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1 From the Department of Radiology, Box 170, University of Virginia Health Sciences Center, Charlottesville, VA 22908. Received July 20, 1999; revision requested September 14; revision received October 5; accepted October 6. Address reprint requests to the author (e-mail: bjh8a@virginia.edu).
Abstract
During the past 25 years, medical imaging research has progressed in both scope and quality. Factors intrinsic to the specialty and changes occurring in medicine and society have fostered imaging research development. The advent of new, computer-based technologies that can be brought to bear on research, the increasing sophistication of researchers, and the greater availability of extramural funding have been primary factors in the promulgation of research improvements. Radiology researchers have the opportunity to play an important role in the genesis of the molecular medicine of the future. Whether they do so is dependent on whether radiologists identify necessary resources, new researchers receive appropriate training, and investigators are willing to think differently than they have in the past about the capabilities of imaging.
Index terms: Radiology and radiologists, history • Radiology and radiologists, research • Radiology and radiologists, socioeconomic issues
Glory days, they'll pass you by. Glory days, in the wink of a young girl's eye. Glory days, glory days.Bruce Springsteen "Glory Days"
During the past quarter century, imaging technology has advanced as fast as any technology in medicine. This extraordinary progress has been the result of a receptive health care marketplace that helps motivate prolific academic and commercial research. In turn, imaging innovations have resulted in enormous expansion of our research capabilities. In this article, I relate how imaging research has changed over the past 25 years, since I began my residency—the charge given me by the Editor. It is necessarily a personal view. I have no doubt that other equally qualified authors would emphasize influences and events other than the ones I have chosen.
In the first section of this article, I have taken a "then and now" approach, the goal of which is to paint images for the reader of major differences in the types of people, technology, culture, resources, and support available for research between 1974 and today. In the second section, I consider some of the influences intrinsic to radiology during this period that have facilitated the changes discussed in the first section, including the roles of publications, organizational support, and collaborations. Finally, I address coexistent medical and societal developments that have had an important impact on the development of imaging research.
THEN AND NOW
Medical Imaging Research in 1974
This section has a particular bias, because my view of radiologic research is largely derived from what I experienced where I trained as a resident—the Peter Bent Brigham Hospital (Boston, Mass)—and from what I read in journals. I have tried to ameliorate the bias somewhat by soliciting the views of radiologists already importantly involved in research during the 1970s.
Although, as now, many radiologists contributed to the radiology literature, few academic departments were seriously involved in scientific investigation. Review of the radiology journals of this period shows that radiologists generally published descriptions of new anatomic signs, series of cases that purported to show the manifestations of various disease processes, and reports of technologic developments. In 1974, immediately after the introduction in the United States of the computed tomographic (CT) scanner and before ultrasonography (US) became widely disseminated, the focus was largely on what could be accomplished with conventional radiography and fluoroscopy. The most rapidly developing field was angiography, as increasing numbers of radiologists who were trained to practice this procedure described the vascular appearances associated with various conditions. Only a fraction of clinical imaging research was hypothesis driven or had a formal analytic component.
Laboratory research did occur in a small number of departments. Imaging laboratories mostly correlated anatomy with pathologic processes or were involved in physiologic investigations where imaging or image guidance was an integral part. Space often was cramped. There typically was physiologic monitoring equipment paired with a fluoroscopic device, often an older model cast off from the clinical setting. The radiologists who worked in these laboratories usually were conducting their research between cases or during off hours.
The National Institutes of Health (NIH) awarded research training grants to some institutions. These grants were not always used in a manner that enhanced research. Still, some programs were successful in using these funds to produce research leaders, some of whom are still active. More generally, there was a perception of palpable biases against radiologic (or radiologists') research at the NIH; so, few radiologists were able to obtain extramural financial support for their research, and there was much less academic-industrial collaboration than there currently is. As a result, most of the funding for laboratory research was "bootstrapped" from clinical and other revenues.
Medical Imaging Research in 1999
Although much of what occupies the radiology literature is still descriptive, journals are more often publishing articles on hypothesis-driven research. There are many more articles that reflect some prestudy consideration of experimental design and analysis, and this is a trend that seems to be progressing.
