Jesse Cole imagined himself becoming a highly paid physician working in a fancy hospital, just like those featured on television shows.
"That would be my career," said Cole, who was raised in suburban Maryland and came to Buffalo to study medicine.
But his thinking shifted.
Why? Because of the semester he and 13 fellow students at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences spent in one of Buffalo's poorest neighborhoods.
Through the fledgling Health in the Neighborhood course, first-year students experienced life in an underdeveloped, mostly black community. Their firsthand look at housing blight, economic challenges, limited access to grocery stores – coupled with health inequities and disparities – resonated deeply as they train to become the next generation of doctors.
"It's got me thinking a lot more about doing straight-up primary care in an inner city neighborhood, which I had not considered before," he said. "It's really important for any health care provider not to write these patients off just because of where they live."
Developed over nearly three years, the course had been a dream of many. The "classroom" is the community. University staff, clergy and community leaders crafted the curriculum with input from previous students who walked the streets of several neighborhoods to gain an understanding of medical disparities and how social determinants can affect people.
It was a wake-up call for aspiring physicians, many of them white and often from privileged backgrounds.
"If you want to learn about the source of that ambivalence and distrust, to discuss what health care providers can do to improve that, you need to go in without your white coat," said Dr. Linda Pessar, a teacher and founder of the course, and director of the Center for Medical Humanities at the medical school.
"How can you trust someone who you feel is clueless about your life?" she said.
"When you go to a doctor's office, he doesn't see where you live, who you live next door to," said Robbie Wildman, 74, a longtime resident of the East Side near Martin Luther King Jr. Park. "He doesn't see your neighborhood is going down."
Once the white coat and stethoscope are off, it's critical to have genuine conversations to get to know patients better. "I don't think you can change it, if you don't go in like that," Pessar said. "It's not, 'Here we are to better your health care. Ta-da!' "
The Rev. Dennis Lee Jr. helped develop the course and is passionate about what it's already meant to his 130-member parish at Hopewell Baptist Church on Fillmore Avenue. The church has become the hub for students to learn from families there.
"We're having a conversation that America needs to have," Lee said. "We're coming face to face with issues of the poor, and what can be done. We all face our bias and we need to talk about it."
Many in the East Side neighborhood do not have a personal physician, lack health insurance or cannot afford medicines they need, Lee and others said. Many depend on the emergency room for care.
Numbers partly tell the story of the MLK neighborhood that is home to more than 3,000 people. The median household income is $20,483, and 41 percent of its families live below the poverty level, according to 2016 U.S. census data. Just 39 percent of homes are owner-occupied and 61 percent are rentals.
A recent walking tour of the neighborhood by students and clergy was eye-opening. Empty lots, broken sidewalks, abandoned buildings and burned-out structures dominated the scene.
"The neighborhood is poor and currently in a state of underdevelopment," said the Rev. Kinzer M. Pointer Jr., pastor of Agape Fellowship Baptist Church on Peckham Street. "You're looking at real urban blight."
"I was blown away by what I saw," Lee said. "It was way worse than I thought."
Some residents feel that doctors talk down to them. Others feel they are being shamed by physicians or don't feel comfortable interacting with health care providers, Pessar and Lee said.
Pessar remembers an incident a few years ago that she described as "very painful" involving a woman who said she felt "rebuffed" by a lot of doctors. The woman's strategy was to interview doctors. While waiting in a patient room, her chart was left out before the doctor came in to meet with her. She ended up reading through her chart beforehand and saw that she had been described as "a hostile patient," Pessar said.
"Now, there's nothing hostile about her. She's just out there, but that chart gets read before the doctor sees her," Pessar said. "This poor lady just wanted to be understood."
"It's the tone and how they say it," Lee said. "It always works better if you understand the people you are administering to."
Wildman said she knows she is viewed as a challenging patient. "I've been given prescriptions, but I throw them away," she said.
She watches what she eats, mostly self-manages a thyroid condition, battles high cholesterol and knows she does not exercise the way she should. She doesn't always agree with her doctors. And says she often lets them know what she thinks, and what her Google research shows.
"I'm not ashamed to go to the doctor's, but I'm not ashamed to let them know I don't take medicine because of the side effects," Wildman said.
Steven Werts, a Philadelphia native who lives with his wife and two young children in the MLK neighborhood, was never a fan of doctors.
"I'm not a doctoring person. For a long time, I lived a certain type of lifestyle and was running the streets. I lived on the wild side for a while," said Werts, 44. "I never had a primary doctor until last week. If it was something serious, it would be the emergency room."
But Werts has turned a corner.
"My lifestyle changed, so I'm thinking different now and doing different things," he said.
