Medicaid has never fully met the needs of the poor. Many “working poor” have jobs that do not offer private insurance and incomes that place them slightly above the poverty level, disqualifying them from Medicaid. Some states require certain groups (for example, single men) to be medically disabled before they can be eligible for Medicaid, regardless of their income level. Between 1987 and 1998, the year that I attended this charity clinic, the number of uninsured rose from 32 million to 44 million.
This environment has led to the evolution of what is called the health care safety net. Here, patients who fall outside the traditional health care marketplace receive services. Alongside public hospitals, academic institutions like Duke and UNC provide hospital-based charity care. In the outpatient sector, a patchwork of federally funded community health centers, public hospital–based clinics, locally funded state health departments, and volunteer-based free clinics provide basic medical services. It was in this sphere as a free clinic that the Duke-staffed rural health clinic operated.
Just a few hours into the Saturday clinic, three issues stood out in my mind. First, all of the patients were black, even though the region was nearly 50 percent white. Perhaps Duke had specifically targeted the area’s black community. But it is known that black people are far more likely to be seen in safety-net settings. One national study found that poor blacks were four times as likely as the general population to receive care in safety-net clinics. Another study in rural Massachusetts observed that black residents sought care at a free clinic at nearly twice the rate of that region’s general population.
Second, there seemed to be clear differences in the type of care that could be provided compared to what I’d seen at Duke. In recounting their respective outpatient experiences at Chicago’s Cook County and New York City’s Lincoln Hospital in the 1970s as doctors-in-training, physicians David Ansell and Fitzhugh Mullan describe clinics with: “no set appointment times … once they showed up, it was first come first served,” with patients seeing different providers each time, provoking feelings that the care they delivered was part of “a separate and unequal second-class system.” Neil Calman, a New York City–based family physician, echoed their sentiments in a 2000 essay where he described the challenges one of his patients, Mr. North, faced getting treatment for his heart failure: “There is absolutely no doubt that Mr. North is treated differently than my white, middle-class patients are treated,” Calman wrote, expressing regret that “I cannot provide Mr. North with all that New York’s great health care institutions have to offer.” Several hundred miles away, Dr. Kelly and the clients at the charity clinic faced a nearly identical set of problems.
The third defining aspect of my experience at the rural clinic was the nature of the patient’s concerns. Each had chronic medical problems either caused or worsened by the way they lived. Pearl’s obesity surely contributed to her diabetes and hypertension. The next patient I saw was a smoker who came in with recurrent bronchitis; another one had developed numbness in her feet from not taking her insulin and enjoying too many desserts. They were like characters out of Henry Louis Gates Jr.’s memoir Colored People, who “drank on top of diabetes and would fry up ham and bacon and sausage for breakfast, directly defying doctor’s orders.” As one person after another came in with similar stories, it became tempting to place the blame for their health problems squarely and solely on their shoulders. Nobody was forcing them to eat at McDonald’s and Bojangles’ or watch TV instead of taking a long walk. No one had held a gun to their heads to make them start smoking cigarettes or keep doing so even as they coughed and wheezed.
This was a simple and detached way to look at things, and it was easy for me to embrace that limited perspective. I began to feel more frustration with each successive patient, a reaction intensified by my being the sole black provider there. As their medical providers, we could only help them so much; the majority of progress, such as eating better and exercising, they had to make for themselves. And most of them simply weren’t doing it. Despite their apparent good intentions, I worried that my white colleagues—Sharon, Mike, Dr. Watson, and Dr. Kelly—had made unconscious or even conscious negative judgments about these black patients, and thus about black people in general. Or was I simply projecting my own racial insecurities onto them?
Despite what I’d seen, it was not until I met Tina, the last patient of the day, that I came to appreciate how the medical system itself is sometimes just as sick as its patients.
* * *
As morning gave way to afternoon at the clinic, patients filed in steadily. We took brief, separate lunch breaks in order to accommodate the thirty people who sought care. Dr. Kelly was briefly worried that we might have to turn people away until the inflow gradually slowed. At three o’clock, I checked in Tina, our last patient. On the surface, she seemed the healthiest of anyone I’d seen that day, but I quickly learned that she had two serious medical problems.
“I’ve been bleeding heavy with my periods and in between them,” she told me.
With my limited knowledge of gynecology, I thought about the possibilities as I jotted down notes. I then looked up at her. Tina was nearing forty, but with bright teeth and smooth dark skin, she seemed a few years younger. She was dressed in a polyester blouse and blue jeans, the kind of neat but nondescript outfit you might find at a bargain store. She showed no outward signs of illness and reported no other health-related issues.
I took her vital signs. At five-seven and 140 pounds, she was slender in comparison to the other women I had weighed that day. Her pulse was steady and calm at 70 beats per minute. Her temperature and breathing rate were also normal.
In order to measure her blood pressure, I had to switch from the large cuff that I had used all day to the smaller, standard-sized one. The result I got was abnormal. Was this cuff broken?
“Does your pressure run high?” I asked, as I pulled the stethoscope from my ears.
