Damon Tweedy: “Black Man in a White Coat” | Talks at Google


MALE SPEAKER: Good
afternoon, and welcome to “Talks at Google” in
Cambridge, Massachusetts. Today it’s my great pleasure
to introduce Dr. Damon Tweedy. Dr. Tweedy is a graduate of
Duke Medical School where his first day was
uncomfortably exciting, but not in a good Google
way, Yale Law School. He is Assistant Professor of
Psychiatry at Duke University Medical School and staff
physician at the Durham VA Medical Center. He is the author of
one of the most talked about books of
this season and one of my favorite
books of the year, “Black Man in a White Coat:
A Doctor’s Reflections on Race and Medicine.” Writing this book is part
of his ongoing effort to honor the pioneering
work of black physicians of previous generations
by giving to the community as they have done. Dr. Tweedy’s
training and practice has shown him the
challenges faced by black doctors and
the health burdens faced by black patients, why being
black is bad for your health. Along the way he’s overcome
his own biases, as well as those from physicians and
patients of all colors. He’s here today to share
with us what he’s learned and his suggestions for
how we might move forward with better treatment and more
compassionate care for all. Please join me in
welcoming Dr. Damon Tweedy. [APPLAUSE] DAMON TWEEDY: Thank you. Thank you. Thanks for everyone
for coming today. Yeah, so it’s funny
to hear Google. My first thought
when I here Google is that I have this sort
of connection to Google. Sergey Brin is
actually from Maryland, and briefly we’ve attended
the same high school, actually, and in the
same magnet program. I’ll tell you a little
bit more about that when I tell you my story. And we didn’t actually
know each other. Maybe I should’ve picked
my friends better. [LAUGHTER] But yeah. So I’ll tell you a little
more about that high school, because that’s really an
important part of my journey as to who I am today. OK. So this is the book. Here’s the cover of
the book, “Black Man a White Coat: A
Doctor’s Reflections on Race and Medicine.” So I guess the first
thought is that there’s so many books out there, so
why should you read this book? What’s in it for you? Race is all over the news. You hear about
race all the time. It’s often talked about
in law enforcement. It’s talked about in
crime and punishment. Those are the areas we hear
it talk about so much now. But race is also an
important issue in medicine. It’s an important issue
in medicine as well. And I wanted to give you a
quote from Martin Luther King Jr. It was in 1966. And this is just sort
of to set the framework. So this is 1966, two years
after the Civil Rights Act had passed, one year
after the Voting Rights Act had passed. And his quote was, “Of all
the forms of inequality, injustice in health
is the most shocking and the most inhumane.” To me, that speaks to
this idea that health is so important to all of
us, vital to all of us. I think he also was
getting to this idea that health is about more
than simply the health care and the medical treatment,
and so many other factors in society also
influence health. So there are really two ways
that the book approaches this issue. One is about the issue of
African American patients and their health. And there are all sorts
of health disparities that are out there,
and I’m going to talk a little bit about
that in a few minutes. And then there’s also
there’s another experience about being an African American
physician and being one of few. So nationwide, about
4% of all physicians are African American. The population of African
American is about 13%. And in some
specialties– it varies depending on the medical
specialty that you’re in– it can be 1% or 2%. It just depends on the field. So you’re really
kind of out there. You’re really sort of
isolated in many ways. And so the book really
explores those two areas. So I set the framework
using the quote from King about race in society,
but this is really very much more personal story. So many years ago– he mentioned
that I went to Yale Law School. And maybe years ago
I may have written a book that was much more
policy-oriented solutions. Let’s attack these problems,
data-driven, solution-driven. This is very much
a personal story. This is very much
how I came at it. I enjoy books by doctors,
and so many of the books that I read going through
medical school and my training, so few of them talked
about race at all. And when they did mention
race, it was only in passing. But it was such an
important issue to me, and I wanted to give voice
to this other perspective out there. So some of the people
who have– so my book has gotten really
good reception. I’ve actually really
been overwhelmed by the positive attention
that I’ve gotten. Media coverage, all those things
that I never really imagined when I first got started. But it has had some criticism. And the criticism
that I’ve gotten is specifically about that, that
it’s not policy-oriented, not solution-driven. But I do talk about
many of those issues. But even though that’s
not the focus of it, I still think there’s a lot
to learn from this book. I’m using my own story and
the stories of other people that I’ve seen, patients. And I think there’s
a lot of ways that we can learn from that. And people can come up
with their own answers. So that’s really kind of where
I’m coming from in this story. But we will talk about some
of the more concrete stuff as well. So I think since I set the
framework of this being a very personal story, I think it’s
helpful to know a little bit about my background. So I grew up in Maryland. And the county’s called
Prince George’s County. It’s about 10 minutes
east of Washington, DC. Now it’s a predominately
African American county, and there’s been books
written about it where they talk about it as
a very affluent, very wealthy community for
African Americans. Now there is a part of the
county where that’s the case, but that’s certainly
not where I came from. So I came from the part that’s
much closer to the Washington, DC line. All black, very segregated,
