Nuclear Pharmacy: Scientific, Specialized, and Radioactive

Timothy Burke, PharmD, is a relief pharmacist at a CVS and a nuclear pharmacist at GE Healthcare in Grand Rapids, Michigan. He sat down with me to discuss his nontraditional career path.

Question: Welcome everyone. Matt Paterini here with The Nontraditional Pharmacist, part of The Pharmacy Podcast Network. I'm joined today by Dr. Tim Burke. Really excited to have Tim on the show today, because Tim is a nuclear pharmacist, and I think a lot of times in the nontraditional pharmacy world, we see nuclear pharmacy pop up on the list, yet I don't think a lot of people know what nuclear pharmacy is, what it entails, and what it's all about, myself included. I'm excited to hear Tim's story today. Tim, we really appreciate you coming on the show today.

Answer: Yeah, thank you very much for having me on here. I hope it's not glistened up too much right now, but I think we'll be able to walk our way through it. I'm happy to be here and talk a little about nuclear pharmacy and let more people know about some of the opportunities that are out there besides the traditional pharmacy roles that we think of.

Q: Awesome. That's exactly what we're looking for and what I think people listening to the show are looking for. Let's start with kind of a basic question we like to ask all of our nontraditional guests. Give us a little bit of background on your path through pharmacy, how you started, where you've been, and how you've gotten to where you are today.

A: Well, when I graduated from high school, I didn't really know necessarily when I wanted to do. Like a lot of high school grads, you go off to college, and I knew I was into science but didn't really know what direction I wanted to take from there. Went down to Baylor University thinking that I wanted to be a forensic scientist, and it was right when the CSI craze was all the rage. That sounded pretty interesting to me, saw a couple of autopsies, and found out that wasn't for me. I realized that I needed to go into something else.

I had a cousin who was at the University of Texas Pharmacy School at the time, and he told me all about pharmacy and the opportunities that were out there, and so, I was like well, you know, I've [already] been taking those kinds of classes. I'll try and go that route. While I was there, my parents moved from Michigan down to Arkansas, so I went there for pharmacy school and was fortunate enough to go to a school where we had a nuclear pharmacy program. There is Dr. Nicki Hilliard, who if you say her name in the nuclear pharmacy world, everybody knows her. Not to mention, I think she's actually the [American Pharmacists Association] president-elect. And so, she's obviously made her mark in the pharmacy world. She was the one who got me interested in it. I did an internship with General Electric (GE) Healthcare up in Grand Rapids, Michigan, between my P2 and P3 year and loved every minute of it. But nuclear pharmacy is kind of a small niche to get into. There's not a whole lot of turnover. So, I had to pay my dues, do a little bit of retail work for a year and a half, and then when GE came calling, I decided that that was a good route for me to go and have been there for about 7 years now and loved every minute of it.

Q: Wow. That's awesome. So, you've spanned some geographic space down from Arkansas up to Michigan. Where does that leave you in terms of sports affiliations?

A: Well, you know I nearly planted myself in front of my Michigan flag that says, "those who stay will be champions," because I know you guys obviously are all U of M Grads and you'd probably appreciate that, and that's always been my childhood team. So, I'm a big fan of the Wolverines, but I will say I was disappointed when they took Arkansas off the schedule for 2018 and 2019 for the Home and Home, because I was ready to wear my Razorback Red in The Big House.

Q: Yeah, we definitely would have appreciated the Michigan flag. It's good to see that Maize and Blue kind of spreads throughout the country. We like seeing that.

Why don't you give us a little bit of an overview of nuclear pharmacy in general? I think just some general background on what nuclear pharmacy is? I think when other pharmacists think of nuclear pharmacy, we think of radioactive substances and things of that nature. But give us some detail around what exactly it is.

A: Sure. The nitty-gritty and the easiest way to describe it is, we compound radioactive pharmaceuticals, and the majority of those pharmaceuticals are for diagnostic imaging only. There's not a whole lot of therapeutic application in what we do. But there is some. The main isotope that we use is called Technetium, and that is what we use for the majority of our diagnostic imaging, but we also do have some applications like I said that are therapeutic. We can use I-131, and we put that in capsules that a patient can actually swallow, and that can ablate their thyroid, take care of thyroid cancer, things of that nature.

