“The Radiology Reset Button – overcoming the normalcy bias”

Fodi KyriakosFodi Kyriakos explores how the COVID-19 pandemic could be the catalyst for change in radiology and encourages our community to grasp the opportunity to “seize the moment”  and plan for recovery.

At the beginning of 2020, if someone had told radiology leaders that all NHS outstanding reporting backlogs would be reduced to virtually zero by May, I’m sure they would have looked at you in disbelief and asked what sorcery had been involved, but this situation is exactly where we find ourselves today.

 

Normalcy Bias – Noun [edit]

normalcy bias (plural normalcy biases)

The phenomenon of disbelieving one’s situation when faced with grave and imminent danger and/or catastrophe. As in over focusing on the actual phenomenon instead of taking evasive action, a state of paralysis.

Historical challenges

In the past, it has often taken lots of effort to either invoke or accept change of any kind in radiology and for those managing services, there’s also been a certain amount of risk associated with putting your head above the parapet or being a trailblazer. It has been sometimes easier to follow the well-trodden path rather than to create a new one. Workloads and budgetary constraints have also been a disabler, restricting decision making to the ‘here and now’. This has resulted in failing, or in most cases, not being able to foresee or plan for events that have never happened before, such as an event like a pandemic crisis. Psychology refers to this state of being as normalcy bias. For those who are not familiar with the term, you will certainly be aware of its connotations and radiology now finds itself at this cross-roads.

Ever since the introduction of digital radiography and PACS, NHS radiology reporting backlogs have been a contentious issue among experts, and a recurring feature in the mainstream media! Often being highlighted (and with some justification) in relation to areas such as missed cancer diagnosis, where even the slightest of delays can have a significant bearing on the overall outcome.

Serious backlogs

The extent to which backlogs were a serious issue in the UK was further exacerbated by various Care Quality Commission (CQC)  inspections, which raised concerns regarding reporting backlogs that resulted in delayed or missed diagnosis of conditions that may have otherwise been picked up.

By the end of February 2020, the situation of backlogs was as much an issue as at any time before. Insufficient reporting capacity had led to a build-up of outstanding reports, which in turn meant that outsourcing was at its highest ever levels and growing pressures to meet new deadlines, such as the cancer pathway targets, were increasingly exposing the lack of options available to resolve the problem.

So, you would have been excused if you thought that a crisis such as the COVID-19 pandemic would simply exacerbate the reporting challenges facing radiology. However, this has not been the case. Instead, we have witnessed radiology’s own “clear the decks” exercise, where in fact the complete opposite situation has occurred, resulting in backlogs across the UK being virtually eliminated. Who would have thought that the worst crisis to hit the country (and the world) in 75 years would be a catalyst for NHS radiology departments to press the reset button?

Reset image

Of course, we recognise the superficial nature of this situation. During the pandemic, practically all routine referral activity came to a grinding halt, which allowed radiology to concentrate on COVID-19 and Emergency Department (ED) patients. Chest X-rays and CTs were identified as two of the key diagnostic tools for the virus, but the volumes were manageable. Accident and Emergency footfall was reduced to almost 50% of its usual figures, so reporters were practically able to deliver a ‘Hot-Reporting’ examination for every patient requiring imaging. Something which ED and Intensive care unit (ICU) consultants have grown quickly accustomed to.

During this time, radiology was also still required to work to critical staffing levels, so radiographers and radiologists were covering 24/7 rotas, but due to the lack of activity outside of portable X-ray scanning in ICU, many staff were not being utilised. So, while this enabled the catch up in radiology reporting to take place, what we witnessed was the ‘ying and yang’ of radiology. On the one hand, integral to the continuity of a patient’s pathway and critical to defining an outcome – AND on the other hand, completely dependent on throughput from referrers to maintain activity levels.

Seizing the moment!

So what happens next? Well, in a world where we can guarantee almost nothing, in this situation, we can guarantee that radiology will remain the centre point for the recovery phase of the pandemic, but with the added challenge of complying to ‘social distancing’ and ‘equipment cleaning’ guidelines, how do we manage the continuation of treating COVID-19 patients, while reintroducing ‘business as usual’ and ‘deferred’ patients whose treatment has been delayed?