very working class. Really there were
very few models of African Americans
in that community who succeeded outside of the sports
and kind of entertainment around that we’re so often
familiar seeing African Americans succeeding in. So as far as going
to college, just going to college as
a student, I mean, that was a really alien
concept in the community that I grew up in. Black men were much more
likely to find themselves in the criminal justice system
and all those other sorts of things that we all
to often hear about. So my parents did
not go to college. My dad didn’t even
finish high school. I did have an older brother. My brother’s ten
years older than me. And he did go to college. He was one of the first people
in my family to attend college. Went to the University
of Maryland. And he was there just
strictly on academics. And I was just a novel thing. So for me to have that in
my home was a huge example. But even still, the
idea of being a doctor was something that was
still far beyond what I could have ever envisioned. So in eighth grade I
was in middle school. A very sort of average, real
average kind of middle school. 90%, 95% African American. And one day a teacher,
a math teacher said, well, you should try and
take this test for this magnet program. You might be able to make it. And my first thought was, no. I’m thinking, no. I’m not going to
be able to do that. No one I know has done that. But I took one of the flyers,
and I got into this program. This is a very great science
technology magnet program. And this is actually
the same one that Mr. Brin was in as well. And so that really kind of
set me on a different path, in a way. And I got to see people
with different aspirations and things of that sort,
different experiences. So that’s sort of how
I got on the trajectory to where I am today. Now it was an appeal to me. Like, why being a doctor? So there was appeal in
science and medicine. So I was really attracted by the
idea of formulas and equations. And it was all very objective
and it was sort of concrete. So much of life is messy as
an African American person. Life in general can be messy,
but as an African American, it can be even more messy. And so there was
a certain appeal that science and medicine held
out for me, that was objective, it was concrete. And I could kind of
escape this other world, this other reality. And so that’s
really what kind of led me on this path
from high school through college and
into medical school. But when I got to
medical school, I kind of had a rude awakening. And so that’s really
where the book begins. it sort of lays that groundwork. So I did really well
in college, and I had a lot of opportunities
for medical schools. And I ended up ultimately
deciding on Duke. I was deciding between
Duke and Johns Hopkins, which was closer to my home. Duke was at that point
trying to recruit more African American
students, and they started to offer
scholarships as a way to entice African
American students, because they’d had a long
history of not being able to recruit African Americans. As you can imagine,
it was in the south. You can imagine all
the reasons why. So let me just read
for a few minutes the introduction to this
story, because I think that really sets the framework. So I’m coming in. I told you about my
background, where I come from, and what I was thinking
when I came to Duke. I was hoping I would be able to
come this cardiologist, someone who’s going to operate,
fix the heart, concrete. Everything– that was
sort of my mindset. And then I got to Duke, and
something else happened. So let me just read
that introduction to. It will take about four
minutes, and then I’ll discuss a little
more after that. “On a spring morning
in 1997, Jim Harper, a young man from
Durham, North Carolina, woke up in his two bedroom
apartment with no clue that he would soon
become gravely ill. The first signs of trouble
seemed innocent enough. Numbness on the right
side of his face 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 work. His fiancee, Regina, 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 floor. His eyes were wide open,
and he 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
arrival at the emergency department, after a neurological
exam and CAT scan of his brain, it was clear what had happened. Jim, just a few weeks shy of 40,
had suffered a massive stroke. The doctors learned that Jim
had high blood pressure that had been poorly treated,
but nothing else to account for his tragic fate. He had no heart problems,
no aneurysms, no diabetes, or high cholesterol. he didn’t smoke, really 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 Hospital. Along with another first
year medical student, I was shadowing Dr.
Wilson, a neurologist, as part of a weekly
class that introduced us to clinical medicine. This was the
highlight of our week, as it gave us a brief break from
the lecture hall and laboratory and provided a peek
at our future lives on the hospital wards. We wore perfectly
knotted ties–” as I’ve tried to today–
“and crisp white coats for the occasion, trying
hard to look like the doctors we would one day become. But Jim’s future seemed
far less promising. A big man, he’d 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 corner of his mouth. Given his lack of
improvement, the doctors had begun to doubt he
could make any recovery. They were preparing to
send him to a facility. This place also had
a long-term care unit where if he made no
progress, he might spend the rest of his life. ‘It’s a very sad case,’ Dr.
Wilson said as we left the room and walked to a conference area
to discuss our patient and his illness. He started by telling us
that stroke was consistently one of the top causes of death
and disability 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 routed off the
usual suspects. Diabetes, high blood pressure,
heart disease, old age, smoking, and high cholesterol.” I ran out of fingers there. “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 pristine white coat. ‘Our patient is black.’
