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.
| Definitions |
| 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.
References:
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
Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.
When I did my general surgery residency in the late 1970’s-early 1980’s, interesting dynamics were in play. I had been warned by a chief surgical resident that surgery would be “a tough row to hoe for a young lady.”
My training program made a concerted effort to include women, yet when I became pregnant, other women in the program expressed significant concerns that I’d lose my place (instead, the program went out of its way to help me out).
I had only two episodes in which patients either expressed concerns or seemed confused about my identity. Interestingly enough, it was not a man who refused to allow me to do his surgery, but a black woman in her 40’s who needed a breast biopsy. (She flatly refused to allow me to do her surgery, insisting on having a male resident). In twenty years in private practice, I never had anyone else refuse my care.
Memory of the other incident still makes me laugh! I was the only female in a group of residents & students who were making afternoon rounds. We’d just left the room of a man in his 60’s when he yelled down the hall, “Send in that NURSE who looks like a doctor!!!” I went back in to chat with him & to be sure he knew that I was, in fact, a doctor.
Oh, yeah…there was the one patient who looked at my 8-month-plus pregnant belly as I was about to repair his hernia & asked, “You aren’t going to deliver during my surgery, are you?” I reassured him I wouldn’t—& I didn’t.
Was I “lucky” & missed micro- & macro-aggressions because of my skin color? I don’t think so.
What I do know is that my being a surgeon AND a female AND the mother of a child who’d had surgery hours after his birth for a diaphragmatic hernia reassured far more people than it alienated.
In my 30 years as a female in a general surgical practice, I was occasionally asked “ Are you going to do the surgery?” I always took it to signify that the patient liked me and wanted to make sure that I would be preforming the operation. It never really felt like micro aggression to me.
Bravo Dr. Cagle! The lack of looking for a reason to be offended says much about your perspective and confidence. Carry on.
I am a woman surgeon who is frequently asked this question. My take on the question is re-assurance that I, the one who has developed a good relationship, am the one who will continue to care for them, not someone else in the office they met. I am not offended if they would prefer someone else, a man or another woman of another background. I want the patient to be comfortable. The patient comes first. I’m here to serve them. If the patient is not comfortable, then we don’t have the relationship that serves them (or me) best. Of course, in an emergency situation, I do explain the risks of waiting for an alternate.
I agree completely with this comment. I have only been practicing as a general surgeon in a rural area for 8 months but I have always taken this question in stride, feeling less a sense this is a micro aggression and more that the patient is simply asking for clarification. In our area the patients often are seen by other care providers such as nurse practitioners or physician assistants for their medical care. I feel they want to know that this person spending so much time to speak with them about their care is the person performing their operation. I try not to feel bad/mad/sad/offended if they wish to see someone else for any reason and I always make this known to them as you said above. I am here to serve them the best way I can (or not). I am sure some may choose to see a different surgeon based on my identity as a young, white, female, etc but others may CHOOSE me for these same characteristics. Also of note, I have been told that my white male (slightly older) partner gets this questions frequently as well.
I am asked everyday if I am the doctor or if I am the one doing the surgery. Every single day I hear, you’re the doctor! I am a 35 year old straight white Male. This article is silliness. If you get upset with a micro aggression then you are a weak person.
What I’m hearing from Rick is that he was upset by this article, leading him to call it silly. Does that make him a weak person?
I have a feeling that you would think someone who suffers from depression is also a “weak person”.
This article is indicative of the times we live in. You must be politically correct. You may never use a trigger word for fear of upsetting someone. You may never make certain observations that actually reflect reality. When did this generation become so fragile? How did we fail to prepare them for the real world? Have they ever learned to take any kind of criticism without emotional collapse?
When a patient asks me if I am going to do their anesthesia my point of view is that they want assurance that it will be me and not a colleague. And if I got the impression that they did not want me as their anesthesiologist I would make an effort to get them someone else without taking it personally.To call that a microaggression makes me think that the physician needs counseling to bolster their self esteem. I do consider it a weakness to label this as microggression.
OMG, get over yourself! Microoaggression!?? Speak real English not the gobbledygook that has pervaded our snowflake “poor pitiful me” generation. Patient’s are naive as to the training and role each physician has as a background. What do you know about their profession, and what seemingly inane questions might come out of your mouth if you were at their workplace? They may just need reassurance that they are speaking to the actual surgeon, and not a physician who works “with” the surgeon. Open your mind and get that chip off your shoulder. Looking for things to be offended over guarantees you will find something. Grow a layer of thicker skin, whatever color it is doesn’t matter!
patients just want to know that the person in front of them is their surgeon… simple as that. As a white male I am asked this all the time. Interesting that our own biases influence our interpretation of the questions we are asked.
Patients in my practice see ER physicians, trauma PAs, ortho PAs and my partners prior to seeing me in the preop area right before surgery. How about they are just confused and sometimes ask a question to clarify actually what physician will be using a scalpel in them. Seems like a logical question I would want to ask for no other reason then maybe I have some more questions to ask or at least I am clear on the physician is treating me.
And what about the last question: ” And how many of these operations have you done?”. This is usually the parting shot after you have explained the procedure and complications.
I am a retired nephrologist in mid seventies and went through training in early seventies as a FMG from India and through my fifty years of practice only once was requested to see my associate. Guys have resilience, toughness and self confidence that comes from within, systems and institutions cannot shelter you from micro aggression. You are lucky to be a doctor and move on like a swimmer in the sea.