The “Reset Button” has enabled something else to happen. For the first time, there is now some headspace to plan for the recovery phase and for the next phase at least, there is now funding available to support the recovery. So how do we avoid going back to where we were before the pandemic? How do we seize the moment?

Time to make the changes!

Albert Einstein once famously said: “We can’t solve problems by using the same kind of thinking we used when we created them.” This quote has never been more poignant in the present day and while the pressure to manage change will be at its highest, this is the right time to make these changes happen! With the benefit of ‘The Reset Button’, if we can learn from the past and apply new ways of working moving forward, we can avoid falling into the trap of the normalcy bias and witness the radiology reset button offering a new, efficient and more streamlined radiology department moving forward.

Everything you wanted to know about radiology but were afraid to ask…

On Wednesday 17 June, a live event organised by InHealth, in partnership with The British Institute of Radiology and the Society of Radiographers is taking place, titled: “The Radiology reset button has been pressed”. The aim is to tackle these challenges and support radiology managers as they enter the recovery phase. It will bring together senior figures from radiology and within healthcare to offer insights, opinions and advice on how we can approach this coming period and use what positives we have experienced during the pandemic to create service improvements throughout radiology.

There will be opportunities for radiology managers, clinical leads, radiographers and radiologists to put their questions to the speakers in the panel discussions after their presentations.

REGISTER FOR THE RADIOLOGY RESET BUTTON HAS BEEN PRESSED HERE

(The event is free for all)
About Fodi Kyriakos

Mr Fodi Kyriakos is a former director of RIG Healthcare and founder of RIG Reporting,
the UK’s first provider of external radiographer reporting services. In 2016 he joined The InHealth Group following its acquisition of RIG Reporting and is now the Head of Reporting across the Group. His service specialises in delivering plain film reporting solutions and is the only provider to offer both on-site and telereporting services.
Fodi has over 22 years experience in workforce and staffing solutions and 17 years working exclusive within Imaging and Oncology. He is a member of the Institute of Healthcare Managers and a regular contributor of professional development events across radiology.

 

The flu epidemic of yesteryear: the role of radiology in 1918–20

adrian thomas

Dr Adrian Thomas

100 years ago the UK was facing a fast-moving outbreak of epidemic influenza pneumonia, known as the “Spanish Flu”.

Radiology played an important part in diagnosis, although the crisis was without the scientific knowledge, strategic management and communications we have today. Here, Dr Adrian Thomas explores the six patterns of infection in this unpredictable and powerful disease.

 

 

Radiology is playing a central role in the diagnosis of COVID-19 today, and 100 years ago was also playing an important role in the diagnosis and characterisation of the outbreak of epidemic influenza pneumonia of 1918–1920. A combination of fluoroscopy and radiography was then used, with the occasional utilisation of stereoscopy. The greatest pointer to a diagnosis of epidemic influenza pneumonia in a given patient was the presence of the epidemic, although there were some specific features to indicate the diagnosis. The etiological cause of influenza was not known at the time, being first discovered in pigs by Richard Shope in 1931.

Spanish flu

The epidemic of 1918 far exceeded previous ones in its intensity. It had a high mortality in young adults with the very young and very old being comparatively immune. The associated pneumonia was particularly virulent. In the case of the troopship The Olympic (sister ship of The Titanic) there were 5,951 soldiers on board. Initially there were 571 cases of acute respiratory disease, but within 3 weeks there were 1,668 cases. Of these, 32% had pneumonia, of which 59% died. In any locality the duration of the epidemic was from between 6–8 weeks, and approximately 40% of the population was affected (Osler, 1930).

Six patterns of infection were identified, with correlation of clinical, radiological and post-mortem findings (Sante, 1930., Shanks, et al. 1938). Dr Leroy Sante, the pioneer radiologist from St Louis, described epidemic influenza pneumonia as “the most lawless of the chest infections.” Abscess formation was seen frequently, and was commonly of the small and multiple type. Radiological changes were seen developing day by day, and clinical resolution needed at least six–eight weeks since there had commonly been lung destruction and healing by fibrosis needed to occur.

The patterns were:

Type 1: Peribronchial invasion with infiltrates that enlarge and become confluent forming small areas of consolidation (figures 1 & 2, below). This was not confined to one lobe, but could appear in all lobes as a true bronchopneumonia. This was similar in appearance to ordinary bronchopneumonia.