‘Exactly,’ Dr. Wilson said, as if I’d now earned a
top score on my exam. Some would say that this is the
most important variable of all. He routed off statistics
about race and stroke. The risk is twice as
high for blacks compared to whites for those over
65, and in younger groups, such as 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 14, my dad’s
brother, who would often drive five hours each
way on a Saturday just to visit us for
a few hours, died within days of
collapsing at his home, putting an abrupt end to his
visits that I always 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 is also 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.” So that really
lays the framework. So I’m coming to
medical school, feeling as if I’m escaping this world
and going into a world that’s objective and concrete. And during that first year, I
was inundated by these messages that there was something
wrong with being black in terms of health. So every time you learn
about a disease– heart disease, diabetes,
cancer– the professors would start with sort
of the biology it it, what they call
the pathophysiology of the disorder. And then they would
always kind of go back to the end, talk about
the demographics. Who does it affect? And there were always
two statements. It’s more common
in black people, and black people who get
the disease do much worse. So those were the
statement they would make. And so for me the next
question was, why? And what could be done about it? And I never seemed
to get answers to either of those
questions during that time. There were just sort
of these statements that were made out there. And not only was it–
these statements– not only was there, like, an
intellectual side to it, but there was this
personal side to it, because these are things that
affected me, my own family, and my actually myself. And I’ll talk about more later. And so it had great meaning. So this is really one of the
two main goals of the book, to really explore
those questions. Like, what does all this
mean, and why are we in this situation? So that’s one of the two
main goals of the book. And what I discovered
along the way as I started to go
out into the community and start to see patients
and get to see– so I really saw that there were,
like, three different ways of looking at this problem. And I talk about
these in the book. And what I do is I use case
studies of people that actually saw in various settings
that illustrate with these issues are. So certainly there’s an
issue at the big level, at the macro level, the
system level, society. Black people are much more
likely to be uninsured, much more likely to live
in communities that are segregated, less access
to medical care, primary care specialists. All those things are very true. And this has all been
known for a long time. What I wanted to
do in the book was to sort of use
examples of real people to illustrate how this
plays out in real life. And so in medical school, we
one day volunteered at a clinic about 90 minutes from campus. And this is a decent
part of North Carolina. The community’s 50-50,
half white, half black. But in this clinic you go
to, everyone there is black. All black. And it’s a charity
clinic, so it’s a clinic for people who can’t
afford other health care. Patients don’t have
health insurance. And it’s pretty clear
when you get there that you’re providing
care, a level of care that is in many ways substandard. Despite your best
efforts or intentions, the patients can’t
afford medications, lab tests, all the usual things
that we take for granted. Even the site of
it is so different. You think about the
typical medical clinic. So this kind of clinic,
there’s no nurse there, and students are taking
the blood pressure and doing everything that a
nurse would ordinarily do. It was a one room house. I mean, you’re not
talking about anything that any of us most
likely are experiencing. And so that really illustrated
sort of the big issue problems in a sort of micro way. There was another
time a couple of years later where I worked in an
inner city emergency room. So it’s sort of
the opposite end. That one was a
very rural clinic. This is an inner city emergency
room clinic down in Atlanta. And there, you saw many of
the same problems again. Even though Atlanta, even
though the residents– people are living in what seems
like a metropolitan area, there are ways that they’re
cut off from society. And it really came
home to me one day when we took an ambulance ride. I was riding with
the paramedics. And we got a call to go
out to this community. And it’s like you
go off this road, and you’re there for,
like, five or ten minutes. It feels like you’re
going into the woods, in the wilderness in a way. It’s like a suburb. And then you come into
this really just gruesome, horrible housing project. And you just see the
chaos, and you see how all that affects health. And so you see obesity,
violence, addiction. Everything’s just there for you. So it was a vivid
illustration, and I describe that scene in the book. I actually describe it
much better than I just explained to you in the book. But those are the system
level things that you see, and how those influence health. But then the next layer to that
is the doctor and the patient, and how they get together,
how they get along or don’t. And how issues like
trust and communication, bias, all these things
impact health care. And so in this part of the
book, I use other examples. So there’s one
example of a gentleman that I mentioned where he comes
to a hospital with chest pain, and seems to have
medical problems, but winds up
leaving the hospital with a psychiatric diagnosis,
which was really unusual. And the book really explores
how that happened in a real way. And so how what seemed
like a concrete issue became something
completely different. And I also talk about a
situation where I was a patient and had a similar
type of experience, where I went in one day to a
clinic dressed very casually, and I was perceived one way,
in a less than favorable way. And then once it was made
aware that I was a doctor, then everything changed. Sort of like being two
different people at one time. So those are just
examples in the book of how these things
can play out and affect health care in real ways. Then there’s this other piece. So we talked about
the system, we talked about the
doctor and the patient. But then there’s the person
themselves and what they do, what they eat, all the
daily things of life and how that
affects your health. And so here in the book, I
use a couple of examples. There was one time where I saw
two different patients, very similar backgrounds, but one was
able to make the kind of health choices that led
