Boxes

No one likes being put in a box. We hate labels, and we fight having them applied to us. I recently saw a patient with adenomyosis. She initially presented with heavy vaginal bleeding and was treated by one of my colleagues with a 6-day taper of combination oral contraceptive pills. Her bleeding stopped while on the pills, but as soon as she stopped taking them, the bleeding returned. She wanted to be treated long-term with combination birth control pills.

She was over 40, hypertensive, hyperlipidemic, and she smoked cigarettes. I talked to my attending, and we found ourselves at an impasse. In my attending’s eyes, anyone who has smoked one cigarette in the past 12 months is a smoker, and if over 35 should not be offered oral contraceptives.

The patient described her smoking as a cigarette when she gets very upset. She refused to say just how often that happens, but the closest estimate that I got was once a week. When I told her that I wasn’t comfortable giving her birth control pills because she is “a smoker,” the patient was livid.  “But I’m not a smoker,” she kept saying. “I just have a cigarette sometimes, when I’m really upset.” To her, even one cigarette a week didn’t make her a smoker. She was angry and insulted to be put in that box.

This made the rest of the conversation, about the risks of long-term estrogen-containing products for smokers over age 35, even more difficult. She didn’t see herself as a smoker, so when I tried to explain that I didn’t want to give her long-term combination oral contraceptives because I didn’t want her to have a stroke, she just kept saying “But I’m not a smoker.”

How do you get past this? How do you convince a patient that she falls into a category that she doesn’t think she fits in? The same thing happens when you call a patient “obese” who just thinks of herself as “a little bit heavy,” or when you tell a patient who says “I’ve been having trouble getting pregnant” that she is “infertile.”

Sometimes people can get past the labels easily, especially if there is relatively little societal stigma attached to that particular label. My patients don’t really mind being told they have polycystic ovarian syndrome (PCOS), for example. No one they know has ever heard of PCOS, and they already knew that they had acne and hair on their chin. The more stigma is attached to a label, or the more a patient has worked to redefine herself apart from the characteristic you are labeling, the more they fight being put into that box.

So how do you get around this? Would my smoker have been happier if I hadn’t called her a smoker? I tried to just say that, based on her history, I didn’t feel that long-term estrogen use was safe for her, but she demanded to know why. I hope I can find a better way to have this conversation next time.

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