ACR/ABR Clinical Statement on Credentialing

and Privileging of Radiologists for

Therapeutic Nuclear Medicine
The ACR/ABR Writing Group

Processes for credentialing physicians and criteria used for delineating their practice-specific clinical privileges
vary widely across the United States. The ACR and the ABR have jointly developed this resource document to
define the requisite credentials for specialty board-certified diagnostic radiologists and subspecialty board-
certified nuclear radiologists to be privileged to practice therapeutic nuclear medicine. Through its initial
specialty and subspecialty certification processes and its maintenance of certification programs for practicing
certificate holders, the ABR assures the competence of its professional diplomates for clinical practice. On the
basis of their education, training, and clinical work experience, board-certified radiologists have the qualifica-
tions to supervise and perform therapies using unsealed radioisotopes. Optimum patient care is best served by
a physician with training and expertise in supervising and performing radioisotope therapies in conjunction
with multimodality imaging technologies for initial diagnosis and follow-up.
Key Words: ACR, ABR, credentialing, privileging, radioisotope therapy, diagnostic radiologists, nuclear
radiologists, nuclear medicine
J Am Coll Radiol 2013;10:774-780. Copyright © 2013 American College of Radiology

INTRODUCTION More recently, several parenterally administered radio-

The ACR and the ABR have jointly developed this resource
document to define the requisite credentials for specialty
board-certified diagnostic radiologists and subspecialty
board-certified nuclear radiologists to be privileged to prac-
tice therapeutic nuclear medicine (NM). This document is
intended to serve as a companion to the 2011 “ACR/ABR
Clinical Statement on Credentialing and Privileging of Ra-
diologists for Diagnostic Nuclear Medicine, Including
Multimodality Hybrid Imaging [1].”
Therapeutic NM began with the clinical use of P-32
and I-131 as unsealed radioisotope sources for the treat-
ment of hematologic and endocrinologic diseases in the
late 1930s and early 1940s. The administration of oral
radioiodine in the form of I-131 sodium iodide has been
a mainstay in both the diagnosis and treatment of hyper-
thyroidism and thyroid cancer for more than 70 years.
Corresponding author and reprints: M. Elizabeth Oates, MD, University of
Kentucky, 800 Rose Street, HX-307B, Lexington, KY 40536-0293; e-mail:
meoate2@email.uky.edu.
The ACR/ABR Writing Group consists of the following individuals: Man-
uel L. Brown, MD, Department of Diagnostic Radiology, Henry Ford Hos-
pital, Detroit, Michigan; Milton J. Guiberteau, MD, Department of
Radiology, Baylor College of Medicine, Houston, Texas; and M. Elizabeth
Oates, MD, Department of Radiology, University of Kentucky, Lexington,
Kentucky.
This statement was approved by the Board of Chancellors of the ACR on
March 2, 2013 and by the Board of Trustees of the ABR on March 22, 2013.
pharmaceuticals have been developed to treat a variety of
medical conditions, including relapsed lymphoma, met-
astatic neuroendocrine tumor, and intractable pain
caused by skeletal metastases. Expanded applications of
these and new radioisotope therapies are anticipated in
the future.
Principal practitioners of therapeutic NM using un-
sealed radioisotopes are specialists in diagnostic radiology
(DR) and/or NM, or in radiation oncology; however,
this clinical statement concerns itself with only the first 2
specialties. The required training and experience for the
safe handling and administration of radioisotopes for
therapeutic medical purposes are specified by the United
States Nuclear Regulatory Commission (NRC). On the
basis of those regulations, as well as clinical practice im-
peratives, the ACGME mandates specific program re-
quirements for training and experience for residents in
DR programs and fellows in nuclear radiology (NR)
programs through its DR Residency Review Committee
[2,3]. Recently approved revisions to the DR and NR
program requirements [4,5], effective July 1, 2013, as-
sure that the highest standards and safeguards will be met
with regard to radioiodine therapies administered by di-
agnostic radiologists and all radioisotope therapies per-
formed by nuclear radiologists.
After successful completion and documentation of
this training, radiologists who pass a series of rigorous
examinations that document mastery of the specified

774 © 2013 American College of Radiology

0091-2182/13/$36.00 ● http://dx.doi.org/10.1016/j.jacr.2013.04.005
 Brown et al/ACR/ABR Clinical Statement on Credentialing and Privileging of Radiologists for Therapeutic Nuclear Medicine 775
knowledge base receive initial certification in DR by the
ABR [6]; those who complete additional training in NM
may obtain further certification by the ABR in NR [7].
