Arriving at his new office to assume the mantle of a freshly created hospital-based chairmanship earlier this year, Conrad E. Nagle, MD, understandably harbored a few concerns about how smoothly things might go that first morningand thereafter.

He would, after all, be leading diagnostic and interventional radiologists. As a nuclear medicine physician trained in internal medicine, he was concerned the decision might unsettle some of those over whom he had been placed in authority. Would they instead be more comfortable having one of their own in this post?

The answer, it would soon become evident, was no. “I came into this position bearing no hidden agendas, and I was totally honest with everyone right up front about what I would and would not do,” says Nagle, since January the corporate chief of diagnostic imaging for William Beaumont Hospitals in Royal Oak and Troy, Mich.

Among the things he promised to do was take a go-slow approach when it came to implementing change. “I viewed it as essential,” he says, “that I come in and learn even more about how our hospital system operates, what our strengths were, and make sure I had first-hand knowledge rather than just assumptions.”


Not that Nagle was lacking in first-hand knowledge: he had been with William Beaumont Hospitals 24 of his 27 years as an internal medicine-trained nuclear medicine physician.

“William Beaumont Hospitals started in 1955 in Royal Oak,” Nagle recounts. “That facility is today a 985-bed tertiary care, teaching, research, and referral center. In 1977, our second hospital opened about 10 miles away in Troy; it’s now a 254-bed acute care community hospital. US News and World Report ranks us as one of the nation’s 100 best, and in a total of 10 specialties. We’re also one of the busiest community hospitals in the country, with admissions last year topping 77,250 and inpatient surgeries numbering 23,438.

“In addition to our two campuses, we have three satellite locations around the regionthey’ll increase within another few yearsand each has imaging capability.” Last year, the system performed 625,000 diagnostic imaging procedures.

Notably, radiology and nuclear medicine are organized as separate departments at each hospital (thus, Nagle oversees two nuclear medicine and two radiology departments). Each radiology department has its own chief, and the two hospitals have separate medical and hospital management. (Nagle earlier was in charge of the nuclear program at the hospital in Troy prior to becoming corporate chairman of nuclear medicine, the post he held until his most recent promotion.)

“The way we’re structured, each hospital is also a semiautonomous facility,” Nagle explains. “That means the Department of Nuclear Medicine at Royal Oak has a different staff than does its counterpart at Troy, and while they each report to the same corporate chief, each enjoys considerable freedom in deciding its own direction. The same is true of the two radiology departments.

“This arrangement allows each department to be run in such a way as to best accommodate the differing expectations of the referring staff at each hospital. It also allows for there to be independent nuclear medicine physicians whose sole responsibility is nuclear medicine, not radiologists who do nuclear medicine at the end of the day after having done other radiology activities.”

Nagle’s current position did not exist until he agreed to accept it. It was created, he indicates, to relieve the corporate and department chairmen lower down of decision-making tasks that had become overburdening, tasks such as the legwork involved in making equipment acquisitions, in developing new imaging protocols, and in expanding the outpatient, off-campus sites. And although Nagle possesses authority to decide what equipment the departments ought to acquire, he demurs that such is not his style.

“I don’t consider autocratic rule a valid approach to management,” he notes. “My mission is to coordinate those various activities for the department chairmen without reducing their independence or otherwise taking away from their drive and expertise. I gather recommendations from the radiologists and nuclear medicine physicians and then try to bring them together at the table to work out any differences in those recommendations.

“So, really, it’s the radiologists and nuclear medicine physicians who are making the decisions; I’m just the coordinator of the process and the one who will relay to senior administration their wishes. The fact that I coordinate purchases for both radiology and nuclear medicine means those acquisitions can be done more economically. Since they can be made more economically, the hospitals will be more inclined to make those purchases in the first place.”

Still, Nagle believes his jobwhich he sees as a value-add rather than an added layer of bureaucracyreflects a recognition higher up in the enterprise of the growth and growing importance of imaging. As he puts it, top administrators are discovering that “the interrelationship of imaging to other specialities is becoming more complex at the same time it’s becoming more important medically and economically.”


