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Report of the 2002 Intersociety Commission Meeting: Radiology 2002—Today's Research Is Tomorrow's Practice

¹ Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109-0030.

Received August 30, 2002; accepted after revision September 3, 2002.

 
Address correspondence to N. R. Dunnick.

Summation statement of the annual summer conference of the Intersociety Commission of the American College of Radiology, July 2002.

Introduction

Top Introduction Radiology Manpower Funding of Radiology Research Training More Investigators Funding Research Restructuring the Residency Conclusion 2003 Intersociety Conference References

 
The American College of Radiology (ACR) 2002 Intersociety Summer Conference was held July 26–28, 2002, in Santa Fe, NM. Representatives from 44 societies met to discuss how we might improve the quality and quantity of radiology research.

The field of radiology has advanced dramatically in the last 25 years. New modalities have either been introduced (MR imaging and positron emission tomography) or improved significantly (CT and sonography). Imaging, including acquisition, interpretation, transmission, and storage, has become electronic. Technologic advances are allowing imaging-guided interventional procedures to have a dramatic impact on patient care, and together these radiologic advances have made a fundamental impact on the way medicine is practiced.

Radiology Manpower

Top Introduction Radiology Manpower Funding of Radiology Research Training More Investigators Funding Research Restructuring the Residency Conclusion 2003 Intersociety Conference References

 
The demand for radiology examinations is outpacing our ability to satisfy that demand. Harvey Neiman, chair of the ACR Board of Chancellors, discussed the shortage of radiologists by presenting the report of the ACR Task Force on Human Resources.

To hold down the cost of medical care in the United States, a variety of managed care plans were introduced in the early 1990s. It was thought that primary care physicians would diminish the need for specialty physicians [1, 2] and that the use of ancillary services such as radiology would fall 30–50%. In 1994, the Council on Graduate Medical Education predicted a 60% surplus of specialists by 2000, which led to cuts in the number of non–primary care residency positions. The Health Care Financing Administration, now the Centers for Medicare and Medicaid Services, froze the number of resident positions at each institution's December 1996 level [3]. This freeze has prevented radiology from responding to the increased demand for radiology services.

The number of medical students entering radiology declined significantly because of both dire predictions for the radiology job market and the reduction in the number of radiology residency positions. The number of medical students entering radiology (both postgraduate year 1 and postgraduate year 2) decreased from 1154 in 1996 to a low of 841 in 1998 (Table 1). That number has only partially recovered to 920 in 2002. This decrease is also reflected in statistics from the American Board of Radiology. The number of applicants for the board examination fell from a high of 1085 in 1997 to a low of 888 in 2001 (Table 2), but has recovered to 1069 applicants for the 2004 examination. However, Neiman estimates that our residency positions, instead of keeping up with the estimated 4–6% increase in radiology work, have decreased by 7%.

The ACR estimates that approximately 390 radiologists retire each year and that approximately 140 deaths occur among radiologists each year, thus accounting for an annual loss of 500–600 radiologists from the workforce each year. The number of retirements among radiologists increased to approximately 800 per year in the latter half of the 1990s, possibly because of the rises in the equities markets. (Recent declines in the market may retard retirements.)

Medicare data indicate that radiologists' workloads increase annually in procedures by 3% and in relative value units by 4.5%. Adding 1% for population increases and 0.5% for changes in population demographics results in an annual increase of 4.5–6.0%.

The radiology workforce, on the other hand, is enlarging by only 2% a year [4]. The 1000 radiologists completing their training programs each year is lessened by the 500–600 radiologists who are leaving active practice.

The shortage of radiologists is seen in both academics and private practice. A review of data from the ACR Professional Bureau shows a reversal of the situation from 1993 to 1996, when the number of radiologists seeking jobs far outnumbered the positions available. In 2000, almost 400 jobs were advertised for fewer than 100 job seekers. From 1998 to 2000, the ratio of radiology jobs offered to diagnostic radiologists seeking jobs increased from 1.3 to 3.8 [4]. A survey conducted by Doug Maynard revealed approximately 600 open faculty positions in academic departments, which is an especially critical deficiency because some of our training programs are threatened by lack of faculty [5].

