Time Stamps

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Show Notes

  • What are microaggressions?
    • Definition: Racial microaggressions are commonplace verbal, behavioral, or environmental degradations, whether deliberate or unintentional, that demonstrate hostile, derogatory, or negative slights and insults toward BIPOC.
      • Definition in Medicine: demeaning comments, behavioral disrespect, assumption of nonphysician status, credential questioning, rejection of care, inquiries of ethnic/racial origin or legal status, and sexual harassment.
      • Racial trauma is the cumulative effects of racism, in the form of workplace discrimination or hate crimes, on the mental health of individuals identifying as BIPOC. It can be the result of an accumulation of several small occurrences, such as casual discrimination and microaggressions.
      • Stereotype threat is defined as a “socially premised psychological threat that arises when one is in a situation or doing something for which a negative stereotype about one’s group applies”.
  • Prevalence and impact
    • In a 2018 study interviewing 27 residents from ethnic and racial minority groups working in different specialities and institutions, participants reported 3 themes: a daily barrage of microaggressions and bias, minority residents tasked as race/ethnicity ambassadors, and challenges negotiating professional and personal identity while seen as “other.” But despite the frequency of these instances, residents were often hesitant to report them to their program leadership.
    • There is evidence that students are more likely to exhibit racial bias themselves if they’ve witnessed similar biases expressed in their curriculum or by clinical professors and supervisors.
    • One study found that 61% of medical students surveyed experienced at least one microaggression weekly, most often due to gender, race or ethnicity, and age
  • How to respond
    1. Bystander vs. Upstander
      • Bystander: An individual who is present during an incident but does not take part in it.
      • Upstander: An individual who speaks up or intervenes to interrupt acts of discrimination or bullying.
    2. Speak up during an event if there are inappropriate comments
    3. Take a moment after an incident to acknowledge that a microaggression occurred; make time for the person who experienced the harm to reflect if they wish to do so
    4. Support can come from those with or without shared experience.
    5. The care of patients from marginalized groups is impacted when providers on their care team have an outdated approach to treatment
    6. It’s not enough to just say “I’m not racist” anymore. Being an anti-racist, by actively opposing racism and attempting to alter beliefes and policies, is the only way to combat racism and promote change.
  • Barriers to a helpful response
    • Defensiveness: People may make comments that are inadvertently offensive, then take it personally when they receive criticism.
      • Solution: Try to take the feedback as a comment on your action, not a judgment on your character
    • Hesitation: People may not feel like they have the right background to interrupt a microaggression as it’s occurring
      • Solution: Stepping in doesn’t need to be a big, dramatic act; usually, a simple acknowledgement that something happened goes a long way
      •  
    • Medical hierarchy: It can be difficult for people in training to feel empowered enough to speak up, particularly if the comment comes from a supervisor
      • Solution: When an inappropriate comment is made, you can bring attention to it by asking a question such as “Can I ask for clarification, I think I heard you say ___”. 
  •  

Transcript

Sofia: Growing up in a post-9/11 America, I had often heard Microaggressions described as death by a thousand cuts. I experienced my thousandth cut as an adult, during a meeting with a team where everyone but me was white. When someone brought up “random” selection by TSA. A concept I was no stranger to because of my name. She joked that her husband gets stopped by airport security every time they travel even though he doesn’t have “a terrorist sounding name”. It was clear what she meant; names like mine. The one that always prompted questions about my background and required help with pronunciation. It felt like an assault. I looked around at the white faces laughing at their unknowing participation in this act of microaggression, all unfazed by the comment. I waited for someone, anyone, to acknowledge my conventionally arabic name and the insensitivity of what she said. That didn’t happen.

The meeting ended and I sat alone with my pain, feeling too new and unsupported to defend myself and the name my mother had chosen for me. My whole life had been filled with moments like these. Moments where I felt torn between standing up for myself and staying silent to avoid making waves.

Her comment reminded me of the time I spent hours in the Emergency room waiting to be seen, only to be approached by a provider whose first question was whether or not I would need an interpreter. And of the patient who told me that he knew I was “one of those” when he heard my name and asked if “more people like me” would be on his care team.

