Black Man in a White Coat (37 page)

6: W
HEN
D
OCTORS
D
ISCRIMINATE

new national guidelines:
In July 2003 (when I began medical internship), the Accreditation Council for Graduate Medical Education (ACGME, for short) released sweeping guidelines restricting how much time interns and residents could work in the hospital. Among the most notable: a maximum 80-hour-per-week schedule averaged over four weeks; a maximum 30-hour duty shift; at least one day off per week averaged over a four-week period; and 10 hours of rest between shifts;
http://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsPapers/dh_dutyhoursummary2003-04.pdf
.

sparked in part by stories of tired doctors hurting patients:
For an overview of the Libby Zion case, largely credited with stimulating duty-hour reforms, see Barron Lerner, “A Case That Shook Medicine,”
Washington Post,
November 28, 2006.

wrote an editorial:
H. Jack Geiger, Race and Health Care—An American Dilemma?
New England Journal of Medicine
1996; 335:815–816.

a widely reported article that suggested that women and blacks with chest pain were less likely to be referred for the best cardiac care:
Kevin Schulman et al., The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization,
New England Journal of Medicine
1999: 340:618–626. This study was covered in the nation's top newspapers and was a feature on ABC's
Nightline
.

though they later took a step back from the full claims of the study:
Five months later, the
New England Journal of Medicine
published a paper that reviewed Schulman's article and found that the reported gender and race disparities in cardiac evaluation, while not invalid, were overstated. See Lisa Schwartz et al., Misunderstandings About the Effects of Race and Sex on Physician's Referrals for Cardiac Catheterization,
New England Journal of Medicine
1999: 341:279–283.

Institute of Medicine added fuel to the discussion:
See Institute of Medicine,
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
(Washington, D.C.: The National Academies Press, 2002).

a plethora of studies:
For example, studies found that black people were less likely to receive kidney transplants and knee replacements while being more likely to undergo C-sections and lower limb amputations. Ibid.

John Edgar Wideman, in his 1984 family memoir:
John Edgar Wideman,
Brothers and Keepers
(New York: Holt, Rinehart and Winston, 1984).

Henry Louis Gates Jr. writes in his childhood memoir:
Henry Louis Gates Jr.,
Colored People
(New York: Vintage Books, 1994).

Wes Moore recounts how his dad was taken to the emergency room:
Wes Moore,
The Other Wes Moore
(New York: Spiegel & Grau, 2010).

acute epiglottitis:
The epiglottis is a small cartilage tissue in the throat that helps prevent food and liquid from entering the trachea, or windpipe. When infected, the epiglottis can swell and cause suffocation, as apparently happened to Moore's father.

Various medical scholars and authors have provided historical context:
For a detailed exploration into the history of how race has adversely affected the care of black patients, see Harriet Washington,
Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present
(New York: Anchor Books, 2006). See also John Hoberman,
Black & Blue
(Berkley: University of California Press, 2012). For a thoughtful look at how race can complicate the doctor-patient relationship, written from the perspective of a practicing physician, see David R. Levy, White Doctors and Black Patients: Influence of Race on the Doctor-Patient Relationship,
Pediatrics
1985; 75:639–643.

when he described a black woman who had nine consecutive pelvic exams:
See David Satcher, Does Race Interfere with the Doctor-Patient Relationship?
Journal of the American Medical Association
1973; 223 (13):1498–1499.

occurred at Los Angeles County
+
USC Medical Center:
See Sonia Nazario, “Treating Doctors for Prejudice: Medical Schools Are Trying to Sensitize Students to Bedside Bias,”
Chicago Sun-Times,
June 2, 1994.

conservative medical writer Sally Satel would argue:
Dr. Satel, a psychiatrist and resident scholar at the American Enterprise Institute, has written extensively about the intersection of race and medicine and what she sees as a misguided effort by some to focus on health disparities in purely racial terms. See for example, Sally Satel and Jonathan Klick, “Biased Doctors? Don't Rush to Pull Out the Race Card,”
National Review
, February 23, 2006. Satel argues that racial bias has a limited effect on health disparities and is a distraction from larger issues of class differences, which she states “makes a much greater contribution than race.” Jonathan Glick and Sally Satel, “The Health Disparities Myth: Diagnosing the Treatment Gap,” American Enterprise Institute for Public Policy Research, Washington, D.C. (2006). Satel also explores this subject in one of her books; see Sally Satel,
P.C., MD: How Political Correctness is Corrupting Medicine
(New York: Basic Books, 2000).

