to the end, and to a new beginning - a letter to congress

[FDGme]

Dear [INSERT NAME OF SENATOR OR REPRESENTATIVE],

Did you know there is an easy solution to end the waste of up to $1,352,000 taxpayer dollars per year? It’s a bit complicated, which is why it has continued so long, but the solution is simple. Please read carefully:

Acronyms/Organizations involved:
ABNM: American Board of Nuclear Medicine
ABR: American Board of Radiology
ACGME: Accreditation Council for Graduate Medical Education
ACR: American College of Radiology
CMS: Centers for Medicare and Medicaid Services
HHS: U.S. Department of Health and Human Services
RRC: Residency Review Committee (of ACGME)
RSNA: Radiological Society of North America
SNM: Society of Nuclear Medicine

FACTS: According to http://www.acgme.org/adspublic/, there are 169 residents currently filling positions at the 56 ACGME-accredited nuclear medicine programs, supported by CMS (part of the U.S. Department of Health and Human Services) at an average of over $80,000 per year per resident, for a total of $1,352,000 per year. Residents completing a 3-year training track in one of these residencies (total cost averaging $240,000) earns eligibility for board certification by the American Board of Nuclear Medicine (ABNM), but not for certification by the American Board of Radiology (ABR), which has a completely separate residency requirement. On 4/25/2010, according to www.snm.org, the Society of Nuclear Medicine’s website, there was only one posted job opening in the whole country. The American College of Radiology’s website, http://jobs.acr.org/search/browse/ , features no jobs for nuclear medicine physicians that are not also ABR-certified radiologists. The Radiological Society of North America (RSNA) Career Connect website, http://careers.rsna.org/, also features no jobs unless the candidate is ABR-certified. A job search for nuclear medicine physician on the popular “Aunt Minnie” website (www.auntminnie.com) resulted in zero returns. Most of the recruiting companies don’t even have a category for “nuclear medicine physician,” and none of them have any jobs posted. Queried firms include PracticeLink.com, Medhunter.com, Alliance Recruiting, Merritt Hawkins & Associates, MDSearch.com, and Action Medical Search. Non-advertized job availability is difficult to measure, but is estimated to be extremely low to non-existent for 3-year nuclear medicine residency graduates.

PROBLEM: Even after 3 years of specialized training in nuclear medicine at huge cost to taxpayers, these board-eligible graduates have near-zero opportunities for jobs. This is due to in part to a marked preference in the nuclear medicine physician market for nuclear radiologists certified by both the ABNM and the ABR, as well as the ABNM’s policy to allow radiologists to qualify for certification after just one year of nuclear medicine.

WASTE and ABUSE: The directors of these nuclear medicine residency programs and the Chiefs of the academic nuclear medicine divisions that host these programs continue to petition the nuclear medicine ACGME Residency Review Committee (RCC) for more resident training spots. They continue to apply for more CMS funding for such residents, and they continue to invite people to come to their programs and fill those spots. Why? These academic directors are benefiting by having residents do a large part of the work required to bill for very expensive procedures. But it is hurting the field of nuclear medicine. The word is getting out that people cannot get jobs coming out of these residency programs, so the number of applicants is sharply dropping. Yet, the residency directors continue to try to fill their programs…at taxpayer expense. Caught in this vicious cycle, residents invited to train at these problems are having a harder and harder time getting jobs, and many are electing to pursue further training in another field. The taxdollar investment is thereby not put to good use actually caring for patients (including Medicare patients).

How do I know? I am one of these residents, and my colleagues and I can’t seem to get a job in what we were trained to do.

WHAT WE WANT:
1. Stop the injustice and immediately END Medicare support for new residents applying for a 3-year training track at any ACGME-accredited Nuclear Medicine residency programs. END new nuclear medicine training for any medical school graduate that has not already completed requirements for board certification in another field (such as radiology, internal medicine, neurology, etc). This should not affect residents already in training in 3-year primary nuclear medicine residency tracks at such programs, allowing those in such programs to complete their programs if so desired. It must also not affect those in a 1-year post-radiology track, or any 2-year post-clinical training track in nuclear medicine, as these residents have many opportunities to find work based on their primary board certification and will be able to augment their practices with their nuclear medicine capabilities, thereby returning the taxdollar investment.

