Black Man in a White Coat (33 page)

As I skimmed through the note from his initial visit with a clinic therapist, it looked as if Keith's main passions were guns, motorcycles, pickup trucks, and race cars, which suggested that we had no common ground. I'd never held a gun, thought motorcyclists were crazy, hated noisy pickup trucks, and found NASCAR more boring than watching a group of men shaving their faces. In contrast, I liked tennis, drank fruit smoothies, and drove an SUV in which I often listened to classical tunes and rap music. It looked like a classic red state–blue state clash.

These differences were magnified when we met each other. He wore a camouflage jacket and hat with brown sweatpants and brown boots, as if his next stop was to take his pickup truck to some rural outpost to hunt deer. Based on previous patients of similar style and background whom I had encountered, as well as my innate biases, I made several negative assumptions about him. I predicted that he smoked cigarettes (and maybe marijuana), ate a poor diet, was narrow-minded, and probably prone to abusing alcohol and prescription drugs. In short, I looked at him in the same derogatory way that doctors so often unfairly approach black patients.

I suspect he had an equally negative impression of me. I had on a cream-colored dress shirt, camel sweater vest, beige pleated slacks, brown Oxford dress shoes, and a necktie that incorporated all of these earth tones. My watch, bracelet, tie bar, and wedding band all had a striped-gold pattern. I probably looked to him like a vain, wimpy guy who had never gotten his hands dirty. Whatever he thought, his face registered complete surprise when I introduced myself as his new doctor. I'd seen it many times: I wasn't what he was expecting. As so many patients and family members before him had reacted to me, Keith couldn't have looked more shocked if Shaquille O'Neal or Santa Claus had emerged from the doctor's office and greeted him.

I had replaced the psychiatrist who prescribed his Zoloft, so it made sense to start there:

“How have you been doing these last few months?” I asked.

“Good.”

“I see that you are prescribed Zoloft 100 milligrams per day.”

He nodded. “How often have you been taking it the last few months?” I asked.

It probably sounded like an accusation, but about half the patients I saw didn't take antidepressants as prescribed. Many preferred to take them only when they felt bad or anxious.

“Every day.”

“Do you feel that it's helping you?”

“Yes.”

“In what way?” I asked.

“I'm calmer.”

I waited a good ten seconds to see if he would elaborate. But his poker-faced stare suggested that he was waiting for me to make the next move.

“Are you having any side effects or other problems with the medicine?”

“No.”

I glanced at my watch. This terse exchange had only taken two minutes of real time. Patients were scheduled every half hour. My remaining questions about sleep patterns, other psychiatric symptoms, and alcohol and tobacco use weren't going to take more than a few minutes at this rate. Rather than simply proceed in this close-ended way and politely usher him out of my office with more than twenty minutes to spare, as many busy medication-oriented psychiatrists might do, I tried a different approach. When he mentioned that his girlfriend told him he sometimes still thrashed about in his sleep, I used that as an opening to ask more about her, inquiring into whether she worked or not, how they'd met, how long they'd been together, and what he liked and didn't like about her and her family. His one- and two-word answers became complex sentences. Before I knew it, our thirty-minute visit had nearly elapsed, forcing me to move quickly through the remaining symptom-based questions. As he left, I felt that we'd laid the foundation for a cordial doctor-patient relationship.

Two months later, he returned for his next appointment. He started off by telling me that he had gotten engaged. That led us to talking about his parents, who divorced when he was in the sixth grade. He discussed the ways he wanted his marriage to be different from theirs. Unlike many of my patients from separated families, Keith seemed to have a good relationship with both parents. He told me about a recent weekend where he watched a NASCAR race with his mom and played pool with his dad.

“Do you like nine-ball or eight-ball better?” I asked.

He looked at me, seemingly surprised that I knew anything about billiards. “I'll do eight-ball with my girlfriend … I mean, fiancée … but nine-ball with my friends or my dad, when there's money to be made or lost.”

