ACR Bulletin

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Changing Direction

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In the wake of COVID-19, leaders must employ change management solutions to drive lifesaving innovation in radiology.

They don’t wait for things to happen then react. They plan, they anticipate, they pay attention.

—Frank J. Lexa, MD, MBA, FACR
May 28, 2020

“We should be fearful of complacency — it is a fatal problem,” says ACR Vice President Alexander M. Norbash, MD, MS, FACR, professor and chair of radiology at the University of California, San Diego, and faculty member with ACR’s Radiology Leadership Institute® (RLI). “You can’t allow a focus on recovering from change to dull your interest in dynamically moving forward.”

This is a core tenet of change management, a long-accepted business discipline aimed at creating successful transformations by moving away from the status quo toward a desired change. Being prepared for a new or altered process is critical to the success and sustainability of adapting to new ideas.1

For radiologists, change may be driven internally — to improve efficiency, quality of service, structured reporting,or economic return, as examples. Change brought about by external mandates could include compliance with new laws, new reimbursement policies, new board education requirements, or the introduction of new technologies. The implementation of new or modified operational or strategic plans can be disruptive for practice managers and radiologists — requiring considerable energy, time, and resources.

Avoiding the cost of addressing potential disruptors to everyday practice can feed a business-as-usual mindset. To avoid being caught unprepared — for the spread of AI, mergers and acquisitions, or even a pandemic like COVID-19 — radiology leaders must tap into the wisdom and determination of a core group with a common vision, Norbash says. “Management is kind of pedestrian — it is a bit of an accounting thing where you are trying to make sure you are falling within budget and following the rules,” he says. “Leadership has to do with the charisma and power of an idea, how you generate that idea, and how people are drawn to it.”

Start Now

Change management starts with a vision — a plan to adapt to possible, inevitable, or even unthinkable disruptions in current practice. That vision often evolves from what you know or suspect you are facing, says Frank J. Lexa, MD, MBA, FACR, chief medical officer of the RLI and chair of the ACR Commission on Leadership and Practice Development.

“Change management comes in many flavors, and certainly there’s a difference between changes you successfully anticipated and changes you did not,” Lexa says. “The latter is the realm of crisis management, where you are in one way or another reacting to something you either didn’t expect or didn’t adequately prepare for.”

According to Lexa, disruptors to everyday workflow that radiologists might see coming could include new technology, such as disruptive imaging technologies or machine learning tools. They might be facing a reduction in pay or new regulatory requirements, Lexa says. “These are things that could add hours to a radiologist’s week or cause financial or labor pressures that ultimately make the specialty less attractive,” he says.

Being forward-looking with hiring practices also falls under the purview of change management. “If you are looking at substantial changes to how radiologists are practicing, you might question if there is going to be an adequate workforce for the amount of imaging we will be doing and how we’ll be doing it,” Lexa says. “Do we have enough radiologists everywhere in the U.S. to read cases? Are we really adept at using teleradiology?” The ratio of specialists to general radiologists is something to evaluate, as is how radiologists are deployed for coverage, Lexa says. Some radiology groups do remarkably well at overcoming these types of logjams, Lexa says. “They don’t wait for things to happen then react. They plan, they anticipate, they pay attention,” he says.

Determining the best place and use for radiologists has been a hot-button issue during the COVID-19 pandemic — an event even most change agents could not have anticipated. Applying the lessons learned once the crisis passes is another matter.

Prepare Without Warning

“Many people thought something like COVID-19 wouldn’t happen in their lifetimes,” Norbash says. “We need to pay close attention to what we are learning from this pandemic. The last thing we want to do is breathe a sigh of relief at the end and go back to business as usual.”

According to Norbash, one unmistakable lesson has come from the availability and proper use of personal protective equipment (PPE). “Up until this crisis, I would say 80% of my department had not watched a PPE video,” Norbash says. “For example, most of us didn’t realize that as you are taking off PPE, you use hand sanitizer in between every single step. You take off your goggles, you sanitize your hands; you take off your mask, you sanitize your hands; you take off your gown, you sanitize your hands.”

As another example, having home teleradiology workstations seems wise, so your faculty are not exposed to danger, Norbash says. “But you want to spend an equal amount of energy and effort to make sure the RTs, nurses, front desk people, transporters, and your residents are safe,” he stresses.

Post-COVID-19, radiologists (and everyone in the house of medicine) are going to have to examine the size and scope of their workforce, Norbash insists. Income will drop, and saving for a rainy day might matter more, he says. “We’ll have to reevaluate how convertible our individuals in academic medical centers may be — in terms of if there is a sudden drop in breast screening, for example, what do we do
with those practitioners?”

In times of upheaval, it is time to reexamine everything, Norbash adds. “How are we imaging? What’s happening with point-of-care imaging and with remote interpretation? How do we crowdsource around interpretation of radiologic images, and how are we introducing AI to decrease our workload?”

Learn by Crisis

“It’s interesting how you can fast-track initiatives you’ve been trying to do for years — things like home workstations or telehealth,” says Dana H. Smetherman, MD, MPH, FACR, chair of the ACR Commission on Breast Imaging and chair of the department of radiology and associate medical director for medical specialties at Ochsner Medical Center in New Orleans.

“COVID-19 compelled us to implement changes we had already considered,” Smetherman says. “Our neuro IR clinics are now all virtual. In 2019, our whole health system did only about 2,500 video visits for all of our clinicians. We now do more than 3,000 a day. There were other things we had planned, pre-COVID, like using Zoom or WebEx or something similar for multidisciplinary conferences,” she says. “For years we couldn’t pull that off. This digital disruption we’ve heard about in meetings for a decade basically happened in a week.”

