Black Man in a White Coat (35 page)

Leslie had put the worst face of black America:
Pervasive negative stereotypes about black people are as old as our nation. As more black people have ascended into the middle class since the civil rights era, tensions have arisen between middle-class blacks and their poorer counterparts. See Lawrence Otis Graham,
Member of the Club
(New York: Harper Collins, 1995); Eugene Robinson,
Disintegration
(New York: Doubleday, 2010) and Sheryll Cashin,
The Failures of Integration
(New York: Public Affairs, 2004).

as they were at many community clinics back then:
These community clinics historically had served poor black patients. Over the last 15 years, however, North Carolina has seen a rapid influx of Hispanic residents. In 1990, Hispanics made up 1.2 percent of the state's population; in 2000, it had risen to 4.7 percent; by 2010, it had climbed to 8.4 percent. Between 2000 and 2010, North Carolina had the sixth greatest Hispanic population growth in the nation;
http://censusscope.org/2010Census/states.php?state=NC&name=North%20Carolina
http://ui.uncc.edu/sites/default/files/pdf/NCCensus2010.pdf
.

As male medical students, we'd been told to have a female staff member:
For a thorough discussion about the complexity of male physicians examining female patients, see Atul Gawande,
Better
(New York: Henry Holt and Company, 2007).

More than 70 percent of black children are born to unmarried women:
According to 2010 data from the Department of Health and Human Services, 72 percent of black children are born outside marriage, compared with 53 percent of Hispanics and 29 percent of whites. See National Vital Statistics Report,
Births: Final Data for 2010
61, no.1 (August 2012);
http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf
.

Many people use these numbers as a statement about the breakdown of black communities:
For what would be considered a traditional African American perspective, see Juan Williams,
Enough
(New York: Crown Publishers, 2006). See also Bill Cosby and Alvin Poussaint,
Come On, People
(Nashville: Thomas Nelson, 2007). For other conservative views on the subject, see Shelby Steele, A
Dream Deferred
(New York: Harper Collins, 1998), and John McWhorter,
Winning the Race
(New York: Gotham Books, 2005). For a more left-leaning analysis, see Eugene Robinson,
Disintegration
.

the rates among black teens remained more than twice that seen among white teens:
National Vital Statistics Report,
Births: Final Data for 2010
.

potentially dangerous sexually transmitted infections:
Untreated gonorrhea and chlamydia in pregnancy are associated with a variety of possible complications, including premature birth and low birth weight. STDs and Pregnancy—CDC Fact Sheet;
http://www.cdc.gov/std/pregnancy/STDFact-Pregnancy.htm
.

Early births, 60 percent more common in black women:
National Vital Statistics Report,
Births: Final Data for 2010
.

infant mortality rate in the United States among blacks remains twice as high as among whites:
National Vital Statistics Report,
Deaths: Final Data for 2010
61, no. 4 (May 2013);
http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf
.

What is known about genetic predispositions:
See Danielle Dick and Arpana Agrawal, The Genetics of Alcohol and Other Drug Dependence,
Alcohol Research and Health
2008; 31 (2):111–118.

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body mass index far above what my pocket guide listed as ideal:
Body mass index (BMI) is a number calculated based on a person's height and weight that is used in adults to identify those with weight problems. A BMI above 25 is regarded as overweight; a BMI over 30 is considered obese. Pearl's BMI was 36.

handful have become famous:
Bellevue Hospital Center is the oldest public hospital in the country (founded in 1736) and is probably best known for its psychiatric facilities. Cook County Hospital was featured in the 1993 blockbuster movie
The Fugitive
and was the inspiration for the equally popular 1994–2009 medical drama
ER
. I describe Grady hospital's history in chapter 4.

Public hospitals began to decline:
For a concise overview of the history of public hospitals, see Howard Waitzkin, Commentary—The History and Contradictions of the Health Care Safety Net,
Health Services Research
2005; 40 (3):941–952.

Combined with other fiscal factors:
In addition to Medicare and Medicaid passage, rising health care costs and local fiscal crises have been implicated in public hospital contractions and closures. Ibid.

