Using the N Word Does Not Warrant a Behavioral Flag in a Patient Chart

“We are desensitized to the N word here,” said my white attending psychiatrist to the medical team.

I quickly replied, “Well, I am not,” returning their calm gaze with a glare. “And I will never be,” I added.

Earlier that day, a Black medical tech returned to the charting room, a look of anguish on their face. I overheard their conversation with a colleague describing being called the N word by a white patient and I hopped out of my chair, poking my head through the glass doors that separated the doctors from the nurses and other medical staff.

“He called you what?! I’m sorry to interrupt…,” I asked.

“Yeah…he called me the N word but it’s okay…” they said. “I have to deal with this a lot…This system won’t protect us anyway. I’ll be okay.”

I sprang into action, as tears filled my eyes, looking into the patient’s chart for any mention of racial targeting. I soon learned from my colleagues that this patient was known to the medical team, and his racist behavior had happened repeatedly, yet there was no mention of racism in his extensive medical notes.

I thought about the fact that my Black patient had a behavioral flag on his chart – a bright yellow warning about his behavior that one had to click through before even accessing his medical information. This behavioral flag was due to a verbal altercation from 20 years ago that he had with a white staff member. Yet, a white patient, who had been consistently verbally abusing Black staff for years, had no warnings on his file.

I put in a behavioral flag consult and explained my reasoning: “This patient has consistently targeted and verbally abused Black staff with racist hate speech, which is psychologically harmful, and creates an unsafe work environment for Black staff.” My attending assured me that the behavioral flag committee would likely not place a behavioral flag on this patient. Behavioral flags were usually for physical, rather than verbal, behavior, they explained. I opened my mouth to mention that my Black patient currently had a behavioral flag for a verbal altercation from over a decade ago, but then decided to say nothing. After all, like my attending said: they are desensitized to the N word. What that meant to me was: We, the system and those in power, don’t care about the effects of racism on Black people.

Systemic Racism Interferes with Policy, Invites Retaliation

Systemic or structural racism in psychiatry refers to the policies, systems, and structures that disadvantage Black people and other people of color. These racist systems not only affect patients but also doctors, other healthcare providers, and staff. The policies in place for deciding who gets a blaring yellow behavioral flag resulted in a white patient being allowed to racially abuse Black staff with no record, and a Black patient being flagged for a 20-year-old verbal disagreement with a white staff member. These processes are engrained and can also feel nebulous. As a psychiatry resident, I can request a behavioral flag but it is not up to me whether it is approved; it is up to the “committee and their policies” – a committee that I may never meet.

Even if I do, it requires additional effort on my part to attend the committee meeting, outside of my regular clinical duties, to advocate for a change in this behavioral flag process – to advocate for the N word to be taken seriously. Not only is this exhausting, but it is also dangerous. After all, as a Black female resident, I am not safe from retaliation.

I quickly learned that Black children and adults are commonly called the N word in many hospital systems and there are scant processes in place to protect them. Systemic racism is not just the presence of policies and structures that harm Black people, it is also the lack of policies that protect them. I was horrified when I learned that many of my Black child patients across multiple units were called the N word consistently, across days, while an all-white staff watched it happen with no effective intervention.

Black children who are suffering from horrific trauma and serious mental illnesses must bear the additional burden of racism. When I document the racism experienced by to these children in the hospital medical electronic record, my note usually stands alone. Often, I find that no other staff have documented when and how frequently Black patients are being called the N word. In addition, I often find no mention of racist behavior in the documentation of the white child patient who has targeted Black patients – only statements such as “they used unkind language towards others.” Meanwhile, these same Black child patients, while being called the N word daily, are described as “violent, oppositional, angry” during morning rounds, while the white children using the N word were described as “suffering and using unsafe language.”

In all these instances, I spoke up. Sometimes, I was met with silent nods from my white attendings and medical team, and other times, I was told that I was being intense and critical of my medical colleagues. I was told that “we always use words like that.” I was told not to challenge an engrained system of practice, even if it results in the harm of Black children.

