Black Man in a White Coat (31 page)

Despite my professional success relative to my family and those from my neighborhood, here, among Duke's black medical elite, I was just another face in the crowd. And that suited me just fine. It meant that I was not alone on my nearly two-decade journey with race and medicine. Furthermore, Duke's story was just one of many throughout the country; most medical schools could tell their own narrative of racial resistance and progress. Meriwether, Armstrong, Spaulding, and other racial pioneers had enabled “people like us” to flourish.

As the evening drew to a close, I migrated toward the front where the distinguished guests had been seated. This was my first time seeing Dr. Meriwether. I wanted to walk up to him and introduce myself, to tell him how inspirational his story was to me. I wanted to tell him that as a former athlete of much less distinction, I admired his achievements in track and field. But he was surrounded by so many people, and as I've always been nervous in such settings, all I was able to do was walk past him, smile, and say “thank you.” He smiled back. I hope that he understood the significance of his story to my own and so many others like me.

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In the months following this ceremony, I revisited some of the places that had served as formative experiences in my medical education.

My first stop was the rural charity clinic where I'd met Tina and Pearl so many years earlier and seen firsthand how not having health insurance can be dangerous to one's health. The clinic still operated on the same schedule, with Duke students from the first- and third-year classes making the ninety-minute commute one Saturday each month.

I arrived on a fall morning not long before the Affordable Care Act took full effect. Since my last visit, the clinic had moved into a 1,000-square-foot double-wide trailer, about twice the size of the previous space. It had come by way of the Federal Emergency Management Agency (FEMA), after flooding caused by Hurricane Floyd in 1999. Despite the upgrade, the new accommodations were still no one's idea of a modern medical clinic.

Inside the patients sat along rows of wooden pews like those you'd see in an old church. By mid-morning, more than a dozen people had arrived. As had been true fifteen years earlier, every patient was black. They didn't have appointments; instead they added their names to a list when they arrived. Rather than a fifteen- or thirty-minute wait to see a doctor for a blood pressure checkup or to get diabetes pills renewed, here a person might have to stay two hours for the same service.

Aside from me, the medical volunteers (a half-dozen students and a supervising doctor) were all white. The patients seemed to eye me as Pearl had done during my first trip there when she'd said: “It's so good to see a young brother in a white coat,” even if I wasn't so young anymore. For the first portion of the day, I settled in the rear of the trailer where Dr. Morgan, the physician volunteer, had set up a makeshift office. Pushed up against the nearby wall were a drum set, a keyboard, and several hymnal books used for a weekly choir practice, clear reminders that we were far away from the usual sphere of medical practice. We sat across from each other at a flimsy rectangular-shaped folding table where Dr. Morgan had stacked a few medical journals to peruse if time allowed.

“Are we ready for another exciting Saturday?” Dr. Morgan asked the group of students, as he sipped a cup of coffee.

Despite nearing retirement age, Dr. Morgan was just as enthusiastic as his students, showing no signs of slowing down. He worked full-time during the week in a busy community health practice a half-hour away. He had no connection to Duke or any other medical school aside from this once-a-month clinic, and relished this opportunity to teach students.

More importantly, he saw volunteering in this setting as part of his mission as a doctor. He knew the economic facts about the individual patients and the broader region: “Over twenty percent of the people who live here are below the federal poverty level. Among people who come to this clinic, the number is probably double that,” he commented. “As a result, we're the entry point for many of them into the health care system. We're delivering a vital service.”

Providers usually saw about fifteen patients on a typical Saturday, but on this cool, sunny day, nearly twice that many people came seeking care. Students saw them in two exam rooms, but so many people had arrived that the team needed to work faster to avoid extra hours in the clinic for everyone—patients, students, and doctor alike. So the students set up a third station at the corner of an open area, next to a water fountain and a bathroom, where they talked to patients in muted tones.

One by one, the students came in to discuss with Dr. Morgan the cases they had seen. Their stories were ones I'd heard countless times. Mr. A had diabetes and high cholesterol and struggled more with his weight since he'd been switched to third-shift. Ms. B had high blood pressure that required the use of three medications. Mr. C had diabetes, hypertension, and early-stage kidney failure. None of them had health insurance. All were the faces of health disparities.

However, these men and women had better options than the ones I recalled from fifteen years ago. The medications they received were largely available for $4 per month through generic medicine plans operated by Walmart and a few area grocery stores. Dr. Morgan could refer some of them to his community practice, which provided medical services, such as blood tests, X-rays, EKGs, mammograms, and the like, on a sliding-scale fee. Even if patients simply came back here to the free clinic in another month, they would be seeing Dr. Morgan again, rather than meeting a new doctor and starting over as in years past. These seemed like clear steps in the right direction.

But as Dr. Morgan knew, the work that they did in this double-wide was not enough to make a dent in the larger problem. North Carolina had hundreds of small towns like this one, many without the access to outreach programs such as what we offered. For a nearly two-year period after I had worked there as a medical student, this town had been in similar straits, as the clinic, without a faculty leader, had to close its doors until they could find a willing physician to volunteer. During that period, some people scrambled and found their way to doctors and clinics in neighboring towns. Others were left behind and simply went without medical care at all.

In October 2013 when I visited this clinic, the Affordable Care Act was preparing to launch in full, but debate about whether to scrap “Obamacare” still raged. Some critics expressed reasonable concerns—that it might escalate our ever-rising medical costs, have a negative impact on small businesses, or place increasing burdens upon medical practitioners that ultimately interfered with quality medical care. Others, however, attacked the law on a socially divisive level, implying that it was just another government handout to undeserving people. Yet it was clear—as it had been fifteen years earlier—that many of these uninsured patients had jobs, but for them, employment did not guarantee health care coverage.

