“Treating to Target”

In medical school, as in any other educational endeavor, being good at test taking isn’t always the same as mastering one’s subject. Tests are easy to administer and their scores, particularly when multiple-choice questions are used, are indisputable and ideal for statistical analysis. Most people tend to agree that there is more to being a good doctor than scoring well on multiple-choice exams. Cultural competency, bedside manner, empathy and clinical problem solving often require other kinds of skills that don’t lend themselves as easily to numerical assessments.

As practicing physicians, we are constantly evaluated, and most of the time this involves the kinds of things that are easy to measure. Nobody is measuring how many years our patients with high cholesterol, hypertension, diabetes and obesity live before their first stroke or heart attack. Instead, we are often evaluated by how many of our patients reach treatment targets – certain levels of cholesterol, blood pressure, blood sugar and body mass index, as these numbers are thought to be approximations that indicate the same thing.

Human nature makes most people pay more attention to those things we are being scrutinized for. Numbers are easy to focus on. But there are problems when the numbers are viewed and pursued uncritically.

For example, two cholesterol medications lower LDL cholesterol to a similar degree, but one is proven to offer better heart attack protection than the other (Lipitor® versus Vytorin®). When physicians “treat to target”, they sometimes don’t help their patients get healthier at all, which was the topic of my very first blogpost.

The same applies to blood pressure medications; some of them prevent heart disease while some may actually increase the risk of cardiac disease and death.

A fundamental problem with treatment targets is how they are chosen. One example is the blood pressure target of 130/80 or less for diabetics. We have been held to this since 1992 as if it were handed down on the stone tablets along with the Ten Commandments. The UKPDS study in 1998 showed that lowering blood pressure for diabetics to a mean value of 144/82 reduced their cardiovascular risk. No study has actually proven that a blood pressure lower than 130/80 is ideal for diabetics with heart disease, and some have shown that pressures below 130/80 are linked not only to higher rates of serious medication side effects, but to an increased risk of death.

Yet I doubt the guidelines will change any time soon just because there are serious questions about their validity. Physicians who balance their professional judgment against the simplistic guidelines will continue to do so at their own peril.

An example of things that work, but cannot easily be measured, and therefore won’t be used to judge physicians’ performance is what diet our patients eat. Patients who eat olive oil have a 25% lower risk of heart disease than others, and patients aged 70-90 who follow a Mediterranean diet have a 50-60% lower risk of dying from heart disease and cancer than patients who eat a “regular” diet.

The Annals of Internal Medicine published an article from the Mayo Clinic last year, titled “Glycemic Control in Type 2 Diabetes: Time for an Evidence-Based About-Face?”. The authors summarize their viewpoints:

“Some diabetes guidelines set low glycemic control goals for patients with type 2 diabetes mellitus (such as a hemoglobin A1c level as low as 6.5% to 7.0%) to avoid or delay complications. Our review and critique of recent large randomized trials in patients with type 2 diabetes suggest that tight glycemic control burdens patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return. We believe clinicians should prioritize supporting well-being and healthy lifestyles, preventive care, and cardiovascular risk reduction in these patients. Glycemic control efforts should individualize hemoglobin A1c targets so that those targets and the actions necessary to achieve them reflect patients’ personal and clinical context and their informed values and preferences.”

The more pressure the pharmaceutical industry, insurance companies and healthcare administrators are under to prove the value patients get for their healthcare dollar, the more pressure we physicians will be under to adhere to numeric targets that others have chosen for us. And the more we concentrate on the numbers we are measured by, the greater the danger we won’t devote enough time and energy to doing the equally or more important things that nobody has figured out how to measure yet. We are at risk of acting like immature students, acing the multiple-choice questions but failing the hands-on clinicals. And this time our patients are not actors or volunteers, but sick people who come to us for help and advice in fighting their diseases.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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