Black Man in a White Coat (28 page)

On this particular day, I'd spent too much time gossiping with colleagues over lunch, so I didn't review the charts of my afternoon patients for any interim updates. When I walked to the waiting area and saw Adrian, it was obvious something had happened since we last met. Something bad. His body trembled as he turned to me. The right side of his face drooped. A shiny metal rolling walker was parked next to his chair. He'd lost at least thirty pounds.

Maybe he had been in a car accident. Maybe he had a brain tumor. Or, most likely from what I knew of his history, he had suffered a massive stroke.

His eyes locked on mine. He recognized me, but his face struggled to generate a smile. Could he move his arms to shake my hand? Could he still talk? I wasn't sure how to respond, so I tried to act as if his appearance wasn't distressing to me. “Come on back,” I said.

Adrian's wife, Ellen, stood first, helping keep Adrian steady as he slowly rose from his chair. She'd come to a handful of visits with him in the past where they'd talked about marital issues, or the problems with their daughter's taste in men. Her focus had now fully shifted to caring for Adrian. She swung the walker so that he could grab hold of it and keep from falling. With Adrian and his walker sandwiched between us, Ellen and I guided him down the narrow hallway to my office. What three months earlier had taken fifteen seconds from start to finish, now took five minutes.

Ellen wasted no time getting to the point: “A.C. had a stroke two months ago.”

She called him “A.C.,” the initials of his first and middle names. This always made me think of my dad, who many relatives still called “C.D.,” as my grandparents had chosen his initials before settling on a name. Adrian's thick graying hair also resembled my dad's. These similarities made me look forward to our visits, even if progress was limited.

“Where did it happen?” I asked.

Adrian tried to answer: “Baa … baa … baa…”

I was thinking as a doctor, trying to decipher what part of the brain had been affected, and in turn, what bodily functions were diminished or lost as a result. I looked over at Ellen, who fought back tears. This was no clinical challenge for her; this was her new, terrifying reality. She took me back to the moment that Adrian's previous life had come to an end: “We was at home. I was fixing dinner when I heard a loud noise in the other room.”

She found him at the other end of their new mobile home, collapsed on the bathroom floor. He couldn't move half his body; he couldn't talk. After a week in the hospital, he was transferred to a rehabilitation facility where he'd received the usual services: physical therapy, occupational therapy, and speech therapy. But Adrian hadn't made much progress, nor did the doctors expect him to based on the severity of his stroke.

I thought about what took place a year earlier. Adrian, then sixty-five, had been admitted to a local hospital for a transient ischemic attack (TIA), or “mini-stroke.” People who suffer a TIA often present with classic symptoms of stroke, such as sudden weakness, trouble speaking, or loss of vision, but the symptoms resolve within a matter of hours with a return to normal functioning. When he came to see me after that episode, Adrian acknowledged that he had dodged a bullet. But while he'd taken his daily aspirin and blood pressure medication, his diet wasn't much better and he hadn't stopped smoking cigarettes as he'd been advised. Now the second bullet had nearly killed him.

I looked back at Adrian. His efforts to talk had generated a slow trickle of saliva. He'd lost control of the ability to swallow. I winced. For some reason, saliva and mucus had always bothered me a great deal, far more than the sight and smell of blood or urine. I offered a tissue, but Ellen pulled out a white handkerchief that she used to wipe the pooling spit.

Adrian couldn't eat without the risk of choking or aspirating food particles into his lungs. Ellen pulled up his shirt to show me the tube that connected to his gut, through which he'd likely be fed the rest of his life. He also wore a diaper. My mind shifted to my own life. I had a toddler son at home who ate few solid foods and made a lot of babbling sounds. Dirty diapers were a daily chore. The thought of Adrian functioning at this level overwhelmed me, especially once Ellen started crying. What could I possibly say that would make the slightest difference for them?

“I'm really sorry about all of this,” I said, offering Ellen a tissue that she used to dab her eyes and blow her nose. “Is there any way that I can help you?”

