A common scenario that female physicians sometimes experience after visiting with a patient in a hospital room is being asked, “When will I see the doctor?”
The slight might not be intentional, and might be more indicative of implicit rather than explicit bias, “but I think, like a lot of my colleagues, I’ve witnessed or experienced these behaviors that later, when I’m driving home, I’m thinking, ‘I don’t know why that rubs me the wrong way, but I don’t feel great about it,’” explains Danielle Miller, MD, M.Ed, an assistant professor of emergency medicine in the University of Colorado School of Medicine.
Those experiences, though seemingly small, are microaggressions that research has shown can have significant physical, mental, and emotional impacts for those on the receiving end. In medical professions, microaggressions from patient can contribute to burnout, stress, and mental health symptoms in residents, fellows, and faculty.
In the recent issue of the Journal of Graduate Medical Education, Miller and her research colleagues offer research-based short- and long-term action items that clinicians and medical institutions can implement to address patients as sources of microaggressions.
“There’s a lot of literature reporting that microaggressions can cause poor sleep, increased anxiety, depression,” Miller explains. “When you look at them in terms of medical students and trainees, microaggressions can disrupt their ability to perform tasks, and that focus is incredibly important when you’re working with patients. Even bigger picture, microaggressions can contribute to imposter syndrome and feelings of not belonging, which is a concern because we want to retain clinicians and make sure health care teams feel joyful coming to work.”
The term “microaggression” first entered the health care lexicon in the 1970s, when it was coined by Harvard University psychiatrist Chester Pierce, MD. Pierce used it to refer to brief, subtle snubs or slights directed toward a member of a historically marginalized population.
Microaggressions can take many forms and may represent explicit or implicit bias. “They can be things like the example of asking a female physician when the doctor is coming, or asking an Asian-American clinician where they’re from,” Miller explains.
“We have a long legacy in health care of just letting it go, saying it’s not a big deal, especially when it comes to caring for patients,” she says. “Our focus is to maintain that therapeutic alliance with the patient and there’s been this idea that if we initiate a conversation with patients about something they said, that will shame them and harm our relationship with them.”
However, the emphasis of initiating conversations with patients about microaggressions is a way to discuss inclusion while acknowledging that nobody is perfect and that most people have biases they might not even recognize or be aware of.
Conversations with patients
Miller and her co-authors propose identifying the microaggression when it occurs and clarifying the behavior so that clinicians can refocus on patient care. For example, Miller outlined a common example in which a senior physician is in the room with a resident and the patient asks the resident when the doctor is arriving.
“In a situation like that, it’s perfectly acceptable for the senior clinician to say, ‘I observed you ask the resident when the doctor is coming,’ which allows you to clarify the statement,” Miller says. “Then you might follow up with, ‘This resident is the doctor and I’m confident you’ll have a good experience working with them.’ Something as simple as that allows us to address the microaggression then refocus on the patient.”
Miller adds that it’s important for experienced health care team members to be upstanders, or people who are willing to discuss a microaggression they observed from a patient that was directed toward another team member.
In the long-term, addressing patients as sources of microaggressions may include anticipatory preparation so that health care providers can practice interventions and familiarize themselves with institutional resources for reporting and support. It also is important to incorporate microaggression training into residency curriculum and faculty development.
A welcoming and safe environment
“I think most clinicians recognize that it’s a delicate balance between maintaining a therapeutic alliance with a patient and making sure you’re supporting yourself,” Miller says. “From my perspective in the emergency department, sometimes patients have such profound medical conditions that you have to quickly address and that might be affecting their cognition, so it might not be appropriate to address microaggressions in that moment, but rather debrief with the team later. Clinicians will use their best judgment and we just want them to feel equipped with the appropriate training and tools.”
Responsibility for addressing patients as sources of microaggressions also lies with institutions to develop patient, family, and visitor codes of conduct and collaborate on finding solutions to mitigate microaggressions in the clinical environment.
“It’s also important for this training to become a part of medical education,” Miller says. “Some of the most recognized experts on this topic are current medical students or trainees, so we need to build on that and continue gathering data. People go into health care because it’s work they love doing, and we need to ensure it’s a welcoming and safe environment for everyone.”