“As a medical student, I often felt marginalized from my medical community. I have been told that my name is ‘not American,’ fallen prey to being confused for support staff such as a janitor (even while wearing my white coat), and been asked questions like, ‘Where are you really from?’ or ‘How old were you when you moved to the United States? or ‘When you’re done with your training, are you going back to your country?’ The greatest barb, however, was being summoned as an ‘interpreter’ by an attending physician during my surgery rounds,” wrote Roberto E. Montenegro, MD, PhD, in his essay, A Piece of My Mind: My Name Is Not ‘Interpreter,’ published in JAMA.¹

These subtle—and often not so subtle—slights are known as “microaggressions”—a term first coined by psychiatrist Chester Pierce, MD, in the late 1970s. According to Dr. Pierce, unlike overt discrimination, microaggressions are the “subtle...often automatic, nonverbal exchanges [that] infringe on a person’s space, energy, and mobility.”² This definition was later expanded by psychologist Derald Wing Sue, PhD, Professor of Psychology and Education at Columbia University in New York, to include “brief and commonplace verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults that potentially have harmful or unpleasant psychological impact on the target person or group.”³

“There are a lot of different ways microaggressions can make a person feel marginalized.”

— Roberto E. Montenegro, MD, PhD

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Unlike overt expressions of racism, microaggressions can be more difficult to identify and address. The reason for this is because they are often unconscious acts, and the perpetrator may not realize the impact his or her words are having on the recipient and so minimize the person’s discomfort as hypersensitivity or misinterpretation of the action—a process known as microinvalidation.

“When an attending asked me where I was from or made comments like, ‘You speak English really well,’ he didn’t necessarily mean to be insulting or demeaning. However, that is part of the invalidating process, in which individuals don’t recognize the impact those questions have on medical students or trainees and that they make students feel like an ‘other’ and not integrated with the rest of the medical team,” revealed Dr. Montenegro.

Although a microaggression may seem innocuous, its effects can be cumulative, impacting the mental and physical health of underrepresented physicians. It also may exacerbate inequities in health care for patients in general and for minority patients in particular, he added.

Alternatively, strong support from medical school leaders and faculty to create an environment that does not tolerate overt or covert forms of discrimination may help underrepresented trainees succeed and thrive in their medical education, according to a study by Hassouneh et al.⁴ “The importance of [these] efforts to the future of medicine cannot be overstated,” wrote the study authors.

In a wide-ranging interview with The ASCO Post, Dr. Montenegro, a Fellow in Child and Adolescent Psychiatry at Seattle Children’s Hospital at the University of Washington School of Medicine, talked about the ramifications of microaggressions on medical trainees, the impact of bias on patient care, and how medical institutions can create environments that blunt microaggressions and support underrepresented medical students and physicians during training.

Making a Person Feel Marginalized

How did microaggression during your medical training make you feel marginalized, and how did it impact your training?

As a medical student, microaggressions were prevalent throughout all 4 years of my training, although some of the most memorable ones were during my clinical rotations. Frequently, these microaggressions came from patients and residents, but more often from the main attending physician.

In a study we are currently conducting, we are trying to identify the frequency and intensity of microaggressions and to determine whether there are differences based on the respective service/rotation, for example, surgery vs internal medicine.

There are a lot of different ways microaggressions can make a person feel marginalized. For me, they centered on comments about my name not sounding American and questions about where I was “really from.” Feeling like an “other” or being singled out because of your background when you are trying to blend into a different culture—the culture of medicine—and survive the rigors of your medical training, can be exhausting and can take its toll.

“It’s often the case that we do not realize we are committing a microaggression until someone points it out to us.”

— Roberto E. Montenegro, MD, PhD

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Microaggressions can also create a hostile and invalidating environment that is not conducive to proper learning. Even though the comments may make you feel like you are being targeted because of your race, ethnicity, gender, or sexual orientation (to name a few), you may often be made to feel that you are overreacting if you question this behavior. Also, there is uncertainty about how to respond to the microaggression because of the disproportionate power dynamic or who to talk to about the problem. This uncertainty may contribute to feelings of being marginalized and may undermine professional development.

Given that most medical institutions are dominated by a white culture, many people believe microaggressions are benign, but they are not. Repeated often enough, they accumulate and can impact every area of one’s life, including one’s health.

