My inclination was to find a different resident for her to see. In that clinic, I worked alongside two white women and a Hispanic woman in my same year of training. Maybe as a sophisticated Duke graduate student, she would even be better off with a faculty therapist. I told Diane that I would call her after consulting with my supervisor.
After I finished seeing a man with bipolar disorder who needed his prescription medications renewed, I went to Dr. Carpenter’s office to discuss Diane’s case. Dr. Carpenter was in her mid-fifties and had been on faculty for two decades. She had gone to medical school knowing that she would become a psychiatrist. During our thirty-minute meeting, I tried my best to get Diane assigned to another resident, offering examples of other episodes where well-intentioned but ill-advised race matching had gone bad. How could it get worse than with a black woman afraid of black men?
“You’re trying to take the easy way out,” she said. “This would be a good case for developing your psychotherapy skills. And if you give up on her now, she will feel abandoned and rejected, which will only feed into her negative feelings about African American men.”
I was skeptical. It sounded like something I might have heard on an episode of Oprah. But sensing that I had no other choice, and fearing a negative evaluation sent back to my training director indicating that I was obstinate and defensive, I followed Dr. Carpenter’s advice. I called Diane later that afternoon and scheduled a visit for the next week, doubting that she would come. A part of me sincerely hoped she would not.
* * *
My suspicion at being assigned Diane’s case based on a race-matching goal was rooted in a larger history; it reflected the evolving rationale for affirmative action in medicine.
Forty years earlier, with the images of Jim Crow still fresh in America’s consciousness, affirmative action programs were started on the notion of redressing historical inequalities in access to education and job opportunities. In medicine, the effect was quickly felt: By the mid-1970s, the proportion of black medical students had nearly tripled. But inevitably, these gains came at the expense of others. The first main challenge to this new order was the 1978 U.S. Supreme Court Bakke case, where an applicant brought suit against a California medical school asserting that his rejection stemmed from the school’s policy of setting aside slots for minority applicants. The Supreme Court agreed that quotas were unconstitutional but allowed schools to consider race toward the end of creating and maintaining a diverse student body. The Court’s decision guided the affirmative action landscape until the mid-1990s, when a second wave of legal protest emerged. Buoyed by a University of California regents ban on race-based preferences and a federal appeals court ruling that struck down race-based affirmative action programs, the diversity argument had also come under assault.
Motivated by these challenges, as well as the persistent problems of health disparities among black patients, several researchers in the mid-1990s began publishing studies that looked at the role black doctors played in the care of minority patients. They found that black doctors served black patients at six times the rate as other physicians; that black physicians were far more likely to treat patients covered by Medicaid; and that the supply of physicians was lowest in areas with higher numbers of black and Hispanic patients.
Over time, a related group of studies reported that black patients tended to have more positive interactions with black physicians. The conclusion from these articles was that increasing the diversity of the physician workforce could help reduce racial inequalities in health care, a position advocated by leading mainstream medical organizations such as the American College of Physicians, the Institute of Medicine, and the Association of American Medical Colleges. This has become the lead argument for affirmative action in medicine.
But this stance too has its limitations. Some of the research in this area has shown no additional benefits to black patients, while critics have argued that several influential studies were either methodologically flawed or overstated their conclusions. There have even been some reports that hint at the possibility that black doctors, for a variety of reasons, might deliver a lower quality of care.
Moreover, the focus on same-race pairings overlooks a larger aspect of U.S. medical care: International medical graduates (IMGs) constitute about 25 percent of American doctors. The vast majority are of Asian and Middle Eastern ethnicity. In many settings where poor patients—black and white—are treated, IMGs make up an even larger percentage of doctors. Unfortunately, much of the medical literature examining same-race pairings specifically excludes these physicians. In a 2005 essay, Alok Khorana, an Indian physician practicing in New York at the time, examined these issues in his description of caring for an elderly black man with cancer. At the end, he questioned the wisdom of moving toward black doctor-patient pairings as a targeted goal, wondering whether this might “close the doors to self-examination and self-improvement” among physicians.
In my own medical experience, I’d seen same-race pairings work both ways. In some cases, a black doctor seemed to make a positive impact on a black patient’s health, whether it was the nephrologist persuading a young man to take his blood pressure medications, the obstetrician convincing a young woman to attend prenatal appointments, or in my case, the delusional Lonnie thinking that I was Michael Jordan and being willing to take antipsychotic medication. On the other side, I’d seen white doctor–black patient unions operate flawlessly and had myself been a part of floundering relationships with black patients.
What all of this would mean for Diane, and my role as her doctor, I wasn’t yet sure.
* * *
Diane returned for her appointment the following week. She immediately brought up her reluctance to come back to see me.
“I was talking with a friend a few days after I saw you,” she began, “about how ironic it was that I got scheduled with, you know, a black man. I seriously thought about canceling this appointment and requesting someone else. But she basically talked me out of it.”
