We shook hands. I certainly wasn’t a better psychiatrist than the person I had replaced. Some of his patients—a handful of whom were black—never warmed to me as they had to him. With others, busy as I was managing a large caseload while saddled with various administrative responsibilities, I felt content to write prescriptions and talk only superficially about their lives, referring those who needed more to a psychologist or clinical social worker. But something—perhaps a challenge to myself to do better, to overcome some of my biases—made me reach out to Keith.
If Keith and I could find common ground despite the huge differences in our backgrounds and attitudes, then why should it be any harder for other doctors to form strong bonds with patients of another race? Many doctors have done so, of course, and I’ll bet they’ve made the same discovery that I have: A big part of the solution is discarding your assumptions and connecting with each patient as a person. Race, while certainly a powerful influence, by itself doesn’t guarantee a human connection any more than any other factor like geography, height, or handedness. It is up to us, as doctors, to find the commonalities and respect the differences between us and our patients. In that way, we can understand what they value, how best to communicate with them, and how to arrive at treatment plans that improve their health while respecting their wishes. This approach is often called cultural competence, but after years of medical practice, it seems to me more like common sense.
I’ve tried to apply the lessons I learned from my time treating Keith and I think I’ve succeeded. After nearly seven years in my outpatient clinic, I’d become so overwhelmed with other duties that I decided to step away from this busy practice. For a period of months, I had to say good-bye to my patients. Many were anxious about starting over with a new doctor. Others cried. They all wished me well. In the end, I found that my white, Asian, and Hispanic patients were just as sorry as my black patients to see me go, which, if I’d done my job as a doctor correctly, was exactly as it should be.
Notes
INTRODUCTION
life expectancy nearly nine years less than whites: See U.S. Census Bureau, Variations in State Mortality from 1960 to 1990, Population Division Working Paper Series no. 49, May 2003. For example, in Alabama, the state where King made his professional home, the life expectancy in the years 1959–1961 for white women was 74.59; for nonwhite women, it was 64.72. The gap was closer in white men versus nonwhite men (about 7 years).
found virtually anywhere one might choose to look: For example, see Centers for Disease Control, CDC Health Disparities and Inequalities Report—United States, 2013, Morbidity and Mortality Weekly Report 2013; 62 (suppl 3); http://www.cdc.gov/mmwr/pdf/other/su6203.pdf. During the last twenty-five years, health disparities have become an established area of medical research. See for example National Institutes of Health, Fact Sheet—Health Disparities, October 2010, available at http://report.nih.gov/NIHfactsheets/Pdfs/HealthDisparities(NIMHD).pdf.
still significantly lags behind whites: In 2010, the life expectancy gap between white and black populations was about 3.8 years. This does represent significant progress. See National Vital Statistics Report, Deaths: Final Data for 2010 61, no. 4 (May 2013).
attended a state university with little name recognition: I attended the University of Maryland Baltimore County (UMBC) on a Meyerhoff Scholarship, which was established in the late 1980s under the leadership of Dr. Freeman Hrabowski to steer black students toward science, technology, engineering, and mathematics careers. As of January 2015, alumni from the program had earned 197 Ph.D.s, 39 M.D./Ph.D.s, and 107 M.D.s from such institutions as Harvard, Stanford, Duke, the University of Pennsylvania, MIT, Berkeley, Yale, and Johns Hopkins. http://meyerhoff.umbc.edu/about/results/. See also Freeman Hrabowski, Kenneth Maton, and Geoffrey Greif, Beating the Odds: Raising Academically Successful African American Males (New York: Oxford University Press, 1998). In retrospect, the Meyerhoff Program prepared me well to succeed at Duke, but being one of its first students to attend an elite medical school, I entered Duke uncertain about my chances for success.
university’s alumni magazine that generated national interest: See Ron Howell, “Before Their Time,” Yale Alumni Magazine, May–June 2011. In the article, Howell recounts the sudden death of his closest college friend, using it as the framework for an exposition on the premature deaths of successful black men from his era, as he soberly notes: “while we African Americans were 3 percent of the Class of 1970, we were more than 10 percent of the deaths.”
1: PEOPLE LIKE US
race was just part of the story: Looking back, many of my difficulties adjusting to Duke in the beginning were as much about social class as they were about race. For an interesting article on this issue, read: Stephen Magnus and Stephen Mick, Medical Schools, Affirmative Action, and the Neglected Role of Social Class, American Journal of Public Health 2000; 90:1197–1201.
very high proportion compared to their numbers in the U.S. population: In 2010, Asians represented 20 percent of all entering U.S. medical students while totaling about 5.5 percent of the entire population. See Association of American Medical Colleges, Diversity in Medical Education: Facts and Figures 2012, Diversity Policy and Programs, Fall 2012; www.aamc.org/publications. See also U.S. Department of Commerce, Economics and Statistics Bureau, Overview of Race and Hispanic Origin, 2010; http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf.
