TRY TO TURN A COWBOY VEGAN | Towela King
I entered room 1. The first thing I notice walking into any patient room is the smell. It was the smell of having been outside in the hot New Mexico sun - a tinge of alfalfa and the precipitate from a liter of evaporated sweat. I see a dad-muscular leathery man with a turquoise bead-trimmed leather vest, thick Cherokee boot cut jeans and well-worked leather cowboy boots. His felt cowboy hat disclosed a thick dark rim sitting just above the brim – evidence of a hard decade’s work and a top suspect for the smell. His wife sat in the chair furthest from the exam table with their collective outwear and bags on the chair that sat between them. Her fit was comparatively drab, a plain black long-sleeved blouse, trousers, and boots. A brown bob topped her head, her face adorned with modest makeup.
I was hit by apprehension from the scent. I grew up in a farming community near the Rio Grande. I had bittersweet memories of biking furiously toward the riverbank, barely escaping the snapping teeth of Blackie the guard dog. I recalled the wretched squealing of new neighbors prohibiting my African mother from using the public road with threats of violence.
I hauled my baggage into the room, confirming the patient’s identity and introduce myself and my role. I started the visit with “What brings you in to the urology office today?”
“Well doc, I just ain’t peein’ like I used to. Its not too hard or nothin, but you know how when you was a boy, you could hit the other side of the room – wait. I didn’t mean to assume,” he caught himself in misgendering me.
I interject, hoping to keep his attention off of my androgynous appearance. “I sit to pee,” I clarified, unsuccessfully, “but I get what you mean. It’s getting more difficult to pee as you’re getting older, is that right?”
“Exactly! I’m healthy as a horse, never had anything major wrong with me. I wanna keep it that way. I’m workin’, but I think I gotta take more breaks than usual to relieve myself. Should I be worried?” His eyes were bright and curious. His leathery skin and chief complaint betrayed his 60 years, but I was surprised his youthful inquisitiveness.
We discussed his symptoms and the workup that my preceptor might recommend for him. We discussed the misnomer “benign” in benign prostatic hyperplasia and I conveyed how important it is for his bladder and kidneys that he attend follow up appointments so that we could, “take a good look at his stream.” I told him we would be using the aluminum and plastic toilet apparatus and real-time scale that sat in the corner of the room - the urodynamics machine.
“Well why not check it out now?” He began to undo his belt.
“I appreciate you being so willing, but I think we should perform a rectal exam to check the size of your prostate. If you’re uncomfortable –“
His voice lowered slightly without losing its brightness “Well that’s no problem, doc.” Without missing a beat, he turned around, continued removing his pants, and looked over his shoulder at me. “How do you want me?”
I typically gave the option of deferring the exam or waiting until my attending or preceptor is in the room to do the exam. I had certainly had patients eager for a rectal exam, but he was suddenly taking control of the exam. This was not in the ballpark of what I expected to make me uncomfortable about this encounter. I was truly proud of this man for thoroughly subverting my expectations.
I didn’t want to betray discomfort given his obvious confidence in me. I looked at his wife, who was unfazed, if not amused. I took her cat-like blink as permission to continue. I frantically washed my hands and clumsily gloved damp skin. I scramble for the lube and tissues and demonstrate the exam position next to the patient.
After completing the exam and sharing interest in his work caring for livestock and his distaste for the government, I left to finish the visit. I reflected on the patient’s life – what prejudice had he overcome to trust a Black, nonbinary medical student less than half his age? From my experiences with neighbors who smelled like him, those tended to be individuals unafraid of protecting their family and property from their fears, both real and imagined.
My fear, I noticed, was now far away - hundreds of miles and decades away. I finally saw someone doing their best to stay as functional as possible for as long as possible.
I left and returned with my preceptor. She confirmed the vital information and finished the visit. Upon soliciting any closing questions, the patient interjected – “What can I do to keep my kidneys as healthy as possible?” one of the most valuable yet rare questions asked in any clinic.
