“What’s been your biggest motivator to lose weight?” I asked him.
He started to tear up. “I want to see how my daughter’s life turns out.”
Henry continued to lose a few pounds between each visit. Three years later, he had dropped fifty pounds and was just a shade over his weight back when he had started his current medication. He no longer needed to take pills for diabetes or high blood pressure. The dose of his cholesterol medicine had been cut in half.
Several months later, however, after missing an appointment, Henry had a setback. My heart sank as the scale showed he’d gained almost ten pounds. Since it is widely known that keeping weight off is harder than losing it, I feared this was the beginning of an inevitable backslide. I reminded Henry of how far he’d come, encouraging him while silently doubting he’d get back on track. Yet when he returned to my office three months later, not only had he shed the weight that he’d recently gained, but he’d lost a few extra pounds too. “Seeing you helps keep me on top of things,” he said.
What had made the difference between Henry and Adrian? The secret didn’t seem to be in their backgrounds: Both had grown up poor, obtained similar educations, held steady jobs and marriages, and had raised daughters on the cusp of middle-class lives. Both had psychiatric diagnoses correlated with worse physical health. Both struggled with lifestyle behaviors that were notoriously difficult to change.
Maybe, I thought, at least part of the difference lay with me. I began examining my own attitudes. Had I treated them the same? I’d never smoked cigarettes or used street drugs, nor had I ever gotten much out of drinking, so I struggled to understand the psychology of Adrian’s addiction. On the other hand, I could fully connect to Henry’s dietary and fitness problems, being intimately familiar with the feelings of making poor food decisions and eating to excess. Maybe these factors made me more invested in helping Henry. Given the impact that physician advice can have on patient behavior, I was left wondering if I’d somehow sold Adrian short.
Of course, it’s possible that nothing could have helped Adrian quit smoking or make other health changes after his mini-stroke. But perhaps if I had tried more, at least I could see him now in his diminished state certain that I had done the best that I could for him.
* * *
Treating Henry and Adrian made me reflect on my own health. After being diagnosed with hypertension and signs of early kidney disease in my first year of medical school, I had spent more than a decade engaged in a health battle of my own. Armed with medical knowledge and motivated by fear, I radically altered my diet and exercised every day. By the time I began seeing patients struggling with obesity and hypertension, my own blood pressure was under control. My health problems seemed to have been solved.
During my last year of medical school, however, I slowly slipped back into old habits. This occurred in such a subtle fashion that I didn’t really notice at first. It started off with me treating myself to a few cookies or a small bag of potato chips after some days in the hospital. On weekends, I’d go out with classmates and pay little attention to what I consumed—eating large amounts of food that were salty and sweet. Overall, I still ate healthier than I had before medical school, and near-daily exercise kept my weight down. I was seduced yet again into the notion that I was healthy simply because I looked that way to the outside world. And when I checked my blood pressure—which I did less frequently—it was higher than the ideal 120/80, but still within the normal range. So I didn’t worry.
But that all changed during my grueling year of medical internship. Borrowing from the language of substance abuse treatment, I relapsed. The hectic pace of work allowed for only quick meals. Our nomadic existence within the hospital discouraged a routine of packing sensible lunches. That left the cafeteria—and whatever free lunches around the hospital we could get our hands on—as the default choices. A typical breakfast might offer a choice between French toast and pancakes, a lunch of fried chicken or a cheeseburger, and dinner some variation on the lunch menu. For overnight shifts, midnight pizzas accompanied by high-sodium breadsticks were a mainstay; a high-salt deli sandwich was the “healthy” alternative. It almost seemed as if the hospitals, with their robust cardiology and oncology divisions, were ensuring a steady supply of future patients.
Under the stress of sleep deprivation and what often felt like unmanageable responsibilities, I lost control of what I ate. Eating became more than simply nourishment; it was soothing my emotions. Being a new doctor who treated patients with heart attacks, strokes, and limb amputations was no buffer. I was like the health-food store owner who, under the strain of a failing business or marriage, reverts to his old ways and starts smoking again. I knew better but simply couldn’t do better.
Despite a conscious awareness, on some level, that I was hurting my body, I didn’t go for a medical checkup that entire year. The fact that my weight held steady—if anything, I lost a few pounds under the intense strain—allowed me to delude myself into believing I was still relatively healthy. Even after I started psychiatry, sixty-five-hour work weeks, coupled with the challenge of learning new terminology and treatments, kept me busy enough that attending to my lifestyle remained a low priority.
Not until eight months into my first year of psychiatry did I finally make a doctor’s appointment. Once there, a nurse quickly ushered me into an exam room and checked my blood pressure. “It’s 155 over 95,” she said after the cuff had fully deflated.
I asked her to check it again after I had a few minutes to settle, but my blood pressure stayed high. The doctor came in and commiserated with me about the stress of residency and asked me to come back in a month. Over the next few weeks, I began eating better and working out at the gym. And while my blood pressure came down a little, it was still elevated, high enough to require medication. After a long discussion, the doctor prescribed a diuretic drug. I took it daily without any problems, and after a few months, my blood pressure approached normal levels. But as a doctor, I’d seen some of the long-term side effects of blood pressure pills. I was only thirty. Was I ready to start taking a medication every day for the rest of my life?
