Reflections from the Culture at Grady: The "Air Apparent" Theory and other reasons I ain't goin'

*details changed in this story to deidentify patient and protect anonymity--based on an amalgamation of true events (xray from Google images)

"Yes, and how many times must a man look up
before he can see the sky?
Yes and how many ears must one man have
before he can hear people cry?

. . .The answer my friend
is blowin' in the wind
the answer is blowin' in the wind. . . ."

from Bob Dylan "Blowin' in the Wind"
 
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"I'm perplexed," said one of our residents, Christina P., as we sat in clinic one day. "Remember Mr. Porter, that guy that we got the chest x ray on that day? You know--the one that had the lung nodule?"

"Wait, why'd we get a chest x ray on him?" I asked while filling out a form our social worker had given me a few moments earlier.

"He'd been coughing--he's a pretty heavy smoker and had noticed a few blood streaks."

"Hmm. Sounds kind of bronchitis-ish, don't you think? Weight loss?" I thought for a moment. Oh yeah, that isn't what she was asking me. I chuckled at my tendency to digress, but paused when I looked up and saw the worry filling her blue eyes. "Wait--I'm sorry. . .what about him?"

She sighed and plunged her hand through her pin straight blond hair in frustration. "Well. . .I got him a chest CT, and then a CT-guided biopsy of the nodule."

I was confused. Sounded like she had done everything right. "Uh, okay and?"

"It's squamous cell lung cancer. Stage 1. Totally resectable. We caught it extremely early."

Um okay. "Wow. Fortunate that you thought to order that x-ray that I was giving you a hard time about." I smiled, but she didn't, which was unlike Christina. "Seems like good news unless I'm missing something, Christina. Have you told him? How did he take the news?"

Christina lay the chart down on the desk and shrugged her shoulders. "He's here now and I just finished seeing him. We spoke at length and he took it fine. Remarkably fine." She furrowed her brow and tapped her pen on the desk. "But. . . . he won't even let me talk about referring him to cardiothoracic surgery. I mean no way, no how. Before I even saw him, I had gone through all this trouble to get him an expedited appointment, but he was resolute. All he keeps saying is, 'I don't want nobody cutting on me.' "

"Hmmm. Do you mind me asking. . . .is he--" without thinking, I pointed at the brown skin on the back of my hand "--African-American?" Christina nodded. "Hmmm." We sat in silence for a few moments.

"Why do you ask?" The concern she had for Mr. Porter was painted all over her face. Christina and I had worked together in the resident clinic for nearly three years. Now, at nearly the end of her residency, our discussions about patients felt more like collegial chats than that between teacher and learner. Even still, I had a not-so-evidence based teaching point that I thought might apply here.

"Christina, have you ever heard any old wives tales about surgery and cancer? There is one belief, in particular, that is quite prevalent in the black community." I waited to see if she knew. "Any thoughts?"

She narrowed her eyes and thought for a moment, hoping some prior experience at Grady might jog her memory. "Hmmm. . . no. Not off hand, Dr. Manning."

"There's this thought that cutting someone open and letting air get to their cancer cells could lead to it spreading. It's a pretty prevalent belief," I told her.

I then reflected on a phone conversation I'd had several years ago with my late Auntie Mattie, who had been diagnosed with cancer. My Auntie Mattie was a stoic, tell-it-like-it-is woman who lived life with zeal. She was robust, smart, spunky, and always decisive. I was early in my training when she was being assessed for surgical intervention for her malignancy, and despite the years that have passed, I never forgot her words about refusing surgery.

"Ain't nobody cutting on me. I'll take the chemo, the radiation and whatever else they got, but ain't nobody cutting me open and letting the air hit my insides."

It was the first time I had ever heard this concept. I decided to explore it further with her. "What do you mean 'the air hitting your insides?' Everything in the OR is sterile, Auntie. The air won't infect you."

"I ain't worried about infections. Everybody know that when you cut open somebody with cancer and the air hit that cancer it spreads. Everybody knows that." No, Auntie, not everybody.

"Are you serious?" I asked while shaking my head and staring at the phone receiver. She cannot be serious. "Come on, Auntie Mattie. That's ridiculous. Air doesn't do anything to cancer." I waited for her response. Silence. "Auntie?"

Then she unleashed stories of at least 5 people that she knew personally who'd been diagnosed with cancer, had surgery, and then subsequently learned that it had metastasized (spread.) I kept trying to get a word in, but she wasn't budging on the theory. To her, it was apparent. Air. Spreads. Cancer.

Air--the devil in disguise

I have since had countless close encounters with the "air apparent" concept. And just like that day when I spoke to my Auntie Mattie, I feel myself turning blue in the face as I explain that sometimes people who get surgery for cancers are already pretty advanced in their disease, making the efficacy surgery limited. But much like my auntie, most of these folks are pretty firm in their position. Like my med school classmate Jada R. says, "Girl, she ain't goin'!" (The Memphis way of saying, "She ain't going for nothing you're saying.")