Quickly composing herself, she went through a list of things that were more appropriate for Adrian's primary care doctor to address, such as renewing orders for his adult diapers and tube feedings. But desperate to feel useful, I obliged. While this surely helped her, I was left feeling that my actions were ultimately pointless. In terms of treating Adrian psychiatrically, there wasn't much to do. I increased the dose of the new antidepressant that had been started in the hospital, but that felt about as useful as giving Tylenol for a severed limb. After they left my office, I went to the break area in search of sugary comfort food.

The next few patients went by in a blur. As they talked about their marital problems and miserable jobs, I thought about Adrian's future of babbling, tube feedings, and diaper changes. I wanted to tell them to just go outside and enjoy the sunny seventy-five-degree weather. To be grateful that they could control all of their bodily functions and stop complaining about things that, in the end, really weren't that important. If they hated their job, they could get a new one. If their husband or wife was a lousy spouse, they could find another one of those too. But Adrian couldn't get a new brain. This was not the day for my patients to see their empathetic shrink. I tuned them out.

Then Henry walked in. He was my last patient of the day. My mind was focused on speeding through his visit and dropping by the store to get an ice cream cone or box of cookies to eat on the drive home. But when I spotted Henry in the waiting room, my heart skipped a beat. His six-foot frame was noticeably thinner than when I'd last seen him a few months before. His polo shirt and slacks were loose and baggy, as if he was a trim teenage boy who'd put on clothes that belonged to his middle-aged dad. Possible causes for his weight loss swirled in my head. Did he have cancer? Had he quit taking his medications and become so manic and psychotic that he'd stopped eating?

I'd seen Henry for about as long as I had treated Adrian, our visits spaced out every few months. He had been diagnosed with schizophrenia in his mid-twenties, but the psychiatric label had changed a few decades later to schizoaffective disorder—a mixture of schizophrenia and bipolar disorder in his case—after he'd been hospitalized with a full-blown manic episode. The doctors in the hospital had started him on a medication that treated his mania and delusions, but it made him tired all the time and made his muscles too stiff to drive a car or work in his garden. His previous clinic psychiatrist tried a few other medications before finding one that treated his mental illness without limiting his daily functioning.

The only problem was that it caused weight gain. A lot if it. In less than five years on the drug, he gained fifty pounds. With this excess weight came diabetes, hypertension, and high cholesterol, all of which required treatment with other drugs. The medicine that calmed his mind was hurting his body. When I saw his weight loss, I wondered if he had decided to stop taking it for this reason. But that would be a quick way to relapse into a psychotic episode.

I ruled out any acute change in his psychiatric condition, however, when Henry greeted me with his usual enthusiastic grin, an amusing cross between comedians Eddie Murphy and Arsenio Hall. “Heya Dr. Tweedy,” he said as always, “it's a pleasure to see you again.”

He sat in the same chair where Adrian had been just a few hours earlier. “How have you been feeling recently?” I asked.

“Good. You know, I still hear that voice, but you know, with the medicine, it's not getting any louder or telling me any of that crazy stuff anymore.”

For many years, maybe decades, Henry heard the voice of a man that told him that his mom was an ugly bitch and that his dad was a child rapist. With medication, the voice only said his parents' names without the added commentary.

“How about physically?” I asked. “Have you felt sick or weak?”

“No,” he replied. “I've been feeling good, man.”

“It looks like you've lost some weight,” I said.

The toothy grin came back. “Yes sir,” he said, rubbing his hands across his smaller belly. “Twenty-five pounds. I can't wait to get on your scale.”

“Have you been missing any doses of your medication?”

“No sir. My wife won't let me get in the bed with her until after I take it.”

I suppressed a smile. Henry handed me the results of recent blood tests from his family doctor. Nothing abnormal there. If anything, his numbers were better, with lower cholesterol and blood sugar values.

“What have you been doing to lose so much weight?”

Falling back on the usual medical pessimism, I wondered whether he was taking some kind of diet suppressant or other quick fix that might ultimately prove harmful.

