Reflecting On Race

In his debut memoir, BlackMan in aWhite Coat, physician Damon Tweedy navigates two complex worlds: society at large and the US health care system. Tweedy, an assistantprofessor of psychiatry atDukeUniversity Medical Center and a staff physician at the Durham VA Medical Center, painfully details numerous cases of racism and bias in health. In some of the cases, he was the victim; in others, providers’ racism was directed at patients. Tweedy also points out the flaws in the health care system that play a role in health disparities seen between black and white patients, including the system’s deep roots in institutionalized racismand its tendency to provide different levels of care based on income, education, and other factors beyond a patient’s control. He also shows that the problems surrounding health issues do not rest solely on the health system or physicians but also on patients’ decisions and cultural influences that can negatively affect health. Race is consistently a factor in the management of patients, warranted or not, Tweedy notes, and he refers to current literature and trends in care, both anecdotal and as described by researchers. He reflects on his role as a provider, tracing his time through the stages of medical education. His evolution as a physician occurred against the backdrop of the traditional training process physicians go through, which easily breeds bias, he points out. Medical students are taught to recognize disease patterns and prevalence, with an emphasis on race and other social factors, hewrites. Providers take this knowledge and create mental shortcuts, or stereotypes, to arrive at medical decisions that fit the diagnosis. This practice is a detriment to patients, but it remains a mainstay of medical decision making. The book is written in a case-based format, with each chapter representing a case—not of a disease or health condition, but of the flaws in the sometimes biased health system that minority patients and physicians must operate in. True to reality, not all of the cases have happy endings. Indeed, some end in tragedies that could have been avoided had the system been better equipped to address the needs of all patients. The book’s strength is the author’s astounding introspection. Tweedy’s ability to recount details about patientprovider interactions and their downstream effects on him is impressive. As he candidly discusses his own experiences and the patient cases, he reflects on how his upbringing and education explain his biases and put limitations on relationships with patients. Yet unfortunately this book—and others like it—fails to focus enough on changes that can and should be made to eliminate health disparities betweenminority and other patients. Much progress has been made to improve the care of all patients, with special attention paid to those considered on the fringes of society. Tweedy, in part because of the semi-autobiographical style of his book, describes the evolution of health care alongside his personal timeline, which leaves him little room to highlight the more recent efforts to eliminate disparities. Nor does he offer any major recommendations for addressing racism in medicine going forward. It is important, too, to remember that Tweedy’s book is a memoir and should not be taken as representing the experience of all black doctors. At times while reading the book, I felt as though the author was telling my own story as a black physician coming of age. In one scene, Tweedy recounts being misidentified by a professor as a member of the maintenance staff—why else would he be in a classroom? It is disheartening to know that so many other physicians have likely had similar negative interactions, but it is encouraging to know thatmanyhaveovercome thepotentially damning effects of bias in medical education. Yet some of our experiences differed, which offers a reminder that each physician brings his or her ownperspective to the table and should not lumped into a group based on race. Tweedy closes the book by noting hopeful trends. For example, the health system is evolving into a higher quality and more efficient environment than the one in which he trained, with better medicine, amore stable physician workforce, and better facilities. He also hints at the opportunities the Affordable Care Act offers for improving the lives of patients with limited access to health care, in particular members of minority and other underserved communities. Race is truly just a social construct, he concludes, emphasizing that if we took time to care for one another genuinely through self-reflection and understanding, our relationships could overcome perceived racial boundaries. ▪