Black Man in a White Coat

by Damon Tweedy, M. D.

  Despite this family history, I had not expected to find myself in this position, certainly not in my early twenties. “How’s your diet?” he asked.

  Terrible, I admitted. I’d grown up eating whatever was placed in front of me—and then seeking out more. My mom worked long daytime hours and my dad worked nights, and healthy homemade meals were the exception rather than the rule. Ready-made processed meals, fast food, and buffet restaurant trips were dietary staples. Every so often, my mom would go on a Weight Watchers diet and eat healthier foods, but that didn’t impact me. Since I was very tall and skinny throughout childhood (I stood six-five and weighed 160 pounds at age sixteen), what harm could come from two foot-long steak subs, an extra-large pepperoni pizza, or a half-dozen hot dogs?

  This eating pattern only worsened in college, as I tried to add weight to keep from getting pushed around during basketball games. Even with an extra thirty pounds, I still fell within the normal weight range for my height, so I saw no reason to cut back. This approach to food continued upon my arrival at Duke, where each day brought dinner at a regularly rotating group of fast-food spots. Just as in college, I rarely drank more than a glass of water daily, and I could go several days without eating a fruit or vegetable (not counting French fries and potato chips). However, with a myopic focus on weight as my barometer for wellness, I’d chosen to ignore basic nutritional facts and believe that I was perfectly healthy.

  Dr. Katz performed a basic physical exam that he said was normal. He then sent me downstairs to the lab, where a pimply-faced young phlebotomist took two tubes of blood from my arm and sent me to the adjacent bathroom to collect a urine sample.

  The following day, I returned to see Dr. Katz to get the results. He wasted no words: “Your creatinine is 1.6.”

  I took a deep breath. Serum creatinine is the baseline test used to assess kidney function. The upper limit of normal at Duke’s lab was 1.3. Something was wrong with my kidneys.

  I searched his face for reassurance, but he looked down at the lab report before speaking. He had more bad news.

  “There were also traces of protein in your urine,” he said.

  A detectable level of protein in the urine, known as proteinuria, is another sign of kidney disease. My face fell into my hands. Worst-case scenarios flashed through my mind.

  Sensing my distress, Dr. Katz tried to calm me down. Even though he spoke for several minutes, I made out only the bare outline of what he said. Something about restricting sodium intake and supplementing basketball with other aerobic exercises, such as jogging or swimming. At the end, he told me to check my blood pressure weekly and return in a few months for repeat tests.

  The day before, Dr. Katz had said that my heart and lungs sounded normal. But as I stepped outside the clinic into the crowded parking lot, my heart pounded as if it were going to explode from my chest. My shirt was soaked with sweat. I could barely breathe. Although I had never experienced one before, I knew I was having a panic attack.

  During the ensuing sleepless night, my mind flooded with images of my grandmother. Around the age of seventy, her memory began to fail rather abruptly—likely from vascular dementia, the result of decades’ worth of mismanaged hypertension. At age seventy-three, she suffered a massive stroke and was later found to have heart failure, which was also related to her hypertension. In those few years, she’d been reduced from the spirited person I’d loved so much to someone barely recognizable: crippled on one side, needing aides to clean her, babbling about places from her childhood and people long dead. Was that my future too?

  From that point forward, hypertension became my obsession. For weeks, I spent hours in the medical library reading everything I could about it. Hypertension is the prototypical disease when it comes to black health disparities. It’s about 50 percent more common in black people than in whites, afflicting nearly two out of every five adults. It also strikes black people at a younger age, and blacks are less likely to have their blood pressure adequately controlled. Consequently, hypertension tends to run a more aggressive course in black people, increasing the risk of several other diseases that are also more common in blacks (e.g., stroke, kidney failure).

