There’s a bottle in the back of your cupboard that’s still half full of a supplement you stopped taking.
Maybe several. There’s the one from the podcast advertisement—a first person endorsement from the clinician you follow and listen to. Then there’s the ones the practitioner sequenced into weeks three through twelve of the program you subscribed to but abandoned in week six. And the one you ordered because a friend said it changed everything for her libido, belly fat, brain fog, or whatever’s been nagging at you.
Or maybe it was a statin. Or an acid blocking medication. Something your doctor prescribed in a seven-minute appointment where you didn’t get to say the sentence you’d rehearsed in the parking lot. You filled the prescription dutifully, and you took it for three weeks. Then the bottle moved to the back of the medicine cabinet because the reasons you were given didn’t register, or you didn’t feel any difference, and you didn’t know enough to ask better questions in the time you were given.
You took each of them religiously for a little while. Then you didn’t.
But it isn’t only the pills.
Maybe the thing that didn’t last was the elimination diet you followed for four weeks and quit in the fifth. Twenty-two foods removed, some of them for reasons nobody explained, the list arriving with a confidence that made questioning it feel subversive. Two eliminations piled on top of one another for natural chemicals that you’ve been told your body has a hard time processing, but you don’t fully understand why. Everybody else you know seems to be fine with these same foods—spinach, almonds, tomatoes, the things that someone else deemed as wholesome last year. What this “revolutionary” restriction required was reading every label, explaining yourself at every dinner, and cooking twice on nights when your family ate something else while you still navigated the same symptoms that led you here.
Or maybe you filled out a quiz online—twenty questions, ten minutes—and a protocol arrived in your inbox before you even closed the tab, your name at the top, everything seemingly tailored to “your unique needs.” Eleven action items. Morning light within thirty minutes of waking. Twenty minutes of zone two cardio, five days a week. Ten thousand steps. A wind-down routine beginning ninety minutes before bed. Bluelight glasses and a powdered concoction to choke down in exactly 6 ounces of water, specifically formulated to reflect your challenges. It arrived in an impressive box. You did some of it, for a while.
You have an explanation for why you stopped each thing recommended to you. And yet, in the back of your mind, there’s something hovering, and it probably involves the word should. I want to tell you what the word should is doing there, and who put it there, because I was one of those people.
Allow me to take you behind the scenes and be frank about a conversation that was happening on the other side of your decision making—a conversation amongst the folks writing the prescriptions and making the recommendations that have become your shoulds.
For nearly two decades I trained practitioners—thousands of them, across dozens of countries. And in the workshops and the message board forums and the Q&A after the lectures, they asked me a version of the same question, over and over.
How do I get my clients to comply?
They meant you. How do they get you to do what they want and have deemed necessary.
The question arrived in every register. Sometimes as logistics—what do you do when they won’t stay on the protocol? Sometimes as exhaustion, late at night on a forum thread, from someone who had built a careful plan and watched it go untouched. Sometimes as something closer to despair, from a clinician who believed she could see exactly what was wrong and couldn’t get the person to move. And sometimes with an edge: she’s just not motivated. She doesn’t want it badly enough. I’ve given her everything she needs.
There was no ill-will or malice in their inquiry. They were confused by the client who agreed and then didn’t do the thing. The bottles still in the cupboard, half full or unopened. The checklist from the last appointment, blank at the next one. They were asking because they believed in what they’d recommended and were watching their best intentions and hard earned knowledge go to waste.
What I recognize now, nearly a year away from that work, is that not one of us found the compliance question as strange or problematic as it actually is.
Not the practitioners who asked it. And not me.
I wish now that I had stopped the conversation. Not to correct anyone, but to look at the word and what it was implying.
Compliance is what we ask of a child or a subordinate. The word carries its own hierarchy—someone sets the terms, someone else meets them, and only one of those people is being evaluated.
What changed in my field is only the vocabulary. We said: partnership. We said: root causes. We said: tell me your story. And then we asked, in the room where no patient could hear us, how to get her to do what we’d decided was right—how to get her to comply.
I could have said: Notice what we just called this. Notice that we’re asking how to produce conduct from a woman who isn’t here to participate in the conversation. Notice that we’re using a punitive word that implies a paternalistic perspective that sits contrary to our ideals and otherwise chosen vocabulary.
I didn’t say those things.
For two decades I answered the question as posed, and I still believe I answered it well. But in answering it well, I also kept anyone from asking whether it was the right question to ask in the first place.
