Why don’t our patients do what we tell them?

This question was what drove me to graduate school for an MPH degree a few years ago.  I was finishing up my family medicine residency at, arguably, one of the top residency programs in the nation.  I had been well trained in both medical science and doctor-patient relationship skills.  Yet my patients still consistently did not adhere to my advice.

I was not disappointed in my MPH studies.  It turns out that most people (with the exception of the cognitively challenged) are rational actors.  They make decisions that seem rational to them, based on their personalities, environments, and social pressures.  One person may not agree with another’s decision, and yet both will arrive at his/her own decision based on some rational process.  This tenet is the basis of health behavior theory (HBT).

Here’s one scenario.

A 3-year old child sees her parents drinking soda pop at dinner every night.  She gets juice to drink several times a day.  When her parents give her a taste of their soda pop, she immediately realizes that this stuff is much tastier than water or milk.  This same child has a TV set in her bedroom, so she sees advertisements for juice and soda pop frequently.  She lives in a disadvantaged neighborhood where there are no grocery stores, just corner markets.  Soda pop is cheap, and WIC covers juice, so there’s always some of both at home.  Her parents, who like drinking soda pop and have no reason to believe it could hurt their health, begin acquiescing to the child’s frequent requests for soda pop.

Before long, this 3-year old is now 14.  Her high school cafeteria stocks Starbucks Frappuccino, which makes her feel very grown up when she drinks it.  The school vending machines can’t sell soda anymore, but there’s lots of juice and flavored waters still to choose from – not to mention that she usually picks up a 20 oz bottle of Mountain Dew or Pepsi on the way to school to help her wake up, since school starts much earlier than her teenage circadian rhythm prefers.  Milk and plain water are anathema to her.

She grows into a young adult, who presents to your family practice office.  She tells you that her dad was just diagnosed with diabetes, so you screen her and find that she has pre-diabetes.  When you talk to her about switching her beverages to water or zero-calorie sodas, she looks at you like you’re from outer space.

This hypothetical patient learned, from a very young age, that sugared beverages taste good. Her experiences provided her with the perceived norm that everyone drinks soda pop and juice multiple times a day.  I now have fifteen minutes during this appointment with her to overcome twenty years of belief and experience that have led to her sugared beverage consumption behavior.

Sounds difficult, right?

Just telling her that sugared beverages are bad for her, and if she doesn’t do anything she’ll end up with diabetes, won’t work most of the time.  What can work, interestingly enough, is asking her (non-judgmentally) about her specific beliefs about soda pop.  What has she seen, what has she heard, why does she like them, etc.  Then, it’s possible to gently explore these beliefs together. I’ve found that patients are usually much more interested in hearing doctors’ advice if they feel they’ve been heard and respected first.

Jennifer Middleton is a family physician who blogs at The Singing Pen of Doctor Jen.

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  • http://www.doctordinusha.info/ Dinusha Sirisena

    Thank you very much for sharing that scenario. It showed that modifications in lifestyle and diet are not easy. We cannot bully the patients into doing what we think is right. It has to be a natural process of self actualization (Maslow). Changing behaviour is not easy. Asking a person to give up smoking is easy, but implementing it is difficult, even without the physiological dependence. The best way as you said is to use the Procheska-DiClemente System of behaviour modification. Go through it with the patient and identify the different obstacles.

    • sarah93

      Smoking is an addiction and a serious one. It’s very easy to judge people, in fact smokers seem to be a new class of whipping boy. (I do not smoke, never have. But I do have friends who are hopelessly addicted and cannot believe the carp they have to put up with.)

  • http://www.HealthcareMarketingCOE.com/ Simon Sikorski MD

    Which patients would be more compliant?

    Scenario 1: Patient schedules appointment. During scheduling the front office person tells patient about required reading on the doctor’s blog with links to specific resources, Facebook, patient ratings. Patient brings questions with him.

