Like Father, Like Son

by WILL DOSS | photography by NATHAN MANDELL
James Carr followed his radiologist father’s footsteps but is forging his own path as Radiology chair.

Throughout their four-year education, medical students ponder their future sub-specialty. Their top choice may change once, twice or a dozen times, reflecting experiences in the classroom and on clinical rotations. However, for one student at the Royal College of Surgeons in Dublin, Ireland, there was a single thought on his mind.

“Because my father was a radiologist, I thought I was going to stay well clear of radiology,” says James Carr, MD, ’00 ’01 GME, chair and the Drs. Frederick John Bradd and William Kennedy Memorial Professor of Radiology.

Carr with Ali Serhal, MD, (left) and Kongkiat Chaikriangkrai, MD, both cardiovascular imaging fellows.

The young physician very nearly chose cardiology, but in the end, he followed in his father’s footsteps. Carr completed a radiology residency program at Saint Vincent’s Hospital, also in Dublin. He never left his interest in the heart behind, though, focusing on the burgeoning field of cardiac imaging. This decision would lead him to Chicago for a fellowship in radiology, to a professorship at Northwestern and as of November 2018, to the chairmanship of the department.

Radiology holds a unique position within medicine. Radiologists primarily serve other physicians in the care of patients. This indirect clinical care approach puts a particular onus on collaboration, a philosophy that was instilled in Carr both through his training and through his father’s advice.

“One of the things I’ve learned is that we must work together, across specialties, to provide information that will help other physicians manage their patients better,” says Carr, who is also a professor of Medicine in the Division of General Internal Medicine and Geriatrics, and a professor of Biomedical Engineering at the McCormick School of Engineering. Spending much of his career improving cardiac magnetic resonance imaging (MRI) to inform patient management, Carr knows that collaboration is essential in the areas of research and education as well clinical care.

“If you don’t have the interdisciplinary framework, the enterprise falls apart pretty quickly,” Carr says.

Fruits of Labor

In 2003, then-assistant professor Carr became director of Cardiovascular Imaging at Northwestern Memorial Hospital. Carr was tasked with building a clinical cardiac MRI program, which, up until this point, existed mostly within the realm of research. Cardiac MRI, which has its experimental roots at Northwestern, could detect scarring on the heart. This sophisticated imaging technology allowed clinicians to predict how patients might respond to bypass surgery without resorting to invasive tests. There was just one problem—nobody knew about it.

“We didn’t have a lot of patients, as not many referring physicians knew about this new modality,” Carr says.

To get the word out, he helped build a program to instruct residents and physicians in this unfamiliar procedure. Training physicians in cardiac MRI both created and met demand, as did a symbiotic expansion of Northwestern’s cardiac surgery program. The largest benefit, though, came from the proliferation of Feinberg-trained cardiac radiologists and cardiologists.

“We sent these ambassadors out into the community, and they became sources of knowledge,” Carr explains. “It was an unintended objective, initially, but my cardiology colleagues and I realized we could actually set the standard for how you use cardiac MRI.”

The modality is no longer used only for projecting recovery from bypass surgery. Today clinicians also employ it for evaluating heart failure and helping determine the effectiveness of drug therapies in other cardiac diseases. The majority of referrals at Northwestern still come from Feinberg-trained physicians — a testament to the reciprocal relationship between education and clinical care.

Advanced MRI techniques at Northwestern Radiology allow for detailed insights into cardiovascular diseases. Left: 3D blood flow dynamics after heart valve repair (TAVR), right: MRI angiography of the thoracic vessels.

Advanced MRI techniques at Northwestern Radiology allow for detailed insights into cardiovascular diseases. Top: 3D blood flow dynamics after heart valve repair (TAVR), bottom: MRI angiography of the thoracic vessels.

