Only 5% of radiology research articles are published with residents as first authors (
1
). Although an increase in that proportion may be desirable, the purposes of requiring or encouraging radiology residents to participate in research extend well beyond publication. Participation in research teaches the resident how new knowledge in radiology is created and how changeable that body of knowledge may be (2
). This article describes the current state of resident research training in radiology, based on published survey data, the mandated requirements for resident research in radiology and strategies for meeting those requirements, and the programs sponsored by professional radiology organizations to facilitate, encourage, or recognize resident research.Survey Data
A 1988 survey of 121 chairs of academic radiology departments to assess how these departments select and educate their residents and fellows in research showed that 32% of residents and 44% of fellows in the responding programs were engaged in prospective clinical research (
3
). Considerably lower percentages of residents and fellows (6% and 17%, respectively) were performing laboratory research. Most of the responding programs selected at least some trainees for their potential as researchers, and nearly all encouraged trainees to perform research. The more the selection process focused on research, the greater the percentage of residents and fellows participating in research during their training. Only half of the responding programs offered formal research seminars, and few trainees opted for additional research training.Respondents' suggestions of ways to increase the number and quality of radiology researchers included the following: improve funding; recruit research faculty and free their time for research; fund research training programs and “centers of excellence”; establish research as a prerequisite for admission to the American Board of Radiology (ABR) examination; increase department priority for research; establish a new ACGME research requirement for radiology residency program accreditation; provide financial incentives to pursue research training; allot time for research and related activities; provide research training seminars at national meetings; emphasize selection of trainees for research potential; encourage fellowship training; change perception of radiologists; increase elective time for trainee research; reduce hours spent in core training to provide more time for subspecialization; increase space and equipment for research in basic science, and provide more opportunities for contact with researchers in basic science; and provide weekly seminars and other instruction in research techniques.
A 1989 survey of randomly selected, practicing radiologists (including the members of the Association of University Radiologists [AUR]) and of radiology trainees, with response rates of 28% and 19%, respectively, showed that radiologists who attended medical school or trained in radiology at an institution among the top 20 for research funding were more likely to choose careers in research than those who matriculated or were trained elsewhere (
4
). Publishing at least one research article, having a dedicated radiology research fellowship, having access to grant funds, and using computers during medical school or radiology training were factors typifying radiologists who chose research careers. Research radiologists were more concerned about the value of performing research and less concerned about personal income than those choosing other careers. The three most important obstacles to performing research were lack of time, pressures to do clinical work, and the need to obtain research funding.A 1990 survey of the American Association of Academic Chief Residents in Radiology (
5
), to which 94 (75%) of 125 chief residents responded, showed that research performed by residents was required in 21% of programs, encouraged in 59%, neither encouraged nor discouraged in 19%, and discouraged in 1%. The majority (58%) of responding chief residents had published one or more articles during residency. Chief residents with no prior publications and those with fewer than three publications before residency had similar publication records during residency, but those with four or more publications before residency were more likely to publish during residency. Although chief residents with more publications before residency initially expressed more interest in academic radiology, they were not more likely to take an academic job at the end of their residency.A 1996 survey of radiology program directors (
6
) showed that residents were required to assist a faculty member with research in 33% of responding programs and were required to perform independent research in 20%. There was no statistically significant difference between private practice–based and university-based training programs. Time off for research activity was granted on request in 23% of responding programs. Programs that did not require research used voluntary research activity (in 25% of responding programs) and teaching opportunities (in 17% of responding programs) to meet the Accreditation Council for Graduate Medical Education (ACGME) scholarly activity requirement. Comments from respondents indicated that case reports, production of resident conferences, and lectures to medical students and staff were activities that satisfied the scholarly activity requirement.ACGME Requirements
The ACGME requirements (
7
) for radiology resident research are as follows:Graduate medical education must take place in an environment of inquiry and scholarship in which residents participate in the development of new knowledge, learn to evaluate research findings, and develop habits of inquiry as a continuing professional responsibility. The responsibility for establishing and maintaining an environment of inquiry and scholarship rests with the teaching faculty. While not all members of a teaching faculty must be investigators, the faculty as a whole must demonstrate broad involvement in scholarly activity. This activity should include 1) active participation of the teaching faculty in clinical discussions, rounds, and conferences in a manner that promotes a spirit of inquiry and scholarship; scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice, 2) participation in journal clubs and research conferences, 3) active participation in regional or national professional and scientific societies, particularly through presentations at the organizations' meetings and publication in their journals, 4) participation in continuing medical education programs, 5) participation in research, particularly in projects that are funded following peer review and/or result in publication or presentations at regional and national scientific meetings, and 6) offering of guidance and technical support (eg, research design, statistical analysis) for residents involved in scholarly activities. During their training, all residents should be encouraged to engage in an investigative project under faculty supervision. This may take the form of laboratory research, clinical research, or the retrospective analysis of data from patients, and results of such projects shall be suitable for publication or presentation at local, regional, or national scientific meetings.