ABR-certified DRs and NRs have received the requisite
education, have demonstrated their capabilities, and are
well prepared to provide a high standard of patient care.
Their expertise enables a comprehensive assessment of
patients in need of radiopharmaceutical treatments, in-
cluding adjunctive clinical evaluation and the multimo-
dality diagnostic imaging that generally precedes and
often follows therapeutic intervention. Moreover, their
solid foundation in radioisotopes and radiopharmaceuti-
cals, radiation physics and safety, dosimetry, and radio-
biology positions them well to serve a critical role in
multidisciplinary clinical paradigms. In addition, radiol-
ogists, who obtain ABR certification in DR and also
successfully complete an examination covering the re-
quired NRC radioisotope safety curriculum, qualify to
become recognized on hospital and facility radioactive
materials licenses as authorized users (AU) of radioiso-
topes. In the United States, only such AUs are qualified
to write prescriptions for the radiopharmaceuticals
needed for patient therapies.
QUALIFICATIONS OF RADIOLOGISTS WHO
SUPERVISE AND PERFORM THERAPEUTIC
NUCLEAR MEDICINE
Nuclear Regulatory Commission Training
Requirements
Under the Atomic Energy Act of 1954, as amended in
NUREG-0980 and the Energy Reorganization Act of
1974, the United States government has authorized the
NRC to govern the medical use of by-product material.
The NRC regulations, including training and experience
requirements for the safe use of radioisotopes, are codi-
fied in the Code of Federal Regulations, 10 CFR Part 35.
The NRC provides oversight for compliance with these
regulations in some states. However, it also has an agree-
ment program that allows individual states to assume the
regulatory authority to license and regulate by-product
materials within their borders. For all practical purposes,
state requirements should be virtually identical to those
of the NRC; therefore, this document refers only to
NRC regulations.
The NRC stipulates the training and experience re-
quirements for the use of unsealed by-product material
for which a written directive is required under 10 CFR
35, Subsection E. The applicable regulations are:
§35.390: Training for use of unsealed by-product ma-
terial for which a written directive is required [8]
and its subsections:
§35.392: Training for the oral administration of so-
dium iodide I-131 requiring a written directive in
quantities less than or equal to 1.22 gigabecquerels
(33 millicuries [mCi]) [9].
§35.394: Training for the oral administration of so-
dium iodide I-131 requiring a written directive in
quantities greater than 1.22 gigabecquerels (33
mCi) [10].
§35.396: Training for the parenteral administration
of unsealed by-product material requiring a written
directive [11].
A written directive is essentially a prescription that
contains certain elements and which must be signed and
dated by an NRC-approved physician, referred to as an
AU, before the administration of the unsealed radioiso-
tope. To become an AU, a physician must either (1) have
completed specified training and experience and have a
written attestation of such training from a preceptor who
is an NRC AU, or (2) be board certified by an approved
medical specialty board, such as the ABR. A physician
may be authorized to perform all of the treatments under
10 CFR 35.390, or may be qualified for specific therapies
addressed in individual subsections.
The first 2 subsections (§35.392 and §35.394) regulate
the most widely employed radioisotope therapy, namely,
the oral administration of I-131 sodium iodide in 2 levels of
activity, often referred to as “low-dose” and “high-dose” for
treatment of hyperthyroidism and thyroid cancer, respec-
tively. The third subsection (§35.396) regulates additional
radioisotope therapies, and includes the parenteral admin-
istration of any beta emitter, any photon-emitting radioiso-
tope with a photon energy less than 150 kiloelectron volt
(keV), and/or parenteral administration of any other radio-
isotope requiring a written directive. The following para-
graphs address the subsections of the NRC regulations to
give a more detailed and complete understanding of NRC
requirements.
