Eur J Nucl Med Mol Imaging DOI 10.1007/s00259-017-3620-9
OCCASIONAL SURVEY
Nuclear medicine training and practice in Turkey Zehra Ozcan 1
&
M Fani Bozkurt 2 & Belkıs Erbas 2 & Hatice Durak 3
Received: 21 December 2016 / Accepted: 4 January 2017 # Springer-Verlag Berlin Heidelberg 2017
Abstract Nuclear medicine applications in Turkey started in the early 1950s, grew as an independent medical discipline and finally were recognized by the Ministry of Health in 1973. Later on, the professional organization of nuclear medicine physicians and other related professionals including radiopharmacists and technologists under the Turkish Society of Nuclear Medicine were established in 1975. Recently after completing more than a half century in Turkey, nuclear medicine has proved to be a strong and evolving medical field with more than 600 physicians serving for the changing needs of clinical practice throughout these years. This article describes past and present facts in this field and attempts to provide insights into the future which hopefully will be brighter than before. Keywords Nuclear medicine training . Continuing medical education . Turkish Society of Nuclear Medicine . Turkey
Historical notes Nuclear medicine combining pathophysiology with molecular principles grew from clinical medicine and devel-
* Zehra Ozcan
[email protected]
1
Department of Nuclear Medicine, Ege University School of Medicine, Izmir, Turkey
2
Department of Nuclear Medicine, Hacettepe University School of Medicine, Ankara, Turkey
3
Department of Nuclear Medicine, Dokuz Eylül University School of Medicine, Izmir, Turkey
oped as an independent medical field through its evolution and never became a subspecialty of Radiology or any other specialty in Turkey. The initial steps of nuclear medicine started in Istanbul in the early 1950s. Prof. Suphi Artunkal, actually a pharmacologist, was the pioneer of nuclear medicine in our country and made also great contributions in medical psychology and endocrinology. He was the founder of the Radioisotope Laboratory in Istanbul and the first physician to use radioactive iodine in hyperthyroidism [1, 2]. This therapeutic application of I-131 has served as a milestone for the development of clinical nuclear medicine mainly in touch with internal medicine and endocrinology. Later on in the early 1960s, Prof. Fevzi Renda and his team established the Radiobiology Institute in Ankara University [3]. With the support of IAEA, this institution became a distinguished research and training facility by the installation of the first rectilinear scanner, external counters and other related equipment in Ankara. In 1961, the Çekmece Nuclear Research and Training Center in Istanbul started to operate radioisotope production, Mo-99, under the Turkish Atomic Agency in cooperation with the International Atomic Energy Agency (IAEA). Therefore, Turkey has been the one of the first countries using Tc-99 m in patients in Europe. In the following years, Prof. Ali Tan Işıtman, Prof. Tarık Kapıcıoğlu, Prof. Coşkun Bekdik and Prof. Nail Tartaroğlu have made great contributions to our field. By the efforts of all these mentors, nuclear medicine was approved as an independent medical specialty by the Ministry of Health in 1973. Through all these years, Turkish scientists were actively involved at the scientific meetings in Europe. Finally, when a unified European Nuclear Medicine Society was established as the European Association of Nuclear Medicine (EANM) in 1985, Prof. Nail Tartaroğlu and Prof. Hikmet Bayhan represented Turkey as founder members of EANM.
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Organizational workforce There are currently 602 nuclear medicine physicians actively offering patient care in 240 nuclear medicine centres throughout Turkey. Of these units, 142 facilities are providing public practice and others are either within a private hospital or imaging centre. As the use of both diagnostic and therapeutic radioisotopes is regulated by the Turkish Atomic Energy Agency (TAEK), all these facilities are licensed and their operations are under supervision of TAEK serving as the major national authority for handling radioactive substances. The number of imaging systems is listed in Table 1. It is of note that while the first PET/CT scanner was installed in 2004 in Turkey, the number of PET/CT scanners has significantly increased during the last decade. It should also be underlined that all hybrid imaging systems are located in Nuclear Medicine Departments. There are two PET/MR scanners in service since 2015, and the third PET/MR will start to operate within the first cycle of 2017. There are 15 cyclotrons, all but one operated by the private sector. There were two new cyclotrons installed in 2016 in Hacettepe and Ankara University Hospitals, mainly dedicated to scientific research. A microPET has also started to operate in Ankara University, which will open a new era in preclinical studies. Regarding in-patient radionuclide therapy units, there are more than 54 centres with a total of 120 individual beds in shielded rooms providing therapeutic care for hospitalized patients. However, the Turkish Society of Nuclear Medicine has been taking action to increase the number of in-patient clinical therapy units in collaboration with national health authorities.