Meeting the ACGME Research Requirements
Recognizing the importance of medical research, Congress recently authorized substantial increases in the budget of the National Institutes of Health (NIH). In December 2000, President Clinton signed into law a bill creating a new institute, the National Institute of Biomedical Imaging and Bioengineering. Yet, at the same time that more money has been made available for medical research and a new institute has been created to focus on biomedical imaging, radiology resources are stretched to meet clinical demand, and the pipeline for new radiologists is restricted. Furthermore, too few radiologists have been sufficiently trained to perform competitive research. The same problems that prevent sufficient faculty research activity also decrease the ability of programs to provide meaningful research opportunities for residents.
Although not every resident will pursue research as a career, exposure to research is important to both the individual and the specialty. To continue as a viable specialty, radiology residency programs must emphasize research during the developmental period. In an effort to increase resident interest and productivity in research, Gay et al (
8
) implemented a 1-month mandatory research rotation. The 24 residents who participated in the research rotation reported performing 17 clinical projects (case reports did not fulfill the requirement), two bench research projects, and two projects involving socioeconomic or legal issues. They reported participation in an average of 2.7 research projects during training. Thirteen residents presented data at a national meeting, and three of them reported that their presentations won awards. Eighteen manuscripts were prepared by 17 residents as a result of the rotation.At the University of Wisconsin, Madison, radiology residents can spend up to 3 months of elective time in performing research. The resident is responsible for call assignments and conference attendance during the elective research period, but not for any other rotation responsibilities. Departmental funding of resident research depends on the perceived merit of the study design and the budget proposal submitted. The resident must apply for elective research time and funding before the yearly rotation schedule has been prepared, and scheduling must be approved by the chief resident. The departmental research and development committee reviews proposals, which must include a succinct description of the research project, the faculty mentor's name, specific aims and hypotheses to be tested, the budget (if applicable), how the data will be collected and analyzed, and the resident's goal regarding submission of results for presentation and/or publication. A requirement of the research elective is that residents present their research results at a departmental conference. The department also sponsors residents' presentation of their research at a national meeting.
In a recent article, Arenson et al (
9
) proposed a tiered approach to research training, which would allow training programs to select the level of intensity based on their human and other research resources. Tier 1 would include radiology departments within institutions that have strong histories of competitive research in other departments and the resources to support research training. The suggested program would provide at least 1 and preferably 2 years of research experience and education during residency and/or fellowship, to include the following: (a) laboratory, engineering, or multidisciplinary (preferably multi-institutional) clinical research experience; (b) focused research education, with the option of pursuing an advanced degree; (c) assignment to mentors; (d) involvement of the department chair and/or vice-chair for research in ensuring sufficient space, mentoring, and resources; (e) requirements of publication and presentation; and (f) training and experience in grantsmanship.Tier 2 would include radiology departments that have substantial research resources and that can make a continuing annual investment in the costs of research development and research training. These departments would agree to train in research a specific number of their residents annually, consistent with the capacity of their human and monetary resources. All other trainees would have more limited research experience. For research trainees the program would be the same as that required by tier 1 departments. For trainees not receiving extensive research training, the suggested program would include (a) a minimum of 3 months research experience with the required outcome of a manuscript to be submitted for publication and (b) a course of lectures, research presentations, and exercises in critical thinking.
