Only 4% of physicians in the U.S. are black. Damon Tweedy, MD, a psychiatrist at Duke University, explores how that statistic plays out in the medical world in his new memoir, Black Man in a White Coat. Tweedy spoke with 鶹ý over the phone last week on the train ride home from an exhausting round of publicity for the new book. An edited transcript of that conversation follows. You can also read an excerpt of the book here.
鶹ý: One of the stories I found most compelling was the patient who was given a psychiatric diagnosis for wanting to try lifestyle intervention to lower his high blood pressure before starting medications. You had your own struggles with hypertension that you controlled with diet and exercise. What did this example illustrate for you?
Tweedy: This was during my intern year and I hadn't solved my blood pressure problem yet, but this gentleman reminded me of myself in that his goal was to make the effort to try to address it with lifestyle changes. That seemed like a reasonable goal. He came to our hospital with chest pain and our first concern was that he was having a heart attack. When it was clear he wasn't having one, the doctors started on secondary prevention to try to reduce his risk factors for heart attack, like stopping smoking and controlling blood pressure.
Everything seemed reasonable up until the point where they started to talk about a blood pressure medicine. He wanted to try to adjust his diet and become physically active, and that's a perfectly reasonable way to start. He agreed to say that even if doesn't work out, he'd come back and take medication. This is the kind of patient you want -- someone who is trying to be proactive about their health. But we were in the setting of a public hospital, where doctors see lots of patients who don't follow their advice. So there was a perception that he was too smart or too knowledgeable or maybe the doctors thought he was challenging them in a way that surprised them. That's when the idea of what is going on with this guy outside of his medical problem came up. The alternative was that he had a mental health issue.
For me, in intern year, I was the lowest person on medical hierarchy so it was a real struggle about the right thing to do [which ultimately involved signing off on a non-existent psychiatric diagnosis]. The more I thought about it, the more I realized how problematic it really was. But I was preoccupied with survival, and only when I had time to step back and reflect on it did I realize how bad that was.
MPT: Your book isn't prescriptive. Instead, you rely on storytelling to illustrate the issues that are important to you. What is the value of a narrative approach?
Tweedy: Storytelling is important. This book is about educating people and increasing awareness. I've been amazed that people I've talked with have no idea about these issues at all. They're aware of racial inequality in the criminal justice system, but they're unaware about how it affects health.
When I would read narrative essays in medical journals and books by other doctors, I found it all fascinating but one missing piece was that they didn't talk about the issue of race, which was very important to me. When it was talked about, it was only glossed over. To me, that was a huge deal given the experiences I was going through as a medical student and the patients I was seeing. Toward the end of residency I started to write articles for medical journals and got good feedback. Based on that I thought maybe there was something more here, maybe I can try and make this into a bigger project. ... Hopefully through the stories I tell, I can inspire people to make changes.
MPT: One of the most staggering statistics I've seen is that only 4% of physicians in the U.S. are black.
Tweedy: Yes, 13% of the population is African-American, but only 6% of medical school students are black and only 4% of practicing physicians are, because the numbers have been so low for so long. It's an interesting dilemma with a couple of different layers.
The breakdown of physicians by gender among whites, Asians, and Hispanics is around 50-50, maybe 53-47 male to female. But for African Americans it's 2-1 women to men. A recent report by AMSA found that the number of African American med students has increased considerably, as had all other demographic groups -- with the exception of African American men, where the numbers had plateaued or slightly declined since the 1980s.
There are so many factors going on at the societal level. There seems to be a certain lane you can travel where people see you being successful, and that filters down to you when you're a young African American male. That has been my experience. I grew up in a community of all African Americans and the trajectory was to play sports -- that's a lane you can travel to succeed, and other than that, the road was much less clear. People going to school and taking an academic track and succeeding was a rare thing to see. Not having [a role model] made it harder for you to perceive it as something you can do yourself.
MPT: Who was that role model for you?