I wondered if anyone else there had given any thought to this issue and shared any of my concerns:
For a discussion about the use of race in clinical cases, see Hamayun Nawaz and Allan Brett, Mentioning Race at the Beginning of Clinical Case Presentations: A Survey of US Medical Schools,
Medical Education
2009; 43:1146–1154. The authors conclude: “we believe that the routine inclusion of race at the beginning of case presentations perpetuates incorrect assumptions about biological significance, promotes potentially faulty clinical reasoning, and reinforces socio-economic and cultural stereotyping.” For an interesting, provocative, alternative viewpoint, see Sally Satel, “I Am a Racially Profiling Doctor,”
New York Times Magazine
. May 5, 2002.

difference between a public hospital where the doctors were paid on salary:
For a revealing and frequently cited article on how physician financial self-interest can influence medical care, see Atul Gawande, “The Cost Conundrum,”
The New Yorker
, June 1, 2009. Cardiologist Sandeep Jauhar uses provocative examples from his clinical practice to illustrate these competing interests. See Sandeep Jauhar,
Doctored
(New York: Farrar, Straus and Giroux, 2014).

Duke was one of the pioneers of the DASH diet:
Duke was among five national sites involved in the original mid-1990s study that investigated the role of dietary interventions in high blood pressure. During this timeframe, it was common to find recruitment pamphlets around the hospital and in local medical offices.

The white coats revealed our hierarchy:
For a story about white coat-length hierarchy at Duke, see Calmetta Coleman, “Just Playing Doctor? Shorter Coats Make Young Residents Feel Naked,”
Wall Street Journal
, February 2, 2000. For a similar discussion at several Boston-area hospitals, see Liz Kowalczyk, “Doctor, Nurse, or Student? Consult the White Coat,”
Boston Globe,
April 10, 2007.

various studies had demonstrated average reductions of 5 to 10 points (or more) with diet and exercise:
For a well-regarded article on the subject that came out in 2003 (my internship year), see Lawrence Appel et al., Effects of Comprehensive Lifestyle Modification on Blood Pressure Control,
Journal of the American Medical Association
2003; 289 (16):2083–2093.

Data from a subset of the DASH study suggested that black patients responded even better:
See Lawrence Appel et al., A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure,
New England Journal of Medicine
1997; 336:1117–1124, and Frank Sacks, Laura Svetkey et al., Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet,
New England Journal of Medicine
2001; 344:3–10.

studies that suggested that black people were less likely than whites to adhere to lifestyle changes:
See for example Jessie Satia, Joseph Galanko, and Anna Maria Siega-Riz, Eating at Fast Food Restaurants Is Associated with Dietary Intake, Demographic, Psychosocial and Behavioral Factors Among African-Americans in North Carolina,
Public Health Nutrition
2004; 7 (8):1089–1096.

Several studies have explored the ways that people with mental illness receive worse medical care:
Most of the research in this area examines schizophrenia, bipolar disorder, and to a lesser extent, major depression, as these illnesses are more closely associated with adverse physical health problems. See Alex J. Mitchell et al., Quality of Medical Care for People with and without Comborbid Mental Illness and Substance Misuse,
British Journal of Psychiatry
2009; 194:491–499 and Graham Thornicroft, Discrimination in Health Care Against People with Mental Illness,
International Journal of Psychiatry
2007; 19 (2):113–122. For a personal, patient perspective on the issue, see Juliann Garey, “When Doctors Discriminate,”
New York Times
, August 10, 2013.

