A Harrowing Misdiagnosis And A Doctor’s Quest For Health Equity

The following is an excerpt from Legacy: A Black Physician Reckons with Racism in Medicine by Dr. Uché Blackstock.

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“You have appendicitis,” the resident told me gravely. “Because it wasn’t caught soon enough, it ruptured. We need to operate immediately.”

Everything happened so quickly, I didn’t have time to ask why my inflamed appendix hadn’t shown up on the prior scan. Suddenly, five or six people were around my bedside, preparing me for surgery. The new CT scan had shown my appendix was perforated, so the senior resident and the rest of the team came downstairs to the ER to make sure I was okay. They needed to get me to the OR as soon as possible. I was in danger, they told me, of losing my life.

I was terrified. I’d never gone under anesthesia or needed surgery before. I looked at Oni and she held my hand tightly, the look on her face mirroring my own fear and concern. The resident explained the procedure to me, but his words didn’t fully register. The last thing I remember is someone starting the anxiolytic medicine through my IV and Oni giving me a kiss on my forehead and saying she loved me before they wheeled me into the OR, and I vanished into my dream world. When I woke up, I was in the recovery room. Hours had passed. I was groggy and my abdomen was sore. I lifted up the sheet and saw bandages over my right lower abdomen and a drain with yellow-white fluid coming out the side. I couldn’t move, but I was alive.

The surgeon came in. He was a short middle-aged white man, very matter-of-fact, but clearly concerned about me. He explained he had to cut open my abdomen instead of the usual laparoscopic approach, which meant I was going to have a substantial scar and a longer recovery time. Apparently, there was so much pus in my abdomen from the rupture, there was no other way to remove the appendix and the havoc it had caused in my body.

But this wasn’t the end of my troubles. I was discharged home three days later, still not feeling like myself. While much of the pain in my abdomen was gone, my belly felt large and full, and I was still nauseated. At my follow-up visit a week later with my surgeon, he examined me and told me he was worried. He sent me back to the same ER for another CT—my third—and they found that my abdomen had not been washed out thoroughly after the surgery, which can happen after a perforated appendicitis, and I had developed an intra-abdominal abscess—an accumulation of pus—that needed to be drained. I was readmitted to the hospital.

I just wanted to feel better again. Why was I still sick? It was one thing after another and I had absolutely no control over anything. By now, I was already a week behind on my schoolwork; I felt confused and frustrated. I essentially had to leave my life in the hands of these physicians, but how could I trust them when it had taken them so long to give me a correct diagnosis? I felt certain that if my mother had been there at my bedside to advocate for me, the outcome might have been different. Certainly, Oni tried. In total, I was out of school for about five weeks with postoperative complications. Most people who have appendicitis re- cover after a few days. A couple of months after my surgery, when I was finally regaining some normality, I happened to be walking down Longwood Avenue, the main drag in front of HMS, when I ran into the young Black surgical resident I had seen when I first came to the emergency room with my symptoms. He recognized me immediately and stopped to ask me how I was doing. I told him I was slowly getting better. The resident then explained that everyone felt horrible about what had happened, especially as I was a student at the medical school. He shared with me that because my case was a delayed diagnosis with complications, it was being presented at a morbidity and mortality conference in the Department of Surgery. They needed to review exactly what had happened and what had gone wrong. These conferences are a tradition in medicine and surgery departments. The case is presented to the whole department, the people involved in the case discuss their thoughts, and then there is an open discussion about what can be learned.

Certainly, it’s not unusual for appendicitis to be misdiagnosed, so it likely wouldn’t have been the first time doctors had met to discuss a failed diagnosis scenario with this problem. Overall, as many as 30 percent of patients with appendicitis are discharged by a physician before a correct diagnosis is made. Does this mean that the misdiagnosis that had cost me so many weeks of school and could have taken my life was simply an awful mistake? Many times since then, I have wondered if the color of my skin was a factor in my misdiagnosis. The second resident I saw, the white woman, was fixated on my sexual activity. Why was she so convinced I had a sexually transmitted infection despite my clear answers about not being sexually active? To me, this may point to some unconscious biases on her part. Negative images or stereo- types of Black women have been a pervasive part of our culture throughout American history. The idea that Black women are sexually promiscuous or lascivious or Jezebels continues to be promulgated in books, film, TV, and other cultural references to this day. It’s entirely possible that this influences the ways that health- care professionals make assumptions about Black women’s sex- ual activity and promiscuity that, in turn, affect communication and clinical decision-making.

The very fact that the second resident didn’t listen to me in that initial evaluation makes me question everything else about the way I was treated. Why did the attending doctor who saw me that first day so grossly underestimate my pain level, therefore ruling out a correct diagnosis of appendicitis? Would he have underestimated the pain of a white patient in the same way? Why did it take my nurse practitioner listening to me to reach the correct diagnosis? And why, even after she ascertained what was wrong with me, was I still given an incorrect diagnosis of colitis? The answer is: I don’t know for certain. I’ll never know if racism was a factor or not. This is part of the problem. It’s much easier to explain blatant acts like burning crosses and racial slurs than it is to explain unconscious bias in medical settings. I don’t know what was discussed at the conference about my case, just as I don’t know whether bias influenced my doctors’ clinical decision-making and whether someone with white skin might have ended up in the same situation. Toni Morrison once wrote, “The function, the very serious function of racism is distraction.” Sometimes you just don’t know if that’s what’s going on—and you waste hours of your life trying to figure it out.

From Legacy: A Black Physician Reckons with Racism in Medicine by Uché Blackstock, MD, published by Viking, an imprint of Penguin Publishing Group, a division of Penguin Random House, LLC. Copyright © 2024 by Uché Blackstock, MD.