Black Man in a White Coat (21 page)

Recognizing that time and urgency constraints might interfere with a good bedside manner did not excuse Dr. Parker's initial actions. At the very least, he should have done a physical exam. While his initial impression proved correct, without an exam or X-ray, a tiny fracture could have been missed and later morphed into something far worse. Had I not had the medical knowledge or sophistication to garner his attention, he would have sent me out of the urgent care—limping, vaguely diagnosed, without brace or crutch, without medicine, and without a follow-up visit. That's bad medicine. Why did I have to prove that I “deserved” the far better care he later showed he was capable of delivering?

Appearance and dress matter for everyone in how they're perceived, but the prevailing wisdom among black people is that it's much more important for us than it is for others. Even if the impact can't be studied or measured objectively, many black people will tell you that they have to dress better than a nonblack person to be taken as seriously. I certainly learned my lesson. Since that day, whenever I have an appointment or tag along with a family member to a doctor who doesn't already know me, I put on a sport coat. Sometimes I'll wear a tie too. At the very least, I'm certain to wear a collared shirt and slacks, and a pair of nice matching socks.

*   *   *

Doctors, like all other people, are capable of prejudice and discrimination. While bias can be a problem in any profession, in medicine, the stakes are much greater. Missing a blood clot in a patient's painful leg because the doctor thinks that black people in a given clinic or hospital are likely to be drug addicts seeking their next fix is a far more dangerous kind of insult than a salesperson assuming that a black customer can't afford a Brooks Brothers suit or Rolex watch. These high stakes make it vitally important for doctors to understand their capacity for prejudice.

The American historical record is full of material about white doctors' abuses and discrimination against black patients, often chillingly described in the words of the doctors themselves. Most of us, including many black people, would like to move beyond the past and accept that this American script has been rewritten. And while many things have improved, studies continue to document the ways that the doctor-patient relationship can undermine the health of black people. My experience with Gary and my own encounter with Dr. Parker are smaller examples of a larger issue.

As doctors, there is ultimately only so much that we can do for our patients, especially for the more disadvantaged in our society. We can't get them good jobs with good health insurance. Nor can we move them into nicer neighborhoods where their children can attend better schools. Despite the knowledge, advice, and treatments we have to offer, we often can't help our patients live healthier lives. But as doctors, we can do one simple thing for them: We can make our very best effort to treat everyone fairly.

 

7

The Color of HIV/AIDS

“I'll be damned,” Adam, a medical resident, said, shaking his head. “Our patient in room thirty has been lying.”

We were sitting next to each other in a musty workroom filled with the scent of stressed-out residents and stale pizza. It was seven p.m. Our sister team had admitted the first wave of new patients to the medical ward and was frantically trying to wrap up their work so they could get home. Adam and I were the long-call, overnight team, which meant we'd been on duty for twelve hours and faced another eighteen before we would be set free. I was writing the admission note on an elderly woman who'd come to the hospital that afternoon with a blood clot in her leg. Adam was on the computer looking over the most recent lab results for our patients.

The patient in room thirty, George, had come to our hospital two days earlier complaining of fatigue, weakness, and short-term memory problems. He'd been losing weight and his blood counts were low. In his late forties, he worked at a local, predominately black college that he had graduated from twenty-five years earlier.

George told us he had been healthy his entire life until about six months earlier, when he gradually started feeling tired and had trouble focusing at work. His appetite went away and his weight dropped; he lost twenty pounds without trying. His red and white blood cell counts were abnormal, and his family doctor worried that he might have cancer. When further tests did not detect any cancer, however, his doctor suspected that George was depressed. He tried Prozac and Zoloft, but neither helped.

Adam's computer screen had revealed some critical truth about George. “Lying about what?” I asked.

As a medical intern, hearing lies was a daily part of my job. We'd been taught—not in a formal way, but through the offhanded comments of our supervisors—to double whatever amount of alcohol or cigarette use the patient reported, and to accept this higher number as being more accurate. For street drugs, a patient's word meant nothing without a urine test. Aside from drug abuse, people most commonly lied about whether they followed a healthy diet, exercised regularly, or took their medications as prescribed. Lastly, many lied about sex.

