Strong, stoic -- and beyond saving

A close friend of mine, also a physician, called late one day a few months ago and quickly got to the point. He wanted me to take over care of his father-in-law.

The 80-year-old was in the hospital after a failed balloon attempt to open the main artery that supplied blood and oxygen to his right kidney. His kidney function was deteriorating, and dialysis seemed likely, but he was now refusing all treatment and had fired his kidney doctor. My friend had contacted a new kidney expert, but he too was suggesting dialysis, and the father-in-law was on the verge of firing him as well.

After what I’d heard, I was wary. But when I arrived at the bedside, I was surprised at how easy it seemed to be for us to establish a rapport.

The father-in-law was a thin, tall man with a quick handshake, and his wife -- who immediately smiled when she saw me -- was sitting faithfully by his side. “We’ve heard so much about you,” she said. “We’re so glad you’re here.” The father-in-law smiled too. I knew better than to discuss dialysis, but in looking over the medical record, I saw that he had a fever and that his white blood count was elevated. My friend had warned me not to offer new treatments, but I feared a kidney infection and -- gambling on our seeming instant rapport -- suggested an antibiotic. The couple nodded and told me they would consider it.

But the next morning, my friend told me he had received a call in the middle of the night from his mother-in-law. She said her husband wanted no more pills and was on the verge of checking out of the hospital.

“He’s a stubborn skeptic,” my friend said to me. “He doesn’t believe in medicines. And he won’t follow any suggestion he doesn’t think of himself.”

My new patient hadn’t said anything about firing me from the case, but my friend warned me that if I mentioned either additional medications or dialysis, that was sure to be the end.

“But I’m not sure why you would want to be on this case any more,” he said. “I feel bad that I asked you. The guy’s impossible.”

My friend told me that everyone -- his father-in-law’s wife and children -- followed his pronouncements because he was the head of the family. His children had been raised to go along with whatever he said, no matter how unreasonable.

When I went to visit the next day, the father-in-law was just as polite as before. Still, I had learned my lesson and didn’t refer directly to either his fever or his kidney function. I did my best to reassure him, but only because I still hoped that by deepening our rapport I could eventually have a positive effect on his health.

Nonetheless, that same day, the father-in-law stormed out of the hospital “against medical advice” when the surgeons and the new kidney expert again mentioned the possibility of dialysis.

I called him at home the next day as a courtesy to my friend, although I suspected that the man probably didn’t want me to continue as his doctor. I was right -- again he was polite, but he asserted he was fine and didn’t need any doctors. As he rushed me off the phone, I marveled to myself that -- although the night before he had been on the verge of dialysis and no doubt still was -- his denial seemed almost palpable.

Somehow, he continued to do well for several weeks after this, against all expectations, until the day he was admitted to a hospital near his home in Brooklyn for a blood clot in his lungs. He was soon refusing treatment there, and my friend predicted he wouldn’t stay with these doctors for very long either.

This refusal to accept medical treatment wasn’t an isolated case. I have treated hundreds of stubborn, recalcitrant patients, most of them men, who deny that they are ill.

My friend’s wife, a psychotherapist, said she believed her father challenged all authority. “He’s in denial,” she said. “He doesn’t like to admit weakness. ... He has the mentality that as long as he doesn’t acknowledge the problem, then it doesn’t exist.”

I understood that her father was deathly afraid of both illness and its doctors. He saw each phase in his illness, each additional pill or treatment, as a threat to his strength, to his invincibility. “He’s the patriarch,” she said.

This astute analysis applies to many of my male patients, who either decline to discuss -- or can’t acknowledge -- their symptoms, as if any disclosure of illness is an automatic admission of weakness. As studies have shown, men as a rule are much less likely than women to seek out medical attention and much more inclined to live in denial of their symptoms. This poor approach to maintaining health is dangerous enough, but it’s reinforced by a traditional family structure in which no one dares to question the patriarch.

Somehow the father-in-law continued to live on, but many don’t.

Just this month he has finally agreed -- in a state of near delirium from his kidney poisons -- to dialysis. When I had tried to break through his well-established macho structure to help him before he reached such a desperate point, it only created more anxiety and distance. He was afraid of becoming frail and dependent because this would negate his established role as his family’s protector. In the end, there was little I could do beyond remaining cordial. This kind of pride and so-called male strength, when a man sets himself up as a quiet unemotional rock who doesn’t need anyone’s help and can’t admit weakness, can be very destructive when it comes to his health.

Too many patriarchs have tenaciously held on to these rigid roles right up until a bitter end.

Dr. Marc Siegel is an internist and an associate professor of medicine at New York University’s School of Medicine. He is also the author of “False Alarm: The Truth About the Epidemic of Fear.” He can be reached at marc@doctor siegel.com.