I smiled. As a psychiatrist, I could have followed up with some screening questions to assess whether he had a gambling problem. Instead, I began a conversation. “How long have you been playing?”

“Since I was in the sixth grade. My dad bought a table for my birthday that year.”

My dad bought a pool table too when I was around that same age. During the summer, I'd watch the pros on ESPN and spend a few hours afterward imitating their shots. As I got busier with basketball in high school, my mom eventually claimed the space that the pool table took up in our cramped basement as her own, giving the table to my brother for his new place. Still, the joy I got from a game of eight-ball never faded. For many years, well into my twenties, whenever I would visit home, my dad and I would go to a neighborhood pool hall and play a half-dozen games. I'd win some and so would he, but we never even bothered to keep score.

“You ever run the rack in either game?” I asked. A few times, I'd come close to running the rack—playing through the entire succession of balls without missing, keeping my opponent from even getting a turn—but had never actually managed to pull it off.

He smiled. “It's been a while. I'm not good enough to get into any of that high-stakes stuff—I never win or lose more than twenty bucks at a time. But it's just fun.”

I'd gotten my answer about gambling without having to ask. The five minutes we spent on pool had nothing to do with Zoloft or anything else ostensibly medical, yet it was important. It helped me see him as more of a person than a stereotype; maybe it did the same for him too.

By the fifth or sixth visit, nearly a year into seeing me, Keith decided he wanted to stop the Zoloft; he didn't like the idea of taking it his entire life. As a medication-based psychiatrist, I could have fallen back on the viewpoint that quitting antidepressant medication was a bad idea. For a subset of psychiatric patients, especially those with schizophrenia and severe forms of bipolar disorder, stopping their medication can be a terrible decision that leads to hospitalization and drug relapse. However, some patients treated for depression and anxiety woes can manage just fine without medicine. You don't know until you give it a try.

So that's what we did. Over the next several months, Keith felt that his mental health remained stable, and from what I could see in our visits, this seemed true. He'd been promoted in his computer information technology job, enjoyed spending time with his fiancée, and had joined a combat veteran's running club that had helped him shed fifteen pounds. Since he was doing well without medication, he could have stopped seeing me, but he continued to keep appointments. We used the time to talk about his engagement, his time in the Army, and anything else that was on his mind. He seemed to look forward to these visits as a way to stay on track—to process in his mind whatever anxiety had built up in the intervening time about the past or present. I looked forward to seeing him as well, as each time he'd tell me some interesting tidbit about hunting, motorcycles, or NASCAR.

Finally, after another year of visits with me, he felt that he could manage on his own. “Thanks. You know the guy I saw before you, he only wanted to talk about medicine and these checklists. I really appreciate your time. Maybe we'll get a chance to shoot some pool one day.”

We shook hands. I certainly wasn't a better psychiatrist than the person I had replaced. Some of his patients—a handful of whom were black—never warmed to me as they had to him. With others, busy as I was managing a large caseload while saddled with various administrative responsibilities, I felt content to write prescriptions and talk only superficially about their lives, referring those who needed more to a psychologist or clinical social worker. But something—perhaps a challenge to myself to do better, to overcome some of my biases—made me reach out to Keith.

If Keith and I could find common ground despite the huge differences in our backgrounds and attitudes, then why should it be any harder for other doctors to form strong bonds with patients of another race? Many doctors have done so, of course, and I'll bet they've made the same discovery that I have: A big part of the solution is discarding your assumptions and connecting with each patient as a person. Race, while certainly a powerful influence, by itself doesn't guarantee a human connection any more than any other factor like geography, height, or handedness. It is up to us, as doctors, to find the commonalities and respect the differences between us and our patients. In that way, we can understand what they value, how best to communicate with them, and how to arrive at treatment plans that improve their health while respecting their wishes. This approach is often called cultural competence, but after years of medical practice, it seems to me more like common sense.

