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  • Applied Radiology Editorial - Do You Drive A Lamborghini?

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    radRounds Radiology Network
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    Abstract: 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.

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    Applied Radiology Editorial- Do You Drive a Lamborghini?

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    Abstract: 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.

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    167 tayangan1 halaman

    Applied Radiology Editorial - Do You Drive A Lamborghini?

    Diunggah oleh

    radRounds Radiology Network
    Abstract: 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.

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    EDITORIAL

    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-

    trump
    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 ©
    www.appliedradiology.com July–August 2009

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