Introduction

n a spring morning in 1997, Jim Harper, a young man from

O Durham, North Carolina, woke up in his two-bedroom apart-
ment with no clue that he would soon become gravely ill.
The first signs of trouble seemed innocent enough: some numb-
ness on the right side of his face and in his right arm and hand, easily
chalked up to having slept on that side of his body. He stumbled as
he got out of bed, but figured he was simply tired from the previous
day’s shift managing angry teens at a group home. His fiancée, Re-
gina, asked if he needed to see a doctor; he smiled and told her that
she worried too much. Her anxiety ebbed as she went off to her job at
Kmart, only to resurface when he didn’t answer the phone during
her lunch break.
When Regina rushed home a few hours later at the end of her
shift, she found Jim sprawled across their bathroom tile. His eyes
were wide open and he clearly recognized her, but his words were
garbled. He couldn’t tell her what was wrong or how long he’d been
that way. She frantically dialed 911. Within a half-hour of his ar-
rival at the emergency department, after a neurological exam and
rapid CT scan of his brain, it was clear what had transpired: Jim,
just a few weeks shy of forty, had suffered a massive stroke.
The doctors learned that Jim had high blood pressure that had
been poorly treated, but found nothing else to account for his tragic
2 Black Man in a White Coat

fate. He had no heart problems. No clotting disorders. No aneurysms.

No diabetes or high cholesterol. He didn’t smoke, rarely drank, and
avoided street drugs. Ultimately, as best they could tell, Jim mostly
had a lot of bad luck.

About two weeks later, I stood at the foot of Jim’s bed at Duke Hos-
pital. Along with another first-year medical student, I was shad-
owing Dr. Wilson, a faculty neurologist, as part of a weekly seminar
that introduced us to clinical medicine. This class was the highlight
of our week, as it gave us a brief break from the lecture hall and
laboratory, where we memorized biochemical pathways and micro-
organism names, and provided a peek at our future lives on the hos-
pital wards. We wore perfectly knotted ties and crisp white coats for
the occasion, trying hard to look like the doctors we would one day
become.
Jim’s future seemed far less promising than ours did. A big man,
he had once been a football player. Now he could not move the right
side of his body. His face drooped as saliva dribbled out of the cor-
ner of his mouth. His words came out choppy, like those of a toddler;
when frustrated, he cried like a child in the midst of his “terrible
twos.” Given his lack of improvement, the doctors had begun to
doubt that he could make any significant recovery. They were pre-
paring to send him to a rehabilitation facility. This place also had a
long-term care unit, where, if he made no real progress, Jim might
spend the rest of his life. According to the nurses, Regina’s visits were
already becoming shorter and less frequent.
“It’s a very sad case,” Dr. Wilson said, as we left the room and
walked to a nearby conference area to discuss our patient and his
illness.
He started by telling us that stroke was consistently one of the
top five causes of disability and death in America. Then he drilled us
about the major risk factors, going back and forth between us in a
competition of sorts. In eager medical student fashion, we rattled
 Introduction 3

off the usual suspects: diabetes, hypertension, heart disease, advanced

age, smoking, and high cholesterol. When it was my turn again,
Dr. Wilson indicated that there was one important risk factor we had
yet to mention. He looked at me with a worried frown. Come on, his
look said, for you of all people, this should be easy. I sighed. I’d hoped
it wouldn’t come to this, but, as I was quickly learning, it always did.
“Race,” I said, looking down at my dark hand against my pris-
tine white coat. “Our patient is black.”
“Exactly,” Dr. Wilson responded, as if I’d now earned a top score
on my exam. “Some would say that this is the most important vari-
able of all.”
He rattled off damning statistics about race and stroke: “The risk
is twice as high for blacks compared to whites for those over sixty-
five. And in younger groups, such as with our patient here, the ratio
is more like three-to-one or even four-to-one.”
I’d seen the impact of stroke on both sides of my family. 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, even-
tually, her body. Like Jim, both had high blood pressure.
“Our patient’s other major risk factor is hypertension,” Dr. Wil-
son 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,
4 Black Man in a White Coat

