You just walked out of a patient's room. At the end of the encounter, the patient asked, “When will I see the doctor?” This has happened multiple times before, and you ask yourself: What do I do? How do I maintain a therapeutic alliance with the patient and foster a positive learning and workplace environment for myself and others? Are there any policies on patient behavior to support me? Should I report this event to my institution?
What Is Known
Microaggressions are defined as “brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults on the target person or group.”1 Often, microaggressions are expressions of implicit bias1 against marginalized groups, including minoritized racial, sexual orientation, and religious groups, as well as women and people with disabilities.2 Microaggressions are associated with increased stress and depressive symptoms, decreased ability to perform tasks, disruption of learning, decreased sleep quality, increased imposter syndrome, and career dissatisfaction.3 Microaggressions can contribute to a toxic clinical environment, which can impair learning and team functions and may contribute to medical errors and unsafe care.
While graduate medical education (GME) sponsoring institutions seek to mitigate microaggressions, trainees and faculty typically lack formal training in recognizing and responding to them. Creating an inclusive clinical learning environment requires that all team members are prepared to take action. Frameworks for responding to microaggressions often include strategies for the individual receiving the microaggression (recipient), the individual witnessing the microaggression (bystander), and/or a witness who acts (upstander) by engaging the perpetrator (source). Sources of microaggressions in the clinical environment can include physicians, nurses, other health care employees, peers, and patients.4 Due to the cognitive and emotional effects experienced by microaggression recipients, we must prepare upstanders to recognize and respond to microaggressions in the clinical environment, such as those initiated by patients. To facilitate upstander preparation, in this Rip Out we focus on patient-initiated microaggressions and distil common aspects across several microaggression frameworks. Recognizing and responding to microaggressions takes practice.
Address the dual challenges of patient-initiated microaggressions: maintaining a therapeutic alliance and addressing the behavior.
When microaggressions occur, identify and clarify the behavior, refocus on patient care, and debrief post-patient interaction.
Senior team members: Be prepared and prepare others to be upstanders.
Graduate medical education leaders: Work with sponsoring institutions to implement patient/visitor codes of conduct, microaggression training workshops, and mechanisms for tracking microaggressions with action plans.
How You Can Start TODAY
Senior team member(s) should assume the responsibility for taking on the upstander role. Pre-brief new learners to the potential for microaggressions and the importance of standing up with curiosity and respect to maintain a therapeutic alliance with the patient.
What You Can Do LONG TERM
Anticipatory preparation. Individuals should expect and prepare for microaggressions in the clinical environment, practice interventions, and familiarize themselves with local mechanisms for reporting and support. Incorporate microaggression training into the residency curriculum and faculty development with case examples and sample responses.
Data. GME leaders and the GME Council (GMEC) must require program reporting on microaggressions, including how programs are addressing microaggressions in the clinical environment, at faculty, Program Evaluation Committee, and GMEC meetings. GME leaders must concurrently work to develop institution-level tracking of microaggressions. Include relevant results from the Accreditation Council for Graduate Medical Education's annual Resident/Fellow and Faculty Survey results, such as personally experienced or witnessed microaggression behaviors (eg, abuse, harassment, mistreatment) to provide information for best practices for institution-specific microaggression interventions. Make the data transparent with action plans and timelines.
Codes and policies. Sponsoring institutions must develop patient, family, and visitor codes of conduct and policies with training to prepare all team members in their use. Engage the sponsoring institution's community advisory board, patient advisory board, and diversity response teams to facilitate awareness and collaborative solutions to mitigating microaggressions in the clinical environment.
Resources. Designate physical spaces and increase mental health resources to address learner and faculty burnout from microaggressions.