Tier 3 would include departments with insufficient human, research, and monetary resources to train competitive radiology researchers adequately. For all trainees, the value of research should be emphasized more than it is currently—a change that may require the provision of incentives by the Residency Review Committee for Diagnostic Radiology and the ABR. The suggested program for tier 3 would include a course of lectures, research presentations, and exercises in critical thinking designed to emphasize the importance of research to clinical practice.
Holman Research Pathway
Dr B. Leonard Holman stated, “If we are to maintain our academic mission, we must customize radiology training and limit it to those individuals with the greatest talent, promise, and interest by offering specific training tracks rather than implementing the same curriculum for everyone” (
10
). The research track named after him was developed to allow certification in radiology for those interested in pursuing an academic career with an emphasis on research in basic and clinical science.The B. Leonard Holman Pathway is an integrated program that combines training in research with training in clinical radiology. This pathway is recommended only for physicians planning a career that focuses primarily on basic science or clinical research. Other physicians should pursue the standard 5 years of training. Prior approval must be obtained from the ABR before undertaking this research pathway. The program is designed for the exceptional trainee, and entry implies a commitment to its completion and a research career. Planning for this pathway should occur either during medical school or during postgraduate year 1. In special circumstances, exceptions can be made as late as postgraduate year 2 or 3. Candidates for this track must submit an application to the ABR that includes a curriculum vitae, an outline of the candidate's career goals, a description of the proposed research program, a supporting letter from the program director or chair guaranteeing availability of and support for research time, a curriculum vitae and supporting letter from the research mentor, and a description of any recent and current grants and peer-reviewed publications supporting the research proposal.
The total period of training is designed to fit within the usual 5-year radiology program. A minimum of 9 months of direct patient care in postgraduate year 1 is required in internal medicine, pediatrics, surgery or surgical subspecialties, obstetrics-gynecology, neurology, family practice, emergency medicine, or any ACGME-approved combination of these. Twenty-seven months of full-time clinical radiology are required, including 3 months in postgraduate year 1. Because of the shorter period of clinical radiology training, it is imperative that the training director, in conjunction with the research mentor (who need not be in the radiology or radiation oncology department), perform annual evaluations of the resident's progress in clinical radiology.
Twenty-four months of research time are required, with 20% of the time being devoted to clinical radiology training. During this 24-month period, trainees must assume clinical responsibilities (including call). The ABR recognizes the attenuated clinical radiology experience acquired in the B. Leonard Holman Research Pathway. The program director must be aware of the importance of the trainee's clinical performance over the 5-year period. In summary, the research pathway requirements are as follows: clinical patient responsibilities, 9–12 months; clinical radiology training, 27 months (including 3 months in postgraduate year 1); research training or experience (80%), 21–24 months; clinical training during research (20%), 1 day per week; total training, 5 years.
Trainees who leave the research pathway must complete the standard 5 years of training, including 4 years of radiology. The following criteria might be used to evaluate research performance: (a) participation in research, (b) acquisition of a graduate degree, (c) participation in seminars and journal clubs, (d) publications and patents, (e) presentations at scientific meetings, (f) basic research elements (protocol design, research methods and statistical analysis, manuscript preparation), and (g) honors and awards.
RSNA/AUR/ARRS Introduction to Research
In 1990, in response to a perceived paucity of quality clinician researchers in radiology, the Radiological Society of North America (RSNA), the AUR, and the American Roentgen Ray Society (ARRS) initiated a collaborative program entitled Introduction to Research. Since that time, the program has been held biannually, at the national meetings of the RSNA and the ARRS. From nominations made by department chairs, a committee of the AUR annually selects 40 2nd-year radiology residents to attend each program. Departments are restricted to one 2nd-year resident nominee. Each candidate must agree to stay at the selected hotel, attend all functions associated with the program, and participate in a longitudinal study to determine whether the program is successful by answering and returning several questionnaires during the next 10 years. Each program has included 12–15 hours of didactic and discussion sessions that cover an array of topics related to clinical and laboratory research in medical imaging, including “The Rationale for Technology Assessment,” “Introduction to Technology Assessment,” “Statistics for Diagnostic Imaging Research,” “Decision Analysis and Cost-effectiveness Research in Radiology,” “Critical Literature Review and Metaanalysis,” “Oral Presentation of Research,” “Preparation of Scientific Manuscripts,” “Essentials of Experimental Design for Laboratory Research,” “Research Relationships with Industry,” “The Excitement of an Academic Career,” “Considerations in Choosing Your Academic Job,” “Organizing and Administering a Research Laboratory,” and “Beginning an Academic Career.”