to a good outcome, and one was the opposite. And I explore the reasons
why and ways in which choices are influenced
by all sorts of things. Family, surroundings, all
those sorts of things. So I explore that. I also talk about it from
my own personal level. Early in medical school, I
was diagnosed with high blood pressure myself. And I’ll talk a little bit more
about that towards the end. But I really explore how things
that the individual does also obviously greatly
influences health. And how there are
cultural issues at work that sometimes,
for many reasons, can affect the health of
African Americans as well. So I explore all these issues. I sort of tackle everything
in this book in that way. So that’s one big
piece of the book. Why is being black
bad for your health? The second big piece
of the book is, what is it like to be an African
American doctor, and what is that experience like? Because that’s really the
second piece of the book that I talk about. As I mentioned at the beginning,
African Americans are about 13% of the population,
4% of doctors. It was very common– so when
I went to medical school, I was in the first class
at Duke where they really were increasing the numbers of
African Americans considerably. In previous years, there had
been much, much fewer numbers. And that raised a couple
of different issues. One was this issue about how
you perceive this perception. So you’re an African American. You’re sort of seen
as a rare thing, and sometimes people don’t
know how to perceive you. And so there are
a couple examples I’ll talk about it the book. One occurred when I was a
first year medical student. When I came into a
classroom, a professor approached me in a
sort of angry way and asked me to fix the
lights in the classroom, and was under the mistaken
assumption that I was someone other than who I was. An so I talk about that incident
and kind of how it affected me because I was already kind
of insecure about coming into medical school. So I explore how I dealt
with that situation. There was another time a few
years later as a first year resident. So this when you finish medical
school, and your first year is called an intern. That’s when you like an MD. So you’re technically an
MD, but you don’t really feel like one because there’s
so much responsibility and you’re just
learning everything. And so it’s a big
adjustment for every doctor. But about a month into that
first year, a patient, an older white gentleman came in
and one of the first words out of his mouth was that he
did not want a black doctor. And he used a racial slur to
sort of express what he meant. And only it happened that I was
the only black doctor working in the hospital at that
time, which was not uncommon. So it was sort of these
twist of fate or karma or whatever that he would
be assigned to the same team that I was at. So that story actually
has a surprise ending that I won’t
spoil for you here. But I’m just giving
examples of some of the different ways
of how perception is so important to my journey. One of the issues
that also comes up with being a black doctor where
you’re one of few black doctors and there’s a large black
population around you is that there’s this
sort of supply and demand kind of issue. So there are often many African
American patients– not always, but there are many
who would like to have an African
American provider, particularly in a field like
primary care or psychiatry, which in my field,
where the relationship with the doctor and the patient
is especially important. And so often there’s
this issue that comes up where
there’s large numbers of African American patients
and very few providers. So for instance in
Durham– so Duke’s in Durham, North Carolina. Populations about
45% African American. But you look at other medical
schools and hospitals. So Johns Hopkins is in
Baltimore, which is 60% black. And Atlanta– in Philadelphia,
UPENN, is 50% black. Even in Boston where
it’s like 25% black, something like that,
that’s still about double the black
population nationwide which is like 12%, 13%. So even in a city like
Boston or New York where the numbers are slightly lower. So you have this
dynamic of places where so many of the doctors or
medical students and residents are trained, being
in these communities where large African
American populations and where there’s
often historically been this sort of tension
between the communities and these very sort of
wealthy institutions. So the book kind of explores
all those dynamics as well, and what that means for you. Finally, there’s
this other piece. Being a black
doctor, I come from, as I mentioned at
the beginning, I come from a very working class
African American community, segregated community. Many of the patients
that I saw reminded me of myself, my family. But then I’m becoming
part of this other system, this white coat and the
hierarchy of being a doctor. So black man in a white coat
is kind of like a symbolism. It’s having two identities. You’re navigating
those two identities. And so in times I would feel
as if– many times I talk about in the book, I feel like
I had a foot in one world, this is the African
American world. Now I’m in the medical world. And so where do I fit in there? And do I have a
foot in this world? And do I have a
foot in that world? Or do I have– so it’s like
trying to find your grounding. People have written– many
African American philosophers have written about this, a term
called double consciousness. I mean, there’s all sorts
of ways of looking at it. But I explore it
from the context of being a doctor in
the medical system. So that’s another big
piece of the book as well. So finally the book talks about,
where does all this leave us? So I’ve outlined all these
problems, these issues we have. And so in the book, towards
the end of the book, I try and touch on that. Say, where do we go from here? And so when you go back
to what the problems are at the level of
the system, there are all sorts of
problems of course. I talk about the
Affordable Care Act and kind of the pros and cons
of that, where that’s left us. And so actually a
few years ago, I went back to some of the
clinics that I initially worked at as a medical student
and sort of tried to take stock of
where things had gone and had the Affordable
Care Act helped? And, you know, it’s
a mixed picture because it’s so politicized. It’s been so politicized. Many states haven’t
enacted certain provisions of the Affordable Care Act. North Carolina’s one of them. And that’s impact sort of
the real world effect of it. But as a doctor, I understand
we have politics and people are bitter and contentious. But as a doctor, it’s hard
to sometimes understand that because you’ve
seen patients from all political