I've tried to apply the lessons I learned from my time treating Keith and I think I've succeeded. After nearly seven years in my outpatient clinic, I'd become so overwhelmed with other duties that I decided to step away from this busy practice. For a period of months, I had to say good-bye to my patients. Many were anxious about starting over with a new doctor. Others cried. They all wished me well. In the end, I found that my white, Asian, and Hispanic patients were just as sorry as my black patients to see me go, which, if I'd done my job as a doctor correctly, was exactly as it should be.

 

Notes

I
NTRODUCTION

life expectancy nearly nine years less than whites:
See U.S. Census Bureau, Variations in State Mortality from 1960 to 1990, Population Division Working Paper Series no. 49, May 2003. For example, in Alabama, the state where King made his professional home, the life expectancy in the years 1959–1961 for white women was 74.59; for nonwhite women, it was 64.72. The gap was closer in white men versus nonwhite men (about 7 years).

found virtually anywhere one might choose to look:
For example, see Centers for Disease Control, CDC Health Disparities and Inequalities Report—United States, 2013,
Morbidity and Mortality Weekly Report
2013; 62 (suppl 3);
http://www.cdc.gov/mmwr/pdf/other/su6203.pdf
. During the last twenty-five years, health disparities have become an established area of medical research. See for example National Institutes of Health, Fact Sheet—Health Disparities, October 2010, available at
http://report.nih.gov/NIHfactsheets/Pdfs/HealthDisparities(NIMHD).pdf
.

still significantly lags behind whites:
In 2010, the life expectancy gap between white and black populations was about 3.8 years. This does represent significant progress. See National Vital Statistics Report,
Deaths: Final Data for 2010
61, no. 4 (May 2013).

attended a state university with little name recognition:
I attended the University of Maryland Baltimore County (UMBC) on a Meyerhoff Scholarship, which was established in the late 1980s under the leadership of Dr. Freeman Hrabowski to steer black students toward science, technology, engineering, and mathematics careers. As of January 2015, alumni from the program had earned 197 Ph.D.s, 39 M.D./Ph.D.s, and 107 M.D.s from such institutions as Harvard, Stanford, Duke, the University of Pennsylvania, MIT, Berkeley, Yale, and Johns Hopkins.
http://meyerhoff.umbc.edu/about/results/
. See also Freeman Hrabowski, Kenneth Maton, and Geoffrey Greif,
Beating the Odds: Raising Academically Successful African American Males
(New York: Oxford University Press, 1998). In retrospect, the Meyerhoff Program prepared me well to succeed at Duke, but being one of its first students to attend an elite medical school, I entered Duke uncertain about my chances for success.

university's alumni magazine that generated national interest:
See Ron Howell, “Before Their Time
,
”
Yale Alumni Magazine,
May–June 2011. In the article, Howell recounts the sudden death of his closest college friend, using it as the framework for an exposition on the premature deaths of successful black men from his era, as he soberly notes: “while we African Americans were 3 percent of the Class of 1970, we were more than 10 percent of the deaths.”

1: P
EOPLE
L
IKE
U
S

race was just part of the story:
Looking back, many of my difficulties adjusting to Duke in the beginning were as much about social class as they were about race. For an interesting article on this issue, read: Stephen Magnus and Stephen Mick, Medical Schools, Affirmative Action, and the Neglected Role of Social Class,
American Journal of Public Health
2000; 90:1197–1201.

very high proportion compared to their numbers in the U.S. population:
In 2010, Asians represented 20 percent of all entering U.S. medical students while totaling about 5.5 percent of the entire population. See Association of American Medical Colleges, Diversity in Medical Education: Facts and Figures 2012,
Diversity Policy and Programs
, Fall 2012;
www.aamc.org/publications
. See also U.S. Department of Commerce, Economics and Statistics Bureau, Overview of Race and Hispanic Origin, 2010;
http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf
.

Native Americans simply make up a very small percentage:
In 2010, Native Americans made up less than one-half of a percent (0.3–0.4) of medical school enrollees. Association of American Medical Colleges, Diversity in Medical Education: Facts and Figures 2012,
Diversity Policy and Programs
, Fall 2012;
www.aamc.org/publications
.