Funding for the program, which includes $1,000 to each participant to help defray expenses, has been the responsibility of the RSNA and the ARRS. The objectives of the program are to (a) make residents aware of the excitement and breadth of opportunities afforded by a research career, (b) expose residents to successful, enthusiastic radiologist-researchers, (c) raise awareness of the importance of research to radiology, and (d) provide residents with a primer in research early in their residencies (
11
).In 1997, all 396 program participants for the 1990–1995 period and 2,047 nonparticipants who were in the same residencies as the participants during that period were sent a questionnaire eliciting data for a comparison of career plans, research participation, and academic achievements between the two groups (
12
). The questionnaire was completed by 321 participants (81%) and 1,153 nonparticipants (56%). More than one-third of participants thought the program had a strong effect on their initial career decision. Forty-one percent of participants who completed training (n = 192) were in academic departments, compared to 26% of nonparticipants (n = 676)—a statistically significant difference. Of the 321 participants, 35% believed they would spend most of their career in academia and 15% thought research would be their primary focus, compared with 19% and 8% for the 1,153 nonparticipants (also statistically significant). Participants had higher levels of academic achievement earlier in their careers, having published more manuscripts, applied for more grants, and received more grants than nonparticipants. These results, however, may be influenced by the self- or departmental selection of participants who were oriented toward research, independent of program participation.Societal Support for Research During Radiology Training
Listed below are some of the grants and awards offered by major radiology societies to support research by radiology residents and fellows. Numerous specialty societies also offer grants and awards, and information regarding many of these programs can be found at the various sponsoring associations' Web sites.
RSNA Programs
Research Fellow grants are targeted to physicians who are nearing the end of their radiologic training. These grants enable physicians to devote a year to research under the guidance of an experienced scientific advisor. The research fellow will gain further insight into scientific investigation and develop competence in research and educational techniques and methods. This program awards a stipend of $45,000 to qualified North American radiologists. The award may be renewed for a second year with a stipend of $50,000. In addition, the host institution may be granted $5,000 each year to help underwrite a part of the research expenses.
Research Resident grants are designed to provide 2nd- and 3rd-year radiology residents an opportunity to explore careers in research by freeing at least 90% of their time for research programs. The year can be planned to develop skills in engineering or administrative sciences or in imaging technology. It may be a year dedicated to learning critical data analysis, including study design and data evaluation. The 1-year grants are for $30,000. Applicants are individuals who possess any degree acceptable for radiology residencies.
The Holman Pathway Research Resident Seed Grant is designed to support selected residents who have been accepted by the ABR into the B. Leonard Holman Research Pathway for their residency training in radiology, radiation oncology, or nuclear medicine. This $30,000 1-year grant, with the possibility of another year's additional support, will be used to support a specific research project.
The Medical Student Departmental Program is designed to help radiology investigators identify medical students who could work with them to mutual advantage. The RSNA Research and Education Foundation provides matching funds to the participating radiology school or department of $1,000 per month for each medical student placed in the program. The school or department identifies qualified medical students who are available for at least 3 months of work.