Racist Language Leads to Incorrect Diagnoses

Words used to describe patients lead to diagnoses, and systemic racism in psychiatry trickles down to differences in psychiatric diagnoses across race – often leading to incorrect or “mislabeled” disorders. Black children are more likely to be diagnosed with disruptive behavioral diagnoses, such as oppositional defiant disorder (ODD), than white children, who are more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD) for comparable behaviors.1 (See also, a related report on disparities in ADHD assessments.)

“Excited Delirium”

Black adults are more likely to be diagnosed with psychotic disorders than white adults with comparable symptoms, who are more likely to be diagnosed with depression.2 After all, haloperidol, an antipsychotic medication, was marketed to quell “protest psychosis” – a racist pseudo diagnosis created to describe Black men during the Civil Rights Movement.3 Benjamin Rush, the father of American psychiatry, coined the term “negritude” in the 1800s, the disorder of being Black.4 The modernized lynching of George Floyd, and the killings of many other Black individuals, was justified under the false diagnosis “excited delirium.”

While delirium is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), defined as an alteration in cognition, excited delirium is not; it is a definition used to justify violence and murder of Black individuals by police,5 just as “protest psychosis” was made up to justify over-medication of Black individuals fighting for civil rights. In each era, there have always those, like me, who took an adamant stand against racism, but our mission has always been colossal. We are attempting to dismantle a system that has been functioning like a well-oiled machine for centuries. And many people of power are not on board with dismantling a system that benefits them.

Positions of Power in Psychiatry Corrupt the Field

White people do not hold most positions of power in psychiatry by pure chance. They hold most positions due to white supremacy, an intentional socio-political power structure that benefits white individuals over others. For the longest time, Black people could not even become doctors in the United States, let alone serve in leadership positions. (The first Black woman to earn a medical degree did so in 1864; fast-forward 154 years to 2018 and only 5% of active physicians in the US are Black; today, that percentage holds at 4% to 5% across the entire mental health care profession).6-8

From slavery, to Reconstruction, to Jim Crow, to redlining, to mass incarceration, systemic racism has resulted in intentional racist policies designed to keep Black people from gaining wealth. And in instances in which Black towns have gained considerable wealth, they were often burned to the ground by white mobs, like in the case of the 1921 Tulsa Massacre, which contributed to the economic oppression of Black Americans.9 Even when Black people do manage to afford the expensive process of becoming physicians, in spite of the intentional barriers, Black physicians still experience racism when it comes to promotion in academic medical leadership.10,11

Being Black and Female in Medicine: A Word from the Author

These racist systems affect my individual experience as a Black psychiatry resident every day. In any given rotation and medical team, I am often one of the only individuals who feels confident enough to point out the rampant racism in medicine, and I am often the only Black person in the room. Fewer than 5% of psychiatrists identify as Black,8 and allies are often sparse or scared to speak up. When I do speak up, there is often a person in power, usually white, who upholds the racist practice or individual behavior. When a white staff member screamed in my face on the first day of a new rotation, I was reprimanded for reporting them. I was supposed to talk it out, not cause problems. When another white staff member screamed at my child patient and I for speaking Spanish together, I was told by the attending that there was a no-Spanish rule because patients might be plotting, and that said staff member was having a bad day. When my Black co-resident was called the N word, the all-white attendings in power watched it happen and offered no support.

It has become clear to me that dismantling racist systems and policies cannot be done without holding racist individuals accountable. Behind every racist system and policy, there are racist individuals who are upholding it and racist behavior that is explained away and protected. The process is tiring, burnout-inducing even, but I continue to speak up, continue to take a stand. I believe that fighting racism is not a matter of politics but of human rights. Not a matter of interest but of necessity. And, I will never be desensitized to racism and injustice.

More from this collection on vicarious racism, gender identity, and disability justice in the BIPOC community; plus, a message from our guest editors and the way forward on DEI from other psychiatry residents.

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Last Updated: Aug 16, 2021