SCIENCE AND SOCIETY
On Denial JOSEPH E. HARDISON, enial
is the cornerstone of many a misdiagnosis. but refusing to see, hearing but refusing to hear, the physician creates his own pitfall that leads to his pratfall. Ignoring reality, he makes the diagnosis as he wishes it to be.
tenderness, hiatal hernia and hyperventilation flow freely from his b’allpoint pen. It is hoped that the next tour will be manned by the nighttime admitting room Sieve.
1. Atypical chest pain: There is an epidemic of atypical chest pain loose in the land. Nobody seems to know exactly what it is or how it differs from typical chest pain, but for those who wish to deny angina pectoris it is an easy diagnosis to make. 2. Chest wall pain: “This patient is complaining of severe chest pain with exertion. He is tender when I press this costochondral junction. You say he was found dead in bed last night? That must be very rare-1 have never heard of a patient dying of Tietze’ s syndrome.
6. The T.I.A.: “This patient was admitted with the diagnosis of an acute myocardial infarction. He doesn’t have a heart attack. His pain only lasted 10 minutes, was relieved by nitroglycerin and his EKG is unchanged. This is a Totally Inappropriate Admission!” “Yes, but what are you going to do about his hematocrit of l7?” The Reluctant Consultant: The patient is admitted to the Medical Service with sudden onset of abdominal pain. There is a previous history of duodenal ulcer disease. The abdomen is rigid and rebound tenderness is present. “I believe we can watch him a while on medicine,” says the surgery consultant. “His amylase is elevated and he may have pancreatitis.”
3. Hiatal hernia: Almost every patient and every problem list has one. This innocent cosmetic roentgenologic defect is conveniently placed to “explain” symptoms occurring either above or below the diaphragm. Hiatal hernia is said to be at least one of the causes of atypical chest pain. 4. Hyperventilation: Dyspnea, perioral and extremity numbness, and tingling are all that is needed to make the diagnosis of hyperventilation. Once this diagnosis is firmly in hand it is easy to explain other symptoms, including chest pain of all types. 6. The Rock: Denial is the armour and shield of the nighttime admitting room Rock. Atypical chest pain, chest wall
The Drunk: “There’ s nothing wrong with him, just drunk. He comes in all the time like that. When he sobers up, we’ll send him home. What do you mean you just checked him and he has a dilated pupil and a stiff neck?” “She’s not like a lot of 9. The Alcoholic: alcoholics. She says she hasn’t had anything to drink in three weeks and there’s just something about her that makes me believe her.” “You’re kidding? You say she thinks she’s in a hotel, got the shakes, and is seeing hairy bugs?” The physician’s denial of the
From the Veterans Administration Medical Center (Atlanta) Decatur, Georgia, and the Department of Medicine, Emory University School of Medicine, Atlanta. Georgia. Requests for reprints should be addressed to Dr. \oseph E. Hard&n, Veterans Administration Medical Center, 1670 Clairmont Road (Atlanta) , Decatur, Georgia 30033.
The American Journal of Medicine
alcoholic’ s denial is a common embarrassing mistake.
10. The Short Form:
“He’s just being admitted for cardiac cath. He’ll only be in for a couple of days so we can work him up on a short form. You say his hematocrit is 39 and his stool guaiac is positive? Those hemorrhoids probably caused the positive guaiac. Repeat his hematocrit tomorrow, maybe it’ll go up.”
I believe there is a nidus of truth in these hyperbolic examples of denial. We deny because we identify with some of our patients and are frustrated and angry with others. Those qualities which make us good physicians paradoxically cause us to use denial. Diagnosis is relatively easy but accepting responsibility is harder. With responsibility comes caring, and this is the hardest of all. We must be objective, and we cannot not care. It is easier to deny that we are needed at all. But care and worry we do although many of us may try to conceal and deny it.
The American Journal of Medicine