Native Americans simply make up a very small percentage: In 2010, Native Americans made up less than one-half of a percent (0.3–0.4) of medical school enrollees. Association of American Medical Colleges, Diversity in Medical Education: Facts and Figures 2012, Diversity Policy and Programs, Fall 2012; www.aamc.org/publications.
a black cardiac surgeon: Levi Watkins Jr. grew up in Montomery, Alabama, during the height of the civil rights movement. His family attended Martin Luther King’s church. In 1966, he became the first black student to attend Vanderbilt University’s medical school. He moved to Johns Hopkins in 1970 for his surgical training where, several years later, he became the first black surgical chief resident. He would remain at Johns Hopkins until his retirement in 2013. For brief profiles of his pioneering life, see http://www.pbs.org/wgbh/amex/partners/legacy/l_colleagues_watkins.html and http://www.thehistorymakers.com/biography/dr-levi-watkins.
brunch at the estate of Ben Carson: Dr. Carson has more recently become known to a wider audience as an outspoken conservative public commentator, highly critical of President Obama’s economic and social policies. From the late 1980s through the early 2000s, however, his narrative of overcoming childhood poverty was framed as an inspirational success story, particularly to black students. He described “a self-imposed obligation to act as a role model for Black youngsters.” See Ben Carson, Gifted Hands (Grand Rapids: Zondervan, 1990). During my medical training at Duke and through my peer network at other elite schools, I observed what I’ve called “The Ben Carson Effect,” where a disproportionate number of black students who enter medical school seek to become neurosurgeons like Carson.
“the best black”: See Stephen L. Carter, Reflections of an Affirmative Action Baby (New York: Basic Books, 1991).
In the mid-1990s, blacks accounted for about 7 percent of medical students: Association of American Medical Colleges, Diversity in Medical Education: Facts and Figures 2012.
figure includes three predominately black schools: Ibid.
less than 2 percent of all U.S. physicians: See Marybeth Gasman, The Morehouse Mystique (Baltimore: Johns Hopkins University Press, 2012).
The vast majority of these doctors were educated at Howard and Meharry: In 1970, national data showed that 83 percent of the nation’s black doctors had graduated from Howard or Meharry; in 1968, the two schools graduated nearly 75 percent of black doctors. Ibid.
Of the prestigious white schools: Several writers have provided background on African American enrollment at other elite medical schools. Kate Ledger describes Johns Hopkins in “In a Sea of White Faces,” Hopkins Med
ical News, Winter 1998. Fitzhugh Mullan writes about his 1968 alma mater, the University of Chicago, in White Coat, Clenched Fist (New York: Macmillan, 1976). John Langone details Harvard’s history in The Racial Integration of Harvard Medical School, Journal of Blacks in Higher Education, June 30, 1995. In a personal conversation, Keith Brodie, president of Duke University from 1985 to 1993, informed me that there were no black students in his Columbia University College of Physicians and Surgeons Class of 1965.
U.S. Supreme Court upheld a lower court ruling: For a historical overview of the process by which hospitals were integrated, see Preston Reynolds, Hospitals and Civil Rights, 1945–1963; The Case of Simkins v Moses H. Cone Memorial Hospital, Annals of Internal Medicine, 1997; 126: 898–906.
black students were not admitted to Duke until 1963: For some historical context to Duke’s history with race, see Stanley Fish, “Henry Louis Gate: Déjà Vu All Over Again,” New York Times, July 24, 2009; Robert J. Bliwise, “A Spring of Sorrows,” Duke Magazine, May–June 2006; Bill Sasser, “Color-Blind or Color-Conscious? Affirmative Action,” Duke Magazine, March–April 1996; Richard Brodhead, “This Is Not the Time to Rest.” Speech to NAACP’s 32nd annual Freedom Fund Banquet, November 18, 2006; Emily Rotberg, “A Happy Anniversary: BSA Turns 40,” Towerview Magazine, February 2007; and Victor Dzau, “Falling Short in America: Increasing Diversity in the Health Profession.” Speech to the Association of Black Cardiologists 30th Anniversary, November 6, 2004.
