Of course, I had several advantages that this young woman and others in the clinic lacked: a steady job with a good income, a marriage partner on even better financial footing, and the invaluable benefits of an advanced education. All these factors made my family’s unplanned pregnancy far less life-altering from a social or economic standpoint. But my behavior and the actions of this eighteen-year-old woman—having unprotected sex without thinking through the consequences—had been the same. I understood how this young black woman had wound up with an unintended pregnancy, even as I saw the terrible cost to the black community of having so many single women bearing and raising children without fathers.
Later that morning, a second student presented a case of an uninsured woman in her mid-twenties seeking contraception. She had experienced bad side effects from birth control pills, so her options were limited. Based on a variety of factors, the patient and the doctor decided that an intrauterine device (IUD) would be best. Then came the hard part: Dr. Norris wasn’t sure whether she would be able to obtain one at a lower price that she could afford. The clinic received a limited supply that they could dispense at reduced cost. That supply had run out.
I asked whether the Affordable Care Act, with its ambitious goal to expand health insurance to nearly 30 million Americans, might have an impact on these sorts of scenarios. His answer was nearly identical to Dr. Morgan’s: “I’m not sure,” he said, clearly frustrated. “I think some of my patients will continue to fall through the cracks.”
He too mentioned North Carolina’s decision to reject Medicaid expansion as a barrier. He offered two real-life casualties, two middle-aged black women whose fibroids caused them to have “basketball-sized uteruses.” Along with significant pain, they experienced heavy bleeding during their monthly cycles. With insurance, they would have been eligible for a curative hysterectomy; without it, their clinical situation had to deteriorate into an emergency before they could get such care. He described both women as hardworking and responsible. It sounded eerily similar to Tina’s situation that I had encountered as a medical student. It was yet another example of how systematic failures could dictate a person’s health and threaten their life in ways beyond their individual control. “It’s really a damn shame,” he said. “I think the system really needs to be turned upside down and inside out in order to be fixed.”
When I started medical school and learned about the adverse health outcomes that afflicted black people, I had assumed these disparities were due chiefly to genetics. To be sure, there are diseases, such as sickle-cell anemia, lupus, and sarcoidosis, which appear to preferentially target black patients at a biological level. But what had become abundantly clear during my years in medical school and as a doctor, however, were the many ways that social and economic factors influence health, and, more than anything else, account for the sickness and suffering that I have seen.
The problems take three forms. First are the system-based disparities that limit black people’s access to medical care. Black people are disproportionately uninsured and, if insured, far more likely to have public insurance than private coverage. Further, owing in large part to geographic and residential segregation patterns, blacks are less likely to have access to primary care physicians, and even when available, such care is more likely to involve trainees and other rotating physicians rather than a consistent long-term relationship with one doctor. I’d seen these factors play out in real life with Tina and others at the charity clinic; with dozens of patients who used Atlanta’s Grady emergency room for routine care; and with Steve and many others in my psychiatric training who couldn’t get the substance abuse treatment or outpatient psychotherapy that they really needed.
Second, the doctor-patient relationship itself serves as a catalyst for differing outcomes. Here, the attitudes and behaviors of both doctors and patients are important. On one hand, some doctors are prone to hold negative views about the ability of black patients to manage their health and therefore might recommend different, and possibly substandard, treatments to them. On the other spectrum, many black people are mistrustful of doctors and medical treatments to their own detriment. I’d seen how Gary’s reasonable assertion of medical knowledge and treatment preferences had left him with what I felt was an improper psychiatric diagnosis; how Carla had wanted Leslie sterilized after her stillbirth, and how I’d been disregarded by Dr. Parker until he learned that I was a physician. Over the years, I’d also watched numerous black patients ignore the sound clinical recommendations of well-meaning doctors of all races.
Finally, the unhealthy lifestyle behaviors of many black people are also a real factor. Pearl and others at the charity clinic ate an insalubrious soul-food diet; Leslie’s drug use had likely caused her son’s stillbirth; Lucy had died before our eyes in the Grady hospital emergency room from a potent mix of hypertension, diabetes, and family dysfunction; Adrian had smoked his way to a second, crippling stroke; and Monica had likely contracted HIV from the clandestine sexual life of her ex-boyfriend.
These heartbreaking stories were each in their own way complex, and illustrate how lasting improvement will only come through an array of changes employed simultaneously. Some of this responsibility rests with government and other large institutions, but much of it must occur at the individual and community level. When it comes to expanding access to quality health care, both government (federal and state) and large private insurers clearly have a major role to play. And it is here that the Affordable Care Act, with its expansion of Medicaid and creation of state-based insurance exchanges, has generated the most attention. The law certainly has some good features: placing millions more under the health insurance umbrella, prohibiting exclusions based on preexisting medical conditions, eliminating co-pays for preventive care, and ending annual or lifetime payout caps. But whether these and other changes will prove to be fiscally viable over the long term, in the face of ever-rising health care costs, remains to be seen.