There now is greater availability of extramural funding from federal, foundation, and commercial sources. More departments participate in extramurally funded research. In 1998, all NIH institutes and centers combined funded an estimated $339 million for over 1,500 biomedical imaging projects—one-third to one-half of this amount was granted to radiology departments (Baum S, Croft B; written communications; 1999). Although there has been a growing concentration of extramural federal funding among a handful of radiology departments, fully half of the 127 university radiology departments in the United States received some NIH funding in 1998. Increasing numbers of departments are participating in commercially supported multiinstitutional clinical trials both as a way for more of their faculty to participate in clinical research and as a source of revenue to support investigator-initiated research. The National Cancer Institute recently awarded a 5-year grant for a national network to conduct multiinstitutional, multidisciplinary clinical trials of diagnostic imaging and image-guided therapeutic technologies—the American College of Radiology Imaging Network (ACRIN) (1).
Perhaps the greatest difference between 1974 and 1999 is the scope of technology that now can be brought to bear for research. Departments with laboratory programs now use dedicated computer-based modalities such as CT, magnetic resonance (MR), US, and nuclear scintigraphic techniques to investigate disease states. More advanced centers are beginning to elucidate how noninvasive imaging can be used to investigate subcellular processes and aid in gene therapy. Radiology researchers are less isolated than they previously were, with much of the best work representing multidisciplinary collaborations with other specialists and experts in study design, across departments and institutions.
MAJOR INFLUENCES WITHIN RADIOLOGY
In my view, five major influences intrinsic to imaging have played central roles in the advancement of imaging research over the past 25 years: the introduction of new technologies, subspecialization among radiologists, collaborations between academe and industry, imaging journals, and the activities of radiologic organizations.
I have already alluded to the importance of technologic development in the promulgation of imaging research. The advent of computerized cross-sectional imaging methods helped increase the sensitivity of anatomic investigation. Computerized imaging methods greatly expanded the potential scope of imaging investigation by facilitating the application of imaging technologies to more basic scientific and clinical questions. New technology also helped promote increased subspecialization among radiologists.
Subspecialization made possible greater research focus (ie, more narrow definition of research problems), collaboration on a more equal footing with other medical specialists, more in-depth understanding of disease processes, and greater understanding of both the potential benefits and the limitations of the application of imaging technologies to research questions. As a result, imaging investigators have become more sophisticated in formulating research questions and more inventive in how they use imaging technologies to address their questions. Greater research collaboration with medical specialists who routinely include research training as part of their training programs also has bred greater familiarity with the requirements of high-quality research. The new organ system–based and technology-based societies that have arisen as a result of subspecialization have almost uniformly adopted as part of their central mission the fostering of research and education in their field.
Burgeoning technology resulted in medical imaging becoming a much bigger business than it had been in the past. Greater competition—especially among manufacturers of CT and MR equipment—required industry to develop alliances with radiologists to enhance their internal technology development efforts, to provide environments for clinical trials to test their innovations in patients and pass regulatory requirements, and to promote their findings in scientific forums. In return, the companies supplied researchers with new technology and the funds to support research. Technologic innovation also allowed new "players" to enter the marketplace, further adding to the frequency and value of corporate-academic relationships.
Publication of articles about medical imaging has flourished, as reflected by the great increase in the number of imaging journals over the past 25 years. As noted earlier, these journals have provided their primary constituency of practicing radiologists with practically oriented, descriptive articles that detail clinical manifestations. Indeed, the radiology literature has been prone to criticism about the biases of such articles, which sometimes make imaging technologies appear to be more effective than they actually are and perhaps influence inappropriate utilization (2,3).
An investigative literature is, however, gaining momentum in our specialty. In 1966, a group of academic radiologists, frustrated in their efforts to publish laboratory and investigative clinical research in the journals of the day, introduced a new journal, Investigative Radiology, which soon became the official journal of the relatively young Association of University Radiologists—perhaps the only radiologic organization at that time that was primarily focused on research. Investigative Radiology, later succeeded by Academic Radiology as the society's journal, became a primary forum for investigative research, communication of research methods, and encouragement of young investigators. In recent years, other journals—including many of the subspecialty journals—have increasingly made space available for reports on basic and animal research. The expectations for greater scientific rigor and the education of potential authors that journals have fostered by publishing more investigative research articles (rather than simple descriptive articles) have, in my opinion, had a generally salubrious effect in improving the quality of imaging research.
Extensive training in research is not a traditional part of a radiologist's training. This has resulted in disadvantages for radiologists in the competition for public funding. Recognizing how important research is to the continued prosperity of radiology, a number of organizations have made substantial investments in the development of more competitive imaging researchers. The most important early initiative was the Picker Scholars program, which was most active in the early and middle 1970s. Many of the Picker Scholars progressed to become the major research leaders of their generation.
