Microaggressions in Clinical Training and Practice

Abstract

Feature Editor: Debjani Mukherjee, PhD Northwestern University Feinberg School of Medicine and Shirley Ryan AbilityLab The term microaggression was coined almost 50 years ago (1970) by Professor Chester Pierce and has reemerged as a topic of scholarly interest, a contested concept, a social media hashtag, and a polarizing issue in our current political climate. A classic article from 2007 by Derald Wing Sue and colleagues defines racial microaggressions as “brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults towards people of color.”1 Sue and colleagues further define three types of microaggressions. Microassaults are a “verbal or nonverbal attached meant to hurt the intended victim through name-calling, avoidant behavior, or purposeful discriminatory actions.” Microinsults are “communications that convey rudeness and insensitivity and demean a person's racial heritage or identity.” Microinvalidations are “communications that exclude, negate or nullify the psychological thoughts, feelings, or experiential reality of a person of color” (p. 274). The term was first applied to race and racism, however, the term also applies to other marginalized groups including women, people with disabilities, sexual and gender minorities, and religious minorities, among others.2 There are critiques of the concept, including the observation that the research on microaggressions is “underdeveloped,” lacks scientific rigor, and may be “embedded in politics.”3 Yet, there is agreement that insults, snubs, and slights undermine relationships and practices and affect health care. How does the experience of microaggressions impact the practice of medicine? How have your experiences or those of your colleagues underscored the complexities of this concept? Illustrative examples, particularly from PM&R, are welcome. What are the ethical implications? Do you have suggestions for decreasing microaggressions, on the individual, group, institutional or societal level? Maryann Katherine Overland, MD University of Washington School of Medicine A man comes to an appointment with his primary care provider. In the exam room, he is greeted by Dr. Morales, a Latina intern, who is not his usual doctor. The patient says, “You aren't a real doctor. You're too young. I want someone who can speak English.” When Dr. Morales leaves the exam room to staff the encounter with her attending, she shares what the patient said. Her attending, an older white man, says, “As a woman of color in medicine, you're going to have to get used to that.” Microaggressions are commonplace in medicine. Although they might be innocuous in intention, they can be harmful in impact. Microaggressions undermine physician–patient relationships, resulting in a lack of trust and lower quality care.1 Microaggressions take several forms in medicine: they can be perpetrated by physicians against patients, by attendings against trainees, between colleagues, among interprofessional teams, and by patients against physicians. Microaggressions by physicians and other healthcare providers against patients are harmful to a patient's health and can lead to worse health outcomes. However, microaggressions by patients against physicians also put a patient's healthcare quality at risk. Although patients occupy a marginalized group relative to physicians due to the inherent hierarchy of medicine, female physicians, physicians of color, international medical graduates, and LGBTQ physicians are often victims of contrapower microaggressions. Contrapower harassment occurs when a person with traditionally less power in a relationship harasses someone with traditionally greater power [ie, a male student harassing his female professor]. Status incongruence - the mixed power differential between an often anxious, sick, stressed patient and a physician from a marginalized group - can lead to encounters that undermine or demean the physician. Although most harassment of medical trainees comes from attending physicians and nurses, many medical trainees report harassment from patients, which can affect career decisions.2 Several years ago, I was attending on the inpatient medicine service at the Veterans Administration (VA) hospital where I work as a primary care physician. We were at the bedside of a man who was discharging home later that day. The senior resident was reviewing his medications. She asked the patient to teach back about the importance of completing his antibiotics as prescribed. The patient replied, “You're so pretty, I'll do anything you ask of me.” After a shocked moment I replied, “Sir, we are here to focus on your health and your doctor is trying to keep you safe.” He apologized and we finished the counseling. Later the resident shared that nobody had ever stood up for her before, in spite of frequent witnessed and unwitnessed inappropriate patient behavior throughout medical school and residency. She asked me to teach her the words I had used so she could do it herself the next time it happened. I realized that I had never been taught to address these behaviors - in fact, I was explicitly told during medical school that it was the doctor's job to “take it on the chin” when patients harassed or demeaned us. It wasn't until I was supervising trainees that the potential toxicity of microaggressions by patients became explicitly apparent to me. Over the ensuing years, individual female residents would approach me, whispering their own stories of inappropriate patient behaviors, and ask for coaching on how to respond. Residents of color and LGBTQ residents were experiencing it as well. The pervasive feelings were of shame, embarrassment, and