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Subsidizing Radiology Research
Perspective
Subsidizing Radiology Research1 G. Scott Gazelle, MD, MPH, PhD, N. Reed Dunnick, MD
Historically, radiologists have played a leadership role in the development, assessment, and clinical application of new diagnostic imaging and image-guided therapeutic technologies. Our involvement has helped to bring increasingly sophisticated technologies into clinical practice and to preserve the critical role of radiologists in the use of these technologies. For many years, this research was largely supported with clinical revenues. Academic radiology departments generated sufficient clinical revenues not only to cover salary and benefit expenses of their faculty, but also to allow faculty to conduct unfunded research. Furthermore, there were sufficient numbers of radiology faculty to allow time off from the clinical schedule to perform that research. However, recent trends in health care financing have made it increasingly difficult to achieve departmental profitability, and the current shortage of radiologists has made it difficult to maintain sufficient staffing levels to keep up with the growing clinical volume. Together, these trends have forced radiologists to reconsider the wisdom and feasibility of subsidizing research and to develop creative solutions to meet our clinical and research needs. Unfortunately, these changes are occurring at a time when the need for research on imaging technologies—and the complexity of that research— continues to grow at an accelerating rate. Imaging technologies have become a central component in the diagnosis and therapy of many more conditions than was the case even a decade ago. This trend is continuing, with more new technologies under development than ever before. As a result of the increasing importance of imaging in the detection of an abnormality, the diagnosis of the disease, and the moniAcad Radiol 2002; 9:195–197 1 From the Department of Radiology, Massachusetts General Hospital, Zero Emerson Place, Suite 2H, Boston, MA 02114 (G.S.G.); and the Department of Radiology, University of Michigan, Ann Arbor (N.R.D.). Received and accepted October 16, 2001. Address correspondence to G.S.G.
©
AUR, 2002
toring of treatment, nonradiologists are attracted to our field. Thus, radiologists are facing more challenging “turf battles” as physicians in other specialties compete in the attractive clinical practice markets associated with the use of imaging technologies. Only through dedicated and sophisticated research can we hope to maintain our current leadership role. For the purpose of this discussion, we will define research subsidization as the practice of using departmental revenues to offset research expenses not covered by external sources. While it is possible to view the traditional “academic day” provided to unfunded investigators as a form of subsidization of radiology research, we are instead referring to the practice of supplementing the incomes of funded investigators whose salaries are greater than the funding provided by their research grants or to providing research time in excess of the percentage effort funded by grants to a given investigator. Since the National Institutes of Health salary cap is $161,400, an individual who is supported 100% by National Institutes of Health grants and whose salary is greater than $161,400 requires subsidization of his or her salary. Researchers whose percentage effort on external grants is less than 100% can generate funds from clinical work or industry funding; in most cases, however, the additional funds are derived from departmental clinical revenues. A department may also decide to invest in an individual researcher or research program to facilitate future success in obtaining independent research funding. In either case, department funds are redistributed to support departmental research priorities. It is important to note that in virtually all departments, some redistribution of clinical revenues already exists. Unless every faculty member is paid entirely in relation to his or her revenue generation, income generated by one faculty member is used to subsidize another. Salaries are often based on a combination of seniority, clinical and/or administrative responsibilities, academic productivity, and
195
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other factors. Research potential and/or productivity, particularly as measured by an individual’s ability to generate grant funding, can be an additional factor used to determine salaries. ARGUMENTS IN FAVOR OF RESEARCH SUBSIDIZATION The most immediately apparent argument in favor of research subsidization is that research is a critical component of our academic mission. The classic triad of clinical care, teaching, and research is included in the mission statements of academic radiology departments, and support of researchers and research activities is a necessary component. Research subsidization can also be viewed as an investment in the future. Radiology and health care in general are advanced through research. By providing the environment and funding for investigators to thrive, we can ensure that new technologies are brought forward and that radiologists will continue to have an important role in their use. If radiologists stop participating in the development of new diagnostic and image-guided therapeutic technologies, physicians in other specialties will fill the void. Research and an environment conducive to researchers are critically important in attracting faculty and trainees to academic radiology departments. Promising young faculty members with academic aspirations are more likely to accept positions in departments where they are surrounded by other productive researchers in an environment where research is valued. The knowledge that a department is willing to subsidize research can be an important factor in recruiting and retaining junior (and senior) staff members. A thriving research program can also be an important factor in attracting patients. Access to information concerning clinical trials and the use of new medical technologies has become more available to the public than ever before. Patients are increasingly willing to travel to centers that have cutting-edge research in areas that are relevant to their conditions. An active departmental research program is also important in ensuring access to the newest and best equipment. Manufacturers prefer to have their equipment (particularly prototypes) located at institutions where it will be used by academic leaders from whom they can obtain useful feedback concerning possible improvements and/or modifications on the technology. Manufacturers also like