§35.392 [9]. This subsection of the rule directs the use
of I-131 sodium iodide for the treatment of hyperthy-
roidism. Authority to perform this level of therapy re-
quires 700 hours of training and work experience under
the supervision of an AU and must involve ordering,
receiving, and unpacking radioactive materials safely and
performing the related radiation surveys; performing
quality control procedures on instruments used to deter-
mine the activity of dosages and performing checks for
proper operation of survey meters; calculating, measur-
ing, and safely preparing patient or human research sub-
ject dosages; using administrative controls to prevent a
medical event involving the use of by-product material;
using procedures to contain spilled by-product material
safely and using proper decontamination procedures;
plus a minimum of 80 hours of classroom and laboratory
instruction applicable to the medical use of I-131 sodium
iodide, including radiation physics and instrumentation;
radiation protection; mathematics pertaining to the use
and measurement of radioactivity; chemistry of by-prod-
uct material for medical use; and radiation biology; plus
personal experience involving the oral administration of
776 Journal of the American College of Radiology/ Vol. 10 No. 10 October 2013
I-131 sodium iodide in an amount less than or equal to
1.22 gigabecquerels (33 mCi) to a minimum of 3 pa-
tients or human research subjects. To qualify for AU
status, the physician must be certified by a medical spe-
cialty board whose certification process includes each of
these requirements, and must present written attestation
of satisfactory completion of these requirements and
achievement of a level of competency sufficient to func-
tion independently as an AU for medical uses.
§35.394 [10]. This subsection directs the use of I-131
sodium iodide for the ablation of residual thyroid tissue
after thyroidectomy for thyroid cancer, or treatment of
regional or distant functioning metastases. The require-
ments are essentially the same as for §35.392, with the
exception of personal experience involving the oral ad-
ministration of I-131 sodium iodide in an amount greater
than 1.22 gigabecquerels (33 mCi) to a minimum of 3
patients or human research subjects.
§35.396 [11]. This part of the rule addresses the use of
various therapeutic radiopharmaceuticals administered
parenterally. Although not specifically named in the reg-
ulation, examples of therapies covered by this subsection
currently include I-131 tositumomab (Bexxar), Sm-153
samarium lexidronam (Quadramet), Sr-89 strontium
chloride (Metastron), and Y-90 yttrium ibritumomab
tiuxetan (Zevalin). One notable difference from §35.392
and §35.394 is that the work experience and the class-
room and laboratory training must be applicable to
parenteral administrations of any beta emitter, any
photon-emitting radioisotope with a photon energy less
than 150 keV, and/or parenteral administration of any
other radioisotope for which a written directive is re-
quired. Personal experience involving the administration
of these applicable radiopharmaceuticals to at least 3
patients or human research subjects is required.
Graduate Medical Education and Training
Pathways
DR: Specialty Training. Diagnostic Radiology is a
4-year residency program approved by the ACGME. As
defined by the ACGME,
Diagnostic radiology encompasses a variety of diagnostic and image-
guided therapeutic techniques, including all aspects of image-based
diagnosis (radiography, nuclear radiology, diagnostic ultrasound,
magnetic resonance, computed tomography, interventional proce-
dures, and molecular imaging). The residency program in diagnostic
radiology shall offer a quality graduate medical educational experience
in all of these associated disciplines [2,4].
Before entering DR residencies, a preparatory clinical
post-graduate year is required. However, some DR resi-
dencies may integrate these 12 months of additional clin-
ical training into the residency. Regardless, this
accredited clinical training must be in internal medicine,
pediatrics, surgery or surgical specialties, obstetrics and
gynecology, neurology, family practice, emergency med-
icine, or any combination of these specialties, including a
transitional year.
During the 4 years of DR residency, a trainee must
complete a minimum of 4 months of clinical training in
NM, which must include therapeutic applications [2].
New program requirements go into effect on July 1,
2013 [4]. In terms of hours of training, residents will
continue to complete the NRC-specified requirements to
become AU-eligible:
IV.A.6.b) a minimum of 700 hours (approximately 4
months) of training and experience in clinical nu-
clear medicine, which may include the required 80
hours of classroom and laboratory instruction; and
IV.A.6.d) at least 80 hours of didactic (classroom and labo-
ratory training) training under the direction of an AU.
DR residents must continue to learn:
IV.A.3.b).(1).(c).(i).(c) the chemistry of by-product
material for medical use;
IV.A.3.b).(1).(c).(i).(d) biologic and pharmacologic
actions of materials administered in diagnostic and
therapeutic procedures; and
IV.A.3.b).(1).(c).(i).(e) topics in safe handling, ad-
ministration, and quality control of radionuclide
doses used in clinical medicine.