  The reasons offered as to why black Americans suffer so severely from hypertension are as diverse as the fields represented. The psychologically oriented journals cite the stress of American racism. Evolutionary scientists theorize that among African slaves, the ones best able to retain water survived the harsh Atlantic journey, passing on their genes, which later proved problematic in the modern world. Public-health writers comment on the various inequities in our health care system and cultural differences in dietary and physical activity patterns.

  Regardless of the cause, or causes, I wanted answers, a fix for my problem. Armed with data from several research studies, I set about changing my life. I started regular grocery shopping for the first time, being sure to eat fresh fruits and vegetables on a daily basis. I replaced soda with water. I supplemented basketball with running on a treadmill and stretching exercises. Within three months, my weight was unchanged, but my blood pressure had dropped to a normal 120/80. From then on, I knew it would be my blood pressure, and not my weight, that would define how healthy I was.

  Later on in medical school when the time came to choose a research project, I jumped at the chance to work in a behavioral medicine lab led by Duke psychologist James Blumenthal that studied lifestyle-based approaches to treating hypertension and heart disease. There, I saw patients, both black and white, reduce their blood pressure through eating better, exercising more, and learning basic stress management techniques. This experience reinforced my own commitment to live a healthier lifestyle.

  When I saw Pearl and Tina at the rural health clinic, I was not just another medical student seeing black patients with poorly controlled blood pressure. I stood before them face-to-face with my family’s past and perhaps my own future.

  Despite our similar health struggles, I quickly recognized the many advantages that I had over Tina, Pearl, and so many others. For starters, I understood the language of medicine. Terms like glomerular filtration rate, thiazide diuretics, and calcium channel blockers were part of my growing medical vocabulary. The patients at this clinic had limited formal education. Tina had a high school diploma; Pearl hadn’t gotten past tenth grade.

  At Duke, I had access to three campus gyms along with several nearby grocery stores and restaurants that served healthy items. Tina and Pearl were constrained by fewer exercise and healthy-food options where they lived. And while I had no money to my name, my social status as a medical student placed me in daily contact with physicians and other medical professionals who could help me navigate the best practices and expose me to the latest medical advances. Tina and Pearl were from families and communities cut off from these advantages.

  A 2005 New York Times article vividly illustrates this dramatic influence of social class as it follows the journey of three New Yorkers—one rich, one middle class, and one working class—who each suffer heart attacks around the same time. In describing their uneven recoveries, in which the wealthy person is left better off, the middle-class man fighting through a setback, and the working-class woman struggling with increasingly complex medical and social problems, the author observed: “class informed everything … from the emergency care each received, the households they returned to, and the jobs they hoped to resume. It shaped their understanding of their illness, the support they got from their families, their relationships with their doctors. It helped define their ability to change their lives and shaped their odds of getting better.”

  I saw a similar contrast between me and the women at the rural clinic. As a Duke student, I had health insurance. I didn’t have to think about seeing the doctor or filling a prescription; everything was covered. For each clinic visit, I’d see Dr. Katz and enjoy the benefits of a stable doctor-patient relationship. Tina and Pearl had to go to a monthly free clinic where doctors rotated each month; this meant th
ey had to “start over” with the hopes that the next doctor would be as caring and competent as the previous one. While Tina’s initial blood pressure pill was cheap, Dr. Watson worried that her blood pressure was so high that she would likely need a second or even third medicine that could each cost in excess of $50 or more every month.

  So while Tina, Pearl, and I were all black and hypertensive, the similarities ended there.

  Given these glaring differences, it should come as no surprise that the poor and uninsured as a group have worse health outcomes and higher death rates than people with health insurance. A 2002 Institute of Medicine report noted that in one study over a seventeen-year period, adults who lacked health insurance at the outset of the study had a 25 percent greater chance of dying than did those who had private health insurance. A major 2001 study found that a lack of health insurance is associated with an increased risk of decline in health for adults over age fifty. Diagnoses are delayed, and chronic conditions are poorly managed. Both factors result in a dizzying array of medical complications on the way toward a premature death.