backgrounds, all the time, who all have the same kinds
of health problems, get sick in the same way. And so you just wonder
as a doctor, why it’s so difficult
for us to have this– why has health care become
such a partisan issue? That’s the doctor hat. I mean, the other
side of me knows why. But it’s such a frustrating
thing to see as a doctor, and I explore that as well. Another piece of it
at the macro level is, how do we get more
African American doctors? What can we do about that? And one of the more
troubling things is that African American–
the numbers of doctors have increased across
the board pretty much over the last 30 years. The population
[INAUDIBLE] growing, and the number of doctors
have grown with it. And that’s true in all groups
of people with the exception of African American men. So African American women and
medical students and doctors have probably doubled
since the late 1970s. But African American men, their
numbers are actually flatlined. In some place, even slightly
declined since the late 1970s. And that’s completely different
than every other group– demographic in America. So that plays out
for me in many ways where I feel like I’m the only
person people are wanting– so you feel this sort of, like,
what is my responsibility? Where do I fit in as an
African American male? What can I do about that? So I explore all those kind
of issues in the book as well. And not just me, but what can
we do as a society as well? There’s also this
piece in the book where I talk about– I think
it’s a really important piece. Because we have
few black doctors, most black patients
are not going to see an African
American doctor. And so there’s this
whole idea about how do we sort of get
along with people who are very different from us? And so in the book
I talk about this. I talk a lot about the
white patients I see, because about half of the
people I see are white. And how do we make
connections with people that we seem at first to
be very different from? And so that’s a really
important piece of the book. And I give a couple
examples of patients where things were just so
completely different at first. You would never imagine that
we could have worked together. I mean, they had perceptions,
biases against me, I had biases against them. We all carry these things. But I give examples of
how we’re able to work through those things. And I’d like for that to
be a lesson or inspiration to other doctors. You know, white
doctors, Asian doctors, for how you can connect with
African American patients from whom you may
have completely different backgrounds. And so again, I’m using these
stories of my encounters with people to sort
of try and illuminate larger problems in our society. So that’s really where I’m
coming from in the book. And really, I think that’s it. I think the really
important piece I want to get about this–
because what I’m learning along the way in writing this
book and getting feedback is how little people
know about these issues. So I really want
to educate people and just make– the
awareness is so key. I mean, we always hear
about, again, race through this lens of
criminal justice and crime and those sorts of issues. But it’s a really huge deal
in the health care sector. Really in the long run, that
affects even more of us. That affects all of us. And so I really wanted to really
get people aware of this issue, and hopefully inspire them
to inspire health systems. Because I’ve been talking to
medical schools and health care systems, inspiring doctors
and patients, all of us to do better and do our part
to really address this problem. So that’s really my
perspective on this issue, and that’s really my story. So thank you for your time. [APPLAUSE] I’m happy to take questions. Actually, I often like
the question part better. Kind of engage
with the audience, see what people have to say. So thanks for bearing with me. [LAUGH] AUDIENCE: Hi. I would love to hear
sometime more of what you have to say about the whole
issue you started to discuss about young black
men, which seems like a really problematic
group in our society right now. But I’d love it if
you’d talk about that and what to do about it. But actually I wanted
to use my one question on another question, which is
more about the Affordable Care Act. DAMON TWEEDY: So I will talk
but the other part too though. AUDIENCE: The
Affordable Care Act, obviously we have some
huge problems with it like the fact that so many
states did not expand Medicaid. Huge problem. But two things that
it’s definitely done, one is it’s insured a
heck of a lot more people. And number two is it has
made preventive care free. Although it did not
make the drugs free, and that’s a really
huge issue I’m sure for issues like
hypertension, for example. But here’s my question about it. With all these newly
insured people, you would think that the
demand for primary care is now growing. It’s gotta be
bigger than it ever was before the demand for it. Nonetheless, I’ve read
recently that like too many of the poor insured patients are
still going to emergency rooms. They’re not making enough
use of primary care at all, and so forth. I’m wondering, how
much of this problem is that the supply of primary
care has not improved? And the incentives
for doctors to go into primary care versus
specialties has not improved. Do we actually have any signs
that we’re making progress in expanding primary
care and preventive care in those communities? And how much of
this is a problem that maybe there
is more of that, but people have habits
formed from long years, and they maybe
don’t know about it or they’re just used to
going to emergency rooms? How much of it is sort
of educational problems and getting that
population to think more about getting primary care
that may be available to them? What are the real problems here,
and what do we do about it? DAMON TWEEDY: Yeah, I think
you touched on really– that was a great question. So I think you touched
on many of the problems. So one is obviously
there’s an under supply of primary care
physicians compared to specialists. Their incentives are–
they make a lot more money. You make two or three
times as much money being a specialist versus
a primary care doctor. Even within that,
primary care doctors often distribute in certain
geographic locations. So there may be a large
number primary care doctors in a certain area in Boston or
certain cities, Washington, DC or wherever. But then you go out to sort
of the more rural areas, you find fewer. And even within larger cities,
the primary care doctors are still often in
certain parts of the city. So there’s still the
issue that you’re dealing with on the access level. So as to how people are trying
