On Following One's Dreams

Donald A. Stewart, MA

As a career, radiology offers its practitioners more opportunities for professional and intellectual development than any other medical specialty-this was the case the first day after Roentgen's discovery and continues to be the case today, current upheavals in our health-care system not-withstanding Radiology residency programs continue to be comprehensive in scope and content, and residents have ample chances to explore the specialty's diversity as they rotate through chest, breast, musculoskeletal, gastrointestinal and genitourinary radiology, pediatric radiology, neuroradiology, and cardiovascular and interventional radiology. During these rotations, they acquire skill in and knowledge of state-of-the-art imaging technologies that allow explication of disease processes and trauma-computed tomography (CT), ultrasonography (US), magnetic resonance (MR) imaging and spectroscopy, radiography, and nuclear medicine-along with experience in interventional procedures such as biopsy, drainage, angioplasty, embolization, infusion, and percutaneous introduction techniques. Radiologic physics, radiation biology and protection, and pathology are also part of the program, as is exposure to computer technology and information science. Radiology generates, evaluates, stores, and retrieves more digital clinical information than any other medical specialty, and adroit synthesis and management of information has become central to the radiologist's daily work.

On completion of their residencies and successful navigation of their American Board of Radiology, or ABR, examinations, young radiologists find themselves at the center of a conceptual locomotive roundhouse where tracks diverge to every point on the medical compass. These tracks can lead to specialization in one or more organ systems or in pediatric radiology, neuroradiology, or cardiovascular radiology; a focus on a specific imaging modality (CT, MR, US, or nuclear medicine); a focus on hands-on interventional treatment; a role in the management of information, capital equipment, and ideas; a role in the teaching of others in an academic setting; the research and development of diagnostic imaging technology or new approaches to diagnosis; departmental management; spectroscopic explication of disease processes; the oversight and integration of image data with data generated by hospital information systems, or HIS, and radiology information systems, or RIS; or a career as a consummate general radiologist at the forefront of primary care.

During and after their residencies, radiologists have access to the richest array of continuing education materials and programs in all of medicine. Radiology's peer-reviewed publications (more than 35 of them) and professional societies (more than 50 of them) produce ideas and knowledge that encompass all facets of the specialty. The Radiological Society of North America (RSNA) alone, with its educational materials, annual scientific meeting, and stellar publications, offers a cornucopia of educational opportunity and has structured its programming so that all radiologists-no matter what their special interests have complete access to germane educational materials (print and electronic) and a means of interacting with peers. RSNA's infoRAD is a testament to radiology's leadership role in interactive electronic education, and to the fact that radiologists are front-runners in medical informatics, physicians who-in a true sense-add value to any clinical enterprise they engage in.

As we witnessed throughout the centennial celebration of Roentgen's discovery, radiology's history is rich because there have always been radiologists and allied scientists who have reveled in the opportunities the specialty affords, individuals with vision, passion, diverse interests, and the will and conviction to walk new paths and follow their dreams. Typically, these individuals are multitalented, inquisitive, driven to share their thoughts with others, active in the stewardship of the specialty, and optimistic about its continued growth. Are there many of these individuals in radiology's ranks today? Of course there are, and they are actively shaping the current chronicle of history that will be scanned at radiology's next centennial. Some have even reached beyond our discipline to play active roles in multidisciplinary higher education.

William R. Brody, MD, Ph.D., took his place as president of the Johns Hopkins University, Baltimore, MD, on September 1, 1996, bringing this institution the visions, skills, and ideas he has developed throughout an active and exciting radiologic career. Inspired by his father, an ophthalmologist, Brody crystallized his dreams early in life and pursued a career that combined medicine and technology, sure that this would lead down an exciting path. A BS and MS in electrical engineering from the Massachusetts Institute of Technology, Cambridge, an MD and a Ph.D. in electrical engineering from Stanford University, Stanford, California, an internship in cardiovascular surgery at Stanford, and a radiologic residency at the University of California, San Francisco, form the bedrock of his academic accomplishments.

Brody's posts have included professor of radiology and electrical engineering at Stanford, chief executive officer and founder of the Resonex Corp, Freemont, California, radiologist-in-chief and Martin Donner Professor and director, Department of Radiology, Johns Hopkins Hospital, chairman of the University-wide Committee for Education in the 21st Century at Johns Hopkins, and-most recently-provost of the University of Minnesota Academic Health Center, Minneapolis, where he oversaw the well-being of all students, faculty, and staff in seven health professions schools, including two medical schools, and a major hospital and health system, managing a budget of $750 million in the process.

Brody has contributed more than 120 scientific articles to the radiologic and electrical engineering literature. His topics have ranged from cardiovascular imaging to minimally invasive imaging, MR imaging, and socioeconomic issues relevant to radiologic education and research. He is a member of the Institute of Medicine of the National Academy of Sciences, Washington, DC, a founding fellow of the American Institute of Medical and Biological Engineering, Washington, DC, and a fellow of the American College of Cardiology, Bethesda, MD, the American College of Radiology, Reston, VA, and the Institute of Electrical and Electronic Engineers, New York, NY. He is 52 years old and married with two children.

Brody is excited about his new post at Johns Hopkins and sees this institution as well positioned to address what is probably the most critical issue facing higher education today (medical and nonmedical alike): How to provide a high quality education, with a strong research component, in an era of increasing competition for resources. An advocate of radical change in medical education, Brody's focus has been on the resolution of financial problems that beset academic medical centers in an era of managed care. He is a questioner and an examiner of educational paradigms. What should a future classroom or campus ideally be? How should medical curricula change? What are the most effective means of educating physicians? How can medical specialties advance their knowledge bases in the face of economic constraint and aridity? In the face of intense competition for fewer research dollars, Brody sees academic centers consolidating their efforts and considers it likely that there will be fewer centers of excellence to carry on the research effort.

