Letters to the Editor

Context matters for DXA

The lead item in the Jan. 24th ACP InternistWeekly highlighted the findings of a recent study on bone density testing (N Engl J Med. 2012;366:225-33), which conveyed the message that older women with normal or near-normal bone mineral density (BMD) may be able to defer BMD testing for several years.

This message is quite concerning because it may be misunderstood by physicians, patients and the media, leading to further underuse of dual-energy X-ray absorptiometry (DXA) in practice, misdiagnosis and failure to treat. Indeed, the International Society for Clinical Densitometry has already issued a warning to clinicians about such misinterpretation of the study's results.

The study in question has several drawbacks that must be carefully considered. We feel the biggest is its attempt to define time intervals for DXA scanning to capture “osteoporosis” based solely on hip/femur neck T-scores. In osteoporosis, the T-score or BMD reflects only part of bone strength. Other risk factors for bone fragility fractures are related to changes in bone quality, which DXA does not detect. These qualitative changes are not measured in a T-score but must be considered in the clinical decision-making process, identified by such risk factors as age and prior fractures.

Clinicians should be aware that many chronic illnesses and drugs can affect bone quality and fracture risk independent of an effect on BMD. Patients with these conditions may therefore need DXA scans earlier and more often than predicted by the current study so that medical treatment can be timely and more efficacious.

We urge all fellow clinicians to consider patients' clinical context at presentation to avoid missing windows of opportunity for intervention when it would matter most, that is, before fractures develop.

Krupa B. Doshi, MD
Leila Z. Khan, MD
Susan E. Williams, MD, MS, FACP
Angelo A. Licata, MD, PhD, FACP
Calcium Clinic Group, Department of Endocrinology, Cleveland Clinic, Cleveland

Better titles needed for ‘internal medicine’

In 1981, I joined a multi-specialty clinic as its first board-certified internist. From the start, I had trouble explaining what that meant. People would ask if I was just starting and still training. A rookie? An intern? Often I would say, “I am a general practitioner who doesn't deliver babies or deal with little kids.”

I suspect my story is familiar to many trained in internal medicine, but perhaps not to those who have received further training and have subsequently been “named.” I'm referring to the cardiologists, rheumatologists, gastroenterologists, and other internists who have specialized in a more focused field. Recently, hospitalists have been added to that list.

All of these subspecialists were internists first. Why does tradition dictate that they drop their internal medicine “surname” once they acquire a given “first name”?

The discussion about renaming internists is not new. We've been designated, by others or ourselves, as general practitioners, generalists, board-certified internists, doctors for adults, internal medicine specialists, complexivists, internalists, and comprehensive care internists, to name a few. But more recently we have been combined with non-internists and non-physicians as “primary care providers.” There's the rub.

The National Board of Medical Examiners has recommended that every provider of primary care pass a common competency test. If such an exam becomes mandatory, I believe the names nurse practitioner, physician assistant, family physician, and general internist will be combined into “primary care provider.” To some degree this is already happening.

I don't argue that the idea of a test is irrational or unfair, or that internists are better than everyone else. But if an internist is not distinct among practitioners, that will be one more reason for medical students to avoid choosing outpatient internal medicine as a career.

With physician shortages looming, doctors trained to care for sick, complex adult patients in the outpatient setting are essential and will become even more so in coming years. We will need such physicians to keep people with complex illnesses out of the hospital, improving care and further reducing costs to patients and society.

Payment reform is not the only step needed to increase medical students' interest in primary care. Internists caring for outpatients should have an identifiable full name. Titles should reflect physicians' current practice while giving credit to their internal medicine training.

An internist doing ambulatory care should be called an outpatient internist. Those previously named hospitalists should be called hospital internists, endocrinologists should be called endocrinology internists, pulmonologists should be called pulmonology internists, and so on.

If we don't address the naming issue, we risk leaving younger internal medicine physicians disconnected and almost disenfranchised. An internist is neither an intern nor a rookie.

Personally, I would like to be called an outpatient and hospital internist. It is recognizable, it defines the scope of what I do, and it reflects the kind of training I received. Best of all, it gives me a first name and a family name, too.

Richard Holm, MD, FACP
Brookings, S.D.