to address that– for instance, I’ll give you an example. So at Duke, Duke’s
historically– it’s one of those–
they call them tertiary academic
medical centers or like the ones here at
Harvard where the goal is often to train specialists
and researchers. But Duke has established
a primary care track for medical students. This has happened in
the last three or four years where they are basically
paying for their medical school tuition, which is
considerable, for students who agree to go into primary care
and practice primary care after medical school. And not only do that,
but there’s also like a– even their education
is somewhat different. It’s really geared more towards
this idea of continuity of care and not just this sort of like–
normally in medical school you’re taught in a hospital
setting where it’s urgent and it’s acute. And so they’re really trying to
build relationships with people and follow them over
time, which is really the purpose of primary care. So there are school– many
schools are doing that, actually. I think Harvard has
a primary care track as well that they’ve set up. So many schools are
trying to do that. We’re still in the early stages. So to see what the long-term
effects of that’s going to be is still kind of unclear. So that’s one aspect to it. So I think they are
trying to address it. It’s clearly a problem
because of the reasons that we just talked about. The other issue– I just
lose my train of– you asked so my
questions, I’m trying to make sure I’ve
addressed all of them. Gosh, what was the other one? Oh, yeah, about the communities. And so the patterns of care. You’re right. So African Americans
are so much more likely to be seen in urgent
care clinics, emergency room settings for what could be
managed in a primary care setting. There is a sort of
this pattern there. There’s no doubt about that. Here’s one road to that. One is that depending on
the kind of job you have, trying to go to see a
doctor requires sick leave. Some jobs don’t have that. And I’ve had patients
where they get sick, they miss a few days
of work, and then they can lose their job. And so it’s so
harsh in that way. Urgent care clinics,
emergency room clinics are always open after
hours, after work. So that’s one way that it’s
kind of been built up that way. That’s one barrier,
for instance. So I think some
primary care clinics have tried to set up more
flexible hours and sort of accommodate people. But then there’s also a
pattern, like you said. You get used to doing
things a certain way. It’s hard to break that. And it’s really unfortunate
because I think– one of the things is when
you’re seeing a doctor, you don’t know that doctor,
they don’t know you, it’s much more likely to
get this impersonal care. They’re less invested in you. And you’re more
likely to have things like bias and other
things sort of intrude in the doctor-patient
relationship. So it’s a big problem. So I think you really outlined
all the problems in many ways. I hope I addressed–
I think we’re trying to address these problems. But they’re huge problems. Huge problems to deal with. The piece about the
African American men and in society and
doctors– I think that was the question
you were mentioning. Yeah, I mean, it’s troubling
on a lot of levels. I mean, so for me,
one of the things that when I was the
first thinking I could become a
doctor, there still were very few role models. But I did a research lab– got a
research position in the summer at the National Institute of
Health, which is in Maryland. And I met an African
American cardiologist. And so the idea of
seeing someone who looked like me and had gone that
route, it was tremendous. I mean, so it was
tremendously important to me. And I think that all too often
as an African American man– I can speak to this growing up–
the perceptions of what you can do and what you can accomplish
are so narrow and limited [INAUDIBLE]. And I think I feel like it
comes from the top of society and it kind of filters
all the way down to the community where you live. And I think that really just
narrows what you can do. I think there was a
kid in my neighborhood who was– I thought he
was smarter than me, but he sort of kind of
fell into that thing about you can only do
certain– there’s only a certain narrow
road to success. And I feel like that really
limited what he ultimately achieved. And so I think that’s
a huge problem. And so I think we can’t
have enough visible African Americans who
are male who are just succeeding in other ways. And so I feel this
real responsibility to try and be
someone [INAUDIBLE]. Even though that goes
against my personality– my personality is really
naturally very introverted and keeping to myself. But it really feels like
it’s such an important issue. And the influence is so
great to be able to do that. So that’s my answer
to that question. I’ll try and shorten my answers
so people can ask questions. [LAUGH] But that’s such an issue of
passion for me, those issues. AUDIENCE: There’s
another barrier, which I don’t think I
have heard mention, but it’s just it’s
something that I’ve observed through personal experience. So I have a son who is just–
he’s a freshman at college. He’s been at college
about two weeks. I also have the
privilege of my godson, who is African American. And wonderful, bright,
nice young man. And he started school last year. He’s at Mass College– MCPHS in
Boston for pharmacy and health services, I think. And he’s in a physician’s
assistant program. It’s a six-year program. So his single mom, low
income, but they’ve just worked so hard. Now his first semester, he went
full scholarship, full ride. Great. Wonderful. Wonderful privilege. His first semester,
he didn’t do well. And second semester,
he worked really hard, brought his grades up, used
tutoring and all of that. Couldn’t bring his average up
enough to keep the scholarship. So now he’s going back,
loans and all of that. Now my son’s going in, and just
for me being in college myself and other parents
and all that, I know that freshman often
tank the first semester. It’s a big shift. DAMON TWEEDY: Big adjustment. AUDIENCE: It’s a
huge adjustment. But people with resources,
they think, well, OK. You got Cs, get
up there, please. When I went to MIT, they’d
actually recognize this, and they have this thing
for all the freshman are pass fail the first year
because they know about that. And I look at my godson, and
it feels like it’s not fair. Like, people with low resources
who are depending on those scholarships, they
have no margin. They have no margin. He comes in and it’s like, whoa. This is harder than I thought. And also, I’ve read– I don’t
know if this is– you tell me if you agree with this or not. I read somewhere,