Governmental obliviousness notwithstanding, Brody believes members of the public expect medical advances to continue and that they would be shocked to learn that our push to expand the frontiers of knowledge can only be diminished in an environment in which everything physicians do-research included-must be justified on the basis of cost or financial return. He cites the automobile industry as an example. Although car manufacturers have become more efficient in production and close down plants to stay profitable, they would not dream of closing down their research and development facilities; lack of improvements, better efficiency, and safer operation would-over time-render their products obsolete and unmarketable. Academic centers of excellence are medicine's research and development facilities, and Brody views the threat of closing down or denervating some as very real.

As he did in 1990 (1), Brody still believes that the development of a sound research program hinges, in large part, on the willingness of departments to invest in people and facilities, investments that are costly and involve risk but that must have a high priority despite the pressures from managed care to generate more and more revenue. Departments, however, cannot bear the entire economic brunt, a state of affairs that some managed care companies and government seem unconcerned about at this stage of health care's evolution while the National Institutes of Health, Bethesda, MD, will probably remain level in constant dollars, with only a small share of these dollars awarded to investigators in medical imaging.

The technologies radiologists use to treat and diagnose disease are also critical in the performance of research efforts, and one can argue-as Brody does-that imaging technology has been a stabilizing element in health-care delivery, not a cost center. Only 4%-5% of health-care costs are due to radiology, and its cost benefits are too huge to quantify. Even though there are always ways to become more efficient, Brody believes that the cost of the radiologic component in hospital budgets is a lower percentage today than what it was 30 years ago.

Sales of MR imagers were down almost 40% in 1996, an inordinate number of freestanding imaging centers began to close (e.g., in California and Florida), and managed care is pushing for the performance of fewer procedures at all centers and institutions that use capitation as an incentive to do less. What the entire system seems to be unable to do, says Brody, is steer a true course between the Scylla of costly overutilization and the Charybdis of doing less than clinically indicated so that patients can navigate the channel with confidence and in good shape.

With all the profound changes in our healthcare system, the physician's increasing need to assume risk and live with uncertainty, the threat to the physician-patient relationship that has worked so well for so long, and the megaexplosion in information science, will young radiologists continue to find a career in radiology attractive or to find jobs? While Brody believes there will be a softening in the job market in the years immediately ahead, he offers some advice and countermeasures to those who see only gloom and doom and obsess about current market forces and the tedious motions of Adam Smith's unseen hand.

First, a large number of currently practicing radiologists are older than 50 years, and many are looking at early retirement or changes in their career paths. Second, newly entering, multitalented radiologists are bringing added value to the specialty with new kinds of skills in addition to clinical ones (i.e., computer, informatics, business, legal, etc). Third, it is impossible to know what the medicoeconomic environment will be in 2005, a year when a resident who starts today will have completed his or her residency and gained only a few years of clinical experience. Can anyone really believe that our health system, managed care, public expectations, diagnostic technology, innovative spirit, and our combined knowledge base and expert use of that knowledge base will remain static?

Brody is as enthusiastic about the growth of that knowledge base as he is about the progress in higher education, although he worries that in our era more and more knowledge is being lost in the clutter of too much information. Currently, he has as much paper piled around his desk, home office, and bedroom as the rest of us, but he sees a day not too far away-when search engines on the Internet will be far more efficient and programmable than anyone can imagine-engines that we can program and teach to retrieve relevant information automatically and display it in an orderly sequence at a time we specify. As for the important print journals in all scientific and medical disciplines, he sees them continuing in tandem with cyberinformation-ensured quality that you can carry around. Likewise, the big scientific meetings will live on in spite of cyberspace. Only by chatting in hallways with one's peers can one efficiently divine the context of the overwhelming content and harvest the perceptions of peers one admires and trusts.

I asked Brody what he would to say to a young medical student at Hopkins who evinced a genuine interest in the specialty and wanted his advice. He replied, ". . . radiology certainly is the most exciting medical specialty I know of. If you think you will love this kind of work, follow your dreams, and work hard; success will be sure to follow. There is always room at the top."

With every passing merger, buyout, administrative morass, and stockholder demand for more profit, the humanistic voices of old are getting harder and harder to hear. Although residents should not be blind to events that affect their chosen career, they need reminders about why they chose that career in the first place, and confidence that they have the smarts, training, talent, and societal mandate to succeed in a rapidly changing world:

If one advances confidently in the direction of his dreams, and endeavors to live the life which he has imagined, he will meet with a success unexpected in common hours. He will put some things behind, will pass an invisible boundary; new, universal, and more liberal laws will begin to establish themselves around and within him; or the old laws will be expanded, and interpreted in his favor in a more liberal sense, and he will live with the license of a higher order of things (2).

The radiologic community can be justly proud to see one of its own assume so prestigious and visible an academic post, a post in which he can foster the growth of all academic and medical disciplines. We wish him the best and will watch his ideas and dreams unfold with confident expectation.
 

References

1. Brody WR. Academic radiology and research: a fresh approach. Radiology 1990; 175:37-38.

2. Thoreau HD. Walden pond. In: Byam N, Gottesmann R, Holland LB, et al, eds. The Norton anthology of literature. New York, NY: Norton, 1989.