Effect of Discrimination on Patient Care

How do microaggressions experienced during medical training affect how physicians provide care for underrepresented patients, who may experience significantly more perceived discrimination from their providers than white patients?

The impact of bias and discrimination on minority patients has been well studied, and they have been shown to strongly impede diagnosis and treatment. Although microaggressions have been studied in the social sciences, psychology, and education, the effects of these subtler forms of discrimination on the health care and health outcomes of minority patients are still to be determined.

An interesting study looked at how the political beliefs of primary care physicians can influence their professional decisions on politicized health issues such as marijuana, abortion, and firearm safety; the investigators found that patients received substantially different care, depending on whether their doctor was a Republican or a Democrat.⁵ Those results are probably close to the impact microaggressions have on the interactions between providers and patients, but we need more research to know what the exact impact is on patient care.

Patients may pick up physical and verbal cues from physicians, feeling liked or not by the physicians and comfortable or not in their care. Can these feelings impact patient care?

Absolutely. I’ve often seen the role microaggressions play in patient care in consultations I’ve had in the psychiatry service on oncology rounds, especially for transgender patients with cancer. For instance, oncologists often will refer to these patients by their natal biologic pronoun rather than their preferred pronoun. This is a good example of how the relationship between patients and oncologists can be affected when patients’ identity preferences are not validated and the rapport between the two is broken, potentially impacting treatment and outcome.

This is especially important when working with younger populations, given the increased social acceptance of gender identity fluidity. In instances like this, it’s typically best to start every patient interaction the same way. First, introduce yourself and then ask the patient, “How would you like to be referred to and what pronoun do you prefer?” This approach may feel odd for some providers and patients; however, it’s a sign of openness and inclusivity for gender-nonconforming patients.

After my essay about my experiences was published,¹ I heard from many physicians able to relate to the concept of microaggressions (either being the recipient or the aggressor). One unusual e-mail, however, was from a dean of a prominent law school who thanked me for allowing him to understand what had happened during his most recent cancer screening appointment. He shared his story of how embarrassed he was when he went for a routine colonoscopy screening and the physician performing the exam asked him if he had ever been told that he looked like a “bandito” and then laughed. She made the remark in front of a medical student and a fellow, who also laughed. The man, I’ll call him Mr. Perez, felt confused, hurt, and angry. To him and his generation, he explained, “bandito” has a common negative connotation as an outlaw or gangster. He was reluctant to say anything because the physician still had to complete the exam and Mr. Perez was in a hospital gown, feeling exposed and vulnerable.

What bothered Mr. Perez the most was that the medical student and fellow were learning microaggressive behavior from their attending physician and a misguided view on how to establish patient rapport. Mr. Perez explained to me that he felt judged by his appearance. In that instant, all the attending saw was a middle-aged Latino who reminded her of a gangster; she inadvertently invalidated his identity as a professional, an attorney and a dean, and clumped him into a category of an “other,” far from how Mr. Perez identifies himself.

The next day, Mr. Perez reported the physician’s behavior in a survey from the medical facility. A few days later, he got a call from the physician excoriating him for his criticism of her. “All I was trying to do was establish a rapport with you and you misinterpreted what I said as racist, and now it’s in my file,” she complained. He also reported to have requested to transfer his care to a new physician.

This story captures how microaggressions can indeed impact the doctor-patient relationship and how rampant the problem is across the field of medicine.

Identifying Microaggression

How can medical educators and physicians tell if they are committing a microaggression?

First of all, it’s important to emphasize that microaggressions are difficult to identify, let alone to confront. It’s often the case that we do not realize we are committing a microaggression until someone points it out to us. However, it’s even more common that no one tells us we are doing this. It’s difficult for a trainee to point out that his or her supervisor has just made an inappropriate/invalidating/hurtful/discriminating comment.

“Medical institutions have to acknowledge that microaggressions exist and that these biases hinder the development of future physicians in all fields.”

— Roberto E. Montenegro, MD, PhD

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One step we can take to learn when we are making these mistakes is to ask for direct feedback from our trainees. From the onset of their rotation, we must model good behavior by acknowledging to our trainees that we may commit microaggressions and we should all be held accountable for discussing and learning from them.

One comment I hear over and over is how “political correctness has made it difficult to have a normal conversation without offending someone.” I can understand this frustration, just the same way I hope others can understand our frustration when we are constantly bombarded with statements that invalidate our presence. This is not about political correctness; it’s about being accountable for how our actions may have negative consequences.

