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Editorial |
1 From the Department of Radiology, Indiana University School of Medicine, 702 Barnhill Dr, Rm 1053, Indianapolis, IN 46202-5200. Received May 11, 2001; accepted May 18. Address correspondence to R.B.G. (e-mail: rbgunder@iupui.edu).
Index terms: Editorials • Radiology and radiologists • Radiology and radiologists, research
There is an everlasting struggle in every mind between the tendency to keep unchanged, and the tendency to renovate its ideas. Our education is a ceaseless compromise between the conservative and the progressive factors.
William James, The Principles of Psychology
As one of the most technologically intensive and rapidly evolving disciplines in medicine, radiology relies heavily on research for its continuing clinical relevance and utility. If new imaging modalities, such as computed tomography, magnetic resonance imaging, and positron emission tomography, had not been developed during the past 30 years, radiology and the whole field of health care would look very different today. Likewise, if radiologic science does not thrive in the years to come, the very survival of radiology as a clinical discipline may be threatened. The moment that the wheels of radiologic research stop turning, radiology begins to become irrelevant and obsolete.
Yet radiologic science is not like a machine that keeps churning out new discoveries as long as we maintain its parts in working order and continue supplying it power. Radiologic research is the direct product of human commitment and invention. Only if bright and enthusiastic people are attracted to careers in radiologic research will the discipline continue to thrive. The quality of radiologic research can only be good as the quality of people attracted to it, and if radiology fails to attract many of its brightest and best recruits into investigative careers, then radiologic research—and ultimately, radiologic practice—will suffer.
To be sure, many bright people have chosen careers in radiologic research, and patients reap benefits every day from their important work. In fact, with the recent formation of the National Institute for Biomedical Imaging and Bioengineering, the prospects for radiologic research are beginning to appear better. Yet the fact remains that academic radiology departments are experiencing difficulties in filling the ranks of their faculties, and many of radiology’s brightest residents are opting for nonacademic careers, in which research is unlikely to play a prominent role.
What steps can radiology take to ensure that top people continue to pursue careers in radiologic research? We need to closely examine the current situation, and in doing so, we must be prepared to ask some hard questions. First, how do radiology residents understand the terms research and science? Before one can inspire people effectively, one needs to know where they are. Second, why are more residents not opting for academic careers that include a substantial component of radiologic research? What factors in the career choice process make research appear insufficiently attractive? And finally, what can be done to increase the appeal of careers that include a substantial investigative component? Are there practical steps that program directors, department chairs, and national leaders could take to bolster the future of radiologic research?
What Are Research and Science?
We recently conducted a series of in-depth interviews with diagnostic radiology residents at our institution that focused on their understanding of radiologic research. After surveying the results, we were surprised by the diversity of opinions about the very meaning of the term research. Simply put, research means different things to different people. Some initial responses included, "research means practicing in a university," "research means trying to figure out better ways of doing things clinically," "research means technology," "research means being able to critically evaluate the literature," and "research means what happens in a lab, like with animals." Accompanying the lack of consensus about the meaning of research is a widespread uncertainty among residents about how funding is obtained for research, how much time the members of the faculty devote to investigation, and even the nature of projects their faculty members are working on.
Part of the problem lies in the relatively superficial research experiences many residents have enjoyed. When asked to describe previous investigational projects they have participated in, many state either that they have not done any research or they describe "cookbook" laboratory exercises for classes they took in college and medical school. In other words, many have no first-hand experience with original investigation. This goes a long way toward explaining the lack of consensus regarding the meaning of research. It also helps to explain residents’ lack of interest in participating in research. In the past, they have studied science not because they were curious or out of an aspiration to advance their knowledge, but because they needed to get good grades to get into medical school or residency.
When asked to describe what science is, a number of residents point to a bookshelf or a library. They regard science as the sum of everything that has been discovered in the past (1). When they think of science, they see themselves struggling in the library to memorize a body of facts for an upcoming examination, or being trapped in a laboratory on a sunny afternoon, rushing to complete a tedious series of laboratory exercises. In their minds, doing research is a chore not unlike studying for an examination. Many evince no appreciation for the idea that science is an ongoing inquiry for which the past serves as prologue, an activity of asking questions rather than a mere collection of preexisting answers (2). In short, their understanding of science, including radiologic science, is relatively superficial, but it needs to be deep.
