Damon Tweedy graduated from the University of Maryland-Baltimore County with extremely good grades and an average score on the MCAT. He was actively recruited by highly-regarded medical schools, including Johns Hopkins and Yale, and ultimately chose to attend Duke, even though it’s located in the south, because it offered him a full scholarship. He was one of 14 minority students among the 100 in the Class of 2000. On his first day of classes, Tweedy says, he looked around and asked himself why Duke had accepted him and offered a full scholarship. “As I played through the scenarios, affirmative action appeared to me the only answer,” an answer that was confirmed when the doctor welcoming the class pointed out the number of “underrepresented minorities” in the class. In his first month in medical school one of his lecturers mistakes him for the handyman sent to fix the lights, then asks if he’s not the handyman why he’s in the class. Happily for us Dr. Tweedy is a deeply thoughtful man, and once he got over his anger, and with dogged hard work restored the confidence that his teachers’ thoughtlessness had shattered, he began asking difficult, useful, questions.
“Black Man in a White Coat” is a sensitive book, and that’s important, because in each chapter Tweedy addresses difficult issues. There’s a chapter called “Charity Care” in which Tweedy describes a monthly clinic volunteer medical students ran for patients living in a rural area (under the supervision of qualified doctors). He describes the chronic problems of people living in poverty in the south: diabetes and hypertension. In the late 1990s, well before the Affordable Care Act, the clinic provided the only care patients could receive; volunteer doctors stocked it with sample medicines they could give to patients who couldn’t afford medications otherwise. (The last patients of the day were often out of luck.) But Tweedy goes deeper: the clinic is a well-meant, even a generous donation of time, but the structure of a monthly clinic with rotating doctors meant the quality of care suffered. Tweedy offers similar chapters on childbearing, especially among drug abusers, the risks to young men living in the inner city (primarily gunshot wounds), hatred in patients, discrimination by doctors, and the heavy impact of HIV/AIDS in the African-American community.
Several themes come out of this, and Tweedy discusses them with nuance and sensitivity. One issue he returns to is the role of the black doctor: does he or she owe patients more than good care? What, if anything, can a doctor do to reduce the disparities in care? Often, the assumptions doctors make about the strangers in front of them are the right ones, even if they’re shortcuts based on cruel stereotypes. In his chapter “Baby Mamas,” for example, Tweedy describes a woman with an advanced pregnancy who denies her pregnancy and denies drug use. Tweedy,who was then a second-year medical student, knew what questions to ask, but is surprised when the supervising doctor, diagnosing an abruptly separating placenta (which can kill both baby and mother), dragged the admission of drug use from the patient. He’s even more shocked when the doctor and nurse agree the baby’s death is for the best, and disturbed by their discussion of whether the mother, age 19, should be asked about having her tubes tied. The reader can’t help but think of forced sterilizations, and then Tweedy adds an important emotional layer in his description of the mother’s keening apologies as she holds her dead infant. It’s an extremely effective technique, one that brings out the policy issues while forcing the reader to remember that Tweedy is telling stories about real people, who have and express their feelings.
It’s clear that Tweedy, now a psychiatrist and professor at Duke Medical School, has answered his question about the role of the doctor in the affirmative. In the final chapter Tweedy identifies three types of problems that need to be addressed so that we can move beyond race in medical treatment: the first is the system-based disparities caused by health insurance or the lack of it (the book was written just as the Affordable Care Act came into effect), and the differences in care those with private insurance receive. The second is the doctor-patient relationship. Both doctors and patients bring attitudes and prejudices into the hospital or clinic with them. Tweedy devotes an entire chapter to the prejudices among his poor white patients, and his often-successful attempts to overcome it, and the prejudice and fear expressed by his black patients. He’s equally thoughtful about the impact of racial pairing during his training – sometimes it worked well, in ways he expected, and sometimes it did not. Finally, Tweedy lists unhealthy lifestyles of many African-Americans, partly due to circumstance (fresh, unprocessed food may be expensive or unavailable) and partly due to culture (deep fried, breaded dishes).
Tweedy could have become bitter and angry, and it’s fortunate for all of us that’s he’s so thoughtful. His book raises important questions and anyone who thinks about medical care should read it.
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