The few changes implemented thus far by Nagle have been winners in the eyes of radiologists and nuclear medicine physicians alike. One of the first he unveiled called for exploring the replacement of older PACS workstations (each hospital possesses its own dedicated version of departmental-level PACS) with new, ergonomically refined models that will improve user comfort and protect health even as they enhance productivity and the quality of reads.

Nagle’s new role also takes him into areas of business development, where he wants specifically to shore up reimbursement-related weakness.

“Poorly reimbursed inpatient services and the high cost of providing images on film via courier to referring physicians off-campus put the hospital system at a competitive disadvantage against small, freestanding imaging centers that provide nothing but better-reimbursed outpatient services,” he says. “To erase some of the edge held by those freestanding centers, we’re planning to invest in web distribution for purposes of delivering images electronically to outside physicians. By some point this summer, we expect to begin integrating web distribution via PACS. We want to be able to deliver images not only to our 2,400 referring physicians’ offices, but to their homes as well: wherever they need to receive them.”

Accordingly, the William Beaumont Hospitals’ information service (IS) department has come under increased pressure to make technology do more for radiology and nuclear medicine.

“Already, we’ve gotten IS to expand our PACS capability by developing an internal network so that the nuclear medicine physicians and radiologists at one hospital can pull up the studies performed at the other,” he says. “A case where such accessibility can be invaluable is when a patient has a heart study in the emergency department at Royal Oak and they want to compare that to the results of a heart study the same patient had undergone on a nonemergency basis a year earlier at the Troy hospital.”

Significantly, this PACS-to-PACS network is expected to play an important part in advancing the hospitals’ positron emission tomography (PET) utilization.

“Currently, because of restrictive state certificate-of-need regulations, we’re able to offer PET services only from our Royal Oak campus,” Nagle notes. “However, in order to provide access to PET elsewhere in our system, IS is establishing at Troy a complete terminal viewing capability. This will make it possible for referring physicians there to discuss cases with their local nuclear medicine physicians even though the study itself had to be performed at the distant other hospital. It also will permit us to strengthen Troy’s medical and business links to PET, not to mention giving us the capability of fully training our Troy physicians in PET, despite the absence of an on-site scanner.”

PET had been offered at the Royal Oak facility for about a decade now. The next step, as Nagle saw it, was to combine PET with CT. However, that could not occur unless the existing PET unit’s volume increased to a level sufficient to satisfy state requirements for the acquisition of a second PET scanner (this added scanner would be the one paired with CT). This meant seeing four PET patients more in the span of a day than the nine that had been the previous maximum. The only way such would be possible were if the PET physicians and technologists agreed to work longer daily hours and start scheduling appointments on the occasional Saturday as well, which, in response to Nagle’s entreaties, they did: from 7 AM to 10:30 PM, increasing capacity to 13 patients daily.

“When it came time to submit to state authorities the request for a second PET scanner, we simultaneously asked permission to acquire the CT machine; the requirements to qualify for that CT scanner were much, much easier to meet,” says Nagle, who adds that he also worked quietly behind the scenes within the hospital system to secure funding for construction of the PET-CT suite, along with capital to pay for modifications necessary to support the unit on the PACS-to-PACS network.


Siting of PET-CT equipment typically poses a problem for hospitals in that it may not be readily apparent where best to place them. Some prefer locating the scanners in the oncology area, but at William Beaumont Hospitals, they’re in the Royal Oak nuclear medicine department.

“Ours are set up with a control room in the middle and the respective machines at either side of that,” says Nagle. “From an efficiency standpoint, this makes a great deal of sense.”

Another challenge associated with the development of a PET-CT service is the question of whether interpretations should be performed by a nuclear medicine physician, a body imager, or both.

“If you want a study that includes PET and CT to be read maximally, it would be wonderful to have two expertsone in CT and one in PETsitting side by side throughout the day,” says Nagle. “However, the economics of that make such an approach unrealisticat least in the short to intermediate termbecause there’s no reimbursement system to accommodate that. Reimbursement has to catch up to the reality that the medical data being dealt with in PET-CT is very sophisticated. When it does, it will pay to have the proper people jointly look at the images. Until then, the economic pressure will be such that only one person performs the interpretation.

