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Education |
1 Department of Radiology, Division of Radiologic Sciences, Medical Center Blvd., Wake Forest University School of Medicine, Winston-Salem, NC 27517.
Received May 3, 2007; revised May 11, 2007;
Address correspondence to C. D. Maynard
(dmaynard{at}wfubmc.edu).
Keywords: academic radiology • Caldwell Lecture • education • National Institutes of Health • public policy • radiology foundations • radiology research • radiology societies
When Tony Hasso called to ask me to deliver this year's Caldwell Lecture, I
was both honored and a little hesitant. Although I have certainly been keenly
interested in watching our field become more research-focused, I questioned
whether I was the correct person for the task. The topic of radiology research
is one that I thought might be better addressed by other individuals, such as
Stan Baum, Jim Thrall, or Reed Dunnick, all of whom have chaired departments
that have demonstrated great strides in developing very successful research
endeavors. However, after some soul-searching, I relented, in part because I
am so proud of what the academic radiology community has achieved during the
past 15–20 years in the national arena and in part also because I am
very pleased that this talk is given in honor of Ed Nagy, past executive
director of the Academy of Radiology Research (ARR). Ed Nagy was a very
special friend of mine and did as much as any other single person has done for
the advancement of radiology research nationally during the past 10 years. His
untimely death last year at the age of 56 was a severe blow to our fledgling
national research agenda.
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Tony has requested that I give you my personal observations of the changing research environment in radiology during my academic career. I joined the faculty in the department of radiology at Wake Forest University in 1966, became the department chair in 1977, and stayed in that job until 2000. After my permanent "retirement," I served as acting dean of the medical school for a short time during our national search for a new dean. I have seen radiology from many angles. What has occurred in our field has been nothing short of miraculous. Clinically, we have gone from a specialty in which it was not rare to interpret studies several days after performance to a situation today in which only 24-hours-a-day, 7-days-a-week (24/7) online coverage is acceptable to our clinician colleagues—in other words, we've gone from ancillary to necessary. What a change! To those who complain about 24/7 coverage, I say enjoy being necessary—it definitely beats being ancillary!
Our research programs have gone from the typical descriptive treatise funded from departmental discretionary funds to fundamental basic-science studies that are essential to the understanding of human disease and are funded by grants from the National Institutes of Health (NIH). I am convinced that our future research will do more for the advancement of personalized, tailored therapy than will be done by research in any other clinical specialty. Unfortunately, I will be the first to admit that our training programs have not yet met the challenges inherent in our lofty position in the national research agenda, and it is crucial that leaders in our field address this shortcoming.
By whatever measurement we apply, our specialty has made giant strides in research during the past 15–20 years. I am certainly comfortable in describing our current research efforts as "good." In his book titled Good to Great, Jim Collins [1] studies outstanding corporations and espouses the theory that "good is the enemy of great." He postulates that the reason we have good schools but not great schools, or good government but not great government, is that we are willing to settle for good. Collins suggests that a different effort is required to go from good to great and to sustain greatness. The challenge to the radiology community is to move on from where we are now—which I classify as good—to become great, where we deserve to be. I challenge each of you to consider what it will take to move radiology to the next level. As we have done with clinical care, let's move from ancillary to necessary in the national research arena.
What Have We Accomplished?
First, the American Roentgen Ray Society (ARRS), the Association of University Radiologists (AUR), the American College of Radiology (ACR), the American Society of Neuroradiology (ASNR), the Society of Interventional Radiology (SIR), and the Radiological Society of North America (RSNA) have all created vehicles to support research training and pilot research projects; second, the American College of Radiology Imaging Network (ACRIN), a framework for organizing clinical trials, was funded by the National Cancer Institute (NCI); third, the ARR was established by a joint effort of many radiology organizations to promote radiology research at the national level; fourth, the research dollars received by departments of radiology from the NIH have increased from $75 million in 1995 to $329 million in 2005; fifth, the support for imaging research at the NCI increased from $48 million to $180 million during that same time frame; sixth, a new institute, the National Institute of Biomedical Imaging and Bioengineering (NIBIB), was established at the NIH; seventh, Elias Zerhouni became the first radiologist to be appointed director of the NIH; and eighth, and perhaps most important, radiology began to "play" the Washington game and learned the importance of an effective lobbying effort.
How Did We Get Here?
Leadership. I would be remiss if I did not point out that it takes leadership to accomplish such lofty achievements. In Good to Great, Collins [1] describes the leadership skills necessary to develop great companies. One characteristic he mentions is that leaders of great companies "are incredibly ambitious—but their ambition is first and foremost for the institution, not themselves." I think this characteristic is evident in the radiologists who I believe have been responsible for the emergence of our field within the national research arena. These individuals not only created great departments, but also gave their time, energy, and commitment to advance radiology at the national and international levels. I would like to pay special tribute to Herb Abrams, Russell Morgan, Alex Margulis, Jim Youker, Len Holman, Charles Putman, Stan Baum, David Bragg, Bob Holden, Bruce Hillman, Nick Bryan, Reed Dunnick, Dan Sullivan, and Elias Zerhouni. I greatly respect and honor these individuals for their devotion to our field. Perhaps other names should be added to the list; however, these are my heroes.