196
Academic Radiology, Vol 9, No 2, February 2002
to see their equipment mentioned in research publications and may be willing to provide funding for researchers who use their equipment. These funds can in turn be used to help offset research expenses. Research subsidization is particularly important in the early stages of an individual’s career. Unassigned time is essential for faculty members to develop research skills and to generate the preliminary data needed to apply for extramural grant funding. Few radiologists complete their residency and fellowship training with the necessary skills and experience to compete effectively for research funding. Even fewer have acquired the necessary preliminary data to develop a competitive grant application. Investment in these young faculty can yield handsome returns when a research program becomes established and generates its own grant funding. Success can be contagious—a successful research program in one area can help related programs in the same department by supporting critical research infrastructures and by attracting talented investigators. Lastly, an active research program lends prestige to the institution, the department, and the investigator. Few researchers and even fewer research programs can exist and thrive without some initial, and thereafter intermittent, departmental support. Though it is hard to pay salaries or buy equipment with prestige, few would deny its importance. ARGUMENTS AGAINST RESEARCH SUBSIDIZATION The most obvious argument against research subsidization is that salaries for all faculty members will be lower in direct relation to the extent that departmental revenue is used to subsidize individual researchers or research programs. Research subsidization accounts for part of the salary gap between academic and private-practice radiologists. University and dean taxes, committee service, teaching obligations, and lack of access to the facility (technical component) fees from radiology examinations are other major contributors to this salary gap. Research subsidization has become increasingly difficult in the current era of shrinking clinical margins. With higher reimbursement rates, excess revenues from clinical operations could be used to subsidize research programs. As salaries for radiologists who perform clinical work consume an ever greater portion of clinical revenues, the decision to subsidize radiology research requires an even greater commitment to research.
Academic Radiology, Vol 9, No 2, February 2002
The current human resource shortage in radiology complicates the issue. In the past, the greatest challenge was finding funding for individuals whose research activities accounted for a substantial component of their professional time. With an insufficient number of radiologists, particularly in academic settings, it has become increasingly difficult to provide research time for investigators, even if the funds are available, as there are not enough faculty available to complete the clinical work. In this sense, research subsidization can exacerbate the problem by providing attractive opportunities for individuals who might otherwise be available to perform clinical work. Lastly, and perhaps most important, subsidization of individual researchers can lead to faculty discontent. Individuals may become jealous of others whom they may view as less productive or whom they may believe are being unjustifiably favored. This can result in a departmental environment that is unfriendly to research and can create additional morale or legal problems for department chairs and other administrators. CONCLUDING THOUGHTS We are working in a rapidly changing environment. Radiology research has become more complicated while
SUBSIZIDING RADIOLOGY RESEARCH
clinical margins are shrinking. Individual researchers who work at night and on weekends can no longer carry out the research necessary to move our field forward. Highquality research in radiology now requires teams of individuals, many of whom are not radiologists and whose principal appointments may be in other departments. These research activities require departmental commitments that are far greater than those made in the past. Fortunately, there are now more opportunities to obtain research funding. We have witnessed the establishment of the National Institute of Biomedical Imaging and Bioengineering. However, radiologists will have to work hard to compete for these funds, and some subsidization of individual researchers and research programs will be required if we are to compete successfully. In the end, it is not a question of whether to subsidize, but rather how to subsidize research. Our mission, the future of our field, and the successful recruitment of staff, trainees, and patients all require active research programs. To promote cutting-edge research, department chairs must have the courage, vision, and judgment to select and recruit researchers who have the promise to generate substantial research funding and to support their research and research programs.