“Here at William Beaumont Hospitals, it’s the PET-trained, PET-experienced, CT-trained, CT-experienced nuclear medicine physician who performs the reads. That said, I nevertheless expect in the next 12 to 24 months, as our volumes grow, to hire a radiologist who might spend 50% of the time in PET so we can tap into an expert in CT and from there have that expertise shared with our PET-trained nuclear medicine physicians. The idea is to be able to grow the CT expertise among the nuclear medicine physicians.”

These same issues arise with the technologists who will position the patients and operate the scanner. “With the acquisition of a PET-CT scanner, we decided to hire a radiology technologist trained and experienced in CT,” Nagle explains. “Our intent is to train that individual in PET and have that individual be responsible for the CT operation and the training of our PET technologists in CT operation. We had the good fortune to find a technologist who has both ARRT [radiology] and CNMT [nuclear medicine] credentials. The technologist has worked in nuclear medicine, CT, and MRI previously. The certifying boards have done a good job working together to allow qualified technologists from either specialty to become certified in CT. This will allow technologists to increase their skills and be cross trained.”

Oncology patients at the Royal Oak facility account for the bulk of patients receiving PET studies. Accordingly, PET’s availability is marketed almost exclusively through internal education at medical conferences. “For example, our PET doctors regularly attend the thoracic tumor conference and the medical tumor conference,” says Nagle. “At almost every one of these conferences, we display PET images, which typically leads to a very vigorous discussion as to whether the PET images were helpful.

“We’re going to be working with radiation oncology physicians and researchers once we have our second PET unit. At that time, we’ll be not only in a better position to accommodate all our clinical demand but also in a far better position to work with radiation oncology services to do cutting-edge simulation studies and help them look at a variety of questions related to their research protocols.”

Nagle reports the PET service is growing about 30% a year, which compares favorably to the national average of about 18% per annum as tracked by the Washington, DC-based Healthcare Advisory Board.

Obtaining sufficient radiopharmaceuticals in the face of such growth is not an issue because William Beaumont Hospitals owns a cyclotron. “We can produce all the radiopharmaceuticals we need, right here,” says Nagle.


Currently, there are 25 nuclear medicine cameras spread across the two-hospital enterprise, the output of which is handled by a combined total of 10 full-time nuclear medicine physicians. The result is that William Beaumont Hospitals can provide a full gamut of nuclear medicine services, almost every type of study the field can offer. Most often requested by referring physicians are thyroid evaluations and thyroid therapy.

“We have three sites within our system dedicated to these,” says Nagle. “Taken together, these sites add up to one of the nation’s larger thyroid evaluation and therapy practices.”

Since the Troy hospital is without a PET scanner, the nuclear medicine department there has sought to take up the slack by developing a position in SPECT-CT. Nagle finds that demand for this SPECT-CT offering is on the rise, fueled primarily by interest from orthopedists who recognize its usefulness for the imaging of small-joint bones, but who at the same time prize the anatomic localization made possible with the hybridized CT.

“SPECT-CT helps us overcome one of nuclear medicine’s past greatest shortcomings, the inability to precisely locate whatever it is that’s been detected,” he says.

Growing, too, is the popularity of 3D imaging. Previously, radiologists and nuclear medicine physicians almost uniformly downplayed the idea that 3D imaging could supply clinically useful views. Now, however, technology’s swift march forward is beginning to change minds.

“In a growing minority of cases, 3D imaging is no longer just a novelty way to show pretty pictures,” says Nagle. “3D systems are beginning to advance to a level where they can answer questions that before could be gotten at only through surgery. For example, trying to get a handle on the actual configuration of a bone fracture. Previously, you could know the fracture was there, but you couldn’t make fully informed treatment decisions, presurgery, because you had no information about the dimensions of the fracture.

“We’ve developed a 3D imaging lab through which referring physiciansorthopedists, neurosurgeons, vascular surgeons, mainlyare being educated about the importance and value of 3D imaging.”