Contributions of Radiology Societies
Our radiology societies have contributed greatly to the advancement of research in our field. Since their inception, they all have provided a forum for presentations of the latest advances in radiology at their annual meetings and through their publications. In recent years several of the larger societies have taken a more active role in the advancement of research, through training programs, research seminars, or providing funding to support research training and pilot research programs. I cannot possibly cover what every society has contributed and do not want to diminish in any way the magnitude or scope of the contributions of the more than 30 scientific radiology societies. It is their collective effort that will get us where we want to be in the future. I would, however, like to mention a few programs that are highly visible and, I believe, significant to our national research effort.
ACR
For many years the ACR was radiology's only lobbying effort in Washington,
DC, and was one of the only radiology organizations that played a major role
in supporting the radiology research agenda. Along with the AUR and the
Society of Chairmen of Academic Radiology Departments (SCARD), it cosponsored
the Conjoint Committee on Diagnostic Radiology to promote support for
radiology research. Two recent ACR initiatives, ACRIN and the Radiology
Advocacy Alliance, are vital components for our future efforts.
ACRIN—ACRIN was established in 1999 as a cooperative group funded by NCI and dedicated to developing and conducting clinical trials in diagnostic imaging and imaging-guided techniques [2]. After a slow start, ACRIN has gained considerable momentum under Bruce Hillman's able leadership. Today ACRIN has an annual budget of nearly $24 million, with more than half distributed annually to fund clinical research in departments of radiology (Apgar C, personal communications). A network of 109 clinical sites has been created and includes 21 nonacademic institutions. Twenty-seven imaging clinical trials have been completed that have influenced the practice of radiology (Hillman BJ, personal communications); of these, the digital versus film mammography study, Digital Mammography Imaging Screening Trial (DMIST), attracted the most national attention [3]. Noteworthy activities of ACRIN include the development of an infrastructure to support large multicenter trials, including the only all-electronic network at the NCI; the establishment of standards for the use of imaging in trials; and establishing radiology as a major player in the national clinical cancer research scene. Perhaps even more important has been its role in helping to develop a culture for clinical imaging research within radiology departments in the United States (Hillman BJ, personal communications).
The Radiology Advocacy Alliance—The Radiology Advocacy Alliance was established in 1997 as a separate corporation from the ACR with fewer restrictions on lobbying than are required of its parent organization. The main purpose of the alliance is to lobby Congress on behalf of radiology. In 1999, it initiated RADPAC, a unit designed to support political candidates, and in a very short period of time it has become a well-respected and influential medical political action group. During the most recent election cycle, it was among the top 10 health professional political action groups in supporting candidates for election, providing nearly $450,000 in contributions. Although the Radiology Advocacy Alliance focuses primarily on practice issues, it is hoped that during the next decade it will also assume an increasingly active role in lobbying Congress on behalf of radiology's research enterprise (Kaiser CP, unpublished data).
AUR
Since its establishment in 1954, the AUR has been the organization most
directly associated with academic medicine programs. It has always provided
the training ground for residents, fellows, and junior faculty to get their
first experience in delivering a scientific paper, and with the RSNA and ARRS,
the AUR started the Introduction to Research Program for second-year radiology
residents [4]. It also joined
with the ACR and SCARD in organizing the Conjoint Committee in Diagnostic
Radiology (Youker JE, unpublished data). In 2000, it began the Radiology
Research Alliance (Thorsby L, personal communications). This group currently
has 71 members, and its primary mission is to encourage multidisciplinary
research in radiology and the radiologic sciences by helping departments to
establish and improve their research programs. The committee is composed of
representatives from the NIH, major national and international radiologic
societies, and radiologic subspecialty associations. AUR's journal,
Academic Radiology, is the only radiology journal devoted primarily
to academic endeavors.
RSNA
The RSNA was one of the first radiologic societies to recognize the need
for a concerted effort to assist radiology departments in the development of
high-quality research programs. It has been a major contributor to the
successes of radiology research.
