Black Man in a White Coat (29 page)

During my general medicine rotation as a second-year student, our team admitted a sixty-year-old black man with chest pain. He had hypertension and high cholesterol, two risk factors for heart disease. He was also about forty pounds overweight. He was the sort of patient we saw dozens of times throughout our training. After all of his tests came back normal, we discharged him with prescriptions for aspirin, a blood pressure medication, and another pill to lower his cholesterol. The doctors told him that he should lose weight, but did not offer any guidance on how to improve his diet or integrate exercise into his life.

A few hours later, I had lunch with the two resident doctors on our team. Angela, the medical intern, was a black woman from South Carolina who planned to become a liver disease specialist. She was about thirty pounds overweight. Mike, our supervising resident, was a sandy-blond ex-football player from Iowa. I asked them their thoughts on counseling patients about nutrition and exercise.

“We should probably do more,” Angela said, eyeing her hot dog and French fries with obvious guilt. “But I guess I'm not in much of a position to tell anyone how to be healthy.”

Mike, who carried a few extra pounds too, seemed free of Angela's self-consciousness. He swallowed a large bite from his slice of thick-crusted pepperoni pizza: “That's the responsibility of his outpatient primary care doctor,” he said. “We're here to deal with the life-and-death stuff.”

This focus on biomedical treatment over preventative care is not limited to Duke or similar schools. Indeed, outpatient primary care physicians—the doctors that Mike felt bore the responsibility for counseling patients on diet and exercise—are often no more inclined than other doctors to have this discussion, even for diseases where these interventions are vital. There are many barriers, among them money (dietary counseling is reimbursed poorly compared to medical procedures), time (physician often see patients every ten or fifteen minutes), and the sense that nutrition talk is better left to dieticians, and that doctors should focus on their expertise (prescribing medications, interpreting tests, and performing procedures). In addition, experience has made many doctors cynical about patient behavior and the likelihood for change.

On the drive home from the tennis court, I tried to remember how much I'd talked to Adrian and Henry about these issues in our past visits, and what I'd said to them. When Adrian didn't stop smoking or eat better after his mini-stroke, did I keep encouraging him to do otherwise? Had I told Henry that weight gain on antipsychotic medication was something he simply had to accept? I could only hope that somehow I'd said the right things. But even if I had, why had Henry listened to me and Adrian hadn't? Was the problem in the system, with them, or with me?

*   *   *

Over the course of several visits, I learned Adrian's history. He'd grown up in the civil rights–era South of the 1950s and 1960s; his dad was a plumber and his mom a homemaker. He'd been drafted into the Army shortly after graduating from a segregated small-town high school. After a year in Vietnam, he came home and found himself overwhelmed by anger and grief, so he turned to alcohol and street drugs to dull these emotions. Nonetheless, he lived a functional life, holding steady work as an electrician. After a rocky ten-year marriage to his high school sweetheart, he divorced, and a year later, met his second wife, Ellen. Together, they had a daughter, now in her late twenties.

By the time we met, he'd gotten involved with a church, and had been clean from alcohol and cocaine for over a decade. But shortly after he retired at age sixty-two, the anxiety and insomnia that had plagued him in earlier years slowly returned. At Ellen's urging, Adrian started coming to our clinic. We talked a little at each visit about the possible causes for his symptoms, such as the conflict with his daughter and his tour in Vietnam, but he was more interested in finding a medication cure than a talking one. Medication did help, but various side effects bothered him when he took them daily, so he settled into a pattern of taking a sedating antidepressant medication a few times a week. This seemed to satisfy him for the most part.

We had been in this state of equilibrium for a while when Adrian came to see me after suffering the mini-stroke. He'd been at home watching TV when the right side of his face became numb and he started slurring his words. He spent two days in the hospital, and his symptoms resolved. The neurologists counseled him on the basics of secondary prevention, which included taking aspirin, starting a blood pressure medication, and revamping his dietary and exercise habits. Last but not least, they told him to quit smoking.

