Black Man in a White Coat (19 page)

“As I mentioned earlier this morning, we're confident that you didn't have a heart attack,” he said to Gary. “Based on your history, we don't see any reason for you to have a catheterization right now; instead, we'd like to have you come back in a few days to the Heart Clinic for a stress test.”

As I stood there listening to Carl, I thought back to what I'd heard about black people with chest pain being less likely than whites to get referred for the best cardiac testing and interventions. However, I'd seen doctors at this hospital recommend stress tests rather than cardiac catheterization for white patients as well. This approach seemed less like prejudice than a function of the difference between a public hospital where the doctors were paid on salary and cost-containment was high priority, and a private facility where doctor's income and hospital revenue was based largely on the number of patients seen and tests performed. Either approach, carried to their extremes, could be harmful.

“In the meantime,” Carl went on, “we've identified a few things for you to address. Number one is smoking.”

“You don't have to say more about that one,” Gary said, confidently. “I already decided. I won't be doing that again. I stopped for nine months a few years ago, so I can definitely do it.”

Carl and Bruce smiled. Doctors loved it when their patients agreed with them. They told Gary they would prescribe him nicotine patches to jump-start his tobacco-free life.

“We'd like you to take an aspirin each day,” Carl continued. “We're also going to give you some nitroglycerin tablets. You can take these if you experience any chest pain.”

Gary had received both treatments in the emergency room and his pain had gone away. “That sounds like a good idea,” he said.

“The next concern is your blood pressure,” Carl said.

“I haven't been taking good care of myself,” Gary conceded.

“We'd like to start you on a daily medication.”

Carl gave the name of a common drug. It was cheap, effective, and relatively safe. Gary nodded in silence as he scratched his beard, like a professor or psychiatrist in deep thought: “I'd like to hold off on that,” he said finally.

Plenty of people don't like taking blood pressure pills. Some cause fatigue. Others cause dizziness. A few kill erections. They can end up feeling worse than they did without them.

Carl sighed. He'd hit a familiar stumbling block. He explained the need for medicine: “Your blood pressure is averaging around 150/100 here in the hospital. The cutoff for high blood pressure is 140/90.”

“I understand,” Gary said. “But I'd prefer to try lifestyle interventions first.”

Carl ran his fingers through his thinning hair as he looked over at Bruce, who arched an eyebrow. “What do you know about lifestyle interventions?” Carl asked Gary.

From a young doctor's perspective, most patients whom we saw in public hospitals and clinics who declined medications seemed equally unwilling to make healthful life choices. “Lifestyle interventions” was not part of their vocabulary. But Gary was different: “Based on my numbers,” he said, “it seems that I have mild hypertension. My understanding is that diet and exercise changes can be tried for a while before starting medicine. I have a lot of room for improvement with both.”

I smiled. For years, I'd seen many black people undermine their health, whether it was the people with diabetes who refused insulin and kept eating doughnuts as they lost all their toes, those with heart failure who continued smoking cigarettes (or crack), or the patients with Hepatitis C who still drank a pint of vodka every day. Some lacked knowledge, while others lacked willpower. Gary seemed to have both in ample supply. From my perspective, it felt good to see.

The other doctors had a different reaction. Carl and Bruce looked at each other in wonder as if Gary had developed a cure for cancer. They glanced over at Dr. Rhodes, who seemed equally bemused. “That's mighty impressive,” Dr. Rhodes whispered to Carl.

Granted, this was more medical knowledge than the typical patient in this setting offered, but it didn't require an M.D. or Ph.D. to grasp. Duke was one of the pioneers of the DASH (Dietary Approaches to Stop Hypertension) Diet—a program shown to lower blood pressure. Between the hospital and local clinics, it was easy to come across patient-education pamphlets that provided the exact information Gary recited. For all these doctors knew, Gary, or someone close to him, might have been in one of these studies.

“It's great that you know all of this, but most patients in our experience here find it very hard to accomplish much through diet and exercise,” Carl said, rubbing the back of his neck. His smile and warm energy had vanished. Gary was no longer being a “good” patient, the kind who did what doctors told them.

