Black Man in a White Coat: A Doctor's Reflections on Race and Medicine
Do you look like your doctor?
For many of us, the answer is no, as Damon Tweedy explains in Black Man in a White Coat. Tweedy, a practicing psychiatrist and assistant professor of psychiatry and behavioral sciences at the Duke University School of Medicine, is the eponymous black man, and he has learned through experience that appearances matter. He has also learned through experience that experience matters, sometimes regardless of appearances.
Tweedy, now in his early 40s, examines the issue of race and medicine in America from a very personal perspective, focusing mostly on his medical school years, when he was one of 13 black students enrolled in Duke’s program. This experience is representative: African Americans make up 13.2 percent of the United States population, yet only seven percent of the country’s medical students. The percentage of African-American doctors is even lower, since not all medical students graduate—and Tweedy provides anecdotal evidence that black medical students often struggle more than their peers.
A 2007 study by the Association of American Medical Colleges found that, among blacks, the 10-year attrition rate in medical schools nationwide due to academic reasons was 6.7 percent. Among whites, that figure was just 0.7 percent. Tweedy examines one of the explanations for the lagging numbers: increased feelings of self-doubt among black students.
One of the causes of this self-doubt, Tweedy argues, is affirmative action. As Supreme Court Justice Clarence Thomas—one of the country’s most vocal critics of the policies—writes in his memoir My Grandfather’s Son, “I learned the hard way that a law degree from Yale meant one thing for white graduates and another for blacks, no matter how much anyone denied it. ... I’d graduated from one of America’s top law schools, but racial preference had robbed my achievement of its true value.” Tweedy, though somewhat sympathetic to this viewpoint, contends that affirmative action ultimately does more good than evil. He himself was the recipient of a full scholarship—a rarity at medical schools—aimed specifically at black students. Until exam time, when he proved he could perform as well as his peers, he was doubtful that he was worthy of his spot. He didn’t look like his peers; he didn’t have the pedigree of his peers; he had no doctors in his family. As a 6’6” black man he was often taken for an athlete first, and a student second. In one embarrassing incident in his first year of medical school, one of his professors asked him, after a break, “Are you here to fix the lights?”
Tweedy obviously found success. He also found that he had a lot more in common with his black patients than just the color of their skin, regardless of socioeconomic status. He tells of a study that followed medical students over decades and found that “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 young age.” As the authors of the study state bluntly: “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.”
Sometimes, though, looking like his patients didn’t mean Tweedy understood them better than his non-black colleagues. Once, while doing clinical rotations, a patient—a young black woman—came into the emergency department with vaginal bleeding. She was pregnant, though she claimed she didn’t know it. After Tweedy interviewed her, he was confident she wasn’t a drug user. His supervising resident, however, stepped in and quickly diagnosed a placental abruption. The resident, a blonde white woman, had experience. She took an aggressive tone and challenged the patient on some of the answers she’d just given to the young Tweedy. The girl broke down, and the medical team got the information—and explanation—it needed: The patient had smoked crack just two days prior, causing the abruption.
Another time, a black patient with high blood pressure told doctors he preferred to reduce his pressure through diet and exercise, rather than taking a pill. He wanted to try to get well without medication; if that failed, then he would be open to other options. The doctors were disdainful of the man’s opinion and labeled him with obsessive-compulsive personality disorder. They felt he was unreasonably trying to take control of the situation and wasn’t listening to medical advice. Tweedy strongly disagreed and felt that, on the contrary, the man was an ideal patient: educated about the facts, helping himself before turning to more drastic measures. Would Tweedy’s colleagues have had the same opinion if the patient had looked different?
Such questions are nearly impossible to answer. Often, it seems, we’re not even conscious of our own prejudices. Tweedy sometimes worried that his white colleagues had made “negative judgments about these black patients, and thus about black people in general.” On the flip side, he tells us, “I found myself more judgmental than white people might be, as these racial stereotypes about [certain patients] felt like they were also stereotypes about me—even though my life bore no resemblance to theirs.”
There are many reasons why “being black can be bad for your health,” as Tweedy writes. And many of those factors are outside the bounds of what a physician and patient can accomplish on the medical front: poverty, education, high incarceration rates, increased stress, a tradition of unhealthy eating (comfort foods). One woman Tweedy encountered died in the hospital's emergency department of a stress-induced heart attack after watching her son get arrested by the police. Of course, anybody can be arrested by the police, but the odds are stacked against African Americans, whose incarceration rate is nearly six times that of whites in this country—and Tweedy shows how this harms the health of the entire community.
But even the most successful black Americans suffer from different, poorer health outcomes. Several times, Tweedy refers to a 2011 article by journalist Ronald Howell in Yale Alumni Magazine, in which Howell recounts how, even among his Ivy League peers, his black classmates had a mortality rate three times as high as the rest of the class. Hypertension, cancer, stress—these factors seem to hit the black population particularly hard across the spectrum. Tweedy himself was diagnosed with hypertension as a young man; through diet and exercise, he has (mostly) gotten his own health issues under control. This perhaps girds an argument Tweedy seems to make, though he is cautious about not chalking everything up to race: Yes, it does help if your doctor is a bit more like you, grew up in the same community, is familiar with your eating habits, stressors, and prejudices (he cites differences in body image perception as a factor in the obesity epidemic that affects black women much more than white women), and has some of those same ailments and issues. But don’t discount experience, either. Race isn’t everything in medical treatment. It is one factor among many that needs to be considered when working in—and having a discussion about—health care in this country.
That’s the message of this book. Tweedy is a perceptive and sensitive-enough citizen-doctor to know that issues of race and health are not easily solvable. They are entrenched in a long history of severe and sometimes appalling disparities and crimes, from medical experimentation on blacks to economic discrimination and unequal access to doctors, clinics, and insurance plans and providers. There’s no magic pill; Tweedy writes no panacea prescriptions. What he offers are the insightful observations of one doctor doing his best to provide quality health care to all, equally, without reservation or discrimination. Good doctors, like their patients, are not defined by their race or ethnicity, but we’d be ill advised to pretend that all patients are the same. Equal? Yes. Identical? No.
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