Understanding, Identifying And Addressing Microaggressions In The Clinical Setting

Everyone assumes just being “kind” is enough in the workplace. However, being a health-care professional, I feel kindness is not only the expectation but the standard. However, I did not truly understand microaggressions and their subtypes (microinsults, microassaults and microinvalidations) until I attended a workshop on this topic several months ago. In that moment, I discovered personal flaws when it came to small statements or behaviors unintentionally committed toward patients or coworkers. 

Words spoken unintentionally still carry weight. I recall viewing an animation online that compared microaggressions to small mosquito bites. Initially, they are just annoying. However, as they escalate, they can become emotionally exhausting to the victim or recipient. 

It would be irresponsible to not admit my experience as both the perpetrator and the recipient of a microaggression. It was not my intention to deliver microaggressions but I was simply unaware and misinformed. I hope this column can raise awareness of this often overlooked issue and perhaps prevent this behavior for others. 

Psychiatrist Chester Pierce, MD first defined microaggressions in the 1970s and other behavioral experts and researchers have expanded discussion on the topic of microaggressions over the years.¹ The concept of microaggression focuses primarily on describing the dynamic interplay between perpetrator and recipient, classifying everyday manifestations, deconstructing hidden messages and exploring internal (psychological) and external (disparities in education, employment and health care) consequences.² 

Essentially, the study of microaggression isolates how the recipient of the microaggression receives and interprets such actions; whether the perpetrator’s action or statement was intentional or non-intentional; and further identifies and recognizes the ripple effects of these actions beyond the singular recipient. 

More specifically, there is the study of racial microaggression, which, by definition, is aversive racism that generally occurs below the level of awareness of well-intentioned people.³ This is usually how most define microaggression. However, microagressions truly involve disenfranchised individuals or recipients who feel devalued based on race, ethnic background, religious beliefs, gender, sexuality and/or disabilities.³ 

This is where I tell you about when I quickly glanced at a new patient’s name without looking for a gender identification in the chart. I subsequently used the inappropriate identifying pronoun. To most, this does not seem like an obvious microaggression or offensive. However, I now have a good rapport with the patient and comfortably addressed that first misstep and how it impacted the patient. Her reply was simply, “It happens all the time, more so in clinical settings.” It was eye-opening because I felt horrible initially and again weeks later after discussing it with the patient. That is the conundrum of microaggressions. They do not have to be intentional. 

There are various subtypes of microaggressions, which include microinsults, microassaults and microinvalidations. Microinsults can be verbal or non-verbal communications that subtly convey rudeness and insensitivity, demeaning a person’s race or ethnic background.³ An example of this behavior could be asking a coworker of a marginalized group how the coworker got the position at the hospital, which could imply a coworker attained the position through an affirmative action program. 

Microassaults are conscious and intentional discriminatory actions, essentially blatant acts or words to ostracize an individual.³ 

Microinvalidations are communications that subtly exclude, negate and nullify the thoughts, feelings or experiential reality of a marginalized individual.³ A classic example of this behavior is asking people where they were born based on their appearance or accent, which could convey a misperception that you are viewing someone as a perpetual foreigner in his or her own land. 

Unfortunately, these are all common behaviors that a majority of people deem social norms. It does not require ill intentions to cause harm to a recipient. Instead, we must make a more conscious effort to speak with full awareness and intention with both our colleagues and patients. 

In closing, I encourage you to become an ally against microaggression and not settle for the status quo of everyday behaviors toward marginalized individuals. As health-care professionals, we all know that it only takes one insect bite to cause a raging infection.

Dr. Johnson is a second-year Podiatric Medicine and Surgery Clinical Research Fellow at the University of Pennsylvania-Penn Presbyterian Medical Center in Philadelphia. He dedicates this column to his beloved colleague Francine M. Williams, DPM (1964-2020), who recently lost her battle to COVID-19 serving on the pandemic front lines in Philadelphia. 

1. Ong AD, Burrow AL. Microaggressions and daily experience: depicting life as it is lived. Perspectives on Psychological Science. 2017;12(1):173-175. 

2. Sue DW. Microaggressions in Everyday Life: Race, Gender, and Sexual Orientation. New York: Wiley;2010. 

3. Sue DW, Capodilupo CM, Torino GC, et al. Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist. 2007;62(4):271–286.