Training resources and organization The nuclear medicine training program in Turkey has been inspired by the BUEMS/EBNM Syllabus for Postgraduate Specialization in Nuclear Medicine^ [4], both regarding fundamental and practical training. The total duration of residency training is formally 4 years, including rotations in Radiology (2 months), Endocrinology (1 month) and Cardiology (1 month). Recently there has been a work in progress for updating the content of the formal residency program and the logbook system for each trainee. Training in multimodality imaging, in agreement with the UEMS/EBNM syllabus, is provided by nuclear medicine academicians since all hybrid imaging systems have been installed in nuclear medicine units since the very beginning in Turkey. At the end of residency training, it is required that a scientific research study, a kind of specialty thesis should be completed; this work has to be presented and approved by a local academic jury. In addition to the scientific thesis, the resident should pass the oral examination including questions from theoretical and clinical aspects of nuclear medicine. In order to harmonize the standards of national training and examination steps,
Table 1 The distribution of nuclear medicine imaging systems is shown
Number PET/MR
3*
PET/CT
122
SPECT/CT Gamma Camera
27 310
* indicates 1of 3 will be installed in 2017
the Turkish Board of Nuclear Medicine (TBNM) is also organizing a national exam during the National Congress. This exam is currently volunteer based, open to all last years’ residents and young physicians. It starts with an MCQ and those passing are accepted as eligible for the oral exam. The whole examination process is supervised by the Examination Commission of TBNM. It is hoped that the National Board exam will be compulsory to replace local specialty exams in the future.
Society activities and continuing education The Turkish Society of Nuclear Medicine is the unique professional organization aiming to promote education, practice and research in nuclear medicine. It was founded in 1975 and holds a unique position to support collaboration with national health authorities, departments, industrial suppliers and other related partners in this field. TSNM has 797 members, including 637 physicians, of which 602 are active nuclear medicine physicians, 35 residents and 125 technologists, radiation physicists and radio-pharmacists. TSNM has been a long-standing member of EANM, World Federation of Nuclear Medicine and Biology (WFNMB) and Asia Oceania Federation of Nuclear Medicine and Biology (AOFNMB). TSNM has also supported the collaboration between the Balkan countries and hosted the first Balkan Congress of Nuclear Medicine in 2012 in Antalya. We have recently set up an international collaboration with the American College of Nuclear Medicine (ACNM) and the American Society of Nuclear Cardiology (ASNC) in 2015 with the goal of enhancing NM practice as well as to facilitate cross-cultural exchange in both countries. The organizational structure of TSNM and task groups is similar to EANM. There are currently eight scientific committees (Cardiology, Neuropsychiatry, Nephro-urology and Paediatrics, Thyroidand Endocrinology, RadiopharmacyRadiation Protection and Quality management, Oncology, Preclinical Imaging and Bone Densitometry) with experts or actively interested members in these particular fields. These task groups are vital for TSNM to achieve the educational and scientific objectives through training sessions, seminars and publication of procedure guidelines. The Turkish Board of Nuclear Medicine is a professional body under TSNM and responsible for educational needs of residency programs. TBNM has several commissions including Examination,
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Education & Syllabus and Accreditation commissions in a very similar way to UEMS/EBNM committees as well. Continuing education is the most important topic within the mission of TSNM. Obviously there is an increasing demand for continuing education due to changing needs of our clinical practice, such as hybrid technologies or recent therapeutic applications. Therefore, courses on cross-sectional anatomy, basics of CT/MR or workshops on ultrasound have been organized to help our members to be up to date with the latest advances. TSNM organizes a National Congress annually in the springtime. This is the most important scientific and social platform to stimulate research and developments in nuclear medicine in cooperation with industry and other partners. In order to establish a deeper educational program on a specific topic, a symposium is organized in the winter season lasting for 2 days. It also aims to enhance the scientific cooperation with other medical disciplines. In addition to this, weekend courses called BNuclear Medicine School^ in which the educational program is designed by the chairs of the TSNM task groups is currently directed by Associate Prof. M Fani Bozkurt. This educational activity, organized in the head office of TSNM in Ankara is open to all residents and young physicians. Courses for technologists have also been offered during the National Congresses. TSNM publishes two journals to provide a forum for the exchange of information related to nuclear medicine and molecular applications with biomarkers (Fig. 1). The delivery of the first official journal, Turkish Journal of Nuclear Medicine (TJNM) goes back to 1991. Its format and title have evolved into Molecular Imaging and Radionuclide therapy (MIRT) in 2011. Now, MIRT is the official journal of TSNM indexed in Pubmed, Pubmed centrale, ESCI, and EBSCO databases. It is a double-blind peer review journal with a considerable impact in the neighbouring countries as well. MIRT has been edited by Prof. Hatice Durak and published in English, three times a year. Nuclear Medicine Seminars (NMS) is rather a new electronic journal edited by Prof. Zeynep Burak published in Turkish. Its publication started in 2015 in honour of the 40th anniversary of TSNM. The mission of NMS is to provide detailed educational materials on a specific topic edited by a guest editor appointed for each issue.
