I limped behind her down the hall into an exam room. Once inside, I gave her a brief history of my knee pain. She typed this information onto a computer screen. She then checked my vital signs. My blood pressure was in the gray area between normal and high. I wasn’t too worried as I’d checked it at work recently, and it had been fine.
“Dr. Parker should be in shortly,” she said. “It’s pretty slow here today.”
True to her words, the doctor opened the door moments later. He gave me a weak handshake as his eyes scanned me from head to toe. It was only then that I realized how casually I was dressed. In contrast to the usual shirt, tie, and slacks I wore to work, I had on a fleece pullover and sweatpants. In haste, I’d put on white socks that were slightly mismatched. I didn’t look homeless, but I didn’t look like I had taken much care with my appearance.
With virtually no eye contact, his eyes fixed on the computer, Dr. Parker verified the information the nurse had obtained. He then had me pull up my sweatpants so he could look at both my knees. Next, he asked me to stand. My knees creaked, like a door hinge in need of lubricant. The pain made me grimace.
“You’re fine,” he said. “Probably just a bruise or sprain. Just take it easy for a while.”
That’s it? All he had done was look at my leg. He had not touched it to feel if my knee was unusually warm or cold, or whether it had accumulated excess fluid. Nor had he moved my knee through the various ranges of motion. He’d offered no explanation of what part of the knee was bruised or sprained. There’d been no mention of pain meds, ointments, or other analgesia. He did not offer nor suggest any type of knee bracing, just rest. But what if I had a job that required me to move around? He was all set to leave. I knew I had to say something.
“I really just want to make sure there’s nothing serious,” I said, hurrying to stop him from walking out the door. “Last summer I walked around with a sore hand for three days before I got an X-ray that showed a left third metacarpal fracture.”
He looked up and established eye contact for the first time. “Are you a medical person?”
“Yes,” I said.
“Are you an X-ray tech?”
“No, I’m a physician.”
His eyes widened with surprise and what seemed to me admiration, as if the last thing he had expected was for us to be in the same profession. We traded a few words about the challenges of internship and residency training and the adjustment to life afterward. “Let me take a closer look at your knee,” he said.
He went through a detailed physical exam—the kind I had expected from the beginning.
“Everything seems okay,” he said. “But I think it would be good to get an X-ray too.”
The nurse returned and escorted me to the basement for X-rays. Dr. Parker then came down and reviewed the film with me. It showed some early knee arthritis, but no other problems. He assured me that when the radiologist gave the official reading, he would call me himself. In the meantime, he recommended a brace, and offered me crutches just to have on hand. He also offered me a prescription for pain medication. Based on the X-ray, I told him that the brace would suffice; I didn’t need crutches and would take over-the-counter ibuprofen.
As promised, Dr. Parker called me the next day. The radiologist’s report had confirmed his preliminary review. He told me that he’d gone over to the nearby orthopedic surgery office and gotten me a better brace than the one they had in the urgent care clinic, free of charge. In the end, Dr. Parker’s initial impression was correct; I had a mild-moderate knee sprain. With a few more weeks away from the basketball and tennis courts, the pain and swelling receded.
But I couldn’t get out of my mind how I’d been treated as two entirely different patients. Damon Tweedy, the unknown black man, dressed like he was about to mow the lawn, couldn’t get the doctor to look him in the eye or touch him; Damon Tweedy, M.D., was worthy of personal, first-class service. While it’s widely known that doctors get special treatment from their colleagues, this went far beyond the usual professional courtesy of an earlier or more convenient appointment. Receiving a physical exam, an X-ray, medication, and a brace, when you otherwise would not, wasn’t just better service: it was different medical care altogether.
Was Dr. Parker aware that his initial lack of attention had been unfair and insulting, leading him to overcompensate with his subsequent actions? Perhaps, but I was more interested in the reasons for his initial approach to me. He evidently saw me through a mental filter, and his assumptions were not positive. Several authors have written about the negative stereotypes that many doctors associate with black patients: poorly educated, drug abusing, not likely to comply with treatments; in short, the kind of person most doctors don’t want to treat.
Granted, the urgent care setting where I saw him, and the emergency room in particular, often bring out the worst in both doctor and patient. From the doctor’s lens, the goal of care in an emergency department or urgent care clinic is different from a family practice office. As one doctor told me during my ER rotation at Grady, “We are not here to make friends with patients, but to make sure they end up in the right place.” In other words, the goal of the physician in this setting is to move the patient along the assembly line, not to establish a meaningful relationship. Yet the patient probably sees it differently. For far too many in our country, black people especially, urgent care and emergency rooms are the portals to the health care system.
Recognizing that time and urgency constraints might interfere with a good bedside manner did not excuse Dr. Parker’s initial actions. At the very least, he should have done a physical exam. While his initial impression proved correct, without an exam or X-ray, a tiny fracture could have been missed and later morphed into something far worse. Had I not had the medical knowledge or sophistication to garner his attention, he would have sent me out of the urgent care—limping, vaguely diagnosed, without brace or crutch, without medicine, and without a follow-up visit. That’s bad medicine. Why did I have to prove that I “deserved” the far better care he later showed he was capable of delivering?