Between 1987 and 1998 … the number of insured rose from 32 million to 44 million:
See Michael Gusmano, Gerry Fairbrother, and Heidi Park, Exploring the Limits of the Safety Net: Community Health Centers and Care for the Uninsured,
Health Affairs
2002; 21 (6):188–194.

One national study:
Christopher Forrest and Ellen-Marie Whelan, Primary Care Safety-Net Delivery Sites in the United States: A Comparison of Community Health Centers, Hospital Outpatient Departments, and Physicians' Offices,
Journal of the American Medical Association
, 2000; 284 (16):2077–2083.

Another study in rural Massachusetts:
Sarah Kemble, Charity Care Programs: Part of the Solution or Part of the Problem?
Public Health Reports
2000; 115 (5):419–429.

In recounting their respective outpatient experiences:
For physician narratives on the disparities observed between public and private clinics, see David Ansell,
County: Life, Death and Politics at Chicago's Public Hospital
(Chicago: Academy Chicago Publishers, 2011), and Fitzhugh Mullan,
White Coat, Clenched Fist
(New York: Macmillan, 1976).

echoed their sentiments:
Neil Calman, Out of the Shadow: A White Inner-City Doctor Wrestles with Racial Prejudice,
Health Affairs
2000; 19:170–174.

They were like characters:
See Henry Louis Gates Jr.,
Colored People
(New York: Vintage Books, 1994). A similar troubling pattern is observed in Lisa Cooper's case study of a young black man with severe hypertension who states, “I don't eat right. I don't cook. I like McDonald's, Burger King, Wendy's, you name it.” See Lisa Cooper, A 41-Year-Old African American Man with Poorly Controlled Hypertension,
Journal of the American Medical Association
2009; 301 (12):1260–1272.

she was slender in comparison:
Tina's body mass index (BMI) was 22, which fell within the recommended normal range (18.5–24.9). Pearl, in contrast, had a BMI of 36. All of the other women I saw that day also had BMI scores over 30, which would classify them as obese.

Not only are fibroids two to three times more common in black women:
For a recent overview, see Heba Eltoukhi et al., The Health Disparities of Uterine Fibroid Tumors for African-American Women: A Public Health Issue,
American Journal of Obstetrics and Gynecology
2014; 210 (3):194–199.

covers more than 50 million people:
In 2000, Medicaid covered 46 million people during some portion of that year. These numbers steadily increased throughout the decade to a high point of 68 million in 2009. See
https://www.ccwdata.org/web/guest/medicaid-charts
.

Hypertension is the prototypical disease:
For an overview of racial disparities with hypertension, see Robin Hertz et al., Racial Disparities in Hypertension Prevalence, Awareness, and Management,
Archives of Internal Medicine
2005; 165 (18):2098–2104. See also David Martins et al., Hypertensive Chronic Kidney Disease in African Americans: Strategies for Improving Care,
Cleveland Clinic Journal of Medicine
2012; 79 (10):726–734.

The reasons offered as to why black Americans suffer so severely from hypertension:
For a brief summary of competing theories, see Flavio Fuchs, Why Do Black Americans Have Higher Prevalence of Hypertension? An Enigma Still Unsolved,
Hypertension
2011; 57:379–380.

Armed with data from several research studies:
The most influential one at the time was the publication of Dietary Approaches to Stop Hypertension (DASH) in which Laura Svetkey, a Duke professor of medicine, was one of the lead investigators. See Lawrence J. Appel et al., A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure,
New England Journal of Medicine
1997; 336:1117–1124.

Terms like glomerular filtration rate, thiazide diuretics, and calcium channel blockers:
Glomerular filtration rate is a test used to assess how well the kidneys are working. Thiazide diuretics are a type of diuretic (also known as water pills) that puts more sodium and water into the urine to reduce bodily fluid volume and blood pressure. Calcium channel blockers are another type of medication that lowers blood pressure.