Wishing aside, I didn’t actually answer the compliance question the way it was asked.
Let’s not ask how to create compliance, I said. Let’s turn the lens around.
If she isn’t doing the thing, that’s information about the recommendation, not about her. Does she understand what you asked for, or did she nod because you were talking? Does it fit inside an actual Tuesday afternoon for her—her job, family, kitchen, budget? Did she agree just to please you?
And then I’d suggest they go even further. Ask what she’s truly after. Not the clinical marker—but the thing underneath it. Not two solid bowel movements a day, or lower thyroid antibodies, but the energy to keep up with her grandkids, the strength to play tennis again. Connect the recommendation to what she wants, in her own words, and you won’t need compliance at all.
We called it the motivating factor.
And I meant it. I still mean it. Mostly. Asking what you want gives you something real—the rare experience of being consulted about your own life and what sparks you. And it gives your practitioner something too: a way to make the plan feel more aligned, more like yours. Practitioners who took it seriously got further with people. Being asked what you want is more than most people get in a health or medical encounter. I had watched a room full of residents discuss my husband’s sutures after brain surgery and never once ask him what he was hoping for in his healing.
But as I explore female aging, I’m humbled by what I also left unexamined in my answers.
My reframe was more compassionate than the original question, but it was also the same shape. It was merely a more sophisticated way to get you to do the thing.
The plan was still the plan, and it still belonged to the practitioner. You—the patient—were still expected to follow it. And the motivating factor—the grandkids, the tennis court—was the vehicle we used to get you there. We were exploring the mode of transport, not the route or the destination. Those were already determined. The plan itself was never touched. It was the trusted given.
Nobody in that room, including me, asked whether your body could use the recommendation. And nobody asked what it costs to keep adding tasks to a woman’s growing to-do list who has been told, for years, that the next thing is the one that will finally give her what she’s been seeking.
This isn’t a retraction of my teaching. It’s a closer reading of the underlying problem, and a transparent telling.
I want to stay with this for a minute, because the language matters and the language is everywhere.
Empowered. Take charge of your health. Become your own advocate. You know your body best. Every one of those is on a sales page somewhere right now, and every one of them is describing something undeniable that women were denied for a very long time.
They’re also describing a transfer.
The recommendation doesn’t change. The judgment about what your body requires doesn’t change. What changes is who’s holding the should.
Because you were asked what you wanted, and the plan was connected to your answer, the plan now feels like yours. You wanted the energy for the grandkids. The protocol is how you get there. Nobody imposed anything. Which makes it more durable, and much harder to set down. It was your concession, after all. Now, when it doesn’t work out, you can’t locate the problem in the recommendation. You didn’t finish it, so it was never tested. Only you were.
You chose this. You said it was what you wanted. There’s nobody left to disagree with.
So when the bottle goes to the back of the cabinet, the explanation is that the only one at fault is you: you should have taken it, and you’re the one who’s wrong for not doing so.
You write your own chart note. Not in those words, and not on paper. But your inner dialogue says: I never stick with anything. I always do this. I get excited and then I drop it. I know what I should do, I just don’t do it.
Same judgment. Now in your own voice, where it can’t be appealed.
I wrote, in a piece that’s still on the internet with my name on it: no more need for compliance. But I hadn’t actually eliminated compliance. I’d eliminated the practitioner’s need to manufacture it. The expectation to follow along still happened. It just stopped feeling like following and became the client’s own should.
And the word we used for that transfer of responsibility was empowered.
Your client becomes empowered with the tools to help herself feel better. My sentence. And I believed it. In that sentence, empowerment means: she follows your instructions willingly.
I read those words again recently. I was proud when I wrote them, and I can still see why. It was the most humane version available for something I hadn’t yet thought to question.
Compliance is not a wellness word. It’s clinical.
It goes in your chart.
Non-compliant patient is an actual notation with real consequences—it changes how the next clinician considers you before you’ve said anything. Your adherence rates are measured, published, and treated as outcomes. There is no matching entry for the practitioner whose recommendation didn’t fit the life it was given to. Nobody charts that.
Patients who didn’t follow instructions have always been called something. In the early 1900s, tuberculosis patients who ignored medical advice were described as ignorant and vicious— language that carried a good deal of contemporary resentment toward poor immigrants, the patients most likely to have the disease. After the war, patients who balked at the new curative antibiotics were recalcitrant, and there was clinical literature on managing them.