  As with so many societal problems, blacks as a group suffer to the largest extent, being nearly twice as likely as white Americans to live without health insurance. And while obtaining health insurance alone does not fix the health problems of the poor, it makes a real difference. A 2007 study found that previously uninsured adults, in particular those with cardiovascular disease or diabetes, reported improved health over a seven-year follow-up period after obtaining Medicare coverage at age sixty-five.

  Back in the late-1990s, Tina was one of approximately forty million uninsured Americans, a tally that climbed closer to fifty million over the ensuing decade. Though I’d heard snippets about the uninsured in college during the fight over the failed 1993 Clinton health plan, I had ignorantly allowed myself to assume that they lacked health coverage because they didn’t work, and that they ultimately received medical care as part of our social welfare system. Because of my growing interest in the topic, I later learned that more than 70 percent of people who are uninsured are either working or, in the case of stay-at-home spouses, live under the same roof with a working person, and that having health coverage could be the deciding factor in whether a person sought health care, or if they could even receive services.

  But I didn’t know any of that when I met Tina. During the previous year of clinical rotations, we had a week or two devoted to an overview of the U.S. health care system. Although I vaguely recall some mention of how the United States lacked universal health coverage in comparison to Canada and Western Europe, the discussions seemed focused more on how managed care organizations potentially threatened our future autonomy and incomes. Or maybe the instructors had tried to teach us about the uninsured but I had simply tuned that part out, dwelling instead on topics related to my own self-interest. In the hospital setting, where most of our rotations took place, I rarely knew whether the patients had insurance or not; the ethos, at least in theory, was that people received the same level of medical care no matter their finances.

  Nor did my family life offer any awareness about the uninsured. My parents and brother all had jobs that came with stable health plans. My grandmother also had employer health insurance, and Medicare by the time she developed serious health problems. Despite working-class roots, I was shielded from the trying experience that someone like Tina could face. How could someone play by the rules as she had—marry, have a family, have a job—and not be able to receive decent health care for a problem, such as fibroids, that was not of her own making? This was a problem that our country should have solved long ago.

  * * *

  When I came back to the free clinic once more that year—about three months later—I didn’t see Tina. I had no way of knowing whether that was good news or bad news. Perhaps she had gotten her blood pressure under control and undergone successful surgery for her fibroids. Or maybe one of her problems had caused a heart attack, stroke, or a life-threatening hemorrhage. I could only hope that she had filled our prescription and was on the path to a healthier life.

  Over the next several months, as I returned to the hospital wards and clinics, I saw two women very similar to Tina. They both lived in rural towns comparable to where I’d met Tina. Francine, an unusually tall woman in her late forties, visited a local clinic after several months of heavy vaginal bleeding. She was approaching menopause, and sensed that something was wrong, but she avoided seeing a doctor until she developed intense pelvic pain. Uninsured just like Tina, her initial concern was the cost of this medical visit, but Francine soon had far bigger worries: Doctors diagnosed her with widely metastatic uterine cancer.

  Stephanie, a struggling, thirty-something, self-employed hairstylist, collapsed at work during a stressful day. She was initially taken to a local hospital and told she’d suffered a stroke. She was then transferred to Duke where she stayed for a week. The doctors did an extensive workup to determine a cause for her stroke; hypertension was the only identified risk factor. She’d had bad side effects from two older, cheaper blood pressure medications and, without health insurance, couldn’t afford the newer one that worked well without problems. Thankfully, despite the severity of her initial symptoms, she made a full recovery.

  For Stephanie, the silver lining of getting sick in such a drastic way was that it resulted in her getting insurance. She became eligible for Medicaid and could now afford doctor’s appointments and the two new medications she’d been prescribed. In short time, her blood pressure came down dramatically. However, it is just as easy to imagine that Stephanie could have had a worse outcome, even a tragic one. Her stroke could have caused permanent paralysis, loss of speech, the inability to swallow, memory loss, or severe depression. It could have simply killed her. These doomsday scenarios, all too common, especially in black people, would have occurred in large part due to her being poor and uninsured.