A 2005 New York Times article:
Janny Scott, “Life at the Top in America Isn't Just Better, It's Longer,”
New York Times,
May 16, 2005.

A 2002 Institute of Medicine report:
See Institute of Medicine,
Care Without Coverage: Too Little, Too Late
(Washington, D.C.: The National Academies Press, 2002).

A major 2001 study:
David Baker et al., Lack of Health Insurance and Decline In Overall Health in Late Middle Age,
New England Journal of Medicine
2001; 345:1106–1112.

nearly twice as likely as white Americans to live without health insurance:
Marsha Lillie-Blanton and Catherine Hoffman, The Role of Health Insurance Coverage in Reducing Racial/Ethnic Disparities in Health Care,
Health Affairs
2005; 24 (2):398–408.

A 2007 study found:
J. Michael McWilliams et al., Health of Previously Uninsured Adults After Acquiring Medicare Coverage,
Journal of the American Medical Association
2007; 298:2886–2894.

Tina was one of approximately forty million uninsured Americans:
See U.S. Census Bureau, Health Insurance Coverage: 2000;
http://www.census.gov/prod/2001pubs/p60-215.pdf
. Since 2000, the number of uninsured Americans has consistently remained above 40 million. For data between the years 2007 and 2012, see the Henry J. Kaiser Family Foundation, Key Facts About the Uninsured Population:
http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population
.

failed 1993 Clinton health plan:
For an overview from a former insider on the subject, see Paul Starr, “What Happened to Health Care Reform,”
The American Prospect
, Winter 1995. See also Paul Starr, “The Hillarycare Mythology,”
The American Prospect,
September 2007.

I later learned that more than 70 percent of people:
See the Henry J. Kaiser Family Foundation, The Uninsured: A Primer, October 2013;
http://kff.org/report-section/the-uninsured-a-primer-2013-tables-and-data-notes
.

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not the classic findings of an acute heart attack requiring immediate cardiac catheterization or clot-busting drugs:
The medical term for heart attack is myocardial infarction, or MI. One of the first steps in evaluating a patient with a suspected MI is to obtain an electrocardiogram (EKG). A waveform pattern known as ST-elevation MI, or STEMI, requires urgent restoration of blood flow. See Elliot Antman et al., ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction—Executive Summary,
Circulation
2004; 110:588–636.

watching TV medical dramas:
ER
, the critically and commercially successful TV series, was at its peak during the mid- to late 1990s. The show was popular among medical students, especially those at Harvard, where the show's creator (Michael Crichton) and lead writer (Neal Baer) had attended. See Ellen Lerner Rothman,
White Coat
(New York: William Morrow and Company, 1999).
Chicago Hope
, created by prolific TV writer/producer David E. Kelley, also had a successful run during this period.

Duke did not have a training program in this field:
Duke established an emergency medicine residency training program in 2002, two years after my graduation.

Extreme emotional distress, such as in response to an earthquake:
On January 17, 1994, a major earthquake struck the Los Angeles area. On the day of the earthquake, researchers noted a sharp increase in the number of sudden cardiac deaths. See Jonathan Leor, W. Kenneth Poole, and Robert Kloner, Sudden Cardiac Death Triggered by an Earthquake,
New England Journal of Medicine
1996; 334:413–419.

less dramatic but nonetheless mentally stressful scenarios could trigger cardiac events too:
For the classic article on the subject, see Alan Rozanski et al., Mental Stress and the Induction of Silent Myocardial Ischemia in Patients with Coronary Artery Disease,
New England Journal of Medicine
1988; 318:1005–1012. See also James Blumenthal et al., Mental Stress-Induced Ischemia in the Laboratory and Ambulatory Ischemia During Daily Life, Association and Hemodynamic features,
Circulation
1995; 92:2102–2108.

rarely worked the way they did on TV medical dramas of the era:
See Susan Diem, John Lantos, and James Tulsky, Cardiopulmonary Resuscitation on Television; Miracles and Misinformation,
New England Journal of Medicine
1996; 334:1578–1582.