Each of those moments and many like them…took something from me; leaving me understand that I couldn’t control the way I would be perceived when people saw me. – – But I did have control over their perception of me when they read or heard my name. And so…I filed to change it. 

I knew that it wouldn’t stop people from yelling to me out their car windows to “go back to where I came from” ..or… from demanding to know where I’m “really from”. But it was one way I could take control of how I was approached in some aspects of my life. 

7 months after that seemingly innocent comment at work, with my legal name change finalized, I was still bothered by that moment. Why didn’t I stand up for myself? Why didn’t anyone stand up for me? Why didn’t they at least acknowledge that I could have been hurt by what was said? .. That moment wasn’t the only reason for my decision to change my name.. But I have thought about it every day since.

Our goal today is to take a look at instances of casual and blatant racism and explore how microaggressions affect marginalized individuals, medical training, and patient care. We’ll also help you understand how to be an upstander, someone who steps in and provides support when microaggressions occur. Welcome back to At the Bedside. I’m Sofia – a Pharmacy student at the University of Cincinnati. I’m excited to join the At The Bedside team to talk about a topic that’s really important to me . 

Jafar: I’m Jafar

Tamar: I’m Tamar

Margot: and I’m Margot

Sofia: We spoke with medical trainees and clinicians about what it’s like to experience microaggressions in their day to day lives. Debbie Fadoju is a 4th year medical student at The Ohio State University College of Medicine. And she describes how being a minority learner presents unique challenges that are faced while struggling to earn the same education as her white peers. 

Debbie: I think a lot of my experiences really center around feeling like I’m struggling to have a voice or that my voice isn’t being heard.

Sofia: Often, to make our voices heard, we have to rely on those around us for allyship in situations that momentarily shake us. 

Dr. Hicks: Allyship is very important. I think there’s strength in numbers. And I think that sadly, very few things get done in this country without allies. And oftentimes it is, since they historically have been the dominant culture in this country, and it’s certainly the fact in healthcare white allyship is impactful.

Sofia: We’re lucky to be joined today by Dr. BJ Hicks, a vascular neurologist at Ohio Health’s Riverside Methodist Hospital, and one of his residents, Dr. Corey Thompson.

Dr. Thompson: Racism can mean different things to different people.Sometimes when you overuse something it holds less power.. like, if all of a sudden everything is racist, then it sort of takes away from when we call something racist because everything’s racist. And so I try to distinguish between racist and like racist, adjacent, like things that are perpetuated by racism.

Sofia: The intention here is not to cover the entire scope of this topic or all the ways to handle these situations, but rather to have the opportunity to hear stories and solutions from people who have experienced these things firsthand. We are going to be discussing microaggressions in a racial context. However it’s important to note that all marginalized groups – gender, sexual orientation, religion, disability AND OTHERS – experience microaggressions and we hope that some of these tools can help to interrupt all forms of microaggressions and indirect discrimination.

Jafar: Let’s start off with a few definitions that can help clarify this issue. Most of us can point to racist words or actions that were used to directly and intentionally harm marginalized people. Like Sofia, I grew up in a post-9/11 world where antipathy towards Arabs hit a fevered pitch. It’s easy to remember when someone told me to “go back to my country” or used a racial slur, but at least for me, these experiences were few and far between, and are what we would define as macro-aggressions. Much more common, though, were the questions about my heritage, anger and confusion about Islam, and expectations for me to explain things about the middle east. We can define these kinds of comments as “microaggressions”, which are indirect, subtle or unintentional behaviors that reveal a bias towards people in marginalized groups, and in the process harm them. 

Debbie: A lot of microaggressions are subtle, so you don’t recognize them when they happen. You just start to ask yourself, like, am I crazy or am I really being treated unfairly? There’s some moments where I’m okay with breaking that level of of uncomfortability with shaking the table in a sense but then there’s some times where I have to go and find safe spaces to reflect because there, there is an emotional toll that, that goes on when you ask yourself, am I going to address this microaggression or this macroaggression right now? 

Jafar: Yea and I often find myself asking, am I just being too sensitive about this? What did they mean by that? Regardless of intention, these kinds of behaviors create a hostile environment that has a huge impact, particularly on medical trainees. 

Debbie: I just came here to learn. In fact, I’m actually paying a considerable amount of money to learn in an environment where I feel safe, where I feel respected.