Their didactic instruction (or work experience) will
continue to include the following:
IV.A.3.b).(1).(c).(ii) ordering, receiving, and unpacking
radioactive material safely, and performing the related
radiation surveys; the safe elution and quality control
of radioisotope generator systems; calculating, mea-
suring, and safely preparing patient dosages; calibra-
tion and quality control of survey meters and dose
calibrators; safe handling and administration of ther-
apeutic doses of unsealed radioisotope sources (ie,
I-131); written directives; response to radiation spills
and accidents (containment and decontamination
procedures); radiation signage and related materials;
using administrative controls to prevent medical
events involving the use of unsealed byproduct mate-
rial. Observation alone is not sufficient.
With regard to therapies, residents currently “must
participate in at least 3 therapies involving oral adminis-
tration of I-131 [2].” The new program requirements [4]
specify not only the minimum number of cases, but also
the specific levels of administered radioiodine activity,
and the associated processes:
IV.A.5.a).(2).(a) Residents must perform under pre-
ceptor supervision at least 3 therapies involving oral
administration of I-131 in quantities less than or
equal to 33 mCi and at least 3 therapies in quanti-
ties greater than 33 mCi; and
 Brown et al/ACR/ABR Clinical Statement on Credentialing and Privileging of Radiologists for Therapeutic Nuclear Medicine 777
Table 1. Therapeutic Nuclear Medicine in Diagnostic Radiology Residency Programs: Alignment of NRC, ACGME
and ABR
Part 35 Minimum Number Administered
Subsection of Cases Activity (mCi) Radiopharmaceutical
§35.392 3 ⱕ33
§35.394 3 ⬎33
NRC ⫽ Nuclear Regulatory Commission; mCi ⫽ millicuries.
IV.A.5.a).(2).(a).(i) Residents must participate in pa-
tient selection, informed consent, understanding
and calculating the administered dose, counseling
of patients and their families on radiation safety
issues and patient follow up.
Thus, on the basis of their training, DRs have been
and will continue to be qualified to supervise and per-
form patient treatments using oral I-131 sodium iodide.
As of July 1, 2013, the ACGME program requirements
will align with the ABR’s existing requirements for DR
trainees, which specify training in accordance with NRC
regulations appropriate to recognition of the ABR’s DR
Certificate with AU Eligibility under the NRC’s specialty
board recognition program (Table 1).
NR/NM: Subspecialty Training. As defined by the
ACGME,
Nuclear radiology is a clinical subspecialty of radiology involving the
diagnostic and therapeutic use of radioactive materials using unsealed
sources. Radiologists select, interpret, and perform procedures, in-
cluding diagnostic imaging by external detection of radioisotopes,
diagnostic in vivo or combination in vivo/in vitro procedures that
involve the administration and detection of radioactivity by non-
imaging means, and therapeutic administration of radioisotopes. . . .
The educational program in nuclear radiology must be 12 months in
length. . . . Diagnostic radiology subspecialty fellowship programs are
designed to develop advanced knowledge and skills in a specific clin-
ical area [5].
Should they choose, physicians who successfully com-
plete DR residencies may obtain additional training in
NR or NM through either of 2 one-year ACGME-ap-
proved training pathways available to radiologists: (1) a
NR fellowship, or (2) a NM residency. Both pathways
provide advanced training in therapeutic NM and both
fulfill the ABR’s training requirements to qualify for
ABR subspecialty certification in NR. Acceptance into
fellowship training in NR requires current or past enroll-
ment in an ABR-approved DR program; therefore, most
NR trainees have already started or may have even com-
pleted the steps to AU-eligible status to perform unsealed
radiopharmaceutical therapy by virtue of their ABR re-
quired training and experience.
In 2011, a conjoint Society of Nuclear Medicine/
American College of Nuclear Medicine/American Board
of Nuclear Medicine position paper [12] noted,
The training requirements for the supervision and administration of
therapeutic procedures using radiopharmaceuticals are not defined
Route of
Administration
I-131 NaI oral
I-131 NaI oral
uniformly in the ACGME program requirements for different spe-
cialties . . . . The purpose of this document is to recommend the
minimum training requirements for therapeutic procedures using
radiopharmaceuticals. These requirements should be uniform across
ACGME specialty training requirements. This training must include
independently evaluating and treating, under supervision, a mini-
mum of 10 cases of radioiodine therapy for hyperthyroidism, a min-
imum of 5 cases of radioiodine therapy for thyroid carcinoma, and a
minimum of 3 cases of parenteral radioisotope therapy. Less training
and experience is inadequate to ensure the safety, appropriateness, and
effectiveness of radioisotope therapy.
