Black Man in a White Coat

by Damon Tweedy, M. D.

  Carl turned to Dr. Rhodes for help. It was time for the boss to take over. At a slender five-nine, Dr. Rhodes was much smaller than Carl or Bruce or me, but there was no mistaking who was in charge. The white coats revealed our hierarchy; his knee-length coat conveyed seniority; Carl’s stopped mid-thigh and Bruce’s and mine were waist-length. Dr. Rhodes maintained good eye contact and spoke with confidence. He stepped forward. “Mr. Warren, it sounds like you know quite a bit about hypertension.”

  Gary put his palms on the bed, arms straight, and sat up even straighter, like a student on good behavior at his classroom desk. He glanced at us before looking up at our supervisor. If we were the teachers, he knew Dr. Rhodes was the principal.

  “My family doctor gave me some pamphlets when I saw him last year and my pressure was up,” Gary replied. “Like I said, I didn’t take it as seriously as I should have. I sorta lost track of things, you know, getting busy with life. But this has been a wake-up call.”

  Dr. Rhodes went into professor mode, giving Gary a mini-lecture about the risks of heart attack, stroke, and kidney failure associated with hypertension. “I can’t tell you how many people I’ve seen on dialysis who were like you at one point. They wish they’d taken their meds.”

  Gary hesitated. “Just give me a month. Two at the most. If I can’t get it down on my own, I promise I’ll come back and start whatever you recommend. I understand that this is serious.”

  “Okay,” said Dr. Rhodes, as he turned to Carl. “He understands the risks involved.”

  Carl finished the conversation, explaining the need to wait for the third cardiac blood test result. Assuming it was normal, the plan was to have Gary go home and come back in a few days for a stress test. In the meantime, he would begin the medications he agreed to start taking.

  Dr. Rhodes extended his hand to Gary’s. “It was nice meeting you. Good luck to you.”

  As we left his bedside and headed back toward our workroom, Dr. Rhodes smiled as he looked over at Carl. “What disorder do you think he has?”

  I presumed he was referring to medical conditions. Given his age, hypertension, smoking, and the onset of the pain while under physical strain at work, heart disease seemed most likely. The forthcoming stress test would give us a better answer. Another possibility was something coming from his gastrointestinal tract—perhaps bad reflux or an ulcer, but our information really didn’t support that. Nor did his symptoms fit the classic picture of a panic attack. Gary did not relate any psychiatric history or acutely stressful events in his life. We’d already been through this discussion after Bruce presented Gary’s case in our conference room. Evidently, after talking with Gary, something had changed. But what? I was jarred by Carl’s answer.

  “Probably obsessive-compulsive disorder,” he said.

  “It seems more like obsessive-compulsive personality to me,” Dr. Rhodes said.

  “What’s the difference?” Bruce asked.

  “Something silly about whether the obsession bothers them or not,” Carl said, shaking his head. With many doctors, psychiatry ranked near the very bottom of the medical pecking order. An old aphorism in medicine was that while surgeons “do everything but know nothing” and internists (my field at the time) “know everything but do nothing,” both were in agreement that psychiatrists “know nothing and do nothing.”

  “Maybe we should get a psych consult to let them sort it out,” Bruce said, smiling. “Maybe if he takes one of their pills, it will convince him to take ours.”

  The three of them broke out in laughter. The medical student on their team frowned at first before forcing a smile to fit in with her supervisors. I stared at my clipboard and pager, pretending to be preoccupied with issues on my roster of patients. None of them seemed to notice my silence.

  Inside, I was quickly moving from disbelief to fury. Gary’s decision seemed reasonable. It was not as if he had a textbook case of bacterial pneumonia and had refused antibiotics. Even on the spectrum of high blood pressure, his readings of 150/100 were relatively mild; various studies had demonstrated average reductions of 5 to 10 points (or more) with diet and exercise. Had his pressure been 190/120, it would have been another story. Further, he had agreed to take aspirin, nitroglycerin as needed, and the nicotine patches.

