An Old Doctor Reading Harrison’s Principles of Internal Medicine for the Last time
Racial Disparities in Health Care-Chapter 7
I entered medical school in 1973, the Tuskegee Syphilis Study ended in 1972. The professors who interviewed me to ascertain if I was of sound moral character to be a doctor were ignorant of or complicit as this federal study was no secret and had been underway for forty years.
The first doctor who complained of the immorality of the study was Dr. Irwin Schatz of the Henry Ford Hospital in Detroit. He died recently but I read this from his obituary in the NYT:
He sent his letter, comprising three sentences, to the study’s senior author, Dr. Donald H. Rockwell. He wrote: “I am utterly astounded by the fact that physicians allow patients with potentially fatal disease to remain untreated when effective therapy is available. I assume you feel that the information which is extracted from observation of this untreated group is worth their sacrifice. If this is the case, then I suggest the United States Public Health Service and those physicians associated with it in this study need to re-evaluate their moral judgments in this regard.”
The letter was passed to a co-author, Dr. Anne R. Yobs of the Centers for Disease Control, who wrote in a memo to her bosses: “This is the first letter of this type we have received. I do not plan to answer this letter.”
Dr. John C. Cutler of the Public Health Service during its syphilis experiment in Tuskegee, Ala., which went on for 40 years.Credit…Coto Report
In 1973 there was little discussion of racial disparity in healthcare in the medical school curriculum. Chapter 7 notes racism has been shown to predict poorer health outcomes. As an example it states that Black patients are less likely to be referred for renal transplantation despite the fact that ESRD is much higher in Blacks.
As a kidney specialist I send all my patients to a transplant center to be evaluated for a kidney transplant regardless of their race. I would be embarrassed to do otherwise.
A study of 16,000 physicians admitted that bias including race and ethnicity effected their decision-making process 42% of the time.
Maybe so but as a physician every patient that comes into my office gets 100% from me. Their health and my reputation is on the line.
An example: One of my Black patients (identity obscured) developed lupus pernio after a successful kidney transplant for sarcoidosis. Sarcoidosis is much more common in Blacks.
The lupus pernio turned her nose into a hideous deformity of enlarged tumors and growths.
She came in for her visit. I entered the exam room. She had a surgical mask on her face this before COVID. She stared at the floor.
“Allison, your disease is in remission. You’re going to be fine.”
“Fine? Try going through life looking like this.”
She removed the surgical mask revealing large grotesque oily tumors covering her cheeks and nose. Areas of skin lost pigment and contrasted cruelly with her brown skin.
“It’s tough enough going through the white sales world, but I was always that pretty Black girl and that got me in the door. Then I showed them, I was the best.”
She covered her face again. Tears flowed from her eyes staining the surgical mask.
I shook my head. I was so proud I’d saved her life. Sarcoid is tricky and there is not much known about it. She was thirty years old, and a single parent.
Disease even when “cured” always leaves scars, some physical, some emotional. I wasn’t so sure I’d helped her that much. I felt responsible.
“I lost all my accounts. I have to work in a cubicle. They gave my office to a pretty young outside salesperson. I go to work early before anyone arrives and I leave when it’s dark and everyone has gone home.”
“I’ve called your HMO,” I said. “I explained what happened, but they said your policy doesn’t cover cosmetic surgery.”
“This isn’t a nose job I’m asking for. I want my life back. If it wasn’t for my daughter, I’d have ended all this.”
“Are you suicidal?”
“Yes, but don’t give me Zoloft, don’t give me Prozac, get my face fixed. I won’t go through this much longer. I’m barely hanging on.”
My throat tightened.
“Please, don’t do anything. I’ll think of something. If only I could get the HMO doctors to see the problem.”
“Why won’t they examine me?”
“It’s easier to say ‘no’ over the phone.”
She got her coat. Left the office.
She forgot to put her mask on. People in the waiting room stared. She met their gaze; they turned away.
My wife worked as my receptionist. She took me aside, squeezed my arm firmly and said, “Do something. Whatever it takes, do something.”
“Her HMO won’t pay for plastic surgery, it’s cosmetic.”
“This isn’t right.”
I shook my head.
“I have a stack of denials for the past year, and she is suicidal and would have done something if it wasn’t for her daughter.”
“This is no longer cosmetic.”
“It is on paper,” I said.
My wife started to cry.
I couldn’t cry, I had patients to see.
* * *
I went to bed thinking about Allison. I woke up thinking about her. Then an idea came to me like a thunderbolt.
“I’ve got it.”
“Wake up and listen to this.”
