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Do you drive a Lamborghini?

Stuart E. Mirvis, MD, FACR

A few weeks ago, I was invited to speak

at an American College of Surgeons
meeting. The presentations were
arranged as point-counterpoint debates. My
assigned topic was “Intestinal (small bowel)
findings of small bowel obstruction even when
it’s not present. I reminded them that some
patient presentations are quite confusing and
that abdominal CT in such circumstances was
fully justified and in the patient’s best interest—
Experience, obstruction: Is there a role for computed tomog-
raphy (CT) if there is already clinical suspicion
as long as the situation did not demand immedi-
ate surgical intervention. It’s the urgency of the
knowledge, and confirmation by plain radiography?” I was
assigned to present the “pro” viewpoint, which
matter that they must decide right away and
need for an emergency laparotomy was the best
and good seemed like a good idea for a radiologist, and an
expert surgeon took the “con” position. When I
reason to skip CT.
I showed a few examples of how CT may
judgment received the program I realized I was the only
radiologist speaking. Though I already knew
clarify atypical clinical presentations. I men-
tioned that in conversations with abdominal sur-

the session moderator, and many of the sur- geons in my own shop the predominant view
geons who would be sharing the podium, I still was that, based on the patient’s clinical status

bravado or
felt like I was going to a knife fight without my and if there was sufficient time, CT provided a
knife (or scalpel I suppose). much higher level of confidence in selecting
My presentation was the last of four that dis- management. I opined that in this clinical con-
cockiness in cussed the role of CT, if any, in different acute text issues such as radiation exposure, cost of CT
clinical scenarios that an abdominal surgeon and the time to do the study were the last refuge
all medical would commonly face. I had the first three dis- of the nearly defeated. In closing, I pointed out
cussions to get the lay of the land. From the that radiologists were really their friends (well,
decision- outset it was clear that the power factions were perhaps not always), that we want the best for
on the NO CT side of every debate. Some of their patients, and that we, along with most peo-
making the “con” presenters argued against CT due to ple living in a capitalist society (even surgeons),
cost concerns, radiation exposure and the time want to work for a better living.
required to get the scan. Personally, I found Finally, my last image was an algorithm for
these arguments weak or just wrong. dealing with potential small bowel obstruction.
To add a little zip to the festivities, the moder- 1. If the clinical picture clearly indicates the
ator and one of the “con” speakers kept showing need for immediate surgery, the patient
pictures of the radiologist’s car, either a Lam- goes to surgery.
borghini or Ferrari, just to remind the audience 2. If the clinical picture and/or abdominal
what these unnecessary CT scans were funding. radiograph are uncertain and the situation
When it was finally my turn to speak, I told is not urgent, request abdominal CT as the
the audience that as the only radiologist there I study of choice.
felt like the proverbial sacrificial lamb. Second, 3. Patients and families today have a much
Dr. Mirvis is the Editor-in- I pointed out that I drove a nice, if fairly dirty, higher expectation for the correct diagno-
Chief of this journal and 2004 Nissan Maxima and I even pointed out sis and treatment than 20 or 30 years ago.
a Professor of Radiology, where it was parked if anyone required proof. I Precision medicine is the norm.
Diagnostic Imaging Depart-
ment, University of Mary-
reminded the group that the surgeon in our case I hope most physicians would agree that expe-
land School of Medicine, was “suspicious” of small bowel obstruction. rience, knowledge, and good judgment trump
Baltimore, MD. Was that 40% or 80% certain? Next, I pointed bravado or cockiness in all medical decision-
out that plain radiographs often show classic making.

4 ■ APPLIED RADIOLOGY © July–August 2009