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Supporting the Academic MissionN. Reed Dunnick, MD

The mission of an academic radiology department includes not only high-quality patient care, but also theeducating of a broad variety of health care professionals, the conducting of research to advance the field, andvolunteering service to the medical center and our professional societies. While funding is available for theresearch and educational aspects, it is insufficient to cover the actual costs. Furthermore, it is becomingincreasingly difficult to make up the deficit by using a portion of the clinical revenues. Development andrevenues derived from intellectual property are becoming essential to support the academic mission.

Key Words: Radiology research, radiology education, technology transfer, philanthropy

J Am Coll Radiol 2010;7:211-215. Copyright © 2010 American College of Radiology

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cademic departments of radiology are struggling to pro-ide high-quality patient care yet fulfill their academicissions [1]. The necessity, often urgency, to attend to

atient care takes precedence over research, teaching, andervice obligations, yet it is essential that we find the timend resources to advance our field. This broad mandate,ften called the “academic mission,” includes developingnd refining new imaging techniques, training the nexteneration of radiologists, providing continuing medicalducation to radiologists who have completed training,ducating medical students and referring physicians onhe appropriateness of medical imaging, and conductingesearch, both laboratory and clinical. The challenge tocademic departments is to find adequate funding, whichsually includes the diversion of clinical revenues foresearch support [2-4]. With declining reimbursementor clinical services, this will present an increasing chal-enge to maintain an academic focus.

Academic medical centers are characterized by a highegree of clinical subspecialization, the presence ofCGME-accredited training programs, and an invest-ent in research. Most of these academic medical centers

re associated with universities. Clinical revenues areenerated through patient care activities, and physiciansunction much like a multispecialty group practice,hough revenues generated by each department generallytay (after the dean’s and other taxes) within the depart-ent, which provides incentive for the department to

ncrease clinical volumes and to practice efficiently.

epartment of Radiology, University of Michigan, Ann Arbor, Michigan.

Corresponding author and reprints: N. Reed Dunnick, MD, University ofichigan, Department of Radiology, 1500 E Medical Center Drive, Ann

brbor, MI 48109-0030; e-mail: rdunnick@med.umich.edu.

2010 American College of Radiology091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2009.09.021

LINICAL SERVICE

ncreases in medical knowledge and the diversity of im-ge-guided interventional procedures are driving subspe-ialization in radiology. The motivations to subspecializeay be in response to demands by referring physicians,

atients, or health care institutions [5]. Individual radi-logists may also be motivated by a personal desire toave a greater level of expertise in a given area. Embracingubspecialization is an important component of main-aining the intellectual leadership in medical imaging [6].

One of the attractions of academic radiology is thebility to subspecialize [7-9]. This varies from a modestestriction of one’s practice domain to having one’s entirelinical assignment within one subspecialty area. Someery large academic practices allow faculty members toake this further and restrict their practices to very narrowocuses within subspecialty areas such as interventionaleuroradiology, mammography, or abdominal CT. Thisllows radiologists to bring tremendous expertise andxperience to bear on limited areas. It is likely to enhancehe quality of teaching and is conducive to clinical re-earch in that area of focus. A practice must be large toupport such a high degree of subspecialization, and itften creates the need for more radiologists to be on callo provide 24-hour, 365-day coverage. Such practices,ith a high degree of subspecialization, are inherently less

fficient than those in which each radiologist covers aroad range of the field.The presence of medical students, especially radiology

rainees, on the clinical service has a mixed effect on thefficiency of the service. Although additional time iseeded for teaching, students and trainees can performseful work in gathering needed information, organizingtudies for review, dictating cases (after review by attend-ng physicians), and communicating with other mem-

ers of the health care team. The net effect of these

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212 Journal of the American College of Radiology/Vol. 7 No. 3 March 2010

rainees on clinical efficiency is quite variable. Althoughome argue that 50% of their clinical time is devoted toeaching [10], others feel that trainees, especially senioresidents and fellows in accredited training programsthose with certificates of added qualifications [CAQs]),ncrease their clinical efficiency.

DUCATION

ost academic radiology departments, whether they areormally part of universities or merely have collaborativeducational or research relationships with university depart-ents, are responsible for one or more aspects of medical

tudent education. This typically includes formal lectures,mall-group “workshops,” and teaching medical studentsho rotate on clinical radiology services in addition to par-

icipation in anatomy instruction. Furthermore, manyedical students want to do research in radiology, and those

nterested in entering our field require counseling.Radiology departments often are reimbursed for the

ost of medical student education. The mechanism forhese payments to radiology departments are often ar-ane and difficult to track, but the reimbursement is faress than the opportunity cost in faculty time.