The practitioner pondered his question briefly, before replying, “We often recommend patients avoid animal products and take up plant-based low-salt diets.”
The first utterance from the patient’s wife followed, a quick laugh. The patient put his chin down just enough to look at her from under the brim of his hat. That glow in his eyes was now a glower. He meditated on his answer before replying.
“We have a steak every night – big crack ’a’ black pepper and a pinch of salt on each side. You want me to stop eating steak?” I sucked on my lips behind my mask, moved by his passion for meat. She gently reminded him that he didn’t have to do anything – he was healthy as a horse after all.
I interjected, thinking I knew better. “I’m not going to ask anyone to stop doing something they like. Maybe you could think about getting some protein from plant-based food – make some baked beans that you like. If you fill up on beans or peas, maybe you end up wanting a smaller and smaller steak portion.” I monologued, realizing I had slipped into a southern New Mexican accent.
He pondered my words for a few beats before tilting his chin back up, the fluorescent lights allowing the glow back into his eyes. “I can certainly do sum’a’ my own research and figure somethin’ out.” He finally decided.
He was contemplative, a good place to be in the cycle of change. I pointed him to the Urology Care Foundation cookbook as a starting place and he thanked us profusely.
Like many patients weathered by their time in the beautiful and brutal southwest, he reminds us that the community needs us to keep caring for them. “We need everyone who wants to be here,” they say. He tips his hat to us as we leave room 1.
My preceptor announces to the workroom, “I just tried to turn a cowboy vegan - it was embarrassing.”
“’I can’t give up steak!’” another practitioner who was not present for our encounter, laughs with a Texan accent thicker than our patient’s Southeast New Mexican accent. Clearly, this patient script has been re-run thoroughly at this clinic.
“He was a surprisingly open and agreeable guy.” I recount, fondness edged with bitterness. Suddenly, I realized I was doing what I expected him to do – these assumptions on what he believed and experienced. This patient didn’t strike me as someone with a racist dog, but I certainly saw him being a Sunday night game type, in both the football and the elk hunting respects. Even if benign, I couldn’t fight the urge to make assumptions about his beliefs. I watched my preceptors do the same. I could see them opening that invisible container labeled with whatever this patient was to them – Farmers, cowboys, Republicans, Libertarians, Veterans, older white guys, “prostrate” guys, etc. This compartmentalizing may be helpful for understanding risks related to patient lifestyle, but it was so limiting applied on an individual basis.
The practitioners were back in their work now. I moved through the hallway to speak with the clinic techs to confirm he is scheduled for follow-up and can discharge.
As the patient walked out of room 1, He saw me just walk by and he clapped me on the shoulder, telling me, “Thanks and good luck, doc, you’re real good at this. I’ll let you know how the beans go. You keep up the good work for us.” A common sentiment from folks in this beautiful and brutal section of the country – they couldn’t afford to lose us.
I jumped at being unexpectedly touched by a patient, my hand raising first defensively, before catching myself and pivoting to waving goodbye. I beamed at him once his words and his trust hit me. I felt seen by the most unexpected individual. People in all boxes are generally capable of kindness and primarily seek understanding. I failed to extend that generalization to this man initially. When a patient surprises me, my expectations are usually the reason. I had a prejudice that a patient showed me was no longer for my protection – it only prevented my own connectedness.
Towela "TK" King is a fourth-year medical student at the University of New Mexico School of Medicine. King was born and raised around Las Cruces, New Mexico and earned their BS and BA in Evolutionary Anthropology and Psychology respectively through the combined BA/MD program at the University of New Mexico. They work closely with underserved communities, including the LGBTQI population and unhoused youth on health education and empowerment. They have been a leader in institutionalizing diversity, equity, and inclusion work as well as implementing trauma-informed care and cultural humility in medical education. They are also a comedian with an interest in utilizing humor in medicine.