icroaggressions commonly occur in medical settings creating psychologically unsafe environments of learning, working, and healing. Learners, educators, and patients can receive, inflict, or witness subtle acts of discrimination. In this article, we highlight microaggressions that are affecting our learners and call on clinician-educators to become aware, active allies or upstanders in real-time to create safer, braver spaces. 

What are microaggressions?

Microaggressions are subtle, almost imperceptible, insults or indignities that communicate hostility towards a person or group’s identity, irrespective of intentionality. The hostility, verbal or non-verbal, is a an act of discrimination against one’s race, sexuality, ability, religion, gender, socioeconomic status, age, or intersections of these identities. 

The term microaggression is not novel. In his 1978 paper "An Experiment in Racism: TV Commercials," Harvard psychiatrist Chester M. Pierce, MD, coined the term microaggression to describe subtle pro-racist behaviors. The term was later popularized and thoughtfully categorized into three forms of microaggressions by Columbia University psychologist, Derald Wing Sue, Ph.D.

Why is confronting microaggressions necessary?

Microaggressions normalize oppression and perpetuate systemic social misunderstandings of marginalized communities. In medicine, we expect our learners to thrive in their commonplace of training. It is harmful and wrong to expect that our learners will accept abuse without our acknowledgement. 

Unfortunately, clinician-educators are often not aware of or do not understand the lived realities of learners. Learners suffer in silence while still figuring out how to thrive amongst their peers. They are made to feel the “otherness” of their identities, which jeopardizes their self-efficacy and resilience.

Learners experience microaggressions daily without warning. With the COVID-19 pandemic, we know more than ever that perpetual uncertainty can be distressing and cause adverse health outcomes. Victims of microaggressions can experience depression, anxiety, self-doubt, isolation, and trauma. And because microaggressions are often refuted and defended by plausible reactions, they can leave the victim feeling invalidated. Therefore, acts of omission or commission by clinician-educators — not recognizing, remaining silent, or contributing to the indignities — deepens the pain of microaggressions and contributes to the immense negative impact felt by learners.

How do clinician-educators confront microaggressions?

Clinician-educators are best positioned to be aware of their learners and their environments, however, they might feel ill-equipped or not empowered to respond. 

Learning how to respond requires intention. 

Here’s how:

1. Willing awareness

• Educate yourself. Read literature written by people with lived experiences of discrimination. Organize or participate in identity and upstander workshops at your workplace. See Local Resources below.
• Self-reflect. Take a deep dive into your identity, your privileges, your vulnerabilities, and your impact at work. Take implicit bias tests. Do it for yourself, no one else. It is a commitment to understand your narrative, question your beliefs, and ask if what you think is true. Plan to repeat the test over regular intervals. Example: Project Implicit. 
• Be empathetic. You are not an imposter. You can be an ally. You can speak out for others even though you aren't like them. 
• Be prepared. Before starting your week on service, take time to talk with your learners. Talk about identity and when each learner would prefer you to confront a witnessed microaggression. Some may prefer you upstanding in the moment or responding at a later time. Talk about the pros and cons of each approach together. Are there cues to look for in the moment to know how best to respond? 
• Be alert. Your learners who regularly suffer microaggressions are on alert. You can be too. 

When you perceive something hostile, ask yourself, would that (microaggression/abuse) happen to each of your learners? If your answer is no, then it was targeted. And your learner is hurt.

2. Deliberate action

Silence and not acknowledging what happened is NEVER the response. 

• Take a deep breath
• Look at your learner, respect their cues 
• If appropriate, choose to respond in the moment
• ​​​​​​​Look at the perpetrator

• If the learner responds first, don’t overshadow their agency, but don’t move on. Stay engaged and provide support if needed.
• At any point, if you are worried that confronting or continuing the conversation will bring more risk to the learner or it is not their preference for you to speak up, it is ok to acknowledge the interaction later with timely mitigation.

3. Timely mitigation

Do this step, ALWAYS, even if action wasn’t taken.

• Place the responsibility on yourself. This prevents your learner from suppressing the abuse.
• Ask the learner to debrief soon after or at a later time.
• Prioritize and make a dedicated time.
• Find a quiet, safe space. In-person is preferred, though due to the pandemic, video or phone call can be an option.
• Acknowledge the interaction, use "I" statements, be curious, name the feeling/emotion, be ready to validate, and offer supportive action.
• Don’t make the conversation about you. Let the learner(s) take the lead. 

The best practice is to practice. You will know that you’re doing it right when it starts to feel more right to you. When you get it wrong (and you will), lean in, make an effort, and repair that interaction by challenging your own resilience. Model your vulnerabilities.

Conclusion 

Let’s return to the case study. The pediatric intern experienced a racist abuse, a microinsult based on the color of her skin. Upon first interaction, she was quickly mistaken to be the environmental service worker, not the doctor. It was an unconscious, subtle gesture that assumed her identity. The response from the nurse and mother was silence. After the attending heard about the microaggression, it was supportive to ask if she was ok and wanted to talk, but she was post-call. She was left with uncertainty of whether anything would be done and whether her attending would reach out again. Throughout residency there was no closure for her.

Here’s what the clinician-educator could have done to confront the microaggression:

Resources

*Originally published in April, 2020