More recently, society-sponsored imaging research enhancement programs have proliferated. Although an exhaustive listing of these programs is not possible, there are several that bear mention. The most extensive set of research programs in our specialty is administered under the aegis of the Radiological Society of North America (RSNA) Research and Education Foundation (4). These programs provide mentored research experiences for imaging investigators at all levels—from medical students through established researchers.
The RSNA, the Association of University Radiologists, and the American Roentgen Ray Society have collaborated on the Introduction to Research program for 2nd-year radiology residents, which was initiated in the 1990s. This program allows each academic department in North America to nominate one resident to be among the 80 residents who attend special instructional programs conducted at the annual meetings of the RSNA and American Roentgen Ray Society. In a recent evaluation (5), the program was shown to both engender enthusiasm about research among participants and lead to a greater likelihood that participants will choose and be successful in academic careers.
Using both NIH grant funds and internal resources, the American College of Radiology has fostered clinical trials of imaging technology under both the now defunct Radiology Diagnostic Oncology Group (6) and the current ACRIN (1). Both of these programs have provided radiologists with what has often been their sole opportunity to participate in high-quality, multiinstitutional clinical research and to learn about the underlying methods.
The General Electric–Association of University Radiologists Radiology Research Academic Fund, or GERRAF, fellows subscribe to a 2-year program of educational and research experiences that are intended to help develop independent, competitive clinical researchers with special expertise in technology assessment, medical outcomes assessment, and cost-effectiveness analysis (7).
There also are numerous subspecialty society research programs. Research training programs are relatively new to radiology. It already is clear, however, that radiologists who have participated in these programs are likely to play important roles in improving radiology research in the future.
Finally, in the past several years, diverse radiologic organizations have banded together to form the Academy of Radiology Research (8), which seeks to address historical inequities in the federal funding of medical imaging research, particularly at the NIH. The problem with NIH funding of imaging research is fundamentally organizational. Funding for medical imaging research is spread diffusely across most of the 18 NIH institutes, such that funding decisions are fraught with inefficiencies, duplication, and missed opportunities and are subject to the biases about imaging research among other specialties. The avowed mission of the Academy of Radiology Research is to influence the U.S. Congress to fund a new institute at NIH that is focused on biomedical imaging. Already, the Academy of Radiology Research has had a positive effect on the level of funding for imaging research, promoted the development of an imaging program at the National Cancer Institute, helped to better empower the NIH intramural program in radiology, and gained ground in the congress for acceptance of the concept of an institute for biomedical imaging.
MAJOR MEDICAL AND SOCIETAL INFLUENCES
A number of important ongoing changes in the broader sphere of medicine and in society at large have had a great effect on medical imaging research. Among these, none has been more important than the application of the digital computer to imaging. The computer has made possible nearly all of the major imaging innovations of the past quarter century, including CT, MR imaging and spectroscopy, positron emission tomography, and digital radiography, to name just a few. In addition, computerization of medical images has fundamentally advanced research in the specialty by providing a foundation for quantification. This has allowed radiologists to more effectively broach the investigation of function. Technologic advances that have improved the spatial and temporal resolution of computerized imaging technologies now permit imaging researchers to extend their inquiries beyond the macroscopic organism and organ-function levels to the cellular and subcellular levels.
The continued development of these capabilities is important for the future inclusion of radiologists in research, because it is clear that the major medical advances in the next century will address disease at the molecular level. Information derived from the now nearly completed Human Genome Project provides the framework for the future diagnosis and treatment of disease at its most fundamental source. Independent investigators and pharmaceutical companies are taking advantage of new knowledge about molecular receptors to design new agents. Medical imaging physicians and scientists have the opportunity to participate in this new era of molecular medicine, if imaging research can translate these advances in basic science to practical new methods for improved screening, diagnosis, staging, and treatment of disease.
Ironically, these extraordinary research opportunities arrive at a time when some of the traditional sources of financing research have come under siege, thus imperiling the research enterprise. During the past 10–15 years, nearly all developed countries have come to recognize that the public's thirst for medical care outstrips their ability to pay for it. Resultant innovations in health care organization and financing that have reduced reimbursement for clinical care mean fewer "slack" funds are available to academic departments to seed research initiatives. Smaller financial margins for providers have diminished the capacity to acquire new technology. Thus, commercial vendors are less able to provide financial support to their traditional academic allies in research endeavors. Although the NIH—and particularly the institute most involved in imaging research, the National Cancer Institute—continues to flourish, NIH grants almost always pay less than the real cost of conducting research. As a result, new pressures are being placed on the research enterprise to find ways to supplement grant dollars with funds from other sources such that researchers become financially more self-sufficient.