I got the phone number of the HMO patient help line. I dialed and got a recorder. I waited for the “leave a message after the tone…”
“This is Dr. Olaf Kroneman, Allison Smith is a patient of mine. I have been trying to get cosmetic surgery for her for over a year. This African-American woman needs surgery and you have denied her. You have two hours to call me back, or I will call the NAACP and tell them what you are doing to her.”
I put the phone down and went into the shower. I was soaped up. My wife shouted over the noise of the shower.
“Olaf the phone’s for you. It’s the HMO–hurry.”
I wrapped a towel around my waist and took the phone, sat at the side of the bed dripping and freezing.
“Who am I speaking with?”
Not a good way to start a conversation, I thought.
“To whom am I speaking?” I asked.
“This is Dr. Gupta. I am the medical director of the HMO.”
“I’m Dr. Kroneman.”
“Did you just call me threatening to call the NAACP?”
“I don’t like to be threatened.”
“It’s not a threat. It’s a courtesy.”
“Damn right I’m angry. I don’t like you jacking my patient around.”
“What do you mean jacking the patient around?”
“It’s an expression for making her fill out forms and making me write letters knowing all along you won’t approve the surgery. I’ve been trying for a year. We’re desperate. She is horribly disfigured.”
“I have reviewed her policy. We don’t cover cosmetic procedures.”
“If you saw her. If you knew her before–if you had a heart, you would have approved this a year ago.”
“I have a heart.”
“Would you at least examine her?”
“I have reviewed her case. She is not covered.”
“Listen,” I said. “My friend is a plastic surgeon. He goes all over the world, fixing children with cleft palates in poor countries. He said he would do Allison’s surgery for free. He said it’s a simple procedure and he can restore her face.”
“You know, Dr. Kroneman, that the doctor’s fee is a fraction of the cost. It’s the hospital fee that’s the problem. The hospital won’t do anything for free.”
“But they’re not–for–profit hospitals serving the greater good.”
He laughed, “You’re an idealist.”
“No,” I said. “I’m a doctor taking care of his patient, like you used to be. I’m going to drop the dime on you.”
“What do you mean, ‘drop the dime’?” He was breathing faster into the phone.
“It means I’m calling the NAACP.”
“Look, I’m a brown man. I know prejudice.” Faster breathing.
“I’m a white man. I don’t know prejudice. But I know how to get things done.”
“You’re playing the race card.” I heard him slap something probably his desk.
“You got that right.”
“Will they listen to you?”
“Are you willing to take that chance?”
“Okay,” Dr. Gupta said. “I’ll approve this.”
“Don’t you want to see her? Get a good look at her face?”
“No,” he shouted.
“I want a date and time and approval number.”
“I can’t give you the date.”
“I’m a reasonable man. Just give me the approval number.”
He gave me the number I wrote it down on a paperback book I found on the nightstand. I looked at my wife who was under the covers. I gave her the thumbs up.
“Dr. Kroneman, I just want to say you are a difficult man, with no tact, and no bedside manner.”
“Dr. Gupta, when my bedside manner gets really bad, I’ll become a director of an HMO.”
He hung up.
I got my approval number and Allison got the surgery and her office back. That really happened. I smile when I recalled the event. The HMO won’t deal with me. It seems the bureaucrats are in charge now. They call the shots. I won the battle, but I, and our profession, lost the war. When a doctor is no longer a clinician and becomes an administrator, they hurt. They abandon compassion, and sacrifice, and become corporate. To do otherwise wound put their job in jeopardy.
The non-medical pencil pushers rule.
One more anecdote-
I would like to be more sophisticated in my caring, but I am busy taking care of patients from different races, cultures and creeds. My patients and colleagues have become quite diverse. Courses on cultural awareness would be very much appreciated and interesting but are not widely available or convenient. So until I become well acquainted with several different cultures I, out of necessity, must default to being kind and acting like a gentleman.
An example comes to mind. I was asked to consult on a Muslim youth, who was stricken with terminal cancer. I could have obtained all I needed to know from the aseptic soulless computerized medical record, but instead I took a time–consuming, tedious history through a translator on Skype. The family was present. It was very important in the establishment of trust.
They thanked me. The men shook my hand and when I extended my hand to one of the women she kept her hand at her side. I realized this to be a cultural faux pas.
It also breaches gentlemanly conduct—for Emily Post etiquette dictates that a gentleman never extends his hand to a lady unless she extends hers first.
She smiled at me. I smiled back, lesson learned, lesson remembered.
“Smile at me, I will understand because that is something everybody in the world does in the same language.” (Crosby, Stills and Nash)
Despite our differences we have a shared humanity that in the intense medical drama transcends all— and should excuse much if done from the heart.