Educators debate ways to integrate MI curricula

Molecular imaging enthusiasts would undoubtedly like to encounter more residents like Dr. Jinha M. Park. In his last year of residency at the University of California, Los Angeles, Park completed his fellowship at Stanford, where he spent a year studying optical imaging modalities.

Few would argue that Park's scholastic pursuits are above and beyond those of most residents. Yet radiologists are voicing a diversity of viewpoints regarding how residency programs should integrate MI curricula. Many experts are pushing for more focused and extensive training. Faculty members and policy makers recommend a more gradual approach. Meanwhile, the debut of MI questions on the American Board of Radiology's certification exam demonstrates that the molecular era of radiology has begun.

Across the country, program directors have taken the cue.

"A subject that's lab-based [like MI] and has clear and immediate clinical applications is important for residents to learn. But competing demands prevent us from requiring residents to spend a lot of time on MI," said Dr. Gautham Reddy, residency program director at the University of California, San Francisco. "In five or 10 years, as MI fulfills its great potential in becoming a clinically important technique, in-depth training is not going to be optional."

For now, required coursework encompasses nine review papers published as a primer on molecular biology for imagers in Academic Radiology between 2003 and 2004. The material forms the basis for MI questions that appear on the ABR test, according to senior author Dr. King Li, who chairs the National Institute of Health's Imaging Sciences Program. The questions focus on differences between the various imaging modalities, such as target specificities, penetration depths, and resolutions. Other questions cover basic molecular biology, genomics, proteomics, and molecular diagnostics.

Residents and practicing radiologists can master the information and then apply the knowledge to considering the molecular basis of morphologic images that they see every day, Li said.

"The first step toward becoming a molecular imager is to start thinking about the molecular basis of disease, even if you're looking at a mammogram or CT scan," he said.

Lectures are also a convenient way for residency programs to address MI. The American College of Radiology's Commission on Molecular Imaging has proposed a set of 14 lectures on DVD that cover the most relevant MI topics. The first three lectures focus on basic molecular biology, which serves as a review for residents, many of whom learned the material in medical school. The next three address probe design and pharmacokinetics that are unique to MI. The final eight lectures address the preclinical and clinical applications of MI in PET, SPECT, optical imaging, MRI, MR spectroscopy, and ultrasound. All members of the ACR will receive a free copy of the DVD with the August 2006 issue of the Journal of the American College of Radiology.

Such endeavors are providing more opportunities for residents to learn about MI. However, depending on the definition, MI has been part of radiology since the field began using radioiodine 60 years ago, said Dr. James H. Thrall, radiologist-in-chief at Massachusetts General Hospital in Boston.

An estimated 80% of nuclear medicine already meets the definition of MI, he said. With molecular imaging probes consisting of a component for localization and another for tracing, they're conceptually similar to traditional radiopharmaceuticals.

"If you understand the mechanism of localization, the target, and the mechanism of detection, then you can infer the clinical applications," he said.

On the other hand, much of MI can't be restricted to nuclear medicine, Thrall said. That fact has some educators in a quandary over how to integrate MI curriculum, especially with the constraint of a fixed four-year span. Others caution that curricula changes could be in vain, given the unpredictability of medicine.

If MI never gains a firm foothold in the clinic, residents would have wasted time that they could have spent on established modalities, said Dr. Jannette Collins, an associate professor of radiology at the University of Wisconsin in Madison.

But patience may not be a winning virtue, according to Dr. Gary J. Becker, assistant executive director of the ABR. In the past, wait-and-see strategies worked because new technologies were natural extensions of existing modalities. Other specialists lacked the basis to get involved. But given the interdisciplinary nature of MI, radiologists must be more proactive.

"We radiologists must become engaged in the basic science, and we must insinuate ourselves into the MI research at the translational interface," he said. "If we do not work to earn our place in directing and conducting the studies that introduce new MI methods into the clinics, we will have lost an opportunity forever."

But radiologists may have a difficult time embracing a new MI paradigm, one that involves examining images of fluorescent molecules or signals resulting from enzymatic reactions, according to Dr. Hedvig Hricak, chair of radiology at Memorial Sloan-Kettering Cancer Center in New York City.

That's partly why Hricak supports the use of training as a way for radiologists to prepare for a future in MI. While some educators suggest introducing MI through lectures, research seminars, and journal clubs, others advocate MI workshops now available at most conferences. Others are not only calling for MI integration but also for a reexamination of traditional approaches to training.

"Unless we're willing to radically change the way we are training our residents, we're not going to add all of the exciting things on the horizon," said Dr. Stanley Baum, emeritus chair of radiology at the University of Pennsylvania in Philadelphia. "I would take a very hard look at the rotations and shave a lot of them."

Eliminating the internship year has also been proposed to make room for MI training.

"We've been on the warpath to do away with the internship year as we know it," said Dr. Ronald Arenson, chair of radiology at UCSF. "Our residents still need clinical exposure, but they also need clinical time as part of their subspecialty training in an expanded fellowship."

At a minimum, residents should have the freedom to spend more time on their future subspecialty and less time on skills that they won't use in their careers, he said. For example, residents who plan to specialize in neuroradiology should spend less time perfecting their mammography skills.

This personalized approach can improve the cookie-cutter nature of current programs, said Dr. Jeremy Friese, a chief resident at the Mayo Clinic in Rochester, MN. While acknowledging the importance of understanding all the modalities and body systems, he points out that after two years, most residents have already chosen a subspecialty.

Another possibility is eliminating outdated modalities that are becoming obsolete. It's a controversial topic. Educators point to barium x-ray imaging of the gastrointestinal tract and nuclear studies using a gamma camera as possibilities. But residents say that board exams require them to learn the older modalities even though they are being used less frequently.

"If there's a way to cut those out, we could focus on the cutting-edge techniques," Park said.

Independent of the board exams, however, residents still need sufficient experience in all imaging techniques before they can choose a subspecialization, Collins said. Without such exposure, residents can't make informed decisions about which rotations will deliver the most value.

"This could lead to deficiencies in training that might be limiting in private practice," she said.

Most educators agree that MI programs should prepare residents for a lifetime of learning. But doing so requires a change in educational philosophy, Baum said. Far more important than maximizing the amount of material, programs should focus on providing a firm foundation in medicine, which residents can use to acquire new skills and learn new technologies.

Research experience has shown him MI's potential to lead the way into the age of personalized medicine. That radiology could be instrumental in bringing about that shift is a great motivator, Park said. In the end, the most exciting goal is very simple.

"Molecular imaging is good for the patient," he said.