My career began over forty years ago. I started in a laboratory as a nuclear chemist, and early on I was introduced to diagnostic imaging, and to me, nuclear medicine was the most interesting of all of the modalities. When I look at how diagnostic imaging has evolved, I see radiology moving from X-ray machines to CT, to more X-rays, then to MRI, and more anatomical imaging; and over the years the stakeholders have worked very hard to introduce more of the same types of machines by making them bigger and faster. Now I don’t wish to take anything away from radiology, because the advances in image quality from X-ray to MRI are remarkable, yet it’s still just anatomy.

Nuclear medicine on the other hand went from the rectilinear scanner to Anger Logic Gamma Cameras in the 1970s; they next moved to SPECT, then PET and now PET/CT, SPECT/CT and PET/MRI. All the time the advancements were focused on the human condition and the function/physiology of the body when in a diseased state.

These advances didn’t just involve bigger and faster machines, as in radiology. No, they were about advancing our understanding of the body’s physiological response to disease and therapy. Yet for some reason nuclear medicine, which, for all of the advances in imaging, should have grown in importance and diagnostic imaging market share, has not. No matter how many breakthroughs are made nuclear medicine plods along as if it is a very mature specialty, with just 2-3% annual growth. Why is this?

Some will say the reason is the technology is too complex. Some claim the images, nonanatomical, are too difficult to read. Others will be convinced nuclear medicine is this strange mix of engineering, medicine, technology, physics, chemistry, pharmacy and short half-lived isotopes that makes it attractive to more scientifically oriented people. They’ll claim all of these reasons limit our ability to use nuclear medicine more broadly. I think this is a piece of the puzzle, but only a small one.

The provision of health care is complex, yet somehow we make it happen. As a business development professional I believe the reason behind the steady yet very slow growth of nuclear medicine is something more obvious. I see many different approaches to the marketplace. Companies or institutions offering products or services can take a market leading strategy and blaze new trails. Or a company may choose to be the next wave in, on the newly created trails. The next wave company is always poised to take advantage of every investment the trailblazing company makes in order to increase their market share and importance.

Nuclear medicine hasn’t chosen either of these viable strategies. Over almost four decades I’ve watched the nuclear medicine specialty take a lead-from-behind strategy. This means when there is a scientific breakthrough, application or device, they wait to see if others find it acceptable before moving forward. This is probably a good strategy if you’re traversing a mine field, but not if you wish to maximize the impact of your contribution.

In an age of health care reform one needs to address the viability of the strategy taken so far by nuclear medicine. Whether this strategy of leading from behind will work with today’s changing health care dynamic is unknown. My observation after four decades of experience in and around the field of diagnostic imaging is that the strategy hasn’t worked very well and I don’t believe the increasing pressures on diagnostic imaging make it likely that the strategy will work better in the future.

Here are some examples of the lead from behind strategy. In the 1980s the nuclear medicine profession stood by passively as cardiologists took over perfusion imaging. A nuclear cardiology specialty was created within nuclear medicine and then the cardiologists separated from nuclear medicine, forming their own society, the American Society of Nuclear Cardiology.

In 1986, when NMR was renamed MRI to remove the dreaded “nuclear” component, nuclear medicine stood by while the radiology world worked diligently to demonstrate they can do the same thing with MRI and CT. How many times do I read an article and think, “That’s already been done in nuclear medicine.” I say it a lot.

Early on, I thought the reason for the passive behavior was because nuclear medicine departments wished to remain autonomous and not become part of radiology. After several years I realized it was just the opposite. Radiology was working to keep nuclear medicine out. If you asked a radiologist about nuclear medicine the almost universal response was, “You mean ‘unclear medicine?’” The radiologist compared the nuclear images to their CT or MRI and called the nuclear images “fuzzy.” They didn’t understand nuclear medicine and saw no reason to spend the time to do so.

In the early ‘90s PET started to emerge as a potential big player in nuclear medicine. But the field was cautious. Some demanded equity in reimbursement and acceptance for clinical practice. Others questioned whether letting PET out into the general diagnostic imaging community made sense. When reimbursement started to emerge in the late ‘90s and early 2000s, nuclear medicine began adopting the modality but, as with nuclear cardiology the nuclear medicine community didn’t do enough to promote and hold on to the modality.

PET took off when it was combined with CT and the hybrid finally produced what the radiologist needed — hard tissue images that, when combined with the PET image, took away the “fuzzy” image problem for the radiologist. Once again nuclear medicine stood by passively as radiology and oncology acquired PET/CT and employed it in freestanding clinics and in hospitals. It was a hit, but not for nuclear medicine.

PET/CT brought a new term to diagnostic imaging, molecular imaging. Unfortunately, and most likely due to the lead-from-behind strategy, others had already grabbed the moniker, setting up their own organizations. One group formed in the U.S. and the other in Europe, to take advantage of the interest molecular imaging was generating. The two groups saw the benefit of coordinating efforts. They developed their own journal and combined resources to form the World Molecular Imaging Society.

