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Stephen Clement, MD, is an endocrinologist who practices at Georgetown Medical School, Washington, DC. Dr. Clement is also widely recognized as an educator and a student of new technology development and use. He can be reached at: CLEMENT@gunet.georgetown.edu

Interviewed by Audrey Kinsella, Information For Tomorrow.

AK: I once heard a nurse with years of experience say that there no such thing as a compliant diabetic. Is there?

Dr. Clement: Your question about compliance is a good one. For patients with diabetes, the whole issue of compliance can be looked at from the point of view of the patient. The patient may say he or she is perfectly compliant with what he or she wants to do. When a patient has developed habits which are at odds with good diabetes care prior to developing diabetes, then changing these habits once diabetes is diagnosed is challenging.

However, blaming the patient has no value in health care. We must take the patient as he or she is, and work from that point on. From the patient's standpoint, the patient takes in the information we give them and either acts on this information or ignores it, depending on how much of an impact the information had on him or her.

AK: How would you suggest that endocrinologists and the diabetic care team work with the issue of noncompliance? What information and tools, particularly those that involve Internet or other telecommunications technology, should be given or made available to patients?

Dr. Clement: I believe, the best way to have an impact on the patient is by giving constant personal feedback to the patient on how well he or she is doing. We also must keep in mind the tremendous barriers which slow our patients' progress with implementing lifestyle changes. Our patients are surrounded by fast, inexpensive food, an abundance of "energy saving" devices, and a world of stress. In addition, our patients have tremendous demands on their time, may have goals and targets which are different than ours, and may lack any social support system. This leads to further stress, anxiety, and depression.

Finally, patients receive mixed messages from health professionals. It is hard for our patients not to be enticed by fad diets which offer a "quick fix" to their weight problem, or by the incredible health claims made by various products. With all these mixed messages from care providers and information sources, the issue of compliance may be meaningless. The patient may not know with which recommendations to be compliant.

As health care providers, our job is to:

In summary, the interaction between the patient and the health professional must be frequent, dynamic, and must be adaptable to the individual patient.

AK: That sounds like a great mission for the healthcare professional. What do you think are key considerations for encouraging diabetics to participate in this interaction and to, say, use telemonitoring systems regularly so that they can get the professional feedback they need?

Dr. Clement: Telemonitoring systems offer the opportunity to engage the patient with diabetes and their health care providers in almost constant dialogue. The anticipated result is much more informed, and hopefully, healthier patients. I believe the key to success using telehealth is patients' having access to their providers, who are key resources for patients. For diabetes, the providers must be absolute experts in the field and must be able to integrate both the behavioral and the medical parts of the therapy into an integrated system.

AK: At Georgetown Medical School, you are heading a team effort, called the MyCareTeam project, for tele-access by diabetics to their providers and needed information. What do you personally hope will be accomplished with this program to help patients be more compliant? Do you think lifetime habits for diabetics can be established with it?

Dr. Clement: The MyCareTeam project is a Web-based interactive program for patients with diabetes that we are currently piloting at Georgetown.. The site incorporates all of the above interactions with our patients and is designed to simulate all the normal interactions we would have with our patients in the diabetes clinic.

It is called MyCareTeam because none of us by ourselves has all the expertise needed to care for all of our patients' needs. When patients enter the site, they can interact with one of us, depending on the expertise needed-- the nurse practitioner, fitness trainer, dietitian, or endocrinologist (myself). For the pilot program, we have recruited patients with both type 1 and type 2 diabetes who have had poor control for over six months. Our primary outcome variable is change in Hemoglobin A1c level over six months.

For the MyCareTeam pilot project on diabetes, we hope to learn in detail what works and what does not work with diabetes care over the Internet. As we gain experience with this new modality, we hope to learn which patient populations respond better (or worse), what can be done and what cannot be done, and how to make the interaction be cost-effective. So far, it has been an exciting project. I think over time, patients with diabetes will become more familiar with interacting with their health care providers "on line."