The Cost of Silence on Racism: A Dialogue

This conversation was inspired by a clinical encounter during an intern’s inpatient psychiatry rotation after which she posed the question, “Was that racist?” An attending psychiatrist offers reflections on her own training experience and continued challenges navigating a marginalized racial identity in psychiatry.

“Was that racist?” As two black female psychiatrists, our professional and personal development have been punctuated by this question too many times to count. We invite you to our dialogue as an early career psychiatrist and resident psychiatrist as we outline a few of these most notable junctures of racism and our personhood. This conversation was inspired by a clinical encounter during Dr Uyanwune’s intern year inpatient psychiatry rotation after which Dr. Uyanwune posed the question, “Was that racist?” As an attending psychiatrist, Dr Isom offers reflections on her own training experience and continued challenges navigating a marginalized racial identity in psychiatry.

Dr Isom: The question rang out seemingly accompanied by a haunting echo when I first heard it from you. I thought to myself that I had asked myself this question numerous times. The answer always lay in the body. I knew I needed to explain the body-based reactions that clue those with darker skin into the realities of a racialized existence. I wanted to say, “Trust your gut!” These were important signals throughout residency. The quickening of the breath. Goosebumps on the arm. Fluttering in the chest. The body sending alarm signals meant to communicate that you, they, we, are not quite right in this moment. Something is awry.

You asked, “Was that racist?” I offered a simple “Yes,” first because it is the most important thing to say. My reply was loaded with memories, pain, and anger as I too had felt and flinched at the experience of interpersonal racism. Did you notice anything in your body during that moment on the wards? Have you felt those clues before?

Dr Uyanwune:Sad to say, I have felt similar feelings and asked myself the same question. However, for me, it wasn’t until I moved from my home country Nigeria and lived in Europe (Holland, specifically) at the age of 11 that I was confronted with those physical sensations more often than not. At the time, my question wasn't, “Was that racist?” Instead, I constantly felt like the other and wondered, “Why am I different?”

I was focused primarily on myself and what I thought I was repeatedly doing wrong on a daily basis that resulted in differential treatment amongst my peers. It wasn't until a few years later that I was able to process these experiences, and as I look back now, when I ask, “Was that racist?”, the answer is, “Yes.”

Let your trainees know they can come to you with difficult racialized experiences. And when they do, listen. This applies to any psychiatrist confronting racism, not just those in training. We could use your support at all levels.

Dr Isom: It is a fascinating thing, racial ethnic identity development. It is a different journey for all of us, so individualized. I remember when I was 10 or 11 and on a family trip to Walmart. I had been told by my parents I was black and the world was going to treat me differently. However, I hadn’t quite experienced the shock of it until I turned the corner in the store and came face to face with an older white woman pushing her cart. She was accompanied by her husband. She nearly spat at me, “Stupid N*****r,” before rushing past me with her husband, who stood silent, as if I were non-existent.

That is when I knew, you can feel it in the body; it’s so visceral. I was terrified. That moment was a reality check that racism had no regard for the innocence of my youth. I still cry at the memory especially when thinking about the possibility of my toddler daughter being exposed to a similar encounter at some point.

Dr Uyanwune:Wow, I’m sorry you had to experience that, especially at that age. After I moved from Holland where I attended a predominantly white school, I went to college in Toronto, Canada, and found myself surrounded by black and brown bodies. In Holland, I didn’t feel comfortable telling my white friends about my racialized experiences. However, in Toronto, I felt more validated amongst my friends. It was a more comfortable space where I wasn’t gaslighted but rather affirmed whenever I spoke about these difficult and traumatic experiences. This allowed me to be more vocal about the discrimination I experienced on an almost daily basis.

Dr Isom: I had the same experience at my historically black college. It was transformative. Wouldn’t it be wonderful to have that kind of mirroring experience anywhere we go such as residency and life in general? To be validated, affirmed, and supported in general but also to have support when processing our experiences of racism? Knowing that that isn’t always the outcome has led me to be more silent in spaces where a validating response is less likely.

The dangers of projection are always around us. We take steps to not appear angry or aggressive which saps our opportunities to assert our humanity. It is nearly surreal that we have to take extra steps to avoid rocking the boat by erasing our own experiences for the comfort of others. Black Lives Matter, right?

Dr Uyanwune: Yes! As a trainee in medicine, it would be healthier to feel comfortable sharing these experiences on rounds with my attendings. Instead, I have found most of the time when discussing difficult patient encounters, my attendings fail to see through a racial lens when working with black and brown residents. Rather, they often put up a defense at the mention of racial dynamics, and this hinders further discussion and subsequently deters me from mentioning future experiences with them. They don’t seem to understand that they are undermining patient care.

Dr Isom: That white fragility is something powerful, isn’t it? With the overwhelming majority of attendings and administrators being white in our training program, it was a concept I remember having to learn quickly. You can never quite tell, particularly early in training, how much your lived experience will be honored. As an attending, I am still navigating spaces where my racialized experience cannot be discussed openly for fear of discussing what seems to be taboo in medicine.

It is interesting to see white people and others purchasing books on white culture now out of interest. I bought the books years ago for my own survival. I needed to read about white culture to be safe and successful. Beyond those who are black, this is an essential lesson for all those who identify as persons of color.

If you could offer one piece of advice to those responsible for trainees and working alongside any psychiatric colleague, what would you say?

Dr Uyanwune:To attendings and supervisors, I would say, read and educate yourself on these issues and topics. It is difficult and uncomfortable work that needs to be done. Let your trainees know they can come to you with difficult racialized experiences. And when they do, listen. This applies to any psychiatrist confronting racism, not just those in training. We could use your support at all levels. Foster a liberated space that allows them to speak their truth to power.

Believe them. Validate them. Affirm them. Lastly, practice calling out injustices and inappropriate behaviors when you see and hear them.

Dr Isom: I echo your suggestions and invite those in the field to examine their racial identity and own the responsibilities that come along with it, for our patients and for our specialty. The cost of silence on racism in medicine must become prohibitive. The time is now.

Dr Uyanwune is a PGY-2 Resident in the Department of Psychiatry, Yale School of Medicine. Dr Isom is an Attending Psychiatrist, Codman Square Health Center and Boston Medical Center.