Get What You Deserve

Photo credit:  INOVA

Photo credit: INOVA

Dr. Stephen Clement was my first endocrinologist out of college. He has been an Army doctor, a fellow at the Joslin Clinic, the head of diabetes program at Georgetown University, and is the architect of the (fairly) new inpatient diabetes program for Inova Fairfax Hospital in Virginia. I’m sure there’s more. Almost 20 years ago, he started teaching me how to be my own advocate. I recently sat down with him to explore how he came to be a patient-first doctor in a generation where such providers were few and far between.

How do you want to be treated in a relationship with your provider?

I was never bullied. It would have been difficult had anyone been inclined. Out-of-control diabetes took me out of school an average of 40 days a year. And I was always treated like a little adult by my teachers and parents’ friends – also a side effect of my early triumph over medical adversity, for better or worse.

But it took a long time for me to understand how I wanted to be treated, how I deserved to be treated, by medical professionals. In fact, I had to be taught by a few special providers that my relationships with my medical team should be no different than any other professional relationship – framed by mutual respect, supported by teamwork, and undaunted by judgment or questions, even if they came in an avalanche.

When I asked Dr. Clement how he got to be such a patient-centric provider, he told me it had a lot to do with lived experience and his own teachers.

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Dr. Clement attended medical at the University of South Alabama and did his residency at Tulane. While he was there, he had a chance to observe doctors who had developed excellent bedside manners. Watching them interact with people facing life-or-death challenges and without a ton of resources was the cornerstone of how he would go on to build his own practice. They were sympathetic, passionate but calm, and spoke to patients in ways that didn’t make them feel bad. It was a lot easier to get the patient to agree to focus on health-promoting behaviors if the provider wasn’t scolding.

As he began to practice in and around Mobile, AL, he worked in emergency rooms, where he observed some not-so-great interactions. He recalled one incident where the patient he was treating hadn’t been taking their medication as prescribed. Which happens (hello, six-year noncompliant diabetic). His regular physician came in and began a profanity-laced tirade. Dr. Clement remembers his shock and thinking how unhelpful it was.

Of course, he was right. I can’t imagine how I would have reacted to something like that. I live in a perpetual state of rebellion, so I probably would have walked out and made whatever the problem was worse.

After watching the mix of interactions at all ends of the helpful to hostile spectrum, he knew life was hard, illness was hard, and chronic illness was incredibly hard. So he made a conscious decision that his job was going to be as a guide. He could nudge and point his patients in the right direction, but even at the beginning of his career, he acknowledged that the patient was the decider. No yelling. No screaming. No telling the patient that they weren’t doing it right. If it works it works, and if it doesn’t, there’s always another day.

But Dr. Clement said that it took a while for patients to adjust to his approach. We are only just now starting to move away from the mindset that doctors are THE authority. When he started, it must have been even more difficult to get patients to play along.

Sometimes it never happens. He said one noncompliant diabetic, who had seen multiple endocrinologists over the years came in and, after he looked over her numbers, asked, “Aren’t you going to yell at me now?” It had happened so often that that was her norm. But the truth is, if that was what had been happening, she knew what was wrong. She didn’t need another doctor to tell her, and Dr. Clement didn’t feel like he needed to be the next in a long line of yellers. Besides, it just wasn’t his style.

That patient never come back. She needed prescribed roles – she was the transgressor and the doctor was the punisher – and it threw her off when she didn’t get that.

He says his colleagues sometimes have an equally difficult time adjusting to the way he practices. When Dr. Clement left Georgetown, he had built up a large practice, many of whom went to colleagues still there. The attending physicians who saw some of his old patients would call and say he had been too nice, that he should have been harder on them. But in his view, chronic illness is all about self care, and if a patient needs him to be the one yelling at them every appointment, treatment is just not going to work. Patients (we) have to do it for them(our)selves.

There will always be patients who need for their providers to be the ones in control, but patient-centric models of care are becoming more and more in demand. Next week, Dr. Clement will share his views on how we get there.