I was once again at a loss for words. This felt like the plot of a formulaic movie, the kind where the first date goes poorly, with the man and the woman swearing never to see each other again, only to be strong-armed into giving it a second try by a friend or domineering parent. But this wasn’t that kind of relationship. I was the doctor, the one she’d come to seek help from, only I didn’t know what to say or do. So there we sat as the session began, fearful patient and frustrated doctor, both uncertain where this clinical venture would lead.
Gradually, we began the business of therapy. I asked more about her family. Diane spent the next half hour talking about her parents’ marriage and their attitudes toward raising her and her older brother. She talked about her brother being a serial dater and his proclamations that he’d never marry or have children, and she wondered whether her family had scarred her in the same way. Then she shifted seamlessly into discussing her ambivalence about getting a Ph.D. and becoming an academic, describing how she felt torn by the desire to do something more exciting and immediately accessible with her life. By the end of that session, I felt a little better about my role: maybe things weren’t going to be as bad as I’d initially worried.
In subsequent visits, we broadened our scope to issues of class conflict within our race, the portrayal of race in the media, and what these larger issues meant for her growing up and for the life she wanted to live. As someone who grasped these racial concerns on an emotional level, I was a good sounding board. Over the ensuing months, our weekly visits challenged her anger toward black men and, by extension, her negative beliefs about herself.
About two months later, Diane started dating Mark, a black student in a different graduate department at Duke. She said it was the first time in her life that she’d dated a black man. It wasn’t that black men never tried, but she always rebuffed their advances, finding them too aggressive, too intimidating, too much like her father. Mark was well on his way to this same fate when Diane decided, after
weeks of exploring her feelings about race in our sessions, that she’d give him a chance. At first she was afraid she might repeat her mother’s mistake, but so far Mark seemed gentle and caring—vastly different from her dad.
It wasn’t my place to encourage her to date a black man. Nor did I have hang-ups about interracial dating. What mattered was the transformation that she was undergoing—from someone who loathed black men and all of our negative stereotypes to someone who was open to the idea of treating each one of us on the basis of our individual merits. Week after week, we talked about the progress in their relationship.
Finally, after several months, she ended one of our sessions: “You know, I feel a lot better. This has been good. Thanks.”
It sounded like a good-bye. When I asked her if she wanted to schedule another appointment, she told me that she would get back to me. About two weeks later, she sent me a heartfelt handwritten note, thanking me for all of my help.
The impact on me was profound. I had entered psychiatry with a biomedical slant, dubious toward those who were strident psychotherapy advocates. But I am certain that no medication could have altered Diane’s outlook on race the way that our sessions did. And I had now witnessed the unique benefit that racial matching could have in a clinic setting.
Several years later, I contacted Diane in order to get her consent for me to describe her case in an article that I was writing. I’d periodically wondered how she had been doing, whether the gains she made during treatment had been sustained or if she’d reverted to past insecurities and conflicts. We met at a coffee shop not far from campus. She seemed surer of herself than I remembered. No diverted glances, no stuttering, no tapping of her feet or trembling of her hands. We were meeting as peers.
I started off giving her updates on my career. Then we turned to her life. “I’ve grown so much since the time I saw you. You really did help me.”
She told me that she’d married Mark. They’d recently celebrated their third anniversary. He was nothing like her father. We talked about how unlikely her present life seemed when she first walked into my office. In other areas of her life, things were going well too. She was about to finish graduate school, and had taken a job as a professor at a college in California. She was also doing some writing for a women’s magazine. She looked happy.
As the rain outside progressed from a few drops to a steady drizzle, I looked at my watch. I had to get back home. Knowing this was likely the last time that we’d see or speak to each other, we shook hands and said good-bye. I couldn’t know whether she would have arrived at this place in life with someone else’s guidance, or even on her own, but for once, I felt that by being a black doctor—rather than simply a doctor—I had truly offered a patient something more.
9
Doing the Right Thing
On an idyllic spring Thursday afternoon, two patients, Adrian and Henry, were among the half dozen on my schedule. Like most people, they had both made decisions that impacted their health. Those choices were diametrically opposed and, not surprisingly, resulted in dramatically different outcomes. These two men raised a question I’d been asking since medical school, one that I’d heard many doctors, in frustrated moments, bring up: How much impact can we really have on patients’ lives when their own behavior influences their health to such a large extent?
After finishing my psychiatry training, I stayed in the Raleigh-Durham area where my wife had established a primary care practice. I’d taken a Duke-affiliated job in which, among other duties, I spent two days each week in an outpatient mental health clinic. Staffed by a mix of psychiatrists, psychologists, and social workers, my primary role was to prescribe medications and provide brief counseling to patients. This followed a model common in mental health practice; the sort of in-depth therapy that I’d done with Diane as a psychiatric resident was carried out by the psychologists and social workers.
For three years, Adrian had been coming to see me every three months for treatment of his chronic anxiety and insomnia. He had a history of alcohol and cocaine abuse, but had been clean for more than a decade. Initially, I had referred him to a psychologist for talk therapy, but he didn’t like it. He wanted to feel calmer and sleep better at night, but didn’t take to the idea that discussing his life in depth would help. Instead, we had tried a handful of medications with varying degrees of success.
