The IAT originators write that people who show moderate to strong preference for one racial group can avoid letting this influence our behaviors, but only if we make a constant effort. If we stop trying, then bias probably gets back to work. Dovidio and his colleagues argue that there are things we health care providers in particular can do to address implicit bias. This is good news for me, as well as for patients.
The exercises they suggest are pretty simple, and designed to address the factors that make docs more likely to act on bias: stress, anxiety, unfamiliarity, and lack of empathy. For example, to reduce anxiety and unfamiliarity, physicians should talk with colleagues of other races. We should use mindfulness techniques, like meditation, to reduce our anxiety before clinical encounters. We should get to know our patients well, so that we think of them not in terms of categories like race or gender, but in terms of their individual selves. And we should actively empathize by trying to imagine what it would be like to be in our patients’ situations. Empathy is a particular sticking point. Because research shows that physician empathy declines throughout our training, any measures we take to foster empathy will probably have to be repeated . . . like, forever.
In much of his writing, Dovidio argues that doctors can begin to address this problem by thinking of ourselves not as a separate group from patients (or members of racial minorities), but rather as members of one overarching group. Humans, say. We could try to remember that we’re all human, and we’re supposed to be working together.
I ENDED UP TALKING with Damien a lot. I guess it was because I felt guilty for being part of the team that was operating on his foot. Maybe I was just trying to comfort myself, but I thought he might feel better if he had someone to talk to. So I’d drop into his room after rounds, and we’d talk. I don’t think it actually made much of a difference to him. In the end, he lost the foot, and that was what he cared about—not connecting with some random, guilty-feeling medical student. When I tried to talk with him about learning to walk again and everything he could still do, he shut me down: “I ain’t going to have no kind of life,” he said, “with half a foot.”
He did tell me a lot about himself, though. He told me how much he loved his mother and how hard she fought for him, hauling him into clinics month after month and getting his paperwork in so he held on to medical coverage, even when they were homeless. He blamed his illness on himself, on running away and getting in trouble, on doing bad things. Teenagers, I told him, always screw up on their diabetic care. When you’re that age, it’s impossible to know how bad the complications will be. Damien was angry, but mostly at himself.
Things become so immediate in medicine. I was an MD/PhD student, and I could easily find myself zooming out into thoughts about the research on race and bias, and everything that we as a profession could do to change things. But when you’re actually doing medicine, you always return to the particular body; every afternoon, I returned to Damien’s room. You can say that the medical system has problems, but then there is the actual pus oozing out of the bottom of this particular wound. And this particular young man, whom I found myself caring about, was actually losing his foot.
We did the surgery late that first night. I brought my size-six nonlatex surgical gloves to the scrub tech, then washed my hands and scrubbed under my nails. I got to the operating room before the rest of the team, and talked with Damien while the anesthesiologists put him under. There was a black line marked on his foot where we were going to cut. “This drug is for pain. This one’s going to make you sleepy. Are you ready? Okay, count backward from ten . . .”
Once he was asleep, we swung into action. We painted his foot with dark-red Betadine and got the overhead lights shining right on it. The senior resident began to cut, while the attending physician observed and I ran a little tube sucking up blood and stray bits of bone. It went quickly. The sick bone crumbled, and we cut away infected tissue until all we could see was healthy looking. We managed to leave his two smallest toes and most of the foot, rinsing the wound thoroughly with sterile water. We bandaged it up, and that was that.
THE NEXT DAY, Damien was playing the snake game on his beat-up mobile phone. We talked a little bit. His pain was okay. He was eating and going to the bathroom. He’d even managed to hobble around a little bit on his crutches.
It was on the third day that he spiked a fever. And when we unwrapped the bandages, the infection was back—despite the antibiotics we were giving him. Thick pus oozed between the exposed bones of his middle foot. The next operation would have to be a BKA—a below-the-knee amputation.
We cut off his whole foot, just above the ankle.