In 2012, Delbeke et al [13] reinforced that there con-
tinued to be “a significant difference between nuclear
medicine and nuclear radiology [in] the amount of train-
ing required for therapy with radiopharmaceuticals as
described in [the above referenced] conjoint statement
on credentialing and delineation of privileges for thera-
peutic procedures using radiopharmaceuticals.”
With the October 2012 approved revisions to the pro-
gram requirements for NR [5], these concerning differ-
ences with regard to radioisotope therapies have been
eliminated. Moreover, the mutually agreed upon desired
harmonization across the NR and NM training programs
outlined in the consensus ACR/Society of Nuclear Med-
icine Task Force I Report will be achieved; that is, “har-
monizing or even equalizing the curricula for the Nuclear
Radiology Fellowship with the 1-year NM residency
available to physicians who are board certified in DR is
desirable [14,15].” The new program requirements be-
came effective on July 1, 2013 and will assure that NRs
are equipped to meet the highest standards and safe-
guards in providing all radioisotope therapies.
With the revisions to the NR program requirements [5],
physicians who follow the DR-NR pathway will be offered
learning opportunities related to radioisotope therapies
equivalent to those in NM programs [16]; the graduates will
have an equal foundation of knowledge, skills, and experi-
ence. Specifically, the new trainees
IV.A.2.a).(2).(b) must participate in therapeutic ad-
ministration of radiopharmaceuticals, including
patient selection, informed consent, understanding
and calculating of the administered dose, counsel-
ing of patients and their families on radiation safety
issues, and patient follow up after therapy; and
they must provide
778 Journal of the American College of Radiology/ Vol. 10 No. 10 October 2013
Table 2. Therapeutic Nuclear Medicine in Nuclear Radiology Programs: Alignment of NRC, ACGME and ABR
Part 35 Minimum Number Administered
Subsection of Cases Activity (mCi)
§35.392 10 ⱕ33
§35.394 5 ⬎33
§35.396 5 any
NRC ⫽ Nuclear Regulatory Commission; mCi ⫽ millicuries.
IV.A.2.a).(2).(b).(i).(a) documentation of participa-
tion in a minimum of 10 cases of oral administration
of less than or equal to 1.22 gigabecquerels (33 mCi)
of sodium iodine I-131, for which a written directive
is required;
IV.A.2.a).(2).(b).(i).(b) documentation of participa-
tion in a minimum of five cases of oral administration
of greater than 1.22 gigabecquerels (33 mCi) of so-
dium iodine-I-131, for which a written directive is
required; and,
IV.A.2.a).(2).(b).(i).(c) documentation of participa-
tion in a minimum of five cases of parenteral admin-
istration of any beta emitter, or a photon-emitting
radioisotope with a photon energy less than 150 KeV,
for which a written directive is required, and/or
parenteral administration of any other radioiso-
tope, for which a written directive is required.
Within the scope of training, trainees must also learn
about
IV.A.2.b).(5).(e) therapeutic uses of unsealed radiophar-
maceuticals, to include patient selection and manage-
ment, including dose administration and dosimetry,
radiation toxicity, and radiation protection consider-
ations in the treatment of metastatic cancer and bone
pain, primary neoplasms, solid tumors, and malig-
nant effusions; and the treatment of hematologic, en-
docrine, and metabolic disorders.
Table 2 summarizes the alignment of the new NR pro-
gram requirements, effective July 1, 2013, with the
NRC.
AMERICAN BOARD OF MEDICAL SPECIALTIES
CERTIFICATION PATHWAYS
DR: Specialty Certification
The ABR was founded in 1934 and is 1 of 24 member
boards of the American Board of Medical Specialties.
