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Abstract

Microaggression is widespread in the health care industry and occurs in every health care delivery setting. It comes in many forms, from subtle to obvious, unconscious to conscious, and verbal to behavioral. Women and minority groups (eg, race/ethnicity, age, gender, sexual orientation) are often marginalized during medical training and subsequent clinical practice. These contribute to the development of psychologically unsafe working environments and widespread physician burnout. Physicians experiencing burnout who work in unsafe psychological environments impact the safety and quality of patient care. In turn, these conditions impose high costs on the health care system and organizations. Microaggressions and psychological unsafe work environments are intricately related and mutually enhanced. Therefore, addressing both simultaneously is a good business practice and a responsibility for any health care organization. Additionally, addressing them can reduce physician burnout, decrease physician turnover, and improve the quality of patient care. To counter microaggression and psychological unsafe, it takes conviction, initiative, and sustainable efforts from individuals, bystanders, organizations, and government agencies.

Background

The resurgence of the microaggression concept in a health care framework is crucial. Of note, it was initially coined in 1970 by Dr Chester Pierce, a Harvard University psychiatrist and science researcher.1,2 In 2010, the term was described as subtle, brief, and challenging to detect due to its indirect nature by Dr Derald Sue.3 Microaggressions may apply to racism, discrimination, and prejudice at individual and systemic levels directed to one’s individualism, association, race, gender, sexual orientation, religion, or other protected attributes.3 Microaggressions can also encompass behavioral indignities (intentional or unintentional), hostile, derogatory, or negative attitudes, and demeaning behavior toward a marginalized group. The "micro" of microaggressions is often subtle or covert, yet powerful in destroying the peace and harmony of the working environment and the morale of the individual and team.4–6
Importantly, microaggressions in the health care system often go unnoticed throughout one’s lifelong medical journey from medical education to clinical practice until it causes severe effects such as depression, anxiety, imposter syndrome, and burnout.4,5,7 It can also cause strife within teams, communities, and work environments within the health care organization.8–10
Microaggressions impose a high cost on health care workers, the health care system, and the quality of health care delivery.11,12 It contributes to psychologically unsafe working conditions and can hinder innovation, improvement, and development within the health care system.13 There is a strong relationship between psychological safety and desired outcomes in the health care industry.14 An environment with higher psychological safety is positively linked to higher performance, knowledge sharing, and creativity. In this environment, the measurable benefit of preventing patient harm can be observed, enhancing the quality of patient care and patient-centered care.15 Workplace psychological safety is positively associated with learning as opposed to hiding mistakes and failures. This also reduces physician burnout.16–18 Unfortunately, the often subtle and hidden nature of microaggressions and psychologically unsafe environments make them challenging to identify and even more difficult to address.
Given the real and widespread damage to the health care system, effectively addressing these issues are beneficial, both fiscally and morally, to the health care industry and to the people the system serves. In this review, the authors focused on microaggressions, their impact on a psychologically safe work environment, and their contribution to physician burnout.

