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

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

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.

Sonia Malhotra, MD MS FAAP, is the director for the Palliative Medicine & Supportive Care program at University Medical Center New Orleans/Tulane School of Medicine and an assistant professor of internal medicine and pediatrics at Tulane and Louisiana State University Schools of Medicine. She was appointed to the Louisiana Governor's Council for Palliative Medicine and leads its DEI Subcommittee. You can reach her at This email address is being protected from spambots. You need JavaScript enabled to view it. .

Aziz Ansari, DO SFHM FACP FAAHPM, is a professor of medicine and associate chief medical officer, clinical optimization and revenue integrity at Loyola University Medical Center. He is a practicing and board-certified hospitalist and palliative care physician. You can reach him at This email address is being protected from spambots. You need JavaScript enabled to view it. .

References

1. 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.
2. Nadal KL. The Racial and Ethnic Microaggressions Scale (REMS): construction, reliability, and validity. J Couns Psychol. 2011;58(4):470–480.
3. Constantine MG. Racial microaggressions against African American clients in cross-racial counseling relationships. J Couns Psychol. 2007;54(1):1–16.
4. Implicit Association Test. Project Implicit website. Published 2011. https://implicit.harvard.edu/implicit/
5. 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.
6. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.
7. 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.
8. The 5 Rs of cultural humility. Society of Hospital Medicine website. https://www.hospitalmedicine.org/practice-management/staffing/the-5-rs-of-cultural-humility/
9. Galinsky AD, Moskowitz GB. Perspective-taking: decreasing stereotype expression, stereotype accessibility, and in-group favoritism. J Pers Soc Psychol. 2000;78(4):708–724.

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