“Not that I know,” she said, a slight frown emerging across her brow. “Is it high now?”
“Let me try again,” I said, without answering her question.
I was more careful this time, slowly deflating the pressure gauge. But the result was the same: Her pressure was 190/110, well above the 140/90 threshold for diagnosing hypertension.
“Your pressure is pretty high right now,” I said.
She pursed her lips, using her forearm to wipe away the sheen on her nose. She’d come to the clinic worried about her irregular bleeding and was learning of an entirely different problem.
“When is the last time you had it checked?” I asked.
“I don’t know,” she said. “I guess when I was in the hospital with my youngest.”
“How long ago was that?”
“She just turned six a few weeks back,” Tina said, as she smiled for a brief moment. “They said it was high when I was pregnant with her, but it came down after I delivered her.”
Before I could ask anything else, Dr. Watson, the resident supervisor, came over to me. With a few strands of reddish hair having escaped from her loose ponytail and her eyeglasses resting on the bridge of her nose, she looked as if she’d spent the day poring over textbooks. She readjusted her glasses as she introduced herself to Tina.
“Is everything okay?” I asked, wondering if she’d been listening in and I’d made an error.
She nodded. “Tell me what you have so far.”
I briefly explained what I knew and showed her the vital sign measurements.
“Since this is the last one,” Dr. Watson began, “how about we do this one together?”
That was her way of saying everyone was tired and wanted to go home. Mike and Sharon had finished with their patients; Tina was the only person standing between us and the trip back to Durham. And even though I had a year of clinical medicine under my belt by then, a good resident could still get more information from a patient than I could, in half the time.
I followed Dr. Watson and Tina into a dinky examina
tion room. Its flimsy, makeshift walls and shower-curtain door offered visual privacy but no sound protection. This was not the place you’d want to reveal intimate details about your sex life or problems with your bowel movements. In a soft voice, I asked Tina more details about her health history and current habits. She did not take medications or supplements. “Do you drink alcohol?” I asked.
She shook her head. “Not at all. Never liked the taste. Don’t smoke or use drugs either,” she said, anticipating my next questions before I could ask them.
She did drink two large cups of coffee each day. While she avoided the saltshaker, she did not monitor the sodium content of her food. She rarely exercised.
“Have you had any headaches or blurry vision?” I asked, trying to determine if she had experienced any symptoms associated with a persistently high blood pressure. She shook her head once again. “Does anyone in your family have high blood pressure?” I inquired.
“My dad,” she said with a wistful look. “My mom always said I was more like him.”
Her father had been diagnosed in his fifties and was on two blood pressure medicines; she also had an older brother with hypertension. Since both men were overweight, smoked cigarettes, and drank alcohol, Tina had always figured that high blood pressure was not going to be a problem for her, at least not until she was much older.
Dr. Watson then took over as she inquired about the bleeding issue. Not only were Tina’s periods heavier and longer-lasting than usual, but she was having some spotting in the intervening days. This had been going on for about six months. “Have you been on birth control pills, or anything like that, for contraception, in the past few years?” Dr. Watson asked.
“No,” Tina said. “I got my tubes tied after my daughter was born.”
“How many times have you been pregnant?” she asked.
“Twice,” Tina said, smiling again. “I have a seven-year-old boy and a six-year-old girl.” Aside from the brief interval with an elevated blood pressure, Tina’s pregnancies had been uncomplicated, with two normal deliveries. She’d never had any surgeries or other gynecological procedures.
After a few more questions, we stepped out so Tina could change into a paper gown.
The room was too small for me to stand over Dr. Watson and observe the pelvic exam, so I waited outside. When Dr. Watson finished, I stepped inside as Tina sat up on the exam table. Dr. Watson then delivered her diagnosis: “You’ve got something that we call fibroids.”
“What’s that?” Tina asked, with genuine puzzlement on her face.
Dr. Watson explained that a fibroid was a benign tumor that enlarged her uterus—in Tina’s case to the typical size for a woman sixteen weeks pregnant—and caused her bleeding. In my head, I ran through what I knew about this disorder, which, like so many others, fit the painful racial profile so familiar to me. Not only are fibroids two to three times more common in black women than in white women, but studies suggest that in black women fibroids develop at an earlier age, grow faster, and are more likely to cause symptoms requiring surgical treatment. No one knows exactly why.
“Tumor,” Tina said with obvious worry. “Is that the same thing as cancer?”
“Yes and no. The vast majority of the time they are benign—meaning that they don’t spread or cause any problems after we remove them. This is a very treatable condition.”
Dr. Watson reviewed the treatment options, which ranged from taking medication, to surgical excision of the individual fibroids, to a full-fledged hysterectomy.
“What do you think I should do?” Tina asked.
Tina’s hopeful eyes suggested that she trusted Dr. Watson’s opinion. In response, Dr. Watson curled in her lower lip for a second. She stepped closer to Tina and lowered her voice. “Given the size of what I felt, you’ll probably need a hysterectomy. I can refer you to a specialist at Duke to discuss your options, unless there’s someone closer that you would prefer to see.”