Jafar: These microaggressions are experienced in many different ways, but let’s call it what it is. It’s a form of racial trauma, and some receivers can experience significant mental and emotional injury from it. It can affect our view of ourselves and the groups we identify with. And some people feel the need to monitor their behavior just to avoid justifying the racial biases that other people carry—an experience called “stereotype threat.” Managing these emotions is another burden for people who already have enough on their plate. Surveys show that medical trainees are frequently the target of racially triggering events, in ways that don’t often get reported. Just as often, though, we may experience it vicariously through negative comments made about patients:

Dr. Hicks: The things that always stuck out to me that were extremely problematic and they could be considered a microaggression or just kind of blatant was how patients were received. Patients that did not have the same lived experiences as physicians or medical students or physicians in training here definitely was a big discrepancy in if you came from a different culture, if there’s a different socioeconomic background. And therefore if you presented to the hospital, if you presented to the clinic in a certain way, and you did not adhere to kind of the straight and narrow way of being a patient in the doctor-patient relationship that modern westernized healthcare requires of patients, that’s when you would hear a lot of just inherent negativity and inherent bias, which I think went on to lead to poor outcomes for those people that they were trying to serve.

Tamar: So let’s dive in a bit deeper at how prevalent this is. Experiences ranging from microaggressions to overt racism or discrimination are not rare in academic medicine or clinical training. In a 2018 study interviewing 27 residents from ethnic and racial minority groups working in different specialities and institutions, one of the of the main themes that emerged was what the authors called a “daily barrage of microaggressions and bias.” These included many experiences of being mistaken for non-medical staff or for other minority residents. But despite the frequency of these instances, residents were often hesitant to report them to their program leadership.

Studies have also shown that these experiences arise from several sources including patients and their families, peer-to-peer interactions, organizational structures in clinical environments, medical educators, and healthcare curricula themselves. 

Dr. Thompson: Lectures would oftentimes have, you know, we’re going through diabetes or we’re going through cardiovascular health. And then you decide to like throw in one slide saying like, oh, black people are more likely to die from this, this and this because they’re black And it’s like, well, let’s take a moment and dissect that, if we could, perhaps it’s because black people are more likely to be in poverty, be in food deserts where they don’t have access to food. That would be heart healthy. A lot of times they seek primary care in the emergency room.  there’s a lot of things to unpack there. And so you’re sort of minimalizing that whole issue to the color of their skin, which really isn’t the problem. The problem is redlining and racism. And I shouldn’t say, I guess it is racism adjacent but discrimination based on these long existing structures that are in place that keep black people in lesser off areas until they decide that they wanna gentrify those areas. And then they end up kicking the current inhabitants out. It’s not anything that can be summed up in one PowerPoint slide. 

Tamar: Dr. Thompson’s example underscores the ways in which the formal medical school curriculum can perpetuate flawed concepts that contribute to discrimination. Race is not an adequate surrogate for biology or a stand-alone prognostic factor, and the focus should instead be on appreciating the impact of social determinants of health and systemic practices that lead to racial inequities. And the informal, or hidden, curriculum can be just as problematic. It’s been demonstrated that students are much more likely to exhibit racial bias themselves if they’ve witnessed similar biases expressed by their clinical professors and supervisors. For healthcare students from racial and ethnic minority groups, these experiences create an uncomfortable and even unsafe learning and practice environment. 

Debbie: As a medical student asking questions gives you two benefits. It shows to other people that you’re curious and that you’re engaged and that you’re involved. And then too, it expands your learning, but that comes at the cost of being vulnerable. And if I’m not, if I don’t feel safe enough to be vulnerable, then so it’s a stumbling block. 

Tamar: A survey of U.S. medical students published last year showed that over 60% of respondents had experienced at least one microaggression weekly, most often due to gender, race or ethnicity, and age. Another really important and painful finding was that these same students were more likely to consider transferring schools, or even withdrawing from medical school altogether. So we need to recognize situations that contribute to these types of experiences and environments and then figure out how to respond to them.

