‘Small actions, big impact’: How physicians can identify, respond to microaggressions

Key takeaways:

• Microaggressions are negative slights based on someone’s marginalized status in society.
• Leaving microaggressions unaddressed in the workplace can have serious impacts on employee morale and patient care.

Microaggressions are just as commonplace in medical settings as other workplaces, and although they may be small behaviors, experts said they can have serious impacts on employee morale and patient care when they go unaddressed.

However, many physicians are not equipped to deal with microaggressions, as they are rarely discussed during training.

In response to this need, Herrick “Cricket” N. Fisher, MD, MPhil, a hospitalist and director of the internal medicine residency’s Integrated Teaching Unit at Brigham and Women’s Hospital and an instructor at Harvard Medical School, took it upon herself in residency to develop a training course and toolkit to help health care providers have the confidence to address microaggressions targeting themselves or others.

Fisher and colleagues also have conducted research to determine just how common microaggressions are in a medical setting. Their findings, published in 2022 in Journal of General Internal Medicine, found 96.1% of 103 internal medicine residents reported witnessing at least one microaggression in the preceding 6 months, and 40.8% reported seeing them at least once a week. Both men and women reported seeing microaggressions related to gender, and residents reported women being targeted for their race and ethnicity more often than men. The researchers noted these estimates regarding the prevalence of microaggressions are similar to what is found in other studies of health care professionals.

Microaggressions can be directed toward anyone, with patients and trainees being especially vulnerable. Microaggressions can also come from anyone — in that same study that looked at microaggressions experienced by trainees, residents reported the most frequent sources were patients and their caregivers, followed by hospital staff such as nurses, attending physicians and other providers

Nancy I. Joseph, DO, FACAAI, an allergy/immunology consultant and medical adviser at Weatherby Healthcare and the Allergy & Asthma Network, said she frequently experiences microaggressions from patients and their caregivers and from other medical professionals.

“I experience microaggressions in all aspects of my professional life, both in and out of the clinical setting,” Joseph, who has spoken about microaggressions at the Annual Medical Education Conference, told Healio. “Microaggressions are common. Even though they seem small, they have a big impact.”

Following Healio’s Women in Allergy’s prior story on the topic of managing difficult patient interactions, we spoke with Fisher and Joseph about what microaggressions are and the consequences they can have for health care workplaces, as well as strategies for specifically responding to microaggressions from both patients and colleagues.

What are microaggressions?

Microaggressions can be a problem in any workplace environment, and health care systems are no exception. But in order to address them, it is essential to understand exactly what microaggressions are.

“It is a negative slight, invalidation or insult,” Fisher said. “Microaggressions can be verbal, behavioral or environmental. The key thing that distinguishes a microaggression is that it is based on one’s marginalized status in society.”

Fisher said the term was introduced in the 1970s by Chester M. Pierce, MD, a former professor of education and psychiatry at Harvard University and Harvard Medical School, specifically when he described how ingrained microaggressions are in marginalized peoples’ everyday lives.

Microaggressions often target gender identity, race and ethnicity, sexual orientation, and language or nationality, but Fisher said they can target any social identity. They also are subjective, meaning some people may consider an action to be a microaggression, whereas others may not. That is one reason why it is important to focus on the impact of the microaggression, not the intent.

One example Joseph shared was male patients who refer to her by her first name, even when she refers to herself as Dr. Joseph.

Another common microaggression she experiences is when patients ask where she is from, then follow up with, “Where are you really from?”

“This says, ‘I already assumed where you are from and your answer did not match my assumption,’” Joseph said. “Maybe they were just curious, but they don’t realize that is actually a microaggression.”

Small actions, big impact

Not addressing microaggressions in the workplace can lead to serious impacts on staff morale and patient care, Fisher said, adding that studies have found experiencing microaggressions was associated with lower self-esteem and higher rates of depression and anxiety, burnout and suicidal ideation. She also said that studies have shown that experiencing microaggressions can lead people to perceive their workplace as hostile and invalidating, resulting in impaired productivity and problem solving.

“This is the opposite of what we are trying to achieve for our places of clinical care and education,” Fisher said.

Despite how common and potentially destructive they are, many of these incidents are never addressed or reported. In a study of 232 residents published in JAMA Network Open, de Bourmont and colleagues found that 85% never reported biased patient behavior they experienced — the most common of which included belittling comments and assumptions of nonphysician status — to their institution. The most common reasons mentioned for forgoing these reports included feeling like they needed to prioritize the patients’ clinical care and that doing so would be futile.

Additionally, 89% of residents said training and policies for biased patient behavior was necessary or very necessary.

“Do not be afraid to bring it up, even if it is coming from a colleague you have known for years or someone you consider a friend,” Joseph said. “Because, in a way, addressing the microaggression is helping that person by bringing awareness to a very important situation.”

Need for guidance

Fisher has dedicated her research to developing training for residents and medical professionals on microaggressions. She became interested in the topic after an incident occurred during her residency, when one of her colleagues in the residency’s Women in Medicine Action Group experienced extremely offensive behavior from a patient and wished they had a guide they could use to better manage such situations.

