Ultimately, the value of Grady was such that it was deemed too important to fail: For an insider’s perspective on the process of saving Grady, see, Katherine Neuhausen, Awaking Advocacy: How Students Helped Save a Safety-Net Hospital in Georgia, Health Affairs 2013; 32 (6): 1161–1164.
one white, one black, reminiscent of many buddy cop shows and movies: This is a staple formula; see Lethal Weapon, 48 Hrs., Beverly Hills Cop, Miami Vice, and Men in Black, for example.
Emergency departments are obligated by law to evaluate those who show up at their doors: In 1986, Congress passed the Emergency Medical Treatment and Labor Act (EMTALA) in response to the prior practice where private hospitals would transfer poor, medically unstable patients to public hospitals. For further history on the origins of EMTALA, see David Ansell, County: Life, Death and Politics at Chicago’s Public Hospital (Chicago: Academy Chicago Publishers, 2011).
speculated that it is a way for the hospital to conduct a “wallet biopsy”: Arthur Kellerman quoted in “Portrait of an ER at the Breaking Point,” Newsweek, May 7, 2007.
Atlanta had one of the highest crime and murder rates: Based on 1993 crime statistics, Atlanta was ranked by one publication in 1995 as the most dangerous city in America. Baltimore and Washington, D.C., were also near the top; see http://www.morganquitno.com/1st_safest.htm.
5: CONFRONTING HATE
chart notations and abbreviations that had once looked like inscriptions from ancient times: For example, a typical opening to a patient write-up might read: Mr. Jones is a 51-year-old male with a PMH of CAD s/p CABG x 3, CHF, IDDM, and CVA who presents with a two-day history of SOB. The translation is that Mr. Jones has a past medical history of coronary artery disease for which he has previously undergone cardiac bypass surgery with three grafts. He also has congestive heart failure, insulin-dependent diabetes mellitus, and cerebrovascular disease (prior stroke) and comes to the hospital with a two-day history of shortness of breath. This is a standard introduction. They are often far more complicated.
not uncommon for patients to question the skills of interns and residents and ask to see the supervisor: From both a legal and financial standpoint, the supervising physician, often referred to as an attending, is in fact the patient’s “real doctor.” However, in an academic hospital setting, the patient typically spends more time with the intern and resident doctors-in-training. Affluent patients, especially those requiring highly specialized medical or surgical treatment, are more likely to request/demand the supervisor’s direct involvement. For an interesting discussion on this subject, see Atul Gawande, Complications (New York: Henry Holt and Company, 2003).
But that didn’t mean things were easy: There have been several excellent accounts of the struggles of internship year. Among the best nonfiction books covering the subject include Danielle Ofri, Singular Intimacies (Boston: Beacon Press, 2003); Robert Marion, Intern Blues (New York: William Morrow and Company, 1989); Sandeep Jauhar, Intern (New York: Farrar, Straus, and Giroux, 2008); and Fran Vertosick, When the Air Hits Your Brain (New York: W.W. Norton, 1996). The perils of internship training have also spawned widely read fictional accounts; see Robin Cook, The Year of the Intern (New York: Harcourt, 1972), and Samuel Shem, The House of God (New York: Richard Marek Publishers, 1978).
black players make up more than 75 percent of NBA rosters: See Richard Lapchick, The 2013 Racial and Gender Report Card: National Basketball Association, Executive Summary. According to their analysis, blacks made up 76.3 percent of NBA players in the year 2013; http://www.tidesport.org/RGRC/2013/2013_NBA_RGRC.pdf.
encountered a family that didn’t want her to treat their grandchild: Women in Duke Medicine, An Oral History Exhibit, Dr. Jean Spaulding interview, October 3, 2006. Interview conducted by Jessica Roseberry.
Nor were these stereotypes restricted to the South: See Otis Brawley, How We Do Harm (New York: St. Martin’s Press, 2011) and Pius Kamau, A Case of Mutual Distrust, Journal of the American Medical Association 1999; 282:410.
detailed interviews of twenty-five African American physicians practicing in the New England states: See Marcella Nunez-Smith et al., The Impact of Race on the Professional Lives of Physicians of African Descent, Annals of Internal Medicine 2007; 146: 45–51. For commentary on this article, see Joseph Betancourt and Andrea Reid, Black Physicians’ Experience with Race: Should We Be Surprised? Annals of Internal Medicine 2007; 146: 68–69.