Sofia: In thinking about how to respond, we can talk about the concept of being an upstander, and how it’s different from a bystander. Upstanders witness instances of injustice but also recognize maltreatment and step in to interfere and provide support. Unfortunately, there are a lot of times when microaggressions occur and nobody speaks up. In those moments, silence is so much louder than anything that could have been said.

Dr. Thompson: A nurse kept forgetting my name and so she decided without necessarily my permission, that she was gonna start calling me, uh, rosta. And  it would happen in front of patients too. And one time it happened in front of my attending And, they just didn’t really address it until a little bit later where, he just kind of said, uh, I think it’s kind of funny. And I don’t think that he meant to be rude would by it. But I didn’t, I don’t think that that was an appropriate response, especially because I didn’t, like, I was kind of like ,I don’t really love it. And he just kind of perpetuated that.

Sofia: Even when we’re able to shrug those moments off, they often come back to us when we’re reflecting on our experiences. That’s why it’s so important to behave the way we wished others would have, when we have the chance to be upstanders. 

Debbie: I was on my psych rotation and we had a patient that was in desperate need of getting electroconvulsive therapy and this patient has like a long history of saying racist things to trainees. But this day, when they were told that the next step is E C T specifically, the patient was like if that N word is doing my procedure, I don’t want it. And they kept repeating it over and over and over. I don’t want that N word touching me. I don’t want that N word in the room. I don’t want that N word here. referring to my attending. So, here was a moment where my attending came back into the break room. She just sat down, she scoffed a little bit just cuz she was frustrated and we talked openly about it. She let out her frustrations. And I think in that moment, my role was just to be a listening ear. It was really just to say like that’s wrong and also it it’s not due to his mental illness. he came from a very rural part of Ohio and we could kind of tell that his family supported his behavior. So yeah, my job there was just to listen and to make her frustrations feel validated and she could do that again because she culturally identified as black. And so did I, so that was the moment where we could just be like, wow, this sucks.

Sofia: Debbie described a heartbreaking moment of allyship between two people who shared the impact of an experience. But sometimes the other person in the room comes from a very different background. But that doesn’t mean they can’t be an upstander. 

Dr. Thompson: I had a really great experience maybe bad experience turned great my third year of medical school. And so getting on the rounds, general us hospitalist service, and we had a, elderly white lady who was suffering from some what we believed to be hospital related delirium. And it was my first time seeing her so we all went in together and the lady took a look at, at us or at, at me I presume and just started yelling for the police.  And it all happened very fast. I didn’t take it too much to heart knowing that she was delirious and tried not to like take too much offense to it.

Sofia: What his attending at the time did next is what had a larger impact on Dr. Thompson.

Dr. Thompson: He actually came over to me almost immediately and just sat me down, said are you okay? I said, yeah, sure. Which would’ve been, what most attendings would’ve done? Just, are you okay, keep it moving. But he took it a step further and let me know that he understands what microaggressions are and that they can be incredibly taxing day in and day out. So if I do need to take a minute to conduct myself, if I don’t wanna see this patient anymore, whatever I need to do to feel better, I’m here for you. And I think that was just like incredible. And that just showed me that he was trying, that he cared that he’s attempting to be a part of the solution. 

Sofia: Support can come in the form of simply acknowledging a difficult moment, or speaking up directly for those who don’t feel like they’re able to defend themselves. But how does this trickle down to the patients who share similar experiences with the trainees and physicians who care for them day in and day out?

Dr. Hicks: I think the old ways of this is how I doctor, I doctor every person the same, I live in a color blind society, and it, someone is a difficult patient or they’re non-compliant it, it’s not up to me to figure out what is that all due to. And I think that was a big missing piece for what I noticed throughout my training,  patients that may come from places that historically were neglected environmentally neglected, financially neglected with their educational opportunities. And therefore a lot of that resonated down to poor health. And what happens is physicians and those in, uh, the medical lens, without understanding that they’re doing a disservice to the patient, they’re doing a service to their community that they’re trying to serve. And I think finally people are understanding that at this is a part of doctoring, and at least what I’m starting to notice is that trainees are no longer thought of as this only a one way street.

Attendings are starting to learn, whether they like to or not, different ways of being compassionate and different ways of understanding how best to approach, um, human beings of all walks of life. And I think that those that aren’t doing that and those that kind of remain set in their ways. I think there’s a lot more channels and avenues to make sure that departments and administrators know that this person at best is behind the times and at worst could be toxic. And I think now is just the perfect time to make sure that we don’t miss this opportunity. 