Appearance and dress matter for everyone in how they’re perceived, but the prevailing wisdom among black people is that it’s much more important for us than it is for others. Even if the impact can’t be studied or measured objectively, many black people will tell you that they have to dress better than a nonblack person to be taken as seriously. I certainly learned my lesson. Since that day, whenever I have an appointment or tag along with a family member to a doctor who doesn’t already know me, I put on a sport coat. Sometimes I’ll wear a tie too. At the very least, I’m certain to wear a collared shirt and slacks, and a pair of nice matching socks.
* * *
Doctors, like all other people, are capable of prejudice and discrimination. While bias can be a problem in any profession, in medicine, the stakes are much greater. Missing a blood clot in a patient’s painful leg because the doctor thinks that black people in a given clinic or hospital are likely to be drug addicts seeking their next fix is a far more dangerous kind of insult than a salesperson assuming that a black customer can’t afford a Brooks Brothers suit or Rolex watch. These high stakes make it vitally important for doctors to understand their capacity for prejudice.
The American historical record is full of material about white doctors’ abuses and discrimination against black patients, often chillingly described in the words of the doctors themselves. Most of us, including many black people, would like to move beyond the past and accept that this American script has been rewritten. And while many things have improved, studies continue to document the ways that the doctor-patient relationship can undermine the health of black people. My experience with Gary and my own encounter with Dr. Parker are smaller examples of a larger issue.
As doctors, there is ultimately only so much that we can do for our patients, especially for the more disadvantaged in our society. We can’t get them good jobs with good health insurance. Nor can we move them into nicer
neighborhoods where their children can attend better schools. Despite the knowledge, advice, and treatments we have to offer, we often can’t help our patients live healthier lives. But as doctors, we can do one simple thing for them: We can make our very best effort to treat everyone fairly.
7
The Color of HIV/AIDS
“I’ll be damned,” Adam, a medical resident, said, shaking his head. “Our patient in room thirty has been lying.”
We were sitting next to each other in a musty workroom filled with the scent of stressed-out residents and stale pizza. It was seven p.m. Our sister team had admitted the first wave of new patients to the medical ward and was frantically trying to wrap up their work so they could get home. Adam and I were the long-call, overnight team, which meant we’d been on duty for twelve hours and faced another eighteen before we would be set free. I was writing the admission note on an elderly woman who’d come to the hospital that afternoon with a blood clot in her leg. Adam was on the computer looking over the most recent lab results for our patients.
The patient in room thirty, George, had come to our hospital two days earlier complaining of fatigue, weakness, and short-term memory problems. He’d been losing weight and his blood counts were low. In his late forties, he worked at a local, predominately black college that he had graduated from twenty-five years earlier.
George told us he had been healthy his entire life until about six months earlier, when he gradually started feeling tired and had trouble focusing at work. His appetite went away and his weight dropped; he lost twenty pounds without trying. His red and white blood cell counts were abnormal, and his family doctor worried that he might have cancer. When further tests did not detect any cancer, however, his doctor suspected that George was depressed. He tried Prozac and Zoloft, but neither helped.
Adam’s computer screen had revealed some critical truth about George. “Lying about what?” I asked.
As a medical intern, hearing lies was a daily part of my job. We’d been taught—not in a formal way, but through the offhanded comments of our supervisors—to double whatever amount of alcohol or cigarette use the patient reported, and to accept this higher number as being more accurate. For street drugs, a patient’s word meant nothing without a urine test. Aside from drug abuse, people most commonly lied about whether they followed a healthy diet, exercised regularly, or took their medications as prescribed. Lastly, many lied about sex.
“He’s HIV-positive,” Adam replied.
Of course, I thought, experiencing the same satisfaction I felt when the final twist is revealed in a good movie or detective novel. HIV made sense. We’d been instructed to always include it on our list of usual diagnostic suspects. The risk of missing it was too great, not only for the patient, but for whomever they could go on to infect. In George’s case, HIV explained everything: the weight loss, fatigue, poor concentration, abnormal blood counts, everything. Yet, despite my textbook knowledge, I was still surprised. What I was about to see was that George, in many ways, represented the changing face of HIV/AIDS.
* * *
The mid-1990s was a time of dramatic developments in the battle against HIV/AIDS. The introduction of a new class of medications, the HIV protease inhibitors, transformed treatment, bringing many people back from death’s door. Between 1995 and 1998, AIDS mortality in the United States dropped more than 60 percent. Among white men, this decline was even more pronounced, with reductions in death rates approaching 75 percent.
The same era also brought what social scientists call “shifting demographics” in the evolution of HIV/AIDS in America. Since the first reported cases in 1981, HIV/AIDS, aside from those with hemophilia or intravenous heroin addiction, was widely regarded as a disease of gay white men. In the early years, movie star Rock Hudson and musician Liberace were its most famous victims, and the activists seen in mainstream media were white men. From the outset, however, this was never the full story, as black people accounted for a quarter of HIV cases during the first decade of the epidemic, a proportion nearly double theirs in the general population at the time.
