Radiology in times of dystopia and black swans: reflections during the COVID-19 lockdown

Dear Editor,

We read with great interest your recent reflections about radiology and its professionals in the coronavirus crisis published in our journal.¹ As Nassim Nicholas Taleb indicated, the impact of the highly improbable reveals the fragility of the foundations of our knowledge.² Until the first European explorers arrived in Australia in the 17th century, in Europe it was believed that all swans were white. The discovery of swans with black feathers broke that paradigm. For Taleb, black swans would be highly improbable and unpredictable events with a powerful impact on our lives, such as the current coronavirus crisis.² Now that we are forced to admit that the pandemic (an improbable event) will be with us for at least some time, it seems, as Slavoj Žižek argued, that it is as though we are living in a dystopia straight out of a film script in which an abnormal new normal has been created.³ A "new abnormal" that, for example, made it "normal" to bump patients in our departments, and that will undoubtedly result in future enhancement of management centred on imaging with added value for patient versus volume management or in a broad implementation of abbreviated study protocols to make optimal use of time.⁴ Moreover, the COVID situation has mandated dual healthcare pathways, with reserves of human and material resources for both, and with patient management that has inevitably been less dynamic given the need to go to great lengths to safeguard something as essential as the safety of patients and professionals. Finally, as you indicated, the pandemic has prompted a necessary return to basic technologies and abilities such as plain X-rays.¹ It has also highlighted the need to enhance the interdisciplinary knowledge of radiologists in order to tackle challenges like this and to avoid excessive super-specialisation.⁴

Nevertheless, following this crisis, medical imaging will be one of the areas to undergo the greatest expansion. Not just because of the things that could not be done or the new things that are to come, but also because, throughout the crisis, prior trends that were already fairly familiar have become more marked (e.g. professionals not making decisions about patients without imaging tests) and because new necessities will arise, such as those deriving from foreseeable enhancement of variations on remote medical appointments to keep patients out of hospitals. With this, inevitably, the genuinely clinical part of medical practice will decrease, thus heightening the importance of imaging and other complementary tests; derivative requirements from hospitals with morning and afternoon activity to avoid groups of people, as a new standard towards which we are heading; and emergence of new indications motivated by the need to increase our safety when caring for possible COVID-19 patients, as is already being proposed for complex surgical procedures,⁵ as well as changes to existing indications (e.g. CT instead of ultrasound in cases of acute abdomen, in order to include the chest). All this will undoubtedly lead to an increased need for and importance of imaging.

Our future, therefore, will be not so much dystopic as plagued by new challenges, faced with which radiology will undoubtedly succeed in reinventing itself once again.