Black Man in a White Coat (39 page)

For a more direct look at some of the problems faced by graduates of historically black medical schools, see Andrew Julian and Jack Dolan, “Historically Black Medical Schools Struggle to Compete for Dollars, Students,”
Hartford Courant,
June 30, 2003. This article reported that graduates of Howard and Meharry face substantially higher disciplinary actions by state medical boards than most other schools. Among the potential causes proffered: institutional financial problems that compromise the quality of education; difficulty attracting quality black students due to more aggressive recruitment from more prestigious, predominately white schools; a patient population that is much sicker and more difficult to treat; and possible racism of state disciplinary boards toward black doctors. For an article emphasizing that minority doctors are more likely to care for sicker patients, see Ernest Moy and Barbara Bartman, Physician Race and Care of Minority and Medically Indigent Patients,
Journal of the American Medical Association
1995; 273:1515–1520.

International medical graduates (IMGs) constitute about 25 percent of American doctors:
This is based on 2006 data. For a brief overview of recent trends with IMG physicians, see
http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/international-medical-graduates/imgs-in-united-states.page?
.

In a 2005 essay:
See Alok Khorana, Concordance,
Health Affairs
March/April 2005; 24 (2) 511–515.

9: D
OING
THE
R
IGHT
T
HING

a mixture of schizophrenia and bipolar disorder in his case:
Schizophrenia is characterized by a variety of impairing symptoms such as delusional beliefs, auditory hallucinations (hearing voices), and distorted thought, speech, and behavior patterns. Bipolar disorder (also known as manic-depression) is characterized by distinct episodes of depression and mania (or hypomania), the latter involving periods of euphoria, excessive energy, less need for sleep, excessive risk-taking, and impaired judgment, among other symptoms. Individuals with schizoaffective disorder can exhibit features from both disorders.

made him tired all the time and made his muscles too stiff:
Fatigue is a common side effect of many, if not most, antipsychotic medications. The older antipsychotics (called typical or first-generation) can cause muscle stiffness through their blockage of dopamine receptors, sometimes causing symptoms similar to what is seen in Parkinson's disease.

The only problem was that it caused him to gain weight:
The newer antipsychotic medications (called atypical or second-generation) are, with a few exceptions, highly associated with weight gain.

estimated that behavioral choices account for at least 900,000 deaths each year:
See J. Michael McGinnis et al., The Case for More Active Policy Attention to Health Promotion,
Health Affairs
March/April 2002; 21(2):78–93.

A large body of research has shown the important role of culture and environment:
For a review article on the subject, see Nancy Adler and Katherine Newman, Socioeconomic Disparities in Health: Pathways and Policies,
Health Affairs
2002; 21(2):60–76.

such factors have a direct effect on health disparities:
For detailed discussions on the ways that socioeconomic class and race intersect with respect to health, see Stephen Isaacs and Steven Schroeder, Class—The Ignored Determinant of the Nation's Health,
New England Journal of Medicine
2004; 351:1137–1142; Ichiro Kawachi et al., Health Disparities by Race and Class: Why Both Matter,
Health Affairs
2005; 24:343–352; and David Williams and Pamela Braboy Jackson, Social Sources of Racial Disparities in Health,
Health Affairs
March/April 2005; 24:325–334.

There are many barriers:
For discussions on the various factors that discourage physician-based nutrition and exercise counseling, see Robert Kushner, Barriers to Providing Nutrition Counseling by Physicians: A Survey of Primary Care Practitioners,
Preventive Medicine
1995; 24:546–552; Gary Foster et al., Primary Care Physicians' Attitudes About Obesity and Its Treatment,
Obesity Research
2003; 11:1168–1177; and Jian Huang et al., Physician's Weight Loss Counseling in Two Public Hospital Primary Care Clinics,
Academic Medicine
2004; 79:156–161.

sense that nutrition talk is better left to dieticians:
In a 2003 survey of more than 600 primary care physicians, a little less than half reported feeling confident in their ability to prescribe a weight loss program for their patients. See Gary Foster et al., Primary Care Physicians' Attitudes About Obesity and Its Treatment.