Sofia: While there is no one size fits all approach to being an upstander, it’s important to look at these moments through the lens of the people who experience them, and to note how those individuals feel they can, and should, be advocated for. So what are some ways victims of racial based microaggressions feel we can interrupt these forms of racism?  

Debbie: I would say the first thing that always needs to be done in these situations is validate people’s experiences. I think at the very minimum, if you were not the person who was going to cus and cry and say that something was wrong, then at the, bare minimum, validate that how someone felt was real. That’s it. Just tell them I saw that that happened to you. That was wrong. And I’m sorry that that happened to you. I stand with you. I think a lot of people don’t recognize that that really goes a long way.

Sofia: Exactly, and though it can sometimes feel daunting to approach these instances without feeling like you’re taking someone’s voice away. Every case is unique and should be handled like a new experience every time, even if it might feel like it’s always the same.

Dr. Thompson: What would be, helpful is that when they do stand up for themselves, you have their back. It’s not putting yourself first different people are going to react differently. So if I decide to say nothing to keep moving, then maybe coming to me and saying, Hey, you know, that was a, that seems like a little off to me. I think that’s appropriate. But if, if I don’t say anything about it and you’re over here yelling at this other person, it now you’ve made it about you. You’ve put yourself in the middle of this situation. And it, becomes more about like this whole white guilt thing. And that’s not really necessarily what, what we’re looking for. And so I think that you need to like thoroughly educate yourself. Don’t like take a vested interest in this read books, watch documentaries. Talk to friends, talk to your black friends, ask them how they want to be supported.

Sofia: Ask people how they want to be supported. That’s so important. And Dr. Hicks explains that it takes a specific type of person who is able to recognize and validate these experiences, and it isn’t just about not being racist.

Dr. Hicks: Whenever I hear the word racist. Now we all know that that’s a trigger. So whenever the race question is popped into play. I like to reorient everything by saying, well, are you an anti-racist because there’s racist thoughts, racist activities, racist policies, but what’s the opposite. It’s it’s quote unquote black and white. So an anti-racist works against these sorts of things.

Sofia: So ultimately, the opposite of racism isn’t ignoring differences and privilege. It’s working as an anti-racist to promote racial tolerance. But what are some of the things that limit people’s ability to respond appropriately to the type of bigotry we’re discussing? I’ll hand it over to Margot to talk about some of those barriers. 

Margot: We recognize that it’s hard sometimes to carry theory into practice. Most people have good intentions, and yet we’re still in an environment where microaggressions are common and many people are bystanders. So what are some of the barriers people experience to carrying out the right action? And how do we overcome those barriers? First off, microaggressions are common in part because people don’t recognize the way their comments may affect others. Even if your intentions were good, what ultimately matters is how the comment was perceived. 

Debbie: Because you’ve never lived my experience because you’ve never walked the world as a black woman. Um, you can’t speak on whether the situation was racist or not. If you’ve never been, if you’ve never been a victim of being marginalized because of the color of your skin, if you’ve never had a shared cultural identity, if you never lived the experience, you have no authority to speak on it. And I think I’d keep it as simple as that. And I’d ask them why can’t you see it from my point of view and I’d interrogate it with that from that way.

Margot: If someone takes offense to your comment, this isn’t the time to get defensive. Try to take the feedback as a comment on your action, not a judgment on your character.

Dr. Thompson: Even if you feel like you’re not racist, that doesn’t mean that you aren’t contributing to a racist society, or you did not do something that was racist. There’s a difference between the act and you as a person.

Margot: Listen to the person you offended, apologize, and strive to do it right the next time.

Dr. Thompson: And maybe an example would be, a patient has a hijab on, and maybe you call it something other than that it’s name like a head wrap or a, I don’t know, scarf or something. And it just, the patient doesn’t like that. Like, there’s no, it’s hijab. So you ask and then you say, I’m sorry, I didn’t realize that’s what it was called. I’ll call it hijab from now on. And so show that you are learning from that mishap. And then the next time you see that patient call it a, hijab, like the very intent about showing them that you have progressed in some way.