2. Immediately set up a training fund for current nuclear medicine residents to complete 2 or 3 years of training in an ACGME-accredited radiology residency, using the CMS funds freed up by immediately ending support for 3-year nuclear medicine residents. The result will be no change in cost to CMS, but a major increase in return on taxpayer investment in residency training (in the form of more high-demand radiologists dual-boarded by ABR and ABNM), by allowing nuclear medicine residency graduates to gain the training they need to enter a market thirsting for radiologists.

Thank you for your attention on this critical matter in the field of nuclear medicine and national healthcare delivery.

Sincerely,

[YOUR NAME, ADDRESS, AND PHONE NUMBER HERE, FOR BEST RESULT]

---

Members don't see this ad.

 

[Cathance]

Woah. That's serious.

Do you really think CMS is going to divert money from new nucs positions to nucs grads seeking radiology training?

Anyone have a thought on this?

 

[partusa]

I completely disagree with your proposal. I don't understand the point of trying to close the residencies, to me is ridiculous that a NM resident pushes against the specialty and the funding by medicare. If you are trying to get a solution to this problem.
I think that you should try to aim to the regulatory entities, like SNM, ABNM, RSNA, ACGME and if you like the department of health.
Medicare is reimbursing the radiologist without adequate training in NM and you think that funding a NM residency program is a waste of money?
You are completely wrong my friend!! Our efforts should be directed in order to try to change the regulations, requirements and reimbursement for NON-NM physicians to read NM studies.
Instead of sending this letter to the congress, senate, etc, you should be giving them the facts, that NM is a completely different specialty from radiology, that we spend 3 years in training and radiology pass by our department to say hi and they get certified in NM.
Why if you want to become a HEM-ONC you have to go through a 3 year fellowship?
Doesn't make sense, no?.
What would happen if surgery residents start rotating in interventional radiology? Do you think that the ACR will certify them?

I am very angry with this situation!!

 

[Cathance]

Who in the world knows 3 different nucs RESIDENTS who got a job without doing a fellowship or without being a radiologist first!!? How come I haven't heard of anyone getting a single job out of a 3 year residency? I don't believe it... Would love to hear the story, though.

 

[NM2010]

good idea actually.

 

[gathi]

i think you have a point. the senator will not only get confused, he will ask if the matter has already been presented to relevant authorities or not.
writing to ACGME, ABNM and ABR will be a good idea, because they all collectively can reformulate the structure of NM training.

 

[NM2010]

Hi, all:

I sent a concern to ACGME:

======================

[email protected]

======================

The email body basically is the letter in the first post.

I encourage all nuc residents and attendings to do the same.

--------------------------------------------

Reporting a Concern or Making a Formal Complaint about a Residency Training Program



Do you have a concern or formal complaint about residency education and/or the learning environment in an ACGME accredited program/institution?

How Resident Services Responds to Concerns and Complaints

Resident Services encourages you to bring your concerns and complaints to the attention of the program director and/or the institution's designated institutional official (DIO). If this does not lead to resolution, bring your concern or complaint to us for review. Resident Services will work with the DIO to resolve issues surrounding concerns. Valid complaints will be processed by Resident Services, which will require a response from the program director and attestation to the response by the DIO, and review by the relevant review committee.

You may submit your:

concern by mail, fax or email
signed complaint by mail or courier service
Be sure to include the following:

a brief summary of the issues, including steps taken - if relevant
the name, street address, city, and state of the residency program
your contact information
Providing your name and contact information enables Resident Services to inform you about the actions taken in response to your concern or formal complaint, and also to contact you should additional information be needed.

It is our policy to treat your name as confidential information and not to disclose it without your permission. However, depending on the circumstance, it may be necessary to share your name with the DIO in the course of the concern (not complaint) investigation.

