It’s not what you know. It’s what you don’t.

The New Physician, March 2001

We need to talk.

Yes, I see you there. Big smile, brand new medical degree. A certain air of newly found authority. Nice white coat you’re wearing. Something pleasingly snug about it. In fact, you’ve probably tried it on in front of the mirror a couple times, haven’t you? Maybe you even added some dialogue, nice and slow and definitive:

I am a doctor.

Well. Got a piece of advice for you. Find a good tailor.

Sorry. Don’t mean to be rude. See, you know your way around a clinic. There’s no denying that. You’ve got book smarts, too. Malignant neoplasms, hypertension, scoliosis, acute myocardial infarction, endometriosis, epilepsy, pneumonia, asthma—you know them all like the back of your hand. But trust me, eventually you’re going to want something a little more, shall we say…functional, than that white coat. Perhaps a garment with a little more elbow room in it. After all, you’re going to need it to fix the leaky pipes.

“What?” you ask?

Just listen to my story. Then you’ll understand.

First, let’s go to the Northeast, where many suffer from neglect. If Dr. Barry Zuckerman listens from his office at Boston Medical Center (BMC), above the din of ambulance sirens, beyond the domain of his profession—if he listens—he can hear the steady drip, drip, drip. That’s the gradual noise of decay, that leak, and when it mixes with the mites in the carpeting and the roaches in the floorboards, it has a steady way of infesting the residents of that home, too.

Zuckerman knows that the leaky pipe walks into his office all too frequently wearing a little girl’s clothing. He knows that she is on steroids, so sick that she can’t even go to school anymore, and he knows that she’s not getting any better. He knows that the United States ranks first among industrialized countries in health technology but 16th in living standards for impoverished children.

And this is what else Zuckerman knows: If the girl’s health problem is going to improve for good, it’s not going to be because of her doctor. Surprised? Don’t be. Hands can’t heal this sickness. Drugs can’t cure it. When you lift up a little boy’s shirt to examine him and a cockroach scurries out, you are no longer soft-shoeing inside a Norman Rockwell portrait.

So, Zuckerman picks up the phone and punts to someone else—to a lawyer from BMC’s Family Advocacy Program. The lawyer steps in front of the landlord, and soon, that leak is repaired and the carpet is replaced and the little girl is off steroids and back in school where she belongs.

“I have found,” Zuckerman says, “that lawyers [can] provide preventive medical care.”

So let’s talk about this: about how being a physician no longer means you know everything about healing, about how being a good physician more often means admitting you don’t. It’s about knowing when to ask for help.

In poverty-stricken sections of Boston, biomedical treatment is just the penultimate step toward health. That’s what you’ll face in so many urban areas nationwide, where poverty reigns like a tattered emperor over neighborhoods.

You can’t do it all. You’re only a physician.

“This is about using nontraditional resources to make a system more whole,” says Zuckerman, who founded the Family Advocacy Program eight years ago and oversees several other outreach programs at the medical center. “People are healing when there are social norms to help them. One of the things doctors can be is a catalyst to work with other people to give patients information and get patients to give doctors information. Because that’s what other people can do.”

DRIP, DRIP, DRIP

Hold on a minute—where are you going? Oh, you’ve got a future to get started on, do you? Well, we’re not done. Not nearly. Have a seat. Listen to me. Because I am your future, and we might as well get acquainted.

Got another story for you. Take this Midwest doctor. Dr. Eric Whitaker. Black man with a medical degree, an engaging manner as impressive as his skills as a physician. Any number of large hospitals would love to have him on staff. But after Whitaker finishes his residency at San Francisco General, he goes back to his neighborhood, to Woodlawn on the South Side of Chicago, to see his grandparents, and he is disturbed. It’s 1998, and nothing looks the same as it did when he grew up. The color of the faces he sees hasn’t changed, but their conditions have. There are no jobs, few buildings without plywood over the windows and fewer impromptu rap sessions on the front steps of neighbors’ homes. There is disease, compounded by a fear to be treated. What was once a community is now a statistic.

Whitaker grows curious when he walks into the Woodlawn Health Center and notices an absence in the patient-body—there aren’t any black men. He wonders why. Know what the clinic staff told him?

“We wondered, too,” they said.

But wondering doesn’t get the job done. Action is what is needed here. Whitaker is going to have a baby in a couple years, and he wants his child to know that Woodlawn is a place of hope. He wants Woodlawn to know it can be a place of hope. How can he make sure this happens when African-American men are leaving their families behind sooner than every other population group in the United States—10 years sooner on average than the life expectancy for white men, which is 73 years?

And in Woodlawn? For black men?

It’s 53 years.

“The shameful thing is that if you pick up a newspaper,” Whitaker says, “and read the headlines, you’d think that homicide is the No. 1 killer of black men.” But in fact, the tally goes like this: heart disease, cancer, HIV/ AIDS, unintentional injuries… and then homicide. Untreated, unnoticed, unmerciful disease is far more murderous than a bullet.