1Type 1, Influenza bronchopneumonia

Figure 1

2Type 1, Influenza bronchopneumonia_Viewed as from behind

Figure 2

Type 2: Peribronchial invasion with infiltrates that enlarge and become confluent to form solidification of an entire lobe (figure 3, below). The changes remained confined to a single lobe. It was viewed as a true bronchopneumonia but with a lobar distribution (“pseudolobar pneumonia”). Different lobes may be invaded one after another. The pseudolobar pattern was the commonest type, and could resolve without further spread. The presence of previous isolated infiltrates would distinguish this type from common lobar pneumonia. There was a tendency to break down with extensive cavitation.

3Type 2, or pseudo-lobular

Figure 3

Type 3: This starts as blotchy infiltrates that coalesced to form a general haziness over a part of a lung, suggesting a haematogenous origin (figures 4 and 5, below). At post-mortem this was found to be an atypical lobular pneumonia, a “diffuse pneumonitis”, that was so commonly seen during the influenza outbreak. It resembled the streptococcal (septic) pneumonia that was often seen in association with septicaemia when there was no epidemic. The spread was rapid, and the prognosis was poor. Death commonly occurred within the week.

4Type 3, resembling streptococcal (septic) pneumonia

Figure 4

5Type 3, resembling streptococcal (septic) pneumonia

Figure 5

Type 4: A type starting in the hilum and spreading rapidly into the periphery, the so-called “critical pneumonia” (figure 6, below). This was attended with a high mortality. Post-mortem showed a purulent and haemorrhagic infiltration around the larger bronchi. There was often marked cyanosis.

6Type 4, the so-called “critical pneumonia

Figure 6

Type 5: This started in the dependent part of the lungs, with continuous upwards spread (figures 7a and b, below). This was an atypical lobular pneumonia, there was no associated pleural fluid, and it was usually fatal. Initial infection in the costo-phrenic angle spread within 24 hours to involve the lower lung, and death occurred within 48 hours. Clinical features included extreme prostration, high temperature, and delirium. This pattern with rapidly advancing consolidation was seldom seen in other conditions.

7a Type 5. This started in the dependent part of the lungs

Figure 7a

7b Type 5. A film taken 12 hours after 7a

Figure 7b

Type 6. A true lobar pneumonia was only seen rarely.
The prognosis of epidemic influenza pneumonia was difficult to determine. So, as an example, a patient who was resolving would suddenly have changes extend into the other lung and then die. Another patient with successive involvement of all lobes could recover completely. A patient with only minor lung involvement might die, and another with extensive consolidation would recover completely.

Radiologists continue to be in the front line in the treatment of infectious diseases, and although our modalities are now more advanced than a century ago, their contributions remain essential. It is also noteworthy that the simple CXR also remains central.

Figures:

1. Type 1, Influenza bronchopneumonia. Image seen as a positive.

2. Type 1, Influenza bronchopneumonia. Peribronchial clusters of infiltration, with no relation to lobar architecture. Viewed as from behind.

3. Type 2, or pseudo-lobular.

4. Type 3, resembling streptococcal (septic) pneumonia. Image seen as a positive.

5. Type 3, resembling streptococcal (septic) pneumonia. Blotchy ill-defined infiltrates which coalesce to form a general haziness. Viewed as from behind.

6. Type 4, the so-called “critical pneumonia.”

7a. Type 5. This started in the dependent part of the lungs, and this early film shows consolidation in the costophrenic angle (black arrow).

7b. Type 5. A film taken 12 hours after 7a. The lower right lung is consolidated, and the patient died 12 hours later. Post mortem showed a solid lung with no effusion.
Readings:

Osler, William. (1930) The Principles and Practice of Medicine. 11th Edition, Thomas McCrae (Ed.). London: D Appleton.

Sante, Leroy. (1930) The Chest, Roentgenologically Considered. New York: Paul B Hoeber.

Shanks, S Cochrane., Kerley, Peter., Twining, Edward W. (Eds). (1938) A Textbook of X-ray Diagnosis by British Authors. London: H. K. Lewis.