Margot: Now we want to turn to a second question: why don’t people always step in? 

Debbie: Some of the reasons I’ve heard is the fear of showing ignorance. Like I’m afraid that, if I speak on something that I’m not knowledgeable about, then people will judge me. I’ve heard that I’m not an expert on the topic. So I’d rather just sit back and listen. I’ve heard that I don’t want anything I say to be misinterpreted. And I think in isolation, none of those thoughts are bad. They’re, they’re reasonable, they’re understandable. I can empathize and sympathize with them, but I have to examine the impact of what not saying anything means specifically to people of color when they’re in situations where they’re, they’re looking for an ally or they’re just looking for someone to recognize that the situation that they faced was unfair. I think that the impact not saying anything is far greater than the emotional toll that it might take to, um, to say something. So I guess to speak to that more so to speak to white silence, like I think someone said it really, really well, like your silence is really, really loud. So I guess I would just challenge people who are, are looking to be allies if possible like step out of step out of that discomfort and, and be there in a meaningful way.

Margot: Sometimes, people are hesitant to step in because they don’t want to draw too much attention to themselves, or insert themselves into a conversation they don’t feel like they’re a part of. It’s important to know that stepping in doesn’t need to be a big, dramatic act. People aren’t looking for a  knight in shining armor; usually, a simple acknowledgement that something happened goes a long way.

Dr. Hicks: It just requires, again, more crucial conversations about making people comfortable being an ally, but not having to be a savior each and every time, but just kind of speaking up here and there, I think it could be very impactful. 

Margot: Sometimes, people may avoid stepping in because they don’t feel like it’s their place. Medical hierarchy can be daunting, but Dr. Hicks has advice for trainees on how to speak up. 

Dr. Hicks: If you’re at a level like a trainee or a medical student, an open-ended kind of response, um, can, again, open things up and, and maybe even trigger the attending that, Hey, I may have missed the, the, the mark here. And I may have miss the nonverbal cues, which quite frankly, a lot of members of healthcare like physicians often do miss those nonverbal cues. Do because it’s such a verbal discipline kind of a written and a verbal discipline, being able to, to make some sort of mention, like, excuse me, you know, can I ask clarification, just, did you say something like that, then it’ll kind of… I’ve seen that, that kind of alerts people to, Hey, I think that was inappropriate. And I want to hear this one more time and allow others to, to chime in and let them know that’s inappropriate.

Sofia:We will never be able to fully describe the toll of experiencing microaggressions and blatant racism, but we can try to identify moments when silence isn’t an option. Moments when disarming these situations is our responsibility. So our goal as those experiencing microaggressions directly or being in proximity of them, should be to understand that being an upstander is always an option – whether that looks like expressing concern and support after the fact or stopping everything and calling something out as it’s happening, and always being aware of discomfort and our own mistakes.

Debbie: I feel like for attendings, for fellows, for seniors, for anyone who’s in a position of authority, in an educational experience, your job is to make your learners feel safe.

Sofia: And as we’ve learned from our discussions, you don’t have to be a person in authority to step in and provide support. 

Dr. Thompson: It is up to the majority in this case to get outside of their comfort zone, learn, ask questions when appropriate, read the room a little bit and understand that you cannot act the same way in every scenario.

 Sofia: This can be a tough topic to tackle but we hope that today’s discussion provided some insight on the effect these situations have on medical trainees and everyone who faces them. We have to understand that it can’t solely be the responsibility of marginalized individuals to create positive change for ourselves.

Jafar: Thanks for tuning in!  We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences with standing up to microagressions. Please continue the conversation with us online at our facebook page, on twitter, or email us directly. Find show notes and contact information for us on our website:  coreimpodcast.com.

If you enjoyed listening to our show and you’d like to break your silence on this issue, please give us a review on itunes or whichever podcast app you use; it helps other people find us.  We work really hard on these podcasts so we’d love to hear from you.  Let us know what we are doing right and how we can improve.  And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions.  

Finally, special thanks to all our collaborators on this episode, our wonderful audio editor Daksh Bhatia, our illustrator and punch-up artist Michael Shen, moral and executive support from Shreya Triveda, and most importantly thanks to you, our listeners!

References

 


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