Black Man in a White Coat (18 page)

I'd seen Gary Warren earlier that day, during morning rounds when another resident and intern had presented his case to our faculty supervisor. He'd come in with chest pain; the last I knew, he'd had two normal EKGs and two sets of blood tests that showed no sign he'd had a heart attack. When the team had seen him that morning, they were waiting for one more blood test. If that came back normal, they were going to discharge him home.

Bruce had forgotten to enter the discharge order in the rush to finish his work and go home. I wanted to be upset, but when I'd made the same mistake, someone had covered for me. Besides, it was an easy task. I pulled up Gary's chart to enter the order. Then I saw it.

The discharge summary listed not just chest pain but a psychiatric disorder. Gary was a thoughtful man who seemed to have no more of a mental problem than I (or any of the doctors who treated him) did. Like me, he was black. The traces of anger that I had felt earlier after we saw him that morning resurfaced and bubbled over. My fellow doctors had jumped to a ridiculous conclusion—and as far as I could tell, it was largely based on race. They were branding Gary with a label that simply didn't fit. This looked like a textbook portrait of racial bias—and I was about to sign off on it.

*   *   *

Throughout medical school and the first half of my medical internship, I'd been witness to the pervasive health problems that black people experienced. Poverty topped the list of culprits. Both at Grady and at Duke, I'd seen how poor black people were more likely to be fat, more likely to have been abused, and less likely to comply with medical treatments. With Tina at the charity clinic and in several other patients, I saw how lacking insurance undermines health, even for those who escape the other afflictions of poverty.

But I had never seen any examples of a doctor's racial bias inflicting medical harm.

Nonetheless, during my years in training, the scientific literature was flooded with articles on the subject. In 1996, Dr. H. Jack Geiger wrote an editorial in the
New England Journal of Medicine
(
NEJM
) where, after reviewing several studies, he questioned whether “racially discriminatory rationing by physicians and health care institutions” was a cause of racial disparity in the health care system. Three years later, the
NEJM
published a widely reported article that suggested that women and blacks with chest pain were less likely to be referred for the best cardiac care, though they later took a step back from the full claims of the study. In 2002 the Institute of Medicine added fuel to the discussion with their book
Unequal Treatment
, in which they concluded: “Although myriad sources contribute to [health] disparities, some evidence suggests that bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care.” Throughout these years, a plethora of studies described racially disparate treatments and outcomes.

For many black Americans, these reports—whether the results were large or small—merely reaffirmed long-standing perceptions. Acclaimed writer John Edgar Wideman, in his 1984 family memoir,
Brothers and Keepers
, writes of the misdiagnosis and death of a family friend in 1970s Pittsburgh through his mother's voice: “Shame the way they did that boy. He'd been down to the clinic two or three times but they sent him home. Said he had an infection and it would take care of itself … you know how they are down there. Have to be spitting blood to get attention … when they finally took him to the hospital, it was too late. They let him walk the streets till he was dead.”

Henry Louis Gates Jr. writes in his childhood memoir,
Colored People
, of his adolescent encounter with a physician who discounted his painful hip as “psychosomatic,” telling his mother: “Because I know the type, and the thing is, your son's an overachiever,” referring to Gates's ambition to be a doctor. According to Gates, “back then, ‘overachiever' designated a sort of pathology, the dire consequence of overstraining your natural capacity. A colored kid who thought he could be a doctor—just for instance—was headed for a breakdown.” Gates's mother later took him to another hospital where he required several surgeries for a slipped epiphysis (a fracture through the growth plate), a condition that resulted in his having leg-length differences that required the use of a cane and an elevated shoe for assistance throughout his adult life.

In his memoir, Wes Moore recounts how his dad was taken to the emergency room in a state of confusion. There, the doctors asked Moore's mother: “Does he have a habit of exaggerating? Is there anything going on in his life that would force him to make up symptoms?” before sending him home with a prescription to “get some sleep.” Moore's father died just a few hours later at home from what later was found to be a case of acute epiglottitis. Moore sums up the way that he feels race and class influenced the doctor's care of his father: “My father had entered the hospital seeking help. But his face was unshaven, his clothes disheveled, his name unfamiliar, his address not in an affluent area. The hospital looked at him askance … and basically told him to fend for himself.” Various medical scholars and authors have provided historical context to these anecdotes, chronicling the abuses that black people have faced from the medical profession dating back to slavery.

This history wasn't covered in any formal way during medical school. Nor had I experienced anything egregious that would call to mind this dark past. I'd seen nothing like the case that future Surgeon General David Satcher wrote about in 1973, when he described a black woman who had nine consecutive pelvic exams by physicians and students without being told whether her exam was normal or abnormal. Or a scene that occurred at Los Angeles County
+
USC Medical Center in the 1980s where a black administrator at the school was reportedly told by an ER doctor after breaking her arm to “hold your arm like you usually hold your can of beer on Saturday night.” My main encounter with racial prejudice—Dr. Gale asking me to fix the lights—took place in a classroom setting.

Even when Dr. Garner brazenly accused the pregnant Leslie of cocaine abuse, what seemed like a verbal assault had actually been clinically useful; she had managed to extract vital information about Leslie's drug use where my gentle probing had failed. Moreover, Dr. Garner defended Leslie against the racially charged assertion of the nurse who wanted Leslie sterilized. By and large, the white doctors whom I'd worked with treated black patients with complete fairness and respect. Dr. Watson and Dr. Kelly from the charity clinic, with their devotion to helping the poor and uninsured, stood out as the prototypes.

Nor do I recall any black classmates telling me stories of black patients being shortchanged because of their skin color. Perhaps we were all too busy worrying about ourselves, securing good grades and recommendations, to notice. It's also possible that our medical knowledge in these early stages was not sophisticated enough to decipher subtler forms of medical discrimination. Or maybe our very presence kept the white doctors honest.