Microaggression

Most physicians, especially women and minority groups, experience microaggressions as early as medical school.19 This experience is directly contrary to their values and beliefs of providing the highest possible service to people regardless of gender, race, religion, culture, sexual orientation, and other characteristics. The daily reminder of microaggressions in their medical education constantly insults their self-worth, self-efficiency, and their trajectory of a meaningful medical career. The erosion of self-confidence and the development of self-doubt throughout one’s career can perpetuate the negative consequences to the health care system overall, which can include a shortened medical career, the deterioration of a psychological safe environment, and burnout.20,21
There are four subtypes of microaggression identified thus far.3,12,22
The first is microassaults, the most blatant form of microaggressions characterized by their clear intent to offend or hurt the recipient. Considered "old-fashioned" racism, microassaults are often conducted intentionally at the individual level in limited private settings that allow for the anonymity of the perpetrator. This form of microaggression harbors private discriminatory feelings expressed publicly when they lose control or feel safe to conduct the assault.
The second type is microinsults, characterized by condescending messages of insensitivity, rudeness, and insults toward one’s heritage, race, gender, identity, or culture. These are either indirect or direct but are often unintended. These can be presented in jest and as a set of hierarchical workplace differences. For example, generalizing about another’s culture and indirectly attributing it to their competency. Due to unintended conditioning, the perpetrators are often unaware of the insult or demeaning message of disqualification and inferiority. Microinsults can be nonverbal as well.
The third type, microinvalidations, refers to excluding, negating, or nullifying an individual’s thoughts, feelings, or experiential reality. There are at least nine distinct themes of microinvalidations, as seen in Figure 1.
Figure 1: Categories of microaggressions, microinsults, microassaults, and microinvalidations.3
The fourth type is environmental microaggressions, which occur when the above three become institutionalized in the overall culture of the workplace environment. This can create an environment that ranges from a feeling of belonging to alienation toward diverse groups. This also includes rejecting certain symbols, pictures, statues, technologies, systems, or policies. For example, a technology that allows for voice recognition but is insensitive to learning accents; food menus that exclude vegetarian or kosher options; marketing that only presents a specific gender or ethnic group; or ancient symbols with links to specific groups. These environmental representations create subtle derogative meanings and can alienate both patients and physicians.
Microaggression in perioperative settings is unique in many ways. Perioperative physicians, mainly represented by surgeons and anesthesiologists, are at higher risk for microaggressions. The operating room (OR) is a highly specialized environment in which preventable surgical errors can introduce morbidity (and sometimes mortality) to the patients and degrade the organizational reputation. A reliable team that practices effective communication, coordination, and collaboration is essential for delivering patient-centered, safe, and quality surgical care. Even in an ideal environment, inevitable human errors can occur. Although some mistakes are inevitable, learning from them can improve the quality of surgical patient care at both the individual and systemic levels. However, learning from mistakes, especially from one’s own mistakes, can only happen in a psychologically safe environment where mistakes can be discussed, dissected, and corrected without fear of repercussions. Unfortunatley, microaggressions are often present in such settings, especially toward marginalized groups. The net effects of these environements can produce psychologically unsafe settings and diminish each team member’s effectiveness in the workplace.23 This can be disastrous during unanticipated events of intraoperative crisis, where correct, coordinated, and timely actuation of the preformulated plan must be conducted flawlessly. The factors that come into play are listed in Figure 2. 24
Figure 2: Top factors that can effect microaggressions.

Microaggressions and Gender, Ethnicity, Race, and Sexual Orientation

Equity, inclusion, and diversity (EID) paradigms typically focus on understanding how gender, race, ethnicity, sexual orientation, and gender identity interplay within social structures and organizations, including team dynamics and group function. Even before the COVID-19 pandemic, women physicians noted facing unique challenges related to their gender. These challenges include harassment, compensation inequity, decreased promotion rates, lack of representation in leadership positions, and work distribution. Given the need for rapid workflow changes due to the COVID-19 pandemic, these conditions worsened over the past few years and highlighted the need to alleviate them.

Gender, Ethnicity, and Race

Racial and ethnicity-based microaggressions exist at a high prevalence among physicians in the perioperative setting, where 81% of racial and ethnic minority surgeons and anesthesiologists reported experiencing microaggressions.25 These findings are particularly worrisome as more than 50% of US medical students are now woman and constitute 35% of practicing physicians.26 One common form of gender-related microaggression is sexual harassment. Most alarmingly, sexual harassment is often dismissed as innocuous behavior (ie, simple compliments) when it is in essence unwelcome predatory or harassing behavior; indeed, 94% of female surgeons and anesthesiologists experience sexist microaggressions, most commonly by overhearing or seeing degrading female-related terms or images.27 Physicians who identified as underrepresented minorities (Black, Hispanic, Hawaiian/Pacific Islander) were likelier to experience environmental inequities. The prevalence of physician burnout was 54% among female physicians, and racial and ethnic minority physicians experienced the lowest rates of feeling personal accomplishment.28,29 Ultimately, female physicians who experienced sexist microaggressions and racial/ethnic minority female and male physicians were more likely to experience burnout than their white male colleagues.25

Sexual Orientation

Not only are microaggressions a prominent issue for women physicians, but a further issue exists in addressing microaggressions toward lesbian, gay, bisexual, transexual, or queer (LGBTQ+) physicians in the health care industry. As a sexual minority, physicians who identify as LGBTQ+ have long been underrepresented or "invisible" within the physician workforce. Identifying as LGBTQ+ is an independent risk factor for microaggressions and burnout among physicians, medical students, and physicians-in-training.30,31 In particular, the perioperative environment represents a highly hostile environment for LGBTQ+ physicians due to long-standing stereotypes and biased standards of behavior. Although the 2020 US Supreme Court ruling affirmed that LGBTQ+ persons are entitled to protections afforded by Title IX of the Civil Rights Act of 1964, there is still a large gap in the ruling’s goals and its practical implementation. Although institutional efforts to improve EID are often well-intentioned, many health care organizations and medical groups still lag behind in addressing LGBTQ+ harassment, burnout, and workplace barriers.32