because I’m very interesting in this whole
topic, that they looked at people who were white,
people who were Asian, people who were
African Americans. And people who are African
American, I’ve read, are less willing to go
out and ask for help, ask for tutoring
resources, than average. Asian Americans tend
to be more willing. And it’s a cultural thing. And so he didn’t ask. This semester he asked
because his mom was like, you’re talking to
the tutors, OK? And so that also, I’m
sure, affected his grade. And this is a good kid,
but he’s now kind of– DAMON TWEEDY: Struggling more. AUDIENCE: –is now in a
more challenging place than he might have
been otherwise. DAMON TWEEDY: Yeah, sure. So, yeah. I would the margin
of error is thinner. I would definitely agree
with you in that part. And that is true. I think there’s also– because
when I started medical school, there’s always this
sort of like– well, there’s this whole perception
for affirmative action. You got in and you’re taking
spots from other people. And so you come–
it affects you. You hear people tell you this. And you go in, and you wonder
if you’re going to measure up. And so the first times
that you don’t measure up, it really– I mean,
you don’t want to ask for help
because it’s sort of fulfilling this perception
people already have of you that you can’t make it,
and so you’re even less likely to seek help because
you don’t want to admit that you might have a problem. So it’s a huge problem. And so I think
several schools have tried to be more aggressive
with being aware of that and trying to be more aggressive
with trying to establish support for students
in those backgrounds from the very beginning. So for instance, in college,
I attended a state college at the University of Maryland. And we had a summer
program which really helped with that
sort of acclimation process. We got you familiar with the
counselors and the people who could help you if
you needed help. So I think that’s
a huge problem, and all too often, African
American students in particular are the ones who sort of
bear the brunt of that. So your story’s one
I’ve heard many times and can definitely relate to. So we’re trying to do better. And I’m part of
a program at Duke where we try and reach to people
who are younger and trying to help them get through
this process, particularly African American
men, because there’s such a huge problem
that’s seen all over. So absolutely. That’s a great question. Any other questions? Any other thoughts? Anyone have any ideas? Yeah. I’m an open book here. [LAUGHTER] AUDIENCE: It’s OK
if you don’t have an answer for this question. But I was wondering if
there’s any ways you think that we can help as
pretty much white people not in medicine. What can we do to help? Because I think a lot of
us care about these kinds of inequalities, and we’d
like to help solve them. DAMON TWEEDY: Yeah,
that’s a great question. People ask that question. So what can you– but the thing
is, people often underestimate. I mean, there’s so much
happening in the world. Problems are so big. You often feel like
you’re just helpless. There’s nothing you can do
versus all these problems. But never underestimate what
you can do as an individual to really improve
someone’s life. I still go back to that teacher. She took time out of
her day to say, well, you really should try
and take this test. And she had to encourage me,
and I didn’t want to do it. I was really thinking
there was no way I’m going to be able to do this. And so for her to sort
of push me along that way and to get me on
this path, I mean, she really helped
get me on the path. This was a 45-year-old
white woman, you know? And so just her
encouragement really changed my life in many ways. I mean, something like that. I think all too often it’s
easy to get discouraged and be cynical. But I think that you
really underestimate the power you can have. So she helped me, and now
I’m in the position where I can help so many other people. And I think it sort
of builds like that. And so I think that’s what
I would tell people who are in a position to help people. Because I mean, all
you folks here and just going to help people
in your own way even if you can’t fix
the whole problem. Because so much of health
is about these issues that aren’t just strictly
about health care and the medical treatment. You don’t have to be a doctor
to really improve health. If you can improve people’s
educational opportunities, job opportunities, you’re
totally transforming people’s lives in ways
that you may not realize. And you’re not only
transforming their lives. You’re transforming their
health, potentially. So just think about that as you
sort of go out into the world. That’s what I would
say to your question. Never underestimate what
you can do in that way. Yeah. Yes sir? AUDIENCE: Have
you looked at some of the stats in
the nursing field, and seeing how those kind
of differ or match up to some of the percentages that
you mentioned with physicians? DAMON TWEEDY: Great question. That’s a good question. So I’m in mental health. And so I’ve looked actually
at– so mental health field, there’s psychiatrists
and there’s psychologists and
family therapists and all sort of things. So the numbers are
really even lower. So actually, even lower
than they are in medicine. That’s also the case if
you’re looking at stats for, like– I’m trying to
think about nursing. I put the nurse practitioners–
the nurse practitioners are sort of like a similar–
the specialist kind of advanced practiced nurse. The numbers there
are actually lower than they are for physicians. So the number’s,
like, less than 5%. So I think that’s
pretty much across– so far as general nursing,
though, like as far as RNs, I would say if it’s higher,
it’s not much higher. I mean, I don’t know the
specific number [INAUDIBLE], but it’s certainly
not much higher. The numbers are pretty
low across the board. I mean, there’s just
no way around that. Yeah. I’ll have to go
look that up though. See, I was always
told that when you come to Google that
people are going to ask you questions and you’re not
coming up with the answer, and you’ve got to
do your homework. So thank you. [LAUGH] Any other questions? Yeah, you have another one? AUDIENCE: So you said that
you’re a psychiatrist. DAMON TWEEDY: That’s correct. AUDIENCE: There
seems to be– and I also– on my side of the
family have some family history of mental illness. And so there’s a shortage
of psychiatrists, and there just seems to
be not that many people going into psychiatry,
black, white, or green. So what– and you may have
covered this, but I’m sorry. I came in late. How did you choose psychiatry
over the other specialties? DAMON TWEEDY: That’s a
really good question. Because within medicine,
