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November 5 , 2007

Changing Scope
By Beth W. Orenstein
Radiology Today
Vol. 8 No. 22 P. 42

PET/CT demand drives nuc med techs to CT training.

Diagnostic imaging equipment continues to evolve at an incredible pace. The jobs of the technologists who operate this new equipment are also changing.

Less than 10 years ago, if physicians wanted to capture a patient’s metabolic and anatomical information, they had to order two separate tests—perhaps a PET scan for metabolic function and a CT or MR scan for anatomy. Today, several companies, including GE Medical Systems, Philips Medical Systems, and Siemens Medical Solutions, manufacture hybrid PET/CT scanners.

According to the Society for Nuclear Medicine (SNM), PET/CT scanners are replacing PET scanners at a rapid rate. The first commercially available PET/CT unit was introduced in 2000. Since then, the percentage of PET/CT scanners in the United States has jumped from 9% to 67% of all PET systems in 2004, the latest year for which figures are available.

“These days,” says Cindi Luckett-Gilbert, BHS, CNMT, PET, RT(N), “you can’t buy a PET scanner without a CT scanner attached to it. That’s where the technology has gone.”

Also on the market are SPECT/CT scanners. Gamma cameras are now equipped with CT scanners that perform the same fusion function as CT performs for PET. Because PET scanners and gamma cameras have CT scanners attached to them, performing low-dose CT for attenuation and anatomical localization has become one of a nuclear medicine technologist’s tasks, says Luckett-Gilbert, supervisor of PET/CT imaging for Presbyterian Hospital in Charlotte, N.C.

Two Techs
And therein lies a problem. Operating CT scanners, which involves ionizing radiation, has not been among the duties and responsibilities included in the SNM’s scope of practice for nuclear medicine technologists.

Because it isn’t part of their job description and/or traditional training, some states prohibit nuclear medicine technologists from performing the CT part of the exam. When PET/CT scans are performed, the imaging facilities want someone who is dual certified in CT, radiologic technology, or radiation therapy and PET or two professionals to be present—a nuclear medicine technologist and a radiologic technologist or radiation therapist. Few people meet the first qualification of being dual certified and having two technologists can “have a big financial impact on any institution,” Luckett-Gilbert says.

“Some state laws say that unless you are a radiologic technologist or radiation therapist, you cannot push the button that turns on ionizing radiation, and this has caused a real big issue in those states with those regulations,” Luckett-Gilbert says.

Also, many institutions get excited about being able to offer SPECT/CT but “do not think about the regulations defining who can operate these pieces of equipment. Some hospitals have purchased SPECT/CT scanners and then realized too late that their nuclear medicine technologists were not allowed to operate the CT part for attenuation correction and anatomical localization,” she explains.

Task Force
To help solve the problem, the Society of Nuclear Medicine Technologist Section (SNMTS) formed a task force—Luckett-Gilbert was appointed as its head—to study the issue and revise the SNMTS’ scope of practice. It took roughly one year of the task force meeting in person and during conference calls to propose and complete the revisions, which went through several drafts and legal review.

The updated scope was presented to the SNMTS and SNM membership and approved by the executive board at its 53rd annual meeting held in San Diego in June. The revised scope of practice took effect immediately, says David Gilmore, MS, CNMT, NCT, RT(R)(N), program director for the school of nuclear medicine technology at Beth Israel Deaconess Medical Center in Boston, who was also installed as president of the SNMTS at that meeting. The updated scope of practice was published in the SNM’s September issue of the Journal of Nuclear Medicine Technology.

Scott Holbrook, BS, CNMT, PET, RT(N), FSNMTS, vice president of Clinical Pharmacy Services, an independent nuclear pharmacy in Gray, Tenn., who was the 2006-2007 SNMTS president and appointed the task force, says it was time for the society to revisit the scope, but the increasing use of PET/CT and other hybrid modalities helped to give the issue immediacy.

The updated scope says that with the appropriate education and training, nuclear medicine technologists can perform CT scans and administer oral and intravenous contrast. Gilmore says that because of the use of hybrid technologies, radiologic schools with nuclear medicine programs have already started to include CT as part of their nuclear medicine technologist curriculum and, by 2010, it is mandated that they teach CT in nuclear medicine schools.