 

Dr Adrian Thomas FRCP FRCR FBIR, BIR Honorary Historian

About Dr Adrian Thomas

Dr Adrian Thomas is a semi-retired radiologist and a visiting professor at Canterbury Christ Church University. He has been President of the Radiology Section of the Royal Society of Medicine, and of the British Society for the History of Medicine. He is the Honorary Historian to the British Institute of Radiology. He has had a long-term interest in role development in radiography, and teaches postgraduate radiographers.

Adrian has written extensively on the history of radiology writing many papers, books and articles. He has, with a colleague, written a biography of the first female radiologist and female hospital physicist: Adrian Thomas and Francis Duck: Edith and Florence Stoney, Sisters in Radiology (Springer Biographies) Springer; 1st ed. 2019 edition (1 July 2019).

© Thomas / 2020

Top tips for honest science messages in the media

13-kate-elliottScience is often misrepresented in the media. The BIR supports the charity Sense about Science in their call for all research to be openly and honestly reported. This year we supported one of their Voice of Young Science workshops called “Standing up for Science” held on 16 September 2016 in London.

Here, Kate Elliott, Medical Physicist at  Mount Vernon Cancer Centre was one of three lucky BIR members to attend the workshop which gave young researchers top tips and advice on how to get their scientific messages across as clearly and accurately as possible.

 

I hate speaking in public and even the thought of writing this article terrified me. Why then, you might ask, did I apply to go on the Standing up for Science media workshop?

I often get annoyed at the coverage of science in the media and the misuse of statistics and results. Recently, the Brexit “debate” has left me ranting at friends, and I often find myself defending junior doctors on social media. When I received the email from BIR advertising the media workshop, it struck me as an opportunity to learn what I could do to positively influence the public perception of science, and to hear first-hand from journalists about their involvement.

The first session consisted of a panel of three scientists who told us of personal experiences with the press and offered advice based on this. An example which stood out to me as a healthcare scientist was Professor Stephen Keevil’s use of the media to highlight a problem with a new EU directive on physical agents[1], which could  have caused problems for MRI. Politicians took heed of his criticism, and effected a change to the directive in Brussels. This was a great example of how the media can be used effectively to influence policy – something that is likely to become increasingly important in the next few years.

The second session was a panel of three journalists, who explained their daily process for13-standing-up-for-science-workshop-sept-2016selecting and pitching stories. Science stories are selected based on interest, accessibility, and importance. These are pitched to the editors, who decide which ones to take further. The journalists pointed out that their duty is to their audience, not to science. Unfortunately, science has to compete with news on David Beckham’s haircut. Time constraints are also a problem. They write multiple articles a day (I’m three weeks and counting on this one…), so it’s important for scientists to be available to discuss their research on the day it’s published.

The third panel was about the nuts and bolts of how to interact with the media, and recommended campaigns such as Sense about Science’s “Ask for Evidence” campaign.

I left the event with the following advice to keep in mind:

  • If you disagree with something: speak out. If the public only hears one side of the story, that’s the side they’ll believe.
  • Stick to a few key points. Get those across, even if it means having to ignore questions or turn them around in an infuriatingly politician-like way!
  • Be available. If you’ve put out a press release, you need to be able to respond quickly. Journalists work to very stringent time scales, so being available in a week’s time is going to be too late.
  • Talk to the public. Attend events such as Pint of Science, or become a STEM ambassador, because that will really help you learn to speak in layman’s terms and get you used to answering obscure questions.
  • Get training. If not full media training, a workshop like this is a really good way to be slightly more prepared – and you get to hear about all the interesting science other people are involved in!

Image: BIR members  Jim Zhong, Kate Elliott and Maureen Obioha Agwanihu who attended the workshop

[1] https://www.myesr.org/html/img/pool/MRI-Report-Stephen-Keevil.pdf

Powerful partnerships

Sophia Anderton, Head of Publishing, BIR

Sophia Anderton, Head of Publishing, BIR

Sophia Anderton, BIR’s Head of Publishing reflects on a week of diversity and partnership at RSNA 2013 in Chicago.

They say Chicago’s the windy city, but last week it was more like the freezing metropolis!

Fresh back from RSNA, one of the world’s largest medical conferences, boasting 20131205_150111more than 30,000 delegates, I’m reflecting on not only the scale but also the diversity within radiology and its allied sciences. The sheer size of the event—so many people gathered together all for the sake of radiology—but also the variety of different disciplines represented were inspiring to say the least. I wonder what Wilhelm Röntgen would have thought of it all?!