Adrian reported taking the aspirin and blood pressure pill. He said that he'd cut back a little on eating fast food but not as much as he was supposed to. “How about smoking?” I asked. Two of my patients in this clinic who had survived serious heart attacks in recent years had quit smoking after their episodes.

“I stopped for a month,” he said, looking to Ellen, then back at me, “but our daughter started having problems with her boyfriend again and…”

I'd heard some variation of this from patients many times before. In a perfect world, they could stop X or Y behavior, only life kept getting in the way. I prescribed an antidepressant helpful in smoking cessation, but it worsened his anxiety, so he didn't take it long enough to help him quit. At the next visit, I prescribed nicotine patches and referred him to a stop-smoking class. Adrian canceled his initial session and did not reschedule. He said the patches didn't work and caused him to have bad headaches.

I gave up. Looking back at my notes, I could see that I never mentioned the smoking issue again. I never bothered to ask at what age he started, whether he had tried to quit before, why he thought he smoked now, or what might motivate him to quit. I never considered prescribing another smoking-cessation medicine that I had given to a handful of patients with good results. I'm not sure why I avoided all of this—had I become too cynical to even care whether he kept smoking?

Silence on this issue during our visits continued up through the fateful day that Adrian lost his ability to speak. He had finally stopped smoking, but it was clearly too late. He had not been able to change his behavior in time. Could I have done more to help him?

Henry, like Adrian, had grown up in rural North Carolina in a poor family. His dad worked in a factory while his mom cleaned houses in town. Henry went into the Army after high school just as Adrian did; however, being five years younger, he avoided being sent to Vietnam. Nonetheless, he experienced his own mental struggles. About two years into his Army stint, he started hearing voices. He began to act so strangely around his superiors that he could no longer perform his duties; he was soon confined to a hospital and put on high-dose antipsychotics. This marked the end of his time in the military.

Unlike some with psychotic illness, Henry's problems ultimately proved mild enough that he could maintain a job and a marriage. Other than one time in his mid-forties when he briefly stopped his medicines because of severe side effects, he'd never been readmitted into a hospital after his initial episode. He settled in to work as a janitor for a local post office. He'd been married to the same woman for twenty-five years. They had a daughter who had recently finished college.

By the time I met Henry, he had been stabilized on his antipsychotic medication for a few years. It was the best he had ever felt on a medication. Some of the previous drugs he'd tried hadn't worked. Others, while effective in calming his psychosis, caused an assortment of side effects—dizziness, tranquilizing sleepiness, muscle stiffness, and a hand tremor, to name a few. With his current treatment, he felt great—except for the fact that he kept gaining weight. I discussed switching him to a newer antipsychotic drug less likely to cause this problem. He resisted. “I don't want to mess with it,” he said. “I can't wind up back in a hospital.”

He had a point. Compared with the psychotic delusions of schizophrenia or bipolar mania, it's better to be overweight. In psychiatry, many doctors have accepted obesity as collateral damage, since some of our best medications can cause substantial weight gain. Establishing sanity and maintaining a healthy waistline can seem like incompatible goals. Removed as we often are from day-to-day general medicine, many of us are tempted to punt responsibility back to the primary care physician for managing the medical problems that our medicines cause or worsen. In Henry's case, that meant pills for diabetes, high blood pressure, and high cholesterol.

Until his most recent visit, Henry had shown no signs that he was serious about losing weight. But somehow, unlike with Adrian, I hadn't given up. At each visit, if only for a few minutes, we talked about what kinds of foods Henry ate and ways he could become more physically active. For more than a year, it had been a losing battle, as Henry soared above 275 pounds. But then, on the same day I saw Adrian, Henry showed up 25 pounds lighter. When he returned three months later having lost more weight, I knew this was more than a fad diet. As we talked about his progress, he brought up the issue of race, which he'd never done before.

“You know us black folks don't always eat like we should,” Henry said. “That's how we grow up. With all that fried food and other bad stuff. Even when we eat greens, we drown 'em in grease and salt. Now I'm trying to eat one big salad every day and lay off the rolls and other bread. I'm drinking water instead of sweet tea. And I'm walking for thirty minutes every day.”