I decided I wasn’t, and weaned myself off the drug over the next several weeks. I intensified my workouts and made my diet more restrictive. Within a few months, I was back to a baseline blood pressure of 120/80. However, my blood pressure eventually climbed yet again, as six months turned into a year and I gradually resumed my previous behaviors. For the next three or four years, I went back and forth in this way. I’d become a close cousin to the yo-yo dieter who loses twenty or thirty pounds only to gain it all back each time. As time passed, I knew that each “diet” would become more difficult. If this kept up, I was going to need medication, perhaps more than one, for good.
Why was making a long-term healthy change so difficult?
For one thing, it’s hard to change patterns formed in childhood, perhaps even more so among blacks. Researchers have speculated that strong cultural influences on food preferences, food preparation, and perceptions about eating practices, passed down from one generation to the next, might make it more difficult for black patients to follow a healthy diet. “Soul food,” especially popular in the South where the largest numbers of black people reside, tends to contain large amounts of red meat, added fats and salt, and is often deep fried. A 2012 study found that a relatively affluent group of black participants were less likely than whites to adhere to the guidelines of the DASH diet—widely accepted as the diet of choice for preventing and treating high blood pressure—even when controlling for socioeconomic factors. I could relate. On the cusp of being comfortably middle class, I still couldn’t get my act together.
I believe the problem runs deeper than simply the food choices themselves. As a general rule, surveys have indicated that black people are more accepting of—and in some cases indicate a preference for—heavier body types. Skinniness is more likely to be seen as a sign of illness—cancer, AIDS, crack addiction, starving
African children—and as a result, lifestyle changes aimed at becoming slender are more likely to be viewed with skepticism than enthusiasm.
I had embraced some of these ideas. Despite being a physician, I still viewed some aspects of healthy living—eating salads, drinking water, going to a yoga class, or jogging on a treadmill—with disdain. Employing my own brand of racial bias, I had internalized such behavior as the domain of perfectionist white women who struggled with self-esteem. White men who ate organic food and ran five miles a day in the woods seemed to be practicing some back-to-nature philosophy that didn’t interest me. Given my struggles with assimilation since high school, but particularly so since starting medical school, adopting these habits to any extent over the long haul meant selling out some essential aspect of both my masculine and racial identity—even if my rational mind knew such a belief was self-destructive. It was not so much the differences in the food or exercises themselves as what lifestyle change represented.
Henry’s progress caused me to rethink my distorted logic. He was a middle-aged, working-class black man with significant mental illness who required long-term use of a fat-promoting antipsychotic medication. In short, he was not the sort of person I would expect to succeed in revamping his lifestyle. Yet he had been able to do just that. Unlike me, he’d been able to see beyond the limitations of race and culture and focus on what was healthy. Inspired by Henry’s progress, I took a closer look at my own beliefs and set about finding ways to incorporate what was nutritious from my upbringing—sweet potatoes, leafy green vegetables, and almonds for example—with healthier foods I’d never eaten (tofu and avocados) or, in some instances, even heard of (pomegranate and green tea) growing up. The result has been a truly sustained period of normal blood pressure.
My experience is not unique among black doctors. Over the years, I’ve seen a far greater proportion of overweight and obese black doctors in comparison to physicians from other racial and ethnic groups. In private conversations, we’ve talked about our challenges with living healthy. Many agree with me that cultural factors ingrained in childhood are a major factor.
The Meharry-Hopkins Cohort study explored our health dilemma on a larger scale. This project used health data collected on black male medical students from Meharry Medical College in Nashville, Tennessee, from the late 1950s to the mid-1960s, and compared the results to those from white male medical students from Johns Hopkins taken during the same timeframe. Both groups were then followed over a period of several decades. At baseline, the black physicians were heavier, more likely to smoke, and had higher blood pressures. Over time, they were more likely to have hypertension, diabetes, coronary artery disease, and to die at a younger age. As the authors state: “The very physicians who historically have provided most of the medical care for the African-American community fall victim to the same diseases that strike down their patients.” Like the demographic data that I heard so often as a first-year medical student, the study’s chorus bellowed the same note: being black can be bad for your health.
But as black physicians, the path to a healthier life is within our grasp. We have the knowledge and the economic resources to do better. Maybe this, in turn, can help all the patients we see, but especially the black patients who are often in greatest need of change. As the Meharry-Hopkins authors wrote, black physicians are “role models for the rest of the community. Such positioning carries with it the need for accountability. African-American health professionals must modify alterable risk factors for disease and adopt healthy lifestyles. We owe it to ourselves, our families, and our communities.”
Henry had helped me see past the thicket of race and culture to focus on what I needed. Now my turn had come to do the same for others.
