Black and Blue. John Hoberman
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physicians. The estrangement from blacks that resulted from this mind-set has expressed itself in many ways. In 1940, Time reported that “few white doctors dare to operate on their 'massively' infected Negro patients” afflicted with tuberculosis.14 At this time black doctors noted with chagrined amusement that, “The average young white physician enters practice with the idea that all Negroes have syphilis or tuberculosis.”15 A generation later the medical anthropologist George Devereux described his observations of “White-Negro doctor-patient pairs” and the diagnostic errors that resulted from the doctor's “'tactful' reluctance to examine closely the most distinctive portions of a racially alien patient's body.”16 White dermatologists may be alternately alarmed about or unaware of the characteristics of black skin and the emotional consequences of skin problems for patients.17 White doctors sometimes underestimate the intelligence and self-control of black patients and treat them accordingly.18 The cumulative effects of such naïveté are often evident to blacks but are less evident to the white medical community that does not monitor and report on such incidents.
The writings produced by white physician-authors reflect the social distance from African Americans they share with a large majority of their fellow citizens. As the black sociologist Orlando Patterson noted in November 2009, “in the privacy of homes and neighborhoods we are more segregated than in the Jim Crow era.” Various degrees of segregation occur within “the disciplined cultural spaces of marriages, homes, neighborhoods, schools and churches.”19 Hospitals and clinics are disciplined cultural spaces that are subject to the same racial tensions and estrangements that occur within the other “disciplined” social venues. It is, therefore, not surprising that physicians who write about race relations within these medical spaces tend to avoid direct confrontations with uncomfortable racial issues. For example, a collection of 80 reflective columns by doctors taken from the pages of the Journal of the American Medical Association during the 1980s contains many profound and moving stories that together constitute the most sympathetic portrait of the medical profession I can imagine. Of the hundreds of people who appear in these stories, there is exactly one African American patient, a humble sharecropper in sweltering Alabama who is grateful to find a white medical student who is willing to talk to him. An elderly black hospital orderly is sympathetically presented as incarnating one of the classic folkloric images of black humanity: the musical Negro. From these dozens of medical authors, there are a handful of references to “slum children,” inner-city “juvenile delinquents,” and a six-year-old West African child who dies despite the best efforts of the American physician who tries to save him. There are no black doctors or nurses. All but a few picturesque and stereotypical examples of black humanity were apparently absent from the recollections of most of a hundred physicians.20
Paul Austin's Something for the Pain (2008), a candid, caustic, sensitive, and sophisticated memoir of his many years as an emergency room (ER) doctor in North Carolina, refers to race rarely, carefully, and allusively. The tone of a young black mother's voice has “a brittle edge” until the doctor's gentle manner wins her over. The author refuses to give a racial edge to the hostility of a despairing young black man whose mother lies dying in the ER.21 Thoughtful writing of this kind reminds us of medicine's color-blind ideal; and it is likely that some physician-authors avoid the topic of race out of fidelity to the dream of medical care that transcends color.
The problem with color-blind writing about medicine is that it ignores the long history and persisting reality of racially motivated medical behaviors that can alienate, injure, and sometimes kill black patients. Another genre of medical writing focuses on the brutal conditions experienced by doctors who practice medicine in the ghetto. Doctors Talk About Themselves (1988) describes the emotional impact on doctors of dealing with the dregs of humanity who show up in inner-city ERs: “You see such awful things that are totally beyond any experience you have ever had. You ask, 'How can people live like this?'” In this “snake pit” the cynicism that has been widely observed in older medical students becomes complete, as beleaguered and resentful physicians absorb “every conceivable kind of abuse” from their black clientele.22
Finally, there is medical writing that ignores the race issue entirely. Jerome Groopman's 2007 bestseller How Doctors Think does not contain a single sentence that addresses the question of how doctors think about race. Groopman confirms that there is a great deal of potentially useful thinking that doctors do not do. He knows that social context and the doctor's emotions matter. But he is unwilling or unable to connect these commonsensical principles to real-life scenarios that involve interactions between patients and physicians across the racial divide.
JUDGING HOW PHYSICIANS BEHAVE
Making judgments about what goes wrong between white doctors and black patients requires a sense of realism and humility on the part of those who observe and analyze these relationships. White professionals in other occupations—professors, for example—should be subject to the same kind of scrutiny of their professional conduct. An important difference is that academics do not as a rule have access to the intimate details pertaining to the minds and bodies of their students. Nor are professors traumatized in the line of duty in the ways that ER doctors or oncologists and other physicians can be. Relations with students are seldom fraught with fateful consequences that might result from a professor's incompetence. In addition, most university students are courteous and cooperative people who can be expected to conduct themselves in a reasonable manner and in their own best interest. The patient population that doctors serve is not so easily managed. My father retired from practicing outpatient medicine in his late seventies when he became exasperated with the noncompliant behavior of the patients he encountered at a hospital in the Bronx, many of whom must have been black or Hispanic. Noncompliance, such as a refusal to take prescribed medications or to stop smoking or drinking, is a massive problem for doctors. Noncompliant students, on the other hand, will either change their behaviors or fail their courses and vanish from their professors' classrooms.
JUDGING PHYSICIAN CONDUCT: PRIVACY AND THE “HALO EFFECT”
The detection of racially motivated diagnoses and treatments by physicians remains an ineffectual statistical exercise that has been repeated in hundreds of papers in medical journals over the past two decades. The systematic use of diagnostic and treatment protocols by doctors who track outcomes and adjust care is modern medicine's best hope for improving the services it offers patients. But peer-reviewed evidence of racially biased medicine has produced no reforms remotely comparable to what is now being done at many hospitals to improve survival rates among diabetics and preterm infants. Frequent calls for “further research” into the causes of racial health disparities simply defer the possibility of intervention into racially motivated behaviors into the indefinite future.
So the fundamental questions here are: Why has the medical profession never systematically studied how physicians produce racially motivated diagnoses and treatments that can cause medical harm? And how has traditional, and often defamatory, racial folklore been absorbed into medical practice in specific forms that have infiltrated medical specialties from cardiology to obstetrics to psychiatry?
Traditional norms discourage the analysis and assessment of physician conduct or even misconduct. The medical community, like some other professional groups, has been reluctant to discipline its members for unprofessional and even harmful conduct. As one physician-author noted in 1988, “doctors are unwilling to blow the whistle on other doctors. It's somehow bad manners or breaking the faith of the medical profession to report a bad doctor.”23 In this sense, the practice of medicine, like police work, is more of a fraternal order than a scientific community that recognizes and acts upon its responsibility to monitor and correct the deviant and dangerous misconduct of its practitioners.
Another powerful factor that shields doctors from scrutiny is the “halo effect” that wraps physicians in an aura of benevolent power. “Doctors,” a New York Times writer noted in 2009, “have a degree of professional autonomy that is probably unmatched outside of academia. And that is how we like it. We think of our doctors as wise men and women who can combine knowledge and instinct to land on just the right treatment.”24 The combination of benevolent intent and the power to heal has traditionally conferred upon doctors