Black Man in a White Coat (32 page)

The Duke-staffed ob/gyn clinic still operated in the same space as it had years before, at the county health department. Two second-year medical students and a second-year ob/gyn resident had taken the identical forty-five-minute drive from Durham that I remembered, one where we had talked about everything from the finer points of examining a pregnant woman to what we would be doing with our lives if we hadn't taken the medical path. But as had been true with the free clinic I'd recently visited, here too I found upgrades from my medical school days. The most obvious was the person who greeted me as I entered the rear hallway.

“You can lose the white coat,” Dr. Norris said as he shook my hand. “I like to keep things a little less formal around here.” Dressed in a mock turtleneck and slacks, with a graying beard and thinning hair, he looked more like the psychiatrists that I worked alongside than an obstetrician.

Dr. Norris offered some personal background while providing a quick tour of the spartan facility. Born and raised in Virginia, he'd moved to North Carolina for residency training and never left. He was approaching nearly twenty years in practice. He worked at this clinic once each week and at a similar one in a neighboring rural county on another day of the week, a schedule he'd kept for nearly ten years. The rest of his time was devoted to private clinic practice. He'd been drawn to this position supervising Duke trainees because of his dual interests in teaching and providing medical care to people who otherwise couldn't afford it. “This is just as much real medicine as taking care of some rich executive's wife,” he said. He sounded a lot like Dr. Morgan.

Dr. Norris's presence had a similar stabilizing effect on this clinic. During my rotation there more than fifteen years earlier, the ob/gyn resident was haphazardly supervised—if at all—meaning that patients were less likely to have consistent medical care. With the reliable presence of Dr. Norris, as with Dr. Morgan at the free clinic, the patients were afforded the luxury of a supervising doctor who knew them. “When you see a different doctor each time,” Dr. Norris said, “you're more likely to get impersonal care, and that's often not so good for the patient.”

The morning was especially busy—a snowstorm had closed the clinic for part of the previous week, and nearly two dozen women had been rescheduled. Many were pregnant and came for checkups; others came seeking to start, renew, or change contraceptives; a smaller group was scheduled for annual gynecological exams. Most were on Medicaid. Many others were uninsured. The demand for care was immense. The flow of patients was so steady that Dr. Norris and his team staggered fifteen-minute lunch breaks to accommodate the influx.

About mid-morning, one of the medical students came to the staff work area to discuss a case with the ob/gyn resident. An eighteen-year-old woman's impending motherhood was prompting her to abandon plans for college. The student seemed to have difficulty understanding how she had ended up in this situation. I could relate, as I'd felt similarly as a medical student about the pregnant women and young mothers I saw back then.

However, with experience, life had taught me a few lessons. While my wife and I had consciously sought to conceive our first child, our second was not planned. The adjustment to caring for an infant was challenging for me, with the constant sleep deprivation, diaper changes, and other struggles of new parenthood. So the news of a second baby arriving before our first child had turned a year old sent me into near-panic. But it shouldn't have been surprising at all: As a medical doctor, I had a good idea of how babies were made.

Of course, I had several advantages that this young woman and others in the clinic lacked: a steady job with a good income, a marriage partner on even better financial footing, and the invaluable benefits of an advanced education. All these factors made my family's unplanned pregnancy far less life-altering from a social or economic standpoint. But my behavior and the actions of this eighteen-year-old woman—having unprotected sex without thinking through the consequences—had been the same. I understood how this young black woman had wound up with an unintended pregnancy, even as I saw the terrible cost to the black community of having so many single women bearing and raising children without fathers.

Later that morning, a second student presented a case of an uninsured woman in her mid-twenties seeking contraception. She had experienced bad side effects from birth control pills, so her options were limited. Based on a variety of factors, the patient and the doctor decided that an intrauterine device (IUD) would be best. Then came the hard part: Dr. Norris wasn't sure whether she would be able to obtain one at a lower price that she could afford. The clinic received a limited supply that they could dispense at reduced cost. That supply had run out.

I asked whether the Affordable Care Act, with its ambitious goal to expand health insurance to nearly 30 million Americans, might have an impact on these sorts of scenarios. His answer was nearly identical to Dr. Morgan's: “I'm not sure,” he said, clearly frustrated. “I think some of my patients will continue to fall through the cracks.”

He too mentioned North Carolina's decision to reject Medicaid expansion as a barrier. He offered two real-life casualties, two middle-aged black women whose fibroids caused them to have “basketball-sized uteruses.” Along with significant pain, they experienced heavy bleeding during their monthly cycles. With insurance, they would have been eligible for a curative hysterectomy; without it, their clinical situation had to deteriorate into an emergency before they could get such care. He described both women as hardworking and responsible. It sounded eerily similar to Tina's situation that I had encountered as a medical student. It was yet another example of how systematic failures could dictate a person's health and threaten their life in ways beyond their individual control. “It's really a damn shame,” he said. “I think the system really needs to be turned upside down and inside out in order to be fixed.”

When I started medical school and learned about the adverse health outcomes that afflicted black people, I had assumed these disparities were due chiefly to genetics. To be sure, there are diseases, such as sickle-cell anemia, lupus, and sarcoidosis, which appear to preferentially target black patients at a biological level. But what had become abundantly clear during my years in medical school and as a doctor, however, were the many ways that social and economic factors influence health, and, more than anything else, account for the sickness and suffering that I have seen.