    Scenario 2: Patient schedules appointment. Reads “Yahoo News” with misinformation on a regular basis or any other “news” that’s entertaining. Waits in the waiting room for 10 minutes looking at either a blank wall or some TV show. Spends 5 minutes with doctor followed by recommendations to follow (more like mandates or scare-tactics)

    How can you ask for patient compliance if they’re not engaged or educated?

    I helped doctors set up hundreds of blogs and educational social media. The dividends from patient education start paying off as soon as the blog is up and running.

  • http://www.twitter.com/alicearobertson Alice Robertson

    Patients don’t view doctors as they once did. They see you as a type of counselor who can order tests and diagnose….or if they are sick a scriptor. They are free to do whatever they want with the information you give them. Basically, they see you as an information bank that can advise them and give them a medication that is supposed to miraculously reverse or prevent the damage their own lousy lifestyle is creating. Only when a penalty of realizing a pill isn’t enough, or cancer, or monetarily (as employers such as Cleveland Clinic are doing to those who can’t pass the physicals) types of punishments come into play will patients see you as much beyond someone who can script them out of an illness. Not that you don’t deserve respect, but clearly doctors don’t wanna play Svengali in this climate of so many choices where even specialists disagree about treatments and ways to obtain optimal health (Steve Jobs is a great example of doctors disagreeing over what works and what doesn’t and a patient having the ultimate responsible for their own decisions. Look at how many doctors disagree with Dr. Agus…patients see this and realize you are just one opinion of many).

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Since that seems to be the consensus there’s no point in going to the doctor at all for most people is what it sounds like to me. And if that’s the case, then the penalty of which you speak is still not going to make the people wake up and see the reality of just how doctors work. They are just going to keep on doing what they do, not having a care in the world.

      • http://www.twitter.com/alicearobertson Alice Robertson

        According to many doctors at Cleveland Clinic that’s exactly what a huge percentage of patients are doing. One doctor said he could be out of a job if patients were responsible in their lifestyles. But the penalty does work on the employees (if there was a chart I would surmise that the more the government picks up the tab the more irresponsible a patient is…and I know how PC incorrect that is to say….but I had to throw it out there because it’s also unpopular for doctors to tell a patient exactly what they should…to lose some weight….they risk the ire of their patient to do so…and that’s a real shame).

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          When I talk about no longer going to the doctor, I am talking about those patients that don’t want to be told how to take care of themselves. And since they know that each time they go they will be counseled about how to eat, etc they are going to say “nope, I have had enough of this” and not go at all. For people who have certain chronic medical conditions that need to be monitored that is not a wise thing.
          As for the penalty working for employees, just wait until the ones who smoke start filing lawsuits for discrimination. When they start suing the companies that refuse to hire workers that smoke or even overweight for that matter it will be another story. The reason that it’s an ire for the patient is because no matter how the doctor tries to explain why they need to lose weight, eat right, exercise is because they are tired of hearing it. The people who choose to do these things don’t give a care in the world, and as a result they think that nothing will happen to them. And even then when something does happen there are those that still remain unmoved. What is a doctor to do then? They could do like I read about doctors in Hungary that do let patients go for noncompliance of medical treatment.

          Is that going to fix the problem of trying to get patients to do what their told? Nope. They are just going to keep on doing what they are doing regardless the consequences. So when they stop going to the doctor all together and they get sicker it’s going to be hard not to want to say, “I told you so” but yet it’s their very own choice how they want to live.

          • http://www.twitter.com/alicearobertson Alice Robertson

            At Cleveland Clinic employees don’t smoke. They are tested. The whole campus is a non-smoking facility where even the snack bar and cafeteria are no trans fat, etc. (I do think after 6 pm the ban is lifted as far as trans fat? At least it was when I was there with my daughter). They are trying and it has helped them quite a bit because employees who don’t pass the physicals are fined about $100 per month until they get in better shape. My daughter’s work at a nursing home with a five point clearance and if you fail two of the points you pay about $30 a week extra towards your insurance (they are penalized for smoking). It’s in their contract and most employees think it’s reasonable, except the ones who have to smoke outside.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            The people who smoke may be tested but guess what? They will find a way to figure out how to manipulate the test results to show that they are non-smokers just like sometimes people may do with a drug screen. However, I am glad that they are a non-smoking facility. I think that they are one of the first to do that). As for the issue of the $100 fine per month until they are in better shape, interesting idea but it won’t be long before someone refuses to pay that fine and then sues.