The RSNA Office of Research—The RSNA Office of Research was established after a 1992 report of an ad hoc committee on strategic planning chaired by Franklin Earnest (Bresolin LB, personal communications). The committee recommended to the Board of Directors of the RSNA that an office of research be established by the organization to promote and support research in departments of radiology. The RSNA Board of Directors believed that in this way the organization could, to some extent, repay academic departments for their contributions to the success of their annual meeting. This office is charged with assisting radiology departments with their research agenda by compiling sources of available funding, coordinating research training programs at all levels (faculty, fellows, and residents), providing expertise in statistical methods and study design, and promoting the importance of radiology research. After the establishment of this office in 1994 and the appointment of a permanent director and staff, the RSNA developed a broad, diversified portfolio of programs. This office was dedicated to the advancement of the national research agenda and has done more than any other entity to foster research in radiology. Time will not permit a description of all the programs sponsored by the Office of Research, but I would like to highlight three.
Introduction to Grantsmanship, a weekend course originally sponsored by the Conjoint Committee on Diagnostic Radiology, was assumed by the RSNA in 1996. It is an extensive primer for individuals seeking basic training in grantsmanship. Attendance is available to approximately 100 individuals each year, and several hundred have participated to date (Schmidt MS, unpublished data).
The Advanced Grant Writing Course, available to 10–12 junior faculty members each year, spans a 9-month, 4-weekend period and is an intensive course designed to help junior faculty prepare a grant proposal for extramural funding. Since its beginning in 1996, 129 faculty members have completed the course (Schmidt MS, personal communications).
Revitalizing the Radiology Research Enterprise (RRRE) is a bold program designed to provide direct assistance to radiology and radiation oncology departments desiring to improve their research capabilities. RRRE is a two-pronged program consisting of a 1.5-day program at RSNA headquarters in Oak Brook, IL, followed by an on-site visit to a selected group of departments by a team of experts to help guide those departments in developing a research plan. To date, 19 departments have participated. Feedback has been exceedingly positive (Schmidt MS, personal communications).
Creation of Research and Education Funds and Foundations
The development of research and education programs by many of our scientific societies has provided an excellent vehicle to support research efforts in radiology departments. Among the organizations with such programs, the RSNA's Research and Education Foundation (R&E Foundation) has been the most successful in raising funds. Initiated in 1984 as a research and development (R&D) fund, with an initial endowment of $1 million from the RSNA's discretionary funds to support scholarships, it has grown to become a separate foundation with an endowment of more than $43 million. It now supports a wide array of programs, from pilot research grants to research fellowships for residents, fellows, and junior faculty (Watson M, personal communications). In 1999, the RSNA transferred an additional $10 million to the R&E Foundation to jump-start the establishment of educational grants (RSNA Foundation brochure, 2006).
Since its beginning, more than $25 million in support has been awarded to more than 600 individual investigators. Each year, $1.5 million is granted to support research and research training programs in departments nationally and internationally. More than 100 radiology departments have been recipients of funding. Surveys have shown that for every dollar received from the R&E Foundation, recipients have leveraged those funds to obtain a $9 match from other sources (Bresolin LB, personal communications).
The other major R&D funds established by societies are The Roentgen Fund of the ARRS, with an endowment of more than $4 million (Sperry K, personal communications); the Neuroradiology Education and Research Foundation (NER Foundation) of the ASNR, with more than $4 million (Gantenberg JB, personal communications); the SIR Foundation, with more than $3.5 million (Becker GJ, personal communications); and the newest fund, the ACR's ACRIN Fund, which to date has commitments of more than $7 million (Neiman HL, personal communications).
Scientific Societies' Support of Research Training
Of particular significance are the research training programs offered by these societies and their foundations.
Introduction to Research for Second-Year Residents
One of the most successful programs was established in 1990 through the
collaborative efforts of the RSNA, AUR, and ARRS
[4]. Every year, 80 second-year
residents are selected by a committee of the AUR from a list of nominations by
department chairs to attend either the RSNA or ARRS annual meeting. There,
they participate in a specially designed 12- to 15-hour course to introduce
the residents early in their training to the excitement and varied
opportunities afforded by a research career. More than 700 residents have
participated. In a 2005 survey of a sample of the attendees, it was reported
that nearly 50% had accepted academic positions. Participants wrote highly
laudatory comments, and many credited their participation in the course as a
significant factor in their decision to select a career in academic radiology
(Bresolin LB, unpublished data).
Research Training Fellowships for Junior Faculty
With a lack of adequate research training fellowship support for clinician
scientists by government agencies such as the NIH, NCI, and National Science
Foundation, and by private foundations, several radiology societies have
stepped forward to help fill that void. During the past 15–20 years, the
research and education funds of our scientific societies have initiated a
number of programs to support research training for junior faculty
members.
The AUR-GE Radiology Research Academic Fellowship (GERRAF)—This fellowship is a 2-year $140,000 research fellowship for junior faculty members. It is available each year to four board-certified radiologists who are committed to research careers [5]. Its main objective is to develop a cadre of academic radiologists trained in patient-oriented and health services research. Since the inception of this program in 1992, 54 individuals have completed it. The success of this program is incredible: 50 (93%) are still committed to academic careers (Thorsby L, personal communications).