  Given this data, why did they assume that he had a psychiatric illness because he wanted to eat better and drop some pounds before resorting to blood pressure pills? Because he was black? Because he was a patient in a public hospital? Because he worked at a hardware store? Or was it because he challenged their knowledge and authority in some fundamental way? Perhaps it was a combination of all these factors. It was as if Gary had shown himself to be “too smart” to be a patient in this hospital and therefore had to be mentally ill.

  I was probably more sympathetic with Gary’s decision because when I’d received my own diagnosis of hypertension years before, I, like Gary, didn’t see taking medication as the first option. For me, the goal of avoiding blood pressure drugs provided motivation as strong as the longer-term fears of stroke and dialysis. Why take a pill, with all of its potential side effects, I wondered, when I could achieve the same result by changing how I ate and exercised?

  My doctor agreed. He urged me to complement basketball with other aerobic and strength training exercises. He talked to me about expanding my range of fruits and vegetables, limiting fast food, and drinking water rather than soft drinks. Like me, he considered it important that I exhaust the basics before starting medication. And it worked. Within a few months, my blood pressure was consistently normal.

  During my third year of medical school, I learned about the DASH diet, targeted exercise programs, and the benefits that both had on patients. Data from a subset of the DASH study suggested that black patients responded even better to the diet with greater reductions in blood pressure than white patients did—a finding validated in a subsequent study. If anything, Gary’s doctors should have eagerly supported his lifestyle goals rather than mock them.

  Perhaps they were more influenced by studies that suggested that black people were less likely than whites to adhere to lifestyle changes. And Gary’s hypertension was not an isolated problem. He’d come to the hospital with chest pain. Further, he smoked cigarettes. And he was in his mid-fifties, prime age for early heart attacks.

  Most doctors would have made similar recommendations and urged Gary to take a blood pressure pill. But the way Carl and the other doctors responded still felt wrong. Why had they treated Gary’s responses and vows to change with what seemed like complete disdain? Even if he wasn’t making the best medical decision, he’d neither done nor said anything that qualified as a prima facie case for a psychiatric disorder. If questioning a doctor’s advice meant getting tagged with a psychiatric label, then virtually everyone I knew was mentally ill. I couldn’t escape the sense that racial bias, likely unconscious, had shaped their response.

  * * *

  I didn’t have time to think about Gary for the next several hours. When we got back to the workroom, a nurse paged me about one of my patients, a frail man in his early eighties with terminal cancer who was in the hospital for pneumonia. The antibiotics we had given him had worked. But he’d started having diarrhea the day before, and now his stools had become bloody. He’d traded one problem for something equally serious. He wasn’t going to live much longer, and his wife and son, whom I had met the day before, knew it. Our goal had been to get him through this crisis and arrange hospice so he could die at home. I hoped that was still possible.

  I paged my supervising resident, who talked me through how to manage the situation. After doing so, he told me that we’d gotten a new admission from the emergency room, another elderly man, this one with fever and confusion from rancid bedsores. Meanwhile, my pager started beeping, another patient urgently needing something. I wanted to hurl the chirping device across the room. How was I supposed to handle all of this sickness?

  The frenetic pace had slowed by the time I rece
ived the page from the nurse asking me to enter the discharge order for Gary. His hospital summary listed two diagnoses. The first was chest pain. Underneath, Carl discussed the possible causes, with coronary heart disease being most likely. The second diagnosis, right there for everyone to see: obsessive compulsive personality disorder. What?! I was confused, then shocked. The fact that Carl, Bruce, and Dr. Rhodes had joked about this was bad enough, but they had gone further and made it part of his medical record. How could they have entered this so cavalierly? Had they consulted psychiatry for a second opinion? The chart gave no indication that they had. Carl, who’d been so disdainful of psychiatrists, nevertheless took it upon himself to dole out one of their diagnoses.