“I thought there had to be a toolkit out there, so I planned to see what people had published and bring it back to the group,” Fisher said. “When I looked, I could not find anything.”

Fisher decided to fill the hole she found in the literature and began collaborating with colleagues to build a toolkit for how to respond to microaggressions. She created the first iteration in 2018 and has updated it as more information gets published.

In 2019, Fisher began offering workshops for residents in her hospital on how to identify microaggressions and a variety of different ways they can respond. She found that the workshop improved their self-assessed comfort identifying microaggressions (29% before vs. 89% after), understanding of the impact of microaggressions (62% vs. 97%) and confidence in responding to microaggressions (13% vs. 70%).

Today, she continues to host this workshop for trainees and faculty at her hospital, and she is often invited to present locally and nationally to health care professionals on responding to microaggressions in the workplace.

“They aren’t novel strategies,” Fisher said. “They are adapted from a lot of great literature and strategies that other people have come up with.”

Tools for any situation

When deciding how to respond to a microaggression and whether your approach was successful, Fisher recommends considering three variables:

• Fit: What fits your personality and the situation?
• Goal: What outcome are you hoping to achieve?
• Satisfaction: Do you feel satisfied with your response?

“We need to have a wide variety of responses because there are huge variations in who we are and what is going to resonate and feel genuine to us,” Fisher said.

Because of those variations, Fisher’s toolkit includes 15 response strategies and encourages users to add others of their own. These response strategies include some indirect approaches such as interrupting and redirecting the conversation or using a phrase like “Pardon me? I didn’t quite catch that” to buy time to prepare a response. The strategies also include direct approaches such as setting respectful boundaries or stating your take in which you clearly and unapologetically describe your experience, such as saying, “I was so shocked by that remark that I stopped being able to think about your treatment plan.” (see Table for additional response strategies).

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“I ask, ‘What do you mean by that?’ or ask them to elaborate on their comment,” Joseph said.

By learning their intentions, Joseph can tailor her response to explain why their comment was harmful.

When working with patients, Joseph often redirects the conversation back to the reason for their visit, but she said it is OK to excuse yourself if their behavior is upsetting you.

“There are tools for you to use that work with whatever situation you are in and whatever fits with your communication style, so do not be afraid to use them,” Joseph said.

‘Your silence is not neutral’

To respond to microaggressions, Fisher offers two guiding principles, the first of which is to center the target of the comment or behavior.

“If that was you, then you get to prioritize your own needs,” Fisher said. “If not, then you need to practice some humility and recognize that you do not know what the person who was targeted needs.”

The second guiding principle is for those who witness microaggressions directed toward others.

“If you are a person with relative power or privilege, your silence is not neutral,” Fisher said. “It can be interpreted as condoning, promoting, endorsing and perpetuating the status quo that allowed the microaggression to happen.”

As physicians, it is important to be a voice for people who experience microaggressions, Joseph said.

“One of the central parts of our job is to advocate and stand up for people who may not be in a position to advocate for themselves at the time,” Joseph said.

Joseph uses microaffirmations to counter microaggressions she witnesses in her workplace, such as when she and a colleague may speak with a patient together, but then the patient only addresses one of the providers.

“In that case you can employ a microaffirmation, where you say, ‘My colleague is very knowledgeable on this subject, and it is important we bring them into this conversation,’” Joseph said.

The same strategy can be used when a colleague is cutting off or ignoring patient input, Joseph said. Fisher said it is important to watch for microaggressions directed toward patients, because providers have built-in power over them.

In cases where you do not feel comfortable or capable of addressing microaggressions yourself, Joseph said you may have to escalate the issue to someone with higher authority.

“It is important to understand the hierarchy in your workplace and the policies of that particular setting,” Joseph said.

‘Fight the defensiveness’

Addressing and preventing microaggressions in the workplace requires institutional buy-in, Fisher said. If the institution realizes microaggressions are occurring, it needs to take on the responsibility for addressing them, which could be through training or new policies.

“Having a patient code of conduct and a provider code of conduct can be helpful if it clarifies how they can be enforced or implemented,” Fisher said. “It would be great to have more institutional repercussions for people who continue to commit microaggressions.”

Individuals should also set up a culture of honesty and openness, Joseph said. For instance, ask your colleagues to tell you if you commit a microaggression and ask them how you should address them when they happen.

And if you do get called out for a microaggression, own it.

“Fight the defensiveness,” Fisher said. “Thank them, acknowledge what you did, apologize and move on.”

References:

• De Bourmont SS, et al. JAMA Netw Open. 2020;doi:10.1001/jamanetworkopen.2020/21769.
• Fisher HN, et al. J Gen Intern Med. 2021;doi:10.1007/s11606-020-06576-6.
• Fisher HN, et al. J Gen Intern Med. 2022;doi:10.1007/s11606-022-07415-6.

For more information:

Herrick “Cricket” Fisher, MD, MPhil, can be reached at hnfisher@bwh.harvard.edu.

Nancy I. Joseph, DO, FACAAI, can be reached at njoseph2014@gmail.com.