Damien left the hospital a week later. He had prescriptions for insulin and follow-up appointments with our medical team, the surgeon, and a physical therapist. He knew how to clean and check his wound. He’d been signed up for the Medical Assistance Program, so he was going to get his supplies and appointments free or cheaply. When he was healed, he’d be able to get a prosthesis. We did all we could—everything that humane medicine can do in the aftermath of a disaster—but of course he was still angry.
Also, there was nowhere to send him. The friend was still homeless, and Damien didn’t want to see him. He couldn’t bear to call his mother yet. We sent him out in a taxi, with his crutches, for a three-night guaranteed stay at the Salvation Army.
* Institute of Medicine, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” (Washington, DC: National Academies Press, 2010), accessed April 10, 2014, http://www.nap.edu/catalog/10260.html.
CHAPTER 14
MY NEXT ROTATION WAS A MONTH OF RURAL FAMILY MEDICINE in Alpine, Texas. Alpine is in the West Texas desert near Big Bend National Park. It’s a gorgeous part of the country and, best of all, my good friend Margaret was assigned to the same rotation. We made the six-hour drive from Austin to Alpine in my trusty Honda, Box, and moved into the house we’d been assigned to by the hospital district.
Margaret and I were grateful for the free digs, but the house was weird. It was, to my eyes, a mansion. It was owned by a guy who travels a lot for work, and who apparently shares custody of his son and daughter. I unpacked in the son’s room, where the linens were all camo themed and a pointillist picture of an eight-year-old holding a crossbow graced the eastern wall. Margaret took the daughter’s room, which was flush with giant stuffed unicorns. There was a Spanish-speaking woman named Marta who cleaned the house and would make our beds each morning; it made me so uncomfortable that, for the first time in my life, I started making my bed. In addition to us and Marta, the house was also shared by a man who worked for some government agency. He would come home from work with a gun strapped to his hip, stroll out to the pool—which, y’all, had fountains that shot from little lions’ heads—and try to strike up a conversation with Margaret. Margaret diligently ignored him.
Margaret and I split our time between the two family doctors in town, Dr. Billings and Dr. Leucke. I started working with Dr. Leucke, who had offices in Alpine and the nearby town of Fort Davis. So on Monday morning, I met Dr. Leucke at the hospital in Alpine. “Hello, hello,” he said when I found him. “Rachel, right?” He was a fit middle-aged man with a young-looking face and sandy blond hair. He wore scrub bottoms and a black T-shirt.
“That’s me,” I said.
“And you’re a third-year student?”
“Yes.”
“So what have you done so far?”
“Surgery,” I said.
“That’s it?” he asked.
“That’s it.”
“Okay, well,” he said, “this will be a little bit different.”
“Great,” I said.
And so it was. We rounded on three patients in the hospital that morning, all of whom Dr. Leucke knew very well. He would say, “Well Roy, how’s your breathing?” or “Sandy, have you pooped yet?” then do a brief physical exam, kiss his patient on the head, and scrawl an illegible three-sentence note on the chart. It took about
an hour. Then we retired to the hospital cafeteria for breakfast—grits and eggs—before driving out to Fort Davis in Dr. Leucke’s SUV. We wound through the Davis Mountains, and each turn showed another beautiful vista: high desert, with the long brown and green landscape stretching out beneath.
“Here’s where the Rock House fire was,” he said, as we approached Fort Davis. “This was all green. Terrible thing. Affected a lot of the ranchers. One of my patients lost his whole herd, had to start over from nothing.”
“That’s awful,” I said.
“Well, thank god for the public radio station,” he said. “They warned everybody in time to get out safe.”
On the rest of the drive, I got a little bit of Dr. Leucke’s story. He had initially trained as a surgeon, but switched to family medicine. He had two daughters, but his ex-wife had left Alpine after a few years and lived in Abilene now. His daughter called while we were on the road, but the phone dropped the call as we passed behind a ridge. We got cell service again near town, and Dr. Leucke’s screen blinked with missed calls—his daughter, and two from patients. All his patients had his cell phone number.
We pulled into Fort Davis, a little strip of a town with one thousand inhabitants, nestled at the foot of the mountains near the McDonald Observatory. The clinic is in a stone building at one end of town, and we walked right in through the waiting room. Dr. Leucke said hi to everybody, then sent me off to see the first patient. “Ooh, it’s Mr. Hausen,” he said. “Talk him down for me, Rachel. Talk him down.”
