Inside every patient, there’s a poet trying to get out. My ideal doctor would ‘read’ my poetry. my literature.
– Anatole Broyard
"When did you first notice the sore?" I ask the newly diagnosed cancer patient. I was taught in medical school that a thorough history includes information on the "duration of symptoms." Over the years, I have been amazed how often the answer is: "Doc, I first noticed something about six weeks ago." Whether the cancer appeared large or small, completely confined or widely metastatic, barely symptomatic or agonizingly painful, the answer was frequently "six weeks."
Early in my career, I didn’t believe the "six weeks" response from patients with advanced disease, although it made sense when coming from patients with small cancers. However, after I noticed that the response was so common, I began to wonder why. Certainly, cancers can grow at different rates. Not every cancer behaves the same. Still, though, I suspected that denial was delaying evaluation and cancer care.
Danielle Ofri, MD, in her wonderful book of medical essays, Singular Intimacies: Becoming a Doctor at Bellevue (Beacon Press, Boston, 2003), tells the story of a prominent psychoanalyst with an unnamed cancer. Over the course of several months, the disease ravages his body and destroys his liver. Even with obvious signs of malignancy, he steadfastly refuses to admit even the possibility that he might have cancer. He is confident that he has a viral infection that will soon resolve. No need for a biopsy! No one can convince him otherwise.
Eventually, he becomes so debilitated that he has to be admitted, very reluctantly, to the hospital where he dies of the cancer and, perhaps, some of the zealous attempts to make a diagnosis. Suddenly, Dr. Ofri realizes that this intelligent psychiatrist had shrewdly used denial to his advantage. He had maintained control for as long as he possibly could. He had delayed the inevitable hospitalization and medical interventions until he was finally completely unable to resist.
There are a host of reasons that people deny things that seem perfectly obvious to others. Perhaps the person has a debilitating fear of medical care, a lack of insight, legitimate concerns about devastating medical costs, or a strongly held system of alternative beliefs.
Until reading Dr. Ofri’s story, though, I had not understood how powerfully denial could also allow the patient to maintain a sense of control over their situation for as long as possible.
For some, the decision to relinquish that control marks the end of denial. They finally admit that their symptoms — the pain, the mass, the bleeding — might represent something bad. They realize that it is time to reach out for help even if they would rather not. Now, six weeks later, they sit unhappily in my office getting ready to find out if their symptoms represent the very thing that they dread the most.
The following is feedback received for this blog:
having worked in ICU for 32 years, denial is huge. It is a good and bad thing. When an alcoholic denies, we know that ruins his life and others around him/her.
Denial does keep people from seeking help sooner, probably based in repressed fear and hope that "it will go away". It also does keep people in control and able to function, fight or carry on in difficult situations.
- Cheryl Scheuerman