Alexander Margulis is one of the great radiologists of our time. The interview that follows nicely highlights some of Margulis’ accomplishments as gastrointestinal radiologist extraordinaire and the builder of what many considered to be the best radiology department in the world. One aspect that is only minimally addressed, however, is Alex Margulis, the man. On the first day of my residency, he walked into a room full of new residents and said, “Hi, I’m Alex Margulis. Call me Alex.” This simple statement not only set the tone for our residency but also revealed the warmth between Alex and all of his trainees. For many of us, he was much more than our chairman; he was our friend, mentor, and surrogate father. So, on behalf of all your “children,” Alex, we thank you for all you have done for us.
William G. Bradley, Jr, MD, PhD
Medical Director, Memorial MRI Center, Long Beach Memorial Medical Center, Long Beach, Calif
Alexander R. Margulis, MD, is an internationally recognized radiologist who served for more than 26 years as the chairman of the Department of Radiology at the University of California at San Francisco. He has received seven honorary doctorates, multiple gold medals, and honorary memberships in numerous radiological societies throughout the world. A prolific author, he has written more than 300 articles and many books. His work with the late Joachim Burhenne, MD, Alimentary Tract Radiology, is the authoritative text on the subject. Margulis currently serves as special consultant to the vice chancellor at UCSF and is a professor of radiology.
Axis Imaging News: You were born in Belgrade in 1921 and 29 years later had graduated from Harvard Medical School. To what do you attribute the drive it must have taken for someone from another country with only an elementary knowledge of the native language to achieve at the highest level of academia?
Margulis: I left Yugoslavia in January of 1946 because I couldn’t stand Tito’s politics. He was then as oppressive as Stalin. Under his rule, people were spying on each other and denouncing each other. It was a police regime, and I could not take it. Logistically, it was difficult to leave. My brother and I acquired passports through friends and patients of my late father. I spent the first 6 months in this country learning English. You know, it was not so difficult. When I was young, improving my English was not so difficult.
I come from a family of physicians. My father was a physician, my brother is a physician, and I always wanted to be a physician. I like medicine. I like to learn. I am still learning. I was very fortunate to be accepted at Harvard Medical School. Going to medical school when I came here was the logical thing to do.
Axis Imaging News: You were the youngest chairman ever at UCSF. In retrospect, describe the key achievements and choices that led up to that chairmanship.
Margulis: I am not sure that I was the youngest. When I accepted that position, I was 41. I graduated from medical school at 29. I finished my residency at 33. I was an assistant professor at the University of Minnesota for 3 years. In 1957 I become an obligated volunteer for the US Army. I had a wonderful time for 2 years, serving as head of radiology and medical education at Womack General Hospital in Ft Bragg, NC. This was a large hospital trying to make it as a big teaching hospital and a learning experience for me. I was a captain, but as head of medical education and of the intern and residency programs, I had to give instructions to full colonels. That was a good education in diplomacy. I had to learn how to get people to do what I wanted when they outranked me. I made a lot of friends during that time. When I was discharged from the Army, I went to Washington University in St Louis. Hugh Wilson, MD, was chairman and he was an outstanding individual. I was the deputy head of the department. He was my mentor. He was often ill, and then I would run the department for him. In 18 months, I went from assistant professor to full professor. In 1963, UCSF offered me a position, and San Francisco was a wonderful place. Jet travel had just opened up the country, so we were able to recruit people from the East. I have never regretted coming here.
Axis Imaging News: The radiology department at UCSF was quite different when you first arrived. What were your key objectives when you assumed the chair of that department? What makes a leading department?
Margulis: When I came here, the department was staffed by general radiologists. I felt very strongly that the radiology department should reflect the outside world of medicine. I decided that it was important to have subspecialists and basic scientists in the department. Technological advances in radiology rely on the work of physicists, chemists, and engineers. By having these scientists and engineers within the department and by including top-notch radiology specialists, we were able to take an active role in advancing radiology.
A department head should be a strong advocate of the university as well as of the department. Sometimes it is necessary to put the interests of the school ahead of the interests of the department. You know, if a ship sinks, the first class goes down with everyone else. Also, a leading department has to be able to integrate with other departments. I think it is extremely important for the heads of departments to create an atmosphere where people trust each other. It is so much easier to be creative in a collegial atmosphere.
A leading department has to be able to recruit quality faculty and staff and attract excellent students. At UCSF, we sought out international students who were interested in academic medicine and who were assured of having leading positions when they returned to their own countries. That is why we have so many radiology professors from around the world who were trained here.