Microaggressions and Psychological Safety

Alarmingly, the detrimental effects of microaggressions on psychological safety are often exhibited and can persist for a long time.33 In developing a psychologically safe environment, organizations can benefit enormously from more engagement and innovation from physicians, higher efficiency and productivity from a well-functioning team, and the reduction of physician burnout and turnover. A thriving, organizational culture with psychological safety (an important facet of EID) and prevention of unconscious microaggressions, bias, and discrimination are the most challenging and important tasks many of these workplaces face.13 Global health care organizations have begun to promote psychological safety in their workplace. Psychological safety is a condition in which one feels safe to learn, contribute, and challenge the status quo without fear of being reprimanded, marginalized, or punished directly or indirectly. A psychologically safe environment establishes a good foundation for building reliable health care teams. It is integral to the success of health care organizations and their customers and the well-being of health care professionals.16,34,35
Psychological safety has broader implications for patients and organizations, as it is the key to building a high-reliability organization, as well as for physicians, as it mitigates burnout.36 Health care delivery is a patient-centered process involving a array of team-based work carried out by various personnel. However, microaggressions in the health care system obstruct the development and maintenance of psychological safety. Microaggressions can be present in many forms during daily patient-physician, physician-physician, and physician-staff interactions beyond racial, gender, age, socioeconomic, and administrative hierarchies.
The OR is considered one of the most complicated working environments. Featuring a locked, multifaceted, and interdependent process, errors may have devastating outcomes for patients due to morbidity and mortality, which often are preventable. Many interventions have been developed over the years by learning from other industries (such as aviation), for example, adopting checklists, practice standardization, continuous learning models, and simulation training.37 Although the small and incremental changes in the aviation industry have produced remarkable results (eg, a significant drop in fatalities despite increased flying hours, year after year38) mortality due to medical errors still claims over 200,000 lives each year.39 Despite multiyear and multilevel efforts to improve patient safety, little progress has been made in reducing medical error-related deaths. Unlike the airline industry, which is often staffed with large teams of psychologists and human factor specialists, the health care industry lags behind in psychological support, human factor reengineering, and culture development.37 Today, the differences are more relevant than ever, as the clinical practice is more intertwined with technology, supply chains, health care economics, and other health care professionals in real-time, under different cultures, systems, or even industries. The industry, as such, is at substantial risk of microaggression-related errors.
Teamwork and clinical tasks surrounding patient care are more complicated and sophisticated. "Teamwork on the fly" or "teaming," as defined by Amy Edmondson, captures today’s health care delivery and health care environment well,40 in which predefined and trained teams delivering the same health care consistently is less common. Rather, the health care delivery team is frequently on the move and constantly changing, and interchangeability is increasingly becoming necessary. As staff shortages become the dominant issue in the health care industry, ”team on the fly” or “teaming” practices will play an essential role in timely and safely delivering health care in the future. However, effective teaming is not without its difficulties. It requires sound organizational, professional, and team cultures that are free from microaggressions and psychologically unsafe practices. Due to the dynamic nature of team composition and culture, new or old team members can feel ostracized due to microaggressions and psychologically unsafe practices. Microaggressions are a huge issue in today’s health care systems, where interprofessional and interdependent practices cannot be meaningfully conducted and the culture of trust, collaboration, and cooperation can be broken.

Microaggressions and Physician Burnout

The subtle and hidden nature of microaggressions carries insulting, discriminatory, demeaning, and negative messages that elevate the rates of physician burnout. This can cause severe and long-lasting damage to a physician’s career and deteriorate the quality of patient care. Microaggressions are widespread in the perioperative setting. Most female surgeons and anesthesiologists experience sexist microaggressions and racial/ethnic microaggressions.25 When adjusted for both gender and race/ethnicity, female surgeons and anesthesiologists are also likely experiencing all forms of microaggressions.41 Moreover, these groups are not only susceptible to microaggressions from their peers but also from patients and their families. For example, female surgeons receive fewer referrals, are more frequently asked to perform nursing tasks, and are replaced by other surgeons by patient request at higher rates than their male counterparts.42 Despite equivalent or superior surgical outcomes and high marks on bedside manner, female patients often rate their female surgeons lower on satisfaction and competency scores.43 As a result, women physicians experience higher levels of burnout than male colleagues.42
The accumulative experiences of microaggressions subjects marginalized physicians to a higher degree of psychological stress and burnout. Interestingly, even in female-dominated medical subspecialties such as obstetrician/gynecologists, women physicians are not immune to microaggressions and gender biases from their colleagues and female patients.43 Because women constitute roughly half of the medical profession, the fact that they are leaving their practices at higher rates today compared to their male counterparts is of great importance. Even worse, marginalized physicians are susceptible to depression, suicidal idealization, and other mental health issues.44