On the doctor-patient level, efforts to improve the care of black patients have come from two directions. One side has taken a race-focused approach, advocating for widespread collection of race/ethnicity data to monitor for disparities, expanded cultural competency training, and increased numbers of minority physicians. The other method is more race-neutral, focusing on universal quality improvement initiatives to elevate the standard of medical care for everyone; its proponents argue that black people will benefit considerably because they often have worse health and have historically received a lower quality of medical care. For largely ideological reasons, there is a tendency to make these strategies an either/or proposition, but I don’t agree. By and large, both methods can be employed simultaneously, and wherever they might conflict, the two sides should be rigorously researched against each other. If the goal is to improve the health of black people, who remain at the bottom of most health indexes, it shouldn’t matter whether the means to achieving this follows a liberal strategy, a conservative approach, or something in between.
On the individual level, Henry’s lifestyle transformation, along with my own, are just two instances of black people seizing control and deciding to live healthier through better choices about diet, exercise, and self-destructive habits. My parents too, thanks to good relationships with doctors and a willingness to reassess their earlier behaviors, have made major strides; they eat predominately fresh foods, go out walking most days, and take their medications as prescribed. Over the last several years, I’ve been comforted to see more and more black people at the grocery store buying fresh fish and bags full of fruits and vegetables. I’ve been equally heartened to see greater numbers of blacks exercising at the gym and at local parks. While there are certainly no guarantees, these habits form the foundation for good health. Ongoing public and private efforts to encourage healthier lifestyles can potentially benefit everyone, but black people especially, given that we are more likely to have an insalubrious foundation.
Despite the tragic stories I’ve written about
in this book, there are clear signs of progress. Nationwide, teen pregnancy, infant mortality, and violent crime among black people are all down from where they were when I entered medical school in 1996. Between 1996 and 2010, the life expectancy of black males increased by more than five years, far exceeding the gains made by any other group during that period. Recent estimates put the narrowing black-white life expectancy gap at less than four years, when it was twice that a half-century earlier. Black people still are not as healthy as whites, Asians, or Hispanics in America, but the foundation has been laid for continued improvement.
* * *
While public health and other research studies teach us many things about medicine, I feel nonetheless that the greatest lessons still come from the stories of doctor-patient encounters. Medicine, no matter the many changes it has undergone in recent decades, remains at its essence a face-to-face, human-to-human endeavor. When it comes to race, this human aspect of medicine has certainly caused injury to many black people over our history. But things have gotten better, even during my short time in medicine, and my experiences as a young doctor point toward ways for even further progress. As a black physician, my interactions with white patients pose the same potential cross-cultural challenges that white doctors face in caring for black patients. I’ve learned a lot about myself in these interactions, and found ways to break through boundaries imposed by racial tension and prejudice.
About six years ago, I met a young man named Keith while working at the same outpatient clinic where I treated Adrian and Henry. Keith was in his late twenties at the time, about five years younger than me, but he’d seen and done things that I couldn’t really fathom. Keith had served two tours in Iraq, where he witnessed severely disabled Iraqi children strapped to bombs and sent on suicide missions. One of his closest friends died in a roadside attack. Another friend committed suicide days after his return home. Within six months of leaving the military, Keith found himself plagued by nightmares, severe anxiety, and suicidal thoughts. He was diagnosed with post-traumatic stress disorder (PTSD). By the time we met, he’d been under psychiatric care—seeing a psychiatrist every two months—for more than a year. He took Zoloft. He’d also attended several months of group therapy sessions.
As I skimmed through the note from his initial visit with a clinic therapist, it looked as if Keith’s main passions were guns, motorcycles, pickup trucks, and race cars, which suggested that we had no common ground. I’d never held a gun, thought motorcyclists were crazy, hated noisy pickup trucks, and found NASCAR more boring than watching a group of men shaving their faces. In contrast, I liked tennis, drank fruit smoothies, and drove an SUV in which I often listened to classical tunes and rap music. It looked like a classic red state–blue state clash.
These differences were magnified when we met each other. He wore a camouflage jacket and hat with brown sweatpants and brown boots, as if his next stop was to take his pickup truck to some rural outpost to hunt deer. Based on previous patients of similar style and background whom I had encountered, as well as my innate biases, I made several negative assumptions about him. I predicted that he smoked cigarettes (and maybe marijuana), ate a poor diet, was narrow-minded, and probably prone to abusing alcohol and prescription drugs. In short, I looked at him in the same derogatory way that doctors so often unfairly approach black patients.
I suspect he had an equally negative impression of me. I had on a cream-colored dress shirt, camel sweater vest, beige pleated slacks, brown Oxford dress shoes, and a necktie that incorporated all of these earth tones. My watch, bracelet, tie bar, and wedding band all had a striped-gold pattern. I probably looked to him like a vain, wimpy guy who had never gotten his hands dirty. Whatever he thought, his face registered complete surprise when I introduced myself as his new doctor. I’d seen it many times: I wasn’t what he was expecting. As so many patients and family members before him had reacted to me, Keith couldn’t have looked more shocked if Shaquille O’Neal or Santa Claus had emerged from the doctor’s office and greeted him.
