiopharmaceutical companies press forward in the field of new therapeutic
radiopharmaceuticals because they became aware
of the potential of radionuclide therapy.
One of the major goals will be to make clinical
PET more available in all countries, to guarantee
that in evidence-based medicine PET, as well as
other nuclear medicine procedures, will play their
role, and to come to a reasonable amount of
reimbursement of clinical PET.
Owing to the competition with other imaging
modalities, more and more radioactive procedures
may be less indicated or asked for, but the treatment
WOLFGANG BECKER
potential with radionuclides will be accepted forever. So more and more new therapeutic procedures will come in the field. The more therapy will
be necessary, the more dosimetry, radiochemistry,
and patient management has to be improved. This,
hopefully, will lead to the predominance of nuclear
medicine physicians in radionuclide therapy, also
in countries where other specialists perform therapy.
Also, here the close cooperation with clinicians
is necessary to give these procedures the rank they
have and not as therapeutic options, if other
therapies are no more indicated and helpful and to
bring radionuclide therapy to a first line therapy.
So there is a catalog of tasks for nuclear medicine physicians in the future: (1) To be more active
and interactive with students at the university and
to offer more lectures and more active training if
possible; (2) nuclear medicine physicians should be
more clinically active to present and interpret their
data in a proper way and should be more willing to
interact and cooperate with other disciplines; (3) if
possible, more studies should be initiated to solve
the problems of cost-benefit ratios and to prove the
clinical relevance of nuclear medicine and to
become accepted by evidence-based medicine; (4)
nuclear medicine clinicians and industry should
communicate more to understand the clinical problems better and to develop adequate radiopharmaceuticals. Industry has to be convinced that nuclear
medicine is worth their investment; (5) nuclear
medicine has to be better promoted in the public
and the risk and benefits of radioactive studies have
to be reasonably discussed.
ACKNOWLEDGMENTS
The author thanks the following national delegates of UEMS for their cooperation: Austria, Dr.
H. Krhn; Dr. G. Riccabona; Belgium, Dr. K. de
Vis; Bulgaria, Dr. S. Milanov; Croatia, Dr. D.
Dodig, Dr. D. Ivancevic; Czech Republic, Dr.
Kubinyi; Denmark, Dr. B. Sonne; Estonia, Dr. S.
Nazarenko; Finland, Dr. R. Harkrnen; France, Dr.
J.-L. Moretti; Greece, Dr. C. Zervas, Dr. J. Malamitsi, Dr. A. Pandis; Hungary, Dr. I. Szilvasi; Ireland,
Dr. G.J. Duffy; Italy, Dr. G. Lucignani (not a
delegate); Luxemburg, Dr. W.J. Pilloy, Dr. D.M.
Doat; The Netherlands, Dr. J.M.H. de Klerk, Dr.
EA. van der Weel, Dr. P.v. Rijk, Dr. Zanin; Norway,
Dr. J.G. Field; Poland, Dr. K. Toth; Portugal, Dr.
M.R. Vieira; Slovakia, Dr. I. Makaiova; Slovenia,
Dr. J. Fettich; Spain, Dr. I. Carrio; Sweden, Dr. P.
TEACHING AND PRACTICE IN EUROPE
Wollmer, Dr. K. Mare; Switzerland, Dr. A. BischofDelaloye; Turkey, Dr. K.M. Kir; United Kingdom,
Dr. T. Nunan, Dr. J. McKillop, Dr. T. Coakley.
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