The ARRS Scholarship Program—This program is a 2-year program providing $140,000 to two individuals for up to 80% release time to pursue a research career in an academic program. These persons must have completed all required residency and fellowship commitments and must be certified by the American Board of Radiology (ABR) or its equivalent. Since it began in 1992, 25 individuals have completed the program, and many are still active on university faculties (Sperry K, personal communications).
The Neuroradiology Education and Research Foundation Scholar Award—This award has been offered by the ASNR since 1986 and, to date, has supported 45 investigators during the early phase of their careers to enhance their competency in areas of importance to the future of neuroradiology. These awards provide $60,000 for 1 year. Of the individuals supported, 80% are still pursuing academic careers (Gantenberg JB, personal communications).
The RSNA Research and Education Foundation (R&E Foundation) Research Scholars Grant Program—This program is for junior faculty members who have completed the conventional resident or fellow training programs but have not yet been recognized as independent investigators. Scholars must devote 50% of their time to an approved research program. The program provides $75,000 annually for 2 years and must be used as salary support. Since its inception in 1985, 88 junior faculty members have been supported, and many are still in academic positions (Schmidt MS, personal communications).
The success of these training programs is readily apparent in the large increase in radiologists who have been successful in obtaining funding from the NIH. The number of MD principal investigators in radiology departments increased from 32 in 1993 [6] to 238 in 2002 (Nagy EC, unpublished data).
The Conjoint Committee on Diagnostic Radiology
The Conjoint Committee on Diagnostic Radiology was initiated by a joint effort of the AUR, ACR, and SCARD in 1978 (Youker JE, unpublished data), and until 1994, with the formation of the ARR, it was the main organization forwarding the research agenda for the radiologic sciences. For more than 2 decades, under the capable leadership of its first chair, Jim Youker, followed by Charles Putman, the committee led the effort to increase the support of NIH for imaging research. The committee conducted grantsmanship workshops in numerous locations between 1986 and 1991. Hundreds of junior faculty members attended these intense 2-day primers on getting started in research. The committee also cooperated with NCI in organizing national consensus workshops in 1984 [7], 1988 [8], and 1994 [9] to develop research agendas for diagnostic radiology.
With a small budget from these three organizations, donations of more than $250,000 from 79 academic radiology departments over a 3-year period, support of the staff of the ACR, and a dedicated committee, the first lobbying effort by organized academic radiology was begun.
ARR
Believing that the lobbying effort should be increased, in 1994 under the leadership of the RSNA, ACR, AUR/SCARD, and the ARRS, the ARR was created to replace the Conjoint Committee on Diagnostic Radiology as a more inclusive and broader organization to represent the research needs of radiology [10]. In 1995, Ed Nagy was recruited as the first executive director, and an office was opened in Washington, DC. Ed had extensive experience in Washington, having served as chief of staff to U.S. Representative Tim Valentine of North Carolina for 10 years and as press secretary to U.S. Senator Sam Nunn of Georgia for 5 years. His leadership paid off. The society quickly grew to participation by 23 radiology societies representing more than 100,000 professionals. Its main mission was to build support for imaging research in the federal government, and a primary objective was to establish an institute at the NIH dedicated to the sciences of imaging. With an annual budget of approximately $450,000 supplied by the societies, the ARR has developed a highly effective lobbying effort for the academic radiology community. To expand its influence, the ARR recently formed the Coalition for Imaging and Bioengineering Research (CIBR) to include patient advocacy groups and industry in its lobbying effort.
Cancer Imaging Program (CIP) at the NCI
For many years, the radiology community strived to attain recognition and support for its research agenda at the NIH. Although small imaging research programs had been housed in the National Institute of General Medical Sciences (NIGMS) and the National Heart, Lung, and Blood Institute (NHLBI), the first official recognition of the importance of medical imaging occurred in 1982 with the establishment of the Diagnostic Imaging Research Branch (DIRB) in the NCI. Fred Ruzicka became its first division head. The imaging programs at the NIH remained there for the next 14 years (Sullivan DC, unpublished data).
In 1996, NCI Director Richard Klausner, recognizing medical imaging as an "extraordinary opportunity" for investment of federal funds, directed the establishment of the Diagnostic Imaging Program (DIP), which later became known as the Biomedical Imaging Program (BIP) and currently is called CIP. David Bragg, a longtime advisor to the NCI, was appointed acting director and served until Dan Sullivan was recruited to become its first permanent associate director. This new program was "guided by a two-pronged mission, to promote and support cancer-related basic, translational, and clinical research in imaging sciences and technology and to integrate and apply these imaging discoveries to the understanding of cancer biology and to the clinical management of cancer risk" (Sullivan DC, unpublished data). Since its establishment under the able leadership of Dan Sullivan, its research budget has grown from $47 million (fiscal year 1996) to approximately $180 million (fiscal year 2006).
