Aiming High in a Different Way

There are a few patients in my diabetes clinic whose notes you'd be surprised to read. Why? At the bottom of the note you would read something to the tune of, “ Goal A1C between 7-8%.”

What? Isn’t the goal A1C supposed to be 7% or lower? You would be correct. However I ask that, prior to shaking your head at me for not knowing better as an endocrinologist, you first check the patient’s age. Perhaps you should also read their complete medical history prior to casting stones on me. I have several times raised my goal A1C in my elderly patients, individuals with significant disabilities that impair their ability to check blood sugars adequately and/or who live alone, and those with chronic heart conditions or other comorbidities that suggest a shortened life expectancy. I had started this approach during fellowship after one of my clinic attendings listened to me rant and rave about suboptimal control in a patient, then quietly brought me down a notch.

"What is your goal here?," he asked me.

"An A1C of 7% of course," I said.

"Why?," he asked.

"Well, the data shows this will prevent complications, etc, etc," I said in my eager-first-year-fellow way.

He sat back in his chair. “And what will that do for this lady,” he asked,” who is in her 80s?”

Then I paused and let his point sink in.

It was an idea that was not foreign to me, but from a different scenario. Just one-year prior I had been sitting next to my mother’s bedside as she lay dying from non-small cell lung cancer. For some reason I knew during those last 72 hours, this was going to be the end. So when the nurses had made mention of blood sugars in the 200’s because of her prednisone, I did not pursue it. Why would I want my mother vexed by insulin shots at this time? I did not know in those painful moments that I was starting to learn some of the art of medicine—when to loosen the perfectionist grip in favor of maintaining quality of life. In some cases, it is not only quality of life but also simply an issue of safety and truly preventing greater harm.

This year many other people will have a chance to read about this very point when they review the recent Clinical Practice Recommendations 2009 from the American Diabetes Association. Some recommendations have been made to consider a higher A1C as target for various subgroups of patients including elderly individuals, those with short life expectancy, and those with extensive co-morbid conditions. The fact that the recommendations are based on level of evidence C or E do not weaken their strength in my eyes, but instead are further proof of the power and necessity of the art of medicine coming into play while still weighing “the data.”

In the adult world of endocrinology, letting go of the goal is sometimes a bit difficult. In medicine overall we tend to be a type A group, wanting perfection every time and that extends often to our patients. We assume that our adult patients are assuredly both responsible and able to care optimally for themselves, so we tend to raise the bar on what is expected. We have more and more data showing tighter control of lipids and glucose for instance can often improve many different outcomes.

But some other data is making its way into the scene as well. Perhaps some of the recent big diabetes studies like ADVANCE are starting to echo what we thought was the “art” of medicine: for some of our patients, too tight a grip may be more harmful than good. Given that physicians are constantly working on that art of medicine aspect, especially while the constant shadow of legal threats seem to loom, it is a great comfort to see formal guidelines recommending that we stop and think again about some of these high bars we have set. As clichéd as it sometimes seems, “do no harm” is still our first commandment as doctors.