John Port is an ISMRM Program Chair and has been working for the Mayo Clinic for 18 years collaborating closely with other physicians and scientists. In his interview with Paul Weavers, he explained how he defines value MRI, why clinicians and scientists need to pull on the same string and whether the popular research is the right research to be pursued.
Paul Weavers: Recently, there has been a big emphasis on value MRI. Do you have an opinion on this?
John Port: Absolutely! The challenge lies in the definition of the word value. Traditionally, if you look it up in any quality book, it will say value equals quality divided by cost. MRI is expensive, so that denominator gets very big. Hence, the value is low unless MRI can give you something that no other modality can give you. That is what makes MRI valuable and that is why we can charge such a crazy price for it.
Jim Pipe is an MR scientist and MRI value expert. His approach is to develop faster anatomical imaging, which is good enough quality-wise, at a low price. So, he maintains if not increases value for the patient. This a great approach, but it also depends on the clinical question. E.g., most of the patients with seizures will get a head MRI and it will be negative. At Mayo, we do a full 3D volume metric head scan with 6 or 7 different sequences, which takes about 45 min. However, by taking the time, we will find the little tiny 2-mm anatomical abnormality that nobody else will find. So, what is the value to the patient? Infinite – because that particular MRI was worth every penny.
PW: Value MRI mainly focuses on anatomical imaging. Is this engough going forward?
JP: I would argue that anatomical imaging is not enough going forward. Simply said, MRI makes pictures of water and fat. That’s it! We are not imaging pain or cell walls or cell division. So, anatomical imaging is just the beginning. One of the best parts about MRI, one of the things I love the most, is that I am going to finish my career and we are still just getting started. There is so much more value hidden in MRI with developing techniques to image stuff that really matters.
PW: When we consider the diagnostic imaging to discover the cause of a malady, how much do we simply see what we expect to see?
JP: The difference between the work of a radiologist and an average person is that the radiologist already knows what he/she is looking for. In the new Sherlock Holmes movie, there is a scene where a lady is about to be sacrificed by an evil guy. Holmes and Watson are running to save her. Suddenly Holmes screams: “Watson, don’t! Observe…” The camera then shows a tiny glass thread which is about to cut Watson’s head off. Naturally, Watson wants to know how Holmes knew about the existence of the glass thread. Holmes answers: “Because I was looking for it”.
In radiology, preconception is extremely important. When I am looking at a case, I look at the symptoms and the disease because this will tell me where to look and what to look for. Thus, it is imperative that we know what to look for. For a new disease, this can be very challenging. What are we looking for? New disease, new symptoms and I have nowhere to look based on the symptoms. For psychiatric illnesses, one of my passion, we have no idea what to look for. So, psychiatric imaging is very hard. In a way, without preconceptions our job gets a lot harder.
PW: What clinical questions are waiting for the enabling technology in MRI?
JP: This is one of themes of the ISMRM, which I absolutely love. The clinicians say: “I need a test that can show me this! Why can’t you make me this test?” And the physicists answer: “We have a test that can show you that. Why do you not use it?” It is a Reese’s Peanut Butter Cup thing which we need to create. Let us take the example of a person who has back pain. To detect the cause of the pain, we do a spine image and list potential pain generators in long reports. Why can I not just image the pain? We know that the pain from simple back problems mostly comes from muscle spasm. Why can I not image the lactic acid build-up? In that way, I could know that the left side is spasming more than the right side.
Another very frustrating part of medicine is that if you have cancer, you will receive several rounds of chemotherapy. The doctors then take a look at you, knowing that after three or four rounds, the tumor is either going to shrink, stay the same size or get bigger. We decide to continue with the chemotherapy based on the size of the tumor. Ridiculous, right? Why do we not give one dose of chemotherapy and look the following day to see the kill rate in the tumor. Give me a cell death scan to see how much of the tumor has been killed. If it is 90% or more, fantastic! If only 10% of the tumor is killed, why should I continue with this chemotherapy? Let us switch to a different chemotherapy. Those are two examples, where MRI could come up tests that would be clinically meaningful to millions of people every year.
PW: You have mentioned the Reese’s Peanut Butter Cup, the clinical question going to the scientist or the scientist having a technique and going to the clinician. Which way do you think that works best?
JP: It works both ways. What I love about ISMRM is that you get the clinicians together with the scientists. Here is an example: On one side, we have a scientist working on something, e.g., tissue microstructure within diffusion tensor imaging. On the other side, we have an oncologist who says that there is a build-up of beta-amyloid in Alzheimer’s disease, and that one could see a change in the microstructure in the brain, if the build-up is big enough. Why can the scientist and the oncologist not work on this together? Input from both sides is absolutely critical. Neither side is going to make an advance alone.