NIBIB
No single event has demonstrated the incredible success of the national agenda for radiology research better than the story of the creation of the NIBIB. The history behind its creation is worthy of special attention because it demonstrates so vividly the importance of the substantial and consistent involvement of the radiology establishment, both academic and nonacademic, in the development and maintenance of a national research agenda.
The origins of the NIBIB can be traced back to the activities of the Conjoint Committee on Diagnostic Radiology, when the first discussions occurred concerning the undertaking of a major imaging thrust at the NIH. Despite the successes at the NCI, which were limited to supporting cancer research, and the establishment of a very small intramural research program, the Laboratory of Diagnostic Radiology Research in the early 1990s [6] under the direction of Joe Frank, it became clear that radiology's position would remain limited until it established a separate national institute devoted to medical imaging research. Considerable discussion took place among the leadership of the ARR about the proper organizational structure for the new entity (center, program, or institute) to advance radiology's research agenda to the necessary level. Despite the obvious roadblocks to the creation of a new institute at the NIH, particularly from the NIH leadership and from institute directors who were opposed to any new competitive program, the board of the ARR decided that the establishment of an institute should be our ultimate goal and took its case to Congress [11, 12].
In September 1996, Republican Congressman Richard Burr (fifth congressional district, NC), introduced legislation (H.R. 4196) [13] to establish the National Institute of Imaging. Richard was my congressman at the time, and although I was a well-known Democrat in his district, I had helped him when he was working on the reorganization of the U.S. Food and Drug Administration. I convinced him to agree to accept leadership in establishing, by congressional mandate, a new institute dedicated to imaging sciences at the NIH. This bill was introduced late in the congressional session and therefore died with no action taken.
In 1997, Congressman Burr reintroduced the bill (H.R. 1715) [14]. It was considered desirable to have a companion bill introduced in the Senate, so I volunteered to speak to Republican Senator Lauch Faircloth of North Carolina to convince him to introduce a similar bill in the Senate. An interesting story unfolded behind the scenes. It's just one of many such stories that I could tell about what was done to be successful in getting this bill passed. I had never met Senator Faircloth, but he was from the area of North Carolina in which the Maynard family is well known. He is a well-known and prosperous hog farmer, and members of my family are major turkey farmers, so to some extent, we talked the same language. Furthermore, the first time I met with him, he thought I was an anesthesiologist, and the story was that the anesthesiology political action committee had supported him quite heavily in his election campaign. After only a brief meeting, he agreed to help this "turkey-farming anesthesiologist" from North Carolina and introduced a Senate bill (S. 990) [15], a companion to Congressman Burr's House bill. I don't think Senator Faircloth ever learned that I was a radiologist with little knowledge of turkeys or hogs, and he certainly didn't understand the magnitude of the effort that would be required. During that session we enlisted 80 cosponsors for the House bill and six for the Senate version. Again, the sessions ended with no action taken, except that Len Holman testified about the importance of the legislation at a Senate committee hearing.
Undaunted, we pushed ahead. Before the next congressional session we joined forces with the American Institute for Medical and Biological Engineering (AIMBE), which is an organization that had a similar history of seeking more representation at the NIH. As a result, the scope of the proposed institute was increased, and it was now to be called the National Institute of Biomedical Imaging and Engineering, later amended to the NIBIB. On the encouragement of Gary Glazer and Ron Arenson, Democratic Congresswoman Anna Eshoo of California joined Congressman Burr as a primary sponsor in reintroducing H.R. 1795 [16], providing nonpartisan appeal. As Senator Faircloth had lost his reelection bid during the change in Congress, we were fortunate that Republican Senator Trent Lott, the Senate majority leader, who had been a cosponsor on the earlier bill, agreed to reintroduce the bill in the Senate (S. 1110) [17]. His next-door neighbor and long-time friend Paul Moore, a radiologist from Mississippi, encouraged him to champion the bill in the Senate. Having the majority leader as our sponsor was to be crucial to the bill's ultimate passage.
In 1999, the entire radiology community got behind the effort. With the leadership of the ARR orchestrating the effort and with the help of numerous radiology organizations, Congress was deluged with more than 13,000 letters and e-mails supporting the bills. With the help of dozens of academic and private practice radiologists across the country, all 535 members of the House of Representatives and 100 Senators were contacted personally—some key members numerous times. Eleven members of the Senate and 171 members of the House of Representatives joined as cosponsors. On September 27, 2000, after a House subcommittee hearing in which Nick Bryan, Reed Dunnick, and Bruce Hillman testified [18], the House passed the bill by voice vote [19]. In a parliamentary move by Senator Lott, Burr's bill was passed by the Senate on December 15, 2000, the last day before the Senate adjourned.