197
Subsidizing Radiology Research1 G. Scott Gazelle, MD, MPH, PhD, N. Reed Dunnick, MD
Historically, radiologists have played a leadership role in the development, assessment, and clinical application of new diagnostic imaging and image-guided therapeutic technologies. Our involvement has helped to bring increasingly sophisticated technologies into clinical practice and to preserve the critical role of radiologists in the use of these technologies. For many years, this research was largely supported with clinical revenues. Academic radiology departments generated sufficient clinical revenues not only to cover salary and benefit expenses of their faculty, but also to allow faculty to conduct unfunded research. Furthermore, there were sufficient numbers of radiology faculty to allow time off from the clinical schedule to perform that research. However, recent trends in health care financing have made it increasingly difficult to achieve departmental profitability, and the current shortage of radiologists has made it difficult to maintain sufficient staffing levels to keep up with the growing clinical volume. Together, these trends have forced radiologists to reconsider the wisdom and feasibility of subsidizing research and to develop creative solutions to meet our clinical and research needs. Unfortunately, these changes are occurring at a time when the need for research on imaging technologies—and the complexity of that research— continues to grow at an accelerating rate. Imaging technologies have become a central component in the diagnosis and therapy of many more conditions than was the case even a decade ago. This trend is continuing, with more new technologies under development than ever before. As a result of the increasing importance of imaging in the detection of an abnormality, the diagnosis of the disease, and the moniAcad Radiol 2002; 9:195–197 1 From the Department of Radiology, Massachusetts General Hospital, Zero Emerson Place, Suite 2H, Boston, MA 02114 (G.S.G.); and the Department of Radiology, University of Michigan, Ann Arbor (N.R.D.). Received and accepted October 16, 2001. Address correspondence to G.S.G.
©
AUR, 2002
toring of treatment, nonradiologists are attracted to our field. Thus, radiologists are facing more challenging “turf battles” as physicians in other specialties compete in the attractive clinical practice markets associated with the use of imaging technologies. Only through dedicated and sophisticated research can we hope to maintain our current leadership role. For the purpose of this discussion, we will define research subsidization as the practice of using departmental revenues to offset research expenses not covered by external sources. While it is possible to view the traditional “academic day” provided to unfunded investigators as a form of subsidization of radiology research, we are instead referring to the practice of supplementing the incomes of funded investigators whose salaries are greater than the funding provided by their research grants or to providing research time in excess of the percentage effort funded by grants to a given investigator. Since the National Institutes of Health salary cap is $161,400, an individual who is supported 100% by National Institutes of Health grants and whose salary is greater than $161,400 requires subsidization of his or her salary. Researchers whose percentage effort on external grants is less than 100% can generate funds from clinical work or industry funding; in most cases, however, the additional funds are derived from departmental clinical revenues. A department may also decide to invest in an individual researcher or research program to facilitate future success in obtaining independent research funding. In either case, department funds are redistributed to support departmental research priorities. It is important to note that in virtually all departments, some redistribution of clinical revenues already exists. Unless every faculty member is paid entirely in relation to his or her revenue generation, income generated by one faculty member is used to subsidize another. Salaries are often based on a combination of seniority, clinical and/or administrative responsibilities, academic productivity, and
195
GAZELLE AND DUNNICK
other factors. Research potential and/or productivity, particularly as measured by an individual’s ability to generate grant funding, can be an additional factor used to determine salaries. ARGUMENTS IN FAVOR OF RESEARCH SUBSIDIZATION The most immediately apparent argument in favor of research subsidization is that research is a critical component of our academic mission. The classic triad of clinical care, teaching, and research is included in the mission statements of academic radiology departments, and support of researchers and research activities is a necessary component. Research subsidization can also be viewed as an investment in the future. Radiology and health care in general are advanced through research. By providing the environment and funding for investigators to thrive, we can ensure that new technologies are brought forward and that radiologists will continue to have an important role in their use. If radiologists stop participating in the development of new diagnostic and image-guided therapeutic technologies, physicians in other specialties will fill the void. Research and an environment conducive to researchers are critically important in attracting faculty and trainees to academic radiology departments. Promising young faculty members with academic aspirations are more likely to accept positions in departments where they are surrounded by other productive researchers in an environment where research is valued. The knowledge that a department is willing to subsidize research can be an important factor in recruiting and retaining junior (and senior) staff members. A thriving research program can also be an important factor in attracting patients. Access to information concerning clinical trials and the use of new medical technologies has become more available to the public than ever before. Patients are increasingly willing to travel to centers that have cutting-edge research in areas that are relevant to their conditions. An active departmental research program is also important in ensuring access to the newest and best equipment. Manufacturers prefer to have their equipment (particularly prototypes) located at institutions where it will be used by academic leaders from whom they can obtain useful feedback concerning possible improvements and/or modifications on the technology. Manufacturers also like
