When Dr. Erica Cohen began looking for employment after her nuclear medicine training, she saw then what many graduates are still seeing today. "It is scary out there," she confided. "I certainly felt the fear myself. Even though I have credentials next to my name, I was not really sure where I was going to end up."
Cohen considered options in academic and private settings, as well as alternative career pathways such as consulting because of the difficult job market. In the end, her persistence paid off. Today, Cohen is chief resident in the department of nuclear medicine at Loyola University Medical Center.
Although her efforts were successful, a survey published in the March issue of the Journal of the American College of Radiology explained in numbers what many nuclear medicine residents like Cohen have felt firsthand. That is, job openings are few and far between, and nuclear medicine residents are concerned about their perceived or actual inability to accurately read radiology images.
While many residents are still looking for work, others have been hired and are contributing to their imaging departments; however, it wasn't easy, according to the survey (JACR, March 2014, Vol. 11:3, pp. 221-224).
The most-cited challenge to employment is the growing trend of employers requiring dual board certification in nuclear medicine and radiology, spurred by the need for night and weekend call coverage. During the day, large radiology groups may have several dozen radiologists working in a practice; such operations may also have a few highly specialized readers who, for example, exclusively handle breast, musculoskeletal, or neuroimaging.
During off-peak hours, though, readers with more diverse training typically are on duty for an emergency chest x-ray, ultrasound, or perhaps a CT or MRI -- modalities that aren't part of standard nuclear medicine training. What's a resident to do?
Off-hour duties
Cohen works from 8 a.m. to 6 p.m. Monday through Friday and contributes when called upon at night or on weekends. At Loyola, nuclear medicine residents are responsible for any emergency cases that arrive overnight or on the weekend. There is also a radiology resident who is always in-house or on call on nights and weekends.
"But if there is anything like a gastrointestinal scan that comes in, it is the nuclear medicine resident who comes in to take care of it," she said.
Still, Cohen said, there are certain places that prefer having staff trained exclusively in nuclear medicine. It seems to be most common in the U.S. Department of Veterans Affairs health system and in practices that maintain their own separate nuclear medicine department from the radiology department.
"The reason that some nuclear medicine groups prefer to hire pure nuclear medicine graduates is because they believe we produce better-quality interpretations, we are more comfortable with the modality in doing therapies, and we are more experienced than, say, a radiology graduate who has four months of nuclear medicine training compared to our three years," she said.
Cohen also believes there may have been some "polarity" in the findings of the JACR employment survey.
"I find it interesting that there are comments about nuclear medicine graduates either feeling inadequate in cross-sectional imaging or being perceived as inadequate," she said. "But there has not been as much attention paid to radiologists and their proficiencies in nuclear medicine."
More applicants, fewer jobs
Even so, the numbers are not in nuclear medicine's favor.
"We have been graduating many more residents than there are available positions," said Dr. Daniel Lee, director of the PET scholarship program at Emory University. "That has led to a lot of handwringing on the part of trainees, which is certainly understandable."
Lee also serves as chair of the Nuclear Medicine Program Directors Association and as associate program director for the nuclear medicine residency and fellowship programs at the Society of Nuclear Medicine and Molecular Imaging (SNMMI).
He concurred that nuclear medicine residents without additional radiology training are at a disadvantage in the job market.
"What is interesting now is that given all the downward pressures on imaging in terms of coverage and reimbursement, some valid criticisms about possible overuse of imaging, the costs associated with imaging, and the radiation burden of unnecessary imaging, the job market has tightened up for radiology people as well," he said. "So that has made things even more complicated and challenging for people training in nuclear medicine who don't also have the radiology training. It has become just that much more difficult to find employment."
Diverse training
Dr. Tatianie Jackson, a third-year resident at Stanford University, took a rather circuitous route to her current position. She followed her undergraduate studies at Clark Atlanta University with five years of medical school at Universidad Autónoma de Guadalajara in Mexico.
She then participated in the Fifth Pathway program at New York Medical College for a one-year externship, which covered internal medicine, general surgery, and pediatrics. The Fifth Pathway is required for some students who attended medical school abroad to become eligible to work in the U.S.
Jackson also completed her Educational Commission for Foreign Medical Graduates (ECFMG) requirements for certification in 2010, after which she went to Boston Medical Center, where she collaborated on molecular imaging research and developed an interest in nuclear medicine.
Next up was a surgical residency at Nassau University Medical Center, and Jackson then took up residency at Stanford at the end of 2012.
She said she's seen the benefit of nuclear medicine residents enrolling in a radiology program to obtain dual certification.
"Places are looking for people who can read diagnostic radiology images, so they can pick up the extra slack on call hours," Jackson added. "If you don't do that, they can phase you out."
A little help with a phone call or a recommendation from a friend or colleague can't hurt either when a job becomes available.
"Every edge helps when an applicant competes against several hundred nuclear medicine physicians, radiologists, and fellows who are out of residency for a couple of years and are still unemployed," Jackson said.
Also, there are employed physicians who are delaying retirement for financial reasons. "It is making it extremely difficult for residents like myself who are recently boarded in nuclear medicine and trying to get a secure position," she said.
Jackson is currently involved in several research projects with her attending physician and recently won a poster award for her own research. She is leaning toward pediatric nuclear medicine, which she thinks is underserved.
"There are only about 20 [pediatric nuclear medicine] programs, which includes Canada, and only about 20 to 22 physicians," she said. "I think that is a market where I can sell myself and be comfortable in reading pediatric imaging."
Networking benefits
While skills obviously are critical, Loyola's Cohen advised residents to network, attend meetings, and get involved in committees to help spread their name.
"Having a good, friendly personality goes a long way, and definitely maintain good relationships with the attending physicians that you work with during your residency program," she said.
Cohen has done well for herself in a relatively short period of time. Early in her residency, she became involved with SNMMI (prior to its name change in 2012), and she joined the American College of Nuclear Medicine (ACNM) when she was still in an internship. She also joined the Nuclear Medicine Residents Organization, moving up through the ranks to eventually become its current president.
Cohen also participates on several boards of SNMMI and ACNM, serves as a delegate to the American Medical Association, and serves as a resident representative on the nuclear medicine residency review committee for the Accreditation Council for Graduate Medical Education.
"You need to be an extremely well-rounded resident, meaning you have to do research, you must have publications, and you have to be involved in leadership," Cohen said. "You have to make yourself exceptional because the number of job opportunities available is so slim."
Cautious optimism
Despite the current employment challenges, Emory's Lee said he remains "cautiously optimistic" that the environment will improve, in part because older practitioners who have been deferring retirement eventually will leave their positions.
"I think and I hope the Affordable Care Act may result in more people accessing care," Lee said. "We are on the leading edge of baby boomers who are retiring, and I think there will be a significant number of people who will need more care and more imaging and therapies."
At least for now, the job market is what it is.
"The reality is that unless you are dual-boarded, it is very difficult to find a job, but the pendulum is always swinging," Cohen said. "Since radiology is trending toward specialization, board exams are becoming more specialized. As this continues, there may yet emerge opportunities for people who are more heavily and specifically trained in nuclear medicine."