            Most of the employees may think it’s a reasonable idea (which I do too by the way), but the ones who insist on continuing to smoke won’t stand for this for very much longer. Just you wait and see.

          • http://www.twitter.com/alicearobertson Alice Robertson

            Well in my unofficial anecdotal data bank it seems that even when healthy food is free it’s thrown away. In places where the school lunches were cleaned up something like 80% of the healthy food was thrown away. I don’t think it costs that much extra to eat healthy, and I do think the Agriculture Dept. is wrong to allow purchases such as pop on food stamps. That’s outrageous that our tax money is being used to buy crap:) It hurts the bones and teeth of those who drink it. If they want the liberty to eat that way do it on their own dime. I think “free” food should be conditional just as “free” government care should have some sort of responsibility with it. If the patient is bullheaded and shows no type of response they should be penalized. In the UK if you get nicotine withdrawal patches you must blow into a breathalyzer at the pharmacy before you get more patches. If you fail, then no patches. It’s a good practice.

          • sarah93

            I’m fascinated as to where these doctors are who supposedly counsel patients to adopt a healthier lifestyle. I ballooned up to 196, then took off 70. I have managed to keep off 50 of them for over a decade. Not ONCE has any doctor mentioned my weight. I have no idea why they dutifully weigh me at my rare visits.

            My husband’s BP rose alarmingly. He had swollen ankles. First choice of his PCP? Pills. Husband was the one to push for lifestyle changes. The first one was to stop going to McDonald’s. That alone brought down his BP to normal and reversed the edema in the ankles. Again, no acknowledgement from the doctor.

            Since then we’ve both gone on to change our diets and now get up at 5:00 am to walk before work. We avoid doctors, actually, because they only seem interested in pushing pills and expensive screenings that make money for their hospital employer.

            So where are these pro-lifestyle doctors? We’ve never met one yet.

  • buzzkillerjsmith

    Human being are apes. Apes like fat, sweets, and salt. Next case.

    • morebuzzkills

      @buzzkillerjsmith:disqus, MD, MPH

    • Suzi Q 38

      I guess I am an “Ape.” I miss the pork rinds, black licorice, and pizza.

  • elizabeth52

    “I’ve found that patients are usually much more interested in hearing doctors’ advice if they feel they’ve been heard and respected first.”

    I agree, but it doesn’t mean I’ll follow all of her advice or recommendations. I’ve declined two different types of cancer screening after doing my own research. I spoke to my doctor about my concerns, she listened and made a note on my file.

    So often women are told, “well, you’re 50 so the recommendation is a mammogram every 2 years”…some might get the official brochure that is IMO, woefully inadequate.

    I don’t blame my doctor, she’s between a rock and a hard place, there is an official program with a govt-set target and if she doesn’t recommend it, she might end up being sued. Also, she probably realizes that most women can’t make an informed decision to screen or not to screen, given the quality of the information that’s provided…it seems few doctors are sued for over-screening, over-treatment or over-diagnosis. (probably because many women/people never work out they were over-treated etc)
    It’s those higher up who should be making changes to allow us to make informed decisions.

    I read a post on another forum, a middle-aged woman who has just realized we have a choice about screening, it’s not compulsory. For many years she was “required” to have screening to get the Pill. Others say they were sacked by their doctors when they declined screening.

    So, I feel fortunate my doctor listens and accepts my informed decisions. I also, take full responsibility for those decisions.
    I’m also, grateful for her many years of professional care and attention.
    I think a respectful two-way relationship is a must in the doctor-patient relationship.

