Tuesday, July 30, 2019

Bias landmines.

12: 01 P.M.

My intern was presenting this patient to me at this exact time. My tumbly was feeling pretty damn rumbly and lunch couldn't come soon enough. But we were almost there. Last patient of the morning. Fairly straightforward. Acute decompensated heart failure--one of the most common things we see.


I have to admit that I was glad it was something "bread and butter" and not something exotic. Nothing about this seemed to be a diagnostic conundrum. And that was a relief considering it had already been a long morning of medical mysteries. On top of that, I was hungry.

Real hungry.

Yup. I'm human so yes, I get hungry. And that can feel more urgent as the noon hour approaches. My mind wanders off for a second and then I mentally smack my own face. Terrible, I know. I shadowbox internally, ignore my growling stomach, and keep listening.

He described a youngish guy admitted for severely elevated blood pressure, heart failure, and fluid on his lungs. "He takes his medications faithfully," my intern said. "And, for the most part, he eats right. Not really sure why this current set back happened."

"Okay," I said. "Where does he get his meds?"

"Grady," he replied quickly. "Right at our pharmacy. And I checked to see if he's filling his meds and he totally is."

"Hmmm. Okay." I thought for a second. "And you said no dietary indiscretions?" My intern shook his head. My belly made another audible protest. "Chest pain?"

"Fleeting chest pain--but his EKG and cardiac enzymes are all normal."

Just then, there was an interruption. A man in a hospital gown shuffled past us, IV tubes dangling from his wrist and forearms. Definitely not much older or younger than me. The ashiness of his skin was amplified against his espresso-colored complexion. He looked over at my intern and smiled revealing the tell-tale dentition of limited resources and a hard life. "Just hitting this commode," he said in our direction.

"We'll be right there," my intern spoke back to the man. "Just telling my team about you."

And the patient nodded and disappeared behind the sliding door to his room.

"Hey--did you check a urine drug screen?"

My intern paused. "I actually didn't, Dr. M. But I did ask him about illicit drug use. He doesn't do any of that."

I nodded and twisted my mouth. "I'd recommend checking anyway."

He looked perplexed. "Check a UDS?"

"Yeah. Cocaine could unify all of this, honestly."

"But. . .he doesn't use cocaine."

"I've been burnt many times."

My intern's face flushed crimson. "Oh. Okay. Sorry about that."

And that was it.

Of course, you know what happened next. I walked in and met this gentleman who told me the exact same story. And the pharmacy record and his appointment history supported what he said. He denied any drug use and, on top of that, had prior screens that all were negative.


He just had bad heart failure. Period. And sometimes bad heart failure just misbehaves without much provocation. And yeah--he had eaten a little bit too much salt but that wasn't on purpose. It was because eating fresh, non-processed foods is expensive and hard. But the brother was trying. Damn, he was.

I gritted my teeth and felt my masseter bulging. Between my stomach growling and my intense remorse about the microaggression I'd just committed against my patient, it was hard to think straight.
Hallelujah for bread and butter medical problems.

We gave him IV diuretics to get fluid off. We optimized his blood pressure meds. We restricted his fluids. And we consulted the heart failure team. And that meant rounds were over. The team broke up and that was it. Before I could even think of a way to right my wrong.


I walked into our team room a few moments later and was relieved to find everyone there. They were all getting their lunches and preparing for the resident conference. I could already feel my face getting hot.

"Umm. . .guys? Can you give me a minute of your time?" They all sat down and obliged me. Even though I'm certain they were hungry, too. I cleared my throat and spoke. "I was wrong."

Their eyes all widened.

"Ummm. So yeah . . . . when Mr. Mackey walked by I sized him up. I saw a youngish, poor black man walking through Grady. And my bias was at play when I asked for that UDS. I looked at him and considered crack cocaine. I was wrong." My intern was staring intently. "I know if he was a white woman at Emory or even an insured black patient somewhere else, I probably wouldn't have suggested that. Please cancel the urine drug screen if it hasn't been collected yet." I sighed hard and looked at the patient's name on my list. "I'm sorry Mr. Mackey."

No one said anything. So I went on. "Look y'all. I'm a work in progress. I'm still messing it up sometimes, too. But I want to own my biases and do better, y'all."

My team was so gracious. After that, we discussed "bias landmines" such as being hungry, tired, rushed, or stretched too thin. We also talked about owning your biases and trying to do better. It was super powerful.