Issue for Older Techs
But the issue isn’t so much with recent or future graduates, says Gilmore. “We felt that people who are coming out of programs are being trained in CT along with contrast,” he says. The concern was for people already in the profession who need updated training.

Currently, more than 21,000 NMTs are certified by the Nuclear Medicine Technologists Certification Board (NMTCB) in Tucker, Ga., or the American Registry of Radiologic Technologists (ARRT) in Saint Paul, Minn.

Most NMTs have been learning to perform CT from in-service training, Luckett-Gilbert says. “Pretty much across the country, when you receive a PET/CT scanner, the facility gets in-service training from nuclear medicine people, and then CT people will come in and give you an in-service. The technologists get maybe 16 hours of CT training, maybe more.” That’s adequate training for the purposes of a PET/CT scan, but it doesn’t train the technologists to do diagnostic CT scans, according to Luckett-Gilbert.

Recently, the ARRT and the NMTCB created certification programs that allow nuclear medicine technologists, radiologic technologists, and radiation therapists to be cross-certified and thus able to perform PET/CT, Luckett-Gilbert says. “ARRT offers a certification for a nuclear medicine technologist who has never been to radiology school to meet particular requirements and then sit for its CT board. If you pass, you have its blessing that you can perform a diagnostic CT scan,” she explains.

CT techs also have pathways to earn credentials for performing PET, but it’s not as easy for them to study PET as it is for nuclear medicine technologists to study CT, Luckett-Gilbert says.

Treatment Planning
Holbrook says the SNM had to act now because with hybrid technology’s potential to revolutionize treatment planning for radiation therapy, the cross-training issue will only become more pressing. For example, intensity modulated radiation therapy (IMRT) allows radiation therapists to deliver high doses of cancer-killing radiation directly to tumors, Holbrook explains. “A PET/CT scan gives radiation therapists a more accurate reference point for IMRT procedures, telling them the functional size and shape of a tumor and showing them precisely where to target the beam of radiation. This ensures the tumor receives the maximum amount of radiation possible while the healthy tissue surrounding the tumor is spared.”

The society also wanted to update its scope of practice before Congress enacts the Consistency, Accuracy, Responsibility, and Excellence (CARE) in Medical Imaging and Radiation Therapy bill, which was introduced in the U.S. Senate in March by Sen Michael Enzi (R-Wyo.) and Sen Ted Kennedy (D-Mass.), Holbrook says. A similar bill unanimously passed the Senate, but time ran out in the legislative session before it could be considered by the House of Representatives.

If ultimately signed into law, the bill would require personnel performing the technical components of medical imaging and radiation therapy to meet federal education and credentialing standards to participate in and be eligible for reimbursement from Medicare and other programs administered by Health and Human Services.

Numerous professional medical societies, including the SNM, have been lobbying for passage of the CARE bill and are optimistic that this may be its time if it finally comes up for a vote. “We are thinking that the CARE bill will pass this year,” Luckett-Gilbert says.

Holbrook says it was important that the SNM revise its scope of practice for nuclear medicine technologists to include CT before the CARE bill passed. This way, he says, states will have good documentation from the SNM that they can lean on when they draft legislation to meet the requirements of the CARE bill. “A big component of the CARE bill is what your current scope of practice is,” Holbrook says. “Now, they can look at the role of nuclear medicine technologists and say, ‘OK, it’s in there for them to do CT.’”

The revised scope also will aid states in defining licensure, as well as hospitals and clinics in approving job descriptions, says Gilmore.

Immediate Need
Holbrook says the SNMTS task force focused on PET/CT because it was the most immediate need. However, he says, the scope of practice also was designed with an eye to the future, which will include greater use of hybrid modalities. “The task force took careful pains to define the scope in such a way that if nuclear medicine technologists have appropriate training and credentials, they will have the flexibility to move into other molecular imaging fields in addition to CT.” For example, he says, “I think, eventually, we will have PET/MRI units and we are in a good position as far as that goes.”

The scope also includes parameters for patient care, quality control, diagnostic procedures, radiopharmaceuticals, radionuclide therapy, and radiation safety. Gilmore says that the document will receive regular review for consistency with current knowledge and practice.

— Beth W. Orenstein is a freelance medical writer and frequent contributor to Radiology Today. She writes from her home in Northampton, Pa.