“That's because they don't take it seriously,” Gary countered. “I know I didn't when my family doctor told me I had borderline high blood pressure, but I will now. You can bet on that.”

Carl turned to Dr. Rhodes for help. It was time for the boss to take over. At a slender five-nine, Dr. Rhodes was much smaller than Carl or Bruce or me, but there was no mistaking who was in charge. The white coats revealed our hierarchy; his knee-length coat conveyed seniority; Carl's stopped mid-thigh and Bruce's and mine were waist-length. Dr. Rhodes maintained good eye contact and spoke with confidence. He stepped forward. “Mr. Warren, it sounds like you know quite a bit about hypertension.”

Gary put his palms on the bed, arms straight, and sat up even straighter, like a student on good behavior at his classroom desk. He glanced at us before looking up at our supervisor. If we were the teachers, he knew Dr. Rhodes was the principal.

“My family doctor gave me some pamphlets when I saw him last year and my pressure was up,” Gary replied. “Like I said, I didn't take it as seriously as I should have. I sorta lost track of things, you know, getting busy with life. But this has been a wake-up call.”

Dr. Rhodes went into professor mode, giving Gary a mini-lecture about the risks of heart attack, stroke, and kidney failure associated with hypertension. “I can't tell you how many people I've seen on dialysis who were like you at one point. They wish they'd taken their meds.”

Gary hesitated. “Just give me a month. Two at the most. If I can't get it down on my own, I promise I'll come back and start whatever you recommend. I understand that this is serious.”

“Okay,” said Dr. Rhodes, as he turned to Carl. “He understands the risks involved.”

Carl finished the conversation, explaining the need to wait for the third cardiac blood test result. Assuming it was normal, the plan was to have Gary go home and come back in a few days for a stress test. In the meantime, he would begin the medications he agreed to start taking.

Dr. Rhodes extended his hand to Gary's. “It was nice meeting you. Good luck to you.”

As we left his bedside and headed back toward our workroom, Dr. Rhodes smiled as he looked over at Carl. “What disorder do you think he has?”

I presumed he was referring to medical conditions. Given his age, hypertension, smoking, and the onset of the pain while under physical strain at work, heart disease seemed most likely. The forthcoming stress test would give us a better answer. Another possibility was something coming from his gastrointestinal tract—perhaps bad reflux or an ulcer, but our information really didn't support that. Nor did his symptoms fit the classic picture of a panic attack. Gary did not relate any psychiatric history or acutely stressful events in his life. We'd already been through this discussion after Bruce presented Gary's case in our conference room. Evidently, after talking with Gary, something had changed. But what? I was jarred by Carl's answer.

“Probably obsessive-compulsive disorder,” he said.

“It seems more like obsessive-compulsive personality to me,” Dr. Rhodes said.

“What's the difference?” Bruce asked.

“Something silly about whether the obsession bothers them or not,” Carl said, shaking his head. With many doctors, psychiatry ranked near the very bottom of the medical pecking order. An old aphorism in medicine was that while surgeons “do everything but know nothing” and internists (my field at the time) “know everything but do nothing,” both were in agreement that psychiatrists “know nothing and do nothing.”

“Maybe we should get a psych consult to let them sort it out,” Bruce said, smiling. “Maybe if he takes one of their pills, it will convince him to take ours.”

The three of them broke out in laughter. The medical student on their team frowned at first before forcing a smile to fit in with her supervisors. I stared at my clipboard and pager, pretending to be preoccupied with issues on my roster of patients. None of them seemed to notice my silence.

Inside, I was quickly moving from disbelief to fury. Gary's decision seemed reasonable. It was not as if he had a textbook case of bacterial pneumonia and had refused antibiotics. Even on the spectrum of high blood pressure, his readings of 150/100 were relatively mild; various studies had demonstrated average reductions of 5 to 10 points (or more) with diet and exercise. Had his pressure been 190/120, it would have been another story. Further, he had agreed to take aspirin, nitroglycerin as needed, and the nicotine patches.