psychiatry in many ways is kind of marginalized. I mean, every walk of life has
their own hierarchy, right? So there’s a hierarchy
within medicine as well, and psychiatrists are often
in some ways marginalized. So when I first went
to medical school, I never thought I would
be a psychiatrist. I thought I was going to
be a cardiologist, a heart specialist. That’s what I was really– I
had done research in that field. I had a lot of family
history of heart disease. And so that was where
I was really going to. And even after medical
school, I actually started my first–
actually matched into a program that was
going to put me on that path. I started in the
general medicine path, which is where you go
before you go into cardiology. So I was all on that
trajectory all the way through. And then about halfway
through the year, you’re getting patients that
are admitted to your team from all parts of the hospital. And some of them– a lot of
them have mental health issues. But they were still sick
enough where they needed to be on the medical service. And something about working
with some of those folks and realizing there’s this
great need to help people, it really just
appealed to me in a way that I never thought it would. Because I didn’t like psychiatry
much in medical school. I did a rotation at a hospital
and didn’t care for it that much. But there’s something about
that particular setting where I was at. And people started to tell
me that I had an attitude. Like, I would be able to get
information from patients that other doctors
weren’t able to get. Like, people were
connecting with me in a way that they weren’t
with other doctors. Which is all surprising
to me, because I never considered myself this great
social person or anything. But people were sort of
connecting to me in that way, and that really kind
of got me thinking that maybe I could do this. And so that’s really how
I got into psychiatry. It’s a huge problem
as far as access to care for psychiatrists
across the board. It’s a huge problem. If you tie back
the race, there’s a huge stigma within the African
American community in terms of mental health treatment. There’s a huge stigma. So the numbers of black people
seeking mental health care, it’s a big issue that
I’m dealing with. So there’s so many
layers to that. I mean, part of it is how
psychiatrists are– again, the perception of it. There’s sort of this stigma. Many times, it was
funded separately. So the mental
health [INAUDIBLE]. It would be medical care, and
people would separate it out. And that’s further sort of
stigmatizing the mental health treatment. So there’s so many
factors at work. There’s supposed to be– I know
they passed the Mental Health Parity Act, and the
Affordable Care Act is supposed to help with
some of these issues. All that remains to be seen. I think it’s still a big
issue, and then hopefully it’ll be getting better. But it’s a huge problem. You see it every day. AUDIENCE: I just wonder
if you have any thoughts about the separation between
medicine and dentistry, and whether you’re aware
of how any of these issues that you talked about
our different or the same in dentistry, or whether
that wall affects things? DAMON TWEEDY: Yeah. So the issues are pretty
similar, actually. If you’re talking about
issues around race and poverty and access to care, in
some ways they’re worse. I mean, in some
ways, dentistry’s often like– finding an
affordable dentist is almost like finding an
affordable psychiatrist. Those are really
difficult things to do. So in some ways, it’s even
worse than in general medicine actually, when you’re talking
about from the perspective of poverty and race. In terms of numbers of minority
providers and all that, it’s even worse. As far as why they’re
separated, yeah, that I’m not so sure about. The historical basis
for separating them out, that I’m not so sure about. But the issues are still very
pertinent, very relevant. No doubt about that. It’s so amazing, actually. You’ll see patients in
the medical setting, and they have all these
[INAUDIBLE] health problems, but you can clearly see
they have dental needs that need to be addressed. And then trying
to find something that they– care they can
receive is just unbelievable. The waits for them to get care
for dental problems, I mean, we’re talking several months. I mean, months and
months and months. Some would have
to come in, like, with just a raging infection
to get any kind of treatment. You had to be really sick
to get treatment, which is sort of perverse, right? Because the whole
point is to sort of prevent these problems
from happening. And dentistry’s
sometimes even worse. That’s been my
experience anyway. Yeah. Absolutely. Great. One more question. Yeah? AUDIENCE: So obviously this
is a very universal problem across the US. Are there any communities
in the US or globally that are doing this– or
handling this issue well, where there’s
progress being made that you guys have identified? DAMON TWEEDY: I think there
are actually quite a few. There are a lot of sort of
small pockets of things. I mean, there are several sort
of– what do you call them? Non-profit institutions
that are sort of dedicated to addressing
some of these problems. There’s like the Kaiser Family
Foundation, Robert Wood Johnson Foundation. A lot of times they
will give grants to various community level
programs, which are helpful. But again, we’re
talking about limited– it’s sort of like a small
piece of the puzzle. And so the issue is,
can we replicate these? Can we get the support we
need to make these happen? But this is happening all
over– even within Durham, there are programs that we’ve
set up that have been helpful. But it’s just like,
how do we sustain it? And how do we just– once the
program’s over, if you leave, then you’re kind of
back where you are. How do we sustain
these initiatives? So I think there are a
lot of examples, actually. I didn’t give you any one
specific one, but there are many. [INAUDIBLE]. AUDIENCE: Thanks. DAMON TWEEDY: [INAUDIBLE]. Yeah. So I thank everybody for coming. I’m going to hang around if
anyone has any other questions. And there’s books. I will say that I only gave a
sort of a sampling of the book, and I think the book’s– I’m
a better writer than I am a speaker. So that’s said. But I really
appreciate– you guys had some really good questions. And, yeah. This is a big problem. And I think, as you say, I think
there’s something for everybody to learn about and to
think about their own role and how they can help. And so I think, yeah. Don’t lose sight of that. I would encourage you all to
feel that way as you leave here today. So thank you. [APPLAUSE]

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