We never expected passage of a freestanding bill. It was unheard of. Bills like ours are usually part of a larger package, not allowing for easy veto by the President. As a result, we faced a unique problem: With opposition from the NIH administration and because it was President Clinton's last week in office, all he had to do was not sign the legislation to result in a so-called "pocket veto." We turned to our Democrat friends, asking anyone we knew with contacts to call the White House to encourage the President to sign the bill. Joanna Siebert, a radiologist from Little Rock, AR, and a close friend of the President's wife, agreed to talk to Mrs. Clinton at a White House Christmas party she was attending; Jeff Immelt, chief executive officer of GE Healthcare, instructed his lobbyist to contact the White House staff; Bill Brody, a radiologist who is now president of The John Hopkins University contacted Donna Shalala, President Clinton's just-departed Secretary of the U.S. Department of Health and Human Services; I encouraged our Democratic governor to call President Clinton, and on and on. We tried not to leave any stone unturned. This effort went on all during the Christmas holidays, much to my wife's chagrin. We still don't know what worked, but on December 29, 2000, President Clinton signed Public Law 106-580 [20] creating the NIBIB. It was the last bill he signed during his presidency. I joke that someone placed it under the many pardons he signed that day, and he never noticed that he was creating a new institute at the NIH!
In retrospect, we were very fortunate. Our success verifies the old axiom that luck is being prepared when the right time arrives. I sincerely believe that creation of the NIBIB could not have been done before this time and could not be done today. The stars were aligned for this event: We had a sound case backed by substantial support in the House of Representatives; the majority leader of the Senate with a good neighbor and friend who was a radiologist; an interim director at the NIH; a changing administration; a doubling of the NIH budget under way; a recognition by the NIH that medical imaging was a vital component to its agenda; and last, but certainly not inconsequential, an incredibly proactive, responsive, and engaged radiology community, both academic and nonacademic.
With grants better suited to the new institute and funds moved from other institutes, the NIBIB got its first budget of approximately $112 million, and under the leadership of an interim director, Donna Dean, began its first year of operation in 2001. Rod Pettigrew was recruited from Emory University to be the institute's first director, an advisory committee was appointed, and the NIBIB joined the ranks of the other institutes at the NIH. Medical imaging sciences finally had a proper home at the NIH [9]. The success to date of the NIBIB is another whole story.
What I Learned As Chair of Radiology
I will be the first to admit that I was not prepared to become chair of radiology, particularly in the area of research. Although I had spent my early years in nuclear medicine, one area of imaging that had a decent track record of research and a culture more inclined to foster basic investigative efforts, I had a lot to learn and it took me some time. What did I learn? Some of the major lessons were the following:
1. Departmental and Chair Commitment Is Essential
The department and faculty must be just as committed to the research leg of
the so-called "academic stool" as to teaching and clinical care.
The culture in the department needs to reward, to promote, and to truly value
research. The chair is the most important ingredient and must set the tone for
the department. The chair must do more than pay lip service; commitment of
resources, faculty dedicated to research, and adequate research space and
support personnel are all essential.
2. Research Faculty Members Need Protected Time
The era of the "triple threat"—a faculty member excelling
in patient care, teaching, and research—is long gone. The past practice
of performing research in your spare time, nights, and weekends, is
unrealistic. A sizeable amount of protected time dedicated to research,
whether in the laboratory or clinical trials, is necessary for faculty to
compete nationally for funding. In today's environment the demands of clinical
care and 24/7 coverage clearly disrupt the life of a researcher.
3. Successfully Competing for Extramural Funding Requires an Investment by the School and the Department
Commitment of space, laboratory equipment, research personnel, pilot
project funding, and startup funds are absolute essentials for an
investigator. Startup funding at our institution for junior faculty averages
between $50,000 and $500,000, depending on the nature of the research.
Continued funding will be required until the researcher is able to obtain
extramural funding. Some "maintenance" funding may also be
necessary. I estimated that every dollar in NIH funding that our department
received had to be matched with a dollar from internal funds.
4. Involvement of and Cooperation with Other Departments Are Essential
The departments of radiology that are most successful in securing outside
funds are those that are closely allied to researchers in other basic science
or clinical departments. Whether the project is basic research in MRI or a
clinical trial of a new contrast agent, a program will achieve success only
with a collaborative effort. Not surprisingly, the radiology departments at
the top level of NIH funding are located in medical schools that rank high in
the NIH "derby"
[21]. Research today is not a
solo act; it takes an orchestra. One of our most successful researchers, Jeff
Carr, works very closely with our department of public health sciences, one of
the most successful research departments in our medical school.
5. "Right" Faculty
Jim Collins says, "The old adage that people are your most important
asset" is wrong; "the right people are." You have to have
the "right people on the bus"
[1] if you are going to succeed
in developing an extramurally funded research program. Recruiting faculty
members who are committed to the research agenda is vitally important, and
undoubtedly they should include a combination of basic and clinical
scientists.