International recognition Several scientists from TSNM hold different positions in EANM task groups.Currently, AssociateProf.M Fani Bozkurt isthe chair of the Level 1 Education chair in European School of Multimodality Imaging and Therapy (ESMIT) and senior advisor for the Oncology Committee. Our colleagues in different scientific task groups are: Dr. Özgül Ekmekçioğlu (Neuroimaging), Associate Prof. Meltem Ocak (Radiopharmacy) and Prof. Cumali Aktolun (Thyroid Committee). Formerly, Prof. Hatice Durak was the task group coordinator of EANM between the
periods of 2007-2010. She was also the Congress President for EANM Congress 2005 in Istanbul, which was a great success. Turkey is currently represented by Prof. Belkis Erbas and Prof. Ozlem Atay as the National Delegate and deputy at EANM. Regarding positions in the UEMS/EBNM, Prof. Zehra Ozcan is presently a member of Fellowship Examination Committee and Prof. Haluk Sayman is also a member of the Education and Syllabus Committee. National Delegate and Deputy to the UEMS/EBNM are Prof. Yakup Yurekli and Prof. Zehra Ozcan, respectively. Many colleagues are also on the editorial boards of EJMMMI and other prestigious nuclear medicine journals. At present, a significant number (26 by 2016) of Turkish physicians, have passed the UEMS/EBNM Fellowship examination and obtained the title of Fellow of the EBNM [5]. Fellowship certification by UEMS/EBNM is strongly encouraged by TBNM, and a grant is provided for a fellow each year by our society. So far five Nuclear Medicine Centres in Turkey are accredited by the UEMS/EBNM Accreditation Committee. Two of them are accredited as training centres, two are accredited as departments, and one is accredited as a combined department and training centre [5].
Final comments and future perspective The infrastructure of nuclear medicine in terms of technology has been well developed during the last years. However, the improvement in the human workforce did not progress equivalently and the number of residency positions has been decreased. Therefore, optimization of the number of nuclear medicine physicians and improved recruitment of young doctors to this field is a priority. In addition to optimization of human forces, it is our objective to harmonize the education program with changing needs of our discipline and improvement of the curriculum in correlative imaging modalities and oncologic therapy. Web-based learning tools might be used as currently emphasized by EANM under ESMIT and this hopefully will provide broader educational resources with the multimodality content for many physicians. Finally, while current challenges and interactions with radiology lead to dramatic changes in some European countries, we would like to underline that the core knowledge of nuclear medicine is based on molecular principles and dependent on the radiotracers more than on the scanners we use. Therefore, nuclear medicine physicians should improve their skills and extend their learning to be able to report any molecular or physiologic information offered by radiotracers using different machines with different cross-sectional capabilities. New targeted radionuclide treatments similarly require wider background in basic and clinical oncology that should be reflected in the training background. We need to increase awareness about the novel radiopharmaceuticals for diagnosis and therapy and make this potential accessible to our patients with good quality management by the support of health
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a
Fig. 1 Cover pages of official TSNM journals, MIRT (a) and Nuclear Medicine Seminars (b) are shown. MIRT provides open access through the website (http://mirt.tsnmjournals.org) in order to make educational materials freely available to all professionals in nuclear medicine and related fields
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b
Fig. 1 (continued)
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authorities. Consequently, a brighter future could be expected for the next generation nuclear medicine physicians with improved skills as a Bmolecular imager and therapist^. Acknowledgements We acknowledge the respectful memories of our mentors who devoted themselves to nuclear medicine and made great contributions to develop this field in our country. Compliance with ethical standards This article does not contain studies with human participants or animals by any of the authors. Conflict of interest The authors declare that they have no conflict of interest.
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