The diversity of opinions concerning the meanings of science and research, coupled with the relatively rudimentary investigative experience of many residents, deserves careful attention. This indicates that in radiology training programs, it is taken for granted that faculty and residents are talking the same language when they discuss scientific investigation. It is not enough to say to a resident, "How would you like to do some research?" Faculty members need to take the time to do two things: First, make sure residents know they are doing research and would welcome their participation. Second, explain to the residents what they are working on and why it is important.
Academic Career or Nonacademic Career?
Given the superficial understanding of research, it is not surprising that many residents evince little interest in participating in research projects during their training. Many have spent their residencies in departments where clinical work, not research, is the priority. Focused exclusively on becoming proficient clinical radiologists, they fail to see links between research and the kinds of knowledge they would value or make use of in clinical work. The problem with failing to interest radiology residents in research is the fact that most who do not participate in research during residency will never play a substantial role as scientific investigators, in part because most will choose nonacademic careers. Their self-image as nonresearchers acts as a self-fulfilling prophecy.
When residents who had not done any research during residency were asked why they would consider becoming involved, some said that the only reason they could see to do research would be to get a good fellowship position. One resident said, "If I chose to do research, it wouldn’t be because I was interested, but to pad my CV [curriculum vitae]." Many residents see few if any rewards for participating in scientific investigation. They have little idea how radiology departments support faculty research, and they know almost nothing about the benefits and rewards that can accrue to successful investigators. The intrinsic rewards of research are even less clear to them. Many have little appreciation for the excitement and satisfaction good researchers find in their work, including collaborative investigation with others.
From the perspective of many residents, practical impediments prevent them from becoming involved in research. One impediment is that they believe that they need to devote their time to learning clinical radiology and, in particular, to preparing for the American Board of Radiology examinations. When they compare the adverse consequences associated with failing to become involved in research with the adverse consequences of failing to pass the board examinations, they usually decide to devote their energies to learning clinical radiology. Their cognitive aspirations are restricted to extant knowledge that radiologists already possess, and they are so overwhelmed by the need to master it that they believe they cannot look any farther.
A second impediment is the lack of any apparent connection between scientific investigation and becoming clinically competent, which obscures the vital role of theory in bridging the scientific enterprise and clinical practice (3,4). They frequently do not realize the improvements that an active research program effects in clinical practice and fail to appreciate that the greatest authorities in different clinical fields are usually prolific research contributors. If you ask most residents what they need to know to become good radiologists, they will point to a textbook or radiology review manual and not to scientific journals or the ongoing work of researchers.
If we are to elevate the profile of radiologic research, it is vital that residency training programs take a number of steps. Teaching and evaluation systems need to be expanded to encompass not only memorization of facts in clinical radiology but also knowledge of the scientific literature, critical thinking skills, and research methods (5). Examinations and the instruction that precedes them should stress these capabilities to a greater degree than they currently do, and resident evaluation forms should include a section that addresses both their understanding of radiologic investigation and the quality of their participation in research. Residents will study what they expect to be evaluated on, and as long as research does not count in this arena, it will tend to languish from neglect.
Residents are powerfully influenced by the culture in which they train. Paying lip service to research will not do any good if residents see that the whole department revolves around clinical work. If they believe, as one resident put it, that "clinical work is what pays the bills," or, in the words of another, that "clinical work comes first, teaching second, and research third," then it should not surprise us that few develop an interest in scientific investigation. In many departments, there are few active researchers among the faculty, and therefore there are few teachers and role models. Others are so tightly focused on increasing clinical throughput and revenue that for a program director or chairperson to stand up and extol the virtues of research would smack of hypocrisy. There is no point in trying to change the culture of residency programs, if such changes are utterly out of keeping with departmental culture as a whole.
That being said, however, the culture of residency needs to change. We need to ensure that we prize the asking of good questions every bit as much as we prize the giving of correct answers. Teaching at the view station needs to be expanded beyond lesion detection and differential diagnosis to include critical appraisal of what the textbooks say, identification of new questions for investigation, and research methods. Conferences should be expanded beyond unknown cases to encompass journal clubs, debates over the scientific literature, and discussions of new frontiers of radiologic investigation. As a practical step in this direction, each resident could be asked to give a quarterly 5-minute presentation on a new research question he or she has identified, including how it was identified and why it is important. We expose residents to thousands of hours of clinical radiology to make them good clinical radiologists, and we should be willing to invest at least a few dozen hours out of the 4-year curriculum to give them a better understanding of the vital link between scientific investigation and clinical practice.