Some innovations propelled to the frontlines during the pandemic may not be rolled back, Smetherman says. “The rapid transition to telehealth is a genie that will not be put back in the bottle,” she says.

“It has been surprisingly well-accepted in our institution by both patients and our clinical colleagues,” Smetherman says. “I could envision a day when the people on-site at healthcare facilities are RTs, some IRs, surgeons, and breast imagers — everything else would be done digitally.”

“I feel like the disaster management skills that we got from Hurricane Katrina definitely translated [for this pandemic]. This is an example of how you should never waste a good crisis,” Smetherman says.
“We have a robust employee stress and psychological assistance system in place now. There is a social worker or a psychologist rounding with every COVID team. If you have these resources available to you, I would encourage your staff to use them.”

While these resources are valuable, as a leader your physical presence in crises is critical, Smetherman stresses. “It would be very difficult to lead remotely during something like this,” she says. “Your team has to feel like you are there for them, alongside them.”

We need to pay close attention to what we are learning from this instance. The last thing we want to do is breathe a sigh of relief at the end and go back to business as usual.

—Alexander M. Norbash, MD, MS, FACR

Welcome All-Comers

Beyond a crisis situation, it behooves radiology leaders to employ change management solutions with the input of individuals who can adapt quickly, Norbash says. “Solicit ideas,” he says. “Some people may turn out to be dangerous risk-takers. Or they could be the change agents you need.”

Once you identify potential disruptors to change and have a clear vision of how to adapt, build a team that welcomes opportunities for innovation. “The team you build should have the same core values and goals,” says Michael P. Recht, MD, Louis Marx professor and chair of the department of radiology at NYU Langone Medical Center. “That doesn’t mean they have to be like you, or even agree with you. It’s okay if they are your critic.”

Change management isn’t predicated on the experience level of team members working to accomplish the same goals, Recht says. Mid- to late-career team members have a lot to offer in terms of trying new ideas, he says. “I have also brought on some very junior level people who have distinguished themselves as really smart, strong, and innovative thinkers,” he adds.

Your best shot at success starts with a diverse team with different skill sets, Recht says. “You have to have people with different points of view.” Members of the team should speak openly and disagree, he says. “But once the team has made a decision, every member has to accept that decision and move on.”

Team leaders are no exception. “Don’t get too attached to any idea, especially if it’s your own,” Recht cautions. “We all love our own ideas, but at some point, if it is not working you have to say, ‘We tried it,
it didn’t work — what did we learn from it?’”

The use of AI in radiology presents a good example. “There may be members of your team who say AI isn’t ready for primetime — and they might have valid arguments,” says Recht. You don’t want them off the team just because they disagree with the majority of the group though, he says.

Reimagine the Process

Progress can be slow. “You don’t want to run into analysis paralysis, where you keep arguing over the same thing year after year and there is never a decision,” Lexa says. The key to successful change management is to look at the whole board of ideas and possible outcomes, he says. “If you’re going to do change management effectively, you need to treat it as a process.”

There will be roadblocks, as some people inevitably slow the process of moving forward. “Sometimes it’s just laziness and sometimes a person’s resistance to change is well-intentioned,” Lexa says. “Then there are people who just don’t want to see anything change. They might have some advantage or secondary gain from preventing anything from changing.”

It is important to remember that leaders are imperfect and can be replaced, Norbash says. Radiologists who aren’t currently in a position to drive innovation and change must prepare now, he says, by connecting with like-minded individuals. “They should be seeking out experiences that help them become more innovative thinkers — and better leaders themselves in the future,” he says.

“We’re starting to do more as radiologists in coming together to share what we are learning,” Norbash says. “We’re asking other groups how they are handling problems and to share ideas.” Social media, he says, is playing a big role in that. “It gives us the ability to connect quickly and effectively across the country and leverage our strengths in a very fundamental way,” he says.

“You have to be able to adapt quickly,” Recht says. “Don’t get locked into place.” Radiology departments need to be agile and should use the same tools other industries have employed, he says. “We’ve been really big on using informatics and analytics. Many radiology departments don’t. They are still managing without those tools, which I think are absolutely necessary to make the right decisions.”

“I try to picture what might happen five years from now,” Recht says. Even that is a tough timeframe the way things change so rapidly, he says. “Few people would have predicted five years ago, for example, that AI would be where it is today.”

Whatever the potential disruptor you are trying to manage or anticipate, Recht says, you should always consider whether the solution is truly going to help patients or is ultimately for financial gain and security. There is an ethical component of change management that must drive the innovation, he says.

“I think we all worry about the financial ramifications, but ultimately we have to be true to ourselves,” Recht says. “We want to survive and we want to do well. But you have to be able to look yourself in the mirror and say that what you’re doing is right for patients.”

Current radiology leaders are well-positioned to challenge the status quo and remove barriers to collaboration — if they continually adjust their outlook based on lessons learned. The COVID-19 pandemic
serves as a reminder that they should never forget what they are going through in the present, Norbash says. “Remembering what is happening right now will ensure that complacency never impacts our children and grandchildren.”


1. Fleishon H, Muroff LR, Patel SS. Change management for radiologists. J Am Coll Radiol. 2017;14:1229-1233.

Author Chad Hudnall, senior writer, ACR Press