Mr. Hausen was a rancher in his sixties with sun-weathered skin and strong arms. “I think I tore myself,” he said, “picking up a hay bale.”
His wife nodded significantly. “Yes he did,” she said. “Down there.”
“I understand,” I said. This was bread and butter for me: on my surgery rotation, I had helped repair a bunch of hernias and learned to do a good hernia exam in clinic. Mr. Hausen told me the whole story: how he’d picked up the hay bale and felt a sudden pain in his groin area, and the pain didn’t go away.
“Go ahead and pull your jeans down,” I said after a while, “and I’ll check you for a hernia.” Mr. Hausen shrugged his shoulders, said, “Well, all right,” and unbuckled his belt. Sure enough, when I pressed my finger up against the opening of his inguinal canal and had him cough, a bulge nudged down against my fingertip.
“Yup,” I said. “That’s a hernia.”
“Well, hell,” he said, looking down at his genitals.
“Yup,” I repeated. I stood up and took my gloves off.
“Well, hell!” Mrs. Hausen said, pointing at Mr. Hausen’s genitals. “It’s broken!”
“Yes ma’am,” I said. “But, um, it’s not too broken. I mean, we can fix it.”
“Damn it to hell,” Mr. Hausen said, putting his hands on his hips. “I sure as hell hope y’all can fix it.”
“That’s right,” Mrs. Hausen said, nodding vigorously.
“You can go ahead and pull your shorts up,” I said. “We’ll have Dr. Leucke take a look.”
I stepped out, and found Dr. Leucke in the office. “How’s Mr. Hausen?” he asked.
“He has a hernia!” I said. “He got it from picking up a hay bale.”
“My goodness,” Dr. Leucke said.
“It’s a left-sided indirect inguinal hernia,” I said.
“You checked him for it?”
“I sure did. I did a lot of hernia exams on my surgery rotation,” I said.
“Well, well. Good for you,” Dr. Leucke said, blushing a little bit.
Back in the exam room, Dr. Leucke had Mr. Hausen pull his jeans down again.
“Yup,” Dr. Leucke said. “That’s a hernia.”
“Well, hell,” Mr. Hausen said.
Dr. Leucke turned to me. “You sure did learn how to do a hernia exam!” he said.
“Yes, sir,” I said. “Thank you.”
“She did a real good job,” Mr. Hausen said.
“Yes sir,” Mrs. Hausen said. “She sure did.”
“Well, thank-y’all,” I said.
“Oh, you can pull your jeans up now,” Dr. Leucke said. “I reckon we’re gonna schedule you for some surgery.”
“Up in Alpine?” Mr. Hausen asked.
“Up in Alpine,” Dr. Leucke said.
“Well, hell,” said Mrs. Hausen. Then she pointed to Mr. Hausen’s genitals. “Will it still work?” she asked.
“Yes, ma’am,” Dr. Leucke said. “Don’t let him fool you. It’ll work.”
“All right then,” she said. Then Dr. Leucke kissed them both on the top of the head and we stepped out.
We saw six more patients before the lunch hour, then Dr. Leucke dismissed me so that he could eat and take a nap on the picnic table behind the clinic. His head nurse had built him a garden back there, and he always liked to nap in the midafternoon. So I wandered over to the drugstore for a sandwich, then took my own nap on the courthouse lawn. I took off my white coat and laid on my back on the sunny lawn, watching the buzzards fly slow loops high above the desert.
MY SECOND NIGHT IN ALPINE, I bedded down in the little boy’s camouflage bedroom and went to sleep. Around four a.m., my phone rang.
“Hello?” I groaned.
“Hi, Rachel,” Dr. Leucke said. “It’s Dr. Leucke.”
“Hi, Dr. Leucke,” I said.
“I reckon you oughta come on down here to the hospital,” he said. “We’ve got a lady in labor, and I think she’s about to pop.”