I hadn’t given thought to what other minority doctors might face: Several Asian American physicians have explored this subject. For example, see Pauline Chen, “When the Patient Is Racist,” New York Times, July 25, 2013. See also Sachin Jain, The Racist Patient, Annals of Internal Medicine 2013; 158:623. For a particularly thoughtful essay looking at this issue from several minority perspectives, see Malathi Srinivasan, Today’s Learning Point, New England Journal of Medicine 2001; 344:1474.
Neurosurgeons Ben Carson and Keith Black described similar breakthroughs in their early years as doctors: See Ben Carson, The Big Picture (Grand Rapids, Mich.: Zondervan, 1999), and Keith Black, Brain Surgeon (New York: Wellness Central, 2009).
Patients with sickle-cell anemia have a reputation in the medical community for what is called drug-seeking behavior: For two compassionate but realistic overviews on the subject see Samir Ballas, Ethical Issues in the Management of Sickle Cell Pain, American Journal of Hematology 2001; 68:127–132; and Pamela Pentin, Drug Seeking or Pain Crisis? Responsible Prescribing of Opioids in the Emergency Department, Virtual Mentor 2013; 15 (5):410–415; http://journalofethics.ama-assn.org/2013/05/ecas2-1305.html.
Tuskegee syphilis study: For a comprehensive, historical overview, see James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment (New York: The Free Press, 1981).
popular works have explored how the Tuskegee study was not an isolated incident: For a detailed look into the history of how race has adversely affected the medical care of black Americans, see Harriet Washington, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (New York: Anchor Books, 2006). For another gripping story that explores the historical intersection of race, poverty, and science, see Rebecca Skloot, The Immortal Life of Henrietta Lacks (New York: Crown Publishers, 2010).
hone their skills on a disproportionately poor, black patient population: Many of the top medical schools in the nation are located in cities with black populations that far exceed the national average of 13 percent. For example, Durham has a black population of about 39 percent; Boston (Harvard), 24 percent; Baltimore (Johns Hopkins), 64 percent; Philadelphia (University of Pennsylvania), 43 percent; St. Louis (Washington University in St. Louis), 49 percent; http://quickfacts.census.gov/qfd/states/. These inner-city residents are more likely to present to emergency room and other acute-care settings where medical students and residents often work.
Now it was my turn: For excellent writing on the ways that doctors navigate death with patients and their surviving family members, see Abraham Verghese, My Own Country (New York: Simon and Schuster, 1994); Pauline Chen, Final Exam (New York: Albert A. Knopf, 2007); Jerome Groopman, The Measure of Our Days (New York: Viking Penguin, 1997); and Victoria Sweet, God’s Hotel (New York: Riverhood Books, 2012). Danielle Ofri also poignantly explores end-of-life moments in her books (Singular Intimacies, Incidental Findings, and How Doctors Feel). Atul Gawande’s most recent book, Being Mortal, deftly examines this subject.
6: WHEN DOCTORS DISCRIMINATE
new national guidelines: In July 2003 (when I began medical internship), the Accreditation Council for Graduate Medical Education (ACGME, for short) released sweeping guidelines restricting how much time interns and residents could work in the hospital. Among the most notable: a maximum 80-hour-per-week schedule averaged over four weeks; a maximum 30-hour duty shift; at least one day off per week averaged over a four-week period; and 10 hours of rest between shifts; http://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsPapers/dh_dutyhoursummary2003-04.pdf.
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br /> sparked in part by stories of tired doctors hurting patients: For an overview of the Libby Zion case, largely credited with stimulating duty-hour reforms, see Barron Lerner, “A Case That Shook Medicine,” Washington Post, November 28, 2006.
wrote an editorial: H. Jack Geiger, Race and Health Care—An American Dilemma? New England Journal of Medicine 1996; 335:815–816.
a widely reported article that suggested that women and blacks with chest pain were less likely to be referred for the best cardiac care: Kevin Schulman et al., The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization, New England Journal of Medicine 1999: 340:618–626. This study was covered in the nation’s top newspapers and was a feature on ABC’s Nightline.
though they later took a step back from the full claims of the study: Five months later, the New England Journal of Medicine published a paper that reviewed Schulman’s article and found that the reported gender and race disparities in cardiac evaluation, while not invalid, were overstated. See Lisa Schwartz et al., Misunderstandings About the Effects of Race and Sex on Physician’s Referrals for Cardiac Catheterization, New England Journal of Medicine 1999: 341:279–283.