Pointer, the pastor of Agape Fellowship Baptist Church, has kept a close eye on obituaries over the course of his 38 years in ministry. He doesn't like what he sees.
"I am growing weary of burying people prematurely," he said. "As I looked back, I began to notice in earnest that I was burying a lot of people at 50-something."
With an African-American male's average life expectancy of 73.7 months, and 79.4 for a female, Pointer said it's disturbing.
"As we get into our 40s and 50s, we still need to talk to the elders to find out their experiential learning," Pointer said. "That's an invaluable experience that ceases when people close their eyes and go to death prematurely."
The cycle, often inadvertently perpetuated by a culture that includes unhealthy eating habits, is heartbreaking, Lee said.
"We'll bury someone who died of heart disease, due to probably a bad diet. Then we'll come back to the church and try to kill the rest of them with fried chicken, macaroni and cheese, and all that stuff that clogs up your arteries," he said.
Lee said he hopes to soon get medical students and doctors to volunteer a day or two a week to run a walk-in clinic at his church. "We're trying to get more people to be responsible for their health," he said.
A learning experience
UB student Connor Orrico of Amherst said he benefited from getting to know a neighborhood family.
"Once you're immersed, then you can develop empathy," Orrico said. "Health and illness happen in neighborhoods, not in hospitals. For medical students and professionals to be able to understand the context of their patient's illness, they need to understand what goes on in their life."
That's why Orrico decided to attend a service recently at Hopewell Baptist Church.
"Black churches are a foundation of the black community, so I wanted to see the church to understand their daily life," Orrico said.
Cole, too, was moved by the impact of social and racial injustices.
"Just as how well your heart works, these things are also contributing to your physical, emotional and spiritual health," Cole said.
The students got a stark lesson in understanding one January day, when they were each given a $50 allowance to buy food to complete meals for a family of two over seven days. They first had to take a bus to Tops Markets on Jefferson Avenue before going to a suburban supermarket of their choice to comparison shop. They discovered chips, soda and cakes near the front of the city store, while suburban stores presented healthier options at the entrance of their stores, Lee said.
It became clear that many in the neighborhood cannot afford to eat healthy because, as Lee said, "Healthy is expensive."
"That budget goes pretty quickly," Pointer said. "Students said they could build the meals nutritionally, but they'd be pretty boring and eat the same thing every day. You can't buy processed food and call it nutritional."
'Taking off the white coat'
Dr. Chester H. Fox has practiced family medicine in the inner city for 25 of his 39 years as a physician. He supervises the newly opened Urban Family Practice clinic at Jefferson and East Utica Street. For more than 20 years, he trained physicians on the East Side for UB until the university shut down that residency training site.
Fox doesn't see inner city residents shying away from health care. He sees the opposite.
"They're trying to get into the doctors and are not trying to avoid us," he said. "We were in a black, inner city, impoverished neighborhood and we had 5,000 active patients when we were at Jefferson and Utica with the residency program. It was much more of a problem that we could NOT fit new patients in."
Since Urban Family Practice opened its clinic at the Jefferson site in the last year, it has added five full-time providers and is at 80 to 90 percent patient capacity, Fox said.
"Taking off the white coat and listening is true for every doctor, no matter where they are," Fox said. "It's not about black and white. We need to do a better job of recruiting minority physicians so we can culture match with the communities. People are more comfortable with people who look like them."
Cardiologist Dr. Kenneth Gayles, one of 17 children, is a household name in the MLK area, where he once lived and has practiced medicine for 32 years.
The doctor, who now lives near Buffalo VA Medical Center, is aware of the challenges his patients face. To combat that, he runs a "one-stop" shop at his office to make sure tests, screenings, rehab and wellness get addressed beyond a checkup.
Gayles said he does not rely on his patients to follow all the rules, keep their appointments, get the necessary blood work done – and the list goes on. "Instead, I have to do what needs to be done when the patient is here," he said. "My experience is pretty unique because it's as if I'm taking care of my family."
A woman who had open heart surgery in 2010 but now needs medical clearance for knee surgery came to see Gayles in May. She had not seen a cardiologist in eight years. "She was not smiling when I walked into the room. She told me she had not had a recent stress test," he said.
Gayles knew what he was up against. He told her how important it was for her to get her cardiovascular system evaluated.
"I knew I was going into a room where I would face opposition. My approach was to get to know her first and talk around the issues, and then I went to the stress test," he said. "I look like her. She looks like me. That helped. When I finished with her, she asked if she could see me as her cardiologist."
"If you show them that you care, that's 95 percent of the battle. It's a matter of looking that person in the eye and having them recognize that you care for them."