  I prodded my memory for what I’d learned in medical school about this disorder, usually referred to by its abbreviation, OCPD. Patients with this condition are perfectionist, inflexible, and controlling. While patients with the better-known obsessive-compulsive disorder (OCD) are distressed by their obsessive thoughts and compulsive behaviors, those with OCPD often perceive themselves as being just fine. They are more inclined to believe that other people, who don’t measure up to their lofty standards, are the ones with problems. A joke in medical school is that if you want to see someone with OCPD, just look in the mirror or at a classmate.

  Although I could have entered the discharge order and let the nurses handle the rest, I couldn’t leave it there. I wanted to talk with Gary, to see for myself whether Carl and Dr. Rhodes had picked up on something I’d overlooked. I found Gary sitting up in bed, reading a science fiction book. The cardiac monitor had been removed. He had on his own clothes—a red polo shirt and a pair of blue jeans. He looked like a dad from my old neighborhood.

  I introduced myself and explained that we were about to discharge him, but first, I was just checking on what had taken place after we’d left his room that morning. “Did any of the doctors come back and talk with you?” I asked.

  He nodded. “They told me that my third blood test was negative and gave me an appointment card for the stress test later this week. They advised me to take off from work until then.”

  “Did they talk with you about seeing anyone else?”

  “They got me a primary care appointment next month. I want to start coming here.”

  “Did they mention anyone else, for any other reason?” I asked.

  He shook his head. “Is something wrong?”

  I was pressing too hard. It wasn’t my job to get Gary upset over something that didn’t seem to have bothered him as far as I could tell.

  Nonetheless, I was dismayed that Carl and Dr. Rhodes had labeled Gary with a psychiatric diagnosis without discussing with him the “symptoms” they thought they perceived. They had not offered any means to address this “problem,” such as a stress management class or other counseling. From what I could tell, their sole basis was a ten-minute interview where he’d agreed with everything they suggested, except when he gave valid and coherent reasons for wanting to delay taking a blood pressure medicine.

  All these thoughts competed for my attention, but all I said was, “No, no problem. I just want to make sure everything is covered. It looks like everything is set until you come back.”

  I wanted to say much more. I wished he’d been in that hallway with me earlier in the day, to see how the doctors had ridiculed him for having ideas about his own health. I wanted him to know what was in his chart, to see what I believed—that his race and class had led doctors to label him as having a mental illness. I was tempted to tell him that I could personally relate to his desire to lower his blood pressure without medications because I’d made the same decision myself. I wanted to tell him that he was just the kind of patient I’d want to treat, the kind who’s thoughtful and knowledgeable about his health. I had an outpatient clinic at the hospital; maybe he’d like to come there and we could work out a plan together.

  I didn’t say any of those things. I felt like doing so would have been opening up a Pandora’s box that I couldn’t close. As a young doctor with no power, I signed the discharge order and wished Gary well.

  “Thanks,” Gary said, as we shook hands. “Good luck in your training.”

  * * *

  A psychiatric diagnosis is not a harmless label. Several studies have explored the ways that people with mental illness receive worse medical care. When psychiatric patients report medical concerns, such as chest pain, doctors take them less seriously. Doctors often review the charts of patients before meeting them and form preconceived ideas based on the information written by other doctors. A person with OCPD may be seen as a potential problem. “He’s going to do whatever he wants anyway, so why bother?” I’ve heard doctors say. While obsessive-compulsive traits might be expected, or even welcomed, in a medical or psychiatric private practice that caters to rich clientele, in a lower-income community clinic where people are stacked one appointment after the next, such a person would more likely be viewed as a “difficult” patient, someone you’d want to get out of your office as soon as possible.

  In this case, Gary’s diagnosis wouldn’t be something that he could easily fix. In contrast, a person recovering from alcohol or drug abuse, while likely to face significant discrimination and distrust, has the ability to establish a clear pattern of clean time documented by laboratory testing. Personality disorder diagnoses are far more subjective. The medical doctor is unlikely to ask, “What progress are you making with your personality disorder?” Rather, depending on their view of psychiatry, treating doctors would view Gary’s labeling as useless at best, or, more likely, as a sign that he is a “problem” patient.

