The Etiology of Denial

I can’t possibly be in denial

"I hear you stopped all your diabetes medications, Mrs. Woycik."¹

"Yes! I don’t need these pills. All I need to do is drink lots of water and go for a walk. My sugars come right down."

"You don't like taking the pills?"

"No, doctor, I don't like putting chemicals into my body if I don't need ‘em. And besides, I'm too healthy to have diabetes. I walked six miles yesterday. Nobody can have diabetes if they're strong like that."

"I see. And what was your sugar before you started walking yesterday?"

"It was pretty high, like 300, but it came down by the time I got home. It was 175, and you said 200 was fine. And I didn't need pills to do it. I thought you'd be proud of me for getting rid of my diabetes."

I could see that Mrs. Woycik was going to be a tough customer today. I needed to find a leverage point to address her denial. How I did that is a topic I’ll return to shortly. But first, I’ll fast forward to what happened right after Mrs. Woycick’s appointment.

As I exited the exam room after seeing Mrs. Woycik, my secretary went running by, crying, "Doctor, doctor, I have a pathologist on the line wanting to talk to a doctor, but it can't be you because it's about your labs."

And off she ran.

Meanwhile, my schedule was packed for the next few hours. I continued my day, treating patients until I had a no-show. Then, I went to find which of my colleagues had gotten stuck with the unfortunate task of speaking with the pathologist.

That day at the clinic would have unfolded very differently if three months prior I hadn't thought I could be my own doctor. I had felt unwell one day, so I ordered labs for myself. They came back abnormal. I knew the old chestnut, "the doctor who treats herself has a fool for a patient," so I reviewed the labs with a doctor friend, saying, "Whatever it was has passed. I already feel better. I'll do a recheck in a couple of weeks to ensure they’re back to normal."

My friend agreed that this was reasonable.

Well…. Except I didn’t actually show him the labs. I just told him about them, a bit selectively perhaps. And, well…. I had made it clear to him that he was not responsible for checking up on me to make sure I'd redone the labs, and how they came out.

In any case, he didn’t.

I was quite impressed with myself. I had not only managed to avoid being my own doctor, but I also avoided creating extra work for anyone else. How efficient!

My colleague who had taken the pathologist's call turned out to be a sweet, young woman fresh out of residency, who had joined our clinic a few months earlier. It turned out that she had a no-show at the same time and so was able to talk with me. As soon as she saw me, she burst into tears. "The pathologist thinks you have leukemia. Oh, I'm so sorry. We'll get you through this!"

I looked at her in shock. She was new to this job and could be excused for not understanding. She did not know that I was too busy to have leukemia. She did not understand that my patients were too sick and too complicated to just hand over to someone else. What was she thinking?

Meanwhile, the young doctor explained that I had an appointment for a bone marrow biopsy the next day and that she would be telling the office manager that I was going to be out of the office for a while.

I looked at her with pity. She would understand things better after she had been a doctor longer. "No, just tell her I'll be out tomorrow. I'm sure this is nothing. Let's not cause a lot of extra work for the secretaries."

I figured the fuss would all be over soon. In all likelihood, the lab tech had made a mistake, perhaps even mislabeled the vials. I would see the oncologist tomorrow and we’d have a good laugh over it.

Now, back to how I handled Mrs. Woycik’s denial about her diabetes.

I say to Mrs. Woycik, "I am proud of you for how you're really taking control of your health! I wish you could just do it all without the help of pills, but I don't think you can. I think your diabetes is too severe. You know, we want to treat your diabetes because the longer your body is exposed to high sugars, the more damage the sugars can do. If they do very much damage, it will be hard for you to take those six-mile walks."²

"But I don't want to take pills. They have side effects."

"I hear you there, Mrs. Woycik."

I didn't know it at the time, but in two days I'd be trying to convince my new hematologist that what looked like an obvious case of leukopenic acute myelogenous leukemia was really an extremely rare side effect of Claritin - based on my literature search in which I found a case report of idiopathic bone marrow suppression from Claritin similar to part of the picture my labs presented.

I ask Mrs. Woycik, "What side effects did the medicine give you?"

"It didn't give me any, but I read that sometimes it can make you have to go to the bathroom a lot. I'm too busy for that. I have to take care of my grandchildren every day after school. I gotta be there for my daughter so she can work!"

"Ah, and you're too busy for going to the bathroom a lot. I bet you're also too busy to have diabetes, aren't you?"

"Well, yes, if I had diabetes, I’d have to check my sugars all the time and have so many doctor's appointments, like my cousin did. I can go for a long walk in the morning when the kids are at school, and then I don't have to do all that other stuff while I'm taking care of them."

For a while we went back and forth like this. Eventually, we negotiated a plan that would disturb her life minimally and that I thought would keep her sugars under control. I wrapped things up with Mrs. Woycik and stepped out of the exam room.

Three days later, I was having chemo. I was fortunate enough to be able to return to practice after my treatment - thinner, balder, and less foolish.

Denial is normal. We know the negatives but don’t usually acknowledge the positives. It can be an affirmation of personal agency. Mrs. Woycik exercised her agency by taking up walking to reduce her blood sugar. She was proud of her accomplishment. Furthermore, her accomplishment enabled her to take care of her grandchildren, giving her life meaning.

If it is not the meaning of your life that is being challenged by bad news, it is easy to see denial as silly and unproductive. But when the bad news truly affects your life or its meaning, you may be surprised at how compelling arguments can be; and how they incentivize one to dismiss incoming inconvenient facts.

Mary Braun Bates, MD

is an internist at an FQHC in rural New Hampshire. Her Substack, Doctoring Unpacked, explains common medical conditions through entertaining fictionalized patient encounters.

1. Everything I say here about myself is true. Mrs. Woycik is an amalgam of patients who are in denial (including myself), and any resemblance to a real patient is accidental.

2. Nothing in this essay should be taken as personal medical advice, except perhaps don't order your own labs."

Photo Credit: Adam Cifu