The mission of the ABR is to serve patients, the public,
and the medical profession by certifying that its diplo-
mates have acquired, demonstrated, and maintained a
requisite standard of knowledge, skill, and understand-
ing essential to the practice of DR, radiation oncology,
and medical physics. As defined by the ABR, DR encom-
passes a variety of diagnostic and image-guided therapeu-
tic techniques, including all aspects of radiological
Route of
Radiopharmaceutical Administration
I-131 NaI oral
I-131 NaI oral
beta emitters or those with parenteral
photons ⬍ 150 keV
diagnosis, nuclear radiology, diagnostic ultrasound, MR,
CT, interventional procedures, and the use of other
forms of radiant energy [6]. Thus, therapeutic NM is
embedded within the scope of the requisite training for
ABR eligibility in DR.
The ABR offers a primary specialty certificate in DR
for physicians who have successfully completed 4-year
ACGME-accredited DR residencies. The current initial
certification examination process for DR [6] includes a
written examination in radiation physics, including NM
physics and radiation biology, as well as both written and
oral examinations covering the fundamentals and clinical
aspects of diagnostic and therapeutic NM. The current
examination contains NRC content that counts towards
the pass/fail score in the nuclear medicine category of the
oral examination; some of the oral items depict situations
and/or scenarios that allow the examiner and candidate
to discuss pertinent NRC principles.
Trainees who began DR training programs in or after
2010 will undergo a comprehensive core examination
[17] covering the same content in a computer-based for-
mat. The ABR core examination includes “Nuclear Med-
icine and Molecular Imaging” as one of its 18 categories.
“Nuclear Medicine and Molecular Imaging” covers ex-
amination content related to therapy for painful skeletal
metastases with Sm-153 and Sr-89, as well as treatment
of hyperthyroidism and thyroid cancer employing I-131
sodium iodide [18].
Embedded within the core examination is Part I of the
dedicated radioisotope safety examination (RISE) that
covers the required NRC curriculum [19]. Part II of the
RISE will be included within the ABR certifying exami-
nation. Upon successful completion of the core and cer-
tifying examinations, a qualified candidate who also
passes both parts of the RISE, will receive an ABR DR
certificate with an “AU-eligible” designation.
The NRC recognizes the ABR as a specialty board
whose examination process (described above) qualifies
DR diplomates whose ABR certificates are imprinted
with “AU-eligible” to be deemed eligible as AUs on ra-
dioactive materials licenses issued by the NRC or by
NRC agreement states. This recognition includes ther-
apy with unsealed radioisotopes under 10 CFR 35.392
[9] and 10 CFR 35.394 [10]. The ABR requires candi-
dates who seek board certification with AU-eligibility to
have participated in at least 3 low-dose (ⱕ33 mCi) and 3
 Brown et al/ACR/ABR Clinical Statement on Credentialing and Privileging of Radiologists for Therapeutic Nuclear Medicine 779
high-dose (⬎33 mCi) I-131 sodium iodide oral thera-
pies. The ABR requires documentation by both the pro-
gram director and qualified AU that the candidate has
successfully completed this training. Specifically, as pre-
scribed by the NRC and the ACGME, each candidate for
AU status through the ABR pathway must have com-
pleted a minimum of 700 hours of training and experi-
ence in imaging and localization studies, and 80 hours of
classroom and laboratory training in basic radioisotope
handling techniques applicable to the medical use of
unsealed byproduct material for imaging and localization
studies as well as the use of I-131 sodium iodide for
procedures requiring a written directive.
The ABR website is an extensive resource for candi-
dates and the residency programs to use in reference to
seeking AU-eligibility for the medical use of radioiso-
topes for diagnostic and therapeutic uses through the
ABR certification process [6,17-20]. The ABR require-
ments are aligned with the NRC requirements and the
revised diagnostic radiology program requirements, ef-
fective July 1, 2013 (Table 1). The ABR endeavors to
ensure safe and effective use of radioisotopes by board-
certified radiologists. The ABR believes that these items
are important components of a responsible education for
radiologists and contribute to the safety of medical prac-
tice in ways that are broadly supported by organized
medicine, regulators and the public.