Radiology has never been more exciting. Imaging technologies and imaging-guided intervention have not only revolutionized our field but have dramatically altered the practice of medicine. Radiology is so important that it must be done, even if there are an insufficient number of radiologists. Gaps in radiology service will be quickly filled by our clinical colleagues eager to perform imaging and interventional procedures. Despite the need to produce more practicing radiologists, the need to train more investigators is even more compelling.

Funding of Radiology Research

Top Introduction Radiology Manpower Funding of Radiology Research Training More Investigators Funding Research Restructuring the Residency Conclusion 2003 Intersociety Conference References

 
Although a shortage of radiologists exists, the money available for radiology research is increasing. Phil Alderson, president of the Academy of Radiology Research, described recent changes at the National Institutes of Health (NIH). The NIH budget is on track to double within 5 years. Several institutes, especially the National Cancer Institute, recognize the increasing importance of imaging and provide significant funding for imaging research [6]. Legislation to provide a new institute, the National Institute for Biomedical Imaging and Bioengineering (NIBIB), was signed into law in December 2000 to focus efforts on imaging and bioengineering research that can be applied more broadly across a variety of organ systems and disease entities [7]. Work then began to establish NIBIB and to provide personnel and funding [8]. Rod Pettigrew was named the first NIBIB director and is expected to assume his duties in September 2002.

NIBIB began with $45 million and received $67 million in grant transfers. This total of $112 million made NIBIB the smallest institute on the NIH campus (Table 3). A committee was then asked to review other NIH grants to see which might be appropriate for transfer to NIBIB. As a result of this review and further negotiations, the NIH has agreed to transfer an additional $150 million to NIBIB in fiscal year 2003. The transfer will increase the NIBIB budget to $262 million, making it still a relatively small institute. The Academy of Radiology Research is continuing to coordinate efforts to lobby Congress to increase NIBIB funding.

Another important effort of the academy is reorganization of the NIH Center for Scientific Review. Many imaging grants are reviewed in organ system– or disease-based committees. These study sections are dominated by nonradiologists who may not understand the uses or potential value of the imaging technology. Because the current reorganization proposal for imaging does not change the review system enough to ensure that imaging proposals will receive appropriate evaluation, the Academy of Radiology Research and other organizations are working for additional changes.

Although a new institute for imaging research has been established and more monies are available, these grants are not reserved for radiologists. Very few radiologists have had training in research methodology. Those who have are often needed to deliver patient care services and do not have sufficient time to develop hypothesis-driven research proposals. Thus, it is imperative that we develop a larger cadre of sophisticated investigators who can compete successfully for the available grants [9]. However, research is not routinely included in the curriculum for radiology residents, and relatively few departments have credible research programs.

In the last fiscal year (fiscal year 2001), the NIH made 24,786 awards totaling $8.6 billion. Approximately 2.3% of both the awards and the dollars went to departments of radiology. A total of 122 medical schools received funding from the NIH, but only 67 radiology departments received funding. (This situation is even more dismal when one realizes that the NIH combines radiology and radiation oncology when reporting these statistics.) Furthermore, a larger portion of these NIH grants is captured by a small group of radiology departments than is true in other disciplines. Virtually half of all NIH awards to radiology are held by only eight departments, whereas 16 departments of internal medicine share 50% of NIH funding (Table 4).

The participants of the intersociety conference broke into subgroups to develop plans to address three major concerns: the shortage of trained radiology investigators, the funding of those investigators, and how the residency might be restructured to improve the ability of trainees to conduct research.

Training More Investigators

Top Introduction Radiology Manpower Funding of Radiology Research Training More Investigators Funding Research Restructuring the Residency Conclusion 2003 Intersociety Conference References

 
Radiology research must evolve from the descriptive studies that have filled our journals for much of the past 50 years to investigator-initiated, hypothesis-driven research. Imaging modalities are now used as probes to answer basic biomedical and bioscientific questions. This research is complex and often requires a team of individuals, each bringing a specific skill set to contribute to the research project.

The solution to the shortage of trained investigators must begin with a shift in our culture to one in which research is more clearly valued. Individual radiology departments are too often concerned only with providing clinical service or with teaching residents and cannot recognize the value of a strong research program. We look to the Society of Chairmen of Academic Radiology Departments to provide leadership in helping academic radiology departments develop a strategic plan to build strong research programs.