“He's HIV-positive,” Adam replied.

Of course, I thought, experiencing the same satisfaction I felt when the final twist is revealed in a good movie or detective novel. HIV made sense. We'd been instructed to always include it on our list of usual diagnostic suspects. The risk of missing it was too great, not only for the patient, but for whomever they could go on to infect. In George's case, HIV explained everything: the weight loss, fatigue, poor concentration, abnormal blood counts, everything. Yet, despite my textbook knowledge, I was still surprised. What I was about to see was that George, in many ways, represented the changing face of HIV/AIDS.

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The mid-1990s was a time of dramatic developments in the battle against HIV/AIDS. The introduction of a new class of medications, the HIV protease inhibitors, transformed treatment, bringing many people back from death's door. Between 1995 and 1998, AIDS mortality in the United States dropped more than 60 percent. Among white men, this decline was even more pronounced, with reductions in death rates approaching 75 percent.

The same era also brought what social scientists call “shifting demographics” in the evolution of HIV/AIDS in America. Since the first reported cases in 1981, HIV/AIDS, aside from those with hemophilia or intravenous heroin addiction, was widely regarded as a disease of gay white men. In the early years, movie star Rock Hudson and musician Liberace were its most famous victims, and the activists seen in mainstream media were white men. From the outset, however, this was never the full story, as black people accounted for a quarter of HIV cases during the first decade of the epidemic, a proportion nearly double theirs in the general population at the time.

Not surprisingly, with all that is known about poverty, race, and poor health, advances in treatments for HIV had a muted benefit on blacks compared to whites. Not only were HIV medications expensive, but patients had to be tied into quality medical care in order to have access to the drugs and the support systems needed to manage the complicated treatment regimens. Given increasing infection rates and less access to state-of-the-art care, during the early 1990s, the death rate from AIDS among blacks exceeded the rates seen in whites. In 1996, for the first time in the epidemic, more black people in America died of AIDS than whites.

In the years that followed, the color of HIV/AIDS in the United States continued to darken. By 2001, the annual death rate from AIDS for blacks was nearly double that of whites. In 2011, when blacks constituted about 12 percent of the U.S. population, they accounted for 46 percent of new HIV infection cases. Put another way, black people in the U.S. are more than eight times as likely as whites to be diagnosed with HIV. Once diagnosed, they are about nine times more likely to die from AIDS. Hispanics are also afflicted in disproportionate numbers. What had once been seen as a white disease has turned black and brown.

*   *   *

HIV had been on his family doctor's list of possible diagnoses, but George had declined the test, saying that he'd tested negative before and hadn't had sex with anyone other than his wife since. It was not until George was admitted to our hospital that he consented to an HIV test.

“I guess he wasn't completely honest with his family doctor,” I said.

“Or with us,” Adam replied. “And probably not with his wife either.”

I went through what we knew. We'd done the standard HIV risk assessment when he'd been admitted to the hospital. He worked in an office setting. He'd been married for almost twenty years. His wife worked at a prison and had tested negative for HIV ten months earlier. He denied any extramarital affairs, as did she. He told us that he did not use street drugs of any kind, much less ever inject them into his veins. He said he'd never had a blood transfusion. Based on this information, HIV seemed unlikely, and we were all set to undertake a detailed and expensive series of tests to uncover some rare disease.

“You wanna tell him?” Adam asked me.

“Sure,” I said. “Let me finish this note, and I'll go do it.”

In the half-hour or so it took me to finish the paperwork on the other patient, Adam had changed his mind. “Why don't we go as a team?” he said. “This might be a good learning opportunity for our student. Besides, I know this sounds awful, but I'm dying to know the truth.”