* * *
About two years ago, I met Cedric, a man in his early sixties who reminded me of Adrian in several ways. Not long after his first appointment with me, he developed chest pain that led to his hospitalization. He suffered a mild heart attack, not that much different from Adrian’s mini-stroke. He too smoked about a pack of cigarettes each day. He was also overweight. While prescribing medication for his chronic insomnia, I homed in on his smoking and dietary choices. We discussed how, although economic and social backgrounds shape our behaviors, with the right motivation, we can change them. With repeated inquiries at every visit and engaging his wife and children in the process, I never let up. Not much seemed to change at first, but then one day after several months had passed, he came back to tell me that he’d cut back to one cigarette each day and hoped to stop altogether soon. He’d lost fifteen pounds by cutting out fried foods and walking a mile per day.
“You’ve been a big help,” he said to me.
After the last patient had left that day, I went to the break room area to grab a snack before sitting down at the computer to type my notes. A tempting cheesecake was in plain sight. Just as I prepared to help myself, a nurse walked in and told me that I needed to write a prescription for another doctor’s patient, as that doctor was on vacation. The path to her office brought me past the clinic scale as well as the automated blood pressure device. While I now made healthier dietary choices than I had in childhood and throughout much of my twenties and early thirties, the birth of my children had caused me to cut corners again. For lunch that day I’d bought fast food. I also had drastically less time for exercise and hadn’t done much in weeks.
When I got on the scale, it showed that I’d put on more pounds than I had realized. My blood pressure had also crept up some since the last time I had checked it months earlier. I’d been down this road many times before and knew what had to be done.
I took a pass on the cheesecake and went home and pushed my sons on the stroller for an hour at a speed-walking pace. In order to credibly persist in my fight for patients to adopt healthy behaviors, I needed to continue my daily quest to conquer my own struggles.
10
Beyond Race
Nearly seventeen years to the day after I committed to Duke, I attended a reunion celebration that honored the medical school’s black alumni. Back in 1996, I had been racially and culturally insecure, afraid that Duke would be too much for me and that I would fail; by 2013, I was a faculty member who comfortably supervised and counseled medical students and residents of all racial and cultural backgrounds. How did I get from point A to point B? As I mingled with classmates and faculty from my earlier years at Duke, I found myself thinking about this transformation more intently than ever. I’d come to the ceremony with the goal of reconnecting with former friends, but the banquet turned out to offer much more; it was the perfect opportunity for me to revisit and reflect upon my past, and to inspire me for the future. My racial journey was part of Duke’s larger story.
The formal festivities began with a video tribute to Delano Meriwether, the first black student to attend medical school at Duke. Meriwether grew up in segregated South Carolina before traveling north in 1960 to attend college at Michigan State. Although he was accepted at many northern universities when he applied to medical school, his father urged him to consider Duke. His introduction could not have been more inauspicious as he arrived in Durham the evening before his interview. With the school cafeteria closed, Meriwether, dressed in suit and tie, walked to a nearby restaurant in search of dinner. He was promptly informed by a waitress that he couldn’t be served there; moments later the owner told him that if he didn’t leave immediately, he would “live to regret his actions.” A furious Meriwether left. The next day at Duke, he walked through the hospital where he saw racially segregated bathrooms. He thought of leaving, but decided: “If I make it through this school, can I possibly help someone besides myself?”
Meriwether ultimately thrived at Duke before enjoying a diverse career as a physician that included stints as a cancer researcher, White House fellow, U.S. Public Health Service administrator, and emergency room doctor. The tribute briefly covered his remarkable athletic career too. In 1970, three years after he graduated from Duke, Mer
iwether began running competitively; several months later, he began winning races. In 1971, he won the 100-yard dash at the national outdoor championships and graced the cover of Sports Illustrated, the dream of any athlete. He was a favorite to compete in the 1972 Munich Olympics before an injury derailed his quest. At the end of the video highlighting his remarkable life, he rose from his chair to a standing ovation.
The program then honored several other black pioneers in Duke’s medical world, among them Jean Spaulding (the first black woman to attend Duke Medical School), Charles Johnson (the first black faculty member at Duke Hospital), Joanne Wilson (the second woman of any race to become a full professor in Duke’s Department of Medicine), and Brenda Armstrong (one of Duke’s early undergraduates in the 1960s and later dean of admissions in the medical school). While I’d spoken with each of them several times during my years at Duke, seeing their interwoven stories in one narrative felt like I was experiencing true living history.
Next, the video highlighted that in 2002, two years after my graduation, Haywood Brown was named chair of the Department of Obstetrics and Gynecology, and Danny Jacobs was appointed chair of the Department of Surgery. Black men had secured two of the top positions within Duke’s medical school (their tenures helped lay the foundation for the January 2015 selection of A. Eugene Washington, a leading black physician, as the chancellor for health affairs and CEO of Duke University Health System). Toward the end of dinner, a final video profiled a handful of under-forty black alumni, and concluded by telling the inspiring stories of some of Duke’s current black medical students, with an eye toward a future so much more promising than the situation Meriwether and others experienced fifty years earlier.
Black Man in a White Coat Page 23