ACR Bulletin

Covering topics relevant to the practice of radiology

Redefining Normal

Practices plan for a future with little resemblance to the past. 
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“My sense is that patients appreciate the precautions, and their confidence is coming back."

—Mahmud Mossa-Basha, MD
July 23, 2020
In the spring, while ICUs were overwhelmed with COVID-19 patients, many radiology departments were eerily quiet. As a result of focusing healthcare resources on the crisis and canceling non-urgent care to curb the spread of the disease, volumes were down 50, 70, even 80% in some places.1

But the need for radiology procedures has not gone away. Procedures that were non-urgent in March were likely urgent by May or June. The evidence for screening mammograms has not changed; women over 40 will still need regular checks. Cancer, chronic disease, and injuries don’t stop for a pandemic.

Whether by sudden surge or gradual uptick, radiology volumes will increase. But this is not a return to normal. COVID-19 has changed things — at least until an effective vaccine is widely available and maybe even longer than that.

Radiologists were key to the pandemic response earlier this year. But are they ready for the “new normal?”

Responding to Demand
With referrals from screening programs down 60–80% and cancer diagnoses down 30–40%, radiology procedures at the University Medical Center Groningen in the Netherlands decreased by half to a third of normal, says Thomas Kwee, MD, radiologist and vice chair of the radiology department there.

Kwee and his colleagues likened the drop in exams earlier this year to what he calls “the tsunami phenomenon, in which the sea water recedes before the actual wave comes.” Kwee is expecting a surge “considerably above the volume our department handles under normal circumstances.” He took advantage of this lull to think through the implications for the future — and write an article for the JACR® on the topic (available at By preparing now, he hopes his department will be better prepared to meet the challenge of that surge.

They expect a considerable rise in oncologic care, especially procedures on the abdomen, chest, and neuro/head and neck. But he also expects other types of care, including a return to cancer screening programs. Their plan — which they’ve dubbed Optimizing Efficiency in Radiology, or OPERA — involves cross-training for radiologists, adding self-educational materials for medical students completing their radiology rotation, and transitioning to “abbreviated MRI protocols” when clinically indicated.

Predicting the Future
Sabiha Raoof, MD, FACR, says she has had little time to breathe, let alone plan for a return to a new normal. In addition to being chief medical officer and chair of radiology for Jamaica and Flushing Hospitals, she is also the chief medical officer for Medisys Health Network in New York and was busy with clinical operations during the crisis.“We saw our first COVID-19 patient on March 3 and soon after that there was a rapid escalation of coronavirus patients at our hospitals,” she says.
By mid-May, COVID-19 cases were declining enough to start focusing on other aspects of care. In the radiology department, a team of radiologists started looking at cancelled appointments, conferring with referring physicians, and determining who should be seen first.

All patients will be tested prior to interventional procedures. They’re also mandating masks and temperature screenings for all patients. They’re ready to extend hours to meet the demand and ensure that they can maintain social distancing in waiting rooms. “We cannot schedule the same way we did before,” she says.
Raoof feels efforts need to be made to educate patients about the safety measures hospitals have put in place to keep their patients and staff safe. She hopes that by standardizing and publicizing measures to keep patients and staff safe, patients will start feeling more comfortable seeking the care they need at the hospital that’s easiest for them to get to.

Even so, she’s not sure when patients will be ready to return. “Even if they are comfortable coming to the hospital, how will they get here?” she points out. Most of the hospitals’ patient populations do not have cars and rely on public transportation. People are even less eager to get on the subway than they are to come to the hospital.
So instead of a surge, she predicts a gradual increase over the summer, with volumes well below normal for the next few months. She’s actually asking staff to take vacation over the summer, so that they are ready for a possible second wave in the fall.

Increasing Confidence
On the other side of the country in Seattle, Mahmud Mossa-Basha, MD, vice chair of clinical operations at the University of Wisconsin’s department of radiology, says his group opted to ramp up services slowly to ensure safety precautions to protect the health of both patients and staff.