This all seemed callous, to be sure. I was looking at George's diagnosis as I would a TV mystery, while Adam was focused on the soap opera element. Our medical student, well into her year of clinical rotations, shared our curiosity. “His wife is going to be pissed,” she said. Trapped inside the hospital vortex where disease, disability, and death were constant companions, our reactions passed for normal behavior.

It was only as we stood outside of George's room that I started to fully appreciate the emotional weight of the diagnosis. HIV in 2004 wasn't the universal death sentence it had been two decades earlier; still, other than cancer, organ failure, and a few neurological disorders, it was just about the worst news that a doctor could give.

“Here goes,” I said, as I knocked on the door to George's room.

By this point, I'd been a medical intern for nearly nine months. Combined with my years in medical school, I'd been a part of delivering enough bad news for a full season's worth of episodes on a TV medical drama: “Sir, you have cancer”; “Ma'am, your cancer has returned”; “Your husband's stroke has taken away his ability to talk or swallow food”; “Your mother's dementia is progressive, and there are no other treatments left for us to try.” Saying and hearing these things for the first time had been heart-wrenching. Now, however, these and other grim pronouncements were stuck in my mind, as accessible to me as the lyrics to my favorite Bob Marley or Marvin Gaye songs. A few days before, I had to tell a woman that her fifty-five-year-old husband had died of a heart attack, and while I truly felt sorry for her, the words had come off my tongue as easily as if I'd been giving directions to the hospital cafeteria.

But I'd never told a patient that he or she had HIV/AIDS—or even watched another doctor do it. All of the HIV-positive patients I'd seen had been diagnosed before I met them. Despite my experiences being part of the worst moments of people's lives, giving George his diagnosis felt different. Cancer, diabetes, and pneumonia were universally seen as diseases of the body, even if the person's lifestyle had in some measure contributed to the illness or made its course worse. HIV, despite its irrefutable biological dimension, was still seen by many as an indictment of one's character or morals. At the time, a part of me agreed. Once universal testing of the blood supply in the mid-1980s virtually eliminated HIV infection through blood transfusions, people came down with HIV in one of two ways: sharing infected needles or, much more commonly, through sex.

When we entered the room, George was propped up in bed, sipping water from a paper cup. A slow-drip intravenous line gave him additional fluids to offset his dehydration. A plastic, handheld urinal hung on his bedrail for easy access; his weakness made the short trip to the bathroom a perilous journey. This was surely not how he had envisioned his life in the weeks before he turned fifty.

“All my young doctors are here,” George said to his wife, Janice, who sat upright in a vinyl chair that doubled as a sleeping recliner for overnight stays. Like so many attentive spouses, she'd dragged him to the doctor when, left to his own devices, he would have continued to downplay or ignore his health problems.

“Any updates?” she asked, putting down her book and moving to the edge of the chair.

I wasn't sure how to begin. If George had pancreatitis or an ulcer, it would have been easy to tell him and his wife together. But HIV would affect Janice and their marriage in a way that other medical disorders did not. For all we knew, it already had. I looked over at Adam for guidance. It was time for him to take over. His instinct was to break the news by separating them.

“We'd like to look him over again closely and do some more neurological tests,” he said. “With the three of us examining him in here, it will be a little crowded. If it's okay with you, we'd like you to give us a little time alone with him.”

Janice seemed confused at first, but she didn't put up a fight. “How much time?”

Adam rubbed his temples. “Give us fifteen minutes.”

“I'm going to go down to the cafeteria and get some food,” Janice said to George. “Anything you want me to bring you back?”

George shook his head. Janice slung her purse over her shoulder and leaned down to kiss him on his forehead. I couldn't help but wonder how long it would be before she kissed him again, if ever.

After she left, Adam and I took a half-step toward George. Up close, his butterscotch complexion was sallow. Now that we knew he was HIV-positive, we examined him more methodically, looking closely for any signs of the complications that might accompany HIV infection. We felt for enlarged lymph nodes, peered into his mouth for signs of thrush, and searched his skin from head to toe for rashes or other discolorations, however slight. We shined a light into the back of his eyes. We didn't find anything new.