The RSNA Roentgen Resident/Fellow Research Award Program was developed in 1996 to recognize and encourage outstanding residents and fellows in radiology research. To participate, a department identifies a resident or fellow in its program who has conducted or participated meaningfully in research during the previous year. Meaningful participation involves the presentation of scientific papers at regional or national meetings, publication of scientific articles in peer-reviewed journals, receipt of a research grant, contribution to the success of a research program within the department, or other substantive research activity. Every resident or fellow in an ACGME-approved program in radiology, radiation oncology, or nuclear medicine is eligible. Once the individual is identified, nominations are made to the RSNA Research and Education Foundation before April 15. Nominations are made by completing a form and submitting a letter outlining the outstanding qualifications and contributions made by the nominee. Each program is limited to one nomination per year, and the nomination form must be signed by the residency or fellowship program director. Participating departments are given a plaque with space for names to be added each year. A brass plate containing the awardee's name is sent to the department and added to the plaque. In addition, a memento is provided to the department to present to the recipient of the award.
More information on these programs is available at the RSNA Web site (www.rsna.org/research/foundation/index.html).
ARRS Awards
The ARRS offers a President's Award ($2,000) and Executive Council Awards ($1,000 each) to residents and fellows in radiology and radiologic sciences for papers submitted on the clinical application of the discipline of radiology and radiologic sciences. The paper should not have been previously presented, published, or submitted for publication. Award-winning papers are presented at the ARRS annual scientific meeting. Each applicant must submit (a) eight copies of the manuscript and eight sets of illustrations, (b) a curriculum vitae, and (c) a letter from the program director attesting that the author is a radiology resident or fellow, the work is primarily the effort of the resident or fellow, each coauthor has contributed to the work, and the manuscript has not been previously presented or submitted for publication. The manuscript format should follow the guidelines for authors published in the American Journal of Roentgenology. Award-winning papers will be submitted to this journal for possible publication. More information on these awards is available at the ARRS Web site (www.arrs.org/scholarships_awards).
AUR Memorial Award
In honor of deceased AUR members, the Memorial Award is conferred annually on the radiology resident or 1st-year fellow who submits the best original paper on any aspect of radiology. The award recipient receives a medal, a certificate, and a $1,000 honorarium. The resident or fellow may be the sole author or may work in conjunction with other residents or fellows and/or with faculty members. In the latter case, the resident or fellow must fully qualify as senior author. All manuscripts submitted are considered for presentation at the annual meeting of the AUR, and the awardee is asked to present his or her paper there. The manuscript submitted for this competition cannot be simultaneously under consideration for publication and/or prize award by another group, cannot be scheduled for presentation before the AUR annual meeting, and must be a first-time submission. Further information is available at the AUR Web site (www.aur.org/memorial.shtml).
ACR Videotapes
In collaboration with the Association of Program Directors in Radiology, the ACR developed a series of videotapes for teaching noninterpretive skills to radiology residents. Pre- and posttesting showed that residents learned from viewing the videotapes (
13
). A tape entitled “Critical Thinking Skills” reviews a number of clinical research study designs, including the associated biases and basic statistical methods; defines validity, reproducibility, and generalizability as applied to research; discusses the technology assessment hierarchy, including efficacy, effectiveness, patient health outcomes, and cost-effectiveness; and offers strategies for critical reading of the radiology literature. This videotape was distributed to all American radiology residency program directors and is also available via the ACR Web site (www.acr.org/departments/residents/ncskills/movielist.php). It can be used in radiology residency training programs as part of a didactic curriculum in research methodology. A publication accompanies this presentation (14
). A second, more recent video presentation entitled “Clinical Trials,” also available at the ACR Web site, provides an overview of protocols and discusses imaging application development, cohort studies, clinical study issues and end points, patient selection, image interpretation, source documentation, and study integrity.NIH Extramural Loan Repayment Program
Because of concern that the number of young physician scientists is declining, the NIH recently instituted a loan repayment program that could serve as an economic incentive for more young physicians to enter into a physician-scientist career pathway. The NIH will be continuing this program into fiscal year 2003, and the criteria for eligibility will extend beyond NIH grantees. The program may repay up to $35,000 a year toward each participant's outstanding eligible educational loan debt. In return, participants must sign a contract agreeing to conduct qualified research activities for a minimum of 2 years. In addition, payments equal to 39% of total loan repayments are credited directly to the recipient's Internal Revenue Service federal tax accounts. General eligibility requirements are described at the NIH Web site (www.lrp.nih.gov) and were published in a recent issue of Academic Radiology (
15
).References
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