“injustice in health is the most shocking and the most inhu-

mane.”
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, espe-
cially 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 dispro-
portionately 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 sig-
nificantly 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 Uni-
versity School of Medicine as one of a half-dozen black students on
scholarship. With the scholarships, Duke sought to cast aside its his-
tory of racial exclusion and become a national leader in producing a
 Introduction 5

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 dis-
orders 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 lec-
ture, my stomach twisted. I knew where this was heading. Seated
in a sea of mostly white and Asian faces, I wondered how this infor-
mation 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 uni-
versity 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 segre-
gated 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
6 Black Man in a White Coat

racial aspect of the lectures so much that I felt intense, perverse re-
lief whenever a professor mentioned that a disease was more com-
mon 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.
While I was learning about the health woes of my race, my own
body began to betray me. The first sign occurred not long after I’d
met Jim, the young stroke victim. As part of that same introductory
course, my classmates and I learned basic medical skills by practicing
on each other. One day, we measured blood pressures. My classmate
frowned as she took mine. The reading was 150/95. Our supervisor,
a family physician, rechecked and confirmed the reading. The doc-
tor I saw soon afterward gave even worse news: My kidneys were
showing early signs of failure.
To a twenty-three-year-old first-year medical student, high blood
pressure and kidney disease sounded like a death sentence. Worst-
case scenarios flashed through my mind: Dialysis. Kidney transplant.
Transplant rejection. More dialysis. Infection. Death. Was I destined
for a similar fate as my uncle and grandmother? Or something worse?
Would I even reach fifty?
The image of Jim flashed through my mind. A few weeks after
leaving the hospital and moving into the rehab facility, he died from
a massive blood clot that lodged in his lungs. He had just turned
forty. I drove home from the clinic picturing Jim in an open casket.
But instead of a stirring eulogy and traditional funeral hymnals, I
heard Dr. Wilson’s voice reciting statistics on race and stroke.

As I struggled to make sense of the prospect of facing chronic ill-

ness in my twenties, I became consumed by the broader health prob-
lems of my race. Along with the many patients I saw who gave life
to my professors’ statistics came reports of prominent black men who
 Introduction 7

had met similar fates. Harvard Law graduate and billionaire CEO
Reginald Lewis died at age fifty from cancer, while football legends
Walter Payton and Reggie White died in their mid-forties from rare
disorders, just a few years before 60 Minutes mainstay Ed Bradley
succumbed in his mid-sixties to cancer. Journalist Ron Howell chron-
icled the premature deaths of his black classmates from Yale in a 2011
article for the university’s alumni magazine that generated national
interest. A large bank account, Ivy League schooling, Hall of Fame
busts, and a quarter-century run on America’s most-watched pro-
gram stood no match against early death for these black men.
Why do black people suffer more health problems than other
groups? What do these challenges mean in their everyday lives? How
do their struggles play out before a largely white medical community?
How can we begin to solve these seemingly intractable problems?
Do I have a special role to play as a black physician? Confronting
these questions has led me on an intellectual and emotional journey,
one that I’ve tried to capture in the pages that follow.
I’ve divided the book into three sections, corresponding to the
different phases of my medical life. Part I surveys my medical school
years. Part II explores my grueling twelve months of medical in-
ternship as a newly minted doctor. Part III examines my subsequent
years in psychiatry training and in early clinical practice. Through-
out each stage, race played a recurrent role, at turns predictable and
unexpected, often annoying, sometimes disheartening, and occasion-
ally uplifting. By sharing my story, as well as the stories of some of
the patients I’ve met over the past fifteen years, I hope to humanize the
dire statistics and bitter racial debates and paint a fuller picture
of the experiences of black patients, as well as that of the black
doctors who navigate between the black community and the pre-
dominately white medical world.
In tracing my journey along the intersection of race and medi-
cine at the end of the twentieth century and the dawn of the twenty-
first, I make no claim to speak for all black physicians or black
8 Black Man in a White Coat

patients, yet I am confident that much of what I have written will

ring true to their varied experiences. By putting human faces on
these serious dilemmas, I hope to contribute to a much-needed pub-
lic dialogue on improving the health of black people. Jim’s fate—a
young black person robbed of his future—is one that far too many
of us suffer.