At the prompting of Ed Staab, the Radiological Society of North America initiated a program, called Revitalizing the Radiology Research Enterprise, to stimulate radiology departments to improve their research efforts. Specific goals included the development of strategic research plans and strengthening the research infrastructure. Five departments participated in the pilot program, which included an on-site visit by two senior radiology researchers. The program was made permanent this year. Experience gained from the Revitalizing the Radiology Research Enterprise program and the practical experience from the more successful research programs could be assembled into a primer and distributed widely.

The ACR was successful in obtaining a grant from the biomedical imaging program of the National Cancer Institute to form a free-standing clinical trials cooperative group. This ACR Imaging Network is led by Bruce Hill-man and is sponsoring a broad range of investigations of imaging trials and imaging-guided therapies [10]. In cooperation with the Radiological Society of North America, the ACR Imaging Network also annually offers three fellowship positions for radiologists to learn more about conducting clinical trials.

The long history of many radiology departments as service departments must be overcome if those departments are to be considered seriously for the allocation of research resources by medical school deans. It has been disturbing to see medical schools selecting radiology chairs internally because the schools are unwilling to offer a competitive package that includes resources for a credible research program that will attract a strong external candidate.

Efforts to educate medical school deans, hospital chief executive officers, and department chairs should also extend to the lay public. Philanthropy is likely to become an increasingly important source of funding for radiology research.

Successful businesses routinely invest a portion of their revenues in research, a practice that is especially important in highly technical fields in which effective research provides a competitive advantage. Hospitals benefit from being associated with research-oriented medical schools. Patients are attracted to such medical centers to take advantage of the latest equipment and of physicians who are leaders in their field and to participate in clinical trials. Money that might otherwise be used for advertising could be diverted to support research programs that will provide a level of advertising that cannot be purchased. The intimate relationship of hospital-based departments such as radiology requires that hospitals contribute to these arrangements.

We must not forget one of the fundamental problems that has helped create this shortage of investigators—the shortage of radiologists. Unless we can bring into better alignment the increasing demand for radiology services and our ability to satisfy those demands, we will continue to struggle to build strong research programs. Although many of our residency training programs have the capacity to enlarge and to train more residents, they are often prevented from doing so by the cap on the total number of trainees at each institution. Participants at the intersociety conference believed that all radiologists must contribute to the solution because it will benefit us all. They suggested that each radiologist be "taxed" $1000 through their memberships in professional societies, and that these monies be placed in a superfund to be used for resident salaries. This step would make available new positions that would otherwise not be possible.

Radiology training programs must also be modified. The current situation does not satisfy either the academic or private practice communities. Radiology residents spend too much of their final year of training memorizing lists of differential diagnoses before taking the oral board examinations. They are not learning the practical skills of running a service or multi-tasking that will be needed in a busy private practice, nor are they getting the training in research methodology to prepare them for an academic career. This topic was addressed in more detail by another working group.

Funding Research

Top Introduction Radiology Manpower Funding of Radiology Research Training More Investigators Funding Research Restructuring the Residency Conclusion 2003 Intersociety Conference References

 
A radiology research program is expensive to establish and requires further maintenance expenditures. Space is needed for laboratories and equipment, which are more expensive than office buildings. Cost estimates for current laboratory research buildings are nearly $500 per gross square foot or $1000 per net square foot of usable laboratory space, after walls, hallways, and utility closets have been subtracted.

A variety of personnel are needed. In addition to radiologists and basic scientists as investigators in physics, engineering, biochemistry, and other disciplines, a whole research infrastructure is needed that includes technologists, animal handlers, biostatisticians, and experts in informatics and outcomes studies.

Documentation of procedures and results is essential and requires meticulous record keeping. Research expenditures must be rigorously tracked, which requires additional personnel and space. If human subjects are involved, another level of approval and documentation further adds to the cost of the project.

Even successful programs incur significant expenses. Start-up packages for new investigations include space, equipment, personnel, and funding for 2–3 years while the investigators design projects and conduct the feasibility studies necessary to show that they will be successful in completing the proposed project. Investigators rarely maintain 100% funding throughout an investigative career. This gap in funding must be provided from departmental funds.

James Thrall discussed an approach to research funding that includes external funding, internal support, and philanthropy. External funding sources include federal agencies such as the NIH, the Departments of Defense and Energy, and the National Science Foundation. Foundations such as the Whitaker Foundation are often able to fund large expenses, including equipment and even buildings. Professional radiology societies often offer research support, although rarely more than seed grants. Research support can also be obtained from industry, although such arrangements are complex and often involve issues of intellectual property. Universities and medical schools may also support research by creating core facilities or by offering seed grants or start-up funds.

