Why Patients Don't Follow Doctors' Orders.

     We often say in a "PC" way  that a patient who refuses to take medicines as  precribed by a doctor is "Pharmacologically Autonomous", but that does not get to the heart of the problem of restoring him/her to health. It is often stated that if patients were better educated about the nature of their (chronic) disease, or their treatment, then compliance would increase, and we would have a healthier society. Nothing that I have seen in over 35 years of practice substantiates that belief:

     1) When I am attending and I poll the medical students and residents, fewer than 50% of them have consistently taken the full course of antibiotics (e.g. 10 days for a strep throat) that was prescribed for them. If patients who are in the medical system and presumably have the most complete understanding of their disease and treatment are not compliant, why should be expect that non-doctors would react any differently? (I won't even mention the large numbers of chest surgeons who operated on lung cancer patients and still smoked cigarettes.)

     2) Most patients believe, either consciously or subconsciously,  that the less medicine they take the less sick they are. That is precisely why although we know than penicillin will cure a strep throat in 7 days we prescribe a 10 day course of the antibiotic. Many patients will stop as soon as they feel better. In fact, a study done about 20 years ago at Columbia's Vanderbilt Clinic demonstrated, by having the mothers bring in the bottle of penicillin at the next clinic visit, that fewer than 80% of them completed the indicated course for their children.

     3) Over the years I have told many diabetic patients that if they lose a certain # of pounds they can recover their normal insulin-glucose axis, and no longer be diabetic. The believe it, but even with support, going to a nutritionist, or going weekly to a diabetic clinic, none of them can achieve and sustain a weight loss. The only method demonstrated to cause sustained weight loss and thus  reverse diabetes is stomach banding or stomach bypass surgery. This is at least 90% successful. And remember that stomach banding does not permanently change a patient's eating habits, but only the amount that can be consumed at a single sitting and within one hour's time. Occasionally, when stomach bypass surgery had to be reversed because of developing liver failure, the patient would put back on the 50 or 100 pounds that was lost.

     4) The only patients who consistently lose weight (besides anorectics, bulemics and purgers) are some overweight men after their first heart attack. This makes instant believers of them of the health benefits of weight loss. Many of them eat so much fish that I have to check their blood mercury levels every six month.

     5) It isn't that patients don't KNOW about healthier actions, they just don't act on their knowledge. Some of this may be wishful thinking, some may be people's refusal to acknowledge their own mortality (Freud stated that it is impossible for the ego to envision its own non-existence), and some is due to the fact that we evolved by reacting to immediate dangers, and not to those postulated to be off in the distant future. Many if not all smokers know that smoking is dangerous (when we were teen-agers we called them "coffin nails") but no one believes that the cigarette they are smoking at this present moment will kill them.

     6) People know from experience how much better they feel after exercising, no matter how tired they thought they were, yet once they get out of the habit, it is very difficult for them to get back into the exercise rhythm. I woke up one day in my dorm room and said to myself "I'm not smoking any more cigarettes", and to this day I have no idea why I stopped. People know they should use seat belts when driving, but the knowledge alone was not sufficient----but when the state started giving out tickets for non-compliance the rate of seat-belting went up sharply.

     7) Some overweight people decide one morning to go on a diet, start eating less, and lose weight. But none of them (usually) can tell you why they made the decision that particular A.M. rather than one week or one month or one year previously. The first time a man goes from a size 36 to size 38 belt, or a woman from a size 6 to a size 8 dress, it is obvious to each and every one of them that they have gained at least 10 pounds, but almost none of them decides immediately to lose the weight. We know from various experiments in big-city schools that if you offer students money to improve their grades, many of them will get higher grades. Perhaps the state should give every citizen $10 for each pound that is taken off and kept off for one year. I bet we would see a lot of weight loss!

     8) And let us not forget individual health belief systems. Some people feel that vaccines are dangerous and unnecessary, some people refuse to get  mammograms or colonoscopies, some people have unprotected sex,
some people don't believe in sleeping pills, some don't believe in anti-depressants, some believe a daily bowel movement is necessary for good health, and so on. Some patients may be covered by their spouse's drug plan, but  need to be on a drug that the spouse does not "believe" in, so they purchase the prescription with their own money and hide the bottle.  Some of my diabetic patients will only take pills for their elevated glucose and absolutely refuse to take insulin-----so long as they don't take insulin they can tell themselves that they are not truly diabetics, but only have a "sugar problem".

     9) In summary, many people know what is "good" for them, so to speak, but refuse to act on their knowledge. Thus we have dead jaywalkers, drunken driving accidents, people who drown while swimming alone, campers who get mauled by a bear while trying to feed it, and people who get severely hung over more than once or twice. No one likes being told what to do, even if it is "for their own good". So all recommendations of prescriptions, actions and tests by a doctor to his/her patients is really a series of negotiations, because you first have to talk to the patient long enough to understand his/her model of disease and treatment, or else none of your recommendations will be followed.