Perspectives on a Pilot PGY-5 VIR Nuclear Medicine Rotation

By Austin Shinagawa, MD (PGY-5, KP VISLA)

Published 8/10/2025

Source for above is the ACGME requirements for VIR residency.

Per ACGME requirements, each resident in an integrated endovascular & interventional surgery (EVIS) residency “must complete a minimum of 700 hours of training and work experience under the supervision of an Authorized User (AU)” (which can include 80 hours of didactic education). This number of hours is fulfilled by 4 months of training in nuclear medicine. If EVIS residents have one nuclear medicine rotation per year built into their training pathway, then a nuclear medicine rotation would still be required in the PGY-5 year. However, by this point, the EVIS resident will have already completed their CORE certifying exam and transitioned into their last two years of interventional training.

The breadth of disease states which EVIS is able to intervene upon is only continuing to expand, and concurrently, the depth and amount of clinical training needed to appropriately care for these patients is increasing as well. Therefore, the question of “What is the best training pathway for EVIS residents?” must again be confronted. Although a relatively “minor” change, optimizing the PGY-5 nuclear medicine rotation is one such way that an EVIS resident can become more well prepared for real world practice. I will discuss my experience with a recently completed pilot PGY-5 nuclear medicine rotation with an emphasis on radioembolization and oncology.

The overall goal for this rotation was to become more well versed and comfortable with radioembolization, particularly dosimetry, as well as the comprehensive management of hepatocellular carcinoma (HCC). The changes incorporated into this pilot rotation to aim to achieve this were as follows:

I spent a day each week performing radioembolization planning and treatments with my EVIS attendings. This was a helpful opportunity to apply dosimetry concepts I was studying to real-world cases as well as also refresh my operative skills. Serendipitously, we had an in-service during this month for resin microspheres and so I was able to become more familiar with this treatment option as well.
I spent a few days with the radiation oncology residents and attendings learning about their specialty. Specifically, I learned about how radiosurgery planning and treatment were performed, got an orientation to EBRT planning from a dosimetrist, had a preview of the entire workflow from clinic to treatment, saw patients in radiation oncology clinic, and participated in brachytherapy procedures. My general understanding of the workflow of radiation oncology, the relative benefits and limitations of EBRT/SBRT, and my relationship with the radiation oncology residency were all improved by this experience.
I spent a few days in clinic with our medical oncologists. During these days, I was able to see both new consults and follow-ups, discuss how to select the best therapy for patients and when to change therapies, learn more about the systemic options for several cancers (not limited to just HCC), and also see firsthand the oncologists’ relationships with their patients. This was an invaluable experience and I think one of the most valuable takeaways for me was learning tips for discussing cancer with patients.
I spent a day in hepatology clinic with one of our transplant hepatologists. I was fortunate enough to see patients both being evaluated for transplant and those who had already received a transplant. I learned more about how hepatologists approach liver disease and also performed an ultrasound elastography. Although I only spent a day with them, I think it was a day well spent, if even only build to stronger relationships with the hepatologists at my hospital. Also, we are incorporating their informational booklet on nutrition in liver disease (created by the hepatologist I spent time with) into our own clinic, so that it is more readily available to patients.
I spent a day with the nuclear medicine technologists to learn about their work behind the scenes for both the Tc-99m MAA mappings and Y90 TARE treatments. I learned how the lung shunt was calculated, how the residual dose is measured, and also how the Yttrium-90 is prepared, checked, handled, and stored.
I was responsible for running our weekly multidisciplinary liver tumor board. This was helpful for building my efficiency at interpreting liver imaging as well as strengthening my acumen for determining the best treatment option for patients with not only HCC, but also cholangiocarcinoma and hepatic metastases. I also was fortunate to participate in our recently instated monthly portal hypertension conference with the gastroenterology attendings and fellows, which we are all looking forward to continuing.
Finally, outside of work hours, I spent time studying the hepatocellular carcinoma guidelines (including AASLD, EASL, and NCCN), dosimetry guidelines on both glass and resin, and listening to the recently released BackTable series on dosimetry. Based on my readings, I was able to compile a document reviewing hepatocellular carcinoma (which I am hopeful to soon share through WCVIS) and am also preparing a talk on dosimetry to the diagnostic residency.
During this month, I also continued to participate in our daily morning EVIS conference and weekly half-day of EVIS clinic. I also still spent about two days on average each week interpreting nuclear medicine imaging.

Overall, my impression was that this month was incredibly high-yield for EVIS training and we hope to continue to implement it and improve it for the junior residents. I also believe it is a fair framework for other residencies seeking to optimize the PGY-5 nuclear medicine rotation for their own residents.

I would be remiss if I did not mention that this experience would not have been possible without the flexibility and support of the nuclear medicine rotation director and diagnostic program director and the openness and generosity of my radiation oncology, medical oncology, and hepatology colleagues. I express my sincere gratitude for everyone involved.

If you have any questions and/or would like to discuss this experience further, please reach out to my email at austinshinagawamd@gmail.com.

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