anger; these residents were suffering from a death by a thousand tiny cuts. Over time, I witnessed marginalized residents avoiding contact with repeat offenders, which had the potential to negatively affect patient care. In his essay on microaggressions and epistemic injustice, M. Tschaepe wrote, “microaggressions undermine the credibility of knowers, and their capacity for becoming knowers. Marginalization and depersonalization from microaggressions places persons who are targets of microaggressions in a position in which their autonomy is called into question and diminished.”3 The experience of being devalued diminishes an individual's ability to fully participate in complex cognitive tasks. Repetitive mistreatment during training leads to negative emotional and physical repercussions, decreased work performance, and ethical distress. Microaggressions committed against people early in their journey of professional identity formation has the potential to have a larger negative impact than when it occurs later in a physician's career. “It is important to emphasize that microaggressions are not about having hurt feelings. Rather, it is about the negative effect that being repeatedly insulted, invalidated, alienated, and dismissed have at both a micro [biological] and macro [social] level.”4 Education to address microaggressions that empowers trainees to prepare for, assess, respond to, and reflect on the microaggression can mitigate the negative impact. In the University of Washington Internal Medicine residency program and our affiliated VA hospital, we have initiated a multipronged education initiative to address and mitigate the impact of microaggressions on trainees. This includes faculty development and resident training. We teach a three-step approach to addressing microaggressions before, during, and after an event. We encourage attending physicians and senior residents to introduce the idea of responding to microaggressions and other mistreatment before the events occur. This conversation happens early in the professional relationship and includes open-ended questions about how individuals on a team prefer to respond to patient microaggressions. Some trainees prefer to address microaggressions themselves, whereas others prefer a response from more senior members of the team. During this conversation, the team can reflect on situations in which a direct response might not be the best one. We create space for trainees to share their own experiences of microaggressions in medicine if they wish to do so. Although every team will have its own dynamics and strategies for responding to microaggressions, we recommend making explicit plans on how to respond. Step 2: Address the comment - name the behavior as inappropriate Step 3: Refocus the conversation on the patient's health Step 4: Share your perspective Step 5: Remind the patient of roles Step 6: Temporarily remove learners from the environment In our experience, we rarely have to move past step 2 to refocus the visit on the patient's health care and protect the trainee's well-being. However, we find that practicing this approach in a role-playing or other nonthreatening setting is vital to empowering trainees to respond in what is a stressful situation. Debriefing is an important step in addressing microaggressions by patients. Make time to reflect on these uncomfortable patient encounters after they occur. We encourage faculty to ask trainees how the situation felt for them. The individual or team can reflect on what went well and what could have gone better in the future. This reflection can mitigate the moral distress and negative impact of microaggressions. Patient–physician relationships are nuanced and complex, even more when an individual in the dyad is from an historically marginalized group. Although addressing every microaggression from patients to physician trainees might not be appropriate, ignoring, suppressing, laughing off, or otherwise minimizing microaggressions is also inappropriate. Respecting our patients means holding them to high standards of behavior. Training, mentoring, and empowering a diverse medical workforce is vital in ensuring the health of our diverse population. Our approach is one possible method to mitigate the impact of microaggressions against trainees. I encourage all training programs to consider what is best for their trainees and patients. University of Washington School of Medicine Jennifer M. Zumsteg, MD, Edwin G. Lindo, JD “No, where are you really from?” “Courtney, I never see you as a Black girl.” “You're not really Asian.” “I'm sorry, I asked for the doctor” (Black female attending wearing her white coat) “Hi Alfredo, good to see you.” (The person's name is actually Edwin) “How old are you?” These quotes are statements made to individuals from marginalized groups. But how can these words, which some suggest to be only missteps of the tongue, be a problem? Shouldn't individuals from marginalized groups build a thicker skin and not be so sensitive to words? That would prevent so much trouble, wouldn't it? We would like to be clear on microaggressions: They are affirmative acts, done subconsciously, that, when compounded over time, cause significant harm to the recipients. Although the word contains the prefix, “micro,” the effects of the acts are far from micro — they contribute to the totality of the systemic oppression of marginalized communities. Starting from this premise, we can explore the nuances of microaggressions in the practice of medicine. Biases are the beliefs and attitudes we hold, implicitly and explicitly, of others. Biases can be negative or positive. 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