Black Man in a White Coat (20 page)

Although I could have entered the discharge order and let the nurses handle the rest, I couldn't leave it there. I wanted to talk with Gary, to see for myself whether Carl and Dr. Rhodes had picked up on something I'd overlooked. I found Gary sitting up in bed, reading a science fiction book. The cardiac monitor had been removed. He had on his own clothes—a red polo shirt and a pair of blue jeans. He looked like a dad from my old neighborhood.

I introduced myself and explained that we were about to discharge him, but first, I was just checking on what had taken place after we'd left his room that morning. “Did any of the doctors come back and talk with you?” I asked.

He nodded. “They told me that my third blood test was negative and gave me an appointment card for the stress test later this week. They advised me to take off from work until then.”

“Did they talk with you about seeing anyone else?”

“They got me a primary care appointment next month. I want to start coming here.”

“Did they mention anyone else, for any other reason?” I asked.

He shook his head. “Is something wrong?”

I was pressing too hard. It wasn't my job to get Gary upset over something that didn't seem to have bothered him as far as I could tell.

Nonetheless, I was dismayed that Carl and Dr. Rhodes had labeled Gary with a psychiatric diagnosis without discussing with him the “symptoms” they thought they perceived. They had not offered any means to address this “problem,” such as a stress management class or other counseling. From what I could tell, their sole basis was a ten-minute interview where he'd agreed with everything they suggested, except when he gave valid and coherent reasons for wanting to delay taking a blood pressure medicine.

All these thoughts competed for my attention, but all I said was, “No, no problem. I just want to make sure everything is covered. It looks like everything is set until you come back.”

I wanted to say much more. I wished he'd been in that hallway with me earlier in the day, to see how the doctors had ridiculed him for having ideas about his own health. I wanted him to know what was in his chart, to see what I believed—that his race and class had led doctors to label him as having a mental illness. I was tempted to tell him that I could personally relate to his desire to lower his blood pressure without medications because I'd made the same decision myself. I wanted to tell him that he was just the kind of patient I'd want to treat, the kind who's thoughtful and knowledgeable about his health. I had an outpatient clinic at the hospital; maybe he'd like to come there and we could work out a plan together.

I didn't say any of those things. I felt like doing so would have been opening up a Pandora's box that I couldn't close. As a young doctor with no power, I signed the discharge order and wished Gary well.

“Thanks,” Gary said, as we shook hands. “Good luck in your training.”

*   *   *

A psychiatric diagnosis is not a harmless label. Several studies have explored the ways that people with mental illness receive worse medical care. When psychiatric patients report medical concerns, such as chest pain, doctors take them less seriously. Doctors often review the charts of patients before meeting them and form preconceived ideas based on the information written by other doctors. A person with OCPD may be seen as a potential problem. “He's going to do whatever he wants anyway, so why bother?” I've heard doctors say. While obsessive-compulsive traits might be expected, or even welcomed, in a medical or psychiatric private practice that caters to rich clientele, in a lower-income community clinic where people are stacked one appointment after the next, such a person would more likely be viewed as a “difficult” patient, someone you'd want to get out of your office as soon as possible.

In this case, Gary's diagnosis wouldn't be something that he could easily fix. In contrast, a person recovering from alcohol or drug abuse, while likely to face significant discrimination and distrust, has the ability to establish a clear pattern of clean time documented by laboratory testing. Personality disorder diagnoses are far more subjective. The medical doctor is unlikely to ask, “What progress are you making with your personality disorder?” Rather, depending on their view of psychiatry, treating doctors would view Gary's labeling as useless at best, or, more likely, as a sign that he is a “problem” patient.

