You had me at "Oh, Hell No!"

The other day I was working with a resident who'd just seen a patient for a medication refill. According to the resident, this fifty-something year-old woman had missed three out of the last four continuity care visits opting for quickfire "med refill only" encounters instead. Fortunately, her only medical problem was high blood pressure, and despite her less than ideal approach to having it managed, it was under control. She'd even had labs drawn after the last refill, all of which were 100% normal.

"Did you review health maintenance screening tests with her?" I asked thinking of things like mammograms and colonoscopies. I noted her age--over fifty--and wondered if this lady had kept appointments for these things even if she wasn't too keen on getting a full physical.

"Screening tests? No way. She pretty much shut down everything except the occasional pap test."

I furrowed my brow and sighed. "Did you ask her why?"

"I did, Dr. Manning. And it was kind of odd. She just kept saying no. Even when I asked why, she just kept saying 'I just don't want it, that's all.' And when I asked if she'd ever had a mammogram or a colonoscopy, she squished up her face and shook her head."

"That's unfortunate," I responded. "Do any cancers run in her family?"

"That's the part that stinks the most, Dr. M. One of her immediate family members died of colon cancer like in their forties. I tried to get her to reconsider using everything I could but she wasn't budging. She just kept on saying no. As a matter of fact, she kept saying. . ."she paused and seemed to be deciding whether or not to go on. She glanced back up and finished, "she kept saying, 'Oh hell no.'"

We both let out a nervous chuckle. Then my wheels started turning. . . .

A black woman in her fifties refusing screenings and missing appointments in an indigent care setting? In the southern United States, no less? Hmmmm. Why is this happening? Is it a trust issue? Or what if this is a literacy issue? Wait. What if it's a financial issue? Or a little bit of several things? Hmmm.

Instead of speaking those thoughts aloud, I just kept staring at the resident intently. She knew I was thinking, so she waited patiently. "Let's go talk to her."

And my resident replied, "I'd like that."

My guess is that this intern was banking on me closing some cultural divide that she, a well-meaning, blonde hair/blue-eyed doctor, might be lost inside of with this woman who could sho nuff pass for one of my first cousins. And I have to admit--she wasn't the only one.

When we walked into the room, we found the patient reading some kind of romance novel. "What's that you're reading?" I asked. She turned it over and showed me the cover. Some Fabio-looking dude held a Raquel Welch-looking woman tightly in his arms.

"Romance," she answered with a timid smile while dog-earing the page.

I remembered some fleeting teaching point I'd once heard about people carrying books as a deterrent when literacy was an issue. Considering that limited literacy is a major issue in this part of the country and at our hospital, I had to at least consider it. But this didn't seem like the case with her. This lady was doing exactly what she told us -- reading about some Fabio-looking dude putting the moves on people during the wait.

We chatted for a few moments about her blood pressure, weight, and keeping appointments. I implored her to see us at least every six months, especially since she was on three different blood pressure medications. We listened as she explained about the hassle of "all that other stuff they want to talk about" during the continuity appointments when all she is interested in is getting her high blood dealt with.

Hmmm.

I sat as still as possible to keep her from feeling rushed and allowed her to finish her thoughts.

"Sometime you jest wont to get in and get ya medicines," she said with a sideways smile. "Y'all be on to some whole other thang. Tellin' somebody they need to lose weight. Signin' 'em up for a bunch a other thangs that they ain't even in-trested in."

Yikes. I didn't even know where to begin. "Uuuuhhh. . . . yeah. . .Dr. Ashley was telling me that you aren't too keen on some of the screening tests." I decided to dip my toe in the water with this to see what she'd say. She simply stared at me expectantly, mindlessly shuffling the pages of the Fabio-book under her thumb. She totally had my number.

"Listen," I spoke carefully, "I just want more of an idea as to why you don't want to get a colonoscopy in particular. I mean, you definitely need the mammogram, but you lost a parent to colon cancer so I just . . . look, I just don't want to miss an opportunity to--"

"I don't want a colonoscopy." She held my gaze and wouldn't move.

"Is there. . .like. . .some particular reason why you don't?"

"The reason is that I don't want it. Somebody ever offer you something and you say, 'No thank you?' You ain't got to tell nobody why. Jest a 'No thank you' is sometimes all you gon' get."

I nodded my head slowly as our eyes continued to face off. "If I offer you a stick of gum and you say 'No, thanks' I'm okay with that, you know? Because that's not life-threatening. But if you lose your mama or your daddy to colon cancer and you don't want me to check out your colon, that's different."

"Not to me," she shot back. "If I say I don't wont no gum, I don't want no gum. Don't care how fresh iss gon' make my breath."

Damn. This was tough. I nervously cleared my throat and gave a nod that said touche. I drummed my fingertips on my lips thinking of what to say next. She still watched me, barely blinking.

"Ms. Johnson, you have a right to make your own decision. But. . .I'm not going to just shrug my shoulders and say, 'Whatever.' I mean, yes. That would be a lot easier than discussing it, but it wouldn't be right." I stopped to see if she was okay, and her face softened a bit. I went on.

"Look. You're a black woman, and the truth is -- when it comes to a lot of these cancers, we were dealt a crappy hand. Guess who is way more likely to die of breast cancer?" I pointed at the brown side of my hand and then aimed the same finger back and forth to us both. "Guess who colon cancer is the most aggressive in and the most likely to take out?" I repeated the same gesture.

"Why is that?" she asked. I felt super excited that she even did because it was the first olive branch I'd received during the whole discussion.

"Partly because we don't always get our screening tests. But it's some other reasons, too, like how we are made genetically. . .you know. . .like what we're made of." And sure, my use of "we" might have seemed like a shameless attempt at bringing home my point, but regardless of all that, it was true. "I mean. . . . look. You just. . I mean we just. . .are the main ones that need to be getting signed up for colonoscopies and mammograms. For real."

The room fell silent as she nervously flipped the pages over and over. After a few moments, it became a bit uncomfortable, so I finally broke the silence. "What do you think?"

"I think I don't want a colonoscopy. Or a mammogram. But I'm gon' think about both of 'em." Then she looked over at the resident doctor and added, "And nen we could talk more 'bout what I'm feelin' when I come back in four weeks."

"You will come back to see me in four weeks?" my resident chimed in incredulously.

"Yeah, I'm gon' come back to see you. And I'm on' thank more about what y'all told me. I might not change my mind, but I like that y'all took the time. Both a y'all. 'Specially when all I signed up for was the refill. I 'preciate that."

And so that's how the encounter ended. We typed into the plan that she'd come back in four weeks. . . and that she'd think about getting a colonoscopy and a mammogram.

And you know what? Something inside of me tells me that at some point she will.

***