All Hands on Deck

About a decade later, another of Carr’s projects showcased radiology’s unique position in the department’s tripartite mission. In 2014, Carr, along with co-primary investigator Michael Markl, PhD, the Lester B. and Frances T. Knight Professor of Cardiac Imaging in the Department of Radiology, received a $3 million National Institutes of Health grant to develop an MRI test to detect complications in patients after heart transplant.

The current method to diagnose transplant complications is with a biopsy. This new MRI protocol measures inflammation of the heart, providing a quantifiable metric that can inform clinicians if the patient is rejecting their new heart. The investigators recruited patients who underwent heart transplants at Northwestern Memorial. While early work in the project focused on developing new MRI techniques, more recent publications have demonstrated its clinical effectiveness to the extent that it has already become standard practice at Northwestern Medicine. “For example, just the other day I evaluated two heart transplant patients using MRI,” Carr says. “It’s becoming quite integrated into the clinical algorithm here.”

This discipline-spanning project includes Feinberg radiologists and cardiologists, McCormick medical physicists and engineers, and even industry partners at Siemens. It aptly reflects how the research enterprise operates in the department, according to Carr.

“One of the reason Northwestern attracts world-class investigators is its collaborative spirit,” he says. “That’s how we’ve structured our research program.”

Looking Forward

These experiences feed into Carr’s governing philosophy as chair. Above all, he knows radiology can’t go it alone. Dimly-lit reading rooms can sometimes isolate radiologists from their clinical colleagues. They also tend to experience fewer face-to-face interactions with other physicians. However, Carr believes that tight-knit relationships between radiology and other Feinberg departments, Northwestern schools and among the entire Northwestern Medicine hospital system, are the key to breakthroughs in the laboratory and in the clinic.

Since his appointment as chair late last year, he’s initiated a new focus on informatics and data sharing. Carr has been working closely with Senta Berggruen, MD, ’04 GME, associate professor of Radiology and residency program director, to begin overhauling trainee education to get students out of the back rooms and onto the clinic floor. Establishing this foundation is important, as radiology, still reeling from the shift from film to digital images, has more major changes on the horizon.

As a primarily physician-service subspecialty, radiology depends on sharing images and patient data from physician to physician and from hospital to hospital. There is a dizzying array of moving parts: picture archiving and communications systems (PACS), electronic medical records and dictation software used by radiologists to record diagnoses. All of these pieces must be compliant with patient privacy laws. A robust information technology infrastructure is required to quickly share these images and clinical information. “We need to develop processes so the services we provide can occur in a seamless manner,” says Carr, who plans to establish a dedicated informatics program within radiology.

Medical education is rapidly transforming, moving away from didactic lectures and toward interactive learning. In this area, Carr is helping tweak the Diagnostic Radiology Residency Program to follow that trend. For example, putting radiology trainees on clinical rotations makes them immediately available to read images on the hospital floor where they can be in direct contact with physicians and patients. “This is just one of the ways that we’re trying to pull radiologists out of those back rooms,” Carr says.

Additionally, the radiology residency pro-grams now feature a wide variety of educational tracks, including courses in business, research or global health. Trainees, for example, have traveled to South America as part of an inter-national aid organization to perform diagnostic ultrasounds in underprivileged communities.

These foundations put the department on strong footing for the future, which promises even more technological change and subsequent adaption. Much has been made about the possibility of artificial intelligence (AI) replacing or crowding out the radiologist. In the near term, though, Carr sees AI as a way of augmenting physicians—rather than an existential threat—to handle the massive amounts of information that newer modalities can generate. For example, a cardiac MRI study can easily produce 4,000 images in a single patient’s study. “It’s just not possible for a single human being to comprehend and understand all of that,” Carr says. “We need AI to help the radiologists do their job.”

Launching new AI research initiatives will pull from every discipline and challenge scientists, but Feinberg is uniquely positioned to be a leader in the budding science.

“Developing algorithms and partnering with our colleagues in Evanston and the larger industry will allow us to build a robust research program,” Carr says. “Because of our clinical volume and our digital infrastructure, we are poised to drive this whole area forward from a research perspective.”