Now Whitaker could have played God with his neighborhood. He could have stood back and pronounced his own explanations for the disappearance of African-American men inside health-care treatment rooms. He could have mustered all the medical training he received from the University of Chicago and then pointed a few fingers in the appropriate direction.

But he didn’t. Because he hears the sound, too. Drip, drip, drip. Only this isn’t about a house. It’s about a community, and the hole that needs to be plugged is bigger than any law any man has ever made. So he asks the voice inside his head to help him admit something to himself, a truth about the limits the privilege of his profession creates. And the voice, one still connected to a boyhood time when his neighbors were connected to each other, answers: “You can’t do it all. You are only a doctor. Ask the people who know best.”

Ask. The. People.

“Why don’t you come into the clinic?” he says, approaching Woodlawn’s black men in focus groups and on the street. “What keeps you away?”

They answer—old and young, straight and gay, the fathers and the homeless and the addicts and the diseased. We don’t come because we don’t see ourselves there. We walk in, and we don’t see you, a black man, there. We see women and we see children and we see white doctors and white social workers, and nowhere in those faces do we see a place where we belong. We see weakness, and we are trying to be strong. We have our problems, but we also have our pride.

Something inside Whitaker clicks. He pictures the clinics. Black man walks in. Ten people in a waiting room, and at least seven are women, and likely all the folks wearing white coats have complexions to match.

Black man walks out.

They still remember Tuskegee around here.

That’s a tidy explanation, though. Because what’s happening inside that clinic doesn’t speak to them any more than the people who work there do. “We discovered that black men have a more expansive view of what health care means,” Whitaker says. “To them, it included not just prescriptions, but living in a safe environment, having a job. All of these things were part of health to them.”

Now, every Thursday afternoon at the stroke of 4 o’clock, the Woodlawn Health Center becomes what Whitaker calls “mellocentric.” It becomes Project Brotherhood: A Black Men’s Clinic. “All the doctors are African-American males, which is in itself an anomaly. All the social workers there are men. The waiting room is filled with men.”

Project Brotherhood also has its own Kinko’s of sorts, where men can get help with résumés, view job listings, have computer and fax access. “You know, in Chicago, you can’t just walk into a workplace and hand them a résumé anymore; they expect you to e-mail it to them. Right there, a whole segment of the population that doesn’t have access is disadvantaged.”

And in the front of the clinic is the key to it all, the reason that 20 to 50 men show up on a Thursday night these days. It’s a barbershop.

“The doctors get hair cuts at the same time as the men who come in,” Whitaker says. “It gives us an opportunity to break down barriers, answer questions they might not otherwise have answered.

“You come to the barbershop and talk and eat pizza and have a good time. And while you’re there, you get treated. Our idea is to get men through the door. Patients then get to know the doctors in a context other than medical.”

These are the sorts of lessons you’ll never learn in medical school. They’re so simple, don’t you see? Sometimes all you have to do to treat your patients, all you have to do to find the answers, is take off the white coat, hang it on the back of the door and look around you.

Dr. Eileen Catterson, a native New Yorker, a nun with a brusque manner and a strong accent, had to really look around when she deposited herself and her pediatrics practice in rural Pineville, West Virginia, 27 years ago. Dental care was awful. Diets were abysmal. Kids wouldn’t listen. Families wouldn’t listen. So Catterson went into the school system and asked them to listen, to change the food selection and the way it was prepared.

“I keep telling medical students that when I started medicine, it was individual-centered; then it became family-centered. Now, it’s community-centered. It’s the wave of the future.”

And why is that?

“Well,” Catterson says, “because the other ideas haven’t worked.”

You must do what you must do. Even if you have to sell tamales.

DRIP, DRIP, DRIP

I see that I have your attention. But I’m not the one who needs it. Look around you. Look over at the West Coast, in Santa Ana, California, for example. Poorest zip code in all of Orange County. It’s a Latino community, and 38 percent of the state’s Latinos have no health insurance. They hold down two jobs, but when they get sick, they won’t come to you. Why?

One word: fragmentation.

When Dr. America Bracho first witnessed this, she grew angry. She came to Santa Ana from Venezuela, and in Venezuela, life does not exist in a vacuum. You are not just a woman. Your farm is not property. You are the land and the water and the crops and the sky, and the matter that fills your home fills your soul and defines who you are more than your very name. Oh, but in Santa Ana, in the Latino community, what did she see? Everywhere, disconnection. Everywhere, lonely hearts. People who were neighbors only by definition, who didn’t know the families living across the hall from them, even if they did know their screams of abuse or their wails of pain or their sense of isolation. You cannot nurture your health when you cannot share your life.

“But this is the way life is,” they told themselves.

