Roles and responsibilities

A nuclear medicine physician is a qualified medical doctor who has had specialist training in nuclear medicine, including the safe handling of nuclear materials. Nuclear medicine is a multidisciplinary practice and the training of medical doctors is critical to the performance of a nuclear medicine facility. The responsibility of the nuclear medicine physician is:

(a) To define the clinical appropriateness and justification for the request or referral, both for diagnostics and for therapy;

(b) To have the overall responsibility of all nuclear medicine procedures, including quality assurance aspects;

(c) To give instructions, based on the facility’s SOP, for the appropriate tests and protocols;

(d) To tailor the protocols to the needs and condition of the patient when necessary;

(e) To assess and carry out interventions (physiological or pharmacological) when needed;

(f) To interpret the study based also on the clinical information;

(g) To interpret the results and to provide a diagnosis insofar possible;

(h) To adhere to SOP to ensure the safety of both the patient and staff;

(i) To provide training (and education) for technical and junior medical staff;

(j) To ensure proper operations of the facility in adherence with quality management rules when in managerial position.

Physicians specializing in nuclear medicine are trained through official programmes of the faculty of medicine or other programmes recognized by the competent bodies. Upon completion of the training programmes they obtain a degree from the appropriate academic institution or competent body.

This qualification forms part of a process to accredit medical practitioners, as specialists in nuclear medicine.

6.1.2. Medical physicists

The use of sophisticated equipment and unsealed radiation sources calls for particular attention to radiation protection and safety and quality assurance. In this setting, the responsibility of the medical physicist for the following areas is defined in GSR Part 3 [9] (see also Ref. [32]).

6.1.2.1. Radiation safety

The main responsibility of the medical physicist is for the patient protection, while the RPO has responsibility for only staff and public protection. The RPO is often a trained medical physicist, although responsibility in a small facility may be delegated to another professional, provided advice can be sought from an available expert.

6.1.2.2. Specification, acceptance testing and quality control of instrumentation The medical physicist is normally directly involved in equipment procurement and takes direct responsibility for acceptance testing and establishment of routine quality controls. In many cases, technologists perform routine quality control, under the supervision of a medical physicist.

6.1.2.3. Maintenance of equipment

The medical physicist is familiar with the operation of the equipment and can identify problems correctly. Medical physicists can undertake first line troubleshooting of equipment in liaison with the supplier or service personnel.

6.1.2.4. Computer system management and support

Increasingly, the medical physicist takes responsibility for overall computer system management and provides advice on computer use as well as first line support for application software. In some countries, the medical physicist is directly involved in routine computer analysis. However, this is the responsibility of technologists in most countries.

6.1.2.5. Development and validation of clinical studies

Nuclear medicine is a continually evolving field and functional information is increasingly obtained from quantitative analysis. The medical physicist usually works closely with the nuclear medicine physician to provide technical advice relevant to the execution of studies. Frequently, software needs to be developed or adapted with the subsequent validation of newly developed procedures.

6.1.2.6. Patient dosimetry and dose optimization

The medical physicist is actively involved in dose optimization, advising on the safe use of radiation and ensuring the quality of diagnostic or therapeutic procedures. The medical physicist is responsible of the determination of patient dose resulting from the administration of radionuclide activity, as well as fetal doses in cases where pregnant patients need to undergo nuclear investigations.

6.1.2.7. Supervision

The medical physicist supervises and contributes to the quality management system (QMS). The medical physicist should also supervise measurement, dispensing and sometimes administration of radiopharmaceuticals for therapeutic purposes and is also involved in radiation safety related to this procedure.

6.1.2.8. Administrative tasks

The medical physicist participates to the management and purchase of equipment and radioactive sources. Most of the above duties involve

administrative tasks such as the preparation of guidelines, record keeping and communication with other professionals and suppliers. The physicist is usually directly involved in the planning of facilities, equipment used and procedures.

6.1.2.9. Teaching and research

Most medical physicists are involved in teaching other professionals (e.g. in radiation safety and instrument principles). Many are actively engaged in development work or undertake phantom experiments as part of validation procedures (applied research) or are involved in clinical research projects (e.g. data analysis, statistical advice).

6.1.3. Radiopharmacists

Radiopharmacy is an essential and integral part of all nuclear medicine facilities. In practice, it is apparent that the preparation of radiopharmaceuticals is performed in a wide range of disciplines including technologists, physicists and nurses. Although pharmaceutical expertise and oversight is essential, the process is not always managed or performed by a pharmacist, which, although desirable, is not necessarily achievable. Standards of practice need to be consistently high, irrespective of the background of the staff performing the process.

