Then Henry walked in. He was my last patient of the day. My mind was focused on speeding through his visit and dropping by the store to get an ice cream cone or box of cookies to eat on the drive home. But when I spotted Henry in the waiting room, my heart skipped a beat. His six-foot frame was noticeably thinner than when I’d last seen him a few months before. His polo shirt and slacks were loose and baggy, as if he was a trim teenage boy who’d put on clothes that belonged to his middle-aged dad. Possible causes for his weight loss swirled in my head. Did he have cancer? Had he quit taking his medications and become so manic and psychotic that he’d stopped eating?
I’d seen Henry for about as long as I had treated Adrian, our visits spaced out every few months. He had been diagnosed with schizophrenia in his mid-twenties, but the psychiatric label had changed a few decades later to schizoaffective disorder—a mixture of schizophrenia and bipolar disorder in his case—after he’d been hospitalized with a full-blown manic episode. The doctors in the hospital had started him on a medication that treated his mania and delusions, but it made him tired all the time and made his muscles too stiff to drive a car or work in his garden. His previous clinic psychiatrist tried a few other medications before finding one that treated his mental illness without limiting his daily functioning.
The only problem was that it caused weight gain. A lot if it. In less than five years on the drug, he gained fifty pounds. With this excess weight came diabetes, hypertension, and high cholesterol, all of which required treatment with other drugs. The medicine that calmed his mind was hurting his body. When I saw his weight loss, I wondered if he had decided to stop taking it for this reason. But that would be a quick way to relapse into a psychotic episode.
I ruled out any acute change in his psychiatric condition, however, when Henry greeted me with his usual enthusiastic grin, an amusing cross between comedians Eddie Murphy and Arsenio Hall. “Heya Dr. Tweedy,” he said as always, “it’s a pleasure to see you again.”
He sat in the same chair where Adrian had been just a few hours earlier. “How have you been feeling recently?” I asked.
“Good. You know, I still hear that voice, but you know, with the medicine, it’s not getting any louder or telling me any of that crazy stuff anymore.”
For many years, maybe decades, Henry heard the voice of a man that told him that his mom was an ugly bitch and that his dad was a child rapist. With medication, the voice only said his parents’ names without the added commentary.
“How about physically?” I asked. “Have you felt sick or weak?”
“No,” he replied. “I’ve been feeling good, man.”
“It looks like you’ve lost some weight,” I said.
The toothy grin came back. “Yes sir,” he said, rubbing his hands across his smaller belly. “Twenty-five pounds. I can’t wait to get on your scale.”
“Have you been missing any doses of your medication?”
“No sir. My wife won’t let me get in the bed with her until after I take it.”
I suppressed a smile. Henry handed me the results of recent blood tests from his family doctor. Nothing abnormal there. If anything, his numbers were better, with lower cholesterol and blood sugar values.
“What have you been doing to lose so much weight?”
Falling back on the usual medical pessimism, I wondered whether he was taking some kind of diet suppressant or other quick fix that might ultimately prove harmful.
“I’ve been doing the right thing,” he said, smiling again. “I’m getting away from eating all that artery-clogging crap. You know, fried stuff, processed stuff. I also started walking a lot.”
It finally sank in: Henry had made real, positive health changes. This visit was going to have a happy ending. Given how the afternoon had started, I’d been so focused on finding the bad that I hadn’t seen the good when it was staring me in the face.
“I finally started listening to you,” Henry said.
I was thrilled. Because he took a medication known to promote weight gain, I checked his weight at every visit. This provided a natural opening for me to ask about his diet and exercise habits. For the hundreds of patients with whom I talked about lifestyle changes over the years, however, my medical advice gradually felt more like a routine than personalized care, as if I was simply going through the motions. The fact that people often ignored my recommendations only heightened my cynicism. However, Henry had taken my words to heart.
