In the United States, the National Institutes of Health (NIH) is the primary agency responsible for medical research. The director of the National Institutes of Health plays an active role in shaping the agency's activities and outlook. The director is responsible for providing leadership to the institutes and for constantly identifying needs and opportunities, especially for efforts that involve multiple institutes. The NIH director is responsible for advising the U.S. president on their annual budget request to Congress on the basis of extensive discussions with the institute directors.