There are a couple other drugs out there as well that we can use for therapeutic applications, but mostly you're going to be hearing about diagnostic. The biggest one and I would say probably 75% of nuclear pharmacy's compound is some sort of cardiac imaging agents. The particular one that we make at GE is called Myoview, but if you've ever had someone in your family, like a grandparent or someone you might know that has had a stress test done on their heart, Myoview in all likelihood could have been the agent that was used to image their heart. So, we compound those radio-pharmaceuticals, send them to the hospitals to where they're going to be administered, and then the nuclear medicine technologist there are actually the ones that inject them into the patient and perform the scans with the cameras and everything. But we work in a lab, making all of these things and then send them out with a fleet of couriers. It's all over the state really, to deliver these products to the hospitals so they can use it and make their diagnoses.

Q: Technetium! That sounds something like it's from the future. That sounds crazy.

A: It's not that scary. It really isn't. We obtained this activity from generators, is what they're called, and the parent isotope of Technetium is called Molybdenum. We call it Molly. And you also hear me refer to Technetium as just Tech. But we allude[to] these generators, and pretty much what happens is we take a saline solution that goes through this generator, and all of the Technetium binds onto this aluminum column that you can see that runs through the generator. When we have students at our pharmacy, we've got a cut out of an old generator that doesn't have any activity inside of it. And they can actually see this column, which the saline rinses that technetium off of. What occurs is anion exchange. So, we're getting our chemistry back here a little bit. But the chloride ions from the sodium chloride swaps with the Technetium ion. And what you end up with on the other side, in your evacuated vial is pretty much radioactive saline. So, there is no color to it. It just looks like a normal, regular-old solution. But if you had it unshielded around a Geiger counter, you'd definitely be getting a lot of activity.

Q: That's so interesting ... You mentioned lab work. You mention a lot of the techniques that you're talking about sound to me a lot like research focused almost or kind of more industry-focused? Is it more so related to that than a practicing pharmacist? Do you see any comparisons with more of the research side of things?

A: A little bit. There's definitely a little bit of crossover there, but this is very patient-specific. You're drawing up a dose for a patient, at a particular time, and it's intended for that 1 person. There might be some crossover between research, but this is patient-oriented, it's just that you don't get that patient-pharmacist interaction. We are on our own site, where we compound all of these things. It's not a hospital or anything like that. So, from that aspect, I guess you could say that we're in a lab, and it's kind of for chemistry nerds, we enjoy it, we love it, but it is for a particular patient. A lot of the times there is a patient name actually associated with the dose that you're dispensing. So, it's kind of a hybrid. It's a little bit of both worlds there.

Q: OK, that makes a lot of sense. Walk us through a little bit of your day-to-day responsibilities. You said it's kind of a hybrid of lab work but it's patient focused, so what do your day-to-day responsibilities look like? Take us through a typical day as a nuclear pharmacist.

A: Part of that has to do with what shift you're working. This is 1 of the big things that turns people off to nuclear pharmacy, is you do have to work some night shifts, so kind of that third-shift work that a lot of people don't necessarily want to work. For some people, they find a lot of benefit in it, and other people think that it's not the greatest. But for us, it works out really well, because say there's a hospital that needs a dose at seven o'clock in the morning. Well, that dose has to be made, compounded, packaged up, shipped out with one of our drivers, and get to the hospital before 7 a.m. So, obviously we have to make that well before the dose is going to be administered. And that's usually going to be in the middle of the night. A lot of people ask me, you know, why don't you just [it] make the day before? The problem with that is, we've got sterile compounding restrictions, where a lot of these drugs are only good for, say, 6 to 12 hours. And so, if they're only good for 6 to 12 hours, we can't make it that far in advance.

The other problem is we're working with radioactive substances that decay over time, and because they decay over time, Technetium has a 6-hour half-life. If we want to make a dose for a patient that's going to be 12 hours later, we need 4 times the activity to prepare that dose at the time, and we're preparing it, versus when it's actually going to be administered to the patient. And so, it's not very cost-effective for us to make something that far in advance, because we're using so much more activity for a dose, because it's so far into the future.

Q: So, it sounds like some later shifts and the schedule can vary. How does that affect work life balance? Do the shifts change from week to week? And how does that fit in with your personal life?

A: Well, like I said, some people look at it in a positive way. Other people look at it in a negative way. That third shift is actually probably our most active shift. That's when we're compounding the most. It's when we're making the most doses. You're staying very involved while you're there. And so, it's not like a third shift that you might think of where the store is dead and you're just struggling to stay awake. It's nothing like that. It's when we probably do 80% of our compounding and dose drawing. So, because of that, you're staying active, you're doing other things, and so, you don't even really think about what time it is, short of when you have to drive in. Obviously, nobody likes driving in at midnight.