196
Academic Radiology, Vol 9, No 2, February 2002
to see their equipment mentioned in research publications and may be willing to provide funding for researchers who use their equipment. These funds can in turn be used to help offset research expenses. Research subsidization is particularly important in the early stages of an individual’s career. Unassigned time is essential for faculty members to develop research skills and to generate the preliminary data needed to apply for extramural grant funding. Few radiologists complete their residency and fellowship training with the necessary skills and experience to compete effectively for research funding. Even fewer have acquired the necessary preliminary data to develop a competitive grant application. Investment in these young faculty can yield handsome returns when a research program becomes established and generates its own grant funding. Success can be contagious—a successful research program in one area can help related programs in the same department by supporting critical research infrastructures and by attracting talented investigators. Lastly, an active research program lends prestige to the institution, the department, and the investigator. Few researchers and even fewer research programs can exist and thrive without some initial, and thereafter intermittent, departmental support. Though it is hard to pay salaries or buy equipment with prestige, few would deny its importance. ARGUMENTS AGAINST RESEARCH SUBSIDIZATION The most obvious argument against research subsidization is that salaries for all faculty members will be lower in direct relation to the extent that departmental revenue is used to subsidize individual researchers or research programs. Research subsidization accounts for part of the salary gap between academic and private-practice radiologists. University and dean taxes, committee service, teaching obligations, and lack of access to the facility (technical component) fees from radiology examinations are other major contributors to this salary gap. Research subsidization has become increasingly difficult in the current era of shrinking clinical margins. With higher reimbursement rates, excess revenues from clinical operations could be used to subsidize research programs. As salaries for radiologists who perform clinical work consume an ever greater portion of clinical revenues, the decision to subsidize radiology research requires an even greater commitment to research.
Academic Radiology, Vol 9, No 2, February 2002
The current human resource shortage in radiology complicates the issue. In the past, the greatest challenge was finding funding for individuals whose research activities accounted for a substantial component of their professional time. With an insufficient number of radiologists, particularly in academic settings, it has become increasingly difficult to provide research time for investigators, even if the funds are available, as there are not enough faculty available to complete the clinical work. In this sense, research subsidization can exacerbate the problem by providing attractive opportunities for individuals who might otherwise be available to perform clinical work. Lastly, and perhaps most important, subsidization of individual researchers can lead to faculty discontent. Individuals may become jealous of others whom they may view as less productive or whom they may believe are being unjustifiably favored. This can result in a departmental environment that is unfriendly to research and can create additional morale or legal problems for department chairs and other administrators. CONCLUDING THOUGHTS We are working in a rapidly changing environment. Radiology research has become more complicated while
SUBSIZIDING RADIOLOGY RESEARCH
clinical margins are shrinking. Individual researchers who work at night and on weekends can no longer carry out the research necessary to move our field forward. Highquality research in radiology now requires teams of individuals, many of whom are not radiologists and whose principal appointments may be in other departments. These research activities require departmental commitments that are far greater than those made in the past. Fortunately, there are now more opportunities to obtain research funding. We have witnessed the establishment of the National Institute of Biomedical Imaging and Bioengineering. However, radiologists will have to work hard to compete for these funds, and some subsidization of individual researchers and research programs will be required if we are to compete successfully. In the end, it is not a question of whether to subsidize, but rather how to subsidize research. Our mission, the future of our field, and the successful recruitment of staff, trainees, and patients all require active research programs. To promote cutting-edge research, department chairs must have the courage, vision, and judgment to select and recruit researchers who have the promise to generate substantial research funding and to support their research and research programs.
197