Denial and the Imponderable Differences

David Foster Wallace Infinite Jest” Page 604

…people of a certain age and level of like life-experience believe they’re immortal: …they deep-down believe they’re exempt from the laws of physics … And they’re constitutionally unable to learn from anybody else’s experience: if some jaywalking B.U. student does get splattered on Comm. or some House resident does get his car towed at 0500, your other student’s or addict’s response to this will be to ponder just what imponderable difference makes it possible for that other guy to get splattered or towed and not him, the ponderer.  They never doubt the difference – they just ponder it.  ….

During the first year of medical school most of us transform from care-free college students into anxious hypochondriacs.  While we are busy cramming for tests, we can’t help but notice that many devastating diseases present with common symptoms that we previously thought innocuous.  That cough you thought might be just a cold? Well, it could be the first sign of lung cancer.  Headache? Brain tumor.  Nausea and vomiting? Stomach ulcer.

We spent a lot of that  year, indeed the first few years, of medical school learning how to discern the probable from the possible.  And with that, we also learned how to distance ourselves from these possibilities.  In embryology, we learned about the various ways in which development can fail:  all the mistakes our cells make, however rare, that may lead to anomalies.  A friend voiced what many of us were thinking:  “Each of these sounds rare,” she said, “but there are so many of them, that it seems the chance of having at least one are pretty high! How does anyone ever have a healthy baby?”  And so, over the following several years we evolved from anxious hypochondriacs to full fledged denialists.

No, the 55 year-old man who was fine until he got pneumonia and is now in septic shock on life support says nothing about what dark possibilities might lurk for us or our 55 year-old relatives and friends.  Why? Well, he is diabetic, or he smoked, or he didn’t go to the doctor on time, or he has blond hair.  We ponder for ever elusive clues as to what the imponderable difference is between this man and us.  This denial is somewhat specific to the problems our patients have, whom we could not care for effectively if we were internally preoccupied with our own mortality.

I’m reminded of this every time I take sign-out from my neurological colleagues.  Their list of patients contains stories of people young and old who were fine, and then one day had a stroke, a ruptured aneurism that bled into their brain, or a seizure, and now these patients are doing “well” because they can move both arms, or say one-word sentences.  The neurologists, no doubt, have developed their own denials about why these unfortunate events cannot befall them, else how could they function effectively in their jobs taking care of people with these ailments?

These defense mechanisms are, in part, why we make such terrible doctors to our friends and family.  We tend to fall in two categories.  We either readily dismiss their symptoms because we couldn’t possibly contemplate that something serious may be underlying that cough.  Or we overreact and insist upon more evaluation because only definitive tests for every horrible possibility, however remote, would serve to reassure us.  When it comes to our children, too, we can be a mixture of paranoia and neglect.  The adult daughter of a famous infectious disease expert shared that growing up she and her siblings never got antibiotics.  Ice and tape, she told me, were the remedies for everything.

A physician told me that after a young patient dies, he usually observes some period of time on rounds where the healthcare team may talk about it.  Why only young, you may wonder, and the answer is:  for most diseases age is a risk factor and most of the people we see are old.  We accept this difference as an explanation for why something bad couldn’t possibly happen to us.  It happened to our patient because he is old, and we define “old” as someone who is older than us.  Occasionally, someone reminds us of ourselves – this young person was previously healthy, went to work every day, had family, and yet, this catastrophe befell them.  It is this stark reminder of our own mortality in the face of illness that catches us.  So we pause to ponder the imponderable differences between us and them, and then we go on to care for the next patient.

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