Diversity, Equity, & Inclusion
Microaggressions and Their Macro Impact on Health Care
Sonia Malhotra, MD MS FAAP, and Aziz Ansari, DO SFHM FACP FAAHPM
You are not like others…." "You are so articulate…." Statements like these are spoken at school, in the workplace, and in healthcare settings. As recent events in the news force our society to examine racism and the structures built around its continuation, individuals need to evaluate their own behaviors that contribute to the construction and maintenance of racist and discriminatory structures. One aspect of this evaluation is identifying microaggressive behaviors toward colleagues and patients.
Microaggressions are defined as brief and subtle verbal or nonverbal behaviors that can be conscious or unconscious (implicit) and that disempower diverse racial, gender, or cultural groups through hostile, derogatory, or negative slights and insults. They are one aspect of clinicians' implicit biases: attitudes or stereotypes that all individuals carry that affect our understanding, actions, and decisions in an unconscious manner and lead to differential treatment of others. When implicit, microagressions are difficult to identify and address. Table 1 discusses subcategories of microaggressions that racial, gender, or cultural groups encounter.
Table 1: Microagression Subcategories
|Physical, verbal, or nonverbal acts of discrimination or racism that communicate the targeted party being of lesser worth||"Why aren't you soft-spoken like other Indian doctors I have met?"|
|Insensitive or disparaging messages about a person's racial or cultural background||"President Barack Obama is the first Black person articulate enough to be a front-runner for president."|
|Behaviors that negate, neutralize, or deny the experiences of others||"I don't see color."|
Microaggressions have macro effects on healthcare systems and patient experience. It has been shown that Black and Latinx patients suffer incredible health disparities.1 In addition, the stress related to discrimination can lead to higher rates of depression, anxiety, and noncompliance.2,3 From a systems level, microaggressions can lead to a lack of diversity and equity in the workplace through poor recruitment and retention of diverse individuals.
Evaluating our own implicit biases, including a critical appraisal of microaggressions, is essential to the delivery of effective palliative medicine. The first step is awareness, which can be attained through taking the Implicit Association Test.4 The second is possessing cultural humility and a lifelong commitment to self-learning and self-critique.5 The management of microaggressions by overcoming implicit bias using tenets of cultural humility is complex and yet approachable.6 Several tools have been developed to practice cultural humility with the goal of overcoming biases and encouraging self-reflection. Two such tools are the 5 Rs of Cultural Humility (Table 2)7,8 and the DEAR mnemonic. The 5 Rs focus on three key techniques for reducing stereotypes9: taking perspectives into account, regulating emotions, and building partnerships with colleagues and patients with an "aim" and an "ask" for each R.
Palliative medicine clinicians have extensive training in communication skills and are well poised to lead efforts at reducing racism and disparities among patients. A critical aspect of this is reflecting on our own implicit biases in interactions with patients and colleagues. Through increasing awareness of our biases and the active use of tools that promote self-reflection, we can achieve positive patient interactions and workplace environments that promote cultural humility and eliminate microaggressions.
Table 2: 5 Rs of Cultural Humility
Aim: One will approach every encounter with humility and understanding that there is always something to learn from everyone.
Ask: What did I learn from each person in that encounter?
Aim: One will treat every person with the utmost respect and strive to preserve dignity.
Ask: Did I treat everyone involved in that encounter respectfully?
Aim: One will hold every person in highest regard while being aware of and not allowing unconscious biases to interfere in any interactions.
Ask: Did unconscious biases drive this interaction?
Aim: One will expect cultural humility to be relevant and apply this to every encounter.
Ask: How was cultural humility relevant in this interaction?
Aim: One will embody the practice of cultural humility to enhance personal resilience and global compassion.
Ask: How was my personal resiliency affected by this interaction?
5 Rs of Cultural Humility. Published in 2017 by the Society of Hospital Medicine. Created by SHM Practice Management Committee, Cultural Humility Workgroup. Reprinted with permission.
- Cuffee YL, Hargraves JL, Rosal M, et al. Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension. Am J Public Health. 2013;103(11):e55–e62.
- Nadal KL. The Racial and Ethnic Microaggressions Scale (REMS): construction, reliability, and validity. J Couns Psychol. 2011;58(4):470–480.
- Constantine MG. Racial microaggressions against African American clients in cross-racial counseling relationships. J Couns Psychol. 2007;54(1):1–16.
- Implicit Association Test. Project Implicit website. Published 2011. https://implicit.harvard.edu/implicit/
- Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117–125.
- FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.
- Masters C, Robinson D, Faulkner S, Patterson E, McIlraith T, Ansari A. Addressing biases in patient care with the 5 Rs of cultural humility, a clinician coaching tool. J Gen Intern Med. 2019;34(4):627–630.
- The 5 Rs of cultural humility. Society of Hospital Medicine website. https://www.hospitalmedicine.org/practice-management/staffing/the-5-rs-of-cultural-humility/
- Galinsky AD, Moskowitz GB. Perspective-taking: decreasing stereotype expression, stereotype accessibility, and in-group favoritism. J Pers Soc Psychol. 2000;78(4):708–724.