Suddenly, I was completely awake. “I’ll be right there,” I said. I threw off the covers, hauled on my scrubs, and jumped into Box to drive across town.
The moon was high over the desert and the town was asleep. I sped toward the hospital, my heart beating fast. I had never seen a baby born before.
As I approached the outskirts of Alpine, however, red and blue lights flashed in my rearview mirror. I was being pulled over. I pulled to the edge of the road and slumped forward in my seat. I was sure I would miss the delivery. The cop sat behind me, lights flashing. I couldn’t stand it. My first baby would be born without me.
Then, I had the bright idea of grabbing my stethoscope off the rearview mirror and sticking it out the window. The cop saw it, and pulled up next to me. He was a young guy.
“Are you going to the hospital?” he asked.
“Yes,” I said. “There’s a baby being born, and I need to get there right away.” For the record, I did not say, I’m a third-year medical student, and this baby will be delivered with or without me. You could arrest me right now, and it would make zero difference to the mother or the baby.
“Okay, follow me,” the cop said. Then he led me through town with his lights flashing, straight to the hospital. Dr. Leucke’s truck was parked next to the emergency room doors. I parked next to him, punched in the EMS code, and ran straight in.
THE DELIVERY ROOM was perfectly quiet except for the heavy breathing of the woman in labor. She was alone in there—no husband, no mother, no sisters helping her out. She was flat on her back on the hospital bed, with her legs spread apart in stirrups. Dr. Leucke was at the foot of the bed in a gown and scrub booties, and a nurse was standing next to a tray covered in sterile blue cloth. Another nurse stepped in as I did, and began speaking quietly to the woman in Spanish. “You’re doing good, mama,” she said. “Keep breathing. You’re going good.”
“No puedo!” the woman gasped.
“Yes, you can,” the nurse said. “Yes, you can.”
Dr. Leucke turned to me. “You made it!” he said.
“Yes sir,” I said. The nurse helped me into a gown and sterile gloves, and I stood next to Dr. Leucke.
“Go ahead and check her,” he told me.
I knew what Dr. Leucke meant: I was supposed to check her cervix, to see how far along she was in labor. But this was my first delivery, and I wouldn’t really know how to check the cervix, or what I was feeling. I knew, too, that unnecessary vaginal exams during labor can increase the chances of i
nfection for mother and baby.
“Okay,” I said.
I didn’t want to say, in front of Dr. Leucke and the nurses and this mother, that I had no idea what I was doing. I easily could have. Dr. Leucke is a gentle man, and he wouldn’t have gotten mad at me. In retrospect, the calculus of this—embarrassing myself slightly by asking for help, versus putting a mother and a tiny newborn baby at risk—is obvious. But in that moment, I didn’t think it through. I just tried to do what I was told.
I stepped between the woman’s legs, and stretched my gloved hand toward her vagina. I was nervous and I moved quickly, barely remembering to introduce myself. “I’m Rachel,” I said in Spanish. “I’m a medical student working with Dr. Leucke. I’m going to check you now.”
She didn’t say anything at all to me.
I pressed my index and middle fingers toward where I thought was the vagina.
“You gonna check her?” Dr. Leucke asked.
“Um, yes sir,” I said.
“Well, that’s the anus. Better wash your glove,” Dr. Leucke said. You complete idiot, I told myself. You just tried to stick your fingers in a woman’s anus during labor. You can’t even find the vagina when it’s about to deliver a baby. I flushed bright red. Behind me, the nurses were silent. One held out a tray of fluid for me to wash my glove.
Still nervous and moving quickly, I dipped my glove in the fluid, splashed it around a little, and quickly turned back to the woman, feeling almost panicky. This woman was in labor, and I had just violated her body. I felt mortified and awful. I wished that Dr. Leucke would banish me from the delivery room, or that the woman would sit up on her bed and demand that the medical student who clearly had no idea what she was doing be pilloried. But they didn’t. I was allowed—asked—to carry on.
This time, at least, I managed to correctly identify the vagina. I moved my hand as gently as I could into her vagina. Inside, I could feel the hard round orb of the baby’s head pushing through her cervix.
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