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Why patients don't follow doctors' orders and what doctors could do about it
Health care providers are increasingly viewed as a valuable resource in the fight against America's obesity epidemic. But health experts said it will take more than doling out nutrition advice for doctors to make a difference. - photo by Kelsey Dallas
Medical students traded stethoscopes for skillets this spring in a course designed to make learning how to cook part of the path to becoming a doctor.

"Cooking skills are an incredible tool for any doctor in any specialty," said Dr. Geeta Maker-Clark, a clinical assistant professor and coordinator of integrative medical education at the University of Chicago who, together with Dr. Sonia Oyola, launched the culinary medicine program at the Pritzker School of Medicine. "They help you become a change agent for your patients."

Chicago's culinary medicine curriculum and similar programs at other schools are targeted, at least in part, at a rising obesity rate among U.S. adults, which increased from 25.5 percent in 2008 to 27.7 percent in 2014, according to Gallup. But this plan for doctors to use cooking skills to create a healthier population is challenged by one ever-present concern in the medical profession, health experts said: patients aren't that good at following doctor's orders.

Patient noncompliance, as researchers refer to this phenomenon, affects all medical specialties, leading to wasted resources, frustrated doctors and delayed healing. It's estimated that around 50 percent of patients treated for chronic disease fail to take medicine or follow dietary guidelines as prescribed, a study (paywall) on the success of high blood pressure treatments reported.

Chicago's kitchen training combats this noncompliance by helping doctors understand how challenging it can be for patients to master healthy recipes and cooking techniques. Maker-Clark keeps the curriculum focused on future patients and helping the budding chef-doctors envision how to help them succeed.

Danielle Ofri, a physician at Bellevue Hospital and associate professor of medicine at New York University School of Medicine, said this attention to patients' financial and emotional struggles pays off in big ways for doctors hoping to make a difference.

"You have to put yourself in a patient's shoes," she said. "You have to ask, 'If I really had to stop eating (the food) I loved, how hard would that be?'"

Why patients misbehave

Ofri learned to be compassionate to her patients' imperfections early in her career. At one point during her first few years of practice, she developed a tooth infection and was asked to take Amoxicillin three times each day.

"I couldn't get the middle dose in, and missed it more than half the time," she said. Her own inability to follow the doctor's orders humbled her, opening her eyes to how difficult it is to remember one medication, let alone five or 10.

At checkups, Ofri asks her patients to reflect on their limitations, discussing how their finances, family members and lifestyle will affect their ability to take prescriptions or follow a diet.

To successfully address the obesity rate with cooking advice, doctors have to be realistic about their patients' lives, as well as what the patients are open to trying, Ofri said. People who come in for a sore throat or skin rash may not be very receptive to unsolicited advice about their weight.

"Most people already know what they could be doing better. We assume (a weight problem) is caused by a lack of knowledge, but that's rarely the case. It's about job or financial pressures," she said.

The culinary medicine pilot program's 15 students were exposed to the roots of poor eating habits when they hosted a class for community members in Englewood, one of the city's most impoverished neighborhoods.

"It's a food desert. People explained the challenges they have" following a doctor's advice to eat more fresh foods or organic products, Maker-Clark said. Community members explained that the nearest market with fresh produce was miles away.

"They actually taught us more than we taught them," she said.

When doctors misunderstand

The path from advice about eating better to weight loss is complicated, and doctors make matters worse when they assume patients willfully disobey instructions, said Dr. Victor Montori, a professor of medicine at Mayo Clinic.

"It's fairly natural for people not to follow orders exactly as indicated," he said. "What's wrong is that we then (make these patients) feel guilty or label them as bad."

According to Montori, the relationship between doctors and patients has long been hindered by the fact that medical schools don't provide lessons on the compromises that have to be made when designing care plans.

"There is very little training on the part of the interaction with a patient in which you formulate a treatment plan together," he said. "Most health professionals think they can formulate a plan and then communicate it to the patient afterward."

As a result, patients leave the appointment unprepared for or uninterested in taking their doctor's advice, instead of empowered to take ownership of their health outcomes.

Doctors also fail their patients when they don't acknowledge how treatment will affect other aspects of a patient's life, said Carolyn Thomas, a heart attack survivor and advocate for women's health.

After her heart attack seven years ago, Thomas was stabilized and sent home with new prescriptions and strict dietary guidelines. And yet no one at the hospital asked her how she planned to implement these changes.

"When I left the hospital, nobody said, 'Do you have somebody at home to take care of you?' or 'Do you have anybody you need to take care of?,'" she noted, adding that care providers also seemed unconcerned with her plans to return to work, her ability to pay for her pills or her mental well-being.

To support healthy outcomes, "doctors need to look at the patient as a whole person who has a family and friends and a job they love, or even a job they hate," Thomas said. "The focus should be on what doctors know about us, not what we need to know from them."

From orders to openness

Montori specializes in the treatment of diabetes, which means he routinely discusses dieting with his patients.

His own experiences have made him skeptical of doctors' ability to impact obesity rates on a large scale, but he said gradual improvements could be made if doctors commit to understanding the realities of their patients' lives and acknowledge the many roles food plays.

First and foremost, food provides nutrition, fueling the body and mind. "But it also plays a social role, like when you go out with friends for pizza, and an emotional one, like when you're eating Ben & Jerry's ice cream" while you watch a favorite television show, Montori said.

He added, "To the extent that food has multiple jobs to do, advice about how to consume food has to account for all those jobs."

Similarly, Ofri said doctors have to be intentional with their approach, in order to keep patients motivated.

"I talk about the things healthy eating can prevent," such as a diabetes diagnosis, she said. "I ask patients about their children," motivating adults to eat better by reminding them that their habits rub off on kids.

Additionally, Ofri offers a list of potential paths to weight loss, allowing patients to choose the option that's most attainable.

"Maybe they'll watch the nightly news from the treadmill or take the stairs once a day. They know their lives and challenges better than I do," she said.

Besides introducing her to a tasty vegetable frittata recipe, Maker-Clark's interactions with the pilot program students taught her to hope for a healthier future in which doctors will work with their patients to find solutions instead of giving orders. She envisions her students discussing recipes with future patients, helping them alter ingredient lists to include a favorite veggie or element of their culture.

"If (patients) aren't following through with advice about food, doctors need to learn to give it in a different way," Maker-Clark said. "Most people are able to take small steps (to lost weight) and want to."