Микроагрессии в медицине: как скрытые предубеждения разрушают карьеру женщин-врачей

‘All of a sudden, it hurts’: Prevalence, cost of microaggressions among women in medicine Key takeaways: - You may not realize you faced a microaggression because they are subtle. - Experiences of microaggressions can contribute to imposter syndrome, burnout and depression because recipients internalize them. Editor’s Note: This is part one of a three-part Healio Exclusive series on microaggressions among women in health care. Part two and part three will be linked here when they are posted. In health care, microaggressions can come from colleagues, patients and institutions or systems, with women more frequently on the receiving end than men. To learn how to best address this form of discrimination, Healio spoke with clinicians about how to identify microaggressions and what effect they may have professionally and personally. Understanding microaggressions According to Mental Health America, microaggressions are a form of verbal or nonverbal discrimination against “a person’s ethnicity, country or origin, race, age, gender, sexuality, disability status, religious affiliation or economic status.” Microaggressions can be intentional or unintentional, and they result in the person feeling invalidated, abnormal or unfit in their environment, Nellie Tran, PhD, community psychologist and professor at San Diego State University, told Healio. Some examples of microaggressions against women include saying “smile more,” calling them “sweetheart” and asking them to get coffee or take notes during a meeting, according to Mental Health America and ComplyEQ. When asked how microaggressions and an incident of sexism/racism differ, Tran said the main difference is how they appear, which impacts how people process them. A sexist or racist incident is clear and can be externalized, whereas a microaggression is subtle and internalized. “When it’s subtle and keeps happening to you, it’s not quite big enough that you go around asking people for help to identify it,” Tran said. “Instead, you end up thinking, ‘Well, it keeps happening to me, so it must be me,’ and internalize it. The inability to cope by saying, ‘It’s not me’ is where we see the problem. “A lot of what people are calling microaggression these days is just straight up sexist, and the switch to talking about everything as a microaggression doesn’t protect us,” she added. “When something is clearly sexist and biased against women, calling it sexism, even just inside our heads, gives us that strategy that is most effective: to externalize.” Tran highlighted one way to think about a microaggression is through the lens of a paper cut. “Paper cuts are small, and sometimes I look down at my hand and have one,” she said. “It’s surprising because it hasn’t hurt all day, but all of a sudden, it hurts more than a big cut.” Due to their subtle nature, Tran told Healio microaggressions can be difficult to spot when they happen, with people sometimes not even realizing they were on the receiving end until much later. “I teach these concepts to college students, and they’ll all of a sudden remember something that happened while they were in high school, and now it hurts,” Tran said. “In actuality, we know that it has been hurting you; you just didn’t quite know it.” Notably, the small subtleness of microaggressions does not mirror the impact they can have on a person as Tran outlined that they can lead to stress, anxiety and depression. “If you have a history of experiencing harm by a particular individual, let’s say by men, then interacting with any man is a potential for not just one harm but multiple harms,” Tran told Healio. “These are micro incidences of when I’m going to feel as though my identity and knowledge are going to be questioned.” In a study of 759 U.S. medical students by Anderson and colleagues, those with the highest vs. lowest frequency of microaggressions had elevated odds for having a positive depression screen on the 2-item Patient Health Questionnaire (OR = 9.38; 95% CI, 3.71-26.69). Research has also shown a connection between microaggressions and burnout in health care professionals, especially women. In a study of 130 surgeons by Ogunnowo and colleagues, a greater proportion of women vs. men agreed or strongly agreed that “microaggressions contribute to burnout at work” (76% vs. 60%). In addition to taking a toll on mental health, microaggression experiences can result in inequities in the workplace, according to Tran. “After a microaggression, it’s not just that I’m now worried that I’m not good enough to be here, it’s that this worry prevents me from being productive and seen as a welcoming worker because I’m constantly having to be on guard,” she said. “That hypervigilance is exhausting, so you see more burnout, fewer promotions and less connection and belongingness in the workplace,” Tran added. In their study of surgeons, Ogunnowo and colleagues also found that a greater proportion of women vs. men agreed or strongly agreed that “microaggressions reduce my career satisfaction” (61% vs. 51%). Additionally, in a study published in Women’s Health Reports, Myers and colleagues assessed questionnaire responses from 117 women residents, fellows or attendings (49.6% white; 43.6% with 15-plus years out of medical school) and reported that approximately 84.6% endorsed experiencing microaggressions. Researchers went on to find that the risk for counterproductive work behavior — defined as “voluntary behaviors that are intentionally perpetrated by an employee with the sole purpose of harming the organization, other employees and clients/customers” — was higher with microaggressions. Harmful impact of microaggressions in health care Since microaggressions lead the victim to internalize and be on guard, Tran told Healio they can be harmful in health care where the patient needs to be the priority. A health care professional who is a victim of microaggression may concentrate more on themself and how they are presenting rather than their patient and the microaggressions to which they could be subjected. “I can’t be focused on my male colleagues when I should be focused on my clients, especially the ones that I’m more likely to harm because I’ve been trained in such a way that I may inadvertently provide lesser care to certain types of individuals,” Tran said. “Patients of color are historically underserved, so I need to be vigilant of how I care for these patients rather than ruminating about my workplace.” Between women and men, Tran noted that historically men tended to hold more power in health care workplaces. This notion points to more microaggressions against women rather than men in medicine and can lead