History

History of the Canadian Association Of Nuclear Medicine (CANM): 1970-1990

The Lineage and Birth of the CANM


The decision to form the CANM was made at a meeting in Ottawa in January 1971. In that era the Royal College of Physicians/Surgeons held its annual meeting in midwinter and its organizational umbrella may have provided the occasion for this gathering.  Other sources reveal that the first President was Donald Wood, then Chief of Nuclear Medicine at the Toronto General Hospital. The correspondence that flowed from the first meeting clearly states that concern for the prevailing standards of education and training of both physicians and technologists provided the major motivation for the formation of the Association. This meeting also launched a formal request to the Royal College for recognition of Nuclear Medicine as a specialty and thereby to permit the development of a national residency training program. The need to develop national standards for the training and credentialing of technologists was also discussed.


Nationally, the cadre of physicians then practicing Nuclear Medicine had varied, not to say often colourful backgrounds ranging from Medicine, Surgery, Radiology, Pathology, Biochemistry, etc. In its earliest days the entry requirement into this work was as little as a three week (or was it 10 days?) course in radiation protection given to prospective nuclear physicians at Oak Ridge, Tennessee. Later, in the 1960s the Atomic Energy Control Board (AECB) and Radiation Protection Branch (RPB) of Health Canada developed a register of physicians given licences to purchase isotopes and to administer them to patients; the criterion for enrolment on this list was certification in any Royal College specialty plus a record of six months of clinical experience working with isotopes. This rudimentary training according to a letter written by JL Chuinard, a physician at McGill, included instruction in radiation safety as well as clinical experience and 50% of the time was devoted to laboratory work (more on that later).  Thus, AECB and RPB effectively became the reluctant foster parents of the infant specialty, a role they devolved to the provincial professional colleges in the mid 1970s.


Although the responsibility for health matters lies with the provinces, the Federal control of isotopes was justified by the history of all things nuclear and the mandate of AECB for the safety of Canadians from nuclear radiations. It is one of the historical anomalies of Confederation that nuclear radiations became a Federal responsibility while x-rays remained with the provinces. Retrospectively, this distinction separating nuclear from radiological safety regulation may also have served to identify the two competencies as different disciplines. Many of the initial nuclear medical practices were set up in cancer clinics, an association that made some sense then insofar as it was logical to lump all isotopes together with cobalt therapy units, therapeutic gold grains, radium sources and the like for regulatory purposes and, by extension, in practice as well. From my personal knowledge, cancer clinics served as wombs for the gestation of Nuclear Medicine in Saskatoon, Winnipeg, London, Ottawa and perhaps elsewhere as well.


Also significant at the national level was that the practitioners of Nuclear Medicine in Quebec had organized themselves and under the leadership of Etienne Lebel, Professor and Chair of Nuclear Medicine at Sherbrooke University,  had developed a formal residency training program and certification by examination process by 1969, a world first.


Internationally, the Society of Nuclear Medicine (SNM), in existence since 1960, was supporting the advancement of nuclear technology in medical sciences and practice; its geographic organization included Canadian chapters and regional meetings. Following the Quebec lead, both and the Australians and Americans announced their intent to found a specialty of Nuclear Medicine in their countries and did so by 1971.

The Royal College in January 1972 rejected the CANM’s first request for specialty recognition but the President personally encouraged a resubmission. Eighteen months later in June, 1973 the College reversed itself and recognized Nuclear Medicine as a specialty. The two factors in favour of the CANM on this occasion were that it had in short order accrued a membership of 48, which impressed the College, and that the Americans in the interim had approved their own Board of Nuclear Medicine.


The ‘bad news’ for the practitioners of the day was the College’s ruling that they would not be grandfathered into Fellowship without examination. Work began at the CANM to define a curriculum of study, standards of training and the examinations for these physicians. Bernard Shapiro, at the Mount Sinai Hospital in Toronto and then the senior nuclear physician in Canada, consented to be the first Chief Examiner with Etienne Lebel as Co-Chief Examiner. Many of the initial applicants for the examinations were mid-career or senior physicians whose anxiety about facing a rigorous exam process at that time of life was understandable. In order to help these candidates, the CANM organized a review course in Montreal in the summer of 1976, the first continuing educational event in our history. The first examinations were held in September 1976. The Chief Examiners’ subsequent report served to justify the concerns earlier expressed over the prevailing standards of knowledge and practice; 63 practitioners sat the written papers of which only 43 passed and of these 7 more failed the oral exam. Analysis of the results identified common weaknesses in the practice of the day and fed into the development of content for the residency programs; Radiologists and Internists had more success than did candidates from other backgrounds and this observation supported the subsequent policy of allowing certificants from these two specialties to sit the exams after only two core years of Nuclear Medicine training.


Following the 1977 examinations Bernard Shapiro reported that there had been only 7 passes among 17 candidates. Therefore, in 1979 we organized a second refresher course prior to the fall examinations, which was held in London and attended by about 40 people including some younger physicians, such as Karen Gulenchyn, who were by then enrolled in formal residency programs. For a week we taught each other through both didactic and informal group study sessions; many long-lasting professional friendships were forged in the course of this exercise.