Resident education is supported by the federal govern-ent through payments to the hospitals for graduate edu-

ation by CMS. These include both direct medical edu-ation (DME) and indirect medical education (IME) pay-ents [11,12]. Whereas DME payments are predictable,

ME payments vary dramatically across institutions.Unfortunately, not all of these trainees are fully cov-

red by DME payments. CMS capped the number of theositions it will fund at the December 1996 levels forach institution. Furthermore, it inflicted a penalty fornstitutions that increase trainee levels above the cap,hough this penalty is for DME but not IME. CMS alsoetermines the length of training it will fund on the basisf the first residency a medical student enters. Any train-ng beyond that residency is funded at only 50%. Inddition, the Balanced Budget Act of 1997 reducedMS payments to teaching hospitals [13].Fellowships fall into one of two categories. Those that

re formally accredited and have certifying examinations,uch as neuroradiology, pediatric radiology, interven-ional radiology, and nuclear medicine, are consideredresidencies” and must adhere to the same regulatoryompliance as residencies in primary certificate pro-rams. These fellows are often referred to as “CAQ fel-ows” because the successful completion of a programnd passing a certifying examination leads to what wasnitially termed a CAQ but is now called a subspecialtyertificate from the ABR. They may not function inde-endently, and the department cannot bill for their ser-

ices, but they are funded by CMS. t

The other category of fellows includes those who are innformal programs. They are not accredited by ACGMEnd receive no funding from CMS. These fellows aresually appointed as “faculty members” and receive clin-

cal privileges to work in the health care system as radi-logists. They can work independently, and departmentsan bill for their services.

Both groups of fellows are likely a net positive finan-ially for radiology departments. The non-CAQ or “fac-lty” fellows are given graded responsibilities for clinicalork. Over the course of the year, they may generatene-quarter to one-third the work relative value units offull-time faculty member. They may also assist facultyembers with call, contribute to educational activities,

nd participate in research projects.The financial impact of CAQ fellows (residents) is less

lear. Although they are funded by CMS, departmentssually contribute money for educational expenses suchs books, CDs, travel to educational conferences, andesearch support. Although they cannot work indepen-ently, they are fully trained radiologists who provideignificant help in carrying out the clinical and educa-ional missions of departments.

ESEARCH

esearch is essential to the advancement of our field ando maintaining intellectual leadership in medical imagingnd image-guided intervention [14-16]. Medical imag-ng provides insight into fundamental principles of phys-ology and disease pathophysiology, while research inno-ations are the foundation of the new techniques wencorporate into our clinical practices.

Much of our hypothesis-driven research is externallyunded by societies, foundations, or federal agencies, es-ecially the National Institutes of Health (NIH). NIH ishe largest research funding agency in the world, with annnual budget of more than $30 billion. Obtaining grantunding from NIH as a principal investigator is a goal ofany academic radiologists and a virtual requirement for

enure in elite research universities.Our professional radiology societies offer a variety of pro-

rams to support and encourage radiology research [17].hose offered by the ARRS and Association of Universityadiologists are designed for faculty development. The Ra-iological Society of North America offers courses in grantriting and clinical trials methodology, in addition to schol-

rships and research seed grants [18,19]. Many of our sub-pecialty societies offer research funding or prizes for the bestesearch presented at their annual meetings.

To be successful in building a strong research program,any components must be made available before researchonies come to a department [20]. Research space, equip-ent, and personnel are needed to conduct feasibility studies

o demonstrate to an NIH study section that the project de-

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Dunnick/Supporting the Academic Mission 213

cribed in the grant application can be accomplished. Whenecruiting faculty members to research positions, it is commono provide up to 3 years of “startup” funding for this purpose.fter this initial period, it is expected that the investigator is

uccessful in bringing in the necessary funding to support theaboratory. However, the investigator can never be 100% sup-orted. NIH offers funding to conduct research but not torite the grant. Furthermore, NIH does not support the ad-inistrative effort needed to run the laboratory.At some time in their careers, even successful investi-

ators run into dry periods, when grants are not renewedn the first application or new projects are not funded inime to maintain laboratories. However, if a laboratory ishut down, personnel will be lost, and no additionalork, including feasibility studies, can be done. Thus,

dditional “gap funding” is needed from the departmento sustain the laboratory during these dry periods.

Radiology investigators include radiologists, basic im-ging scientists, and a smattering of others, includingtatisticians, psychologists, and physicians from otherisciplines. If their salaries exceed the NIH salary capcurrently $199,700), the department must make up theifference. Any bonuses or administrative differentialsaid to them are also funded by the department, not byIH. This “cap gap” is another cost to departments, even

or very successful investigators.

INANCIAL IMPLICATIONS

he margins in each area depend on the specific param-ters unique to each department. In most departments,edical student education, resident education, and con-

inuing medical education all run negative margins. Fel-ows who are not part of formal training programs should

ore than pay for themselves in the clinical work theyan perform independently. However, the sum of theducational programs is a cost center.

The research program is a serious investment thathould not be undertaken lightly. The investment inpace, equipment, and personnel is significant and is notikely to be made up by indirect cost recoveries [2]. Be-ause both education and research are likely to run ategative margins, an academic radiology departmentust generate a significant positive margin on its clinical

perations to support its research and teaching missions.