I had replaced the psychiatrist who prescribed his Zoloft, so it made sense to start there:
“How have you been doing these last few months?” I asked.
“Good.”
“I see that you are prescribed Zoloft 100 milligrams per day.”
He nodded. “How often have you been taking it the last few months?” I asked.
It probably sounded like an accusation, but about half the patients I saw didn’t take antidepressants as prescribed. Many preferred to take them only when they felt bad or anxious.
“Every day.”
“Do you feel that it’s helping you?”
“Yes.”
“In what way?” I asked.
“I’m calmer.”
I waited a good ten seconds to see if he would elaborate. But his poker-faced stare suggested that he was waiting for me to make the next move.
“Are you having any side effects or other problems with the medicine?”
“No.”
I glanced at my watch. This terse exchange had only taken two minutes of real time. Patients were scheduled every half hour. My remaining questions about sleep patterns, other psychiatric symptoms, and alcohol and tobacco use weren’t going to take more than a few minutes at this rate. Rather than simply proceed in this close-ended way and politely usher him out of my office with more than twenty minutes to spare, as many busy medication-oriented psychiatrists might do, I tried a different approach. When he mentioned that his girlfriend told him he sometimes still thrashed about in his sleep, I used that as an opening to ask more about her, inquiring into whether she worked or not, how they’d met, how long they’d been together, and what he liked and didn’t like about her and her family. His one- and two-word answers became complex sentences. Before I knew it, our thirty-minute visit had nearly elapsed, forcing me to move quickly through the remaining symptom-based questions. As he left, I felt that we’d laid the foundation for a cordial doctor-patient relationship.
Two months later, he returned for his next appointment. He started off by telling me that he had gotten engaged. That led us to talking about his parents, who divorced when he was in the sixth grade. He discussed the ways he wanted his marriage to be different from theirs. Unlike many of my patients from separated families, Keith seemed to have a good relationship with both parents. He told me about a recent weekend where he watched a NASCAR race with his mom and played pool with his dad.
“Do you like nine-ball or eight-ball better?” I asked.
He looked at me, seemingly surprised that I knew anything about billiards. “I’ll do eight-ball with my girlfriend … I mean, fiancée … but nine-ball with my friends or my dad, when there’s money to be made or lost.”
I smiled. As a psychiatrist, I could have followed up with some screening questions to assess whether he had a gambling problem. Instead, I began a conversation. “How long have you been playing?”
“Since I was in the sixth grade. My dad bought a table for my birthday that year.”
My dad bought a pool table too when I was around that same age. During the summer, I’d watch the pros on ESPN and spend a few hours afterward imitating their shots. As I got busier with basketball in high school, my mom eventually claimed the space that the pool table took up in our cramped basement as her own, giving the table to my brother for his new place. Still, the joy I got from a game of eight-ball never faded. For many years, well into my twenties, whenever I would visit home, my dad and I would go to a neighborhood pool hall and play a half-dozen games. I’d win some and so would he, but we never even bothered to keep score.
“You ever run the rack in either game?” I asked. A few times, I’d come close to running the rack—playing through the entire succession of balls without missing, keeping my opponent from even getting a turn—but had never actually managed to pull it off.
He smiled. “It’s been a while. I’m not good enough to get into any of that high-stakes stuff—I never win or
lose more than twenty bucks at a time. But it’s just fun.”
I’d gotten my answer about gambling without having to ask. The five minutes we spent on pool had nothing to do with Zoloft or anything else ostensibly medical, yet it was important. It helped me see him as more of a person than a stereotype; maybe it did the same for him too.
By the fifth or sixth visit, nearly a year into seeing me, Keith decided he wanted to stop the Zoloft; he didn’t like the idea of taking it his entire life. As a medication-based psychiatrist, I could have fallen back on the viewpoint that quitting antidepressant medication was a bad idea. For a subset of psychiatric patients, especially those with schizophrenia and severe forms of bipolar disorder, stopping their medication can be a terrible decision that leads to hospitalization and drug relapse. However, some patients treated for depression and anxiety woes can manage just fine without medicine. You don’t know until you give it a try.
So that’s what we did. Over the next several months, Keith felt that his mental health remained stable, and from what I could see in our visits, this seemed true. He’d been promoted in his computer information technology job, enjoyed spending time with his fiancée, and had joined a combat veteran’s running club that had helped him shed fifteen pounds. Since he was doing well without medication, he could have stopped seeing me, but he continued to keep appointments. We used the time to talk about his engagement, his time in the Army, and anything else that was on his mind. He seemed to look forward to these visits as a way to stay on track—to process in his mind whatever anxiety had built up in the intervening time about the past or present. I looked forward to seeing him as well, as each time he’d tell me some interesting tidbit about hunting, motorcycles, or NASCAR.
Finally, after another year of visits with me, he felt that he could manage on his own. “Thanks. You know the guy I saw before you, he only wanted to talk about medicine and these checklists. I really appreciate your time. Maybe we’ll get a chance to shoot some pool one day.”
Black Man in a White Coat Page 25