Tweedy: Few people in my family had attended college, but older brother did graduate as a biology major, so that was a big start. In my community, I was one of a very few people who went to college. In 8th grade I tested into MAGNET program, suggested to me by a teacher in my middle school that was 95% black. I was initially reluctant but decided on a whim to take it. I got into a program that brought together students from many different backgrounds. In college I continued on a science and technology path, and my first summer after college I worked in a research lab.
There was a young African American cardiologist there who a huge influence. I saw him as someone who had gotten to the point where I wanted to be. That was a big inspiration for me. He'd gone to Johns Hopkins for med school and did his training there as well. He was succeeding at the highest level, so he was a great example. He introduced me to several other African Americans in other specialties like anesthesiology and surgery, and seeing that community was an eye opener for me as well.
MPT: Xavier University in New Orleans was recently for its mission to better prepare African American students for medical school.
Tweedy: In the African American medical community it's well known that school has been a standout for many years in terms of how they are able to recruit African Americans and nurture them in a way that can get them on the path to medical school. One challenge African American students find in college, particularly in predominantly white colleges, is that there sometimes can be a feeling of being isolated which can have significant effects on your academic performance. If you're not being integrated into the full mix of the school, you don't know all the ins and outs of the school, like what classes you need and how to make your application as strong as you can. There's a pathway to becoming a good medical school applicant. If you're isolated, not because of racism, but because of your own internal feelings of insecurity, anxiety, and uncomfortable, there can be self-segregation in some ways -- and that can be detrimental.
There's also the perception around affirmative action, that maybe you're not as qualified. If you have that feeling in your mind and you are in a setting where you're having some difficulties, you may be less likely to own up to those issues because you're concerned that it may fulfill stereotypes. That can make you even less likely to reach out for help. So Xavier has an aggressive way of nurturing students and building people up as that article talked about very well. It's really a model.
MPT: You say there are three main forms of health problems facing blacks today: socioeconomic disparities, the doctor-patient relationship, and poor lifestyle choices. Is there a way to focus on one of these to improve the others?
Tweedy: They're so intertwined, it's hard to untangle them. For example, when I was in med school in the charity clinic, the issues are all there. You have the issue that folks are poor and they don't have health insurance. That's a system level problem. Because of that, they can't afford to see a doctor, and they're not seeing the same doctor, so you have a lost doctor-patient connection. And in a community that's somewhat cut off from other parts of society, your lifestyle choices are impacted. It's all so intertwined, but education and poverty are probably the most important factors. Jobs and education could probably correct most of this. If people have those things, they can make better choices and have better access to doctors.
MPT: What have you observed about the doctor-patient relationship among African Americans, and what changes are needed there?
Tweedy: There's a history there that leads to a lot of mistrust. Even though it's a distant memory, a lot of it is echoing into the present time. Some of the things I talk about in the book, like increasing the number of African American doctors, is one component. There are experiences you can relate to in order to make patients open up more about their own experiences. Time constraints may make it hard to make connections, ... but you would be surprised how easy it can be to make a connection with a person with a different background. It can only take a minute or two and it can make all the difference. I try to teach that to all the med students and residents I supervise. The other big thing that major medical centers need to do more is to engage their communities to facilitate trust. So it has to happen at the level of teaching young doctors, but also at the level of engaging the community and teaching the community.
MPT: You say that health disparities are more socio-economic than racial. How so?
Tweedy: Race and socioeconomic status are so difficult to separate. Historically, blacks have been much poorer and of lower socioeconomic status, so it's hard to distinguish between the two. I wouldn't say it's exclusively socioeconomic, but it's a bigger piece. In the clinic I worked at, all of the people there were black and uninsured, so you can see how poverty affects health. There's no doubt that wealthier blacks have better health outcomes than poorer blacks, but at the same time there is still a racial component. One study that compared health outcomes for African American doctors with Caucasian doctors still found disparities even though both groups had the same socioeconomic status. What class doesn't account for is the history, the idea of what it took for you to get to the same level, what sorts of stress and barriers did you have to deal with? That's where race can still play a role. But if I had to pick one, socioeconomic status is more important, though race is still a concern.