experience has made many doctors cynical about patient behavior and the likelihood for change:
For brief, thoughtful articles that explore this subject, see Sandeep Jauhar, “No Matter What, We Pay for Others' Bad Habits,”
New York Times
, March 29, 2010; Pauline Chen, “Getting Patients to Take Charge of Their Health,”
New York Times,
January 12, 2012; and Danielle Ofri, “When the Patient Is ‘Noncompliant,'”
New York Times,
November 15, 2012.

basics of secondary prevention:
Primary prevention involves protecting healthy people from developing a disease or suffering an injury, for example, receiving a vaccine or wearing a seat belt. Secondary prevention takes place after an illness has occurred, such as taking daily aspirin following a heart attack or stroke. In Adrian's case, he had already experienced a mini-stroke, so the neurologists' recommendations were part of a secondary prevention strategy.

black people, who are 50 percent more likely than whites to be obese:
For data on higher obesity rates among black people, especially among women, see Liping Pan et al., Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults, United States 2006–2008,
Morbidity and Mortality Weekly Report
2009; 58 (27):740–744;
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5827a2.htm#tab1
.

Given the impact that physician advice can have on patient behavior:
For example, a 2011 study concluded that physician counseling on obesity was associated with greater efforts by patients to lose weight; see Robert Post et al., The Influence of Physician Acknowledgment of Patient's Weight Status on Patient Perceptions of Overweight and Obesity in the United States,
Archives of Internal Medicine
2011; 171:316–321. A 2000 study found that physician advice was associated with greater efforts by patients to quit smoking and make positive changes in diet and physical activity, see Matthew Kreuter et al., How Does Physician Advice Influence Patient Behavior? Evidence for a Priming Effect,
Archives of Family Medicine
2000; 9:426–433. An older study looking at cigarette smoking reached similar conclusions, see Erica Frank et al., Predictors of Physicians' Smoking Cessation Advice,
Journal of the American Medical Association
1991; 266:3139–3144.

Why was making a long-term healthy change so difficult?:
For perhaps the best overview and discussion of the individual, health system, and doctor-patient barriers to effective blood pressure control for African Americans, 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.

Researchers have speculated that strong cultural influences … might make it more difficult for black patients to follow a healthy diet:
For a recent review on the subject, see Dawn Epstein et al., Determinates and Consequences of Adherence to the Dietary Approaches to Stop Hypertension Diet in African-American and White Adults with High Blood Pressure: Results from the ENCORE Trial,
Journal of the Academy of Nutrition and Dietetics
2012; 112:1763–1773.

A 2012 study:
Ibid. For a personal perspective on the subject from a black physician, see Khaalisha Ajala, “How Soul Food Stymies African-Americans' Low Salt Efforts,” ABC News medical unit, available at:
http://abcnews.go.com/Health/soul-food-stymies-african-americans-low-salt-efforts/story?id=17265086&singlePage=true
.

surveys have indicated that black people are more accepting of—and in some cases indicate a preference for—heavier body types:
See for example, Rashida Dorsey et al., Racial/Ethnic Differences in Weight Perception,
Obesity
2009; 17:790–795.

The Meharry-Hopkins Cohort study explored our health dilemma on a larger scale:
See John Thomas et al., Cardiovascular Disease in African-American and White Physicians: The Meharry Cohort and Meharry-Hopkins Cohort Studies,
Journal of Health Care for the Poor and Underserved
1997; 8:270–283.

10: B
EYOND
R
ACE

the first black student to attend medical school at Duke:
For profiles of Delano Meriwether, see “Medical Miracle: Meriwether Beats All Odds on Track & in Life,” (New York)
Daily News,
January 14, 2007; Sandy Treadwell, “Hey, I Can Beat Those Guys,”
Sports Illustrated,
January 18, 1971; and Robert Boyle, “Champion of the Armchair Athletes,”
Sports Illustrated,
February 22, 1971. Meriwether was on the cover of this issue.