NR: Subspecialty Certification. Nuclear radiology is a
subspecialty of DR that encompasses the use of radio-
pharmaceuticals for dynamic and static imaging of
pathophysiologic processes and the treatment of a spec-
trum of benign and malignant diseases [7]. The ABR
offers radiologists who have achieved certification in DR
the opportunity to achieve further subspecialty certifica-
tion in NR after an additional year of ACGME-approved
NR fellowship or NM residency [7]. In the realm of
therapeutic NM practice, NR prerequisite training in-
cludes oral radioiodine therapies under 10 CFR 35.392
[9] and 10 CFR 35.394 [10] and, concordant with the
NRC regulations and revised ACGME program require-
ments, parenteral therapies under §35.396 [11] (Table
2). The virtual equivalency of training between the NM
residency and NR training requirements, accomplished
by recent approval of the revised NR Fellowship Program
Requirements by the ACGME in September 2012 (ef-
fective beginning July 1, 2013), should lead inevitably to
future equivalency of NRC recognition in therapeutic
uses of radioisotopes of both ABR (NR) and American
Board of Nuclear Medicine (NM) certification processes.
With the recent change to a 36-month core curriculum
in DR residencies and the increase in permissible months of
training in a particular subspecialty from 12 to 16 months
within a 4-year (48-month) program, the opportunity for
significant additional NM training in DR residencies has
become possible. With this in mind, in 2010, the ABR
approved 16 months of NM training within a DR residency
in an institution with an ACGME-approved NR fellowship
or NM residency as another pathway to ABR subspecialty
certificate eligibility in NR.
Currently, the ABR conducts oral examinations to
ascertain the qualifications of DRs who have studied NR.
In the near future, this examination will be transitioned
to a computer-based format while maintaining compre-
hensive content. “A board-certified nuclear radiologist is
one who has demonstrated knowledge, problem-solving,
and application of those skills to a degree worthy of the
public’s and the profession’s trust. This is someone
deemed capable of working in various sectors of the field
safely and effectively.” [7]
MAINTENANCE OF CERTIFICATION
PATHWAYS
The ABR maintenance of certification program for spe-
cialty [20] and subspecialty [21] diplomates includes
continuing medical education, self-assessment modules,
and practice quality improvement requirements tailored
to a diplomate’s specific clinical practice, including NM
therapy using unsealed radioisotope sources. As the ap-
plications, technologies, and methodologies of the radio-
logical and therapeutic armamentaria continue to
expand and develop, the ABR understands that lifelong
learning is critical to ensure that new information and
knowledge are incorporated into clinical practice to
maintain the essentials of quality patient care.
ACR PRACTICE GUIDELINES
For DRs, including those practicing NM, to achieve
consistency in the therapeutic use of unsealed radiophar-
maceuticals, they need to become familiar with the ACR
practice guidelines. These are important educational
tools designed to assist practitioners in providing effec-
tive, high-quality clinical care. The ACR has developed a
collaborative clinical guideline with the American Soci-
ety for Therapeutic Radiology and Oncology addressing
the performance of therapy with unsealed radiopharma-
ceutical sources [22]. Developed from literature review,
expert opinion, open commentary, and consensus, this
Practice Guideline outlines recommended conduct in
this specific domain of clinical practice.
Through training and lifelong work experience, radi-
ologists practicing NM, including radiopharmaceutical
therapies, are able to assist referring physicians in select-
ing and delivering the most clinically appropriate thera-
peutic strategy to meet a particular patient’s needs.
SPECIALTY AND SUBSPECIALTY PRACTICE
OF RADIOISOTOPE THERAPY
On the basis of their education and training pathways,
initial board certification(s) and maintenance of certifi-
cation(s), and NRC AU status, DRs’ participation in
unsealed source therapies usually follows 1 of 3 common
practice paradigms:
780 Journal of the American College of Radiology/ Vol. 10 No. 10 October 2013
● Radiologists who are ABR-certified in DR, but do not
hold AU status: These physicians may participate in
the practice of therapy with unsealed radiopharmaceu-
ticals under the supervision of an AU of therapeutic
radioisotopes. Although they may not issue written
directives for the necessary radiopharmaceuticals, they
may administer such a dose as designated by an AU.
● Radiologists who are ABR-certified in DR and hold
AU status based on that certification: These physicians
may practice radioisotope therapy consisting of oral
radioiodine at all dosage levels under their own AU
qualifications.
● Radiologists who are ABR-certified in DR, with or
without ABR certification in NR, and hold the appro-
priate AU statuses: These physicians may practice as
complete a gamut of oral and parenteral therapeutic
NM as permitted by their own specific training leading
to such AU statuses.
It is recognized that local practice and individual radi-
ologist qualification variations and regulatory require-
ments may, of necessity, dictate site-specific practice
patterns, and radiologists may best participate in practice
according to their special interests and qualifications.
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