Sometimes, what matters most is how far a patient has come.
Fam Pract Manag. 2010;17(6):44
Dr. Brill practices at the Aurora University of Wisconsin Medical Group in Milwaukee. Author disclosure: nothing to disclose.
Congratulations were definitely in order. Joe, a 54 year old with diabetes, hyperlipidemia, hypertension, sleep apnea and morbid obesity was in for a follow-up visit. I had been his physician for four years and, for most of that time, had very little demonstrable success in helping him with these problems. During the last eight months, however, since the sudden death of his older brother, he had worked diligently at exercising more and eating in a healthier way. He had lost 30 pounds, including 14 pounds since his last visit four months ago.
A few days earlier, he had come in for his labs. His A1C had plummeted from 11.3 percent eight months ago to 9.3 percent four months ago to 7 percent currently, aided by maximum doses of metformin and glyburide. His glucometer, which in the past he had always forgotten to bring, also showed steadily improving sugars. Previously, we had discussed the benefits of insulin, but he had refused, positive that he could get his sugars under control with lifestyle changes and oral medications.
His cholesterol was also much improved. He was taking the maximum dose of simvastatin, had seen a dietician and made dramatic changes in his eating habits. He hadn't stopped in to McDonald's for his usual breakfast in months. His lipid panel reflected this, with total cholesterol down from 235 to 176 and LDL dropping from 142 to 101. He proudly showed me the new notches he had cut in his belt to fit his slimmer girth. I applauded his dedication and told him how much healthier he looked.
Before Joe committed to making these life changes, we had a very difficult time controlling his blood pressure. On the highest doses of lisinopril, hydrochlorothiazide, metoprolol and amlodipine, his systolic blood pressure had been in the 160s. But his blood pressure in the office today was 132/82. “Take a look at these, doc,” he said with a smile, pulling a card out of his wallet that showed a cluster of recent blood pressures in the 130s over 80s.
Across all measures, his numbers were unquestionably much better, and yet …
Sitting on my desk was a report from Joe's insurance company listing all of my patients whose care did not meet its quality benchmarks. Joe's name was on it in three areas: glycemic control (A1C below 7 percent), LDL (below 100) and blood pressure (below 130/80).
I agree that if we achieved these standards with all of our patients who have diabetes, they would suffer fewer cardiovascular events. And I agree that we need to measure what we do in order to improve. But where's the evidence that lowering a man's A1C from 7 percent to 6.9 percent will improve his health? How many Joes would have to be switched to a more potent and costly lipid medication to prevent one MI? Is a three-point drop in blood pressure worth the risks of yet another anti-hypertensive agent?
I am fairly sure that lowering Joe's A1C from 11.3 percent to 7 percent has helped him more than any further reductions. What he needs now is reinforcement and anticipation of relapse, not more meds. So, I congratulate him, heartily, frequently and sincerely, and I recommend that he just keep doing what's he doing. His numbers may get better still, but even if they don't, and even if he stays on the “bad” list, I think that I have done right by him.
I'll keep advocating for better measures of quality. But in the meantime, I'll just have to hope that most of my patients (or at least their numbers) aren't like Joe.