Key tips for medical residents facing microaggressions

Microaggressions in the workplace might seem like small-scale offenses, but cumulatively they can cause serious harms to their recipients over time, including burnout, worsened mental health, moral distress and poor performance. These indirect expressions of prejudice can even leave people questioning their choice of a career in medicine.

“Responding to Discriminatory and Excluding Comments: A Novel Framework for Empowering Residents and Faculty,” a workshop at the inaugural AMA GME Innovations Summit, outlined a framework for dealing with microaggressions in medical settings and provided an easy-to-remember model for guiding responses in the moment.

Find out more about the AMA Reimagining Residency initiative.

While many residents are familiar with microaggressions from patients, they can also come from attending physicians, staff and their resident colleagues.

They are the everyday “verbal, nonverbal and environmental slights that … target individuals that are lower on [the] power and privilege hierarchy, and those can include people along different races, ethnicities, gender, sexuality, ability,” said Daniel Cabrera, MD, MPH, clinical assistant professor of internal medicine at University of Washington School of Medicine, adding that the damage they can do is “not really surprising if you think about them as micro-traumas.”

Still, it might not always be opportune to address a microaggression immediately—consider if one happens in an acute situation in an emergency department, for example—so the first step is to decide whether to deal with it at all.

“Sometimes it's just not even worth the mental space or energy, and sometimes it might be better to walk away,” said Roberto Montenegro, MD, assistant professor of psychiatry at University of Washington School of Medicine. “If you assess the situation and you think there's potential for change, you also should keep in mind: Can you be proactive, respectful and firm at the moment? Can you have a frank discussion with the individual, or is that person going to be someone that just is not able to have that type of discussion? … And also, what are the consequences if you choose to speak to that person?”

If you decide you should respond, first figure out what you want to get out of the conversation, Dr. Montenegro said.

“Is your goal, for example, to stop the behavior or to educate?” he said. “It's critical to remember that this can be very difficult. So, having a set of responses in your repertoire and practicing them will make this a lot easier for you as you progress in your training and in your career.”

This is not unlike having to deliver bad news to a patient, Dr. Montenegro noted, so having a set of responses in your repertoire—and practicing them—will make it easier to meet the moment.

He outlined several principles to keep in mind:

• Attempt unconditional positive regard. This means accepting and supporting a person regardless of what he or she says or does.
• Identify or name the mistreatment.
• Separate intent from impact.
• Focus on the behavior, not the individual. “That's something often that allows you to be able to continue with the medical care that you're providing,” Dr. Montenegro said.
• Redirect to a shared goal of having a safe and friendly work environment.
• Practice dialectical thinking and understand the other person’s emotional distress. “Even though it's very difficult and hurtful to experience, this is very important, as well,” he added.

Read this special communication published in JAMA Surgery, “Recognizing and Reacting to Microaggressions in Medicine and Surgery.”

On more a practical level, Dr. Montenegro recommended following the D.E.A.R. model to guide conversations.

“Sometimes it can feel robotic and it can feel odd, but it's a really great way of keeping structured … and being to the point in a way where it separates your emotions [from] your intent and goals so that the recipient can listen to you clearly,” he said.

• “D” — describe the situation. “Here, you just stick to the facts,” he said.
• “E” — express your feelings. “Use ‘I-statements’ there.” Rather than assume intent, describe the impact of the behavior on you.
• “A” — ask or assert. “Ask for what you want.”
• “R” —reinforce. “Think of something that will motivate the person to carry through with your ask or your assertion.”

Learn what to do when patient says, “I’d rather have a white doctor.”