Some critics expressed reasonable concerns:
Many critiques of the Affordable Care Act (ACA) come across as overtly partisan. For authors who seem to take a balanced approach in weighing the pros and cons of the ACA, see Darshak Sanghavi, “Don't Celebrate Yet,”
Slate,
June 28, 2012; Steven Brill, “Bitter Pill: Why Medical Bills Are Killing Us,”
Time,
February 20, 2013; Tina Cheng and Paul Wise, Promise and Perils of the Affordable Care Act for Children,
Journal of the American Medical Association
2014; 311:1733–1734; and Mehroz Baig, “A Physician's Take on the Affordable Care Act, Interview with Dr. Victoria Sweet,”
Huffington Post,
April 15, 2014;
http://www.huffingtonpost.com/mehroz-baig/a-physicians-take-on-the-_b_5155995.html
.

North Carolina, like its neighboring Southern states, largely opposed Obamacare and rejected the law's provision:
Along with extending private insurance coverage to individuals through a variety of mechanisms, the Affordable Care Act relies on a large expansion of Medicaid, a joint federal-state program for the poor. In the 2012 U.S. Supreme Court decision
, National Federation of Independent Business v. Sebelius
, the court allowed individual states to decline the expansion of Medicaid. In what largely mirrors (although not perfectly) the red state–blue state divide in recent elections, the blue states have mostly chosen to opt-in to the Medicaid expansion while the red states have mostly elected to opt-out of the expansion. North Carolina, under the leadership of Governor Pat McCrory (R) and a Republican legislature, has shifted to the “red state” ledger since President Obama narrowly won the state in the 2008 election.

Analysis from the Kaiser Family Foundation:
For data on Medicaid expansion, see The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid—Issue Brief 8505-02, Kaiser Family Foundation, April 2, 2014;
http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid
.

While I agreed that having Medicaid was better than having no health insurance:
The effectiveness of Medicaid in improving health has yielded some interesting results. See Benjamin Sommers et al., Mortality and Access to Care Among Adults After State Medicaid Expansions,
New England Journal of Medicine
2012; 367:1025–1034. This study found that state Medicaid expansions in New York, Maine, and Arizona were “significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health.” Another study found that Medicaid recipients in Oregon showed no significant improvement in measured physical outcomes (blood pressure, cholesterol, glycated hemoglobin levels), but exhibited lower rates of depression and reduced financial strain after receiving Medicaid. Katherine Baicker et al., The Oregon Experiment—Effects of Medicaid on Clinical Outcomes,
New England Journal of Medicine
2013; 368:1713–1722. Further study in this area is needed. One future approach might involve comparing various health and financial parameters from a state that accepted Affordable Care Act Medicaid expansion with a similar state that declined the expansion.

The problems take three forms:
For a journalistic-style overview of the multiple factors that are involved with health disparities, see Chelsea Conaboy, “Racial and Ethnic Disparities in Health—and How to Fix Them,”
National Journal,
March 13, 2014. Using Philadelphia as the focus for the article, Conaboy concluded: “the main obstacle to good health is poverty.” See also Peter Kilborn, “Nashville Clinic Offers Case Study of Chronic Gap in Black and White Health,”
New York Times,
March 21, 1998. In an interview with black doctors treating black patients at Meharry Medical College, the doctors there felt that health disparities were “a socioeconomic thing,” and that in order to reverse them “you have to reverse a whole way of being.” For a narrative and historical look at the subject, see Fitzhugh Mullan, Still Closing the Gap,
Health Affairs
2009; 28:1183–1188.

And it is here that the Affordable Care Act:
For a book-length examination written in support of the Affordable Care Act, see Ezekiel Emanuel,
Reinventing American Health Care
(New York: Public Affairs, 2014). For a similar perspective written in shorter form, see the writings of Harvard surgeon and medical writer Atul Gawande: “Now What?”
The New Yorker,
April 5, 2010; “Something Wicked This Way Comes,”
The New Yorker
, June 28, 2012; and “States of Health,”
The New Yorker,
October 7, 2013.