I renewed his medication, energized by his gratitude. We then walked down the hall to the scale. Henry had indeed shed twenty-five pounds. Keep it up, I urged, even as part of me feared that he, like so many other people, might soon slip back into unhealthy habits. Nevertheless, seeing Henry was just what I needed. I decided to follow his lead and go play tennis rather than gorge myself on ice cream and sugar cookies.
On this day, one man had made good choices and increased his odds of a healthy future. The other hadn’t and, at least partly for that reason, faced a heartbreakingly new life. Driving to the tennis court, I was nagged by the same unsettling thought that had come to mind periodically over the years, one I usually tried hard to keep at bay: Could it be that despite all the years I spent in medical school and residency training acquiring specialized knowledge and practical skills, that this expertise mattered little to my patients’ overall health?
People either made healthy decisions or they didn’t. Those behaviors in turn would determine, far more than anything a doctor could do, whether they had a heart attack at fifty-five, cancer at sixty, or lived to be seventy-five or eighty before developing any serious problems. Time and again, black people, such as Adrian, suffered the worst outcomes from these bad decisions. As a physician, what influence could I have, if any, in helping them do better?
* * *
The choices that we make have a profound impact on our health. Sometimes it’s a single, simple decision—wearing a seat belt or a condom at a given moment, for instance—that can have far-reaching consequences. More often, though, it’s the daily decisions repeated over time that catch up with us. Smoking cigarettes, abusing alcohol or drugs, eating too much and too many bad foods, and exercising too little all can lead to an array of diseases. Of the ten leading causes of death in America (among them heart disease, cancer, stroke, and diabetes) each is strongly influenced by our actions. Researchers from the Robert Wood Johnson Foundation, a New Jersey–based philanthropic organization devoted to health and health care, estimated that behavioral choices account for at least 900,000 deaths each year and “represent the greatest single domain of influence on the health of the U.S. population.”
While all of us make decisions that shape our health, the reasons we make those choices are more complex. A large body of research has shown the important role of culture and environment. Socioeconomic status, both as we begin life and as we traverse it, is paramount. Whether measured by educational level, income, occupation, or some combination, low socioeconomic status is linked to a wide range of health problems and higher mortality rates.
Low-income settings adversely impact individual behaviors, such as smoking, drug abuse, nutrient-poor diets, sedentary lifestyles, and less likelihood of following medical treatments. These negative patterns in poor neighborhoods often become self-perpetuating. Clearly, such factors have a direct effect on health disparities, as black people remain, on average, at the bottom of the socioeconomic scale. But putting all of the blame on socioeconomic status and personal choice didn’t feel right. Was it possible that I was making excuses for inattentive medical practice?
Looking back to medical school, I remember little instruction on how to address the role of lifestyle habits on our patients’ health. For example, we learned how cigarettes and alcohol damage the body, but not about why people smoked and drank or how we might intervene beyond prescribing a handful of modestly effective medicines. This biomedical focus persisted as we transitioned to the medical wards. Patients on our services were broken in some physical w
ay, and our job was to fix them, or at least make them temporarily better, whether through surgery or intensive medication therapies. A high premium was placed on “doing something,” which meant using your hands or your knowledge of pharmaceuticals.
During my general medicine rotation as a second-year student, our team admitted a sixty-year-old black man with chest pain. He had hypertension and high cholesterol, two risk factors for heart disease. He was also about forty pounds overweight. He was the sort of patient we saw dozens of times throughout our training. After all of his tests came back normal, we discharged him with prescriptions for aspirin, a blood pressure medication, and another pill to lower his cholesterol. The doctors told him that he should lose weight, but did not offer any guidance on how to improve his diet or integrate exercise into his life.
A few hours later, I had lunch with the two resident doctors on our team. Angela, the medical intern, was a black woman from South Carolina who planned to become a liver disease specialist. She was about thirty pounds overweight. Mike, our supervising resident, was a sandy-blond ex-football player from Iowa. I asked them their thoughts on counseling patients about nutrition and exercise.
