Heroes in Proving the Value of Imaging: Part 1

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Heroes in Proving the Value of Imaging is an occasional series about advocates for the profession who are working to enhance radiology through research, governmental affairs, humanitarian efforts, and more. In Part 1, ImagingBiz speaks with academic leader Bruce Hillman, MD.
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Bruce Hillman
The academicians best positioned to advance the science of imaging and help prove its value are those most willing to embrace, as research partners, specialists in fields outside radiology, according to Bruce Hillman MD, FACR, Theodore E. Keats professor of radiology and professor of public health sciences at the University of Virginia, Charlottesville. “I enjoy what I do. Research presents me with great challenges—and I happen to love great challenges. Fortunately for me, the challenges inherent in this type of research often turn out to be the most interesting part of each project.” —Bruce Hillman, MD “Today, if you really want to make a major contribution to imaging’s knowledge base, your research needs to be conducted using a multidisciplinary approach,” Hillman says. “This is true whether your aim is basic laboratory research, clinical trials, or socioeconomic research.” In order to embark successfully on multidisciplinary research, however, “You must first possess investigatory skills equal to those possessed by your partners in those other disciplines,” Hillman says. Other important attributes for researchers are an ability to think critically, solve problems, and write cogently, he adds. “All three of these skills come into play because one of the challenges of research, nowadays, is that you have to be able to communicate complex concepts fluently, so that your ideas and arguments are understandable by peers, colleagues, and even others outside the scientific community,” Hillman says. Proud of His Roles Communicating in lucid, persuasive terms has never been difficult for Hillman, editor-in-chief of the Journal of the American College of Radiology: JACR (a post that he accepted five years ago) and former editor-in-chief of Investigative Radiology and Academic Radiology. (Hillman helped launch both JACR and Academic Radiology.) Communication and clarity of thought have been Hillman hallmarks throughout the more than 1645 studies that he has written or cowritten for major medical publications. There is little wonder, then, that Hillman was named RSNA 2007 Outstanding Researcher of the year, an award recognizing an individual who has made original and significant contributions to the field of radiology or radiologic sciences throughout a career of research. Hillman, a member of the ACR Board of Chancellors, also emerged as a recipient of the George C. Marshall Memorial Fund Fellowship and the John A. Hartford Foundation Fellowship. A Pew Memorial Trust Fellowship honoree, he is an honorary member of the Society for Imaging Informatics in Medicine. When it comes to accomplishments, Hillman is most proud of the pivotal role that he played in transforming a small radiology research program at the University of Virginia into one of the nation’s more productive scientific investigatory units during his turn as chair of the radiology department there. He also helped start a number of other programs aimed at drawing fresh faces into imaging research, such as the Introduction to Research Program jointly sponsored by RSNA, the American Roentgen Ray Society, and the Association of University Radiologists (AUR); the Picker–AUR Young Faculty Academic Development Program; and the GE–AUR Radiology Research Academic Fund. Important Legacy Hillman’s name as a researcher is indelibly linked with numerous studies dealing with the issue of self-referral. Beginning in the early 1990s, he wrote a series of articles on that subject (which the New England Journal of Medicine and JAMA were among the most prominent publications to carry), and these were widely credited with favorably influencing changes in state and federal laws. His ultimate legacy in research, however, may well be his work in establishing the ACR Imaging Network (ACRIN), the clinical-trial cooperative group funded by the National Cancer Institute of the National Institutes of Health (NIH), which he led for nine years. “ACRIN provides us an infrastructure that enables our specialty to compete hard and effectively in the clinical research arena, with rigorous research, multicenter studies, and generalizable studies—some of which are influencing payment policies in ways that traditional radiology research has never been able to do,” Hillman says, as ACRIN chair and principal investigator from 1999-2007. “For example, through ACRIN, we have (to date) worked on over 30 studies and have received more than $250 million in NIH grant funding.” Three of ACRIN's most important studies, according to Hillman, were the Digital Mammographic Imaging Screening Trial (DMIST), the National CT Colonography Trial, and the National Oncologic PET Registry. DMIST, he explains, influenced not only how mammography is performed in the United States, but also how its providers are reimbursed. The National CT Colonography Trial, meanwhile, remains important as state and federal governments and private payors grappled with questions of how to pay for CT colonography, and to what extent. “Ours was the big decider trial, the one that brought this screening tool to the forefront and that paved the way for the American Cancer Society