  The following morning during attending rounds, I thought about confronting the doctors who had labeled Gary to make them aware of the role that I felt racial bias had played. But I kept quiet. I’d gotten just about an hour of sleep overnight and simply wanted to get home in time for a nap before Kerrie and I met with the wedding planner that evening. In addition to the typical intern’s fear of challenging supervisors and becoming a “difficult” person myself, I already knew how they’d respond. They would have told me that I had misinterpreted the situation, that race had nothing to do with their psychiatric diagnosis of Gary. They would have cited legitimate medical evidence for their blood pressure medicine recommendation and reminded me of how hard people find changing their behaviors. Perhaps they would have suggested that the stress of internship was affecting me, and that maybe I should talk with someone about that?

  Surely, I had no reason to think of these doctors as racist in any classic sense. I’d had lunch with Bruce and we’d discussed in depth our internship experiences and future ambitions; he’d given me advice prior to one of my rotations that proved helpful. I’d talked about pro football and college basketball with Carl, who’d gone to a Big Ten school, and he’d invited me for drinks with some of his friends. Dr. Rhodes had mentored a few black students and residents in the past and was always friendly with me. As far as I could tell, all three doctors regarded me as a genuine peer, as one of them, in contrast to the way it seemed they saw Gary.

  But at that moment, I didn’t feel like I was really one of them. Nor was I like Gary, who reminded me of a past that I could never reclaim. I had a foot in both worlds, but didn’t have two feet in either.

  My suspicion that, if confronted, these doctors would have vociferously denied that Gary’s race influenced their psychiatric diagnosis is supported by the Kaiser Family Foundation’s 2002 national survey of physicians, published not long before our encounter with Gary. It found that an overwhelming 75 percent of white physicians said race and ethnicity do not affect the treatment of patients, while 77 percent of black doctors said that race and ethnicity do impact how patients are treated. Smart people from two groups were seeing entirely different realities.

  It was clear that my colleagues did not see their actions toward Gary as racially biased, or else they would not have been so brazen in my presence. But I avoided approaching them about wh
at they had done. Once again, personal ambition and comfort trumped racial solidarity. Learning to be a doctor was hard enough without my trying to change the whole system too. Further, I didn’t want to deal with possibly being mislabeled as racially paranoid, especially considering how deeply most educated white people take offense to being accused of racial bias. But was I selling myself, and my race, short in the process?

  In the end, I pretended that nothing had happened. We went about our usual business. Life went on. Gary probably never learned how his doctors had callously mislabeled him.

  * * *

  Several years later, I had an experience similar to Gary’s. In my mid-thirties, my knees were paying the price for many years of playing basketball. I’d grown up spending hours upon hours running, jumping, and cutting on unforgiving blacktop. I practiced and competed on just-slightly more merciful hardwood floors throughout high school and college. After my formal playing days were over, the urge to compete remained strong, so I participated in campus intramural games, joined local recreational leagues, and found pickup games whenever I could.

  The cumulative effect was gimpy knees. I had torn my right ACL many years before, but I’d recovered fairly well with surgery and physical therapy. Now my left knee was the one bothering me. Recently when I had played tennis, it had buckled slightly as I rushed to the net to retrieve a drop shot. When the swelling didn’t go down after several days, I decided to get it checked out. It didn’t seem serious enough to justify a visit to the emergency room, but I didn’t want to wait another week to see my primary care physician or several weeks to see an orthopedic surgeon. An urgent care clinic, part of the same health care system where my primary doctor worked, had recently opened. This seemed the best option.

  Within a few minutes of arriving, an energetic nurse called my name. She gave a warm, friendly smile. “Good morning,” she said. We shook hands. “Follow me.”