According to Wikipedia a white paper is “a report or guide that informs readers concisely about a complex issue and presents the issuing body's philosophy on the matter. It is meant to help readers understand an issue, solve a problem, or make a decision” (1). This definition also shows that within our community the term “White paper” is used more loosely. This in contrast to medical societies in which the terms “White paper”, “Position paper”, “Clinical consensus statement”, and “Clinical practice guideline” are more strictly applied (see e.g. https://www.jfas.org/article/S1067-2516(15)00004-6/pdf). In our field of research, I think that a White paper is considered to be a consensus paper from the relevant experts in the field to describe current knowledge and to provide recommendations on the use, implementation (both acquisition and post-processing), and interpretation of techniques. There are therefore two important differences compared to a review article: 1) it is written by a much broader representation of experts; 2) it focuses also on recommendations instead of just reviewing past research (it is therefore also more influential by stimulating vendors/clinicians/researchers to stick to certain settings, as compared to a review article that is often more aimed at providing an overview of all relevant developments). Both points also play an important role to determine when it is time for a white paper:
1) Do the leading experts in a field wish to join forces?
Frequently a workshop, studygroup, or a webinar is a good opportunity to start considering to write a white paper. For example, during a workshop it will become clear whether the leading experts are willing to put their own interest and ego’s aside and to step back to see the bigger picture and agree with the other experts about the general direction of the field. When in a workshop all experts are perfectly willing to agree on a common approach, as long as this would be their own approach, a white paper is not going to happen or will not have a considerable impact (no real recommendations). When experts are still too much attached to their own approach, one could consider to write a Review article or even to write more in a ‘Debate’-form than a White paper.
2) Is there general consensus on what the right approach is?
To have a major impact, a white paper should provide proper guidance to the readers on how to proceed. This implies that the White paper should provide essential consensus guidelines on how to implement and apply a certain technology: the more clear statements, the bigger the impact of the White paper. Within the perfusion community, it was quite clear that around 2011-2012 a general consensus was evolving that single PLD pseudo-continuous ASL with background suppression and a 3D readout was the only candidate to be used as working horse for clinical applications of ASL. From the start, it was clear that this would be the basis of the White paper and it also had therefore considerable impact, in the sense that all major MRI vendors implemented this consensus sequence. This impact can also be judged from the number of citations (1599) and the frequent use of sentences like “For ASL a sequence closely adhering to the consensus article (Alsop, et al, 2015) was used with the following settings…” in the Methods sections, as well as the frequent discussion that many authors will have had with reviewers of their manuscript why they did not (completely) adhere to this consensus statement… At the same perfusion workshop in Amsterdam that the ASL white paper was discussed, in a parallel session a similar discussion took place about a DSC-MRI White paper. Here, it was clear that no real consensus was present and no White paper was published by the Perfusion Studygroup (the following is based on my memories from this meeting, which can be quite different from how others experienced the same meeting). This was partly, because already a Clinical consensus paper on DSC for Stroke applications was published (3) and that similar efforts where ongoing for tumor imaging, but starting from clinical societies (4). No coherent picture emerged when discussing such a white paper within a more technical oriented society as the ISMRM, and for example quite different recommendations were proposed for different applications, such as Stroke, brain tumours, and other brain applications. Moreover, the level of claims (how quantitative is DSC-MRI) and implementation details (what devonvolution method, how to select the AIF, how to deal with contrast agent leakage, how many baseline scans, gradient vs spin echo, single vs multi-echo) were severely debated. No quick summary (like for ASL “pCASL, single PLD, background suppression, 3D readout”) emerged, but rather a very long list of insights from the many experts present. This made it quite clear that it was too early to result in a White paper, although the discussions were very valuable and may have helped in formulating the ASFNR recommendations in 2015 (4) and the QIBA profile on DSC-MRI in 2020 (5) and may have aided the research of the attendees and review articles written by them in the years after the workshop.
3) Is the field confusing to users and vendors?
When we started the process of the ASL white paper many different labeling approaches, readout choices, and settings were used in papers. This led to quite amusing series of acronyms (FAIR, FAIRER, FAIREST, UNFAIR), but also confused both clinicians, vendors as well as researchers entering the ASL-field. After publication of the white paper, the availability of ASL as commercial products as well as its use increased, most probably because it was much clearer what sequence (settings) to use.
4) Will the White paper age well?
To have impact, a White paper should set the stage for the next 5-10 years. This implies that somehow a clear difference with the past is needed to set the recommendations apart from previous statements, and research & development should have converged, so that no important changes are expected to emerge in the near future.
When the time is right for a White paper, there are many things that need to be solved:
1) Find the correct setting to discuss consensus.
Past experience have learned that ISMRM Studygroups and workshops organized by them (2, 8-11) as well as European consortia grants (such as COST-actions (2,6,7)) are great vehicles for bringing together the experts. Workshops and network meetings have the proper combination of formal and informal meetings to reach consensus.
2) How to involve the relevant persons?
This will always be a tricky issue: it is important to be inclusive and thereby to be able to reflect the broader community, but authors also should have a real contribution and the combined authorship should have the authority to be taken seriously. White papers are frequently highly cited papers and therefore researchers might want to push themselves to become a co-author even without real contributions to the paper or the research-field. Within White paper discussions that I was involved in, we always started with a core-team, quickly expanding to a wider, already broadly representing group. Subsequently, in a final reach-out it was still possible for authors to join this group at the last moment, but only when they had a real contribution. Similarly, it is important to pay attention to not only involve the ‘usual suspects’ (frequently the old people…), but also the more junior talent (although frequently the more ‘junior’ contributors to White papers are already well-arrived and respected researchers within the field!). The involvement of more ‘junior’ (less senior…) authors ensures that more recent developments are included and bring the necessary energy and fresh minds into the process that can also help to bridge between strong competitors of the past.
3) How to keep on stimulating new innovations?
A White paper has the risk of stalling developments: when vendors, clinicians and researchers feel they have to stick to the consensus implementation, new developments will have a hard time to get tested in practice and thus to be accepted. It is therefore essential to also provide sufficient openings within the White paper that make it clear that new developments might very well be better than the consensus recommendations, but that they just need more validation and development. This is also where providing a proper Review of new developments and current shortcomings of the recommendation can actually stimulate new research directions!
4) To seek official endorsement or not?
To further increase the impact of a White paper one can seek endorsement of relevant organizations. The ISMRM has a process in place to allow endorsement by Study Groups involving voting by Study group members on the paper with a chance to propose changes, and subsequent permission by Board of Trustees (for official rules, it is advised to contact the ISMRM office). It is also important to consider endorsement by other clinical organizations; this will promote the White paper in other communities and reach clinical specialists that would e.g. not read MRM.
5) How and where to publish?
In recent discussions, I have found it very helpful to contact editors and to discuss with them what the possibilities are regarding publication. This is not limited to e.g. open access or going over the maximum word count, but also whether it is possible to publish multiple White papers back-to-back or to shape a Special Issue around the same topic. Of course, for the ISMRM it is important that MRI White papers are published in our home journals: JMRI and MRM.

Acknowledgements

MJP van Osch is supported by the Medical Delta Cancer Diagnostics 3.0 and research programme Innovational Research Incentives Scheme Vici with project number 016.160.351, which is financed by the Netherlands organisation for Scientific Research.

References

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