But the other shift that we have is kind of a typical first shift. It's from about 8 a.m. to 4 p.m. Now, of course, this is going to vary from pharmacy to pharmacy. You have some pharmacies that might be open from 3 a.m. until 3 p.m. Some pharmacies ... might be open from midnight until 5 p.m. the next day. So, it really can vary from site to site. But because of that, there are going to be 2 shifts that you could be working. Depending on if you've got lots of pharmacists because you're busy, there might be 2 or 3 different types of shifts that you could work. But for myself, I feel like it works out very well for my work-life balance. I've got 2 kids at home, a wife, and dogs, and to know that even if I'm working third shift, I can be home for supper. You can have all that family time. But if you're working first shift, you're getting out at 4 p.m. or 5 p.m. and you can do those same things. When kids grow up, I'm not going to have to worry about whether or not I can make a soccer game or a band concert or something like that. So, from that perspective, I do think it provides a little bit more family-friendly shift than say you're 9 to 7 or 9 to 9 that you might be working in the retail world.

Q: Yeah, work-life balance is so important. I think going through pharmacy school and even post-graduate pharmacy practice, it's not emphasized a lot. So, it's good to hear that you keep that in consideration. And it's really a big part of how you work in your professional and your personal responsibilities. So, on that note, for your personal and professional goals moving forward, how does the role that you're in right now help you to achieve those? Are you where you want to be? And what's next or in the future for you?

A: Right now, I'm very happy with where I'm at. I work with 2 other pharmacists that are great. I couldn't have 2 better partners out there, 1 of which is my pharmacy manager. The other 1 is the pharmacist that I switch shifts with every couple of weeks, working third or working first shift. So, I'm very happy where I'm at right now, works great for my family life like I say. But there are ways that you can kind of climb the ladder in nuclear pharmacy, just like you could in any other area of pharmacy. One of the things that my partner does, is he [is] what's called our radiation safety officer. He is the one who keeps track of all of our equipment, making sure that things are reading efficiently, are constantly the way they should be. He has all the responsibilities with limits on how much activity we can be releasing into the public, things of that nature. So, there's more responsibilities that I could gain over time. There's also management possibilities out there, too. You've got pharmacy managers just at a particular site like you would at a retail pharmacy. You've also got district managers who might be over 5 to 10 to 15 pharmacies, depending on the size of your district, and figuring out all sorts of things associated with that. There's so many factors in nuclear pharmacy that just don't even show their face in any other type of pharmacy setting, whether it be, do you guys have big enough generators to have the activity you need to get your runs out? Do you have enough drivers to supply to all the different areas of the state that you're driving to? There's quite a bit to think about that you never really would have thought of as being a pharmacy role. It's almost more of a business-type role than it is pharmacy.

Q: Interesting. Yeah, I think a lot of a lot of roles are like that, and you know on the surface you can say what nuclear pharmacy is, but there's so much behind the scenes that people don't know. And different facets of the business really, the practice side of things, the operations, the business and everything that goes along with it. So, it sounds like there's a lot of different roles within nuclear pharmacy. What's the landscape look like currently, in terms of the job market? Are there opportunities available? And what does it look like moving forward?

A: Right now, I would say there are job opportunities out there. But if you're someone who might want to stay exactly where you grew up and things of that nature, it's going to be a little bit tougher to find because this is a pretty specialized niche. There's also training that has to be done on top of it, too. So, you have to make yourself marketable to be able to be a nuclear pharmacist. If someone out there has training versus someone that does not, obviously a pharmacy is going to be more interested in hiring that person who is what they call an "authorized user" with the Nuclear Regulatory Commission (NRC), which is a regulatory body we have to deal with. But I would say there is plenty of opportunity out there if you're willing to relocate. That's a huge factor I would say, just because the state of Michigan, at least with GE, we only have 2 pharmacies in the whole state. And then if you include all of the other companies, you know independents, etc., there might be 6 to 8 pharmacies. There's just not nearly as many as you know your CVS or Walgreens that are on most of the street corners that you can find a job at.

So, from that standpoint it is a little bit tougher to get into. But like I say, you can make yourself more marketable. I think there's a lot of advancements that are going on with nuclear pharmacy, and there's even some other roles besides the pharmacy setting that I've told you about, that you can use your nuclear pharmacy education as well. And that would be more of your what they call PET aspects. What we do is SPECT. PET involves using a cyclotron and typically is going to be inside of a hospital. I think U of M might even have 1, and so you can use your nuclear pharmacy degree there as well. There is a little extra training involved with that. There's a lot of opportunity out there, but there's going to have to be a little bit of give and take with where you're willing to work and what kind of role you'd like to have.

