Black Man in a White Coat (27 page)

As if my limitations weren't enough, Diane imposed her own upon me. “I don't know if you can help me,” she said.

“What do you mean?” I asked, worrying that my inexperience had shone through so soon.

“Please don't take offense,” she began, looking away. “But I don't trust black men. They scare me. Especially when they are bigger or darker-skinned like you.”

I sat speechless as Diane talked. This seemed like the worst match imaginable.

She said that her father had a dark complexion and stood a broad-shouldered, thick-chested six foot two. Diane had taken after her mother and was five-one and little more than a hundred pounds. My instinct was to take offense that by virtue of my appearance, she had lumped me with a person whose actions sounded despicable. But another thought entered my mind. This sounded like textbook transference, a psychological term for when patients project feelings and emotions about an important person in their early life (like a parent) onto their therapist. Until then, I had been somewhat dismissive of the psychotherapy glossary, but with Diane, the concept of transference finally made sense to me. I could see why a man who reminded her of her father would make her afraid. But where was I supposed to go with this knowledge?

My inclination was to find a different resident for her to see. In that clinic, I worked alongside two white women and a Hispanic woman in my same year of training. Maybe as a sophisticated Duke graduate student, she would even be better off with a faculty therapist. I told Diane that I would call her after consulting with my supervisor.

After I finished seeing a man with bipolar disorder who needed his prescription medications renewed, I went to Dr. Carpenter's office to discuss Diane's case. Dr. Carpenter was in her mid-fifties and had been on faculty for two decades. She had gone to medical school knowing that she would become a psychiatrist. During our thirty-minute meeting, I tried my best to get Diane assigned to another resident, offering examples of other episodes where well-intentioned but ill-advised race matching had gone bad. How could it get worse than with a black woman afraid of black men?

“You're trying to take the easy way out,” she said. “This would be a good case for developing your psychotherapy skills. And if you give up on her now, she will feel abandoned and rejected, which will only feed into her negative feelings about African American men.”

I was skeptical. It sounded like something I might have heard on an episode of
Oprah
. But sensing that I had no other choice, and fearing a negative evaluation sent back to my training director indicating that I was obstinate and defensive, I followed Dr. Carpenter's advice. I called Diane later that afternoon and scheduled a visit for the next week, doubting that she would come. A part of me sincerely hoped she would not.

*   *   *

My suspicion at being assigned Diane's case based on a race-matching goal was rooted in a larger history; it reflected the evolving rationale for affirmative action in medicine.

Forty years earlier, with the images of Jim Crow still fresh in America's consciousness, affirmative action programs were started on the notion of redressing historical inequalities in access to education and job opportunities. In medicine, the effect was quickly felt: By the mid-1970s, the proportion of black medical students had nearly tripled. But inevitably, these gains came at the expense of others. The first main challenge to this new order was the 1978 U.S. Supreme Court
Bakke
case, where an applicant brought suit against a California medical school asserting that his rejection stemmed from the school's policy of setting aside slots for minority applicants. The Supreme Court agreed that quotas were unconstitutional but allowed schools to consider race toward the end of creating and maintaining a diverse student body. The Court's decision guided the affirmative action landscape until the mid-1990s, when a second wave of legal protest emerged. Buoyed by a University of California regents ban on race-based preferences and a federal appeals court ruling that struck down race-based affirmative action programs, the diversity argument had also come under assault.

Motivated by these challenges, as well as the persistent problems of health disparities among black patients, several researchers in the mid-1990s began publishing studies that looked at the role black doctors played in the care of minority patients. They found that black doctors served black patients at six times the rate as other physicians; that black physicians were far more likely to treat patients covered by Medicaid; and that the supply of physicians was lowest in areas with higher numbers of black and Hispanic patients.

Over time, a related group of studies reported that black patients tended to have more positive interactions with black physicians. The conclusion from these articles was that increasing the diversity of the physician workforce could help reduce racial inequalities in health care, a position advocated by leading mainstream medical organizations such as the American College of Physicians, the Institute of Medicine, and the Association of American Medical Colleges. This has become the lead argument for affirmative action in medicine.

But this stance too has its limitations. Some of the research in this area has shown no additional benefits to black patients, while critics have argued that several influential studies were either methodologically flawed or overstated their conclusions. There have even been some reports that hint at the possibility that black doctors, for a variety of reasons, might deliver a lower quality of care.

Moreover, the focus on same-race pairings overlooks a larger aspect of U.S. medical care: International medical graduates (IMGs) constitute about 25 percent of American doctors. The vast majority are of Asian and Middle Eastern ethnicity. In many settings where poor patients—black and white—are treated, IMGs make up an even larger percentage of doctors. Unfortunately, much of the medical literature examining same-race pairings specifically excludes these physicians. In a 2005 essay, Alok Khorana, an Indian physician practicing in New York at the time, examined these issues in his description of caring for an elderly black man with cancer. At the end, he questioned the wisdom of moving toward black doctor-patient pairings as a targeted goal, wondering whether this might “close the doors to self-examination and self-improvement” among physicians.

In my own medical experience, I'd seen same-race pairings work both ways. In some cases, a black doctor seemed to make a positive impact on a black patient's health, whether it was the nephrologist persuading a young man to take his blood pressure medications, the obstetrician convincing a young woman to attend prenatal appointments, or in my case, the delusional Lonnie thinking that I was Michael Jordan and being willing to take antipsychotic medication. On the other side, I'd seen white doctor–black patient unions operate flawlessly and had myself been a part of floundering relationships with black patients.