6. You Can't Be All Things to All People
Unless you are in a very large institution, you must carefully select your
department's area of research, one that fits your departmental and
institutional strengths. This determination will entail considerations such as
department capabilities, school's research emphasis, patient population, and
research strengths in other departments. Once a theme is selected, you must
develop a realistic research plan. A critical mass must be created within the
program, involving faculty both inside and outside the department.
7. Success Is Possible
For proof, look at what has happened at the University of Michigan and at
Massachusetts General Hospital (MGH) under the respective guidance of Reed
Dunnick and Jim Thrall. Reed Dunnick assumed the chairmanship of radiology at
the University of Michigan in 1992. The department had approximately $0.75
million in funding. Now they have 75 grants with more than $20 million in
extramural funding (Dunnick NR, personal communications). Jim became chair at
MGH in 1988 when the department had less than $5 million in extramural funding
with fewer than 10 principal investigators. Now MGH has more than $63 million
in extramural grants and 168 principal investigators (Lee JW, personal
communications). I still remember a conversation I had with Jim Thrall when he
first became chair. He said he was not interested in competing with other
radiology departments; he wanted to compete with the department of internal
medicine. He has certainly achieved his goal.
What Is Needed for Radiology to Move from Good to Great in the Next Decade?
As Jim Collins [1] warns us, "good is the enemy of great." Radiology has made giant strides in developing a national research agenda, and we have substantially increased the federal research support for radiology departments. We should not, however, rest on our laurels. We can, and should, continue to increase our research efforts. An informative and thoughtful 2004 article by Phil Alderson in Radiology [22] contains a list of recommendations from a 2003 consensus conference held by the RSNA, ARRS, AUR, and ARR on how to increase research productivity. What do I think we need to do?
1. Accelerate Our Cultural Transformation
During the past 15–20 years we have begun to recognize the need to
develop a culture more supportive and embracing of research, both basic and
clinical. This culture is needed not only in academic programs that are
training the next generation of radiologists, but also throughout the entire
radiology community. Every radiologist must recognize and embrace the premise
that today's research is tomorrow's practice
[23].
2. Expand the Research Enterprise to More Departments
Seventy-five percent of radiology's research funding comes from the NIH. In
2005, only 64 radiology departments received any NIH funding. Despite the
existence of 125 medical schools and 200 residency training programs, one half
of the funding went to only eight departments and 80% to 21 departments. This
anomaly is obvious when compared with other medical specialties such as
internal medicine, with 80% going to 40 departments, and surgery, 33
departments [20]. A commitment
by radiology chairs is necessary to help spread and expand the funding. Some
academic departments may be unable to become significantly involved in basic
research, but all can and should participate in clinical trials. The RSNA's
RRRE program and ACRIN are excellent programs that could lead this effort.
3. Enlist the Deans of Medical Schools to Provide Specialized Research Facilities
During the short time I served as dean of our medical school it became
quite clear to me that, unlike radiology chairs, who view clinical care and
resident and fellow training as paramount, deans are primarily interested in
medical student education and research, particularly extramurally funded
research. They are more than willing to help establish and support the
creation of research programs or provide research facilities that involve
multiple departments that allow faculty to compete successfully for extramural
funds. In a series of excellent articles in Radiology, Jim Thrall
states, quite correctly, that you first invest in facilities and then in
people to obtain extramural funding
[24–26].
Deans can and will help with facilities and startup funds, as they should.
4. Change Our Residency and Fellowship Programs
We are still training our residents the same way I was trained in the
1960s. Elias Zerhouni, in one of his talks after assuming the NIH
directorship, said, "The majority of academic radiology departments are
based on the clinical training paradigm. I call it the trade school
paradigm" [20]. We need
a radical change in our approach. We are attracting the brightest students,
but they are not exposed and encouraged sufficiently to entice them into
research careers. The ABR took an enlightened step in 2000 in establishing the
Holman Pathway, which allows for 1 year of radiology research during a 4-year
program. However, of more than 6,000 diagnostic radiology residents, the
number who selected that pathway to date is disappointing: only 14 (Hattery
RR, unpublished data). Residents and fellows need more exposure to research
during training, and we need to provide extensive research training for a
selected number. Like the Marines, we only need a "few good men (and
women)." In 2002, after a meeting of the chairs of the top NIH-funded
radiology departments, Ron Arenson, Reed Dunnick, and Bruce Hillman offered a
new approach to training programs and encouraged radiology departments with
substantial involvement in research to step forward and meet the challenge
[27]. I am sorry to say that
nothing significant has happened since that meeting, but it is still not too
late. The Association of Program Directors in Radiology (APDR), the Residency
Review Committee (RRC) for diagnostic radiology, and the ABR should organize a
summit on training and take the lead in reforming our training programs. We
must not continue to train residents as if "one size fits
all."