I had no reason to think of these doctors as racist in any classic sense:
Substantial attention has been paid in recent years to the possibility that unconscious (implicit) bias among health care professionals contributes to health disparities. See Alexander Green et al., Implicit Bias Among Physicians and Its Prediction of Thrombolysis Decisions for Black and White Patients,
Journal of General Internal Medicine
2007; 22:1231–1238; and Adil Haider et al., Association of Unconscious Race and Social Class Bias with Vignette-Based Clinical Assessments by Medical Students,
Journal of the American Medical Association
2011; 306 (9):942–951. For a broader discussion of these and related topics, see Lisa Cooper, A 41-Year-Old African American Man with Poorly Controlled Hypertension,
Journal of the American Medical Association
2009; 301:1260–1272.

supported by the Kaiser Family Foundation's 2002 national survey of physicians, published not long before our encounter with Gary:
National Survey of Physicians, Part 1: Doctors on Disparities in Medical Care. Washington, D.C.: 2002;
http://kaiserfamilyfoundation.files.wordpress.com/2002/03/national-survey-of-physicians-part-1.pdf
.

He evidently saw me through a mental filter:
Pauline Chen briefly explores the potential pitfalls of cross-cultural doctor-patient interactions: “when I meet individuals whose race or ethnicity differ from mine,” she writes, she “unconsciously taps into past experiences” and admits “it's difficult to acknowledge that what I have tapped into may not always be fair.” Pauline Chen, “Confronting the Racial Barriers Between Doctors and Patients,”
New York Times
, November 14, 2008.

Several authors have written about the negative stereotypes that many doctors associate with black patients:
For example, a 2000 study of nearly 200 physicians revealed that doctors reported negative opinions about black patients' intelligence, health behaviors, and ability to comply with treatments. See Michelle van Ryan and Jane Burke, The Effect of Patient Race and Socio-economic Status on Physicians' Perceptions of Patients,
Social Science and Medicine
2000; 50:813–828.

7: T
HE
C
OLOR
OF
HIV/AIDS

hearing lies was a daily part of my job:
For two recent perspectives about patient lying, see Sumathia Reddy, “I Don't Smoke, Doc, and Other Patient Lies,”
Wall Street Journal
, February 18, 2013, and Daphne Miller, “Why Do My Patients Keep Secrets From Me? I Only Want to Help Them,”
Washington Post,
March 14, 2010.

Between 1995 and 1998, AIDS mortality in the United States dropped more than 60 percent:
From 1981 to 1995, the estimated annual number of deaths among persons with AIDS increased from 451 to 50,628. By 1998, that number had dropped from 50,628 down to 18,851. See HIV Surveillance—United States—1981–2008,
Morbidity and Mortality Weekly Report
2011; 60 (21):689–693.

reductions in death rates approaching 75 percent:
See Robert S. Levine et al., Black-White Mortality from HIV in the United States Before and After Introduction of Highly Active Antiretroviral Therapy in 1996,
American Journal of Public Health
2007; 97 (10):1884–1892.

black people accounted for a quarter of HIV cases during the first decade of the epidemic:
See HIV and AIDS—United States 1981–2000.
Morbidity and Mortality Weekly Report
2001; 50 (21):430–434.

In 1996, for the first time in the epidemic, more black people in America died of AIDS than whites:
See Update: Trends in AIDS Incidence, Deaths, and Prevalence—United States, 1996,
Morbidity and Mortality Weekly Report
1997; 46 (8):165–173.

the color of HIV/AIDS in the United States continued to darken:
For a visual depiction of the statistical racial differences in HIV/AIDS, see HIV Surveillance by Race/Ethnicity, 2008–2011 data, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Division of HIV/AIDS Prevention. Available at
http://www.cdc.gov/hiv/pdf/statistics_surveillance_raceEthnicity.pdf
.

that I started to fully appreciate the emotional weight of the diagnosis:
For excellent physician narratives that explore the emotional impact (on both doctor and patient) of delivering a HIV diagnosis, see Abraham Verghese,
My Own Country
(New York: Simon and Schuster, 1994); Jerome Groopman,
The Measure of Our Days
(New York: Viking Penguin, 1997); and Daniel Ofri,
Singular Intimacies
(Boston: Beacon Press, 2003).