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Thursday, September 10, 2015

#BlackDocsMatter: Race and Health; it's not just about the patients.

Listened to a very interesting NPR "Fresh Air" segment yesterday while returning from dropping off a load of shelves at my daughter's new office in Point Richmond.

A compelling segment (embedded below). Bought the book straight away. Just started reading.

When I was fourteen, my dad’s brother — who would often drive five hours each way on a Saturday to visit us for a few hours — died within days of collapsing at his home, putting an abrupt end to his unexpected and always enthusiastic visits that I so enjoyed. A few years later, my maternal grandmother — Grandma Flossie — developed dementia from a series of minor strokes that slowly stole her mind and, eventually, her body. Like Jim, both had high blood pressure. “Our patient’s other major risk factor is hypertension,” Dr. Wilson continued. “This also is much more prevalent in blacks — nearly twice as common.

No matter how you slice it, race is a very big deal when it comes to stroke.”

Dr. Wilson had hammered home something I would learn time and again, both at Duke and beyond: Being black can be bad for your health.

“Of all the forms of inequality,” Martin Luther King Jr. told a gathering of the Medical Committee for Human Rights in 1966, “injustice in health is the most shocking and the most inhumane.”

At the time of his remarks, the United States had begun to take several formal steps to end its century-long practice of state-sponsored segregation that had followed the end of slavery. In medicine, this meant that black people could begin to receive treatment side by side with whites rather than being relegated to separate and unequal facilities or sectioned off in run-down areas of white hospitals. Such practices had undoubtedly contributed to their poorer health, especially in the Deep South of Dr. King’s time, where black people on average had a life expectancy nearly nine years less than whites. While the civil rights movement ultimately stirred remarkable racial progress in various areas of American life, many of King’s concerns about health and health care remain valid to this day.

From cradle to grave, these health differences, often called health disparities, are found virtually anywhere one might choose to look. Whether it is premature birth, infant mortality, homicide, childhood obesity, or HIV infection, black children and young adults disproportionately bear the brunt of these medical and social ills. By middle age, heart disease, diabetes, stroke, kidney failure, and cancer have a suffocating grip on the health of black people and maintain this stranglehold on them well into their senior years.

Thus, it is no surprise that the life expectancy among black people, despite real progress over the last twenty-five years, still significantly lags behind whites. In suffering a crippling stroke at age thirty-nine, Jim had become another casualty of inequality, a fresh case that Dr. Wilson could use to illustrate the health burden of being black.

Three decades after Dr. King’s 1966 remarks, I entered Duke University School of Medicine as one of a half-dozen black students on scholarship. With the scholarships, Duke sought to cast aside its history of racial exclusion and become a national leader in producing a new generation of black physicians who could change the face of medicine. My goal as I headed for Durham was much less ambitious and civic-minded. I simply wanted to make my parents proud of me and set myself up to earn a good living. Race-based concerns ranked low on my list of priorities.

But my professors couldn’t stop talking about race. During my early months, as they taught us about diseases both common and rare, they inevitably cited the demographics, explaining which disorders were more common in the young or old, women or men, and one racial group or another. When they spoke about race, they would sometimes mention Asians, Hispanics, and Native Americans. Yet invariably, as it always seems to in America, their analysis came down to comparing blacks and whites.

It seemed that no matter the body part or organ system affected, the lecturers would sound a familiar refrain: “It’s more common in blacks than in whites.”

Each time the demographics of a new disease came up in a lecture, my stomach twisted. I knew where this was heading. Seated in a sea of mostly white and Asian faces, I wondered how this information affected their views of black people, whether they already had biases against us, and whether any of this impacted the way they saw me. This racial health data intensified my already uneasy feelings about my place at Duke. My classmates largely hailed from well-to-do suburbs and had attended prestigious, brand-name schools; I came from a working-class neighborhood and had attended a state university with little name recognition. Their parents all seemed to be doctors, lawyers, or professors. My dad didn’t finish high school and worked as a meatcutter in a grocery store; my mom attended segregated inner-city public schools before embarking on a forty-year career in the federal government. From the moment I walked along Duke’s manicured lawns and inside its Gothic buildings, I worried that I was at a stark disadvantage, both socially and academically.

Constantly hearing about the medical frailties of black people picked at the scab of my insecurity. Over time, I came to dread this racial aspect of the lectures so much that I felt intense, perverse relief whenever a professor mentioned that a disease was more common among white people. But this list was short and the refrain that accompanied it proved equally painful. For example, while breast cancer got diagnosed more often in white women, “black women who get this disease do much worse,” the professors would say...

Damon M.D., Tweedy (2015-09-08). Black Man in a White Coat: A Doctor's Reflections on Race and Medicine (Kindle Locations 54-95). Picador. Kindle Edition.

UPDATE: I have now finished this fine book. All the way through the substantial end notes. I found it riveting. Excerpt from the author's website here.

