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

This question was what drove me to graduate school for a Master's in Public Health 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:

3 year 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 Frappucino, 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.

In my next post, I'll talk a little about some of the more specific constructs, or ways of thinking about health attitudes and beliefs, in HBT.  Identifying which one is at play with your patient may just help you both achieve a better outcome.

* And they do taste good.  The manufacturers of these beverages know exactly what they're doing.  Soda pop is very inexpensive to produce, so it can be sold for a huge profit margin while still keeping prices affordable.  High profit margin, tasty product = big bucks for these companies.  Sugared beverages are so ubiquitous and socially acceptable that it's hard for me to imagine how anyone is able to resist them.