I cried as soon as they left the room. Not out of shame but more because I honored my patient and believe that I taught my team more about bias through that one moment than any lecture they could ever get.


Look, man. I do NOT have all this stuff figured out. Mr. Mackey fell in a group that I believe myself NOT to be biased against. Still, my actions said otherwise. That's what's so troubling about implicit bias. The heart feels one thing but the mind goes rogue.

And so. I call it what it is and vow to keep fighting. Fighting the monsters that hurt my patients and my community--even when that monster is me.


*name and details changed to protect anonymity

Stand by you.

"I'll stand by you." - Chrissy Hynde, The Pretenders

Rounds were over and, mostly, not much more had to be done other than write notes and arrange discharges. She, the resident physician working with me, was still at Grady. I was not.

That morning, things were fine. But then came the call from his nurse. A new complaint--one that hadn't been there before and that wasn't there on morning rounds. My diligent resident quickly went to assess the patient. Vital signs not normal. A heart beating over 120 times per minute, little beads of sweat on the forehead of a person who was cracking jokes just an hour before.


"He doesn't look good," she said to me over the phone. "I'm concerned about him."

And the way her voice sounded over the phone, I knew she meant it. Even crackling through my blue tooth car microphone, I could tell. I also knew because I'd been working with her all week and had seen her empathy in high def for nearly seven days already.

"What do you think is going on?" I asked. And, with that, she described everything she'd seen. A head to toe examination, a review of the labs, and a thoughtful differential diagnosis of things it could be.

"Does it sound like I'm missing something?"

"If I were by myself, I'd be thinking the same things," I replied. "I have nothing to add. This plan sounds very good."


"Would you like me to come up there?"

There was a pause. "I don't think so," she finally said. "I feel better since we talked through everything. But thank you for offering, Dr. Manning." And I could tell she meant that.

This woman is a senior resident. And not just that any senior resident. I highly competent, extraordinarily professional, incredibly thoughtful young physician with a knack for caring for the sickest of patients. Honestly? She was all over this. Her fund of knowledge in a lot of areas exceeds my own. In my head, I was saying these words: "You've got this." Because she did.

I came in anyway. It was almost 5pm.

Let me tell you what I saw when I got there: Exactly what she described without a single surprise. I examined the patient for myself, yes, but mostly? I simply came there to stand beside her.

I was standing at a computer scrolling through labs when she walked up. At first, I worried that she'd think it was because I didn't trust her. But as soon as she saw me, her face erupted into this complicated smile. "You came anyway," she said with a chuckle. Then she sighed this breath of relief.

"Yeah. I came to stand next to you. And worry with you. Is that okay?"

We both laughed and went to see our patient together. We talked to him and to each other and to radiologists and consultants. He was sick, too. And of all the people who looked the most relieved? He did. Having those two women standing side by side fretting about him on a sunny weekend day meant something.

I didn't say or do anything to change the ball my resident had put into motion already for this patient. It was she who saved a life that day--not me. I had nothing to add or change or suggest or modify. Nope. I just stood there, hands pushed down in my white coat pockets, nodding more than anything else.


Sometimes my job as a clinician-educator calls for lots of high-level medical knowledge. Other times, not so much. Either way, I came in because now I get it. What holds true for most aspects of life is true here, too: Sometimes the most powerful thing you can do is just show up--show up, stand next to someone, and be there. And nothing else.

And this weekend, that's exactly what I did.



“And who knows but that you have come to your royal position for such a time as this?” 
- Esther 4:14 NIV

A door had closed before her. It seemed like there was no way out. Some way, somehow our paths crossed.

She was miles away on the eastern seaboard and had somehow found my email. “I went to Clark Atlanta,” she said over the email. And that was when I knew. This medical student looked like me.

No. She wasn’t at my institution. But something about that message grabbed me that day. Was it the first such email I’d received asking for my help or attention? No. But something about this felt different. It’s hard to explain.

I was in Jury Duty so things were still. Her email crossed my box during an idle period and, as fate would have it, afforded her my full attention. I don’t think that was by accident.


Emails went back and forth for about 30 minutes. Then this lady with a flat voice spoke into a microphone. She rattled off some names in a monotone voice. “If I called your name, your case has been settled. Thank you for your service.” One of those names was mine.


An unexpected window. What to do? Call her. That’s what God laid on my heart. Her number was at the end of the email. Before I could overthink it, o decided to be obedient.