Technologic innovation has borne much of the brunt of concern about health care inflation, because it has often been difficult to show that the incremental benefit of new technologies is worth the cost. Medical imaging technologies have come under particular scrutiny because they tend to be expensive to acquire and operate and have a high degree of public visibility, and there frequently is little evidence linking the use imaging technology to improved patient health.
The combination of increased societal concerns over costs and the need to better evaluate the cost and benefit of imaging technologies to satisfy the concerns of payers and regulators has led to the emergence of two new genres of imaging research—socioeconomic research and technology assessment. Socioeconomic research encompasses, among other fields, the ambiguously related fields of medical organization, health care financing and regulation, and practice management. The goal of technology assessment is to quantify the extent to which imaging technology affects the gamut of societal interests, from improving diagnosis to influencing the managing physician's decisions to affecting patients' health outcomes and episodic health care costs. Both types of research are, at their best, interdisciplinary by nature, incorporating the expertise of radiologists, other physicians, experts in study design, economists, statisticians, and sociometricians. Although there are great hopes for the potential of socioeconomic research and technology assessment to inform and validate medical imaging practices, extramural funding has been scarce. The establishment of the ACRIN represents a considerable boost in federal funding for technology assessment activities. However, the constituencies that would seem to have the greatest stake in supporting these genres of research—industry and payers—have, to date, been reluctant to support the needed research on any substantial scale.
CONCLUSION
There is a tendency to view the past sentimentally, as though through a slightly unfocused lens. In the case of medical imaging research, however, there can be no doubt that improvements in technology, radiologists' research training, attitudes of practicing radiologists and radiologic organizations, and concurrent major societal changes have fostered great advances over the past quarter century.
Radiology has the potential to become a burgeoning research specialty that, with further development, can provide enormous opportunities for enhanced research over the next 25 years. Whether this occurs depends on a number of factors, including whether (a) current investments in training competitive researchers turn out to be effective; (b) practitioners in the specialty have the creativity and will to expand research investments in the future; (c) academic radiology departments, which are the traditional source of most radiology research, can sufficiently prosper in the current climate of decreasing per case reimbursement and managed health care to continue to foster research; (d) the academic culture can sufficiently change to better foster research training and accomplishments, develop and support a research infrastructure, and provide research time for qualified investigators; and (e) radiology researchers can effect the transition from what has traditionally been viewed as radiology research and successfully grasp the new molecular paradigm.
Acknowledgments
The author is grateful to Herbert Abrams, MD, Stanley Baum, MD, M. Paul Capp, MD, Barbara Croft, PhD, Alexander Margulis, MD, C. Douglas Maynard, MD, and Daniel Sullivan, MD, for the contribution of their insights in generating the manuscript.
Footnotes
Abbreviations: ACRIN = American College of Radiology Imaging Network NIH = National Institutes of Health RSNA = Radiological Society of North America
References
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  L. Arrive and A. Miguel-Dasit Declining Number of Publications by American Authors in Radiology Radiology, January 1, 2008; 246(1): 330 - 331. [Full Text] [PDF]
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 |
|
 M. Y. Chen, C. B. Jenkins, and A. D. Elster Internationalization of the American Journal of Roentgenology: 1980-2002 Am. J. Roentgenol., October 1, 2003; 181(4): 907 - 912. [Abstract] [Full Text] [PDF]
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Y. Ozsunar, A. Unsal, A. Akdilli, C. Karaman, T. A. G. M. Huisman, and A. G. Sorensen Technology and Archives in Radiology Research: A Sampling Analysis of Articles Published in the AJR and Radiology Am. J. Roentgenol., December 1, 2001; 177(6): 1281 - 1284. [Abstract] [Full Text] [PDF]
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P. O. Alderson A Balanced Subspecialization Strategy for Radiology in the New Millennium Am. J. Roentgenol., July 1, 2000; 175(1): 7 - 8. [Full Text] [PDF]
|
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|
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A. V. Proto Radiology 2000-Explore the New Millennium Radiology, January 1, 2000; 214(1): 1 - 2. [Full Text]
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