“For something like that,” Tina answered, “I want to go to Duke.”
“Okay,” Dr. Watson said. “But we’ll have to treat your high blood pressure first.”
She asked me to check Tina’s pressure again. It had gone down to a less dangerous level, now about 180/100. But it was still far too high.
“Do you have a family doctor that you can see in the area?” Dr. Watson asked.
“No,” Tina said, as she looked down at her lap. “This is it. I don’t have no insurance.”
“But you have small children?” Dr. Watson said, more a plea than a question, as a streak of red flushed her cream-colored cheeks. Low-income parents of young children are a preferred group for Medicaid, which covers more than 50 million people in the United States each year.
“I got temporary Medicaid during my last pregnancy,” Tina said. “My girl is still on it, but they cut me off not long after she was born.”
At that point, we had not gotten a full “social history,” as it is called in medicine. Specifically, we knew nothing about her work or marital status. Without thinking, I had filled in those gaps with stereotypical assumptions. First, I concluded that the reason Tina was uninsured was that she didn’t have a job. Second, as she wore no wedding ring, I’d assumed she was a single mom. But I was wrong on both fronts. Tina worked at a local convenience store. Her husband of ten years worked with his brothers in a small home repair business. Neither job came with health insurance. Their combined income, she told us, was around $25,000 per year. Medicaid cut her off because “they said we made too much money.”
She and her husband had looked at a private plan, but realized that they couldn’t afford the premium and still pay their other bills. So, comforted that their children had health coverage, Tina and her husband went through life praying not to get sick.
I drew blood as Dr. Watson counseled Tina on ways to reduce her salt/sodium intake. We then went to the medicine cabinet in search of free pills while Tina produced a urine sample. But Tina had the misfortune of being the last patient of the day, and like a shopper arriving late to a post-Thanksgiving Black Friday sale, she was out of luck. In this case that meant missing out on much-needed medicine rather than failing to score a discounted fifty-inch television.
Instead, Dr. Watson wrote a prescription for a diuretic pill, which would cost just five dollars a month. She explained that someone would contact Tina with the lab results, and that Tina should return to the next free clinic the following month. With the clinic now closed, we packed up our medical supplies and personal belongings. Before we left the building, Dr. Kelly wrapped up the day as he began it: “I hope everyone took something positive from this experience today. I hope that in whatever field you choose, you devote at least some of your time to caring for people who otherwise couldn’t afford to see you.”
We all nodded in agreement and approval, as if our leader had preached a medical gospel. I had gone through my first day of hands-on medicine in months, and been reminded of what I enjoyed about it: the data of vital signs and lab tests; the intricacies of the human body seen through the physical exam; synthesizing these findings into a treatment plan. But mixed with these thoughts about process and analysis came concerns about the people we’d seen.
Would Pearl lose weight, take medicines, and stave off the complications of diabetes and hypertension that struck her brother? Would the man with recurrent bronchitis quit smoking? And Tina? Could we get her blood pressure under control? Would she be able to get surgery?
After saying our good-byes to the doctors in the gravel parking lot, Sharon and I got into Mike’s car for the drive back to Durham. We took in our dilapidated surroundings one more time. “Being here really does make you appreciate what you have,” Sharon said.
“Amen to that,” Mike replied.
But as the single-lane road became a two-lane highway and then a three-lane interstate, we gradually put the day’s patients behind us.
* * *
Two years earlier, during my first year of medical school, I sa
t nervously in an exam room at the student health clinic. A nurse had just left the room. She had confirmed the high blood pressure readings that a classmate had discovered a few days before during our weekly introduction to medicine course. Dr. Katz, a small-framed, middle-aged man with short brown hair and large glasses, entered the room and scanned the nurse’s notes before asking me the same questions I would ask Tina two years later. My answers were simple: Other than mild scoliosis, I didn’t have any health problems. I didn’t smoke, drink, or use drugs.
“Do you have a family history of high blood pressure?”
I nodded. About twice a month after Sunday church, my mom would drive to my grandmother’s second-story, one-bedroom apartment off Georgia Avenue in Northeast Washington, D.C. One afternoon, when I was about ten or eleven, my grandmother had cooked salty ham, and this led to a heated discussion with my mom about how my grandmother had not been taking her blood pressure medication or cutting back on high-salt foods as her doctor had recommended. My grandmother argued that the medication made her go to the bathroom all night, and, in her usual blunt style, announced that she had no plans to stop enjoying the foods she’d eaten her whole life. Frustrated, my mom backed off, realizing that there was nothing more that she could do. That was the last time I remember them talking about her high blood pressure.
On the other side of my family, I didn’t yet know about my dad’s hypertension, because he’d avoided doctors for more than three decades. When he was finally diagnosed, he wound up requiring three different medications to control his blood pressure. But I did know that his older brother, who died from a stroke when I was fourteen, had hypertension. Like my grandmother, he apparently had not followed medical advice either.
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