Building Psychologically Safe Working Environments

Building psychological safety in the health care industry is an urgent and unmet need. It affects the quality of patient care, the well-being of its workforce, organizational sustainability, and financial solvency. It also greatly affects productivity, efficiency, patient-centered care, and innovation.45 Psychological safety was especially relevant during the COVID-19 pandemic due to the need to quickly update policies and workflows based on rapidly emerging information on the virus. This required rapid collaboration among health care professionals, which could have been hampered by a psychologically unsafe working environment. In that unique situation, a strong and collaborative response to the pandemic was fostered, collectively managed, and implemented in a psychologically safe environment. However, it is well known that knowledge does not always lead to correct practice especially when it is not implemented properly.46 Without a psychologically safe working environment, implementing new workflows based on emerging knowledge, such as during the pandemic, can become harder to accomplish. Indeed, the multifaceted approach to improving psychological safety is a team effort where all health care professionals are stakeholders. Interventions that are purpose-driven, targeted to the stakeholders, team-based, and geared toward the organization may prove more productive and sustainable.

1) Becoming Advocates and Active Bystanders Against Microaggressions

Physicians spend an inordinate amount of time at work when compared to other professionals. The working environment and the nature of a physicians' work make them interdependent and codependent on each other. Without civility, mutual respect, and inclusivity, the working environment can deteriorate quickly. Because of the often subtle nature of microaggressions, it is vital to be vigilant and on high alert for their occurrence.47 There is no bystander in this matter; advocacy against microaggressions and responsibility for building a psychologically safe environment is crucial. The phrase "see something, say something" and its accompanying sentiment not only exposes the occurenceof a microaggression but also can disarm it.47 Only through meaningful and respectful engagement can it raise the aggressor’s awareness and address their behavior constructively and assertively.11,48,49
Microaggressions, either implicit or explicit, can nullify a team’s culture and teamwork beyond the moment of the microaggression.50 Many mitigating methods, such as educational classes and workshops, have been developed. These often include didactic presentations, videos, toolkits, group discussions, and other approaches.12,51,52 These efforts are comprehensive. Their scope is broad and encompasses race, age, gender, ethnicity, and culture, and in parallel, they utilize concrete methods and strategies. Although these programs have imperfections, such as causing people discussed in the interventions to feel "isolation" or "targeted," they provide tools and training for detecting and acknowledging the microaggression and crafting a thoughtful and timely response.

2) Microaffirmation

Addressing microaggressions through microaffirmation involves acts of kindness, empathy, and goodwill. It includes but is not limited to opening doors to possibilities and opportunities for marginalized groups and individuals. It is a potent antidote against the negative effects of microaggressions.53 Microaffirmation is defined as "apparently small acts, which are often hard-to-see, public and private events, often unconscious but very effective, which occur whenever people wish to help others to success,"54 which can be measured through a microaffirmations scale.55 The scale can track, measure, and foster a microaffirmative environment in progress. Even though the tool is yet to be validated in the health care industry, random or purposeful kindness through microaffirmations can help rebuild a sense of community, trust, and teamwork.32

