Editorial: Do you drive a Lamborghini?

Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland School of Medicine, Baltimore, MD.

A few weeks ago, I was invited to speak at an American College of Surgeons meeting. The presentations were arranged as point-counter-point debates. My assigned topic was "Intestinal (small bowel) obstruction: Is there a role for computed tomography (CT) if there is already clinical suspicion and confirmation by plain radiography?" I was assigned to present the "pro" viewpoint, which seemed like a good idea for a radiologist, and an expert surgeon took the "con" position. When I received the program I realized I was the only radiologist speaking. Though I already knew the session moderator, and many of the surgeons who would be sharing the podium, I still felt like I was going to a knife fight without my knife (or scalpel I suppose).

My presentation was the last of four that discussed the role of CT, if any, in different acute clinical scenarios that an abdominal surgeon wouldcommonly face. I had the first three discussions to get the lay of the land. From the outset it was clear that the power factions were on the NOCT side of every debate. Some of the "con" presenters argued against CT due to cost concerns, radiation exposure and the time required to get the scan. Personally, I found these arguments weak or just wrong.

To add a little zip to the festivities, the moderator and one of the "con" speakers kept showing pictures of the radiologist's car, either a Lamborghini or Ferrari, just to remind the audience what these unnecessary CT scans were funding.

When it was finally my turn to speak, I told the audience that as the only radiologist there I felt like the proverbial sacrificial lamb. Second,I pointed out that I drove a nice, if fairly dirty, 2004 Nissan Maxima and I even pointed out where it was parked if anyone required proof. I reminded the group that the surgeon in our case was "suspicious" of small bowel obstruction. Was that 40% or 80% certain? Next, I pointed out that plain radiographs often show classic 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-as long as the situation did not demand immediate surgical intervention. It's the urgency of the matter that they must decide right away and need for an emergency laparotomy was the best reason to skip CT.

I showed a few examples of how CT may clarify atypical clinical presentations. I mentioned that in conversations with abdominal surgeons in my own shop the predominant view was that, based on the patient's clinical status and if there was sufficient time, CT provided a much higher level of confidence in selecting management. I opined that in this clinical context issues such as radiation exposure, cost of CT and the time to do the study were the last refuge of the nearly defeated. In closing, I pointed out that radiologists were really their friends (well, perhaps not always),that we want the best for their patients, and that we, along with most people living in a capitalist society (even surgeons), want to work for a better living.

Finally, my last image was an algorithm for dealing with potential small bowel obstruction.

1. If the clinical picture clearly indicates the need for immediate surgery, the patient goes to surgery.
2. If the clinical picture and/or abdominal radiograph are uncertain and the situation is not urgent, request abdominal CT as the study of choice.
3. Patients and families today have a much higher expectation for the correct diagnosis and treatment than 20 or 30 years ago. Precision medicine is the norm.

I hope most physicians would agree that experience, knowledge, and good judgment trump bravado or cockiness in all medical decision-making.