The following morning during attending rounds, I thought about confronting the doctors who had labeled Gary to make them aware of the role that I felt racial bias had played. But I kept quiet. I'd gotten just about an hour of sleep overnight and simply wanted to get home in time for a nap before Kerrie and I met with the wedding planner that evening. In addition to the typical intern's fear of challenging supervisors and becoming a “difficult” person myself, I already knew how they'd respond. They would have told me that I had misinterpreted the situation, that race had nothing to do with their psychiatric diagnosis of Gary. They would have cited legitimate medical evidence for their blood pressure medicine recommendation and reminded me of how hard people find changing their behaviors. Perhaps they would have suggested that the stress of internship was affecting me, and that maybe I should talk with someone about that?

Surely, I had no reason to think of these doctors as racist in any classic sense. I'd had lunch with Bruce and we'd discussed in depth our internship experiences and future ambitions; he'd given me advice prior to one of my rotations that proved helpful. I'd talked about pro football and college basketball with Carl, who'd gone to a Big Ten school, and he'd invited me for drinks with some of his friends. Dr. Rhodes had mentored a few black students and residents in the past and was always friendly with me. As far as I could tell, all three doctors regarded me as a genuine peer, as one of them, in contrast to the way it seemed they saw Gary.

But at that moment, I didn't feel like I was really one of them. Nor was I like Gary, who reminded me of a past that I could never reclaim. I had a foot in both worlds, but didn't have two feet in either.

My suspicion that, if confronted, these doctors would have vociferously denied that Gary's race influenced their psychiatric diagnosis is supported by the Kaiser Family Foundation's 2002 national survey of physicians, published not long before our encounter with Gary. It found that an overwhelming 75 percent of white physicians said race and ethnicity do not affect the treatment of patients, while 77 percent of black doctors said that race and ethnicity do impact how patients are treated. Smart people from two groups were seeing entirely different realities.

It was clear that my colleagues did not see their actions toward Gary as racially biased, or else they would not have been so brazen in my presence. But I avoided approaching them about what they had done. Once again, personal ambition and comfort trumped racial solidarity. Learning to be a doctor was hard enough without my trying to change the whole system too. Further, I didn't want to deal with possibly being mislabeled as racially paranoid, especially considering how deeply most educated white people take offense to being accused of racial bias. But was I selling myself, and my race, short in the process?

In the end, I pretended that nothing had happened. We went about our usual business. Life went on. Gary probably never learned how his doctors had callously mislabeled him.

*   *   *

Several years later, I had an experience similar to Gary's. In my mid-thirties, my knees were paying the price for many years of playing basketball. I'd grown up spending hours upon hours running, jumping, and cutting on unforgiving blacktop. I practiced and competed on just-slightly more merciful hardwood floors throughout high school and college. After my formal playing days were over, the urge to compete remained strong, so I participated in campus intramural games, joined local recreational leagues, and found pickup games whenever I could.

The cumulative effect was gimpy knees. I had torn my right ACL many years before, but I'd recovered fairly well with surgery and physical therapy. Now my left knee was the one bothering me. Recently when I had played tennis, it had buckled slightly as I rushed to the net to retrieve a drop shot. When the swelling didn't go down after several days, I decided to get it checked out. It didn't seem serious enough to justify a visit to the emergency room, but I didn't want to wait another week to see my primary care physician or several weeks to see an orthopedic surgeon. An urgent care clinic, part of the same health care system where my primary doctor worked, had recently opened. This seemed the best option.

Within a few minutes of arriving, an energetic nurse called my name. She gave a warm, friendly smile. “Good morning,” she said. We shook hands. “Follow me.”

I limped behind her down the hall into an exam room. Once inside, I gave her a brief history of my knee pain. She typed this information onto a computer screen. She then checked my vital signs. My blood pressure was in the gray area between normal and high. I wasn't too worried as I'd checked it at work recently, and it had been fine.

“Dr. Parker should be in shortly,” she said. “It's pretty slow here today.”

True to her words, the doctor opened the door moments later. He gave me a weak handshake as his eyes scanned me from head to toe. It was only then that I realized how casually I was dressed. In contrast to the usual shirt, tie, and slacks I wore to work, I had on a fleece pullover and sweatpants. In haste, I'd put on white socks that were slightly mismatched. I didn't look homeless, but I didn't look like I had taken much care with my appearance.