LOSING THE FINANCIAL GAP

here are many strategies to cover the losses realized inulfilling our academic missions. Universities and medi-al schools want successful teaching and research pro-rams throughout the institutions. Often, fundingources are made available for bridging funds, the cre-tion of new initiatives, or the establishment of new

aboratories, especially if they might serve as core labora- p

ories and help support the work of other investigators inhe universities or medical centers. Services such as imag-ng tests are made available to other investigators, and coreaboratories are supported through recharge mechanisms.

Capital equipment needed for imaging research maye supported by administrative entities within a medicalenter. Cancer centers, cardiovascular institutes, or neu-oscience programs are often large enough to have discre-ionary monies to invest in imaging equipment that willelp advance the research done by many investigators.nless restricted by certificate-of-need laws, imaging

quipment may be acquired to be used for both clinicalatient care examinations and research studies. Thus,linical revenues generated by this equipment may besed to support research projects.

NDUSTRY-SPONSORED RESEARCH

uccessful academic radiology departments actively cul-ivate mutually beneficial partnerships with industry21]. Radiology departments benefit by having early-elease technology before competing institutions. Thisives the faculty members a head start in using the newquipment and presenting and publishing the results ofhose clinical applications.

Whereas in the past, vendor-supported research wasften linked to sales, this is no longer the case. Researchgreements are now formal documents with specifictatements of industry support, department deliverables,nd the assignment of intellectual property. Vendorsay provide equipment and fund the personnel needed

o conduct the research in exchange for rights to thentellectual property or unlimited-use licenses.

In some settings, academic faculty members may worklosely with industrial scientists to jointly develop imag-ng equipment. These relationships are complex and typ-cally include visits of the faculty members to the vendor’saboratories and industrial scientists working on-site in uni-ersity laboratories. Involvement of the university intellec-ual property office with lawyers from the vendor is essentialefore this work can begin. However, once worked out,hese relationships can be very beneficial to both industrynd academia.

ECHNOLOGY TRANSFER

nvestigators are able to protect their intellectual propertyhrough patents. Although patents are commonly obtainedy investigators working in industry, there has been a signif-cant increase in the number of patents filed by academicaculty members [22]. The concepts pertinent to radiologyhat are appropriate for patenting include imaging systemardware and software, data acquisition methods (includingontrast enhancement), image reconstruction, and image-

rocessing methods [22]. Revenues generated from the use

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214 Journal of the American College of Radiology/Vol. 7 No. 3 March 2010

f patent-protected intellectual property may be derivedrom licensing its use to others or by forming a “spinoff”enture capital company to produce and sell a productased on the patented concept. There is a cost to process aatent, and research universities have developed specificules on how these expenses are defrayed as well as howevenues are dispersed.

HILANTHROPY

his important method of supporting the academic mis-ion is often overlooked because the payoff to a depart-ent is usually delayed. Although monies given for a

pecific purpose may be expended at the time they areiven, they do not have the opportunity to appreciate asnvestments. More often, funds are placed into an en-owment and invested for long-term growth. The corpusf the endowment is invested in instruments that haveistorically returned 8% to 10% a year. Typically, aepartment can access about 5% of the corpus each year.he growth in the corpus, the margin between return andayout, keeps up with or, hopefully, exceeds inflation.

There are several other important advantages to thesendowments. First, they are attractive to donors. An en-owment can be given for a specific purpose, somethinghe donor feels passionately about supporting, often aisease with which a family member has been afflicted, orossibly a technology. Second, the endowment is named,nd that name is selected by the donor. Although it isften named for the donor or the donor’s family, it maye named for someone the donor would like to honor.hird, the corpus of the donation lies within a legal

ntity such that, unlike general funds, it cannot be ap-ropriated by the dean, medical school, or university. (Its also true that the department cannot access the body ofhe endowment. However, the department does receivehe payout every year, forever.) Fourth, many endow-ents are named professorships. Faculty members who

old these positions receive honor and recognition atheir home institutions and nationally through their ti-les as the named professors. This can be a valuable assetor recruiting or retaining faculty members.

Successful development programs require the activenvolvement of the faculty, especially the departmenthair. A development officer serves many purposes, in-luding identifying potential donors, tracking contactnteractions, clarifying the many vehicles for giving, anduggesting development activities. Successful develop-ent officers bring in more than 10 times their annual

alaries. However, success does not begin immediately.here is often a long period of cultivation before signif-

cant contributions are realized.

ONCLUSION

cademic radiology departments are essential to our dis-ipline. They provide intellectual leadership in medicalmaging through both basic and clinical research. Thesedvances are translated into clinical applications throughwide variety of educational programs.Because the funding available for the research and

ducational components of our academic mission doot cover the full costs, additional sources of revenueust be found to bridge the gap. Seed grants from

rofessional radiology organizations, gap fundingrom institutions, research equipment through indus-rial research agreements, and philanthropy all con-ribute to reducing or eliminating these negative mar-ins. These investments in our academic mission arenvestments in the future of our field.

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