The problems take three forms. First are the system-based disparities that limit black people's access to medical care. Black people are disproportionately uninsured and, if insured, far more likely to have public insurance than private coverage. Further, owing in large part to geographic and residential segregation patterns, blacks are less likely to have access to primary care physicians, and even when available, such care is more likely to involve trainees and other rotating physicians rather than a consistent long-term relationship with one doctor. I'd seen these factors play out in real life with Tina and others at the charity clinic; with dozens of patients who used Atlanta's Grady emergency room for routine care; and with Steve and many others in my psychiatric training who couldn't get the substance abuse treatment or outpatient psychotherapy that they really needed.

Second, the doctor-patient relationship itself serves as a catalyst for differing outcomes. Here, the attitudes and behaviors of both doctors and patients are important. On one hand, some doctors are prone to hold negative views about the ability of black patients to manage their health and therefore might recommend different, and possibly substandard, treatments to them. On the other spectrum, many black people are mistrustful of doctors and medical treatments to their own detriment. I'd seen how Gary's reasonable assertion of medical knowledge and treatment preferences had left him with what I felt was an improper psychiatric diagnosis; how Carla had wanted Leslie sterilized after her stillbirth, and how I'd been disregarded by Dr. Parker until he learned that I was a physician. Over the years, I'd also watched numerous black patients ignore the sound clinical recommendations of well-meaning doctors of all races.

Finally, the unhealthy lifestyle behaviors of many black people are also a real factor. Pearl and others at the charity clinic ate an insalubrious soul-food diet; Leslie's drug use had likely caused her son's stillbirth; Lucy had died before our eyes in the Grady hospital emergency room from a potent mix of hypertension, diabetes, and family dysfunction; Adrian had smoked his way to a second, crippling stroke; and Monica had likely contracted HIV from the clandestine sexual life of her ex-boyfriend.

These heartbreaking stories were each in their own way complex, and illustrate how lasting improvement will only come through an array of changes employed simultaneously. Some of this responsibility rests with government and other large institutions, but much of it must occur at the individual and community level. When it comes to expanding access to quality health care, both government (federal and state) and large private insurers clearly have a major role to play. And it is here that the Affordable Care Act, with its expansion of Medicaid and creation of state-based insurance exchanges, has generated the most attention. The law certainly has some good features: placing millions more under the health insurance umbrella, prohibiting exclusions based on preexisting medical conditions, eliminating co-pays for preventive care, and ending annual or lifetime payout caps. But whether these and other changes will prove to be fiscally viable over the long term, in the face of ever-rising health care costs, remains to be seen.

On the doctor-patient level, efforts to improve the care of black patients have come from two directions. One side has taken a race-focused approach, advocating for widespread collection of race/ethnicity data to monitor for disparities, expanded cultural competency training, and increased numbers of minority physicians. The other method is more race-neutral, focusing on universal quality improvement initiatives to elevate the standard of medical care for everyone; its proponents argue that black people will benefit considerably because they often have worse health and have historically received a lower quality of medical care. For largely ideological reasons, there is a tendency to make these strategies an either/or proposition, but I don't agree. By and large, both methods can be employed simultaneously, and wherever they might conflict, the two sides should be rigorously researched against each other. If the goal is to improve the health of black people, who remain at the bottom of most health indexes, it shouldn't matter whether the means to achieving this follows a liberal strategy, a conservative approach, or something in between.

On the individual level, Henry's lifestyle transformation, along with my own, are just two instances of black people seizing control and deciding to live healthier through better choices about diet, exercise, and self-destructive habits. My parents too, thanks to good relationships with doctors and a willingness to reassess their earlier behaviors, have made major strides; they eat predominately fresh foods, go out walking most days, and take their medications as prescribed. Over the last several years, I've been comforted to see more and more black people at the grocery store buying fresh fish and bags full of fruits and vegetables. I've been equally heartened to see greater numbers of blacks exercising at the gym and at local parks. While there are certainly no guarantees, these habits form the foundation for good health. Ongoing public and private efforts to encourage healthier lifestyles can potentially benefit everyone, but black people especially, given that we are more likely to have an insalubrious foundation.

Despite the tragic stories I've written about in this book, there are clear signs of progress. Nationwide, teen pregnancy, infant mortality, and violent crime among black people are all down from where they were when I entered medical school in 1996. Between 1996 and 2010, the life expectancy of black males increased by more than five years, far exceeding the gains made by any other group during that period. Recent estimates put the narrowing black-white life expectancy gap at less than four years, when it was twice that a half-century earlier. Black people still are not as healthy as whites, Asians, or Hispanics in America, but the foundation has been laid for continued improvement.

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While public health and other research studies teach us many things about medicine, I feel nonetheless that the greatest lessons still come from the stories of doctor-patient encounters. Medicine, no matter the many changes it has undergone in recent decades, remains at its essence a face-to-face, human-to-human endeavor. When it comes to race, this human aspect of medicine has certainly caused injury to many black people over our history. But things have gotten better, even during my short time in medicine, and my experiences as a young doctor point toward ways for even further progress. As a black physician, my interactions with white patients pose the same potential cross-cultural challenges that white doctors face in caring for black patients. I've learned a lot about myself in these interactions, and found ways to break through boundaries imposed by racial tension and prejudice.

About six years ago, I met a young man named Keith while working at the same outpatient clinic where I treated Adrian and Henry. Keith was in his late twenties at the time, about five years younger than me, but he'd seen and done things that I couldn't really fathom. Keith had served two tours in Iraq, where he witnessed severely disabled Iraqi children strapped to bombs and sent on suicide missions. One of his closest friends died in a roadside attack. Another friend committed suicide days after his return home. Within six months of leaving the military, Keith found himself plagued by nightmares, severe anxiety, and suicidal thoughts. He was diagnosed with post-traumatic stress disorder (PTSD). By the time we met, he'd been under psychiatric care—seeing a psychiatrist every two months—for more than a year. He took Zoloft. He'd also attended several months of group therapy sessions.