Some Attendings Are Safer Than Others: Navigating Supervision as a Black Psychiatry Resident

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COMMENTARY

“You know, I am not typically attracted to Black men, but…” said my non-Black attending as we walked down the hallway to our next patient. I did not listen to the rest. Fortunately, she was not looking at me as she spoke. If she had been, my facial expression would have clearly communicated my disdain. Listening to this attending sexualize Black men, which is a longstanding racist behavior,¹ was not something I ever wanted to do—let alone as I was being supervised during a clinical rotation in my first year of residency. Racist statements are cognitively disarming when I am at work trying to learn how to be a psychiatrist. But, as a Black resident, I have learned to deal with them—I have to.

I thought back to medical school when I was summoned by a senior attending to discuss a psychiatric patient. I ruffled through my notes as I walked towards his office, reviewing my patient formulation and speculating about the questions he might ask me. I took a deep breath and pushed open the door, making a mental note of my proposed medication management for the patient. “Ah, Amanda,” said the senior attending, looking up from his desk. “I wanted to ask you. This patient wants to apply to college, but she does not think she can get a scholarship. I was wondering if you had some tips. I mean, she’s Black, she’s female, and she has a mental illness. Isn’t that the perfect trifecta for easily getting a scholarship to college?”

I frowned. “I don’t think there is anything easy about being Black, female, and having a mental illness. Unfortunately, I cannot give tips about scholarships because I did not have one as a college student at Yale.” His jaw dropped.

Conversations like these are some of the least troublesome I have encountered during supervision. In fact, I have come to expect them, and growing up in predominantly white spaces, insensitive statements with racist assumptions that I am somehow less-than are commonplace.² As a child, they upset me, but I had coaching from brilliant parents who are professionals at navigating racism.

Troubling Encounters

Some interactions with supervisors are more troubling. Attendings have deleted my notes documenting racist events in the hospital, stated that my activism can “hurt or help me” in my written evaluations, or told me that I am overly confident when I state that the impact of racism cannot be minimized. I find that some supervisors simply do not want to discuss racism at all, maybe because they do not believe it is a factor or maybe because their knowledge is lacking in the area.

There is a hierarchy in medicine, and psychiatry is no exception. I am not just a resident learning psychiatry—I am also an activist and a scholar in anti-Black racism. In addition to my lived experience, I am pursuing a PhD focusing on the impact of racism on Black youth, and I relentlessly study the work of Black scholars before me in conceptualizing racism and its impacts. While I do not consider myself an expert yet, many others do, and that can make some supervisors, who expect to know more than me about everything, feel uncomfortable. Navigating the supervisor-supervisee relationship as a Black female resident, activist, and scholar in anti-Black racism can be challenging, but I have refined my process of interaction along the way, largely by trial and error.

Temperature Checks

I always do a supervisor “temperature check.” A supervisor’s response to my vague and palatable statement about racism often gives me more than enough information about safety. The temperature is just that: a range of safe to unsafe, with many nuances along the spectrum. A supervisor may be safe to discuss racism with abstractly, but not in real-time clinical circumstances.

For example, the supervisor may feel that racism plays a role in the medical system at large, but if I point out that a white staff member in their unit seems to be treating patients differentially based on race, the supervisor becomes angry or defensive, rather than investigative and concerned. Of course, sometimes the supervisor sets the temperature before I test it. If they make an offensive statement like, “you know where the most child abuse happens? In Native American reservations…,” then I know that the supervisor is unsafe. On the contrary, if they make a statement acknowledging the impact of racism, stating the actual word racism, or even better, white supremacy, then they are on the safer end of the spectrum.

Actions are important, too—maybe more so than words.

Actions are important, too—maybe more so than words. Once, a supervisor and I were listening to a white psychiatric patient discuss his experience. During the story, and quite randomly, he stated, “Yeah and then the visiting nurse came in…and you know, she was Black…” My ears perked up immediately. The supervisor let the patient finish and then replied, “I noticed you mentioned the race of the visiting nurse. Why? Did you have an issue with the fact that she was Black? Was racism at play there?” The actions of that supervisor spoke volumes for me.

My perceived safety level of a supervisor determines whether and how often I discuss racism. I may leave out any mention of racism during supervision with unsafe supervisors, even though helping the patient to navigate racism was a crucial part of their treatment. On the contrary, I discuss racism much more openly with safe supervisors. We may engage in in-depth discussions about how to shape the patient’s treatment in the context of the racism they experience. The safest attendings are the ones who not only discuss racism in an abstract and intellectual way, but who respond to racism in real-time, in hospital settings, and in their own departments.

If I witness or experience racism while working with an unsafe supervisor, I will not consult them about it. My next step is deciding whether to report the racist event, which is a complex decision. Reporting racism requires that I attend a series of meetings with leadership, which is taxing in and of itself. Not to mention, there are inherent risks of retaliation when one reports. Usually, I will reach out to a trusted supervisor to seek advice about next steps—a “supervisor for my supervisor.”

Racist events that clearly impact patient care only touch the surface of the many types of racism that are problematic in the medical system, like everyday racism. Everyday racism (also known as microaggressions) refers to the common cuts and slights I experience—the lack of eye contact and eye rolling by certain white staff (behavior that they do not exhibit towards my white colleagues), the constant questioning of my orders, the ignoring of my questions—the list goes on. Everyday racism may be subtle to those who are not targeted by it, so voicing when it happens, even though its effects are profound,³ requires that I have the utmost trust in my supervisor. The usual end result? I never mention the everyday racism I experience to most supervisors, even if I am quite upset by it. And frankly, I will not report it either. It is too difficult to “prove,” and sadly, there are few structures in place in the medical system to adequately capture and effectively respond to everyday racism that Black and other minoritized physicians and staff experience.

Concluding Thoughts

To be sure, there are many positive aspects to the supervisor-supervisee relationship. As a resident, supervision is crucial to my learning and development as a psychiatrist. The invaluable opportunity to present and discuss patients with a senior attending is a central part of psychiatric training. Nevertheless, navigating the supervisor-supervisee relationship as a Black woman and an anti-Black racism scholar can be tricky.

It is uncomfortably common to have unsafe supervisors, so navigating supervision requires additional planning as a minoritized supervisee, which often results in missed opportunities for important conversations about racism to occur in supervision. But, encountering truly safe supervisors is invigorating for me, because many spaces are not safe to discuss racism. In fact, I firmly believe that safe supervisors are the best supervisors. They feel that supervisees, like me, have knowledge to contribute through our lived experiences and our scholarship. They listen to us in addition to teaching us, and, in situations where racism plays out in real time—they help us.

Dr Calhoun is an Adult/Child Psychiatry Resident at Yale Child Study Center/Yale School of Medicine. She is also a Public Voices Fellow of the OpEd Project at Yale University.

References

1. Smith D. Fetishization of Black men is a form of prejudice. North Texas Daily. November 7, 2020. Accessed October 19, 2021. https://www.ntdaily.com/fetishization-of-black-men-is-a-form-of-prejudice/ 

2. Anderson E. The White space. Sociology of Race and Ethnicity. 2015:1(1):10-21.

3. Overland MK, Zumsteg JM, Lindo EG, Sholas MG. Microaggressions in clinical training and practice. PM&R. 2019;11(9):1004-1012.