It turns out that Mr. Porter wasn't goin' for much of anything. Chemo? No'm. Radiation? No'm. Surgery? Oh hell naw, y'all ain't cuttin' me open.

Along with Christina, I pulled out every stop to explain how early his diagnosis was made, and how fortunate it was that this was the case. "Surgery could put all of this behind you," I implored. "You're not even seventy five, sir. And you're otherwise healthy." Silence. Sigh. "What does your family think about this, sir? Mr. Porter, have you spoken to them?"

"Yeah, and they said they don't blame me. 'Specially the surgery part." Take that, Miss Manning. Fifteen minutes later, I had to finally accept the obvious. Girl, he ain't goin'. At least, not today.

What Mr. Porter had in common with my Auntie Mattie is that he was senior-aged African American reared in the south. What's the significance of that? That's simple. Some pseudobarriers to health care are more cultural than anything else. Perhaps it has to do with growing up in a Jim Crow era where just about everything you received was secondhand, separate and no way no how equal. Or just maybe you read the paper in the 70's and discovered that less than two hours away from your home, men your daddy's age were being used as a big ol' human syphilis experiment. Then again on another day, it could be that your grandmama, and her grandmama before her--you know, the ones who told you that babies that "sit high" are boys, and that if your face and nose swell when you're with child, then "it's a girl all day," 'cause everybody knows that girls rob your beauty-- yeah, those same grandmamas who told you those pearls of wisdom also told you that being "cut on" was bad news, especially if it was cancer. Air + Cancer = Bad -- which by the time you turn seventy-anything translates to "Oh hell naw y'all ain't cuttin' on me."

Yeah. So just maybe your take on things isn't that you're ignorant or ornery or difficult or mentally ill. Just maybe it's cultural, and if somebody took two seconds to explore yours, they'd fully understand exactly why you ain't goin'.

I think it's our job to fold culture into our understanding of our patients just like blueberries into pancake batter. Every belief, value, and custom adds to the finished product--and when carefully considered, make for better doctor-patient interactions. And so, lucky for me, it turns out that understanding the souls of southern black folks is a perk--especially at Grady. Admittedly, as the child of a sixty-something year old African American Alabama natives, I was born into this understanding--- which sort of feels like cheating, but that's okay. Getting the "culture" dialogue going, no matter how it happens, is always a good thing. It opens everyone up to be authentic; which always makes things better if you ask me.

Learning about people and who they are, and then actually remembering what they say, is an act of love. And even though many might not think of their feelings for patients as "love," in my experience, it sure does make a person feel good when someone cares enough to explore more than just the basics.

"Lovely accent--where are you from?"

"Guyana. Guyana, South America."

"Right, that's near Venezuela, correct?"

"Wow, I'm impressed. Whenever I say 'Guyana', people think I mean 'Ghana' in Africa."

"Yeah, my last Guyanese patient schooled me, so I was ready for you."

*Smile*

Showing love. . . . .

Sometimes it's as simple as determining if a Chinese patient speaks Cantonese or Mandarin, or taking the time to find out if an African person who looks Ethiopian is indeed Ethiopian or instead Eritrean, or perhaps recognizing that all Spanish-speaking patients aren't Mexican--they just might be from Uruguay or Guatemala or even El Paso, Texas, or it could be remembering that your last Muslim female patient preferred not to see a male doctor, so this time taking it upon yourself to ask that nice woman in the waiting room clad in a hijab just who she's scheduled to see. . . .and yeah, sometimes it's simply acknowledging that beliefs run deep and can, literally, scare people to death. . . . like fear of the potential for air to make quietly hibernating cancers on the inside awaken to become ferocious, spreading beasts.

After every possible example, explanation, scary what-if, and usually persuasive hypothetical, Mr. Porter still didn't agree to see the surgeons that day. But he did say something to Christina at the end of that visit that I did find reassuring:

"I guess I'll thank about it, since y'all care so much and asking me so many questions. I never had nobody spend so much time asking me questions and caring about me like that."

Believe it or not, it's actually been studied, and it looks like air probably doesn't make cancer spread. . . . .but you know what I think does? Not listening and not caring. Being a little "culturally competent" just may be your only explanation for what otherwise would be completely perplexing--like Mr. Porter saying no to a potentially lifesaving treatment, and his whole family cosigning his position. . . . . .

. . . . .Thanks to Christina committing herself to trying to understand more than just the basics about her patient, she was able to evolve "I ain't goin'" to "I'll thank about it." And if you know the souls of black folks like I do, that's a pretty big deal. :)

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Food for Thought:

Never heard the "Cancer spreads when air hits it" theory? Google this: 

"if air hits cancer it will spread"

and see how many hits you get. . .or better yet, read this great NY times article from 2003:

Finding of Fact: Myth About Lung Cancer Can Be Deadly

Homework assignment:

Learn 3 things about 3 people of completely different cultures than your own this week.