PW: Mayo has a strong focus on MR methods development. How has your approach to clinical practice changed knowing that there are guys down the street who know how to do MRI physics?
JP: I am a radiologist, which is a middle man between the frontline clinicians, who need answers to their questions, and the technology side. A case in point: I had a colleague who came to me one day and said: “John, our MS imaging sucks!” Surprised, I answered: “Wow – this is Mayo, we have the best imaging in the history of mankind.” Not too happy with my answer, my colleague went on: “I want to see cortical lesions that are 1 to 2 mm in size. What can you do to help me?” I told him to give me a week.
So, I talked to our Mayo MR physicists as well as our Siemens and GE site representatives. I also talked with Josh Trzasko on mathematics and reconstructions. I told them that I want to do high-resolution imaging and asked them what they can do to help. So, the Siemens representatives twiddled with things and Josh supported me with a denoising algorithm. Together with the help of Matt Bernstein, we reached 700 microns isotropic imaging in patients with MS in roughly 7 minutes. It is about 1 minute longer than the conventional best imaging that we have ever had, 3 times the resolution and it clinically shows me things which I could never see before This is the sequence that we use in all my research projects and soon we will be rolling it out to the clinical practice.
PW: How do you roll that out to the clinical practice? Does that go through a separate FDA approval?
JP: No, these are standard clinical sequences that we are using in non-standard ways. Josh’s reconstruction with the denoising is not FDA approved, that is true. Dan Blezek is helping us with the translation into practice. He is automating the processing and insertion of the results into the clinical record. We have an MR registry which allows us to use non-FDA approved processing techniques in patients as long as we keep track of every single one and make sure we do no harm. At Mayo, we have built enough infrastructure to do this. In the end, we always come back to needs of the patients, which come first.
PW: If can I clarify: From the clinician to the regulatory guy, there are a lot of different people involved to get something as you have mentioned done?
JP: In my experience, this is one of the few, if not the only medical institution in the world that can pull this off. We have the resources and the people with the expertise to be able to do it. I have been here 18 years and I cannot imagine going anywhere else.
PW: As a program chair, how do you set the appropriate time for these research topics in a limited space of a meeting such as the ISMRM?
JP: It is a real challenge. There is always more material than we could present. Last year, and I am just paraphrasing numbers, we had about 6900 abstract submissions, of which about 5500 abstracts were accepted. This is roughly an 80-85% acceptance rate. So, we have to find clever and innovative ways to cram all of that science into a 4-day meeting. A large part of it is getting creative with the presentation forums. ISMRM has come up with something called the power pitch. This is where we take 15 scientific presentations and you get 3 minutes per pitch. So, 15 presentations go within an hour, followed by a 1-hour poster session where you can talk to the presenters. This allows us to cram more science into a fixed amount of time in a way that is useful to the membership.
PW: We have seen big pushes at time, such as parallel imaging a number of years ago and machine learning right now. How do we know whether the popular research is the right research to be pursued?
JP: That is the million-dollar question, right? You can never truly predict. I am the program chair of ISMRMs, but I work with a group of 90 physicians and scientists from all over the world. Those people on the annual meeting planning committee do the heavy lifting. They are the ones that know what is hot and what is not. We put together a pretty good overall program that is sitting right at the cutting-edge. For example, Cartesian imaging methods are considered last year but we are still keeping them as a category for now. We track the number of abstracts that go into each category. When a category no longer has that many submissions, we just phase it out.
That being said, we realized a few years ago that we have a problem. The AMPC members are 90 members out of 7000 in our society. We know things pretty well, but there are plenty of smart members out. Last year, we created the member-initiated symposium. The thought was to ask the membership to create sessions. Anyone can submit a proposal and organize a 2-hour session. We select topics which the AMPC does not cover. In that way, we are trying to fill in the holes for subjects that the AMPC might have missed. We had 26 member-initiated symposia last year on a wide range of topics not covered by the AMPC educational program. All together, we had an amazing meeting in Paris, and we will continue these programs in Montreal to keep our society vibrant and cutting-edge.
MAKING THE LEAP IN IMAGING PERFORMANCE
Prof. John Port, MD, PhD
Professor of Radiology, Associate Professor of Psychiatry and Radiologist
at Mayo Clinic, Program Chair at ISMRM