With virtually no eye contact, his eyes fixed on the computer, Dr. Parker verified the information the nurse had obtained. He then had me pull up my sweatpants so he could look at both my knees. Next, he asked me to stand. My knees creaked, like a door hinge in need of lubricant. The pain made me grimace.

“You're fine,” he said. “Probably just a bruise or sprain. Just take it easy for a while.”

That's it? All he had done was look at my leg. He had not touched it to feel if my knee was unusually warm or cold, or whether it had accumulated excess fluid. Nor had he moved my knee through the various ranges of motion. He'd offered no explanation of what part of the knee was bruised or sprained. There'd been no mention of pain meds, ointments, or other analgesia. He did not offer nor suggest any type of knee bracing, just rest. But what if I had a job that required me to move around? He was all set to leave. I knew I had to say something.

“I really just want to make sure there's nothing serious,” I said, hurrying to stop him from walking out the door. “Last summer I walked around with a sore hand for three days before I got an X-ray that showed a left third metacarpal fracture.”

He looked up and established eye contact for the first time. “Are you a medical person?”

“Yes,” I said.

“Are you an X-ray tech?”

“No, I'm a physician.”

His eyes widened with surprise and what seemed to me admiration, as if the last thing he had expected was for us to be in the same profession. We traded a few words about the challenges of internship and residency training and the adjustment to life afterward. “Let me take a closer look at your knee,” he said.

He went through a detailed physical exam—the kind I had expected from the beginning.

“Everything seems okay,” he said. “But I think it would be good to get an X-ray too.”

The nurse returned and escorted me to the basement for X-rays. Dr. Parker then came down and reviewed the film with me. It showed some early knee arthritis, but no other problems. He assured me that when the radiologist gave the official reading, he would call me himself. In the meantime, he recommended a brace, and offered me crutches just to have on hand. He also offered me a prescription for pain medication. Based on the X-ray, I told him that the brace would suffice; I didn't need crutches and would take over-the-counter ibuprofen.

As promised, Dr. Parker called me the next day. The radiologist's report had confirmed his preliminary review. He told me that he'd gone over to the nearby orthopedic surgery office and gotten me a better brace than the one they had in the urgent care clinic, free of charge. In the end, Dr. Parker's initial impression was correct; I had a mild-moderate knee sprain. With a few more weeks away from the basketball and tennis courts, the pain and swelling receded.

But I couldn't get out of my mind how I'd been treated as two entirely different patients. Damon Tweedy, the unknown black man, dressed like he was about to mow the lawn, couldn't get the doctor to look him in the eye or touch him; Damon Tweedy, M.D., was worthy of personal, first-class service. While it's widely known that doctors get special treatment from their colleagues, this went far beyond the usual professional courtesy of an earlier or more convenient appointment. Receiving a physical exam, an X-ray, medication, and a brace, when you otherwise would not, wasn't just better service: it was different medical care altogether.

Was Dr. Parker aware that his initial lack of attention had been unfair and insulting, leading him to overcompensate with his subsequent actions? Perhaps, but I was more interested in the reasons for his initial approach to me. He evidently saw me through a mental filter, and his assumptions were not positive. Several authors have written about the negative stereotypes that many doctors associate with black patients: poorly educated, drug abusing, not likely to comply with treatments; in short, the kind of person most doctors don't want to treat.

Granted, the urgent care setting where I saw him, and the emergency room in particular, often bring out the worst in both doctor and patient. From the doctor's lens, the goal of care in an emergency department or urgent care clinic is different from a family practice office. As one doctor told me during my ER rotation at Grady, “We are not here to make friends with patients, but to make sure they end up in the right place.” In other words, the goal of the physician in this setting is to move the patient along the assembly line, not to establish a meaningful relationship. Yet the patient probably sees it differently. For far too many in our country, black people especially, urgent care and emergency rooms are the portals to the health care system.