“This isn’t the way life is,” Bracho told them. “It’s what you make of it.” So she aimed to make it better. She told the local and national nonprofits who claimed to be helping Latino health to stop pretending. Then one day she realized she was the one who was pretending. If Latinos would not find their way to a clinic on their own, she would simply create some guideposts. Not going to light a fire under other people, she thought; have to help them light their own fires. Make the citizens officers of their own health, talk to them, show them their wealth, not their needs. Must give them some empowerment so they start thinking….

“I can read. So I can teach my neighbors who cannot.”

“I can plant a garden. So I can pull the weeds in our neighborhood.”

“I have diabetes. I am blind. But I can make sure my neighbors never will be.”

So, the first group of promotores reports for duty—local residents recruited to lead their community toward good health, to keep watch over it. One of them, a diabetic in a culture in which one in four people over the age of 45 has the disease, says he would have done anything, anything, to come up with the money for an operation that would have saved his sight, had he only known such a procedure existed. Anything, he said, “even if I had to sell tamales.”

And just like that, the Latino Health Access (LHA) group had a rallying cry, a Spanish saying that has long been used to evoke humility and pride in the face of adversity—what one does when there is no other path to take. From it sprung the tamalada, an annual fund-raiser during which Santa Ana Latinos host tamale-baking classes to raise money for low-income Latinos with diabetes who need costly eye surgery.

This year’s tamalada was just completed, and my, what a sight. Picture chief executive officers of HMOs and local hospitals paying money to learn how to make the Latino culture’s food, standing side by side with the patients who struggle to pay for their services, getting wrapped up in the very tedious process of creating a delicious reward: one dozen tamales to take home to their families and one unforgettable glimpse into their social network.

Nice white apron you’re wearing, Doc.

“We are an organization where people can come together and do something for themselves and not just wait around to die,” says Gerry Balcazar, a director at LHA.

DRIP, DRIP, DRIP

Let me ask you a question. Do you believe you could lose your soul if you had an operation to repair an ailing leg? Do you?

Then what do you believe?

Because we are back in Boston now. And maybe you’re treating a man of African descent. You’re telling him, “You must have the operation. You must or you could lose your leg. You could die.” And you’re frustrated, because he is telling you, “No, I will not have the treatment.”

The patient’s head is whispering to him, Yes, I know. I know that what you say is true, medically. But his faith is pronouncing something else. You don’t understand my God. You only understand yours.

Western medicine is a wonderful thing—if you were born in the West. You might know the name Lia Lee. She’s the little Hmong girl journalist Anne Fadiman chronicled in her book, The Spirit Catches You, and You Fall Down. Lia was diagnosed with epilepsy by her pediatricians in Merced, California. Her parents, refugees from Laos, diagnosed her with what is known in the Hmong culture as qaug dab peg—an illness characterized by evil forces that they believed had stolen their daughter’s soul. She was treated with 23 Western drugs. She was treated with Hmong rituals. But through it all, the assumptions and beliefs that both parties held were rarely discussed. At 5 years old, after years of miscommunication and overmedication, Lia was pronounced brain-dead after a powerful seizure.

Today, Dr. Linda Barnes, an anthropologist at BMC, is trying to change that lack of trust and respect between families and physicians. She has a quarter of a million dollars in grant money at her disposal right now, and she plans to turn it into the Landscape Project, for which graduate researchers from Boston University School of Medicine will go out to refugee communities and create partnerships.

They will knock on the doors of faith centers for the African Diaspora, because they know that religion is the first place refugees turn. They will frequent the owners of local markets and health stores, because they don’t yet know all the herbal remedies and tonics that refugees trust to heal them.

And in the end, they hope, they will take what they’ve learned to medical students, to residents, to established physicians on staff, and they will ask them to kneel before the altar of understanding.

“We want doctors to learn how to talk to patients about everything they do with their health, to become at least familiar with the terms, so that when a patient mentions a practice, they can at least nod their heads and say, ‘I know what you’re talking about,’” Barnes says. “Most families put together their own health-care system,” she says, “and it may consist of family medicines, the health food store, the local market, traditional practices or complementary practices of other kinds…and then the doctor. The doctor is usually the last to know that he or she is the last piece in that framework. And it’s a little bit humbling for them. But no cultural group exists that doesn’t have a number of resources to treat its health. It’s important for doctors to know that. It’s a hard thing to ask them to realize, because part of the socialization of the profession is the belief that biomedical resources are the highest form of health services available.”

Maybe you won’t lose your soul to leg pain. But you might lose your patient to his.

I swear. You swore, too. Remember?

I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients….

For the benefit of your patients: There are leaks in pipes, leaks in health care—the leaks will find you as a physician; as a human, you can find the ultimate repairs.

No, you can’t do it all. You are only a doctor. But it’s a good place to start. Yeah. It’s a good place to start.

 Copyright 2001 American Medical Student Association