In truth, at that stage in my training, I hadn't bought into the whole discussion of “discriminating doctors,” seeing it mainly as the talk of academic types in search of grant money, or, as conservative medical writer Sally Satel would argue, those seeking to advance a political agenda. While I'd clearly seen how poverty adversely impacted the care that many black people received, this seemed to me an indictment of the health care system and broader social inequality rather than the thoughts or actions of any individual doctor.

But when I met Gary, I saw how doctors, in my view, could discriminate against a black patient.

*   *   *

I saw Gary around the halfway point of my internship. I'd spent the previous month on the neurology ward where I found the subject matter interesting and welcomed the less hectic pace. Like a golf scorecard, 70 (hours per week) sure beat the 80-plus customary on the general medicine ward.

“Welcome back, Dr. Tweedy,” a senior nurse said, flashing a crooked smile as I stepped off the elevator onto the unit. “I know you've missed us.”

“I've been thinking about you every day,” I replied. “But you don't want to know what.”

The nurse laughed. I'd taken the advice of many senior residents to be nice to the nurses, as they held the power to make an intern's life even more miserable than it already was. If a nurse didn't like you, they could wake you anytime they wanted, using the need for an unimportant order—say a three a.m. call for Gas-X for a patient who was sound asleep—as the ostensible reason. Getting on the nurses' good side prevented most of that. Being friendly also made them more willing to go the extra mile for you wherever they could.

I was alone as the day began, my supervising resident downstairs in his weekly outpatient clinic. That left me to manage our load of patients. Earlier in the year, the prospect of working by myself during a busy weekday would have overwhelmed me. Now six months into my internship, I could order surgical consults, coordinate radiology studies, and interpret blood and urine tests rapid-fire without flinching.

At ten a.m. we rounded with our attending faculty physician, a daily event where the teams in training—each consisting of a resident, an intern, and a medical student—review the list of patients with their senior physician supervisor. Ideally, the attending physician turns discussion about some or all of the cases into teaching exercises. In medical school, I'd always enjoyed the meetings, as they allowed me to show what I knew and gave me an opportunity to learn new things. Now, as an intern, attending rounds felt like a waste of time, a nearly two-hour delay in my day of drawing blood, writing notes, ordering tests, prescribing medications, and answering page after page to put out an inevitable series of fires.

Our sister medical team—with whom my team shared the conference room and the senior physician—had been on call the previous night, which meant they had new admissions to review.

“Good morning, everyone,” Dr. Rhodes, our attending physician said as he entered our workroom. “How was the night?”

“We got five,” Carl, the resident replied, a half-empty coffee cup in one hand and a chewed-up pencil in the other. He probably hadn't slept more than an hour—two at the most. “But one is on their way to surgery and the other one can probably be discharged today.”

Along with the more noble goals of learning and helping people, most residents and interns wanted to keep their number of patients low. Fewer patients usually meant fewer calls and less paperwork, and that could mean the difference between a seventy-hour week and a ninety-hour one. The ideal was an admission that could be transferred elsewhere or discharged home within twenty-four hours. Getting two such cases in one cycle added up to a good night.

“Another day at the office,” Dr. Rhodes said. “Let's review the possible discharge first.”

Carl turned to Bruce, the intern on his team. I'd worked with Bruce earlier that year. He'd gone to medical school in Ohio and had told me he wanted to become a gastroenterologist. He began his summary of the patient's case.

“Mr. Gary Warren is a fifty-five-year-old African American male.”

This three-pronged age-race-gender description was the traditional way to present a case. Once again the only black person in the room, I wondered if anyone else there had ever given thought to this method and shared any of my concerns. Age was obviously important to know; the cause and severity of chest pain in someone sixty-five years old had different implications than it did when presenting in a twenty-year-old. Gender too had important distinctions; lower abdominal pain in a woman meant considering the pathology of completely different internal organs than did the same complaint in a man. But why did it matter so much whether the patient was white, black, or something else? Did this way of presenting cases assume that race should automatically color the way a doctor approached a patient's chest pain or achy stomach?

The presentation continued. Aside from high blood pressure and his near pack-a-day smoking, Gary had been in good health. This was his first time in a hospital. The day before, for the second time that week, he had developed chest pain near the end of his shift at a hardware store. His initial tests were normal. The team was awaiting a third normal test result, which would rule out an acute heart attack. For the moment, Gary seemed safe.

“Very good,” Dr. Rhodes said after Bruce had finished. We sat silently while waiting for him to direct the discussion or move on to the next patient. Dr. Rhodes was a nephrologist, a kidney specialist, who spent most of his time in the research lab. But he knew clinical medicine. We talked about the blood pressure medicine options that we had, comparing their pros and cons, and discussing the different effects that they had on the heart and kidneys. “Let's go see him,” Dr. Rhodes finally said.

Gary's room was at the far end of the hall. He looked like the healthiest patient on the ward. He was neither skinny nor fat. He didn't have tubes going into his nostrils or penis. He sat comfortably on his bed. The combination of eyeglasses, goatee, and receded hairline gave him a scholarly look. Aside from the hospital-issued gown and the partially covered wires of his heart monitor, he could have been your average middle-aged black man lounging at home on a leisurely Saturday morning.

His attention was focused on the overhead TV, where a reporter talked about potential Democratic presidential contenders and their stances on the Iraq War. Gary turned down the volume and sat up on the edge of the bed, surrounded by our fleet of white coats, his chocolate scalp glistening under the fluorescent lights. I was the only member from my team, as the resident had taken our medical student with him to his clinic. Dr. Rhodes introduced himself to Gary, after which Carl took the lead.