These were real accomplishments. Over the years, I'd seen many black patients undermine their health through bad eating and sedentary living. While America as a nation struggles with its waistline, nowhere is this more evident than with black people, who are 50 percent more likely than whites to be obese. Stunningly, black women are nearly twice as likely to be obese as white women. The role of lifestyle in health disparities cannot be overstated.

“What's been your biggest motivator to lose weight?” I asked him.

He started to tear up. “I want to see how my daughter's life turns out.”

Henry continued to lose a few pounds between each visit. Three years later, he had dropped fifty pounds and was just a shade over his weight back when he had started his current medication. He no longer needed to take pills for diabetes or high blood pressure. The dose of his cholesterol medicine had been cut in half.

Several months later, however, after missing an appointment, Henry had a setback. My heart sank as the scale showed he'd gained almost ten pounds. Since it is widely known that keeping weight off is harder than losing it, I feared this was the beginning of an inevitable backslide. I reminded Henry of how far he'd come, encouraging him while silently doubting he'd get back on track. Yet when he returned to my office three months later, not only had he shed the weight that he'd recently gained, but he'd lost a few extra pounds too. “Seeing you helps keep me on top of things,” he said.

What had made the difference between Henry and Adrian? The secret didn't seem to be in their backgrounds: Both had grown up poor, obtained similar educations, held steady jobs and marriages, and had raised daughters on the cusp of middle-class lives. Both had psychiatric diagnoses correlated with worse physical health. Both struggled with lifestyle behaviors that were notoriously difficult to change.

Maybe, I thought, at least part of the difference lay with me. I began examining my own attitudes. Had I treated them the same? I'd never smoked cigarettes or used street drugs, nor had I ever gotten much out of drinking, so I struggled to understand the psychology of Adrian's addiction. On the other hand, I could fully connect to Henry's dietary and fitness problems, being intimately familiar with the feelings of making poor food decisions and eating to excess. Maybe these factors made me more invested in helping Henry. Given the impact that physician advice can have on patient behavior, I was left wondering if I'd somehow sold Adrian short.

Of course, it's possible that nothing could have helped Adrian quit smoking or make other health changes after his mini-stroke. But perhaps if I had tried more, at least I could see him now in his diminished state certain that I had done the best that I could for him.

*   *   *

Treating Henry and Adrian made me reflect on my own health. After being diagnosed with hypertension and signs of early kidney disease in my first year of medical school, I had spent more than a decade engaged in a health battle of my own. Armed with medical knowledge and motivated by fear, I radically altered my diet and exercised every day. By the time I began seeing patients struggling with obesity and hypertension, my own blood pressure was under control. My health problems seemed to have been solved.

During my last year of medical school, however, I slowly slipped back into old habits. This occurred in such a subtle fashion that I didn't really notice at first. It started off with me treating myself to a few cookies or a small bag of potato chips after some days in the hospital. On weekends, I'd go out with classmates and pay little attention to what I consumed—eating large amounts of food that were salty and sweet. Overall, I still ate healthier than I had before medical school, and near-daily exercise kept my weight down. I was seduced yet again into the notion that I was healthy simply because I looked that way to the outside world. And when I checked my blood pressure—which I did less frequently—it was higher than the ideal 120/80, but still within the normal range. So I didn't worry.

But that all changed during my grueling year of medical internship. Borrowing from the language of substance abuse treatment, I relapsed. The hectic pace of work allowed for only quick meals. Our nomadic existence within the hospital discouraged a routine of packing sensible lunches. That left the cafeteria—and whatever free lunches around the hospital we could get our hands on—as the default choices. A typical breakfast might offer a choice between French toast and pancakes, a lunch of fried chicken or a cheeseburger, and dinner some variation on the lunch menu. For overnight shifts, midnight pizzas accompanied by high-sodium breadsticks were a mainstay; a high-salt deli sandwich was the “healthy” alternative. It almost seemed as if the hospitals, with their robust cardiology and oncology divisions, were ensuring a steady supply of future patients.