In conjunction with his new duties as corporate chief of diagnostic imaging, Nagle is attempting to develop means of leveraging nuclear medicine capability throughout the enterprise. A perfect illustration comes in the form of nuclear medicine pregnancy screenings. It so happens that the two hospitals arrived at their protocols independently of one another, which resulted in slight but noticeable variances. To prevent those patients from having different experiences at each facility, representatives of the two nuclear medicine departments gathered at Nagle’s behest for a series of meetings to iron out those disparities and come up with a single, unified set of protocols, Nagle says.

Nuclear medicine also is becoming leveraged throughout the enterprise by means of new partnerships with radiology. For example, the radiology departments’ interventionalists have developed a service to treat liver metastases with sirspheres and hepatocellular carcinoma with theraspheres, and nuclear medicine has assisted in setting forth the physics parameters and the radiopharmaceutical requirements of such a service.

“Beyond that,” says Nagle, “we’re talking with neuroradiology about something similar for intervention with certain brain tumors. I think as some of the recently researched monoclonal therapies come to fruition, we’ll see more of these kind of therapies, some of which may turn out to need deeper cooperation yet from nuclear medicine.

“That’s going to lead, I believe, to the creation of a nuclear medicine division of therapy, a division that will be dedicated to therapy.”

The most important nuclear medicine referrers at William Beaumont Hospitals turn out to be thoracic surgeons (they were the first to truly embrace PET for spotting lung cancers), followed by head-neck surgeons and others who, in previous times, might have been disinclined to use nuclear medicine for anything other than bone scans.

“We’ve seen more surgical referrals, but I think that will decrease and be replaced by increased referrals from medical oncologists because PET is evolving into a modality that finds more ways to determine therapy success or failure well in advance of when it would otherwise be clinically obvious,” says Nagle. “In non-PET areas, we’re continuing to be strong in our relationships with endocrinologists because we do so much thyroid work with them. Typical of what we do there is go into the preoperative area and inject radiopharmaceuticals for the surgeons who are going to use a gamma probe to do sentinel lymph node procedures.”

But there also have been some declines in referrals. Mostly, these have come from cardiology. “Cardiology,” shares Nagle, “has been developing its own nuclear medicine capabilities for stress testing in low-risk and intermediate-risk areas.”

Not to worry. Enough innovation is arising from all quarters of the nuclear medicine field to keep the team at William Beaumont Hospitals busy far into the future. Says Nagle, “When nuclear medicine is practiced well, it’s clinically productive and economically profitable. And here at our hospitals, nuclear medicine is certainly both.”

Rich Smith is a contributing writer for Decisions in Axis Imaging News.

Musings on the Future

Where will nuclear medicine be 5 years from now? In much stronger shape than it is today, predicts nuclear medicine physician Conrad E. Nagle, MD, corporate chief of diagnostic imaging for William Beaumont Hospitals in Royal Oak and Troy, Mich.

“Just look at what’s happening with nuclear medicine tracer techniques: because of things like monoclonal antibody therapies, the value of our service on the research side alone is greatly increasing,” he says.

Nagle also believes that “there will be new relationships, such as between radiologists and cardiologists with CT-angiography. In the course of that, nuclear medicine’s role in stress testing will come under scrutiny, as it should, but that does not mean it will go away. It may change in some fashion. For example, what we’re exploring here is, instead of doing the traditional nuclear medicine stress-and-rest test, we might look at doing just the stress portion.”

Another trend he foresees: an increased disappearance of residency routes into nuclear medicine for newly minted internal medicine doctors.

“Over time, we’ll gradually see more nuclear medicine provided by radiologists than already is the case,” Nagle speculates. “No surprise there. A decade ago, the majority of nuclear medicine studies61%were done by radiologists as opposed to internal medicine-trained nuclear medicine physicians. However, in my view, it isn’t all that important whether nuclear medicine is provided by an internist or a radiologist. What is important is the matter of that individual being well trained in nuclear medicine and then performing the studies on a dedicated basis, not at the end of the day as an afterthought.

“Here at William Beaumont Hospitals, we don’t shy away from hiring a radiologist in nuclear medicine. We look for the person who has the best qualifications.”

Perhaps the most reassuring development will be a nuclear medicine growth rate nationally of 5%-7% annually. “I’m more convinced than ever that nuclear medicine techniques remain valuable and will enjoy increased demand,” he says.

R. Smith