Non-compliant was meant to be an improvement on that language. Measurable instead of moral. A description rather than a judgment.
It’s also newer than it sounds. The term was formalized through a workshop held at McMaster University Medical Centre in the early 1970s, and through two volumes that came out of it: David Sackett and Brian Haynes’s Compliance with Therapeutic Regimens in 1976, and Compliance in Health Care in 1979. Sackett and Haynes had been studying why hypertension patients’ blood pressure didn’t respond the way the drug trials predicted.
Hypertension is asymptomatic. Chronic. Treated indefinitely.
The patient typically feels nothing, perceives no benefit, and is asked to take a pill every day for decades without supervision. Nothing in acute medicine echoed that shape. Compliance became a research object at the exact moment treatment stopped being a critical event and became a persistent condition of daily life.
The fields of Functional, Integrative, and Preventive Medicine—and especially Nutrition—are rarely acute. They may be indefinite, self-administered, autonomous. They are felt, if at all, only in aggregate. Protocols measured in months and years, as a constellation of factors rather than a single intervention.
These fields inherited the compliance problem because it is structurally identical to chronic disease management. We didn’t adopt the word by accident. We borrowed it because we were doing the same shape of work, and the word seemed to fit.
Sackett and Haynes’s definition, which still predominates, is this: the extent to which the patient’s behavior—taking medications, following diets, executing other lifestyle changes—coincides with medical advice.
Read that twice.
The patient’s behavior is the variable.
The advice is the constant. And it’s unquestionable.
The definition provides an equation with only one term permitted to move.
The word was intended to be neutral. But neutral for whom?
And what the word inherited was much older than 1976. Women had long been given instruction by people who examined them briefly and “knew better.” What was new was the measurement—a term for whether she’d done what she was told, a rate at which she did it, a notation when she didn’t.
It then took less than a decade for that equation to become a sales pitch.
From the mid-1970s onward, drug advertisements in American medical journals promised that a particular product’s simpler dosing schedule or gentler side-effect profile would improve patient compliance. The word was barely old enough to be standard before it was a reason to switch prescriptions.
That’s worth digesting. Once you name a problem as the patient failing to follow the plan, you have created a market—and every solution sold into that market is another product. What’s not on offer is a longer appointment, a different plan, or a question about whether the plan was right to begin with. What’s on offer is only a better-tolerated version of the same instruction.
What’s rarely measured beside those compliance rates is whether the thing you were supposed to stick with was right for your body and your life in the first place.
In the first decades of that research, hundreds of variables were studied to predict who complies and who doesn’t. But if you stopped because the protocol made you feel worse, or because you didn’t feel anything you were told you would feel, or because the recommendation was too much on top of everything else you were already doing, that doesn’t appear in the data as information. That appears as attrition. Your non-compliance.
Your body filed a report. But there was no category for it except failure, since you didn’t follow the instructions given to you. You didn’t do what you should. The bottle in your cupboard isn’t evidence that you didn’t follow through. It might be evidence that something in you had already read the situation correctly.
By the time I was writing, medicine had already renamed compliance twice. Adherence arrived in the nineties, on the reasoning that compliance implied obedience while adherence implied agreement. Concordance came out of Britain around the same time, meant to describe the appointment as a negotiation between two people who each knew something rather than as a set of instructions and a rate of follow-through.
Both were reforms. Both were argued for by people who found the word compliance demeaning. And yet adherence rates are still calculated exactly the way compliance rates were—the degree to which the patient’s behavior coincides with medical advice. Concordance didn’t survive the trip to the clinic. You can’t chart it, and it’s hard to build a quality metric around a word most people might associate with a kind of grape.
So the sequence goes: find the word that sounds like submission, replace it with one that sounds like partnership, but keep measuring the same thing.
I did the reconfiguring in a different room, on my own, without knowing anyone had tried to do it before. And yet the impulse was still to find a better word, or a different method. It was never to ask what the word was measuring. That’s what an established frame does—it makes some improvements obvious and others invisible. The ones it hides are always the ones that would cost something.
In 1988—when I was still in college—a medical anthropologist named James Trostle looked at the compliance literature. By then there were four thousand papers, and still no reliable account of who complies or why. He proposed that the inconclusiveness was the tell. He argued that compliance was best understood not as a behavior to be measured but as “an ideology that assumes and justifies physician authority.”
And that’s what I’ve been contemplating—not that I got it wrong a decade or so ago, but that I got it as right as the frame allowed, but never fully questioned the frame.