Not surprisingly, with all that is known about poverty, race, and poor health, advances in treatments for HIV had a muted benefit on blacks compared to whites. Not only were HIV medications expensive, but patients had to be tied into quality medical care in order to have access to the drugs and the support systems needed to manage the complicated treatment regimens. Given increasing infection rates and less access to state-of-the-art care, during the early 1990s, the death rate from AIDS among blacks exceeded the rates seen in whites. In 1996, for the first time in the epidemic, more black people in America died of AIDS than whites.
In the years that followed, the color of HIV/AIDS in the United States continued to darken. By 2001, the annual death rate from AIDS for blacks was nearly double that of whites. In 2011, when blacks constituted about 12 percent of the U.S. population, they accounted for 46 percent of new HIV infection cases. Put another way, black people in the U.S. are more than eight times as likely as whites to be diagnosed with HIV. Once diagnosed, they are about nine times more likely to die from AIDS. Hispanics are also afflicted in disproportionate numbers. What had once been seen as a white disease has turned black and brown.
* * *
HIV had been on his family doctor’s list of possible diagnoses, but George had declined the test, saying that he’d tested negative before and hadn’t had sex with anyone other than his wife since. It was not until George was admitted to our hospital that he consented to an HIV test.
“I guess he wasn’t completely honest with his family doctor,” I said.
“Or with us,” Adam replied. “And probably not with his wife either.”
I went through what we knew. We’d done the standard HIV risk assessment when he’d been admitted to the hospital. He worked in an office setting. He’d been married for almost twenty years. His wife worked at a prison and had tested negative for HIV ten months earlier. He denied any extramarital affairs, as did she. He told us that he did not use street drugs of any kind, much less ever inject them into his veins. He said he’d never had a blood transfusion. Based on this information, HIV seemed unlikely, and we were all set to undertake a detailed and expensive series of tests to uncover some rare disease.
“You wanna tell him?” Adam asked me.
“Sure,” I said. “Let me finish this note, and I’ll go do it.”
In the half-hour or so it took me to finish the paperwork on the other patient, Adam had changed his mind. “Why don’t we go as a team?” he said. “This might be a good learning opportunity for our student. Besides, I know this sounds awful, but I’m dying to know the truth.”
This all seemed callous, to be sure. I was looking at George’s diagnosis as I would a TV mystery, while Adam was focused on the soap opera element. Our medical student, well into her year of clinical rotations, shared our curiosity. “His wife is going to be pissed,” she said. Trapped inside the hospital vortex where disease, disability, and death were constant companions, our reactions passed for normal behavior.
It was only as we stood outside of George’s room that I started to fully appreciate the emotional weight of the diagnosis. HIV in 2004 wasn’t the universal death sentence it had been two decades earlier; still, other than cancer, organ failure, and a few neurological disorders, it was just about the worst news that a doctor could give.
“Here goes,” I said, as I knocked on the door to George’s room.
By this point, I’d been a medical intern for nearly nine months. Combined with my years in medical school, I’d been a part of delivering enough bad news for a full season’s worth of episodes on a TV medical drama: “Sir, you have cancer”; “Ma’am, your cancer has returned”; “Your husband’s stroke has taken away his ability to talk or swallow food”; “Your mother’s dementia is progressive, and there are no other treatments left for us to try.” Saying and hearing these things for the first time had been heart-wrenching. Now, however, these
and other grim pronouncements were stuck in my mind, as accessible to me as the lyrics to my favorite Bob Marley or Marvin Gaye songs. A few days before, I had to tell a woman that her fifty-five-year-old husband had died of a heart attack, and while I truly felt sorry for her, the words had come off my tongue as easily as if I’d been giving directions to the hospital cafeteria.
But I’d never told a patient that he or she had HIV/AIDS—or even watched another doctor do it. All of the HIV-positive patients I’d seen had been diagnosed before I met them. Despite my experiences being part of the worst moments of people’s lives, giving George his diagnosis felt different. Cancer, diabetes, and pneumonia were universally seen as diseases of the body, even if the person’s lifestyle had in some measure contributed to the illness or made its course worse. HIV, despite its irrefutable biological dimension, was still seen by many as an indictment of one’s character or morals. At the time, a part of me agreed. Once universal testing of the blood supply in the mid-1980s virtually eliminated HIV infection through blood transfusions, people came down with HIV in one of two ways: sharing infected needles or, much more commonly, through sex.
When we entered the room, George was propped up in bed, sipping water from a paper cup. A slow-drip intravenous line gave him additional fluids to offset his dehydration. A plastic, handheld urinal hung on his bedrail for easy access; his weakness made the short trip to the bathroom a perilous journey. This was surely not how he had envisioned his life in the weeks before he turned fifty.
“All my young doctors are here,” George said to his wife, Janice, who sat upright in a vinyl chair that doubled as a sleeping recliner for overnight stays. Like so many attentive spouses, she’d dragged him to the doctor when, left to his own devices, he would have continued to downplay or ignore his health problems.
“Any updates?” she asked, putting down her book and moving to the edge of the chair.
Black Man in a White Coat Page 16