Microaggressions Persist in Medicine and Surgery

By Will Boggs MD

July 17, 2019

NEW YORK (Reuters Health) - Raising awareness, voicing concerns, and confronting microaggressions are critically needed to foster a more accepting culture in medicine and surgery.

"Microaggressions are experienced by women and underrepresented minorities on a frequent basis," Dr. Arghavan Salles from Washington University in St. Louis, Missouri told Reuters Health by email. "While each microaggression may seem minor to an observer, as a person who is a minority, experiencing these all the time is like a thousand paper cuts."

Dr. Salles and colleagues define microaggressions, discuss their effects, and offer suggestions for how recipients or bystanders might respond to them in their July 10th JAMA Surgery online special communication.

Microaggressions are defined as "subtle snubs, slights, and insults directed towards minorities, as well as to women and other historically stigmatized groups, that implicitly communicate or at least engender hostility." They extend beyond verbal abuse to encompass general disrespect, devaluation, and the exclusion of recipients.

Microaggressions can be subdivided into four groups: microassaults, characterized by verbal or nonverbal attacks clearly intended to offend the recipient; microinsults, subtle snobs or humiliations that convey a demeaning message to the recipient in a way that may be unintentional to the one doing it; microinvalidation, actions aimed to exclude, negate, and dismiss the personal thoughts, feelings, or experiential reality of a person; and environmental microaggressions, when any of these actions are reflected in the culture, processes, and climate of the workplace.

Microaggressions generate stresses equal to or worse than overt discrimination. They contribute to lower self-esteem and have been linked to depression, anxiety, and trauma responses.

Several frameworks have been proposed for how to structure a response to microaggressions by either recipients or bystanders. The "Observe, Think, Feel, Desire" approach begins with stating what was observed and proceeds through a discussion of how the comment was interpreted, how it made the recipient feel, and what the desired outcome might be.

"ACTION" involves six steps: Ask clarifying questions; Come from curiosity, not judgment; Tell what you observed in a factual manner; Impact exploration-discuss what the impact of the statement was; Own your own thoughts and feelings around the situation; and Next steps.

Perhaps the simplest approach is XYZ: "I feel X when you say Y because Z." This framework reduces the potential for defensiveness and encourages dialogue.

The ultimate goal of any approach, the authors say, is to work toward a mutual understanding of why something can be perceived as a microaggression and its effect on the recipient.

"Letting microaggressions regularly occur without any commentary facilitates their occurrence," Dr. Salles said. "People often make the mistake of thinking it's not their place to say anything if the comment wasn't directed toward them. But really anyone and everyone can speak up when these inappropriate comments are made. Depending on the power structure and the context, sometimes the target is able to respond, but sometimes that person is in a vulnerable position and can't afford to say something for fear of retribution. We can all step up in those moments."

She added, "We ought to be teaching medical students, residents, fellows, and faculty about microaggressions - what they are and how to react to them. We should be teaching trainees to recognize these moments and give them tools to respond, if and when they choose to do so. Since microaggressions often come from patients, faculty should be taught how to intervene, both on behalf of trainees and on their own behalf."

"Microaggressions are unfortunately a real part of the experience of many physicians and physicians-in-training," Dr. Salles said. "These microaggressions may impact people's career choice and their ability to contribute to healthcare to the best of their ability. Ultimately, microaggressions may impact patient care. If we are left wondering about whether a particular comment was meant to be an insult or not, or whether a patient or colleague doubts our ability, it is difficult to focus on making a diagnosis and identifying the optimal treatment plan. We all want the best for our patients, and we should be able to focus 100% of our capacity on their care."

Dr. Javeed Sukhera from Western University, London, Ontario, Canada, who has extensively researched implicit bias in healthcare settings, told Reuters Health by email, "We need to bring microaggressions out of the shadows and start an uncomfortable conversation about what they are, and how they impact patient care. We also need to have an even more uncomfortable conversation about how we can address them."

"Health professionals are often educated about microaggressions through curricula that enhance awareness, communication skills, and promote feedback seeking, while addressing the intersecting forms of discrimination and prejudice within organizations," he said. "Despite some promising results, efforts to promote education about microaggressions have been constrained by numerous barriers. For example, simply educating individuals to address broader structural inequities without attention to organizational and cultural influences may prove unsustainable. In addition, topics such as microaggressions can trigger negative emotional reactions for health professionals, leading educational efforts to backfire."

"I think the greatest emphasis should be on the impact of microaggressions," Dr. Sukhera said. "When we know that they perpetuate psychological distress, erode trust, and inevitably hurt patient outcomes, then we know that we must do something about the problem."

Dr. Scott O. Lilienfeld from Emory University, Atlanta, Georgia recently bemoaned the lack of research regarding microaggressions. He told Reuters Health by email, "I was pleased to see that in their recommendations, (the authors) appear to suggest that microaggressions be the starting point for discussions aimed at increasing mutual understanding rather than opportunities to accuse others of intentionally malicious actions. I also agree with the authors that subtle prejudice still exists in medicine, and that it is important to be able to discuss this issue openly and nondefensively."

He suggested, though, that "the concept of microaggression tends to be vague and ill-defined. This ambiguity is potentially dangerous, as it can allow individuals to classify a large variety of behaviors as microaggressive."

Dr. Lilienfeld also noted that "the authors don't discuss the possibility that some microaggressions merely reflect inadvertent cultural or racial slights or misunderstandings on the part of those who emit them. By referring to those who commit microaggressions as perpetrators - a common term in the microaggression literature - they may be perpetuating the idea that these individuals are somehow malicious in intent."

Dr. Zareen Zaidi from University of Florida College of Medicine, Gainesville, who recently completed an exploratory study on microaggressions in medical school, told Reuters Health in an email, "Microaggressions can be contrasted with macroaggression (i.e. racism), which is by and large not tolerated in Academic Medicine. However, microaggressions are much more insidious and often committed by well-meaning individuals who don't realize they contribute to and negatively impact the careers of women and minorities."

"Awareness about microaggressions is step one," she said. "Training targeted individuals and bystanders is step two. Institutional interventions and policies is step three. Until medical educators make a concerted deliberate effort to deal with microaggressions, women and minorities will continue to experience 'death by a thousand feathers' - the phenomenon described by Phyllis Carr to describe the continuing attrition of women and minorities in medicine."

SOURCE: http://bit.ly/2Z3Syrb

JAMA Surgery 2019.