Stella seems like a sensible woman. She has had two basal cells removed, so she comes regularly for me to check her sun-damaged skin.
About 4 years ago, I prevailed on Stella to let me examine her in full, something she had insisted wasn't necessary. I was almost done, when I looked under her bra and noticed something. Further inspection showed both her breasts completely covered with a deep-red, erosive rash. Taken aback, I asked her how long this had been there.
“Oh, about a month,” she said, indifferently.
Not terribly likely. Biopsy showed Paget's disease. She had this treated, along with the intraductal breast carcinoma beneath it. Stella continues to come once a year, and she still gives the impression of being level-headed and sensible.
But I have to ask myself: All that time (months? years?), whenever this sensible woman undressed or showered and saw her breasts, what was she thinking? That they were supposed to look that way? That what was staring her in the face really wasn't there?
I ask myself the same about Robert, an amiable if absent-minded professor with a bushy red beard. Underneath the hair on his left cheek he had a gaping, oozing hole. Who knows how long that had been there? Although his beard made this chasm—which turned out to be a huge basal cell—invisible to onlookers, Robert must surely have washed his face now and then. What was he thinking when he touched or saw this defect, which measured several centimeters in diameter by the time he showed up in my office? That oozing holes belong on the face?
Like Stella, Robert readily agreed to take care of his cancer. He follows up regularly, showing no sign of being delusional, or even much odder than the average professor.
Denial is indeed a powerful thing. It helps people ignore what is right before their eyes.
I can think back over the years to spectacular instances like those of Stella and Robert, patients who let visible cancers grow and fester for decades. Twenty years ago a patient phoned. “My wife is coming to see you,” he said, “and I want you to know in advance that we're aware we have a problem, and we're working on it.” I asked him what he was talking about. “We've been married 12 years,” he said, “and she's never taken off her shirt.”
His wife turned out to be a globetrotting business executive in her mid 30s. She showed me a basal cell that extended from her suprasternal notch to her left shoulder.
But there also have been many less dramatic examples of people who just couldn't be bothered to take care of things they knew they had to treat, or to follow up on what they agreed they ought to. Some claimed they were too busy, others were clearly afraid of bad news. So they looked at themselves with eyes wide shut.
The lesson I draw from behavior like this is that we can't simply assume our patients will act in their own best interests—that they will get a skin cancer removed because we told them they have one, or that they will come back regularly because they're at high risk. Beyond making a recommendation, we need to check whether they followed it and badger them if they haven't.
I sometimes shrug when experts—from economists to ethicists—describe people as rational actors who make sound decisions to advance their interests as long as they have the proper data with which to do so. I wonder which people they have in mind. They obviously can't mean Stella and Robert, and many other people I meet every day.