Addressing Microaggressions in the Health Care Workforce—A Path Toward Achieving Equity and Inclusion

Despite a persistent clarion call to enhance diversity, equity, and inclusion (DEI) in academic medical centers, there has been a lack of recognition of the experiences of underrepresented minority (URM) and women physicians and how that impedes DEI work. Both Alexis et al¹ and de Bourmont et al² underscore how prevalent this problem is in their respective publications, “Assessment of Perceptions of Professionalism Among Faculty, Trainees, and Staff of a Large University-Based Health System” and “Resident Experiences With and Responses to Biased Patients.” Alexis et al¹ used a mixed-methods analysis of survey data to understand how professionalism is operationalized and recognized in diverse environments. Their findings indicate that individuals who are underrepresented in academic medicine experience more “infringements on professional boundaries, as well as increased scrutiny over their professional actions.”¹ Individuals from underrepresented groups also experience the stress of feeling like they need to assimilate into a professional culture, whose norms have been centered around a White male heterosexual identity, instead of being their authentic selves. de Bourmont et al² surveyed internal medicine residents in California and North Carolina to determine the frequency of resident experiences and responses to biased behaviors of patients. They found that patients frequently display bias, and it is mostly directed at women and URM trainees. In addition, sexual harassment was experienced by 87% of female respondents in their study. However, when it comes to addressing these issues, most trainees relied on peers and family for support as opposed to elevating their concerns to institutional and program leadership. As both authors highlight, microaggressions, bias, and sexual harassment are prevalent in academic medicine and disproportionately affect women and URM health care professionals.

Current events have highlighted the historical impact of structural racism, bias, and discrimination on people of color in the United States. This lived experience is magnified when you also encounter microaggressions in your workplace, increasing the toll on physical and mental health and the inability to be authentic to oneself in the process. Racial battle fatigue is a concept that summarizes the collective impact of repeated experiences of microaggressions on one’s physical, emotional, and mental health.³ For example, research has shown that Black women have worsening health due to the cumulative impact of repeated experiences related to toxic stressors, such as discrimination and bias.⁴ They must also face being labeled the angry black woman as a way to dismiss them when they speak out about what they and other people of color experience. Another effect of consistent exposure to microaggressions is the internalized sense of inadequacy, leading to what is known as imposter syndrome, in which an individual doubts themselves and their actions.³ Imposter syndrome may lead to isolation, affect engagement, and hinder professional achievement and career advancement, which can ultimately limit the unique contributions to the overall workplace. The stress that women of color experience is compounded by sexual harassment, which is prevalent in academia.⁵ Given this environment, it is not surprising that women and URM physicians experience greater levels of burnout, which could lead to them leaving medicine altogether.⁶

DEI are known drivers for organizational excellence.⁷ Microaggressions, bias, and discrimination in academia must be addressed to truly create a diverse, equitable, and inclusive environment that fosters organizational excellence. To achieve this goal, organizations will need (1) leadership accountability, (2) committed resources, and (3) “an evidence-based, data-driven, and transparent approach to evaluation and reporting.”⁸ As Marc Nivet, EdD, MBA, the former chief diversity officer at the Association of American Medical Colleges, has stated, diversity should be seen as a solution as opposed to a problem.⁹ Leaders of academic medical centers need to prioritize and encourage all team members to consider issues of DEI across strategic areas. Strategic and principled investments in these efforts can lead to greater organizational health, innovative solutions, and, ultimately, exceptional financial and operational outcomes.⁷ A focus on recruitment alone—without attention to the systems, structures, and policies that guide academic medical centers—will not lead to a full realization of the potential of a diverse workforce. Approaches to address microaggressions, bias, and discrimination require the allocation of resources for training and professional development of facilitators to engage in dialogue and develop responsive programming. Creating ad hoc committees and time-limited task forces to discuss microaggressions, bias, and discrimination does not replace the need for valuable metrics, which are required to gain transparent understanding of their workforce. The Diversity Engagement Survey described by Alexis et al¹ is an example of a validated instrument that organizations can use to assess diversity and inclusion efforts. Measuring bias, discrimination, and microaggressions is critical for beginning the process of creating a more diverse, equitable, and inclusive organization.

An essential step to achieving an equitable environment is recognizing some women and individuals from URM groups feel obliged to be the advocates and ambassadors for DEI initiatives and may end up doing an excessive amount of service activities. This is known as the minority tax—the disproportionate responsibility usually placed on individuals from URM groups—which can lead to exhaustion. This is further compounded by the fact that this work is frequently uncompensated and undervalued and, until recently, was not considered in academic promotion and tenure decisions. This is counterbalanced by what is known as the majority subsidy,¹⁰ the perceived addition of time and opportunity that those in the majority have to devote to career advancement.

Leaders of academic medical centers must recognize the microaggressions and subtle indignities that affect their workforce’s daily lives, which are currently magnified by their personal lived experiences. Further work is needed to better understand effective strategies that incorporate leadership accountability and the use of resources and data to meaningfully change the workplace environment. Persistent and deliberate actions will collectively move us further along the path to understanding and transformation of the workplace environment for women and individuals from URM groups, with the ultimate goal of achieving equity and inclusion in health care.

Published: November 23, 2020. doi:10.1001/jamanetworkopen.2020.21770

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Acholonu RG et al. JAMA Network Open.

Corresponding Author: Rhonda G. Acholonu, MD, Division of Pediatric Hospital Medicine, Department of Pediatrics, The Children’s Hospital at Montefiore, 3411 Wayne Ave, Bronx, NY 10467 (racholon@montefiore.org).

Conflict of Interest Disclosures: Dr Acholonu reported being a founding member of TIME’S UP Healthcare.