to women feeling they are lesser than or do not belong, which can interrupt their focus on patient care. In their study of women physicians, Myers and colleagues also observed an elevated risk for imposter syndrome with microaggressions. Importantly, studies have shown that imposter syndrome is more frequent among women vs. men physicians. In a study of 3,116 U.S. physicians by Shanafelt and colleagues, the mean imposter phenomenon score among women was 10.91 (moderate intensity), which was significantly greater than the mean score of 9.12 among men physicians. Similarly, a study of 2,183 U.S. physicians by Iwai and colleagues found that a significantly larger proportion of women vs. men surgeons reported imposter syndrome (90% vs. 67.7%). This was also true in women vs. men nonsurgeons (88.7% vs. 72%). After experiencing a microaggression, there are often many thoughts bouncing around in a victim’s mind. Tran outlined that they question if what happened was actually a microaggression, how they reacted in the moment, why they reacted the way they did, how the person who made the microaggression feels about them and if they should say something to the person. Victims can spiral from these thoughts and questions, and the spiral can end with negative thoughts about themselves and their response. “Every time I ruminate on something, I’m worrying and that creates stress,” Tran said. “It’s taking time and energy away from other things I could be doing with that mental energy. “In spaces that are high demand with high-volume interactions, you don’t have time to repair relationships,” Tran added. “You need to be on good working terms all the time, except you’re not, and no one’s talking about it.” Microaggressions from patients In addition to coming from colleagues, microaggressions can come from patients, introducing a different situation for health care providers to navigate. Working in health care you expect patients to respect your degrees and training that permit you to care for them, so when that respect is absent and a microaggression is expressed, Tran said it upsets the power dynamic. As Healio previously reported, a study of 297 physician-completed surveys published in the Journal of Women’s Health found that female physicians experienced microaggressions from patients more often than male physicians (P < .001). Notably, the researchers divided microaggressions into four themes within the survey: sexual objectification, use of sexist language, assumptions of inferiority and assumptions of traditional gender roles. This study also found that more than three-quarters of female physicians (79%) reported an experience in which a patient assumed that they were not a physician. Other microaggressions commonly experienced by female physicians included patients being surprised by their role (66%) and patients assuming their expertise to be inferior (59%). During these types of situations, Tran told Healio it is important that physicians stand up for themselves without reducing quality of care. “You should feel as though you stood up for yourself and can externalize later,” Tran said. “That helps reduce the potential harm that might be done when you feel rightfully so victimized.” Structural microaggression Microaggressions in the health care space can also come from institutions and systems in the form of set rules or policies that dismiss a marginalized group. While pregnant during the COVID-19 pandemic, Payel Gupta, MD, FACAAI, was faced with this type of microaggression after her request to work from home to reduce risk to herself and her unborn child was denied. She told Healio she immediately advocated for alternative solutions that would allow her to continue contributing safely but was given unpaid, job-protected time off as her only option. “Pregnancy was treated as a chronic medical condition like diabetes rather than an acute condition, where I am two individuals and not one,” Gupta, owner and medical director of Ease Allergy and assistant clinical professor at Mount Sinai Medical Center and SUNY Downstate Medical Center, told Healio. “I was asking for a temporary accommodation and not an accommodation for a chronic condition that would not have an end date. “The message — implicit but clear — was that there was no place for flexibility for pregnant physicians, even during a public health emergency,” Gupta, also a member of Healio’s Women in Allergy Peer Perspective Board, said. As Healio previously reported, pregnancy as a physician can be a challenge in itself, especially if you experience pregnancy complications. In addition to encountering a structural microaggression, Gupta told Healio her judgement as a physician “was effectively discounted” in this situation. “As a physician, I understood the evolving risks of pregnancy during the pandemic and proposed solutions grounded in safety and feasibility,” she said. “Those recommendations were dismissed without meaningful consideration. “By restricting my options to unpaid leave alone, the institution signaled a lack of trust in both my medical expertise and my ability to contribute outside of traditional clinical structures — consistent with subtle decredentialing described in the literature,” she continued. Decredentialing is another form of gender microaggression. In a study of family medicine educators and practicing physicians by Mahon and colleagues, this was characterized as “being addressed by first name without permission or being mistaken as a nonphysician provider.” With respect to the first part of the decredentialing definition, a significantly larger proportion of the surveyed women vs. men physicians reported this from both men patients (15% vs. 3%) and women patients (7% vs. 3%). Similarly, significantly more women vs. men physicians reported frequently being mistaken as a nonphysician by patients (39.8% vs. 1.1%), clinical staff (13% vs. 0.7%) and other physicians (10.9% vs. 1.1%). In the end, Gupta took the unpaid leave offered to her but left this position following her maternity leave. “The experience prompted significant reflection,” she told Healio. “Being forced to choose between safety and participation highlighted how misaligned the role was with my values and long-term sustainability as a physician.” Looking back on this situation, Gupta is glad she chose to leave this work environment. “While the decision was difficult, it became a catalyst for positive change,” she said. “Leaving allowed me to pivot my career toward work that better aligned with my expertise, autonomy and priorities. It was the best decision of my life.” For more information: Payel Gupta, MD, FACAAI, can be reached at [email protected]. Nellie Tran, PhD, can be reached at [email protected].