E-mail:
[email protected]

Fax:
(312) 755-7498

ACGME Staff:
Marsha Miller, MA



Mail:
Resident Services
ACGME
515 North State St. Ste 2400
Chicago, IL 60654


Scope of Concern Evaluations

Information provided is used to investigate, in a confidential manner, specific concerns by physicians in graduate medical education (residents, fellows, and faculty members) when the existing channels of communication or dispute resolution have proven unsatisfactory. If, in the judgment of Resident Services, any given case suggests a need for change to specific institutional, common program requirements, procedures, or policies, Resident Services will direct its recommendation to the ACGME Chief Executive Officer. Submitting a concern does not affect the program and/or institution's accreditation status. There may be instances when Resident Services will recommend that you submit a formal complaint, which could affect the program and/or institution's accreditation status.

Scope of Complaint Evaluations

Information provided is used to investigate, in a confidential manner, specific alleged areas of non-compliance with the ACGME's Institutional and Program Requirements. Anyone having evidence of non-compliance with these standards by a program or institution may submit a formal complaint to the ACGME. Please review the "Procedures for Addressing Complaints against Residency Programs and Sponsoring Institutions" at www.acgme.org. You will find the document under "Resident Services." Submitting a formal complaint may affect the program and/or institution's accreditation status.

Scope of Egregious or Catastrophic Events

The occurrence of an alleged egregious accreditation violation or catastrophic institutional event, which, because of its urgency, must be addressed outside of the established processes of the ACGME is reported promptly to the Chief Executive Officer of the ACGME who will initiate an investigation to determine credibility and degree of urgency. Examples of egregious or catastrophic events are: loss of the program's entire faculty; hospital bankruptcy that affects residency training; or program closure without assistance provided to the residents and fellows in locating other positions. Please review "Egregious Violations" at www.acgme.org. You will find the document under "Resident Services."

 

[partusa]

NM2010,

At the SNM I made a contact with one person from the JNM, and they are interested in publishing something about the job crisis. We are working in a template, and before sending the final note, we will email it to the NM residency programs, attendings, etc... and try to get their signatures.
We will also send the note to the ACGME.

I will keep you all updated.

 

[gathi]

the ACGME complaint site is basically for non-compliance of program towards ACGME regulations. the basis of complaint of NM residents is not that.
what you guys are suggesting is something entirely different - changing the policies of ACGME, which i think requires to be addressed by very high authorities.
i doubt if the ACGME will take the representation from residents only, seriously. in long run, it seems necessary that the whole pure nucs community including PDs and other attendings (opinions of PDs are very important for ACGME) present the matter to ACGME and ABNM, ABR as well. The role of common board members of ABR and ABNM should be really important.
the role of ABMS is also not discussed so far, which regulates 24 member boards. i think the changes in the regulatory requirements of boards, development of new board and conflicts between overlapping specialties are handled under leadership of ABMS and it makes final recommendations to ACGME. the ABMS has representatives from all boards, like Dr. Segall, VP of SNM is on ABMS and it is a common platform for various specialty boards to discuss certification issues.
so, the roles of ABNM, ABR and ABMS can not be underestimated and they must be involved before ACGME can take some steps.
please correct me if i am wrong anywhere.

 

[NM2010]

when the existing channels of communication or dispute resolution have proven unsatisfactory. If, in the judgment of Resident Services, any given case suggests a need for change to specific institutional, common program requirements, procedures, or policies, Resident Services will direct its recommendation to the ACGME Chief Executive Officer.

\

Gathi, did you read before you wrote? Do you think the communication channel is existing? What is your suggestion? Talk to the members of ABMS? Talk to ACR or SNM/ABNM? Tell me how. One thing I know: PDs are not interested. ABNM/SNM is not interested.

Sending concern to ACGME is based on the responsibility ACGME should take. I told you I may consider to sue ACGME. At the same time, I understand this is a complicate issue. But I would like to do something before I leave this field. I don't think it is right time to comment only without any virtual action.

 

[NM2010]

Hi, PARTUSA:

Thanks for your excellent works.


If I were you, I would send a complaint to ACGME first. Then focus on your template. Collecting signature takes time and you may encounter many politics. Many people may not agree with you.

