Managing Microaggressions in Practice

Words matter. The wrong ones can leave lasting scars that affect one’s overall health and diminish the joys of life. A substantial volume of literature has been dedicated to linking everyday discrimination to negative physical and mental health outcomes.^1-3

Blatant racism, sexism, and discrimination still exist, but as they have become less prominent, more insidious forms of discrimination have taken their place.

A recently popularized term for these daily impactful transgressions is microaggression. This term was coined in 1970 by Chester M. Pierce, MD, who defined microaggressions as minor yet damaging humiliations and indignities experienced by African Americans.⁴ More recently, the use of the term has been broadened to include snubs, slights, or insults directed toward minorities, women, or members of other historically stigmatized groups to implicitly communicate hostility.⁵ Academic literature breaks the term down further to encompass microassaults, microinsults, and microinvalidations.⁵

Microassaults are conscious and explicit “old fashioned” discrimination. They manifest as demeaning statements or actions, such as calling a person of Asian descent “oriental” or, in our field, suggesting that a female physician may not be as capable as a male counterpart.

Microinsults are often unconscious but similarly carry demeaning messages about a person’s identity. An example would be applauding Black individuals for being “well-spoken,” which carries the assumption that this is atypical.

Microinvalidations are also unconscious but reflect exclusions or dismissals of the recipient’s feelings, thoughts, or reality. This category includes the common statement, “I don’t see color,” which tends to undermine the exceptionally different experience that people of color have in our society.

Importantly, most microaggressions do not come from a place of a malintent; in fact, they frequently manifest under the guise of comedy, as attempts to console or understand a colleague’s or patient’s struggle, or simply from poor word choice. This does not diminish their impact, nor does it make them excusable.

Thus, we must be intentional when we interact with one another because subconscious acts of racism and sexism can have lasting effects on both patients and colleagues.

It is important to note that some, including author and antiracist activist Ibram X. Kendi, PhD, have moved away from using the term microaggression altogether, noting that it fails to convey the damage these abuses can inflict. Although this may be true, this argument is beyond the scope of our article, and we feel that the term suffices for our message.

Addressing microaggressions is no easy task. Using examples from our own lives, in our separate sections below we highlight a framework to help you recognize and respond to microaggressions in the medical workspace. Recognizing a microaggression is the first step, but most people do not know what it is like to exist in a space where they do not feel valued. Recognition is not enough. Action is necessary.

When microaggressions occur in practice, we support the use of the mnemonic GRIT outlined by Warner et al:⁶

• Gather your thoughts. Do not react with anger, and decide if it is the appropriate time and place to address the perceived microaggression.
• Restate the comment. Allow the person to clarify or realize the negative impact of their words.
• Inquire to seek clarification. Be nonjudgmental and address the comment or action without making it about the person.
• Talk it out. Discuss the impact on others and your personal perception of the comment or action.

It is just as important to know how to respond if you are called out for a microaggression. The most important step is to listen; give the other person a chance to explain their perspective. Do not become defensive. These interactions can be valuable teaching moments to help us confront our own internal biases.

Educating others about microaggressions can be a tiring task for those who experience them on a frequent basis. If friends or colleagues are willing to educate you about your microaggressions, they are acknowledging how challenging it is to be self-aware. Their challenge is a genuine symbol of respect and acceptance. The effort to educate is often reserved for the people we care most about.

VAGUE CONNOTATIONS

By Nathan L. Scott, MD, MPP

I was a third-year medical student—my first time on the medical wards. Admittedly, I was certainly not what one might call an all-star student. I was quiet, but not shy. I was confident in my abilities, but I deliberately tried to avoid seeming arrogant or overconfident. I had never received negative feedback on rounds, and I got along with my clinical teams and colleagues. Many had noted my unique ability to bond with patients. At lunch, I ate alone to escape the perpetual evaluations of medical school life.

During my mid-year feedback session, the program director started with a simple question: “How are things going?” I told him that everything was great, and I was learning a lot. I really enjoyed my clinical teams and taking care of patients. His response? “You know, you’re a big strong guy. You should smile more.”

The feedback was genuine, and he explained that there was no negative feedback about my effort, attitude, or clinical knowledge, but that “there was concern.” To me, however, this was just another confirmation that I was different, that my appearance was intimidating, and that I needed to change my reserved demeanor to better fit the mold of the excitable, overeager medical student.

In translation, the microinsult I heard in that statement was, “You’re a Black man in medicine, so you need to make sure people don’t think you’re angry or unhappy.” I recounted the meeting with several of my minority mentors who not only confirmed my translation, but to my surprise (and dismay) also agreed with the feedback and premise—in our profession, Black physicians must work harder to ensure that other people don’t think they are angry. I did not address my concerns with my program director or my mentors.

At the time, I didn’t know about the GRIT framework; looking back, that feedback session was the perfect scenario to gather my thoughts, restate what I was understanding the comment to mean, and inquire about exactly what the “concern” was. Talking, not only about mitigating concerns but also about what it is like to receive feedback with vague terminology, could have led to a more productive and impactful interaction for both me and my program director.

WHAT’S IN A NAME?

By Hasenin Al-khersan, MD

“What’s your name?”

I nervously glanced at my new classmates before turning back to answer my teacher: “Hasenin.”

The teacher’s face contorted into befuddlement. “What?”

I replied again, this time more slowly, but I knew I wasn’t making any progress—three syllables might as well have been a hundred.

“That’s way too hard. I’m gonna call you Al.” And he did, for the next 6 years.

That incident, burned vividly into my memory, is the earliest microaggression I can recall. At the age of 10, my family had just moved to rural northern Michigan, and it was my first day of school. Even at that age, I was already keenly aware of my identity as an Arab in post–9/11 America. Though my physical appearance may be culturally ambiguous, my name has always been foreign.

For a child, moments like these are demoralizing and invalidating. Any child with a “different” name can empathize with the feeling of waiting for a substitute teacher to butcher your name during roll call after admitting, “I’m going to definitely mess this next one up.”

This scenario has since been played out hundreds of times throughout college and my medical training. Professors or colleagues who were hesitant to muster a second attempt at pronouncing my name often disengaged from me in classes or on the wards.

Fighting this perpetual battle is exhausting. I have learned three languages but, for some, three syllables seem insurmountable. And, as with most microaggressions, it can be difficult to advocate for yourself without feeling as if you are being difficult. Most of the people committing these slights are good people with good intentions, which makes confrontation complicated. Nonetheless, the impact of their actions is deeply felt.

These days, I choose my battles. When it matters most, I’m more adamant that others learn my name. If they continue to mispronounce it, I continue to correct them. But at other times I don’t engage for the sake of my own well-being. I am constantly working on this balance, but I now know my name deserves respect like any other.

For the record, it sounds like it’s spelled: “Ha-se-nin.”