The Evolving Role of the Endocrinologist and Primary Care Doctor in Establishing Goals of Care

Dr. Doron Schneider: Hi, I'm Dr. Doron Schneider. I'm a general internist at Abington Health Center right outside of Philadelphia. There I am the chief quality and safety officer for the health system and deputy program director for internal medicine. And with me I have Dr. Jack Leahy. Jack …
Dr. Jack Leahy: Great. I'm Jack Leahy. I'm the endocrine chief at the University of Vermont here in Burlington. I'm very interested in diabetes pathogenesis, but also clinical care.
Dr. Doron Schneider: Thanks, Jack,   I wonder if it may be an evolving role of the endocrinologist in their relationship with the primary care doctor is to help establish the goals of care. Does this belong at a primary care level? Does it belong at the endocrine level? This is a very critical thing for us to get right as we need to ensure that that balance of safety does occur against the expectancy and the possible benefits of driving people down who should be driven down to a goal of A1C of even 6.5. This does require a certain level of expertise that I worry does not currently exist in the primary care community and that is a major departure in this position statement, and I wonder if you have any reflections on this notion of goal setting.
Dr. Jack Leahy: So this is a hard question because it is very much a moving target. I'm in total agreement. It makes a hundred percent sense to me that if the only criteria that's used to define success or failure with a diabetes drug is attaining a certain level of blood glucose control and/or level of hemoglobin A1C, that is limited and a bit naïve, and this concept of individualization of care should be done. So I'm a total believer in this concept of individualization of care and I just don't think that there is a primary care doctor who sees patients who thinks that the idea of basing all the decisions that success or failure is based upon blood glucose control and level of hemoglobin A1C and nothing else is complete, and I totally agree with that. But what factors are most important factors is how you weight those is incredibly complicated and incredibly difficult, and I think a comment maybe for this is really is the art of medicine. That the discussion with any individual patient—what are the dominant issues for them, what is most influential for them, and what is going to be most beneficial in their overall healthcare—is where we should all shoot for. Now, now, the sort of the one easy part of this discussion—or at least one direct part o f this discussion—is having said all of that, what we do with blood glucose goals because that has been a very confusing issue in the last couple of years related to the ACCORD trial and to the ADVANCED study and to the Veterans study and ORIGIN, and what do we actually do in terms of the blood glucose goals, and I think there a reasonable summary to take away from all of that would be to say that early intensive blood glucose control, when the disease is fairly new and when patients are fairly healthy and when there's not any other major overriding illnesses getting in the way, makes absolute sense and a hemoglobin A1C of even less than 6.5 very early in the course of the disease seems to bring long-term benefits. Going to the other end of the spectrum when there's a lot of other comorbidity and a lot of other disease, especially cardiac disease and people are failing or at least not intensively treated already on a couple of diabetes agents, I think one can buy into being a little bit conservative and not be nearly as intensive and going slowly and having a development of goals of avoidance of hypoglycemia because I think we're a little afraid of that and certainly in those kinds of patients. And then for the huge group of patients in the middle that the average primary care doctor sees who are not that sick or have the disease for a while, they're failing an agent or two, but they're, you know, they're not that old, I think the goal of less than 7 may makes absolute sense, is defendable, and seems to bring some benefits.
Dr. Doron Schneider: Thank you for your wisdom. And reflecting back on other conditions that this type of crisp clarity may exist at least in guidelines and in thinking about the measurement of cholesterol, for example, and the tack that has been taken by thought-leaders and guidelines to provide guidance off of the Framingham calculator for cardiovascular risk is where we need to be heading, I believe, for the guidance required for the primary care community to be able to put in factors into a calculator to say this should be this patient's goal. And that may be the evolution of how we do goal setting as the stakes are going to increasingly be raised. We're entering an environment now that looks at scorecarding physicians, that looks at that scorecarding being transparent and available to the public, and the control of diabetes is a prominent feature of scorecards. And being able to administratively look at a database and exclude patients who should not be at goal, less than 7, for example, becomes increasingly important as that information is used for the migration of healthcare to become consumer driven, for patients to begin the process of selecting their clinicians, their doctors, based on outcomes, and then even more so as payment models are beginning to evolve to reward physicians toward the attainment of goal. These are sort of the next steps for us to be really thinking about from a policy perspective, from a payment perspective and will really need to be addressed in future iterations of guidelines, consensus data and position documents. We look forward to the feedback of the readers and the listeners of Beta Cells in Diabetes. We would like to hear your comments, suggestions, thoughts and reflections on what you've heard. Please submit those at betacellsanddiabetes.org. Thank you.