Some blurbs from a couple of the many medical authors I've cited on this blog:
"A sincere and heartfelt memoir about being black in a mostly white medical world. Essential reading for all of us in this time of racial unrest."
Sandeep Jauhar, author of Intern: A Doctor's Initiation and Doctored: The Disillusionment of an American Physician
"Eye-opening and compelling examination of medicine's continued discomfort with race. Damon Tweedy is unafraid to dissect the both the intriguing and disturbing elements of becoming a doctor. Required reading for anyone wishing to understand medicine in America today."
Danielle Ofri, MD, PhD, author of What Doctors Feel: How Emotions Affect the Practice of Medicine
Ten years ago I was working in my second of three tenures with HealthInsight. My major focus was that of the CMS "DOQ-IT" initiative, the baby-steps precursor to the ensuing 2010 ONC/CMS "Meaningful Use" program.

DOQ-IT was CMS 8SOW ("8th Scope of Work") contract section 1(d)(1). I was also assigned to work on Section 1(d)(2) -- health care "Disparities," "Cultural Sensitivity," "Cultural Competency."

In Vegas, our minorities "disparities" focus was devoted to Black, Hispanic (mainly Mexican origin), and Asian patients (mostly Japanese and Chinese origin), and, to a minor degree, Native Americans (who were predominently served by the Indian Health Service).

I was an 8SOW contract overspend casualty in 2007 and got laid off amid a 10% staff RIF, so I didn't get to do much with 1(d)(2).

Now, the hope is that Health IT-enabled "big data" accruing from the mature Meaningful Use years will enable us to mine the socioeconomic/ethnic "Upstream" and mitigate health disparities. We'll see.  apropos, see my January 2014 post When it comes to health, your zip code matters more than your genetic code.

Also, on doctoring in general, see my posts "The Yeshi Dhonden dx, and other business," and "Nurses and doctors in the trenches."

Racial/ethnic disparities are no abstract academic concern for me. My younger daughter is biracial.

A long story. Recounted here. Given that we have no information regarding her paternal medical history, we have indelible concerns.

More later. Gotta run. Calypso prostate Rad Onco tx 3 of 45.

My new BFF.

I have to drink about a liter of water every day about 40 minutes ahead of my radiation dose. I'm not sure we have 45 liters of water left in California.

I've named my lesion "The Donald." Nuke The Donald.



The mind-bending progress of information technology makes it easier every day for us to imagine a nightmare future. Computers become so capable that they’re simply better at doing thousands of tasks that people now get paid to do. Sure, we’ll still need people to make high-level decisions and to develop even smarter computers, but we won’t need enough such workers to keep the broad mass of working-age people employed, or for their living standard to rise. And so, in the imaginary nightmare future, millions of people will lose out, unable finally to best the machine, struggling hopelessly to live the lives they thought they had earned. 

In fact, as we shall see, substantial evidence suggests that technology advances really are playing a role in increasingly stubborn unemployment, slow wage growth, and the trend of college graduates taking jobs that don’t require a bachelor’s degree. If technology is actually a significant cause of those trends, then the miserable outlook becomes hard to dismiss.

But that nightmare future is not inevitable. Some people have suffered as technology has taken away their jobs, and more will do so. But we don’t need to suffer. The essential reality to grasp, larger than we may realize, is that the very nature of work is changing, and the skills that the economy values are changing. We’ve been through these historic shifts a few times before, most famously in the Industrial Revolution. Each time, those who didn’t recognize the shift, or refused to accept it, got left behind. But those who embraced it gained at least the chance to lead far better lives. That’s happening this time as well.

While we’ve seen the general phenomenon before, the way that work changes is different every time, and this time the changes are greater than ever. The skills that will prove most valuable are no longer the technical, classroom-taught, left-brain skills that economic advances have demanded from workers over the past 300 years. Those skills will remain vitally important, but important isn’t the same as valuable; they are becoming commoditized and thus a diminishing source of competitive advantage. The new high-value skills are instead part of our deepest nature, the abilities that literally define us as humans: sensing the thoughts and feelings of others, working productively in groups, building relationships, solving problems together, expressing ourselves with greater power than logic can ever achieve. These are fundamentally different types of skills than those the economy has valued most highly in the past. And unlike some previous revolutions in what the economy values, this one holds the promise of making our work lives not only rewarding financially, but also richer and more satisfying emotionally.

Step one in reaching that future is to think about it in a new way. We shouldn’t focus on beating computers at what they do. We’ll lose that contest. Nor should we even follow the inviting path of trying to divine what computers inherently cannot do— because they can do more every day...

Colvin, Geoff (2015-08-04). Humans Are Underrated: What High Achievers Know That Brilliant Machines Never Will (pp. 3-5). Penguin Publishing Group. Kindle Edition.
Now, this one obviously goes to several I've recently finished and cited, with an eye toward toward the healthcare workforce implications of automation and "AI":

See "The Robot will see you now -- assuming you can pay," "AI vs IA: At the cutting edge of IT R&D," "Medical Progress: Looking back, looking ahead," and "It's not so elementary, Watson." Developments in Health IT.

We'll see about Geoff Colvin's optimism. I'll have to park my skepticism until finishing close study of his book.

More to come...

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