Doctor's Orders

When Tiger Woods won the U.S. Open on Monday, he had many fans behind him--and his doctor against him. Woods, who was recovering from knee surgery, winced throughout the tournament, but kept playing despite his physician's concerns that he hadn't made a full comeback and might even worsen his condition by playing. On Wednesday, Woods has announced that he won't play again for the rest of the year as he undergoes surgery on a torn ligament in his left knee. "Now, it is clear that the right thing to do is to listen to my doctors, follow through with this surgery and focus my attention on rehabilitating my knee," he said in a statement on his Web site. NEWSWEEK's Tina Peng spoke to Carl E. Schneider, a professor of law and internal medicine at the University of Michigan and the author of "The Practice of Autonomy: Patients, Doctors, and Medical Decisions," about why patients often ignore their physicians' advice--and what doctors do to get around that. Excerpts:
 
NEWSWEEK: Tiger Woods said he'd gone against his doctor's advice by playing on his injury. How often do patients expressly ignore their physicians' advice?
They don't expressly ignore their doctors' advice very often, but they very often fail to follow their doctors' advice. About 50 percent of the people told to do something do not complete doing it or don't do it at all. For example, I just had a small eye procedure and they said, "Take steroid drops four times a day." For two days in a row I've taken them only three times in a row because I've forgotten. Lots of things doctors want you to do are trouble, a small nuisance or a larger nuisance. On the larger-nuisance side, for example, once you get past 50 your doctor will tell you to get a colonoscopy. Many of the people who are told to get one never quite manage to get around to it. Doctors call this noncompliance. The noncompliance rates are very high. The other thing is, we don't know how often people really ignore their doctor's advice, because one way they do it is just by not showing up. It's very hard for the doctor to know whether the patient has gone somewhere else, moved or just decided not to take the doctor's advice.
 
How frustrating is this for doctors?
It frustrates doctors a lot--what's the point of seeing somebody to help them get better if he refuses to do the thing he needs to do? There are lots of ways in which patients don't cooperate; some of the most important ones are lifestyle kinds of things, like not getting enough exercise and not losing weight. Doctors who have diabetic patients, for example, know that the patient would live a lot longer and much more healthily if the patient would get exercise, control your blood sugar, control your cholesterol, and patients won't do that, and that is very frustrating.
 
How strongly can doctors impress their advice on patients?
If you have a patient and you recommend that they get this test or that they get surgery, and the patient says, "Well, I don't think I feel like doing that," there is a wide range of possibilities for that doctor. One of them is to just say, "Do you understand why I think you should do this?" Because often the patient doesn't really grasp why this is such an important thing to do. Another standard approach is to say, "Why don't you want to do this?" And that may produce information, like the patient thinks it's too expensive and can't afford it, or the patient thinks it'll hurt when it may not, or the patient doesn't have any way of getting to the hospital he's being sent to, doesn't want to go out of town. Often it's some practical thing that can be dealt with. If the doctor thinks it's really important but the patient doesn't want to do it, the doctor can start putting psychological pressure on the patient, which doctors don't want to do casually. Because patients, after all, are the ones who have the legal authority to decide and generally have to live with the consequences. The theory of ethics is, patients make their own decisions and that's an end to it. In real life, when doctors are really worried about a patient, doctors, I think, regard it as the kind and helpful thing to do to try and persuade patients to take care of themselves. I know one doctor who had a patient who said, "Well, I can't come in because I have to stay to take care of my grandson." The doctor said, "Well, you know, if you're dead, you can't take care of your grandson."

If the Tiger Woods situation is what you would think it is, it's the kind of thing where the doctor would probably say something like, "Well, Tiger, I think it would be a mistake to play the U.S. Open because it could make your knee worse." And Tiger says, "But I really want to do this." And the doctor says, "Well, that's not really a medical decision. There's nothing in my technical knowledge that will help you decide this. This is a decision about what kind of risks you want to take in life."
 
Are celebrities and athletes more likely to ignore doctors' orders because of their status?
I don't know, it's easy to imagine that they would also feel more vulnerable: their whole livelihood and celebrity depends on being able to play. If I were Tiger Woods or Roger Federer--which would be very nice!--I'd be very nervous, would follow my doctors' advice very scrupulously, because people's careers have been cut short really badly by injuries. But in a team sport, you're under pressures that you aren't in an individual sport. It's assumed that football players play through pain and injury because they feel they owe it to their teammates, and the team, which is employing him, has reasons to want him to play. Tiger Woods is playing for himself, and Tiger Woods's need for money is very small. Among athletes, whether it's a team sport or an individual sport probably makes a big difference. 

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