the medical school decided to offer full-tuition scholarships: Dan Blazer II, Dean of Medical Education at Duke from 1992 to 1999, was instrumental in establishing these minority scholarships and increasing black student enrollment during his tenure. During an email exchange, he recalled that increasing minority enrollment was one of his top goals as dean. He believed that “developing a critical mass of URMs [underrepresented minorities] could ease the problems socially for those students in our classes,” and that the scholarships, because of Duke’s racial history, geography, and its aspirations to establish itself as a national leader, were “the only reasonable approach we could take if we wanted the best and brightest black students.”
elite schools are widely known to give clear admission preferences to the children of alumni and faculty: Daniel Golden, The Price of Admissions (New York: Crown, 2006). See also Richard Kahlenberg, ed., Affirmative Action for the Rich (New York: The Century Foundation, 2010).
famous 1978 U.S. Supreme Court Bakke decision: See Regents of the University of California v. Bakke, 438 U.S. 265, 1978. Allan Bakke was a white male applicant in his early thirties at the time of his application to UC-Davis medical school. He had served in Vietnam as a Marine officer and worked as a NASA engineer. He brought suit against the school after being rejected twice, arguing that the school’s special admission policy of setting aside a specified number of seats, or quota, for minority applicants was unconstitutional. The case eventually went to the U.S. Supreme Court. In a fractured opinion authored by Justice Lewis Powell, the court struck down the school’s use of numerical quotas while continuing to allow schools to use race as a factor in making its admission decisions.
Although they ultimately graduated at similar rates: Robert Davidson and Ernest Lewis, Affirmative Action and Other Special Consideration at the University of California-Davis, School of Medicine, Journal of the American Medical Association 1997; 278:1153–1158. The authors concluded: “an admissions process that allows for ethnicity and other special characteristics to be used heavily in admission decisions yields powerful effects on the diversity of the student population and shows no evidence of diluting the quality of the graduates.”
who oversaw the school’s implementation of affirmative action: Langone, Racial Integration of Harvard Medical School.
mismatch between the student and the school they attend: See Richard Sander and Stuart Taylor Jr., Mismatch: How Affirmative Action Hurts Students It’s Intended to Help, and Why Universities Won’t Admit it (New York: Basic Books, 2012).
this is one of the costs of affirmative action: See Shelby Steele, The Content of Our Character (New York: St. Martin’s Press, 1990). See also John McWhorter, Losing the Race (New York: Free Press, 2000). Several black authors have acknowledged the shortcomings of race-based affirmation action while ultimately supporting its use in modified forms. See Randall Kennedy, Sellout: The Politics of Racial Betrayal (New York: Pantheon, 2008). See also Eugene Robinson, Disintegration (New York: Doubleday, 2010), and Sheryll Cashin, Place, Not Race (Boston: Beacon Press, 2014).
Other doctors have traveled this same terrain: See Keith Black, Brain Surgeon (New York: Wellness Central, 2009) and Ben Carson, Gifted Hands.
praise felt like another aspect of Stephen Carter’s “best black” syndrome: Stephen L. Carter, Reflections of an Affirmative Action Baby.
Affirmative action, despite its flaws: In addition to concerns about inferiority stigma and academic mismatch, other critics argue that affirmative action is mainly helping middle- and upper-class blacks rather than the working-class and poor groups most in need. They have a point, one acknowledged by some left-leaning writers who suggest a class-based approach to affirmative action. See Richard Kahlenberg, The Remedy (New York: Basic Books, 1996) and Sheryll Cashin, Place, Not Race. I lean toward this approach. In practice, this means the belief that my working-class background made me a good fit for class-based affirmative action but would not apply to my children.
2: BABY MAMAS
Duke condensed the traditional two-year classroom training into a single year: For a detailed overview of Duke’s curriculum, see Colleen Grochowoski, Edward Halperin, and Edward Buckley, A Curricular Model for the Training of Physician Scientists: The Evolution of the Duke University School of Medicine Curriculum, Academic Medicine 2007; 82:375–382.
delusions about pregnancy were not uncommon: For an interesting series of case reports on the subject from one psychiatric hospital, see Albert Michael, Anil Joseph, and Alphie Pallen, Delusions of Pregnancy, British Journal of Psychiatry 1994; 164:244–246.
grown far too comfortable categorizing patients as organ systems or diseases: There is much thoughtful discussion about the ways that the increased emphasis on medical technology and the business elements of medicine have usurped the traditional focus on the doctor-patient relationship. See Abraham Verghese, Culture Shock—Patient as Icon, Icon as Patient, New England Journal of Medicine 2008; 359:2748–2751; Brendan Reilly, One Doctor (New York: Atria Books, 2013); Victoria Sweet, God’s Hotel (New York: Riverhead, 2012); and Barron Lerner, The Good Doctor (Boston: Beacon Press, 2014).