On this particular day, I’d spent too much time gossiping with colleagues over lunch, so I didn’t review the charts of my afternoon patients for any interim updates. When I walked to the waiting area and saw Adrian, it was obvious something had happened since we last met. Something bad. His body trembled as he turned to me. The right side of his face drooped. A shiny metal rolling walker was parked next to his chair. He’d lost at least thirty pounds.
Maybe he had been in a car accident. Maybe he had a brain tumor. Or, most likely from what I knew of his history, he had suffered a massive stroke.
His eyes locked on mine. He recognized me, but his face struggled to generate a smile. Could he move his arms to shake my hand? Could he still talk? I wasn’t sure how to respond, so I tried to act as if his appearance wasn’t distressing to me. “Come on back,” I said.
Adrian’s wife, Ellen, stood first, helping keep Adrian steady as he slowly rose from his chair. She’d come to a handful of visits with him in the past where they’d talked about marital issues, or the problems with their daughter’s taste in men. Her focus had now fully shifted to caring for Adrian. She swung the walker so that he could grab hold of it and keep from falling. With Adrian and his walker sandwiched between us, Ellen and I guided him down the narrow hallway to my office. What three months earlier had taken fifteen seconds from start to finish, now took five minutes.
Ellen wasted no time getting to the point: “A.C. had a stroke two months ago.”
She called him “A.C.,” the initials of his first and middle names. This always made me think of my dad, who many relatives still called “C.D.,” as my grandparents had chosen his initials before settling on a name. Adrian’s thick graying hair also resembled my dad’s. These similarities made me look forward to our visits, even if progress was limited.
“Where did it happen?” I asked.
Adrian tried to answer: “Baa … baa … baa…”
I was thinking as a doctor, trying to decipher what part of the brain had been affected, and in turn, what bodily functions were diminished or lost as a result. I looked over at Ellen, who fought back tears. This was no clinical challenge for her; this was her new, terrifying reality. She took me back to the moment that Adrian’s previous life had come to an end: “We was at home. I was fixing dinner when I heard a loud noise in the other room.”
She found him at the other end of their new mobile home, collapsed on the bathroom floor. He couldn’t move half his body; he couldn’t talk. After a week in the hospital, he was transferred to a rehabilitation facility where he’d received the usual services: physical therapy, occupational therapy, and speech therapy. But Adrian hadn’t made much progress, nor did the doctors expect him to based on the severity of his stroke.
I thought about what took place a year earlier. Adrian, then sixty-five, had been admitted to a local hospital for a transient ischemic attack (TIA), or “mini-stroke.” People who suffer a TIA often present with classic symptoms of stroke, such as sudden weakness, trouble speaking, or loss of vision, but the symptoms resolve within a matter of hours with a return to normal functioning. When he came to see me after that episode, Adrian acknowledged that he had dodged a bullet. But while he’d taken his daily aspirin and blood pressure medication, his diet wasn’t much better and he hadn’t stopped smoking cigarettes as he’d been advised. Now the second bullet had nearly killed him.
I looked back at Adrian. His efforts to talk had generated a slow trickle of saliva. He’d lost control of the ability to swallow. I winced. For some reason, saliva and mucus had always bothered me a great deal, far more than the sight and smell of blood or urine.
I offered a tissue, but Ellen pulled out a white handkerchief that she used to wipe the pooling spit.
Adrian couldn’t eat without the risk of choking or aspirating food particles into his lungs. Ellen pulled up his shirt to show me the tube that connected to his gut, through which he’d likely be fed the rest of his life. He also wore a diaper. My mind shifted to my own life. I had a toddler son at home who ate few solid foods and made a lot of babbling sounds. Dirty diapers were a daily chore. The thought of Adrian functioning at this level overwhelmed me, especially once Ellen started crying. What could I possibly say that would make the slightest difference for them?
“I’m really sorry about all of this,” I said, offering Ellen a tissue that she used to dab her eyes and blow her nose. “Is there any way that I can help you?”
Quickly composing herself, she went through a list of things that were more appropriate for Adrian’s primary care doctor to address, such as renewing orders for his adult diapers and tube feedings. But desperate to feel useful, I obliged. While this surely helped her, I was left feeling that my actions were ultimately pointless. In terms of treating Adrian psychiatrically, there wasn’t much to do. I increased the dose of the new antidepressant that had been started in the hospital, but that felt about as useful as giving Tylenol for a severed limb. After they left my office, I went to the break area in search of sugary comfort food.
The next few patients went by in a blur. As they talked about their marital problems and miserable jobs, I thought about Adrian’s future of babbling, tube feedings, and diaper changes. I wanted to tell them to just go outside and enjoy the sunny seventy-five-degree weather. To be grateful that they could control all of their bodily functions and stop complaining about things that, in the end, really weren’t that important. If they hated their job, they could get a new one. If their husband or wife was a lousy spouse, they could find another one of those too. But Adrian couldn’t get a new brain. This was not the day for my patients to see their empathetic shrink. I tuned them out.
Black Man in a White Coat Page 21