If you’re somewhere between fifty and eighty, you may have been raised in a house where because I said so was a complete answer. It was for me. I can remember my dad saying it again and again until I mustered the skill and the courage to appeal the ruling. You may have been raised in a culture where the doctor knows best was not a slogan but a description of how things worked. You were measured before you had language to refuse—by the mirror, the scale, the dress size, the report card. You learned early and thoroughly that being good was something other people weighed, and that the assessment was never yours to make. The should was in the house before you were.
Then the rules changed. Not at the beginning, when you might have learned differently, but in the middle—after the deferring was already automatic.
Now the woman who doesn’t research her own hormones is passive. Uninformed. Not advocating for herself. And the woman who does arrives with printouts and gets called difficult, or anxious, or told she’s been reading too much.
We are a generation of women who were expected to submit to our superiors and stand up for ourselves. And we are graded on both.
Our mothers weren’t raised to question. Our daughters were expected to. We’re the hinge.
Recently I told my mother I was thinking of leaving a professional relationship. She was quiet, and then she asked whether there was a way to make it work that kept everyone happy. She wanted my happiness, of course, but she also didn’t want anyone else to be uncomfortable. She wanted a better way. And she meant for them.
I think she meant: is there a way to not disrupt.
At twenty I’d have heard that as a door closing and gone straight through it anyway. I’d have pushed back, argued, determined to get her to understand my perspective. At sixty I heard what it was: the question of a woman who learned early that the cost of an unhappy room is charged to whoever made it unhappy. She wasn’t trying to manage me. She was managing something she had been saddled with as a girl.
So I asked her what she was hoping to maintain or save.
I’m not going to tell you she had a ready answer. She’s eighty-seven, and I wasn’t trying to win anything. But I’ve thought about that question every day since, because it’s the one underneath all of this. Compliance always protects something, and it’s rarely the person complying.
What I’ve been circling lately is that the compliance never ended. It just changed hands.
Father, then doctor. Then the mirror, then the diet. Then—and this is the one I helped build—a marketplace that gave you the panel, the protocol, and the tracker, so you could (and should) administer the regime yourself.
And that marketplace has a stake in whether you keep going that the doctor never had. A program with twelve weeks of sequenced supplements is a twelve-week purchase. The woman who follows it buys the sequence. The woman who stops at week three buys a fifth of it. Nobody in those workshops or Q&As was thinking about revenue when they asked me how to get her to comply. But the incentive doesn’t require anyone to be thinking about it. It just sits underneath, subtly aligned with the answer everyone wanted.
Each handover looked like progress. And maybe it was in some ways.
But each step forward left one rule intact because we didn’t question it: your body is a project requiring correction, and someone else is qualified to say what the correction is.
Before I go further, a caution. The risk in a piece like this one is that it reads as permission. Some of what you stopped, you needed. The vitamin D or blood pressure medication you never felt working may have been doing an important job. The not feeling is what makes it hard to take, and it’s the exact problem Sackett was studying when the word compliance was coined. Thyroid replacement isn’t always optional. I take it, even though I can’t register its effects in the same way I do a dance class, a cup of coffee, or a great conversation with a friend.
What I’m describing is not a case for stopping. It’s a case for the conversation that should have happened before you did, and the one that should happen now, with someone who has time to ask why.
I don’t have this fully worked out, which is why I’m writing it here, for our collective consideration and discussion.
But the question I’m carrying is this one:
What if your non-compliance was evidence?
Not defiance. You didn’t refuse. You said yes in the room and meant it, and then the thing didn’t happen. That’s a different event, and it’s the one that shows up in the chart with a word attached to it.
And not distrust of medicine—I’ve watched medicine do things nothing else could do, and I write about that too.
This is something narrower and stranger than either.
Consider what would have to be true for a woman to agree to a plan in good faith and then not carry it out. Something in the plan didn’t fit a life the plan didn’t ask about. Or her body was in a state that couldn’t use what she was given, and some part of her registered that before any of us did. Or the thing she wanted was never the thing on the page, and the conversation never got there.
Every one of those is information. Not about her character. About the fit between a recommendation and a person.
We had a word for it and the word closed the inquiry. Non-compliant is an answer, and it arrives so quickly that nobody has to ask what the behavior was reporting.
So here’s what I’d offer instead of a conclusion and instead of another should.
Think of one thing you agreed to and didn’t do. Don’t explain it, and don’t defend it. Just ask yourself what the not doing might have known.
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