In arguing that research should play a greater role in departmental conferences, we are not suggesting an annual course on biostatistics taught by a biostatistician who knows little or nothing about radiology. We mean regular, perhaps monthly, conferences that introduce residents to radiologic researchers and give residents a chance to pose wide-ranging questions about their clinical work and potential research agendas. They need to hear prospective mentors answer questions such as: How did you formulate your research question? How much time do you devote to your research? How did you get your research funded? What do you hope to learn? How might it influence clinical care? Residents who get excited about research as a result of such encounters should be given time and resources to develop their interest and appropriate opportunities for mentorship. Radiology faculty members who serve as research mentors should be recognized and rewarded.
What Can Be Done?
The overarching research imperative is to move the culture of radiologic education from one that mainly prizes memorization to one that also prizes creation of knowledge (6). Learning can mean many things, and it should not be regarded as synonymous with the transfer of facts from a teacher to a student. In higher education research, it is widely known that students learn more from investigating things themselves than from merely being told things by their teachers (7). If faculty radiologists can make it clear to residents that they, too, are learners, residents will begin to prize more highly their own capabilities as active inquirers instead of as mere information sponges.
We must cultivate greater appreciation among faculty and residents for the tools of knowledge acquisition. Textbooks are a good place to start, at least in building a foundation for later learning. Yet residents should be encouraged to regard textbooks not as Bibles overflowing with absolute and immutable dicta, but as provisional estimations of the real situation. One need merely pick up a 20-year-old radiology textbook to appreciate that, if we do our jobs, textbooks of today will appear no less quaint to our successors a generation hence. Beyond textbooks, journals and electronic sources of information, including the Internet, should assume increasing prominence in clinical work, not merely because they contain the most up-to-date information but because they help facilitate the active interchange of ideas and perspectives.
Residents need to appreciate that radiologic research is not confined to mysterious laboratories located in some far-flung corner of the hospital. They need to realize that much of the best radiologic research takes place in reflection and conversation among inquisitive people, spawned by things they have encountered in their daily work. Successful science is the art of asking good questions, which involves seeing connections and drawing distinctions that other people, for whatever reason, fail to consider. Science involves asking not "What do we know?" but "What don’t we know?" and "How can we go about finding out?" (8). Some people are better at asking these questions than others, and radiology training programs need to do their best to identify such people and provide ample opportunity for their residents to interact with them.
We need to foster the development of an intellectually fertile environment for residents, one that invites them to become not only good practitioners of clinical radiology but also good consumers and even producers of science. The goal of residents should be to interrogate their own practice and that of their teachers, to poke holes where assertions have no backing, and to make their colleagues and their teachers as intellectually honest as possible (9). We must be willing to admit what we do not know, for that is the first step in learning something new. This is the attitude that fuels the spark of curiosity.
Research is crucial to the future of clinical radiology, for the research of today defines the radiologic practice of tomorrow. Likewise, the quality of radiologic research is utterly dependent on the quality of the people performing it. Hence, it is imperative that radiology attract bright residents into careers that involve a substantial component of radiologic research. To do that, our residency programs must take several steps. First, radiology must attract bright medical students who show promise as researchers. Second, we must ensure that all our residents, not just the one or two on the research track, really understand the nature of radiologic science and the practice of research. Third, we must foster their development as critical learners, who approach their training with a skeptical eye and who are rewarded for asking good questions. Fourth, we must provide them with opportunities to participate in and develop research projects, providing both the time and resources necessary to succeed and opportunities to share their work with others. Finally, we must foster ongoing departmental and profession-wide conversations on the role of inquiry in professional life.
REFERENCES
This article has been cited by other articles:
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  E. J. R. van Beek and D. E. Malone Evidence-based Practice in Radiology Education: Why and How Should We Teach It? Radiology, June 1, 2007; 243(3): 633 - 640. [Abstract] [Full Text] [PDF]
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M. E. Spieth and R. B. Gunderman Radiologic Research and Residency * Dr Gunderman responds: Radiology, February 1, 2003; 226(2): 593 - 593. [Full Text] [PDF]
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