Axis Imaging News: It has been said that you trained more radiology department chairs than any other man in the country. What would you say are the most important skills you gave them that enabled these radiologists to achieve the top distinction at their institutions?
Margulis: Leo Rigler, MD, from the University of Minnesota may have trained more department chairs. A good department chairman has to be part psychiatrist and has to have courage and vision. Perhaps the most important skills I taught my students had to do with relating to people. Diplomacy and loyalty are important. Praise in public and chastise in private. Be the last in the chow line and the first in the firing line. Help others to advance. Do not ask others to do something you would not do yourself.
Axis Imaging News: Your reputation and affiliations are international in scope. How important are international associations to the future of radiology? And what are the benefits that can be derived from such associations? What role did your international relationships play in your career?
Margulis: It is such a shrinking world. We must realize that we live together and depend on each other. It is important that young people have the opportunity to train at the very best place, wherever that is. It is also important that physicians and scientists from around the globe collaborate with each other. I was very fortunate because so many people from all over the world trained here. This department has personal connections everywhere. We became the focus of a great deal of international attention. I have received many, many awards from many different countries. I do not think of myself as having received those awards personally. I received them for the department.
Axis Imaging News: Who were the key people who influenced you in your career?
Margulis: I mentioned Hugh Wilson, MD, earlier. Carl Moore, MD, head of medicine at Washington University, also was an important mentor as was Leo Rigler from Minnesota.There were many capable, hard-working, bright, and modest people who were excellent role models for me. Having good role models is very valuable. They taught me the important things in life-to enjoy life, to be loyal, to have good values.
It is a great honor to be a mentor as well. We are alive only for a short time, but as mentors, we leave behind all those young people who go on to train others. We can perpetuate our knowledge and our values. Science and technology alone are sort of cold. The human element is very important.
Axis Imaging News: Research funds are evaporating, leaving it more difficult for university-based radiology departments to conduct the research required to move the specialty forward. What must radiology do to generate the research dollars required for progress? Does the venture capital marketplace represent a viable resource? What are the dangers in that?
Margulis: To attract research money and to advance radiology, it is crucial for a department to recruit and train quality people who are interested in staying in academic medicine. You must have the basic scientists-the physicists, engineers, and chemists who can work with the radiologists. It is a bit of a paradox: If a department is good, the best people will want to come; if the best people come, the department will be good.
I do not think venture capital is a viable resource. Meaningful research sometimes takes a long, long time. Venture capitalists usually want a quick return on their money. It is best to work with organizations that have the same goals as you do, that is, to advance science and technology. The government and private foundations are the best source of research funds.
Axis Imaging News: “Quality improvement” has become a catchall term in health care to refer to everything from perfectly calibrated equipment to the number of days a bill spends in accounts receivable. How does a department head insure quality among radiologists and what is the best way to achieve that?
Margulis: I have not headed a department in the present time of managed care. The key to a quality radiology department is having quality people. To insure quality among your radiologists, you have to be both humane and hard-nosed. People usually do not change very much as adults. Good performers will keep on performing. If scientists and physicians advance to a faculty position at a major medical school, they must have many skills and talents. On occasion, however, the match between the faculty member and the department is not so good. Then, as chief, you try to help them find a position elsewhere where they can star and you keep attracting the ones who will do the best for your department.
Axis Imaging News: At the same time that you were building a world-class radiology department, you were developing a world-class reputation in gastrointestinal imaging. How did you find a balance between the work you did for radiology and the work you performed for the institution? How did you manage that and how would you counsel future and current chairs on that subject?
Margulis: Never forget that when you are head of something, you are very visible. Whether you like it or not, you are a role model. I believed in those days that it was very important for somebody who is head to also be prominent clinically in one area. It is much more difficult now with managed care. Times have changed. It takes a lot more time for a chairman to run a department now. Some people can still do it, but not many. It takes tremendous energy, creativity, discipline, and focus. Time, like money, has to be budgeted. One has to be very parsimonious with time.
Axis Imaging News: Where you see medicine going? What do you think about the future of radiology?
Margulis: I think the future of radiology is very bright. Medicine is becoming increasingly molecularly and genetically oriented. Much of that work will be image-guided. I believe that in the future, service teams will work together with radiologists as part of the team. A formula will have to be developed to determine how radiologists will be compensated. It may look easy to interpret images, but it takes a lot of training. A good radiologist is like a detective who examines all the evidence and discovers things that others might not notice. Also, it will take trained radiologists and radiology departments to keep advancing imaging technology.