Of course, if you collect significant signatures from the nuclear medicine society, it would be very powerful to present to ACGME and also ABNM/SNM.

Give our voice in the JNM is good. But it may not be that useful. I remember the NMRO wrote an article to oppose increasing the duration of training to 3 years, which was published in JNM. And it didn't work.

The PDs wouldn't listen to you. They just simply don't care our future.That is why the problem is here. That is why it doesn't work if you complain to your PD, to SNM/ABNM. thumbdownthumbdown

And that is why I would like to focus on ACGME. Complain to ACGME!!!!!!!!!!!!!!

 

[eddieberetta]

I have a few comments. I am a radioloigst (I do not practice NM).

The first is that efforts to prevent radiologists from being AUs and practicing NM are misguided. Why?

Those who are opposed to the fact that radiologists can bill for NM studies and seek regulations on who can bill for particular studies need to understand that in the USA this type of restriction is very rare and difficult to implement. By default, any state licenced MD can do anything. In certain cases, to reign in excess self referral, fraud, or [in theory] poor quality [in practice they do not care about quality], individual payers MAY say we will only reimburse this fee code for this type of provider. This is piecemeal, varying by insurance company and location. In other words, by default nothing is stopping a dermatologist from billing for a psych counselling, or a OB ultrasound or a bone marrow biopsy (to use the heme onc analogy)! I.e. scrutiny of physician training is not built into the reimbursement system. Radiologists are not protected neither are neurosurgeons!

Now, individual hospitals will not credential people to do work clearly outside their scope of training, for liability and quality reasons (but there is plenty of politics and room for interpretation, which is why many allow non NM trained cardiologists to read cardiac NM).

Moreover, in many small hospitals the volume of NM is not enough to support a full NM person. And giving that work to one person makes call and vacation a major issue. It is for these practical reasons that a radiologist is more appealing for both hospitals and individual radiology groups to hire.

And lets also remember, general radiologists are in fact trained and examined in nukes, and actually have some familiarity and respect for the body of knowledge, the physics and the medicine of NM -- far more than many other specialties i.e. cardiology, endocrinology (some of these practice NM without any formal training).

And finally, multimodality imaging training is highly germaine to nukes in the PET CT, SPECT-CT, NM-MRI fusion era!

So imho, trying to both fight radiology on one front (preventing general rads from doing NM) and trying to join radiology at the same time is a bad strategy.

I think at the society level, the best strategy would be to unite under radiology or embrace the fact that there are many routes to NM, but one needs a base specilaty first (like critical care medicine, interventional neuroradiology/Endovascular NSX etc). For the individual residents though, the best approach would be to try to get into rads residency (you would already be done fellowship!)

 

[NM2010]

the best strategy would be to unite under radiology or embrace the fact that there are many routes to NM, but one needs a base specilaty first (like critical care medicine, interventional neuroradiology/Endovascular NSX etc). For the individual residents though, the best approach would be to try to get into rads residency (you would already be done fellowship!)

I fully agree.

Try to restrict radiologist from reading NM scans will never happen.

Market decides everything. Market decides Nuclear medicine residency is worthless, then it is worthless.

1. I think so far the agreement we reached is complain to ACGME and ask it to shut down all 3-year track nuclear medicine residency.

2. We agree nuclear medicine should be under the umbrella of radiology. A fellowship or a special track.

3. All current 3 year track nuc residents need a base specialty. better off radiology. Like you said. But it depends on many factors. God helps us.

Please spread the words in the radiology community, and if possible, to ACGME, ACR, SNM. Tell them no need for a nuc residency and nuc board.

We, nuclear medicine residents, need your guys, radiology community, to help us. Please find a solution to place us. We have our suggestions. But we need your help.