The examination results were beginning to improve by 1980, due in part to the appearance of second discipline candidates who had by this time completed the mandatory two year Nuclear Medicine core residency program. Following the 1981 examinations Michael Chamberlain, then Chief Examiner, documented in a letter to the Royal College that this was the first year in which all candidates had completed a formally structured residency training program and that the improved success rate had gratifyingly reflected the fact.

Evolution of Nuclear Medical Practice


Since the founding of the CANM there have been dramatic changes in the nature of the practice. Radioimmunoassay, also known as ‘wet work’, formed a major part of the practice in the 1970s and 80s. On this account, from the time of its founding CANM was intimately associated with laboratory medicine and a member of the Intersociety Council of Laboratory Medicine in Canada. I well recall that during my time as a College Examiner in the early 1980s it was a given that there would always be a major question about radioassays on the written exams. It may seem odd to practitioners in 2011 that laboratory work was once an integral part of our activities but recall that imaging only latterly grew out of bench work when rectilinear scanners with focusing collimators made it possible to image discrete volumes of tissue as if they were arrays of ‘in-vivo test tubes’; and we were very proud as a profession when Rosalyn Yalow, an American medical physicist, received the Nobel Prize in 1977 for her role in the development of these assays. Toward the end of the 1980s radioassays progressively gave way to the new technologies and hospitals turned these over to their laboratory services and away from Nuclear Medicine.


Inter-specialty and Organizational Relations


An early activity of the CANM was the annual scientific meeting programs and at first these were held in conjunction with the annual meeting of our Royal College. All specialties except Radiology at that time utilized the College’s meeting umbrella and we profited from it both organizationally and through opportunities for multispecialty interactions.  In 1980 and for four years following, the CANM meeting was held in conjunction with the Canadian Association of Radiology (CAR). This arrangement made the meeting affordable for our non-physician colleagues but other difficulties arose, most significantly being that its timing was too close to and sometimes even coincided with the annual SNM meeting. These complexities eventually forced a decision to organize our own meetings independent of other specialties. The first independent meeting was held in Quebec City in 1986 with our francophone colleagues and more than 300 registrants; it was considered a resounding success.


While the intellectual lineage of our specialty seems, at least to us to be robustly rooted in its basic sciences, at the organizational level we have repeatedly experienced ‘sibling rejection’ on the part of other specialties who, to our perception, crowded around to advantage themselves at our cost; progressively special interests crowded around to take laboratory procedures, therapies and organ-specific procedures such as bone mineral density and cardiac imaging; the processes are ongoing. Given the chronic manpower shortages and under-powered training programs that are not even replacing retirements, the realities of patient care require that in some places compromises will not be avoided. However, the greatest loss has been that as hospital budgets have become ever more tightly constrained, we were forced to concentrate ourselves ever more exclusively on the provision of clinical service to the exclusion of clinical research and development that was a daily part of our lives in those early years. I believe that it is this progressive strangulation and resultant redirection of our intellectual curiosity into mere technological virtuosity that threatens the specialty more now than any aggression from aggressive sister specialties ever have.


The first recorded minutes of the CANM show that the practitioners of the day were as concerned for the advancement and improvement in standards of training and credentialing of technologists as they were for themselves. The Association supported the efforts that led to the modern credentialing role of the Canadian Association of Medical Radiation Technologists (CAMRT) in Nuclear Medicine.


January 1976 a motion was passed approving establishment of a multidisciplinary Canadian Society of Nuclear Medicine since Royal College rules required the CANM to be exclusive to physicians. It was not until a decade later that the Society of Nuclear Medicine in Canada (SNMC) was formed. The CANM archives do not shed any light on the events that led to the metamorphosis of SNMC into Canadian Society of Nuclear Medicine (CSNM).


In 1986 the CANM, under the leadership of Raymonde Chartrand, determined to bid for the 1990 Congress of the World Federation of Nuclear Medicine and Biology (WFNMB). We found ourselves in direct competition with the SNM whose initiative was led by Henry Wagner; that became the most intensely competitive activity that any of us had ever been involved with but, in the end, the effort was rewarded and the meeting was hosted in Montreal with more than 3,000 people in attendance.


Mark Twain once wrote to a newspaper that had erroneously published a notice of his death, saying that the facts had been greatly exaggerated. During my career there have been repeated ‘death notices’ concerning Nuclear Medicine as well. I was in my second year of practice when the invention of the CT scanner was announced; the SNM meeting that year felt like a funeral, people feared the loss of nuclear brain scans would rob them of their livelihood and so on. I myself wondered whether I had hitched my career to a falling star. Eventually it was Henry Wagner who took the podium to tell us to get over it and to remind us that the work we were losing to CT was precisely the anatomically exact work that we, as clinical physiologists, had never been that good at. Similarly, the debut of high resolution MRI early in the 1980s brought on another round of funereal pessimism concerning our future. Yet we are still here and that fact should cause us to take heart for our continuation. Our future will be in molecular medicine and imaging and, since opportunity only happens to prepared minds, we must toil to make it happen. That is why I am so despondent about the state of research in clinical departments today; the future won’t happen unless we address the intellectual frontiers of our discipline every day.


Al Driedger

Archivist, CANM
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