Institute of Medicine added fuel to the discussion: See Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, D.C.: The National Academies Press, 2002).
a plethora of studies: For example, studies found that black people were less likely to receive kidney transplants and knee replacements while being more likely to undergo C-sections and lower limb amputations. Ibid.
John Edgar Wideman, in his 1984 family memoir: John Edgar Wideman, Brothers and Keepers (New York: Holt, Rinehart and Winston, 1984).
Henry Louis Gates Jr. writes in his childhood memoir: Henry Louis Gates Jr., Colored People (New York: Vintage Books, 1994).
Wes Moore recounts how his dad was taken to the emergency room: Wes Moore, The Other Wes Moore (New York: Spiegel & Grau, 2010).
acute epiglottitis: The epiglottis is a small cartilage tissue in the throat that helps prevent food and liquid from entering the trachea, or windpipe. When infected, the epiglottis can swell and cause suffocation, as apparently happened to Moore’s father.
Various medical scholars and authors have provided historical context: For a detailed exploration into the history of how race has adversely affected the care of black patients, see Harriet Washington, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (New York: Anchor Books, 2006). See also John Hoberman, Black & Blue (Berkley: University of California Press, 2012). For a thoughtful look at how race can complicate the doctor-patient relationship, written from the perspective of a practicing physician, see David R. Levy, White Doctors and Black Patients: Influence of Race on the Doctor-Patient Relationship, Pediatrics 1985; 75:639–643.
when he described a black woman who had nine consecutive pelvic exams: See David Satcher, Does Race Interfere with the Doctor-Patient Relationship? Journal of the American Medical Association 1973; 223 (13):1498–1499.
occurred at Los Angeles County + USC Medical Center: See Sonia Nazario, “Treating Doctors for Prejudice: Medical Schools Are Trying to Sensitize Students to Bedside Bias,” Chicago Sun-Times, June 2, 1994.
conservative medical writer Sally Satel would argue: Dr. Satel, a psychiatrist and resident scholar at the American Enterprise Institute, has written extensively about the intersection of race and medicine and what she sees as a misguided effort by some to focus on health disparities in purely racial terms. See for example, Sally Satel and Jonathan Klick, “Biased Doctors? Don’t Rush to Pull Out the Race Card,” National Review, February 23, 2006. Satel argues that racial bias has a limited effect on health disparities and is a distraction from larger issues of class differences, which she states “makes a much greater contribution than race.” Jonathan Glick and Sally Satel, “The Health Disparities Myth: Diagnosing the Treatment Gap,” American Enterprise Institute for Public Policy Research, Washington, D.C. (2006). Satel also explores this subject in one of her books; see Sally Satel, P.C., MD: How Political Correctness is Corrupting Medicine (New York: Basic Books, 2000).
I wondered if anyone else there had given any thought to this issue and shared any of my concerns: For a discussion about the use of race in clinical cases, see Hamayun Nawaz and Allan Brett, Mentioning Race at the Beginning of Clinical Case Presentations: A Survey of US Medical Schools, Medical Education 2009; 43:1146–1154. The authors conclude: “we believe that the routine inclusion of race at the beginning of case presentations perpetuates incorrect assumptions about biological significance, promotes potentially faulty clinical reasoning, and reinforces socio-economic and cultural stereotyping.” For an interesting, provocative, alternative viewpoint, see Sally Satel, “I Am a Racially Profiling Doctor,” New York Times Magazine. May 5, 2002.
difference between a public hospital where the doctors were paid on salary: For a revealing and frequently cited article on how physician financial self-interest can influence medical care, see Atul Gawande, “The Cost Conundrum,” The New Yorker, June 1, 2009. Cardiologist Sandeep Jauhar uses provocative examples from his clinical practice to illustrate these competing interests. See Sandeep Jauhar, Doctored (New York: Farrar, Straus and Giroux, 2014).
Duke was one of the pioneers of the DASH diet: Duke was among five national sites involved in the original mid-1990s study that investigated the role of dietary interventions in high blood pressure. During this timeframe, it was common to find recruitment pamphlets around the hospital and in local medical offices.
