By Eva M. Luo, MD, MBA and Rose L. Molina, MD, MPH
“Lucy” is a new patient in the Gynecologic Oncology Clinic and she is visibly anxious. As you carefully explain your recommendation for surgery, the pathophysiology of ovarian cancer, expected postoperative course, potential complications and overall treatment trajectory, the tension eases as she gradually transfers her trust to you.
This is a familiar exchange. Over ten years of practice, you have developed a confident demeanor that has allowed you to build this special relationship with your patients and their families.
Just before you begin to review the consent form, Lucy asks tentatively, “I see you are in the same practice as Dr. Richard Smith. Are you doing my surgery?” You smile and say, “Yes.” In the back of your mind, you wonder why this question was asked.
The surgeon in this vignette is a black woman at a well known cancer institute who trained at prestigious institutions. “Are you doing my surgery?” While a seemingly innocuous question, it probes the intersectionality of multiple identities: race/ethnicity, gender, country of nativity, sexual orientation and any other aspect of an individual’s identity. The question exposes doubt between the patient and surgeon. This and other microaggressions impact relationships in clinical encounters and interactions in the workplace. Microaggressions can be particularly hurtful as female surgeons and surgeons of color may already feel the need to prove themselves as competent due to the cumulative impact of these insults.
|microaggression: a statement, action or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized group (Merriam-Webster)|
|micro-affirmations: apparently small acts, which are often ephemeral and hard-to-see, events that are public and private, often unconscious but very effective, which occur wherever people wish to help others to succeed (Rowe)|
It is no question that the face of surgery is changing. A workforce report compiled by the Association of American Medical College (AAMC) in 2018 illustrates an increasing number of female physicians in all surgical specialties.
The data about race paints a different picture. According to the AAMC’s 2014 Diversity in the Physician Workforce report, out of the total active physicians in the U.S, only 4.1% were Black or African American, 4.4% were Hispanic or Latinx, 0.4% were American Indian or Alaska Native while 11.7% were Asian and 48.9% were White. The case for increasing diversity and inclusion in the physician workforce has been well described and promoted as a priority.
While social media movements like #ILookLikeASurgeon have highlighted the changing face of surgery, there is a need for a deeper understanding of the lived experiences of physicians of color. In a qualitative study of 27 resident physicians who identified as underrepresented in medicine, three major themes emerged: a daily barrage of microaggressions and bias, being tasked as race/ethnicity ambassadors, and challenges negotiating professional and personal identities while being seen as “other.”
What are appropriate next steps to address microaggressions in surgery?
One strategy to address microaggressions between patients and surgeons is to simply repeat the offending statement. This gives both individuals the opportunity to acknowledge the microaggression and clarify intent. In the vignette above, one possible response is “I am a surgeon.” This would open the opportunity for the patient and surgeon to discuss any concerns about who will be performing the procedure and reestablish trust.
Premkumar, et al outline strategies at various levels to develop a culture responsive to microaggressions. These include training in cultural humility and implicit bias through case discussions, encouraging faculty to lead “in the moment” debriefs when microaggressions occur, and creating a taskforce dedicated to developing institutional policies. Most importantly, at all levels, a chain of command for escalation should be formalized.
While sensitization is important, Molina, et al advocate creating a culture of micro-affirmations. Micro-affirmations (examples below) positively recognize, validate and ultimately empower individuals within a work environment. When micro-affirmations are intentionally used, individuals who feel marginalized are made to feel welcome, visible and capable. Department and institutional leaders are critical in role-modelling intentional micro-affirmations to foster a more inclusive environment.
Examples of Micro-affirmations (adapted from Molina, et al)
|Appreciative inquiry||“Heard you had a busy clinic. Any interesting cases coming up?”|
|Recognition and validation of experiences and feelings||“I know that was a difficult interaction.”|
|Reinforcing and rewarding positive behaviors||“Congratulations on the teaching award!”|
|Intentional inclusion in professional settings (meetings, conferences, presentations) and information networks||“There is an upcoming prestigious meeting that I think you should attend. I’ll forward your name to the organizers.”|
|Introducing team members by name and role||“This is Dr. __, a resident working on your care team.”|
|Diverse representation in public spaces||Departments or institutions should ensure that a diverse group of speakers are invited to present at Grand Rounds.|
By encouraging micro-affirmations and addressing microaggressions, we will be able to support our colleagues while continuing to build a more inclusive work environment. Everyone has a role to play.
1. Premkumar A, Whetstone S, Jackson AV. Beyond silence and inaction: Changing the response to experience of racism in the health care work force. Obstet Gynecol. 2018 Oct;132(4):820-827.
2. Osseo-Asare A, Balasuriya L, Huot SJ, Keene D, Berg D, Nunez-Smith M, Genao I, Latimore D, Boatright D. Minority resident physicians’ view on the role of race/ethnicity in their training experiences in the workplace. JAMA Netw Open. 2018 Sep 7;1(5):e182723.
3. AAMC 2018 Physician Specialty Data Report. https://www.aamc.org/data/workforce/reports/492536/2018-physician-specialty-data-report.html Accessed April 29, 2019.
4. Reede JY. A recurring theme: the need for minority physicians. Health AFF (Millwood). 2003 July-Aug;22(4):91-3.
5. Axelrod DA, Goold SD. Maintaining trust in the surgeon-patient relationship: challenges for the new millennium. Arch Surg. 2000 Jan;135(1):55-61.
6. Molina RL, Ricciotti H, Chie L, Luckett R, Wylie BJ, Woolcock E, Scott J. Creating a culture of micro-affirmations to overcome gender-based micro-inequities in academic medicine. Am J Med. 2019 Feb 2. https://doi.org/10.1016/j.amjmed.2019.01.028
Eva M. Luo MD, MBA is a Chief Resident of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center in Boston. She is creative problem solver passionate about improving the entire spectrum of women’s health. Her primary area of focus is in pregnancy care redesign, global health, and understanding how innovative models of care that arise from the entrepreneurship space can impact overall policy and systems of care. Twitter: @EvaMLuo
Rose L. Molina, MD, MPH is an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School. She works as a board-certified obstetrician-gynecologist at The Dimock Center, a federally qualified community health center in Roxbury, and Beth Israel Deaconess Medical Center. She is also the Faculty Director of the Medical Language Program at Harvard Medical School and the Director of the Obstetrics and Gynecology Diversity, Inclusion & Advocacy Committee at BIDMC. Twitter: @Rose_L_Molina
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