“We should probably do more,” Angela said, eyeing her hot dog and French fries with obvious guilt. “But I guess I’m not in much of a position to tell anyone how to be healthy.”
Mike, who carried a few extra pounds too, seemed free of Angela’s self-consciousness. He swallowed a large bite from his slice of thick-crusted pepperoni pizza: “That’s the responsibility of his outpatient primary care doctor,” he said. “We’re here to deal with the life-and-death stuff.”
This focus on biomedical treatment over preventative care is not limited to Duke or similar schools. Indeed, outpatient primary care physicians—the doctors that Mike felt bore the responsibility for counseling patients on diet and exercise—are often no more inclined than other doctors to have this discussion, even for diseases where these interventions are vital. There are many barriers, among them money (dietary counseling is reimbursed poorly compared to medical procedures), time (physician often see patients every ten or fifteen minutes), and the sense that nutrition talk is better left to dieticians, and that doctors should focus on their expertise (prescribing medications, interpreting tests, and performing procedures). In addition, experience has made many doctors cynical about patient behavior and the likelihood for change.
On the drive home from the tennis court, I tried to remember how much I’d talked to Adrian and Henry about these issues in our past visits, and what I’d said to them. When Adrian didn’t stop smoking or eat better after his mini-stroke, did I keep encouraging him to do otherwise? Had I told Henry that weight gain on antipsychotic medication was something he simply had to accept? I could only hope that somehow I’d said the right things. But even if I had, why had Henry listened to me and Adrian hadn’t? Was the problem in the system, with them, or with me?
* * *
Over the course of several visits, I learned Adrian’s history. He’d grown up in the civil rights–era South of the 1950s and 1960s; his dad was a plumber and his mom a homemaker. He’d been drafted into the Army shortly after graduating from a segregated small-town high school. After a year in Vietnam, he came home and found himself overwhelmed by anger and grief, so he turned to alcohol and street drugs to dull these emotions. Nonetheless, he lived a functional life, holding steady work as an electrician. After a rocky ten-year marriage to his high school sweetheart, he divorced, and a year later, met his second wife, Ellen. Together, they had a daughter, now in her late twenties.
By the time we met, he’d gotten involved with a church, and had been clean from alcohol and cocaine for over a decade. But shortly after he retired at age sixty-two, the anxiety and insomnia that had plagued him in earlier years slowly returned. At Ellen’s urging, Adrian started coming to our clinic. We talked a little at each visit about the possible causes for his symptoms, such as the conflict with his daughter and his tour in Vietnam, but he was more interested in finding a medication cure than a talking one. Medication did help, but various side effects bothered him when he took them daily, so he settled into a pattern of taking a sedating antidepressant medication a few times a week. This seemed to satisfy him for the most part.
We had been in this state of equilibrium for a while when Adrian came to see me after suffering the mini-stroke. He’d been at home watching TV when the right side of his face became numb and he started slurring his words. He spent two days in the hospital, and his symptoms resolved. The neurologists counseled him on the basics of secondary prevention, which included taking aspirin, starting a blood pressure medication, and revamping his dietary and exercise habits. Last but not least, they told him to quit smoking.
Adrian reported taking the aspirin and blood pressure pill. He said that he’d cut back a little on eating fast food but not as much as he was supposed to. “How about smoking?” I asked. Two of my patients in this clinic who had survived serious heart attacks in recent years had quit smoking after their episodes.
“I stopped for a month,” he said, looking to Ellen, then back at me, “but our daughter started having problems with her boyfriend again and…”
I’d heard some variation of this from patients many times before. In a perfect world, they could stop X or Y behavior, only life kept getting in the way. I prescribed an antidepressant helpful in smoking cessation, but it worsened his anxiety, so he didn’t take it long enough to help him quit. At the next visit, I prescribed nicotine patches and referred him to a stop-smoking class. Adrian canceled his initial session and did not reschedule. He said the patches didn’t work and caused him to have bad headaches.