In the following interview, Herbert Y. Kressel provides us with a thought-provoking glimpse into the future of medicine and radiology. Throughout an illustrious career, Kressel demonstrated leadership and innovation in pursuit of medical and academic excellence. His candid views on medical delivery and patient care in a highly competitive medical delivery environment provide ample evidence that the future of medicine will require a new set of skills and methodology for cost-containment . From a unique vantage point, Dr Kressel discusses the future of radiology and academic medicine, and offers a virtual road map for delivering high-quality care, with particular emphasis on how medical care, research, and institutional missions can be preserved and enhanced.
Howard B. Kessler, MD
Director, Clinical Imaging
Fox Chase Cancer Center, Philadelphia
Herbert Y. Kressel, MD, has served as president and chief executive officer of Beth Israel Deaconess Medical Center, Boston, since July 1998. Before this appointment, he was chief medical officer at Beth Israel Deaconess and head of the radiology department. Kressel has received numerous honors and holds membership in many professional societies. He is a prolific writer and served until recently as the editor of Magnetic Resonance Quarterly. Kressel is the Miriam H. Stoneman Professor of Medicine at Harvard Medical School.
Axis Imaging News: When you assumed the position of chief medical officer of Beth Israel Deaconess, you had to make the decision to leave radiology behind. Your newest appointment as president and CEO seems even more final. Was this a difficult decision, and how did you justify the decision to leave behind a distinguished career in the specialty?
Kressel: Health care is at a turning point right now. It is a very difficult time for academic medical centers. I thought that this new role as president and CEO of Beth Israel Deaconess presented a great opportunity for me to make a contribution. I think that the contribution I can make is actually a greater one than I could make as head of the radiology department.
When I assumed the role of chief medical officer, I actually continued as chief of radiology. In assuming the role of CEO and hospital president, it was clear to me that the scope of the position and the amount of work that needed to be done would prohibit me from continuing to head radiology. It was a very difficult decision on a number of fronts. I enjoyed the academic, scholarly aspects of serving as the department chair. I was particularly interested in the development of research programs and in faculty development. Practicing radiology also was something that I enjoyed very much. I have been through this rather intensive period of getting used to my new role, but one of the goals I have set for myself in this next 6-month period is to get back to doing some clinical radiology.
Axis Imaging News: What contribution would you like to make?
Kressel: To help recast the academic medical center so it can be successful in these very difficult financial times. I want to be a part of fashioning an academic medical center that has solved the clinical service issues and is effective at delivering patient-centered care, but one that also stays on the forefront of developing and implementing the fruits of all the technology that we now have available for us.
Axis Imaging News: You have been quoted as saying, “No money, no mission.” Would you explain precisely what you mean by that?
Kressel: I am sure that I am not the only one who has said that. The issue is that if medical institutions can not be financially successful, their mission will be endangered. Managed care and Medicare policies have reduced reimbursements, patient demand, and graduate medical education support. Combine this with the slow but persistent rise in the costs of labor and supplies and the opportunities and pressures to respond to new advances in technology, and it is no wonder that medical institutions are facing a crisis. Having sound financial underpinnings is critical for sustaining their mission. The mission to provide high-quality, compassionate health care and to further medical practice has not really changed; rather it is what we need to do to accomplish this mission that must change.
Axis Imaging News: How is radiology research at Beth Israel Deaconess being funded now?
Kressel: Most research is funded through research grants. There has been a greater emphasis on industry funding over the past 10 years. There has been an increase recently in funds available from the federal government and also an increase in funding through philanthropy. A benefit of our economic boom is the rather dramatic wealth generation with a spin-off of increased funds available through private foundations and philanthropists.
In the past, a lot of research was funded through departmental overage, but that has been whittled away. Even with increasing funds from the federal government, private industry, and philanthropists,there is a significant financial shortfall, which impacts research.
Axis Imaging News: Who influenced you most in your career?
Kressel: I had a number of key mentors. Alex Margulis was my chairman when I trained in San Francisco. He is very much a personal role model for me. He is an expert negotiator, great at interpersonal skills, and provides an excellent example of organizing for performance.
Stanley Baum, chief of radiology at the University of Pennsylvania, is another wonderful mentor. He has terrific people skills and a great commitment to excellence and to supporting creativity. He is very much a can-do type of person. He also has a good sense of the relationship of the department to the institution. He was a strong advocate for both the department and the institution. Finding that balance now is more important than ever.
Mitchell Rabkin was hospital president at Beth Israel when I arrived here. He is a phenomenal leader with great vision who created a culture of caring that was manifested throughout the entire organization. He was sensitive to the human aspects of care and created a people-oriented environment At the same time, he expressed great respect and drive for excellence in research and education.