What all of this would mean for Diane, and my role as her doctor, I wasn't yet sure.

*   *   *

Diane returned for her appointment the following week. She immediately brought up her reluctance to come back to see me.

“I was talking with a friend a few days after I saw you,” she began, “about how ironic it was that I got scheduled with, you know, a black man. I seriously thought about canceling this appointment and requesting someone else. But she basically talked me out of it.”

I was once again at a loss for words. This felt like the plot of a formulaic movie, the kind where the first date goes poorly, with the man and the woman swearing never to see each other again, only to be strong-armed into giving it a second try by a friend or domineering parent. But this wasn't that kind of relationship. I was the doctor, the one she'd come to seek help from, only I didn't know what to say or do. So there we sat as the session began, fearful patient and frustrated doctor, both uncertain where this clinical venture would lead.

Gradually, we began the business of therapy. I asked more about her family. Diane spent the next half hour talking about her parents' marriage and their attitudes toward raising her and her older brother. She talked about her brother being a serial dater and his proclamations that he'd never marry or have children, and she wondered whether her family had scarred her in the same way. Then she shifted seamlessly into discussing her ambivalence about getting a Ph.D. and becoming an academic, describing how she felt torn by the desire to do something more exciting and immediately accessible with her life. By the end of that session, I felt a little better about my role: maybe things weren't going to be as bad as I'd initially worried.

In subsequent visits, we broadened our scope to issues of class conflict within our race, the portrayal of race in the media, and what these larger issues meant for her growing up and for the life she wanted to live. As someone who grasped these racial concerns on an emotional level, I was a good sounding board. Over the ensuing months, our weekly visits challenged her anger toward black men and, by extension, her negative beliefs about herself.

About two months later, Diane started dating Mark, a black student in a different graduate department at Duke. She said it was the first time in her life that she'd dated a black man. It wasn't that black men never tried, but she always rebuffed their advances, finding them too aggressive, too intimidating, too much like her father. Mark was well on his way to this same fate when Diane decided, after weeks of exploring her feelings about race in our sessions, that she'd give him a chance. At first she was afraid she might repeat her mother's mistake, but so far Mark seemed gentle and caring—vastly different from her dad.

It wasn't my place to encourage her to date a black man. Nor did I have hang-ups about interracial dating. What mattered was the transformation that she was undergoing—from someone who loathed black men and all of our negative stereotypes to someone who was open to the idea of treating each one of us on the basis of our individual merits. Week after week, we talked about the progress in their relationship.

Finally, after several months, she ended one of our sessions: “You know, I feel a lot better. This has been good. Thanks.”

It sounded like a good-bye. When I asked her if she wanted to schedule another appointment, she told me that she would get back to me. About two weeks later, she sent me a heartfelt handwritten note, thanking me for all of my help.

The impact on me was profound. I had entered psychiatry with a biomedical slant, dubious toward those who were strident psychotherapy advocates. But I am certain that no medication could have altered Diane's outlook on race the way that our sessions did. And I had now witnessed the unique benefit that racial matching could have in a clinic setting.

Several years later, I contacted Diane in order to get her consent for me to describe her case in an article that I was writing. I'd periodically wondered how she had been doing, whether the gains she made during treatment had been sustained or if she'd reverted to past insecurities and conflicts. We met at a coffee shop not far from campus. She seemed surer of herself than I remembered. No diverted glances, no stuttering, no tapping of her feet or trembling of her hands. We were meeting as peers.

I started off giving her updates on my career. Then we turned to her life. “I've grown so much since the time I saw you. You really did help me.”

She told me that she'd married Mark. They'd recently celebrated their third anniversary. He was nothing like her father. We talked about how unlikely her present life seemed when she first walked into my office. In other areas of her life, things were going well too. She was about to finish graduate school, and had taken a job as a professor at a college in California. She was also doing some writing for a women's magazine. She looked happy.

As the rain outside progressed from a few drops to a steady drizzle, I looked at my watch. I had to get back home. Knowing this was likely the last time that we'd see or speak to each other, we shook hands and said good-bye. I couldn't know whether she would have arrived at this place in life with someone else's guidance, or even on her own, but for once, I felt that by being a
black
doctor—rather than simply a doctor—I had truly offered a patient something more.

 

9

Doing the Right Thing

On an idyllic spring Thursday afternoon, two patients, Adrian and Henry, were among the half dozen on my schedule. Like most people, they had both made decisions that impacted their health. Those choices were diametrically opposed and, not surprisingly, resulted in dramatically different outcomes. These two men raised a question I'd been asking since medical school, one that I'd heard many doctors, in frustrated moments, bring up: How much impact can we really have on patients' lives when their own behavior influences their health to such a large extent?

After finishing my psychiatry training, I stayed in the Raleigh-Durham area where my wife had established a primary care practice. I'd taken a Duke-affiliated job in which, among other duties, I spent two days each week in an outpatient mental health clinic. Staffed by a mix of psychiatrists, psychologists, and social workers, my primary role was to prescribe medications and provide brief counseling to patients. This followed a model common in mental health practice; the sort of in-depth therapy that I'd done with Diane as a psychiatric resident was carried out by the psychologists and social workers.

For three years, Adrian had been coming to see me every three months for treatment of his chronic anxiety and insomnia. He had a history of alcohol and cocaine abuse, but had been clean for more than a decade. Initially, I had referred him to a psychologist for talk therapy, but he didn't like it. He wanted to feel calmer and sleep better at night, but didn't take to the idea that discussing his life in depth would help. Instead, we had tried a handful of medications with varying degrees of success.