to declare it a front-line screening technique,” Hillman says. The National Oncologic PET Registry project was one that ACRIN designed and managed. Hillman says, “Earlier this January, I saw that CMS is now proposing to open many, many more reimbursed applications for PET as a cancer diagnostic tool, based on data aggregated and analyzed by the National Oncologic PET Registry.” A more recent ACRIN effort, still in progress, is the National Lung Screening Trial. “Our findings are eagerly awaited owing to their potentially huge social and financial implications,” Hillman says. Hooked on Research Hillman, a Florida native who grew up in Miami Beach, says that he found his way into research by having the good fortune to meet the right people at the right times in the right places, beginning with medical school at the University of Rochester (he graduated in 1973) and extending into a one-year internal-medicine internship at George Washington University. “I originally had the notion of becoming a general-practice physician, possibly in a small city,” he says. At Rochester, however, he was recruited to help a member of the pediatric faculty conduct survey research on community-based health centers. “I wrote and published a paper on the findings,” Hillman recalls. “After that, I was hooked.” His clinical interest eventually shifted to radiology, and he undertook residency in that specialty at the Peter Bent Brigham Hospital (now Brigham and Women’s Hospital) in Boston, where he soon found himself named an NIH research fellow. “The Brigham was one of the very few learning sites that had NIH funding for the training of young radiology researchers,” he says. During the year that followed, Hillman kept up with his research interests by participating in various laboratory and clinical investigations. His fellowship training ended in 1978, by which time Hillman had decided to devote himself to an academic career. First to offer him a position (which he accepted) was the University of Arizona. “In addition to clinical work, my job was to help develop the radiology department’s research laboratory,” Hillman says. Current Projects Today, Hillman’s focus is on the administrative side of research. Most prominently, he serves as chief scientific officer of ACR Image Metrix. “ACR Image Metrix is an imaging contract research organization that leverages the ACR’s more than 40 years of experience in coordinating large-scale clinical research to accelerate advances in radiologic care and fund future research to benefit patients,” he explains. “Our enterprise offers a complete menu of imaging contract research organization services, from study design to design of electronic data forms and image archiving to image interpretation and quantitation.” ACR Image Metrix shares its Philadelphia headquarters with the ACR’s clinical research division, which has provided administrative, data management, IT, image archival, and statistical support for more than 500 clinical research studies. “The ACR’s clinical research programs are among the largest recipients of federal medical research grants and have an established reputation for handling large-scale clinical trials involving up to 50,000 patients and some 20 million images at a time,” Hillman says. “ACR Image Metrix enhances this reputation by providing support to pharmaceutical companies, biotechnology firms, and medical-device manufacturers seeking FDA approval to bring new drugs, therapies, and medical devices to market.” The idea for ACR Image Metrix came to Hillman a few years after starting ACRIN. “I saw an opportunity to create a new revenue stream beyond grants for ACRIN and we moved forward from there,” he says. “Today, we’re doing very well. We have a fairly large number of contracts, and are selling services at a brisk clip.” Confidentiality agreements preclude Hillman from divulging details about what is being studied and for whom, with a few exceptions. One is a contract held with Nashua, NH-based iCAD Inc, which is relying on ACR Image Metrix for help in proving to the FDA that a number of its newest, most innovative computer-assisted detection technologies are safe and effective. Reflecting on the breadth, depth, and fruits of his research career, Hillman insists that he has been less a man with a mission than simply a man with a passion for exploring and answering provocative, important questions about imaging. “I enjoy what I do,” he says. “Research presents me with great challenges. Fortunately for me, the challenges inherent in this type of research often turn out to be the most interesting part of each project.” He continues, “Is there something I’m hoping to accomplish with all of this? Yes, I hope to move our field forward,” he says. “Take ACRIN, for instance. It has presented me with many, many challenges—challenges of all types and sizes. Early on, there was no model for conducting multicenter clinical research in radiology, so a major challenge was to invent the model. What would it look like? What rules would underpin it? What would be the incentives for participation?” Hillman recalls, “Later on, the challenges were along the lines of securing sizable sums of extra funding for our largest and most important trials when the base funding proved wholly inadequate. There were also the challenges of dealing with the sharp-elbowed politics surrounding some of the hot-button issues our research touched upon. This is what I love about imaging research. It’s what makes slowing down or altogether stepping away from it something I’m in no hurry to do.”