Opinion
LESS IS MORE PERSPECTIVE
Lorna A. Lynn, MD American Board of Internal Medicine, Philadelphia, Pennsylvania.
Corresponding Author: Lorna A. Lynn, MD, American Board of Internal Medicine, 510 Walnut St, Ste 1700, Philadelphia, PA 19106 ([email protected]).
A Dual-Energy X-ray Absorptiometry Scan Need to Know vs Nice to Know I know I am not alone in this. While making sure that my children and pets received all recommended vaccinations and medical care, it had been 8 years since I had seen a health care provider. My reasons for joining the ranks of the lost to follow-up are typical: I changed jobs, my gynecologist moved away, and I was embarrassed to have gone so long without having seen a physician. I had another reason for my absence: unlike most patients, I know what preventive care can and cannot do in terms of lengthening life, or at least improving its quality. Still, turning age 50 years meant that it was now time for the mammogram and for colon cancer screening. I was pleased to get an appointment with a female physician, a general internist who made it easy for me to confess my sins of neglect and listened empathetically to my chief concerns. Telling me that I had saved society a lot of money for the past decade, she said it was time to catch up on testing: lipids and glucose measurements, electrocardiographic (ECG) and dual-energy X-ray absorptiometry (DXA) scans, and a mammogram and colonoscopy. We were both internists, and had we been discussing a case at a conference for residents or a continuing medical education course, I would have challenged her about the need for the ECG and DXA scans. My 10-year risk for coronary heart disease was very low. Deciding whether I needed a DXA scan was a little tougher. On the one hand, other than drinking 3 cups of coffee a day, I was not at elevated risk for osteoporosis. On the other hand, my 90-year-old mother had lost several inches in height because of osteoporosis. Once my physician rec-
ommended the DXA scan, I thought that it would be nice to know where I stood. I also wanted to be a patient, not a colleague. I did not want to question my physician. The tests felt like evidence of her care, concern, and thoroughness; she wanted to make sure that she did not miss anything that might help me. I wanted to follow her recommendations. I wanted a guide who knew where I needed to go and what I would need along the way. Unsurprisingly, my ECG scan result was normal. The DXA scan result placed me in the category of low bone mineral density, for which calcium and vitamin D and weight-bearing exercise are all recommended—as they would have been without the test result. While my insurance covered the cost of the DXA scan, I am not sure who benefited, beyond the manufacturers of the test. When a physician suggests a test, it is easy for a patient to believe that it is important and necessary. It is easy to believe that the test result will tell us the right next step or will assure us that all is well. But the harder reality is that there is so much we just cannot know, that tests cannot make clear. The harder role for the physician is to help the patient understand that there will be uncertainty and that perhaps the best we can do is work on developing habits of healthy living. The harder explanation is about the limits and risks of tests. It is time for me to schedule another appointment with my internist. I know I can rely on her compassion and her good intentions. This time, I will also help her think through exactly how any medical tests will help me. I will help her think through with me what we really need to know.
Published Online: December 2, 2013. doi:10.1001/jamainternmed.2013.12819. Conflict of Interest Disclosures: None reported.
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JAMA Internal Medicine February 2014 Volume 174, Number 2
Copyright 2014 American Medical Association. All rights reserved.
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183
LESS IS MORE PERSPECTIVE
Lorna A. Lynn, MD American Board of Internal Medicine, Philadelphia, Pennsylvania.
Corresponding Author: Lorna A. Lynn, MD, American Board of Internal Medicine, 510 Walnut St, Ste 1700, Philadelphia, PA 19106 ([email protected]).
A Dual-Energy X-ray Absorptiometry Scan Need to Know vs Nice to Know I know I am not alone in this. While making sure that my children and pets received all recommended vaccinations and medical care, it had been 8 years since I had seen a health care provider. My reasons for joining the ranks of the lost to follow-up are typical: I changed jobs, my gynecologist moved away, and I was embarrassed to have gone so long without having seen a physician. I had another reason for my absence: unlike most patients, I know what preventive care can and cannot do in terms of lengthening life, or at least improving its quality. Still, turning age 50 years meant that it was now time for the mammogram and for colon cancer screening. I was pleased to get an appointment with a female physician, a general internist who made it easy for me to confess my sins of neglect and listened empathetically to my chief concerns. Telling me that I had saved society a lot of money for the past decade, she said it was time to catch up on testing: lipids and glucose measurements, electrocardiographic (ECG) and dual-energy X-ray absorptiometry (DXA) scans, and a mammogram and colonoscopy. We were both internists, and had we been discussing a case at a conference for residents or a continuing medical education course, I would have challenged her about the need for the ECG and DXA scans. My 10-year risk for coronary heart disease was very low. Deciding whether I needed a DXA scan was a little tougher. On the one hand, other than drinking 3 cups of coffee a day, I was not at elevated risk for osteoporosis. On the other hand, my 90-year-old mother had lost several inches in height because of osteoporosis. Once my physician rec-
ommended the DXA scan, I thought that it would be nice to know where I stood. I also wanted to be a patient, not a colleague. I did not want to question my physician. The tests felt like evidence of her care, concern, and thoroughness; she wanted to make sure that she did not miss anything that might help me. I wanted to follow her recommendations. I wanted a guide who knew where I needed to go and what I would need along the way. Unsurprisingly, my ECG scan result was normal. The DXA scan result placed me in the category of low bone mineral density, for which calcium and vitamin D and weight-bearing exercise are all recommended—as they would have been without the test result. While my insurance covered the cost of the DXA scan, I am not sure who benefited, beyond the manufacturers of the test. When a physician suggests a test, it is easy for a patient to believe that it is important and necessary. It is easy to believe that the test result will tell us the right next step or will assure us that all is well. But the harder reality is that there is so much we just cannot know, that tests cannot make clear. The harder role for the physician is to help the patient understand that there will be uncertainty and that perhaps the best we can do is work on developing habits of healthy living. The harder explanation is about the limits and risks of tests. It is time for me to schedule another appointment with my internist. I know I can rely on her compassion and her good intentions. This time, I will also help her think through exactly how any medical tests will help me. I will help her think through with me what we really need to know.
Published Online: December 2, 2013. doi:10.1001/jamainternmed.2013.12819. Conflict of Interest Disclosures: None reported.
jamainternalmedicine.com
JAMA Internal Medicine February 2014 Volume 174, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Michigan User on 05/19/2015
183