In partnership with ordering physicians, they went through the backlog of procedures. “During this time of crisis everyone has come together, resolved to do what’s best for the patients and the system as a whole,” he says, adding that he’s seen increased cohesiveness both within the department and across departments during the pandemic. Because the health system has been upfront about the financial implications of the pandemic, staff understand the financial difficulties and the reasons behind schedule changes, furloughs, and salary reductions.

To increase efficiencies and spread patients and staff out, they have moved volume (and staff) among facilities, staggered shifts, and expanded hours. In addition to reducing the number of chairs in the waiting room and instituting hourly cleaning procedures, they have also set up an area in the parking lot where patients can wait in their cars until their appointment. Some procedures will require more precautions than others, he says. They are staggering appointments for their MRI scanners to minimize waiting room overlap among patients. All patients are required to wear a mask — hospital-supplied, if necessary.

The radiology department is using the automatic texting system they already had in place to let patients know about safety measures. They also created videos that were posted on social media to the general public in July.

So far, he says, patients have reacted positively. “My sense is that patients appreciate the precautions, and their confidence is coming back,” he says, noting that patients are starting to return — ED volumes are almost up to pre-COVID levels.

Safety as Recurring Theme
As an interventionalist treating emergent or semi-emergent cases, David S. Kirsch, MD, FACR, has continued close to normal workloads in his private practice serving hospitals and clinics in Louisiana and Mississippi. “You can’t really defer emergent or semi-emergent care, especially in a hospital setting,” he explains. But that doesn’t mean he hasn’t been affected by the pandemic.

From a financial/volume perspective, outpatient clinics have taken the financial brunt. “Volumes are down across the board, but outpatient clinics have been hit hardest. April was by far the worst,” he says. Inpatient volumes were down 50% in April, he says, and outpatient as much as 90%.
Kirsch’s practice currently has about 40 contracts in place with facilities. That means that he has 40 different plans for how to ramp services back up again safely and efficiently. “Every location is slightly different,” he says. But any patient coming into the hospital for a non-emergent procedure has to have a COVID test 48–72 hours before their procedure. Patients coming to the ED receive a rapid test when they get there.

Letting patients know about the precautions is key to getting volumes back up, he says. “If the patients do not feel comfortable or if they feel we don’t value their safety, they’re not going to use the services, whether it be in retail or in medicine.”

So far, the message seems to be getting across. After the first week of May, volume has gradually increased, with a nearly 50% recovery from April lows. Kirsch said there was a big uptick in June, with volumes back to “reasonable levels” in July. One of the clinics is currently trying to reschedule 4,000 mammograms. The practice accelerated plans to increase remote reading by buying home workstations for all radiologists back in March. This will allow them to expand hours and continue with specialization studies without overtaxing their physicians.

One consideration in rescheduling procedures is not only reauthorization but also changes in patients’ financial or insurance situations because of layoffs or furloughs. He says his practice has worked with patients on payment plans or coordinating with insurance.

Kirsch says radiology practices have to think strategically about how to manage cash flow through the ups and downs of this pandemic — and crises to come. The Paycheck Protection Program (a loan program that originated from the Coronavirus Aid, Relief, and Economic Security Act to provide a direct incentive for small businesses to keep their workers on the payroll) was “a godsend,” allowing the practice to restore full salaries to their IT and support staff despite the volume drops. Kirsch warns against making rash decisions that will affect the practice’s future, pointing out, “You don’t want to do anything that’s going to impair your ability to react to future challenges and opportunities.”


1. Cavallo JJ and Forman HP. The Economic Impact of the COVID-19 Pandemic on Radiology Practices. Radiology. 2020.
2. Kwee TC, Pennings JP, Dierckx RAJO, Yakar D. The crisis after the crisis: the time is now to prepare your radiology department. J Am Coll Radiol. 2020;17(6):749-751.

Author Emily Paulsen,  freelance writer, ACR Press