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.

Good.

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.

Yup.

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.

Yup.

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.

Yup.

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.

Yeah.

*name and details changed to protect anonymity

Bias is heavy.

There is this thing I had to fight off the moment I laid eyes on you. This feeling, this bias that I wish I didn't have toward you but that I know I do. As soon as I stepped over the threshold into your room, I could feel my heart shadowboxing to try to press it down, hold it back.

Sigh.

They make whole television shows about you. And people tune in as appalled voyeurs, wondering how someone could reach the kind of weight that renders them immobile. Or totally isolated. Or maybe not isolated but still unable to fully participate in the kinds of things that most people can do. Admittedly, I don't watch. But I'd be lying if I said it was because of my tremendous empathy and disapproval of people making your reality into a spectacle. Instead, it just reminds me of those who come before me as my patients who are like you. And how helpless I always feel.

Yes. That.

See, that's my bias. I like feeling like I can do something. And a body mass index that matches my age always makes me feel like my hands are tied. And like there is nothing I can really, truly do. Especially when resources are low on top of it.

Sigh.

So after I saw you, I told my team what I am saying now. That I am struggling with my bias and I want to do better, be better. And that I would try. Like, really try.

"How?" my student asked me.
"I don't know," I said. "But I think first? I'm just gonna be still and think about it."

Which I did.

And so. I came back. And this time, I didn't just go through the motions. I sat down and spent some time talking to you. I told you flat out about how sometimes I struggle with seeing my patients who carry as much weight as you. And then I said sorry in case it sounded mean. You said it was cool.
But then we started talking. About music. About family. About parents saying crazy stuff and what we put them through as kids. We laughed about land lines and how kids now will never know how it feels to have somebody pick up the phone and start dialing while you're trying to ask somebody to go with you. Or pretend you ain't eavesdropping on a three-way call. We cracked up laughing.
Then, after that, you took out your phone and showed me a picture of yourself. Not in the hospital. Standing outside at a cookout. And yes, you were still as heavy as you are now, but your eyes were dancing and you looked alive. You did.

"You still struggling?" you asked me.
I thought for a minute. "You know what? No."
"People don't see me," you said.
"I didn't before. I do now," I replied.
"It's crazy because when you real, real big, people treat you bad and the world seem like they cool with it." You shook your head. "I'm not talking about being husky. I'm talking about when you get like me. Like people let they kids stare or they look at you and frown right to your face. Like 'Uggh.' And don't nobody say nothing."

"Dang." That's what I said.

Because that was all I could think to say. And because I felt my toes squishing under the weight of that truth.

I'm learning that confronting our biases head-on is one of the only ways to overcome them. I'm also constantly reminded that the longer you stay with someone, the more you'll find where you intersect. And the more you'll see them.

Because I saw you, I took better care of you. The plan became more meaningful and, as the leader of the team, allowed me to help my whole team see you, too. Like, for real see you. I also told them what you said and we all promised to do better. Or at least try, man.

Thanks for helping me to be a better doctor. I'm a work in progress for sure. But today--thanks to you--I think I progressed.

Yeah. 

***

Ms. Doctor.

I was walking near the hospital entrance today and saw three young brothers standing out front talking and laughing in the sunshine. One was slender with long locs rolled into an afrocentric hipster man-bun. He was animated and talking with his hands. Another was short and stout with flawless espresso skin and a close cut fade haircut. His mouth was gleaming with gold teeth. The third fellow was leaning on the wall chuckling in response to his comrades. His dancing eyes were a beautiful shade of amber and his nose was dusted with freckles.

They were beautiful. Seriously, they were. They greeted me in deference as I passed by.

Manbun: "Hey Ms. Doctor."
Me: "Hey gentlemen. You guys doing alright?"
All: "Yes, ma'am."
Me: "That's great. Have a good day, gents."
They smiled and all said it again: "Yes, ma'am."

I liked the way they all called me ma'am. Even though hearing it always jolts me out of this frozen-in-time idea in my head that I'm forever thirty years old, something about hearing it said in my direction feels maternal and special. I always return the favor, greeting the young men I see around Grady as "gentlemen"-- no matter who they are. Just like I do my own sons.

Yep.

I could immediately tell they weren't being fresh. Just pleasant and respectful toward a woman that they saw as--dare I say it? An elder.

Gasp. An elder.

Ha.

As I walked by, I admired the vast variations in blackness that each of them represented. All so different yet clearly unified in this cultural thread that weaved them all together.

And me with them.

Manbun reached for the door when I got to it and held it open. Just then I noticed that all three of them had their pants hanging nearly to their mid thighs. At first I was going to ignore it but then I decided to use my elder license instead.

Sure did.

Me: "Now you know I don't like seeing my three handsome little brothers standing out here with their pants falling down. Pull up those britches, gentlemen."

And yes. I said "britches."

You know what happened next? All three of them immediately pulled up their low slung jeans up over their hips. And all of them mumbled apologies and words like "my bad" and such.

Me: "Who y'all here to see?"
Manbun: "Our homeboy."
Me: "Is his mama there, too? Did she have to see what I just saw?"

*laughter*

Me: "If she is there, I know she don't want to see your whole behind hanging out of your jeans."

And yes. I said "whole behind."

Manbun: "Ha ha ha we hear you, Auntie."
Me: "Okay, but for real--what's the deal with your entire butt and drawers hanging out of your pants?"
Them: *looking at each other with amusement*
Me: "I'm serious, y'all!"
Freckle face: "It's just the style, I guess."
Me: *old lady scowl* "A style that makes  it where you walking like a penguin?" *shaking my head playfully*

*laughter*

Me: "Okay, gentlemen. Let me go in here and do my job."

*laughter as I walked through the door*

Manbun: "Hey Ms. Doctor!"

I turned around from the door and looked back. All three of them were standing in a row with their pants pulled all the way up and holding them at the waist. They all had these goofy, exaggerated smiles that reminded me of my own sons. Then we all burst out laughing.

I waved my hand at them and walked away shaking my head and smiling.

I told my team on rounds today: "If you stay with someone long enough, you'll always find a place where you intersect. Always."

No-- I don't like the sight of sagging jeans. At. All. And honestly? I'm not a huge fan of gold fronts either.

But I also don't like that video game Fortnite.
Or the random YouTube gamers I have to hear about nonstop from the backseat of my minivan.
Or dinner table discussions about Fortnite skins and virtual outfits for video games.

Nope.

But what I DO have is a soft spot in my heart for goofy sons with silly smiles. And beautiful brown manchildren with knotty hair and easy slang who hold doors and also poke fun at me and each other. Just like the ones that stood outside of that hospital entrance today.

And just like the ones that came from my own body.

Yeah.

***