Michelle York, MD, has mostly fond memories of the clinical rotations she did during her second year of medical school. They offered meaningful interactions with patients and hands-on lessons from physicians.
The experience also brought unwelcome instances of microaggressions. These are loosely defined as verbal or behavioral indignities that communicate hostile, derogatory or negative slights and insults against a person or group, and they are far too frequent in the clinical realm.
“You just inherently either witness and or experience microaggressions all the time in the clinical space,” said Dr. York, now a second-year internal medicine resident at Johns Hopkins Medicine. “Whether it's peer to peer, along the clinical hierarchy, or from or towards patients. I found myself in each one of those instances thinking: I don't really know how to respond to this. I know it makes me feel uncomfortable either for this person or for myself, but I don't really know what to do.”
Those experiences and the corresponding research Dr. York and colleagues conducted has resulted in the implementation of a curriculum that teaches medical students and faculty the value of being “active bystanders” or “upstanders” in instances in which a microaggression takes place.
“An active bystander is essentially somebody who witnesses an encounter, in this case of bias or microaggression,” said Dr. York, who is white. When seeing a racist act or microaggression, Dr. York said, an active bystander will stand in unison with the person who is being wronged.
According to an AMA survey conducted in the early phase of the COVID-19 pandemic, 20% of Black physicians reported that they were sometimes treated with less dignity and respect due to their race or ethnicity.
Meanwhile, 9% of all physicians from historically marginalized or minoritized racial or ethnic groups indicated that they were sometimes or more frequently called insulting names related to their race, ethnicity or skin color at work. Other research has found widespread mistreatment of medical residents from historically marginalized racial or ethnic groups.
Follow the five D’s
The curriculum is based on teaching the 5 D’s behavioral response model, developed by Dr. Kimberly Manning, MD of Emory University. It offers an empowering skill set for medical students that allows them to advocate for the harmed party by applying one of five methods. These are referred to as the five D’s, outlined below. Here’s a look at what they are and when they might be useful in an encounter.
Direct
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Verbally address the microaggression and respond to the perpetrator in real time. A direct response may be difficult for some bystanders. To do it effectively, Dr. York said that the best approach is to first state the objective facts of what happened (what you saw or heard), followed by your subjective interpretation of what you heard.
“Share how it made you feel and then just be ready for dialogue,” she said.
Distract
Defuse the situation by shifting the focus of the perpetrator to prevent further harm.
“If a patient asks a colleague, ‘Where are you really from?’ you might say, ‘We have limited time and I really want to make sure we talk about the thing that brought you into the emergency room,’” Dr. York said.
Delegate
Entrust the response to another individual who may be able to better approach and engage the offending party.
“This might mean reaching out to a charge nurse or a clerkship director, sharing with them what happened, and asking them to help support addressing this with the perpetrator,” Dr. York said. “It’s a useful method for students.”
Delay
Discuss the microaggression with the perpetrator at a different time and place.
Doing so “allows that space for both processing and a change in environment,” Dr. York said. “We do encourage our learners to try and keep this as close to the actual time of the event as appropriate and possible, just because memories for both parties get skewed as time elapses.”
Display discomfort
Express nonverbal discomfort or concern in the immediate aftermath of the incident.
“As learners, we give a lot of external validation to our teachers through smiling, nodding, and other affirming behaviors that say: Yes, we hear you. Yes, we understand. Yes, we agree,” Dr. York said.
“And by doing things like raising eyebrows, showing signs of concern, shaking your head, those are all signs that can very quickly and nonverbally attract attention to the perpetrator or to the targeted individual that that was not an appropriate thing to say or do.”
The AMA Center for Health Equity focuses on facilitating, strengthening and amplifying AMA’s work to eliminate health inequities. Explore the AMA Ed Hub™ Health Equity Education Center to learn more about confronting health injustice and advancing health equity.