Another strain of medical writing highlights that some elements of dehumanization have been a part of medical training for a longer time. See Robin Cook, The Year of the Intern (New York: Harcourt, 1972); Melvin Konner, Becoming a Doctor (New York: Viking Adult, 1987); and Robert Marion, Learning to Play God (New York: Addison-Wesley, 1991). No list of books exploring this subject would be complete without mentioning Samuel Shem’s The House of God (New York: Richard Marek Publishers, 1978), the highly cynical novel still widely read by those in medical training.
inched closer to experiencing the personal side of death: For an excellent book about physicians’ formative exposures to death, see Pauline Chen, Final Exam (New York: Knopf, 2007). See also Sherwin Nuland, How We Die (New York: Knopf, 1994), Danielle Ofri, Singular Intimacies (Boston: Beacon Press, 2003), and Atul Gawande, Being Mortal (New York: Henry Holt and Company, 2014).
We’d been taught that 24 weeks was the cut-off point for a viable pregnancy: This has improved slightly since the 1990s. For a thorough discussion on the subject, see Jon Tyson et al., Intensive Care for Extreme Prematurity—Moving Beyond Gestational Age, New England Journal of Medicine 2008; 358 (16):1672–1681. They found that of children born at 23 weeks, 25 percent were alive at 18 months; for those born at 24 weeks, 56 percent were alive at 18 months. The authors also highlight other factors involved in premature infant survival, such as birth weight an
d gender (girls do better).
Carla was voicing the fear and anger: The late 1980s and early 1990s were filled with news stories forecasting a stark future for children born to crack-addicted mothers. In 1989, neoconservative Washington Post columnist Charles Krauthammer famously opined that “the inner-city crack epidemic is now giving birth to the newest horror: a bio-underclass, a generation of physically damaged cocaine babies whose biological inferiority is stamped at birth.” (Charles Krauthammer, “Children of Cocaine,” Washington Post, July 30, 1989). While Krauthammer’s claims are now often scorned, liberal writers expressed similar concerns about the damage crack-addicted women could cause their children. See Dorothy Gilliam, “The Children of Crack,” Washington Post, July 31, 1989, and Michele Norris, “Suffering the Sins of the Mothers,” Washington Post, June 30, 1991.
started paying drug-addicted women: Cecilia Vega, “Sterilization Offer to Addicts Reopens Ethics Issue,” New York Times, January 6, 2003.
South Carolina enacted a policy: George Annas, Testing Poor Pregnant Women for Cocaine—Physicians as Police Investigators, New England Journal of Medicine 2001; 344:1729–1732.
Carla’s view had once been official policy: Kim Severson, “Thousands Sterilized, a State Weighs Restitution,” New York Times, December 9, 2011. See also “Against Their Will, a five-part series. North Carolina’s Sterilization Program,” Winston-Salem Journal, December 2002.
A national survey in the mid-1990s: Robert Mathias, NIDA Survey Provides First National Data on Drug Use During Pregnancy. NIDA Notes. Women and Drug Abuse January/February 1995; 10 (1); http://archives.drugabuse.gov/NIDA_Notes/NNVol10N1/NIDASurvey.html
turned out to be more fiction than fact: Although cocaine can clearly be harmful to a developing fetus, increasing the risk of premature births, low-birth-weight babies, and stillbirth, the crack-baby epidemic itself never came to pass as once feared. When followed over time, children born to cocaine-abusing mothers are at increased risk for attention deficit problems, but not the severe intellectual disability and antisocial criminality once predicted. See Susan Okie, “The Epidemic That Wasn’t,” New York Times, January 27, 2009, and Theresa Vargas, “Once Written Off, ‘Crack Babies’ Have Grown into Success Stories,” Washington Post, April 18, 2010. Research in this area is complicated by the fact that children born to crack-addicted mothers often grow up in harsh environments where they are exposed to poverty, violence, neglect, and abuse, all of which predispose children to behavioral problems. Many experts now believe that cocaine’s effects in pregnant women are comparable to cigarettes and less severe than alcohol—two legal drugs used much more commonly among pregnant women. For example, see profile of Emory University researcher Dr. Claire Coles in Mary Loftus, “Just Blowing Smoke,” Emory Magazine, Autumn 2013.
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