 

[partusa]

In my opinion, the only who can close the residency, is the PD! They can refuse to take more residents, etc... but, the problem is that our spots have to be covered by radiology residents. This means, no more full time 100%dedicated residents, no more research and more work for the attendings, including the PDs. Probably, this will affect their pockets as well.
So, that's not going to happen, unless they want to struggle with the radiology residents.
If you are thinking that the radiology society, including, RCA, ABR, attendings, PDs, etc... will open the door for NM residents to get into their preciated specialty ($$$$$$$$$$$$$$) you are absolutely wrong. They are saying that the job market for them is not good, do you believe that they will take us to make it worse?. NO WAY!!
My dear friend, I will fight until the end, but unfortunately I know that my only choice is to get into a second residency after NM.

eddieberetta,
"And lets also remember, general radiologists are in fact trained and examined in nukes, and actually have some familiarity and respect for the body of knowledge, the physics and the medicine of NM -- far more than many other specialties i.e. cardiology, endocrinology (some of these practice NM without any formal training)."

COME ON!!! That's riduculous!! and this is the reason why, radiologist are reading nuclear medicine, because they think that NM is easy, right?
NM residency is 3 years for us. Ohhh, I forgot that radiologist are smarter than us, so they just need 4 months and 10 cases during the boards to read NM and treat patients with radioactivity.

The only solution for this problem, has to come from our own PDs and chairmans!

 

[NM2010]

sorry, Partusa, I have to say you are a little bit off.

Talk to ACGME and ask it to change the common program requirements is the only way. To me, it means shut down the 3 year track.

Remember all nuclear division is within department of radiology. Unfortunately, you have to deal with them. Even your current training. And we are at disadvantage. As of current 3 year track residents, ideally radiology or radiology training within the nuclear medicine residency. But that is really out of anybody's hand.

Now don't think about what is fair, what PD should do or what PD will do, what ACR/SNM/ACNM will do, who should read nuclear scans.

You can't do anything to it. PD wouldn't change. PD/SNM just don't care. Only ACGME has the authority to force them to change.

In my opinion, when you fight, you have to focus. I choose ACGME. I complain to it what are not right based on common values, which are in the petition letter of the first post. (I fully agree with the petition letter.)

What I want to achieve is

1. at least shut down the 3 year track.

2. Then reasonable accommadation of current residents.

3. My opinion: nuc should be within radiology.

 

[partusa]

sorry, Partusa, I have to say you are a little bit off.

Talk to ACGME and ask it to change the common program requirements is the only way. To me, it means shut down the 3 year track.

Remember all nuclear division is within department of radiology. Unfortunately, you have to deal with them. Even your current training. And we are at disadvantage. As of current 3 year track residents, ideally radiology or radiology training within the nuclear medicine residency. But that is really out of anybody's hand.

Now don't think about what is fair, what PD should do or what PD will do, what ACR/SNM/ACNM will do, who should read nuclear scans.

You can't do anything to it. PD wouldn't change. PD/SNM just don't care. Only ACGME has the authority to force them to change.

In my opinion, when you fight, you have to focus. I choose ACGME. I complain to it what are not right based on common values, which are in the petition letter of the first post. (I fully agree with the petition letter.)

What I want to achieve is

1. at least shut down the 3 year track.

2. Then reasonable accommadation of current residents.

3. My opinion: nuc should be within radiology.

NM2010,

We all want a solution for this, there are different points of view and solutions for this problem. I believe that the ACGME can only intervene in closing the residencies, and not even that, they can withdraw the accreditation from the NM programs, and they will be non-ACGME accredited, meaning WORTHLESS!but do you really think that they are going to accomodate all of us in radiology residencies. They cannot force a residency program to take more residents.
As I said, radiology don't like NM residents and we don't like radiology residents.
Let be honest, radiology residency is one or the most competitive residency to get into currently, meaning that they prefer only residents with high scores, american grads, etc..., by the other hand you have NM residencies, which at the moment is the most easiest to get into, meaning anyone can get a spot in NM and we all know why!
In my opinion, only the SNM/ABNM along with the radiology society can solve this problem, we are on their mercy!
It is worth to try to get help from the ACGME, and I am not against it. As I said before, I will probably get into a second residency after NM.
Sad but true, I will include my NM specialty/board, in the hobby section of my CV.