“I'm really struck by how hard it can be for someone with a steady job to afford health care,” one of the students said to Dr. Morgan as we discussed a woman she'd just seen.

I'd experienced the same revelation in medical school. Because health insurance in the United States is most often employer-based, I once thought that most uninsured people simply didn't work
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“I just don't think people take the time to understand how diverse the uninsured are,” Dr. Morgan replied to her. “Most of them go to work and raise their families just like the rest of us.”

“How much impact do you think the Affordable Care Act will have with the people you see here?” I asked Dr. Morgan.

“It has good intentions,” he said. “But I'm really not sure if it will do enough.”

One big reason, he said, was that North Carolina, like its neighboring southern states, largely opposed Obamacare and rejected the law's provision that would have extended Medicaid coverage to people slightly above the federal poverty level. Analysis from the Kaiser Family Foundation estimated that about 350,000 additional people in North Carolina—including, clearly, many of those who came to this clinic—would have been eligible for coverage if the state had allowed the expansion. Nationally, they estimated that nearly 5 million people in the more than twenty other states that declined the Medicaid expansion would be excluded. Dr. Morgan felt certain that many of his patients would find themselves in the same health care straits as they always had. “It's sad,” he said.

While I agreed that having Medicaid was better than having no health insurance, I wasn't entirely convinced that it would fix the health problems of the people we'd seen. I thought about the Medicaid patients—both medical and psychiatric—that I'd treated over the years who were in much worse health than privately insured patients. I recalled the many times I'd heard doctors complain about Medicaid, bemoaning its lower payments and burdensome paperwork. Where would these new Medicaid patients go to seek medical care? But then I remembered the many uninsured patients I'd seen—black and white—who had lost their homes and life savings from an unexpected, and often unpreventable illness, and reminded myself that having health insurance was about more than what took place inside the doctor's office or hospital.

That afternoon, I drifted toward the front of the trailer where the remaining patients calmly waited their turn. Three elder community members who served on the clinic's board had arrived for a scheduled meeting with the student volunteers. They had all been involved with the operation of the clinic since its inception in the late 1980s. When I introduced myself to them as a former medical student who had volunteered there many years earlier, Kathy, affectionately known as the clinic's “matriarch,” took off her glasses and smiled.

“I remember you,” she said. “I have a picture of you picking cotton next to the clinic.”

I laughed in embarrassment, thinking that she had confused me with someone else, but she pointed toward a thumbtack board covered with more than a hundred photographs. There, a twenty-year time capsule came into view. In the photos, I saw classmates and other medical school contemporaries whom I liked and many more whom I hadn't thought about since graduation. Sure enough, near the bottom, I saw the picture of me with two classmates, each of us wearing the short white coats of medical students, our fingertips reaching out to touch the cotton plants all around us. We looked like small children pulling up dandelions in an open field. A second photograph showed me in the clinic sitting next to a classmate while she examined a patient. Memories of the past rose from these images, and I couldn't help but feel nostalgic for those early days of my training.

Kathy and her friends went on to talk about the changes in the town over the years. They told me about how one of the area's main employers had closed down in the 1990s and taken many jobs with it. I learned about the history of segregation in the area and how the civil rights era of their youths had inspired them to persist in their fight for black people to lead better lives. They told me how various family circumstances had made them stay or brought them back to the area, rather than take their chances permanently migrating north as my mother's parents had done. These felt like the stories my dad had told me so often over the years of his family's rural life in southern Virginia. As I had so many years before, I felt an intimate connection between this clinic and my ancestry.

I had one more stop to make before driving home. “Where is the old clinic?” I asked.

“Right down the street,” Kathy said. “Go down there and make a left past the church. It'll be the second one on your left.”

I followed Kathy's directions, and in less than three minutes, I had arrived. On my own, I would not have recognized the site of the former clinic. The cotton was gone; the fields had been left to the weeds. Across the one-lane road, I saw the old white house where we'd once seen patients. It looked like the small country home it was and gave no clues that it had once doubled as a medical clinic. A family lived there now, but they were not home when I arrived, so my opportunity to peek inside was lost. The surrounding area was filled with the sights of rural poverty I'd grown accustomed to over the years: a single-wide trailer next door, beat-up cars parked in several front yards, a friendly woman and man—perhaps mother and son—with several missing teeth.

Throughout my medical career, black doctors had often asked me to “give back” in two specific ways. One was through community volunteer work, such as at church-based health fairs and urban charity clinics. The other involved reaching out to black college students, medical students, and young physicians in social settings. More often than not, I'd found excuses to avoid both. I'd tell myself that I was too busy being a doctor, one whose clinical work already involved treating the downtrodden on a regular basis. Or that I lived too far away from Duke to drive back to socialize on my own time. Or that my difficulties with public speaking and large social gatherings made others better suited to act as mentors to young and future doctors. Once my sons were born, I shut off even the very limited volunteer engagement that I once had.

But as I left the small town that day, crossing over the railroad tracks and getting back on the highway, I felt that I'd reached a point in my life where I needed to do more on both fronts. On the heels of the banquet celebration, I'd been reminded not only of the impact that the pioneering black doctors of my parent's generation had on later generations of black doctors and students, but also their influence on their surrounding communities of black citizens. Writing this book has been my effort to live up to the standard they set.

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A few months later, I ventured to another rural county of North Carolina where I'd rotated during my ob/gyn clerkship as a second-year medical student. There, I'd helped treat many “baby mamas,” young black girls with limited education and job prospects facing the reality of raising children as single moms. Back then, I was a sexually naive medical student; I'd since become a full-fledged doctor, married for ten years, with two kids of my own. I was eager to see whether maturity had altered my perspective on these women and their lives.