Q: Where would people go, pharmacy students and pharmacists ... to do some more research and learn more?

A: Well, the 3 big universities that have nuclear pharmacy programs are Purdue (probably the number one for proximity for us), but also University of Arkansas, and New Mexico is another big pharmacy school. All 3 of those are probably your top 3 for finding information about nuclear pharmacy. There's also a website called Nuclear Education Online, and that is a collaboration between the University of Arkansas as well as New Mexico, and they've got a whole program that you can actually do most of your didactic training to become an authorized user online. So, you don't actually have to go to a class and do all these things, because beyond that, you do have to get more training hours on-site at a nuclear pharmacy. So, that's how you get all of that hands-on training as well. But there is that website, and you can do all of it online, do it at your own pace. It was actually a resource that I used while I was at the University of Arkansas. And I did a lot of those classes while I was doing rotations during my last year of pharmacy school. So, you kind of knock everything out all at once.

Q: So, [there are] a lot of resources available, and we'll be sure to share those with our viewers so that they know where to go to learn more information. But what advice would you give students or pharmacists that are looking to make a career transition? What advice would you give to them if they're looking to pursue nuclear pharmacy?

A: Well, for students, I feel like it's a lot easier. You're out, you're young, you've got a little bit more flexibility, you might not be somebody who's already got a family and established in a job and everything. But for students, I would definitely recommend checking out Nuclear Education Online. I think that's a great place to start, because there's just not that many pharmacy schools out there that offer this kind of information. So, to go to a resource like that would be really beneficial. They get to see a lot of pictures of what we use, the shielding that we use, how we compound things. It's very informative there. There's also links off of the University of Arkansas, that might even go over to Purdue University's website, of more pharmacists like myself that have been interviewed and talked about what they do and probably more extensively than what I've gotten into. We certainly could get a lot more in-depth if we wanted to. But that would be a great starting point for students, and I would say if you if you're interested in it, get it done, get yourself marketable, because that way if you realize that retail or the hospital or a clinical pharmacy setting isn't necessarily for you, you've already taken the steps to be able to do this kind of role.

As for pharmacists that are already established in a job, I've had a few inquire already about this job and what all is required of you in order to become a nuclear pharmacist, and that tends to be the biggest roadblock is that you've got to do all this didactic work, and then on top of that you have to have 500 hours of actual work at a nuclear pharmacy before you can even apply to the NRC to become an authorized user. And so, when they hear that, and know that they also need to hold down their other job, because obviously a lot of people can't just stop working, that makes it a little bit tougher. So, I will admit there can be some roadblocks but no more difficult than going back to school to change what you wanted to do to begin with, and how many people are doing that these days? So, it's certainly a manageable thing, but I understand it's a little bit more difficult for them.

Q: Very true. Very true. Well, thanks for the insight into nuclear pharmacy, Tim. We like to talk a little bit with our nontraditional guests about their take on the pharmacy profession in general, because we think you have a unique perspective on the field of pharmacy, doing something different than a lot of other pharmacists. So, what are your thoughts on the field of pharmacy in general and the future of the profession?

A: You know, really, I feel like the possibilities could be endless. It seems like even since I'm graduated, and I've only been out since 2009, I think we were able to do flu shots, but beyond that, I don't really think there was much going on in the way of immunizations. Now we're doing Zostavax, DTap. We're doing all these different things. And then also many states are allowing us to use our clinical judgment. We're able to make therapeutic substitutions. If we get an error from an insurance company, we can substitute with the product that they'd prefer, just like they would at a hospital with their formulary. I think the more that we're allowed to use our clinical knowledge, the more ways that pharmacists could be used. We're a great resource to the public. We're a lot more accessible than doctors are a lot of the time. So, I feel like really, we could do anything and then now, too, they've got residencies that are going up to 3 years. You're talking about a lot of higher education right there. And so, I think it's just a matter of state board of pharmacies and things of that nature allowing us to use that knowledge, and then really we could go anywhere.

Q: Well, there you have it. Scientific, specialized, and radioactive is Dr. Tim Burke. Tim, we certainly appreciate you joining us on The Nontraditional Pharmacist. We'll be sure to share the resources that you've shared with us, with our viewers. Everyone please connect with Tim at The Pharmacy Network on The Nontraditional Pharmacist. Tim, thanks again, we appreciate it. And we will talk to everyone next time on The Nontraditional Pharmacist.

A: Absolutely. Thank you very much, Matt, I appreciate you having me on.