When we think of philanthropy to fund medical research, we often think of the grateful patient who gives money for research on a disease affecting a family member. Radiology is not likely to be successful with this approach, although radiation oncologists and interventional radiologists may do better than diagnostic radiologists.

The unique attraction of radiology is our technology. The ability to depict human anatomy in a noninvasive manner holds tremendous attraction for potential donors. Postprocessing of CT and MR imaging data sets, real-time imaging, and positron emission tomography all offer tremendous potential that may appeal to donors.

Restructuring the Residency

Top Introduction Radiology Manpower Funding of Radiology Research Training More Investigators Funding Research Restructuring the Residency Conclusion 2003 Intersociety Conference References

 
The third group was charged with the task of suggesting how residency training programs can be revised to improve radiology research. The group's primary recommendation was to address our culture. The entire field of radiology must recognize that today's research is tomorrow's practice, and that research benefits all radiologists.

Ron Arenson described efforts already under way. Representatives of the leading radiology research departments met in San Francisco in the fall of 2001 and adopted a resolution to provide a significant research experience for all residents. Recognizing that there are vast differences in the ability of programs to provide this experience, Bruce Hillman suggested different levels of research experience proportional to the resources of the department [11]. Although only research-oriented departments may have the needed infrastructure for laboratory research, all residents need training in critical thinking, outcomes, and decision analysis.

Pat Turski made specific suggestions for revisions in residency training programs that would provide time for research. After completion of the clinical year, the radiology resident would complete a 36-month core curriculum. The fourth year of residency would be available for research and specialty training. Alternatively, the same basic program could be combined with a year of fellowship so the research and elective time would be integrated with the subspecialty training.

Practical methods to facilitate this shift in emphasis were offered by Stephen Baker. He suggested that we review the criteria we use to select applicants to our residency programs. Prior research, as evidenced by research projects, presentations, and publications, indicates an interest in research. Once in the training program, residents must be given time to conduct research. Proper incentives to conduct research are also needed. Residents can be provided incentives of time and support to present their research at a national meeting. The work of the faculty who serve as mentors for these residents should be included in annual faculty evaluations and compensation plans.

However, none of these plans or incentives can be successful unless we reduce the frenzy fourth-year residents experience in preparing for the oral board examinations. These residents, who should be getting their most valuable clinical training, embarking on research projects, and initiating subspecialty training, are instead memorizing lists of differential diagnoses, many of which they are unlikely to encounter during their entire career.

Although most conference attendees advocated changing the timing of the oral board examinations, no consensus was reached as to how. Some thought that the oral examination should be moved into the third year of residency, but others thought it is best given in June of the fourth year, as it is now. The American Board of Nuclear Medicine conducts their final examination several months after completion of the training program. Other suggestions included giving the oral board examinations 1 year after completion of training so that the board frenzy would not be simply transferred into the fellowship year, and reviewing examination questions to ensure they are relevant to clinical practice.

Conclusion

Top Introduction Radiology Manpower Funding of Radiology Research Training More Investigators Funding Research Restructuring the Residency Conclusion 2003 Intersociety Conference References

 
The meeting concluded with a brief review of the recommendations of each group. We must effectively address the workforce shortage that is impacting the academic community so severely. We must continue to help our culture evolve into one that values research, and our entire field must appreciate its value. Although more money is available for imaging research, the funds will be awarded to radiology departments only if they submit high-quality grant applications. Successful grant applications require training radiologists in research methodology, providing a research infrastructure, and making the time available to conduct the research. Research should begin in the residency training programs, which must be revised. Finally, incentives must be aligned to encourage residents, fellows, and faculty to participate in the research enterprise.

2003 Intersociety Conference

Top Introduction Radiology Manpower Funding of Radiology Research Training More Investigators Funding Research Restructuring the Residency Conclusion 2003 Intersociety Conference References

 
The next intersociety conference will be held August 1–3, 2003, at the Ritz-Carlton Hotel in Huntington Beach, CA.

References

Top Introduction Radiology Manpower Funding of Radiology Research Training More Investigators Funding Research Restructuring the Residency Conclusion 2003 Intersociety Conference References

 

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