“I've been doing the right thing,” he said, smiling again. “I'm getting away from eating all that artery-clogging crap. You know, fried stuff, processed stuff. I also started walking a lot.”

It finally sank in: Henry had made real, positive health changes. This visit was going to have a happy ending. Given how the afternoon had started, I'd been so focused on finding the bad that I hadn't seen the good when it was staring me in the face.

“I finally started listening to you,” Henry said.

I was thrilled. Because he took a medication known to promote weight gain, I checked his weight at every visit. This provided a natural opening for me to ask about his diet and exercise habits. For the hundreds of patients with whom I talked about lifestyle changes over the years, however, my medical advice gradually felt more like a routine than personalized care, as if I was simply going through the motions. The fact that people often ignored my recommendations only heightened my cynicism. However, Henry had taken my words to heart.

I renewed his medication, energized by his gratitude. We then walked down the hall to the scale. Henry had indeed shed twenty-five pounds. Keep it up, I urged, even as part of me feared that he, like so many other people, might soon slip back into unhealthy habits. Nevertheless, seeing Henry was just what I needed. I decided to follow his lead and go play tennis rather than gorge myself on ice cream and sugar cookies.

On this day, one man had made good choices and increased his odds of a healthy future. The other hadn't and, at least partly for that reason, faced a heartbreakingly new life. Driving to the tennis court, I was nagged by the same unsettling thought that had come to mind periodically over the years, one I usually tried hard to keep at bay: Could it be that despite all the years I spent in medical school and residency training acquiring specialized knowledge and practical skills, that this expertise mattered little to my patients' overall health?

People either made healthy decisions or they didn't. Those behaviors in turn would determine, far more than anything a doctor could do, whether they had a heart attack at fifty-five, cancer at sixty, or lived to be seventy-five or eighty before developing any serious problems. Time and again, black people, such as Adrian, suffered the worst outcomes from these bad decisions. As a physician, what influence could I have, if any, in helping them do better?

*   *   *

The choices that we make have a profound impact on our health. Sometimes it's a single, simple decision—wearing a seat belt or a condom at a given moment, for instance—that can have far-reaching consequences. More often, though, it's the daily decisions repeated over time that catch up with us. Smoking cigarettes, abusing alcohol or drugs, eating too much and too many bad foods, and exercising too little all can lead to an array of diseases. Of the ten leading causes of death in America (among them heart disease, cancer, stroke, and diabetes) each is strongly influenced by our actions. Researchers from the Robert Wood Johnson Foundation, a New Jersey–based philanthropic organization devoted to health and health care, estimated that behavioral choices account for at least 900,000 deaths each year and “represent the greatest single domain of influence on the health of the U.S. population.”

While all of us make decisions that shape our health, the reasons we make those choices are more complex. A large body of research has shown the important role of culture and environment. Socioeconomic status, both as we begin life and as we traverse it, is paramount. Whether measured by educational level, income, occupation, or some combination, low socioeconomic status is linked to a wide range of health problems and higher mortality rates.

Low-income settings adversely impact individual behaviors, such as smoking, drug abuse, nutrient-poor diets, sedentary lifestyles, and less likelihood of following medical treatments. These negative patterns in poor neighborhoods often become self-perpetuating. Clearly, such factors have a direct effect on health disparities, as black people remain, on average, at the bottom of the socioeconomic scale. But putting all of the blame on socioeconomic status and personal choice didn't feel right. Was it possible that I was making excuses for inattentive medical practice?

Looking back to medical school, I remember little instruction on how to address the role of lifestyle habits on our patients' health. For example, we learned how cigarettes and alcohol damage the body, but not about why people smoked and drank or how we might intervene beyond prescribing a handful of modestly effective medicines. This biomedical focus persisted as we transitioned to the medical wards. Patients on our services were broken in some physical way, and our job was to fix them, or at least make them temporarily better, whether through surgery or intensive medication therapies. A high premium was placed on “doing something,” which meant using your hands or your knowledge of pharmaceuticals.