 

[Cathance]

Any solution must include the following:
1. Closure of the 3-year independent pathway to board certification in Nuclear Medicine. This should occur immediately, with option to those starting this summer to continue their pathway to completion if desired, but with the understanding that the market may not be any better at the end of 3 years.
2. Immediate efforts to secure a pathway to board certification in Radiology for those who are interested. This can include assistance to acceptance and entry into radiology residency program, or development of a new "fellowship in Radiology" pathway for Nuclear Medicine physicians by the ABR and the ACGME Radiology RRC committee. Not all Nucs residents and graduates will choose to become radiologists, but this pathway will ease the pressure on the supply/demand for those who are on the job market right now, and will assure success in the long run for nuclear medicine physicians.

I, for one, like a lot of my fellow radiology residents, and I respect the vast majority of them. That does not mean I don't envy every one of them, though. They are in the dominant position, and we just have to accept that and deal with it. I've said it before: If you can't beat them, join them.

 

[FDGme]

Love to all! I'm finally employed! (Won't say where…or how. Yes, it's legal.)

Anyone know if the 4 graduates from UCLA's nucs program ever got jobs? Or are they all doing fellowships?

What about the grads from Stanford?
Oregon?
Hopkins?
Harvard?
Other places?

Also, what is up with the new Johns Hopkins University advertisement on the SNM job website? Are they seriously looking for two people, while they're graduates don't have jobs? I guess they don't train their people to be faculty. For that, you have to be a radiologist. "Board certification in Nuclear Medicine required and board certification in radiology preferred…" At least they value the nucs board certification above the radiology board cert. (Or did they ever get jobs?)

I still say stop the 3-year program. Tell ACGME. Tell Medicare. Tell congress.

 

[partusa]

Love to all! I’m finally employed! (Won’t say where…or how. Yes, it’s legal.)

Anyone know if the 4 graduates from UCLA’s nucs program ever got jobs? Or are they all doing fellowships?

What about the grads from Stanford?
Oregon?
Hopkins?
Harvard?
Other places?

Also, what is up with the new Johns Hopkins University advertisement on the SNM job website? Are they seriously looking for two people, while they’re graduates don’t have jobs? I guess they don’t train their people to be faculty. For that, you have to be a radiologist. “Board certification in Nuclear Medicine required and board certification in radiology preferred…” At least they value the nucs board certification above the radiology board cert. (Or did they ever get jobs?)

I still say stop the 3-year program. Tell ACGME. Tell Medicare. Tell congress.

Congratulations!! Are you now officially a Walmart employee? LOL!!
Please, give some advice/tips on how to get a job!, for sure that will be appreciated by a lot of people.
Did you get a private practice or academic position?

Thank you and good luck

 

[FWHM]

PartUSA,

how are you going to deal with the issue of funding for a second residency? Sorry if you already mentioned in one of the posts(couldn't find it). If you are participating in the match do you think the programs will atleast offer an interview or just ignore the application because of the funding issue? How do you plan to do it?

 

[partusa]

PartUSA,

how are you going to deal with the issue of funding for a second residency? Sorry if you already mentioned in one of the posts(couldn't find it). If you are participating in the match do you think the programs will atleast offer an interview or just ignore the application because of the funding issue? How do you plan to do it?

FWHM,

Good question! To be honest I don't know if I will get any interviews. I will finish NM and then I will see, as I mentioned before I know some guys who did 2 residencies. I know someone who did IM+Critical care, worked as an attending for a couple of years and now he is a radiology attending. I will ask him about the funding issue.
This whole situation sucks very bad and nobody cares about it, that makes this situation worse!
I know that this will sound silly and rebel, but I think that we all should strike for 1 day!

 

[FWHM]

Thank you. Like you said 'nobody cares'! One day strike would get some attention if significant numbers show up (which I doubt looking at the responses here)!
At least some of us have started talking about it which is a good start. Apart from writing to the various bodies, mass education on the status of the specialty and the future might do the trick. It will take a while but at least it will prevent significant number from applying to the specialty. Three years ago, no such info was available on the web. If I had, then obviously I wouldn't be in the state I am today.
Good Luck to all those who are making the effort.

 

[Hedgeman]

Don't be fools, guys. Let me say this once and let it sink in:

ABNM stands for American Board of No Marketability