3) Organizational Development

Organizations must set achievable goals around microaggressions and psychological safety through culture and community reengineering. In essence, culture is the personality and spirit of an organization, be it invented, discovered, or developed.56 Leaders must devote themselves to culture building within the organization, including the new shared vision, new workplace ethics, and acceptable behaviors such as the principles of EID. Health care workers excel in psychologically safe environments; conversely, they struggle in hostile environments that exhibit bias, discrimination, and microaggressions. Even though it is beneficial for leaders to allocate time and resources toward these issues, it requires commitment and sustained efforts to achieve desirable outcomes and effectiveness. This is difficult as culture change requires overcoming the hurdles of tradition, group thinking, and existing workplace cultures and philosophies. However, there are few alternatives in today’s health care industry other than progressing steadily toward building a psychologically safe work environment that is free of microaggressions.
Psychological safety consists of shared beliefs, thoughts, and behaviors vital for addressing microaggressions in the workplace. It not only provides a repercussion-free environment for speaking up, but it also enables a constructive channel for interpersonal, professional, and team growth.56 The presence and prevalence of microaggressions often produce psychologically unsafe environments. Microaggressions are often constant, continuous, and pervasive throughout groups, systems, and institutions. There is a known relationship between microaggressions and the development of psychologically unsafe environments. Although microaggressions can worsen psychological safety, a psychologically unsafe environment also fosters the growth and spread of microaggressions. Figure 3 shows some programs that have been piloted to address these issues.
Figure 3: Piloted programs to combat microaggressions and associated burnout.
All of these programs can contribute to reducing microaggressions and physician burnout; however, their effectiveness is highly variable depending on the subculture of the organization and the degree of the program’s personalization. Individual-directed programs may lead to more psychological stress or pressure if not appropriately balanced. Furthermore, even though addressing one may not necessarily prevent the other from happening, successful management needs conscious effort.56 Another challenge is that psychological safety and a microaggression-free environment can be easily experienced but not readily measured.56 This may hinder understanding of the root cause of microaggressions and psychological unsafety in health care. To mitigate the systemic problem, leadership has an ethical responsibility to focus on issues, metrics, processes, policies, enforcement, and critical interventions.56

4) Collective Responsibility and Accountability

The goal of building microaggression-free and psychologically safe work environments is to improve health care quality and patient care as well as the workplace environment for health care professionals. A solid psychological safety background improves health care delivery, reduces costs, and improves clinical outcomes. Therefore, in partnership with patients, it is the collective responsibility of all health care leaders and professionals to advance this cause. To accomplish this goal, health care leaders and professional must create structures to support communication and intervention and mechanisms to monitor both the process and outcomes of these efforts.
Additionally, systemic and organizational improvements must continue into the future in order to reach desirable results. It is challenging to scale these efforts to a broader systemic level without the support of everyone involved in these organizations. A collaborative top-down and bottom-up approach between leaders and workers at all levels should be produced, which can be tailored to various settings. Finally, clear accountability is necessary to develop psychologically safe and microaggression-free environments. The design of a clear accountability structure is crucial to safeguard the program’s integrity. All stakeholders are accountable for their actionsand it takes leadership, ownership, and partnership to accomplish these goals.

Conclusion

Microaggressions and psychological safety are closely related and can mutually enhance each other. Addressing them simultaneously is a good business practice and should be considered a necessity for any health care organization to optimize patient care. To counter microaggressions and psychological unsafe work enironments in health care settings, it takes the initiative and sustainable effort from individuals, bystanders, organizations, and government agencies.

Footnote

Author Contributions
Chunyuan Qiu, MD, MS, participated in manuscript preparation, critical revision, conceptualization. Philip Shin, MD, participated in manuscript preparation, critical revision, conceptualization. Vimal Desai, MD, participated in manuscript preparation, critical revision, conceptualization. Janet Hobbs, EdD, participated in critical preparation and revision. Antonio Hernandez Conte, MD, MBA, FASA, participated in manuscript preparation, critical revision, conceptualization. Neha T Sudol, MD, participated in manuscript preparation, critical revision, conceptualization. Vu T Nguyen, MD, participated in manuscript preparation, critical revision, conceptualization.

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Information & Authors

Information

Published In

cover image The Permanente Journal
The Permanente Journal
Volume 27Number 2June 15, 2023
Pages: 169 - 178
PubMed: 37292028

Keywords

  1. burnout
  2. microaggression
  3. psychological safety
  4. sexual harassment
  5. perioperative safety

Authors

Affiliations

Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
Antonio Hernandez Conte, MD, MBA, FASA
Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
Vu T Nguyen, MD
Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
Philip Shin, MD
Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
Neha T Sudol, MD
Department of OBGYN (Obstetrics Gynecology), The Permanente Medical Group, Redwood City, CA, USA
Janet Hobbs, EdD
Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
Chunyuan Qiu, MD, MS [email protected]
Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA

Notes

Chunyuan Qiu, MD, MS [email protected]

Conflicts of Interest

None declared

Funding

None declared

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