One of our patients, Ms. R, was not only the most symptomatic patient I had worked with, but also one who had little to no insight into her condition. Throughout the interview I struggled with my own thoughts. Watching her, I quickly realized that without active resistance, I would slip into voyeurism, as if she were a form of entertainment. Seeing how distraught her sister was with her worsening symptoms often snapped me back to the gravity of the situation, but without any real way of engaging with the patient it was all too easy to forget that she was a human being. This was a disturbing disappointment in myself.
While the appointment started off as friendly, by the end, Ms. R was sure that we were all her enemies. We were trying to increase her dosage of medicine for no good reason and kill her off by ruining her kidneys or sedate her to the point of floppiness. As her anger peaked she turned to me and my attending, a black man, and stated, “You're black and yellow pieces of shit.” She continued to repeat this several times until her ramblings turned into a string of noises and whistling with intermittent references to president Obama. While it was easy to take the comments in stride, this woman clearly wasn't herself, her sister was appalled and extremely apologetic. She insisted that this wasn't her sister and that in reality her sister is “the most loving person who couldn't hurt a fly.” In her eyes I could see the fear that we would not only judge her sister, but her.
It's easy to say that we weren't offended because it's not fair to be upset with someone who's delusional and paranoid – of course, the fact that she was floridly psychotic made the comment much easier to ignore - but it occurred to me that there was something larger at play. The actual content of her statement was not actually racist. The only insulting part of the sentence was being likened to a poop; the usage of black and yellow were simply descriptive. She never explicitly said, “You folks are inferior because you are not white.”
Ultimately, Ms. R wasn't trying to be racist, she was angry and trying to insult us. If we had both been white she still would have likened us to shit in some other way (though she would have had to be more creative). Certainly, it's possible that she has a certain level of implicit bias that is held in check when she's more cogent, but I also wonder if her usage is actually more reflective of society than herself. Insults are only effective when we collectively agree that the leveled comparison is bad. Just as we are (relatively arbitrarily) taught to consider the product of bowel movements to be smelly and messy and thus bad, millions of messages everyday also tell us that being non-white is bad. In her mind, she was just remembering the list of things that she had been taught were bad and using whatever seemed to apply.