A resident discusses dialysis with her elderly patient, who later says, “You look too young and pretty to be a doctor!”
Microaggressions are “subtle, stunning, often automatic, and non-verbal exchanges which are ‘putdowns.'”1(p272) Commonplace in medicine, these interactions can degrade one's health over time. Because of their subtle nature, they can be difficult to classify.1 Discrimination in medicine is multidirectional, and all perspectives are a crucial part of the conversation. Here, we focus on microaggressions that occur from patient to medical trainee to provide targeted teaching tools to mitigate the impact of microaggressions.
Historically, medical training has promoted a culture of silence and submission—suggesting that, somehow, experiencing inappropriate behavior is a rite of passage.2 Problematic patient behavior contributes to physician burnout, poor work performance, and avoidance of specific patients.3,4 Medical education in the United States has not adequately addressed this problem. While many residents experience inappropriate behavior from patients, they lack specific strategies to respond.5 The hidden curriculum in medicine around problematic patient behavior should become explicit to build trainee resilience. Studies from other health disciplines suggest that training on how to respond to inappropriate patient behavior reduces its negative impact.6 Protecting our residents from the harm caused by inappropriate behavior is vital to ensuring the health of the workforce and, ultimately, our patients.
Embedded in the patient-physician relationship is a complex power dynamic. We must acknowledge the privilege of the physician in understanding patients' biopsychosocial contexts to reflect on difficult encounters and improve clinical care. Psychiatrist James Groves elucidated the importance of this:
Negative feelings about . . . patients constitute important clinical data about the patient's psychology. When the patient creates in the doctor feelings that are disowned or denied, errors in diagnosis and treatment are more likely to occur. Disavowal of hateful feelings requires less effort than bearing them. But such disavowal wastes clinical data that may be helpful in treating the “hateful patient.”7(p887)
The physician aims to get to know the patient better, forming a relationship built on mutual respect. The following tools may allow for reflection in order to build patient rapport, promote patient-centered care, and attend to resident well-being. While there is no one-size-fits-all approach to microaggressions, we offer an approach to the complex nuances of experiencing a microaggression that integrates a 3-pronged approach to address transgressions before, during, and after the clinical encounter.
Step 1: Before the Encounter
An Asian American resident anticipates his next patient interview at the VA, wondering what comment he will receive this time. In his previous interview, his patient asked, “Are you planning on returning to China after your training?”
It is crucial to prepare faculty and residents for discriminatory events before they happen. Setting expectations provides residents and supervisors with appropriate in-the-moment responses and prepares them for meaningful reflection and debriefing. It is the attending physician's role and responsibility to create a positive learning climate.
During orientation to clinical rotations, we learn about the values of team members, discuss how the team would prefer to address inappropriate patient behaviors, and prime residents with the skills to respond. Attending physicians make an explicit pledge to protect their learners as much as possible and invite open dialogue if their learners feel that supervisors are contributing to a negative clinical learning environment. Anecdotally, across multiple hospitals at our institution, this first step of reflection is well received by residents, who are grateful for the safe space created for discussion.
Start the conversation about problematic patient behavior in an open-ended manner (table 1). Ask residents how they might respond and how they would like their supervisors to respond—if at all. Microaggressions can occur in the discrepancy between a patient's intentions and a target's perception; therefore, it may not always be appropriate to address a microaggression with a patient. If residents determine that they would appreciate a response, it could happen in the moment, after the encounter, with the patient alone, or with everyone present.
Formal curricula may include implicit bias training, communication skills, and role-playing. These have been shown to empower residents to respond in the moment.5 Training structures can target a training level. Curricula for residents might involve practicing how to respond to problematic patient behavior directed at interns and students. As this occurs across all levels of training, it is crucial to address the roles within the existing hierarchy of medicine.
Step 2: During the Encounter
An African American resident is discussing a care plan with her patient on the wards with the rest of the medical team in the room. The patient later asks, “Can you step out so I can just talk with my doctors?”
Residents may lack the tools to respond in a way that avoids negative repercussions.8 Our approach (table 2) prioritizes patient care by first assessing the patient's clinical and mental stability before naming inappropriate behavior gracefully, clarifying roles, and (re)establishing respect. As in other stressful situations, practice the steps in a no-risk situation so you are prepared to respond in real-life situations. In our experience, we rarely have to progress past step 2 to redirect the conversation and demonstrate an environment of respect.
When used in a stepwise fashion, patient care is prioritized while respecting learner well-being. Clarifying roles is a significant step of this process. Sometimes residents appreciate when their attendings speak up,9 while others may appreciate addressing the situation on their own. When a patient behaves inappropriately (assuming the patient is clinically stable), the care of the team can be directed toward the target of the problematic behavior. Business as usual is not an acceptable response.
Step 3: After the Encounter
After returning to the team room, a resident states, “I just don't know how to get patients to take me seriously! It makes me feel inadequate when they call me ‘sweetie' or ‘honey.' I don't want to go back to the patient's room.”
Debriefing is crucial after a patient behaves inappropriately. As suggested in table 3, start by inquiring how the situation felt to the residents. They might think about what felt empowering or disempowering, discover defense mechanisms, or reflect on their response. Faculty can highlight the importance of depersonalizing the event to redirect the team's energy toward the goal of “do no harm.”5 Residents should provide feedback on what could have gone better. Sometimes supervisors do not recognize the problematic behavior or know how to respond, which leads to silence. By reflecting on these situations, negative consequences may be mitigated.
In addition to debriefing, wrap-up sessions after rotations can improve morale and camaraderie. During these sessions, teams can review their patient cases from a biopsychosocial view. This fosters a healing discourse and long-term insight, potentially reducing the likelihood of lasting moral distress.
The patient-physician relationship is nuanced and may require intense reflection in order to promote patient care. Reflection is crucial in preventing burnout. Silence is not an option in the face of problematic patient behavior. We can address discriminatory patient behavior while preserving relationships and promoting outstanding care. Preparing, having a framework to respond in the moment, and reflecting represent significant steps to improve both resident and patient well-being. This 3-step approach can empower everyone to speak up to protect the learning and working environment for residents and encourage a diverse medical workforce that can improve care for future diverse populations.