5. Private Practice Radiologists Must Assume a Leadership Role in Funding Various Radiology R&D Foundations such as ARRS's The Roentgen Fund and RSNA's R&E Foundation
These funds are crucial to the future of radiology and to our maintaining
"ownership" of our techniques. They are especially vital to the
development of new young investigators. As Bill Thorwarth pointed out to me,
these funds are the research and development program for all radiologists.
They fund our future, and we should all be contributing. Currently, the
collective endowment of all the radiology societies' R&D programs is
approximately $60 million, which amounts to an investment of only $2,000 per
U.S. radiologist. If every radiologist donated $1,000 to one of these R&D
funds, no matter which one, radiology's endowment would increase by $30
million, or 50%, in 1 year. That is equivalent to the global fees (100% of
Medicare allowable) on four CT scans of the head with contrast medium, or two
MRI studies of the knee for each radiologist. Imagine what could be
accomplished if that were done every year! The RSNA and the ACR are currently
trying to increase giving, particularly from private practice radiologists. I
encourage everyone to answer the call for support.
6. Academic Positions Must Be Viewed as a Different Type of Job from the Private Practice of Radiology
Under the current reimbursement scheme, we cannot expect salaries for
academic positions to compete with salaries in nonacademic practices.
Radiologists spending all their time in clinical practice will undoubtedly
produce more clinical income than individuals who participate in teaching,
conduct meaningful research, and are involved in other academic activities
that are remunerated at a lower rate. Academic jobs are different, and they
pay less, so why not accept this fact and revisit what it is to be an academic
radiologist? The more we try to emulate the private practitioner, the less
desirable the job will be to the person who has selected a career in academics
[28]. The rewards for the
academician are different. They include the enjoyment of teaching the next
generation of radiologists, the excitement of discovery, the pleasure of being
at the cutting edge of your specialty, the satisfaction of introducing new
techniques to your field, and the camaraderie within an academic
environment.
7. Continue to Change our Research Direction
In 1990, an article by Len Holman in Radiology
[29] noted that most articles
published by radiologists focused on technology development, and he called for
a new direction. Len would be very pleased; research in radiology has vastly
changed in the past 15–20 years, and because of the increasing number of
new imaging techniques, now encompasses every discipline of medicine. Our
involvement in research borders on the unlimited. An article titled
"Blueprint for Imaging in Biomedical Research," prepared for the
NIBIB and the NIH through the combined efforts of the RSNA, ARRS, ACR, and the
ARR, was published in the July 2007 issue of Radiology
[30], illustrating the vast
and diversified scope of future research. The nature of our research will
necessitate multidisciplinary, collaborative involvement of individuals from
engineering, physics, chemistry, mathematics, computer science, biology, and
other basic sciences, not to mention every clinical specialty. Research teams,
trained to work together, will be the pattern of the future, and we have a
unique and vital role to play in their development and implementation.
8. Support and Strengthen the ARR
Key to our success at the federal level will be a strong lobbying effort by
the ARR in concert with the Radiology Advocacy Alliance of the ACR
[31]. The NIBIB needs to grow
from its current yearly budget of $300 million to a medium-sized institute at
the NIH with a yearly budget of approximately $1 billion. Without patient
advocate groups such as the Susan G. Komen Breast Cancer Foundation or the
Pulmonary Fibrosis Foundation, ARR is our primary resource and catalyst to
press our needs and enlist other groups to join us in lobbying for medical
imaging sciences research at the federal level. Without the ARR, we would not
have had the significant increase in federal support to radiology departments
and certainly would not have the NIBIB.
Summary
We have taken a whirlwind tour through radiology's meteoric journey onto the national research scene. I fully realize that to many this is just history and the important work is yet to be done. I think, however, that we should pause with pride to acknowledge what we have accomplished, learn from our successes, challenge the next generation of radiologists to continue this incredible progress, and take the necessary steps to make certain that we heed Collins's caveat that "good is the enemy of great." We should aspire and strive to achieve a position of greatness. If we accept the challenge, I am confident that we can succeed. We are truly in charge of our own destiny.
Acknowledgments
My thanks go to all of the following individuals for their help: from the RSNA, Linda B. Bresolin, Susan Thomas, Roberta E. Arnold, Tracy Schmidt, and Mark Watson; the ACR, Harvey Neiman, Mary Jane Donahue, Otha W. Linton; ARR, Renée L. Cruea; AUR, Lise Thorsby; ASNR, James B. Gantenberg; ARRS, Susan Brown Cappitelli, Keri Sperry; ACRIN, Charles Apgar; others: James H. Thrall, Jae Lee, Stanley Baum, Daniel Sullivan, Bruce J. Hillman, Robert R. Hattery, James E. Youker, Gary J. Becker, and N. Reed Dunnick; and Donna S. Garrison for editorial assistance.
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