I gave up. Looking back at my notes, I could see that I never mentioned the smoking issue again. I never bothered to ask at what age he started, whether he had tried to quit before, why he thought he smoked now, or what might motivate him to quit. I never considered prescribing another smoking-cessation medicine that I had given to a handful of patients with good results. I’m not sure why I avoided all of this—had I become too cynical to even care whether he kept smoking?
Silence on this issue during our visits continued up through the fateful day that Adrian lost his ability to speak. He had finally stopped smoking, but it was clearly too late. He had not been able to change his behavior in time. Could I have done more to help him?
Henry, like Adrian, had grown up in rural North Carolina in a poor family. His dad worked in a factory while his mom cleaned houses in town. Henry went into the Army after high school just as Adrian did; however, being five years younger, he avoided being sent to Vietnam. Nonetheless, he experienced his own mental struggles. About two years into his Army stint, he started hearing voices. He began to act so strangely around his superiors that he could no longer perform his duties; he was soon confined to a hospital and put on high-dose antipsychotics. This marked the end of his time in the military.
Unlike some with psychotic illness, Henry’s problems ultimately proved mild enough that he could maintain a job and a marriage. Other than one time in his mid-forties when he briefly stopped his medicines because of severe side effects, he’d never been readmitted into a hospital after his initial episode. He settled in to work as a janitor for a local post office. He’d been married to the same woman for twenty-five years. They had a daughter who had recently finished college.
By the time I met Henry, he had been stabilized on his antipsychotic medication for a few years. It was the best he had ever felt on a medication. Some of the previous drugs he’d tried hadn’t worked. Others, while effective in calming his psychosis, caused an assortment of side effects—dizziness, tranquilizing sleepiness, muscle stiffness, and a hand tremor, to name a few. With his current treatment, he felt great—except for the fact that he kept gaining weight. I discussed switching him to a newer antipsychotic drug less likely to cause this problem. He resisted. “I don’t want to mess with it,” he said. “I can’t wind up back in a hospital.”
He had a point. Compared with the psychotic delusions of schizophrenia or bipolar mania, it’s better to be overweight. In psychiatry, many doctors have accepted obesity as collateral damage, since some of our best medications can cause substantial weight gain. Establishing sanity and maintaining a healthy waistline can seem like incompatible goals. Removed as we often are from day-to-day general medicine, many of us are tempted to punt responsibility back to the primary care physician for managing the medical problems that our medicines cause or worsen. In Henry’s case, that meant pills for diabetes, high blood pressure, and high cholesterol.
Until his most recent visit, Henry had shown no signs that he was serious about losing weight. But somehow, unlike with Adrian, I hadn’t given up. At each visit, if only for a few minutes, we talked about what kinds of foods Henry ate and ways he could become more physically active. For more than a year, it had been a losing battle, as Henry soared above 275 pounds. But then, on the same day I saw Adrian, Henry showed up 25 pounds lighter. When he returned three months later having lost more weight, I knew this was more than a fad diet. As we talked about his progress, he brought up the issue of race, which he’d never done before.
“You know us black folks don’t always eat like we should,” Henry said. “That’s how we grow up. With all that fried food and other bad stuff. Even when we eat greens, we drown ’em in grease and salt. Now I’m trying to eat one big salad every day and lay off the rolls and other bread. I’m drinking water instead of sweet tea. And I’m walking for thirty minutes every day.”
These were real accomplishments. Over the years, I’d seen many black patients undermine their health through bad eating and sedentary living. While America as a nation struggles with its waistline, nowhere is this more evident than with black people, who are 50 percent more likely than whites to be obese. Stunningly, black women are nearly twice as likely to be obese as white women. The role of lifestyle in health disparities cannot be overstated.
Black Man in a White Coat Page 22