As we are the educators and providers, it is unfair of us to place the onus of responsibility in creating an environment that is conducive to learning onto trainees. It’s important to be reminded that microaggression is not about having one’s feelings hurt or being offended; it’s about the negative impact that being repeatedly insulted, invalidated, alienated, and dismissed can have on people socially and biologically. Again, individually, these incidents seem innocent or benign, but cumulatively, I believe, they act like low-grade microtraumas, with potentially negative health impacts.

Responding to Microaggression

How should medical students and trainees respond when an attending physician has committed a microaggression?

We are completing research now on determining how best to approach this issue. What I would advise is not to respond immediately to the comments, because there is a high likelihood of resistance from the perpetrator. Some trainees say they feel more comfortable confronting the situation after their medical rotation is completed, so their grades aren’t negatively impacted.

What we are suggesting in our current curriculum on this topic is to take 1 or 2 days to assess the situation before taking action. Talk with a mentor or colleague and process the event. In psychiatry, we’ve developed a lot of techniques, such as dialectical behavior therapy, to teach people how to have difficult conversations and defuse potentially volatile situations with nonconfrontational approaches.

The acronym DEAR (describe, express, assert, reinforce) is often useful to achieve clear communication in these situations. First, we suggest you approach the perpetrator in a curious and nonjudgmental manner. Second, describe the situation. For example, you might say, “Dr. Smith, yesterday I noticed you said you, ‘didn’t think I would understand football because in my country we play soccer.’” Third, express, without blame, how it made you feel: “I felt that you were treating me as if I were from another country and different from someone like yourself.” Fourth, assert your wishes: “It’s important for you to recognize how assumptions like this can negatively impact people.” Finally, reinforce the positive effects of getting what you need: “Keeping this in mind will help me feel like you are not intentionally judging me based on my appearance or my background. I appreciate your being open to talking about this with me.”

Combating Unconscious Bias

How can medical institutions create awareness surrounding the common occurrences of microaggressions and equip faculty and students with self-awareness of the potential impact of unconscious bias and microaggression in all aspects of health care?

This is a question that has not yet been fully addressed by medical institutions. It is a sensitive topic to raise with faculty, because many microaggressors may automatically hear, “You are racist” when confronted and may become defensive. Most people in senior leadership positions in medical schools are white men, so it is understandable there may be discomfort in confronting this problem. But everyone, from senior leaders, residents, and attending physicians to medical students and trainees, needs to be aware of how microaggressions—and even overt discriminations—interfere with medical training and affect physicians’ ability to provide equitable care to patients.

Some institutions have developed continuing education curricula to raise awareness of unconscious bias and training on how to deal with microaggressions. Some have put practices in place to make it easier for medical students to report microaggressions anonymously—these procedures are good first steps. However, most institutions have not yet determined how to appropriately respond to these complaints.

Most important, we learn in medical training, “First, do no harm.” We should be cognizant that these slights can harm the very people we are training. Medical institutions have to acknowledge that microaggressions exist and that these biases hinder the development of future physicians in all fields, including oncologists and future oncology leaders. When underrepresented individuals do not feel comfortable being part of an institution, the likelihood of their remaining with that institution and fulfilling their goal to become academic physicians is not high. When this happens, the whole field of medicine suffers, especially patient care.

We must all be vigilant about creating an environment that promotes a medical community of safety, advocacy, and compassion. 

DISCLOSURE: Dr. Montenegro reported no conflicts of interest.

REFERENCES

1. Montenegro RE: A piece of my mind: My name is not ‘interpreter.’ JAMA 315:2071-2072, 2016.

2. Pierce CM, Carew JV, Pierce-Gonzales D, et al: An experiment in racism: TV commercials. Educ Urban Soc 10:61-87, 1977.

3. Sue DW, Capodilupo CM, Torino GC, et al: Racial microaggressions in everyday life: Implications for clinical practice. Am Psychol 62:271-286, 2007.

4. Hassouneh D, Lutz KF, Beckett AK, et al: The experiences of underrepresented minority faculty in schools of medicine. Med Educ Online 19:24768, 2014.

5. Hersh ED, Goldenberg MN: Democratic and Republican physicians provide different care on politicized health issues. PNAS 113:11811-11816, 2016.