Training should be adapted to the background and level of expertise of the trainees in order to ensure that they have the necessary grounding in those aspects of radiopharmacy relevant to their intended role [8, 33]. In most cases that are competency based in which understanding of SOP theory and practice is appropriately established and signed off by authorized person. The pharmacist or person managing the preparation of radiopharmaceuticals needs to be able to demonstrate a thorough knowledge of all areas of the specialty. The responsibilities of a radiopharmacist include the following:

(a) The safe preparation and dispensing of radiopharmaceuticals to national regulations;

(b) Quality control and record keeping;

(c) Follow-up factors affecting unusual biodistributions of radiopharmaceuticals;

(d) Oversight and governance of ‘hot laboratories’ and patient safety.

6.1.4. Nuclear medicine technologists

The nuclear medicine technologist plays a critical role in the routine practice of nuclear medicine, since the quality of work and care taken during diagnostic studies determines the ultimate diagnostic capability of the test being performed.

In many countries, the importance of training technologists has been poorly understood, and consequently the professional development of this group has lagged behind that of others. As a result, there are many technologists working in nuclear medicine who have had little or no formal training. The IAEA has taken this into account and developed a distance assisted training programme.²

The role of the nuclear medicine technologist is to perform diagnostic studies. This involves understanding the overall procedure and taking responsibility for all technical aspects of the study. The breadth of responsibility varies in different countries, with an overlap of activities between different professional groups (e.g. nurses, radiopharmacists), depending on resources.

Where comprehensive training is established, and based on existing SOP, the tasks undertaken by a technologist are likely to include the following:

(a) Radiopharmaceutical preparation and quality control especially at IAEA hospital radiopharmacy operational levels 1 and 2;

(b) Activity measurement;

(c) Patient preparation;

(d) Radiopharmaceutical administration;

(e) Scanner preparation;

(f) Image acquisition;

(g) Data processing;

(h) Display of imaging or data;

(i) Routine nuclear medicine equipment quality control;

(j) Routine nuclear medicine workplace radiation monitoring;

(k) Contribute to save handling of radioactive waste.

Technologists are also likely to have responsibilities in management (personnel and data), teaching and research.

6.1.5. Nurses

The role that nurses play in patient care is just as important in nuclear medicine as in any other clinical practice. A nurse is the first interface with both in and outpatients and, following appropriate indications from the attending physician, should be able to inject patients with radiopharmaceuticals after training in radiation protection issues. The presence of nurses in the therapeutic

2 For further information, see https://humanhealth.iaea.org/HHW/index.html

nuclear medicine wards and during nuclear cardiology stress testing is essential.

Nurses in nuclear medicine can be required to perform the following duties:

(a) Booking of patients;

(b) General physical and mental care of patients;

(c) Examination of vital signs;

(d) Administration of drugs and injections on the instruction of doctors;

(e) Explanation of procedures to patients and provision of support to the receptionist;

(f) Handling of radiopharmaceuticals and radioactive waste in cooperation with pharmacists and technologists;

(g) Handling and care of consumables and pharmaceuticals used in nuclear medicine;

(h) Safe collection and handling of blood sample;

(i) Taking appropriate radiation protection measures for patients and families especially those comforting children and elderly people.

In order to carry out these functions correctly, nurses need a basic knowledge of radiation, radionuclides and the biological effects of radiation and should receive training on the safe handling of radioactive materials as well as radiation protection.

6.1.6. Supporting staff

Office staff in nuclear medicine should have a basic training on the specificity of the process in nuclear medicine, in order to fully understand their responsibilities. An introductory training on patient radiation protection is also necessary, to understand the relevance of medical exposures and avoid unnecessary repetitions, as well as the necessity of proper patient preparation.

Cleaners need specialized training, since they will operate in a classified area in which radioactive contamination is possible. Clear instruction on management of all types of waste should be imparted. Cleaning products and equipment should be specifically dedicated for use in nuclear medicine. So specific training is needed in case of laboratories and imaging rooms cleaning.

6.1.7. Coordination with other clinical services

Nuclear medicine techniques require a multidisciplinary approach.

Other specialists (e.g. cardiologist, endocrinologist, radiologist, oncologist, pulmonologist) may contribute to the report. Experts recommend participation in multidisciplinary meetings, such as tumour boards is highly advisable.

Multidisciplinary care is a standard feature of high quality care. In many centres, multidisciplinary meetings is an integral component of clinical practice. Health professionals from medical and allied health disciplines review diagnostic imaging and pathology, jointly discuss a patient’s case, and recommend a treatment plan. This approach eventually results in evidence based practice that is individualized for the particular patient. For the nuclear physician, the value of participation is also to nurture personal clinical competences and to inform of the value of nuclear medicine studies and to learn from the general discussion.