I spent several years working with [a vendor of imaging equipment], mostly with my work in MR and some in CT. I was on a number of their medical advisory boards and that helped me to develop insights into corporate function. I worked closely with Maury Blumenfeld, a physicist. Maury taught me a lot.
Axis Imaging News: What skill sets did you acquire that enabled you to move from the reading room to the boardroom?
Kressel: The people skills I acquired were very important. As a division chief at the University of Pennsylvania, I learned to manage people and to create an environment that promotes performance. When I arrived at Beth Israel, I became very active in the physicians’ organization. I was involved in managed care contracts, and so I picked up a lot of skills in terms of contracts, reimbursements, and capitation. I had an interesting experience as the president of the Society of Magnetic Resonance in Medicine. It merged with the Society of Magnetic Resonance Imaging in the early 1990s. It took about a year to bring these two organizations together. I served as head of the merger evaluation committee and gained insights from that process that were very useful when Beth Israel Hospital merged with Deaconess Hospital, both in terms of facilitating the merger and of integrating both radiology departments.
In radiology, there is a premium on administrative issues. As department chair, you have to develop an understanding of service and function because you deal with a very broad constituency. Radiology departments tend to be large and they interface with many other departments. There is an increasing need for physician-administrative leadership. Radiologists get lots of exposure to administrative issues.
Axis Imaging News: Could you provide an example of a situation in which those skills were demonstrated, both as a radiology chair and as chief medical officer?
Kressel: The radiology department of Beth Israel and the radiology department of Deaconess moved very rapidly to integrate when the two institutions merged. These departments served as a model for other merging departments. The functions and skills of the training program, the professional staff, and the technical/administrative staff were leveraged in such a way that people from both merging departments felt that they were becoming a part of something different and better than what they had been a part of before. I was able to work very closely with my counterpart at Deaconess, Mel Clause, who is now chief of radiology here. We consciously created an environment where we both could work together. As a result, the rest of the institution could increasingly work together.
Imaging.Economics: As radiology chair and chief medical officer, turf issues department-wide and institution-wide invariably present a challenge and an opportunity. What role will turf issues play in the 21st-century health care institution?
Kressel: Embedded in that question is a key issue. The model of the physician as an isolated unit with his own patients and with singular responsibility for the success of his patients’ experience does not really work anymore. We are all very interdependent. Take any medical patient encounter now and map out the processes that need to happen. Then determine who is responsible for those processes. You will realize that there are dozens, if not hundreds, of processes that must be coordinated and integrated to perform a simple medical procedure. People have to think about their roles and each other’s roles in an organization. An institutional viewpoint is very important.
Patients want care that is integrated, coordinated, and personalized. That will require providers to integrate and coordinate. The notion of turf runs counter to that. There is a widespread trend and national interest in developing service lines. These tend to be multidisciplinary, perhaps multiinstitutional business units that are organized by medical processes to streamline and coordinate care while reducing costs. When groups of physicians go into this, there is a tremendous stress on the discipline’s turf versus the need to integrate the services. Radiologists, as a core service, frequently butt up against other services when coordinating patient care.
I think we are all in the middle of learning as we go forward. Integration is being driven both by economics and by advancing technology. This process of integration and coordination is in evolution nationwide with creative conflict resolution techniques being implemented to help facilitate the process. We need to identify the problems we are trying to solve and then create new platforms on which to move forward. At the same time, I think it is very important for radiology not to lose its wholeness as an intellectual endeavor. But that identity has to be maintained in the context of facilitating the structures that will allow care to be delivered in a more integrated fashion. I think the best way to deal with turf issues is to participate intensively in this process.
Axis Imaging News: Where do you see radiology moving within the institution and what is its ideal role?
Kressel: I personally am a big advocate for radiology as a core clinical service rather than an ancillary service. Radiology provides vital information and is a purveyor of much-needed information. Radiology is a clinical resource and a resource to the institution as a whole. I think understanding the dimensions of those services and then figuring out how to add value in those areas are very important for radiology departments.
At academic institutions, it is critically important that the research base for radiology be strengthened. In an era when there is increasing integration and coordination across disciplines, the intellectual vitality of the discipline is rooted in its research mission. Research must be strong for the discipline to stay strong.
Axis Imaging News: What advice could you offer to department chairs and section chiefs who want to move up within the institution?
Kressel: To take on an institutional perspective, to understand the role of radiology as a core function that adds value to the institution, and then to try to leverage that value.
Sabine Kremp is a contributing writer for Decisions in Axis Imaging News.