Given this data, why did they assume that he had a psychiatric illness because he wanted to eat better and drop some pounds before resorting to blood pressure pills? Because he was black? Because he was a patient in a public hospital? Because he worked at a hardware store? Or was it because he challenged their knowledge and authority in some fundamental way? Perhaps it was a combination of all these factors. It was as if Gary had shown himself to be “too smart” to be a patient in this hospital and therefore had to be mentally ill.

I was probably more sympathetic with Gary's decision because when I'd received my own diagnosis of hypertension years before, I, like Gary, didn't see taking medication as the first option. For me, the goal of avoiding blood pressure drugs provided motivation as strong as the longer-term fears of stroke and dialysis. Why take a pill, with all of its potential side effects, I wondered, when I could achieve the same result by changing how I ate and exercised?

My doctor agreed. He urged me to complement basketball with other aerobic and strength training exercises. He talked to me about expanding my range of fruits and vegetables, limiting fast food, and drinking water rather than soft drinks. Like me, he considered it important that I exhaust the basics before starting medication. And it worked. Within a few months, my blood pressure was consistently normal.

During my third year of medical school, I learned about the DASH diet, targeted exercise programs, and the benefits that both had on patients. Data from a subset of the DASH study suggested that black patients responded even better to the diet with greater reductions in blood pressure than white patients did—a finding validated in a subsequent study. If anything, Gary's doctors should have eagerly supported his lifestyle goals rather than mock them.

Perhaps they were more influenced by studies that suggested that black people were less likely than whites to adhere to lifestyle changes. And Gary's hypertension was not an isolated problem. He'd come to the hospital with chest pain. Further, he smoked cigarettes. And he was in his mid-fifties, prime age for early heart attacks.

Most doctors would have made similar recommendations and urged Gary to take a blood pressure pill. But the way Carl and the other doctors responded still felt wrong. Why had they treated Gary's responses and vows to change with what seemed like complete disdain? Even if he wasn't making the best medical decision, he'd neither done nor said anything that qualified as a prima facie case for a psychiatric disorder. If questioning a doctor's advice meant getting tagged with a psychiatric label, then virtually everyone I knew was mentally ill. I couldn't escape the sense that racial bias, likely unconscious, had shaped their response.

*   *   *

I didn't have time to think about Gary for the next several hours. When we got back to the workroom, a nurse paged me about one of my patients, a frail man in his early eighties with terminal cancer who was in the hospital for pneumonia. The antibiotics we had given him had worked. But he'd started having diarrhea the day before, and now his stools had become bloody. He'd traded one problem for something equally serious. He wasn't going to live much longer, and his wife and son, whom I had met the day before, knew it. Our goal had been to get him through this crisis and arrange hospice so he could die at home. I hoped that was still possible.

I paged my supervising resident, who talked me through how to manage the situation. After doing so, he told me that we'd gotten a new admission from the emergency room, another elderly man, this one with fever and confusion from rancid bedsores. Meanwhile, my pager started beeping, another patient urgently needing something. I wanted to hurl the chirping device across the room. How was I supposed to handle all of this sickness?

The frenetic pace had slowed by the time I received the page from the nurse asking me to enter the discharge order for Gary. His hospital summary listed two diagnoses. The first was chest pain. Underneath, Carl discussed the possible causes, with coronary heart disease being most likely. The second diagnosis, right there for everyone to see: obsessive compulsive personality disorder.
What?!
I was confused, then shocked. The fact that Carl, Bruce, and Dr. Rhodes had joked about this was bad enough, but they had gone further and made it part of his medical record. How could they have entered this so cavalierly? Had they consulted psychiatry for a second opinion? The chart gave no indication that they had. Carl, who'd been so disdainful of psychiatrists, nevertheless took it upon himself to dole out one of their diagnoses.

I prodded my memory for what I'd learned in medical school about this disorder, usually referred to by its abbreviation, OCPD. Patients with this condition are perfectionist, inflexible, and controlling. While patients with the better-known obsessive-compulsive disorder (OCD) are distressed by their obsessive thoughts and compulsive behaviors, those with OCPD often perceive themselves as being just fine. They are more inclined to believe that other people, who don't measure up to their lofty standards, are the ones with problems. A joke in medical school is that if you want to see someone with OCPD, just look in the mirror or at a classmate.