Several years after the formation of the World Molecular Imaging Society, the SNM thought it time to consider a name change and became the Society of Nuclear Medicine and Molecular Imaging, the SNMMI. My observation is that the lackluster annual growth of nuclear medicine suggests that the rebranding didn’t work as well as hoped.

What are the leadership issues facing nuclear medicine today? Today all of health care is faced with huge obstacles brought about by changing demographics, anemic economic results, and health care reform created by the passage of the ACA. Leading from behind will not help the nuclear medicine community to find its spot in this changing marketplace.

For the nuclear medicine specialty to secure a larger place in diagnostic imaging, a strategy change is required. No longer should nuclear medicine professionals lead from behind, acting as a cheering squad for others who take the first steps to solve problems that confront the entire nuclear medicine community.

The SNMMI, through its counsels and members, with their formidable experience in the use of radiopharmaceuticals for molecular imaging and radionuclide therapy, must take a leadership, trailblazing position in the diagnostic community if they wish to have a voice in the future of diagnostic imaging. With education, credentials and viable, cost-effective clinical solutions, the nuclear medicine community can lead the way to the diagnostic imaging and therapy management solutions demanded by a fast-paced and changing diagnostic imaging marketplace.

If the lead-from-behind strategy isn’t altered and replaced with a trailblazing strategy I predict the function of nuclear medicine will be absorbed and included with imaging modalities in radiology. The ability to deal with the complexity of the nuclear medicine process will be lost to cost-cutting, leaving the other modalities to fill the void. This would be a disservice to the nuclear medicine community and more importantly to the larger patient population.

Resolving the supply of Tc-99m is critical to the survival of nuclear medicine. It’s a big issue and it’s very complicated. The Tc-99m problem has been front and center since 2009. Here is where the SNMMI should take the leadership role. Someone needs to define what’s needed, chart the path, explain why we must go in a direction, and lead all the potential contributors to the solution.

Rather than take the lead, to date, what the SNMMI has done is applaud every group proposing a solution. That leaves the community with a piecemeal approach to the Tc-99m shortage and no way to determine if the pieces add up to a viable solution. Chalk River and other older reactors are definitely on a path to shut down. Dates aren’t always set in stone but it will happen.

Who, other than the SNMMI, is better prepared to lead the way in solving this raw material supply problem? The answer is: no one.

As the ACA matures, hospitals are forming local oligopolies as they acquire other hospitals, diagnostic imaging clinics, and practices. Cardiologists and radiologists are returning to the hospital and becoming employees. The expectation is that this will be a return to the old paradigm with diagnostic imaging placed back in the hospital.
What does this mean to nuclear medicine? I think it’s pretty straightforward. Nuclear medicine has to step up and take a lead in the way these imaging services are reintegrated into the ACA hospital model. If nuclear medicine stands by passively there will be an integration of nuclear imaging into the newly established diagnostic imaging service, with the very real risk that nuclear medicine will lose its identity.

Within this new ACA-integrated hospital model, nuclear medicine can carve out its own space by taking ownership of its future. That requires educating referring physicians about the importance of the service. It also requires developing a new set of bona fides. The ACA demands increased quality and lower costs for the provision of health care.

Nuclear medicine professionals are uniquely qualified to develop solutions that meet the ACA objectives. Every day they deal with decaying isotopes, on-demand imaging, and no inventory of consumables. Yet they image patients and keep the patient flow moving. Other modalities reach into the supply closet and use a non-decaying standing inventory for their consumables. Nuclear medicine professionals can lead the imaging department in the most cost-effective way of scheduling non-critical patients. Knowing how to schedule and make the most of every hour is what nuclear medicine does better than any other imaging modality.

To remain clinically relevant, nuclear medicine needs to focus on becoming disease specific rather than device specific. Helping referring physicians within the hospital by defining a “best practices” path between disease and device/application will boost the importance of nuclear medicine.

The late Dr. Henry Wagner at Johns Hopkins did this very well. Referring physicians knew that nuclear medicine had solutions. They’d call Dr. Wagner, describe the problem and ask, “What can you do to help with the management of this patient?” Dr. Wagner made certain everyone understood nuclear medicine was an important solution.

An emerging area, targeted radionuclide therapy, sometimes called peptide receptor radionuclide therapy or hormone-delivered radiotherapy, is one in which nuclear medicine should play a major role. There is a major intersection with radiation therapy, just as there was with nuclear medicine and nuclear cardiology back in the 1980s. If nuclear medicine employs a lead-from-behind strategy this emerging application could go completely to radiation therapy, with no involvement from nuclear medicine.

Today, solving the cost and quality puzzle under the ACA is critical. The SNMMI and its members have to demonstrate a willingness and reason for being at the table. Altering the 4-decade old lead-from-behind strategy and employing a trailblazer strategy will be critical to growing the importance and marketplace acceptance of nuclear medicine.

About the Author: Wayne Webster is the founder of Proactics Consulting. Providing business development support services for technology-based businesses, the firm has helped many companies and institutions realize their goals. Learn more about Proactics Consulting at www.Proactics.net.