20131201_102950

BIR stand on Publishers’ Row

The BIR had a stand in a prime location on Publishers’ row so I was lucky enough to meet with a vast array of different people from around the world, working in diverse disciplines across the field (consultant radiologists, trainees/residents, radiographers, physicists, students and representatives from manufacturers). Everyone had a different story to tell.

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Professor Andrew Jones (left) with the Indian Radiology and Imaging Association President Elect, Bhavin Jankharia

There was great interest in both the BIR and BJR; we were giving away free copies of Best of BJR, highlighting some of the best articles from the last year (they’re all free to download to all until the end of the year at http://bit.ly/1f7GT0c). What really caught people’s attention was our interdisciplinary ethos. As a society and journal uniquely covering all disciplines relating to radiology, there really is something for everybody. We now offer an international membership package and it was a real joy seeing people realise that the BIR could really be for them, and we look forward to working with lots of new people in the future.

With so many people, societies and companies represented, the BIR took the opportunity to make contact with as many of them as possible. For some it was the start of a new relationship, but for others it was an opportunity to reacquaint themselves with long-standing connections. One of the BIR’s newest partnerships is with Health Management (http://healthmanagement.org/) which will be available free of charge to all BIR members from 2014. Look out for the interview with our President, Andrew Jones, early in the new year.

20131204_153927

Grant Witheridge from corporate subscriber AGFA meets up with Professor Andrew Jones

RSNA’s key theme this year was The Power of Partnership and I think that really sums up what I was hearing last week. Working together with energy, vigour and strength to have an influence on the radiological sciences is an important message. In distributing over 1,400 copies of Best of BJR and talking to even more people about publishing, education, events and membership, the BIR is doing its part in promoting the influence and diversity of radiology.

I’m now looking forward to next year and the centenary meeting of the RSNA.

Happy belated 65th birthday

Neil Mesher, Managing Director, Philips Healthcare

Neil Mesher

It is rare for a day to pass when the healthcare system in the UK is not in the media spotlight, and it’s not very often that good news sells newspapers. Indeed, as I write this blog, I notice that the “crisis” in A&E is back on the home page of the BBC, with fears over how prepared the system is for the onslaught of winter, while it’s still 30 °C outside!

 

1017632_10151463792547721_1128585289_n

Of course, it’s worth remembering that for every newspaper headline, millions of people are cared for and successfully treated by the health service in all its guises, each day.  However, as the NHS turned 65 last month we have to acknowledge that the system does have structural, long-term challenges. Those born in the years before the NHS, the over 65s, currently make up 17% of the population. In the next 50 years that percentage will rise to 27%, with the over 85s set to be the fastest growing part of the population. These statistics are in part a measure of the past success of the NHS, but an ageing demographic, living with multiple long-term conditions, will be a key factor in how its future is shaped.

1948-NHS-leafletThere are many debates in the public arena about how to address these challenges in the coming years. The quality, innovation, productivity and prevention (QIPP) agenda undoubtedly has a significant role to play as a framework for the NHS. The rapid adoption and spread of innovation, supporting better quality care and improvements in productivity are all objectives that the whole of the healthcare “industry” can sign up to. Putting the patient at the centre of this process, supported by appropriate technology and resources, will positively impact patient outcomes.

Radiology has a pivotal role here in delivering accurate and timely diagnosis, enabling clinicians and patients to make informed choices about the direction of treatment and care. There was a fascinating debate on the radio last week about the notion of “too much healthcare”, and it concerned a patient who had been successfully diagnosed and treated for cancer. However, the aggressive approach to his treatment had left him with a number of serious long-term issues which could have been avoided. I was left with a sense that better diagnosis and information could have led to a better patient outcome, and significantly reduced the initial and ongoing treatment costs.

As a manufacturer and provider of healthcare services, at Philips we are working to understand how the QIPP agenda is being implemented at local levels, so that we can deliver tailored solutions. By combining the capabilities of the NHS with the technical expertise and infrastructure of a large multinational company, we believe that we can achieve more together. We are on a quest to develop more innovative solutions that will enable you to collaborate freely, diagnose more confidently and provide care passionately.

Here’s to the next 65 years!

Neil Mesher, Managing Director, Philips Healthcare