The white coats revealed our hierarchy: For a story about white coat-length hierarchy at Duke, see Calmetta Coleman, “Just Playing Doctor? Shorter Coats Make Young Residents Feel Naked,” Wall Street Journal, February 2, 2000. For a similar discussion at several Boston-area hospitals, see Liz Kowalczyk, “Doctor, Nurse, or Student? Consult the White Coat,” Boston Globe, April 10, 2007.
various studies had demonstrated average reductions of 5 to 10 points (or more) with diet and exercise: For a well-regarded article on the subject that came out in 2003 (my internship year), see Lawrence Appel et al., Effects of Comprehensive Lifestyle Modification on Blood Pressure Control, Journal of the American Medical Association 2003; 289 (16):2083–2093.
Data from a subset of the DASH study suggested that black patients responded even better: See Lawrence Appel et al., A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure, New England Journal of Medicine 1997; 336:1117–1124, and Frank Sacks, Laura Svetkey et al., Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet, New England Journal of Medicine 2001; 344:3–10.
studies that suggested that black people were less likely than whites to adhere to lifestyle changes: See for example Jessie Satia, Joseph Galanko, and Anna Maria Siega-Riz, Eating at Fast Food Restaurants Is Associated with Dietary Intake, Demographic, Psychosocial and Behavioral Factors Among African-Americans in North Carolina, Public Health Nutrition 2004; 7 (8):1089–1096.
Several studies have explored the ways that people with mental illness receive worse medical care: Most of the research in this area examines schizophrenia, bipolar disorder, and to a lesser extent, major depression, as these illnesses are more closely associated with adverse physical health problems. See Alex J. Mitchell et al., Quality of Medical Care for People with and without Comborbid Mental Illness and Substance Misuse, British Journal of Psychiatry 2009; 194:491–499 and Graham Thornicroft, Discrimination in Health Care Against People with Mental Illness, International Journal of Psychiatry 2007; 19 (2):113–122. For a personal, patient perspective on the issue, see Juliann Garey, “When Doctors Discriminate,” New York Times, August 10, 2013.
I had no reason to think of these doctors as racist in any classic sense: Substantial attention has been paid in recent years to the possibility that unconscious (implicit) bias among health care professi
onals contributes to health disparities. See Alexander Green et al., Implicit Bias Among Physicians and Its Prediction of Thrombolysis Decisions for Black and White Patients, Journal of General Internal Medicine 2007; 22:1231–1238; and Adil Haider et al., Association of Unconscious Race and Social Class Bias with Vignette-Based Clinical Assessments by Medical Students, Journal of the American Medical Association 2011; 306 (9):942–951. For a broader discussion of these and related topics, see Lisa Cooper, A 41-Year-Old African American Man with Poorly Controlled Hypertension, Journal of the American Medical Association 2009; 301:1260–1272.
supported by the Kaiser Family Foundation’s 2002 national survey of physicians, published not long before our encounter with Gary: National Survey of Physicians, Part 1: Doctors on Disparities in Medical Care. Washington, D.C.: 2002; http://kaiserfamilyfoundation.files.wordpress.com/2002/03/national-survey-of-physicians-part-1.pdf.
He evidently saw me through a mental filter: Pauline Chen briefly explores the potential pitfalls of cross-cultural doctor-patient interactions: “when I meet individuals whose race or ethnicity differ from mine,” she writes, she “unconsciously taps into past experiences” and admits “it’s difficult to acknowledge that what I have tapped into may not always be fair.” Pauline Chen, “Confronting the Racial Barriers Between Doctors and Patients,” New York Times, November 14, 2008.
Several authors have written about the negative stereotypes that many doctors associate with black patients: For example, a 2000 study of nearly 200 physicians revealed that doctors reported negative opinions about black patients’ intelligence, health behaviors, and ability to comply with treatments. See Michelle van Ryan and Jane Burke, The Effect of Patient Race and Socio-economic Status on Physicians’ Perceptions of Patients, Social Science and Medicine 2000; 50:813–828.
7: THE COLOR OF HIV/AIDS
hearing lies was a daily part of my job: For two recent perspectives about patient lying, see Sumathia Reddy, “I Don’t Smoke, Doc, and Other Patient Lies,” Wall Street Journal, February 18, 2013, and Daphne Miller, “Why Do My Patients Keep Secrets From Me? I Only Want to Help Them,” Washington Post, March 14, 2010.
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