  • Suzi Q 38

    Two years ago I embarked on a weight loss program that involved monitoring food and exercise everyday.
    I lost 45 pounds the first year and a half.
    I used MyfitnessPal dot com, and weight myself everyday.
    I exercised about 45 minutes to an hour each day, 5 days a week.
    Doing it all was a lot of work. Soon, I did not crave the sweets and carbs.

    I have slowly left the bad foods back in my life.
    I had to have spine surgery, so I have not been allowed to exercise for 3 months. My exercise is nothing like I could do before. I don’t really burn as much.

    I stopped weighing myself everyday, and quit logging in my food.

    the result? I have gained 10 pounds in 4 or 5 months.

    I found that weight loss is 80% food and 20% exercise.

  • Dorothygreen

    It is very acceptable now to deal with the issue of smoking. Even a 14 yr old would know this. It’s not advertized anymore, cigarettes are expensive and not so easy to purchase. There are gruesome ads on TV about the dangers.

    Not so, sugary products (including soda) chips, other low nutrient foods. What do you see when you see first when go to a grocery store – pastries on sale!

    Physicians can’t change this addictive behavior one by one. It is a public health issues. In fact it is the biggest and costliest health issue in America. Chronic preventable, NC, diseases eat up over 50% of our health care costs. The 14 yr old and her family has no way of knowing this as they have of knowing the extra cost of cigarettes and dangers of smoking.

    If the US Congress continues to be subsidized by the BIGS (Bullies Invested in Government) – About 20 BIGS control our food supply – we will be destroyed from within. Every conversation about debt considers Medicare the driver. It is all health care costs and the preventable chronic diseases driven by SAD -standard American diet.

    The majority of Americans enable the BIGS. It is extraordinarily difficult to “kick the SAD (standard america diet habit” – high amounts of sugar (refined grains included) added salt and the fat are the life blood of processed food. Banning soda in schools is a good thing. This is but a bandaid of what needs to be done.

    Low nutrient, addictive substances in foods must become more expensive that nutrient dense foods. The revenue as an excise (RISK) tax (on added sugar, fat and sodium, must be put into primary preventive health care.

  • http://twitter.com/DroopySocialwkr DroopySocialworker

    I hardly ever go to doctors. First because I live rurally there is no continuity in care. Like clockwork the docs come in for their mandated 3 year stint and leave (if that). Because I have moved around over the years the local facility does not have an accurate medical history on me. Think any one of the docs I’ve seen in the last 10 years have got one? Nope. I try to tell them and get blown off.

    So I go to the clinic and may get to see the doctor of the moment for about 5 minutes. I come prepared with specific questions which I rarely get answers to. It makes me think really why am I really bothering to even come here then.

    I even tried tried to come to the primary with very specific concerns after being referred back for follow up after a specific medical event? Got completely blown off and spent a year throwing money out the window on a dietician who wants to spend our 15 minute appointments discussing my work.

    I tried for years to address multiple time a week migraines. I don’t want pain pills. The minute I said that I wasn’t taken seriously. Had they taken a history they would know I had a problem in the past with narcotic abuse. It’s not that I’m not in pain. I’m just not willing to put the narcotic in my house as an open invitation. The result of one of those doctor of the moment appointments? Referrals to the city (over an hour away) to do tests like MRI’s and see specialists. Each of those trips is a day off of work that I don’t get paid for and I was minimally insured at that point. I’m not sure what money tree the doctor thought I could shake and make that happen with. It took 7 years to finally get the doctor of the moment to take me seriously.

    So basically at this point I explain on the front end with the doctor at the moment if they aren’t going to be bothered to take a real history, going to simply be a referral source for the specialists in their medical system every time I come in, treat my questions like they’re trivial etc. one can expect me to be non-compliant. I’m not an endlessly flowing well of money, I don’t have endless numbers of sick days to make repeated visits to them or their specialists hours away, I don’t have the best insurance (but at least I have some), and I need to be mindful of my realities as well. Unless they are willing to take that all into consideration every time they see a patient I think to a degree non-compliance can easily be expected.