  In the end, while Stephanie ultimately got the care that she needed, this outcome spoke less to the quality of our system than it did to her own good fortune. Francine was not so lucky. Where Tina fell on this spectrum is something that I’ve wondered about ever since.

  For all the billions of dollars in the health care industry, it seemed that there had to be better ways to promote community health. What could be done about all the people in rural North Carolina and beyond, the millions living outside the reach of health insurance and medical charity? Did the government—and wealthy institutions like Duke—have any responsibility to reach them? As a future black physician, did I have some special obligation?

  4

  Inner-City Blues

  As I sat alone flipping through a coffee-stained textbook in the hospital conference room, Dr. Collins, the resident doctor on duty, opened the chipped wooden door. “We’ve got a case of acute chest pain coming in,” he said, excitedly.

  I shared his energy. In my fourth and final year of medical school, chest pain was probably the one clinical problem that I understood best. As a second-year student, I received my highest evaluation on the general medicine rotation where cardiology was a core subject. During third-year, I’d gained additional knowledge working in a clinical research lab that studied heart disease. Earlier in my fourth year, I’d spent a month in the cardiac intensive care unit where I’d also done well. At the time, among the array of clinical specialties, cardiology seemed the logical choice for me.

  After just a few days on my new emergency medicine rotation in Atlanta, however, the confidence I’d built at Duke had begun to fade. This place—the crowds, the filth, the despair—overwhelmed me. So the thought of evaluating chest pain felt welcome, like a chance to play on familiar turf.

  “What’s the story?” I asked Dr. Collins.

  He told me that the patient was a fifty-year-old woman who’d developed chest pain while arguing with her son that morning. The electrocardiogram (EKG) obtained by paramedics at the scene showed some abnormalities, but not the classic findings of an acute heart attac
k that required immediate cardiac catheterization or clot-busting drugs.

  I grabbed my temporary ID badge off the ink-stained table. It proclaimed that I was in Atlanta, but I might as well have been in a foreign land. The setting—Grady Memorial Hospital, an inner-city public hospital—bore little resemblance to what I’d grown accustomed to at Duke. Grady’s emergency department (ED) took up about three times more space than Duke’s ED, yet stepping inside it felt like being on a crowded elevator. Everywhere I looked I saw patients. Some were in the single and double-bed rooms I’d seen at Duke, but most were in the hallways. Gurneys were stacked along both sides of the hall like parked cars on a city street.

  The patients on this day ranged in age from eighteen to eighty-six. All were black. Some were quite sick—a homeless man with AIDS wore a special blue mask to prevent him from sneezing and coughing particles possibly infected with tuberculosis. Others were there for mundane problems better handled elsewhere—a thirtyish woman with a sore throat, a forty-something man with a sinus infection. A few were downright scary—a heavily tattooed twenty-five-year-old in a bright prison uniform, handcuffed to a bedrail with a corrections officer standing over him, receiving treatment for a hand infection he sustained after knocking out someone’s front teeth.

  Why was I in an inner-city emergency department? Why had I left the comfort of Duke?

  The answer was simple and complicated: love. For the first two years of medical school, my social life consisted of the occasional awkward first date that rarely resulted in a second one. My fortunes changed during my third year, as I started dating Kerrie, a student in the class above mine. She was originally from Jamaica but had spent most of her childhood in Florida. I was smitten by her photogenic smile and radiant eyes as well as her soft-spoken, understated style—she didn’t wear heels, makeup, or tight-fitting clothes. We’d chatted from time to time earlier in medical school, but our schedules and social lives didn’t line up until her final year. One date turned into two. Soon, we saw each other every day. We had a lot in common; we enjoyed basketball, tennis, and watching TV medical dramas. More important, she shared my insecurities about being a black student at Duke from a working-class family. I was in love for the first time.