What happened next—you wouldn’t believe it unless you knew me personally. But here is what I will say: I've always thought that that, just maybe, that one moment in time was pre-appointed long before I ever even thought of becoming a doctor. Maybe even before I was born.

The best part is that I could feel it in that moment. I could feel that the universe was telling me loud and clear: This is your Esther moment. And so I held on tight to that idea and pushed. Trusting and believing and touching and agreeing.

But then? Just like that, the door that I thought I could open for her closed. I fell to my knees crying that day. “I did what You said!” I cried. “I was obedient!”

A friend told me to be still. So I did.

And then, a door opened. Not the door I expected. An entirely different door opened by someone entirely different—but to whom I was connected. She opened that door in a whole different state. We hadn’t even been talking. I’d just been writing. And her reading.

Whew. It was so big, so divine that I still struggle to wrap my head around it. This wasn’t MY Esther moment. It was OUR Esther moment. A moment for which we were BOTH created.


That girl from Clark Atlanta who cold-called me all those years ago? She walked straight through that open door and never looked back. Wait—I take that back. She only looks back to see who’s rattling the door handle trying to get in.

Today, as I was sitting alone quietly eating lunch at a soul food counter between rounds, guess who came up behind me and wrapped me in a hug? It was her. After all these years.

Dual board certified. An assistant professor and full time faculty member. Living the dream. At Grady Memorial Hospital of all places. Took everything in me not to cry into my black-eyed peas and collard greens.

“Wow.” That’s all I could say as she told me about all of the wonderful things she’d been doing.

“I will forever be grateful to you both. Forever I will.”

“And I will forever be grateful to God for letting us be there in that moment all together.”

She nodded and we hugged tight. Then I pulled her back, looked at her, and hugged her again. After that I snapped this picture to send to the other Esther so she, too, could feel all the same feels.

I do struggle sometimes with asks and recognizing my limitations. I can’t be everything to everyone. Sometimes I can’t be even a little something. But that moment taught me to just listen. Listen so that I know when I should.


What an ordinary lunch at the Sweet Auburn Curb Market this started out as today. Just like that ultra ordinary day in Jury Duty back in 2012. Now I know that nestled in every ordinary moment is the potential for something extraordinary just waiting to happen.

And maybe—just maybe—you were created for a moment such as this.


Happy Tuesday.

Breath regular.

On rounds the other day

Him: "You alright, doc?"
Me: "Me?"
Him: "Yeah you. You seem outta sorts."
Me: *smiles* "I'm in sorts I promise. Now tell me--how you doing?"
Him: "Feeling a little better today."
Me: "How's your wind?"
Him: "Way better."

I sit him up and carefully untie the back of his gown. On cue, he takes breaths in and out as I listen intently.

Me: "Lungs sound good." *moves around to front of chest* "You can just breathe regular."
Him: "I know."

After pressing my palm to his chest to feel his heart, I search his chest with stethoscope. Although it's not normal, it hasn't changed. Like always, he keeps making big gasps, forcing breaths in and out the whole time exaggeratedly.

Me: "It's okay. Just breath regular."
Him: "Sometimes you want to breathe regular but you can't."


Him: "Miss Manning?"
Me: "Sir?"
Him: "You okay?"
Me: "I'm okay."
Him: "You sure?"
Me: "Just got some bad news today about a friend is all. A friend who passed."


Him: "I'm sorry."
Me: "Yeah. Me, too. Was a real good dude. Through and through."
Him: "Damn. Shot?"
Me: "Nah."
Him: "Kids?"
Me: "Yup."
HIm: "Damn."


Him: "I knew you was out of sorts when I seent you."
Me: *taking a drag of air* "Yeah. You were right."
After that we just sat there for a few moments in silence. Then my patient asked me about my friend and I told him a really funny story about him. We both laughed out loud.
Me: "That dude was wild."
Him: "Sound like he was cool as hell."
Me:  “That he was.”


Him: "It's gon' be okay, Miss Manning."
Me: *eyes stinging and wanting to cry* "Yeah. Sometimes you want to breathe regular but you can't. You know?"
Him: *staring at me* "Yeah. . . I do know."

If you think the only ones doing the healing around Grady are the doctors and nurses? Think again. These patients save my life every single day.

Rest well, my friend. Praying we can all breathe regular soon.