In the wake of the gruesome murder of George Floyd and the disproportionate impact of COVID-19 on communities of color, America is facing a reckoning over race and the historical inequities that underrepresented minorities have endured. Our institution of medicine has been forced to look inward and evaluate its own role in perpetuating these inequities.

Casual discrimination occurs in our classrooms, hospitals, operating rooms, doctors’ lounges, clinical workspaces and board rooms in the form of microaggressions. “Microaggressions” was coined by African American Harvard psychiatrist Dr. Chester Middlebrook Pierce.¹ This term was used to convey the everyday verbal and nonverbal slights, snubs or insults that communicate hostile, derogatory or negative messages to degrade Black Americans. In modern times, the definition has been expanded to include the subtle denigration of any marginalized group, whether intentional or unintentional. Microaggressions stem from implicit bias: the attitudes, assumptions or stereotypes we hold subconsciously towards members of a particular group. None of us is immune to implicit bias. Therefore, we are all capable of perpetrating microaggressions. In fact, microaggressions are often perpetrated by individuals with good intentions. Yet it is not the intent but the impact that matters. Committing a microaggression is not necessarily a reflection of one’s values, but evidence of the dominant culture or point of view that is so deeply entrenched in society.

Microaggressions can be divided into 3 types, as defined by Dr. Derald Wing Sue.² Microinsults are comments or actions that are unintentionally discriminatory. Examples of microinsults include assuming a person of color or woman is not the doctor and statements to minorities such as “you are so articulate” or “you are a credit to your race.” These convey that minorities, women or members of a discriminated group are typically less capable.

Microinvalidations are comments or actions that invalidate the experience of marginalized groups. For instance, the commonly perpetuated statement “I don’t see color” is often stated to express that the speaker is not prejudiced. This notion of “not seeing color” is flawed in a society where skin color unfortunately matters and racism is a reality. The phrase denies the reality of racial groups who have unique experiences as a direct result of skin color. Albeit generally well-intentioned, the phrase trivializes the complex issue of racism and is counterproductive to the fight against racism. Microinvalidations also include the use of heteronormative language that assumes heterosexuality and binary gender. This language invalidates the experiences of and can alienate LGBTQ persons.

Microassaults are intentional discriminatory or derogatory statements or actions against a marginalized group, which can be best exemplified by an offensive joke.

The impact of microaggressions cannot be understated. “Micro” does not imply that these are insignificant forms of discrimination. Behind every microaggression is a message that conveys otherness and/or inferiority, resulting in a consistent onslaught on one’s self-worth. A focus group study of underrepresented medical and nursing students found the following effects of microaggressions: increased stress and anxiety, decreased concentration, feelings of isolation and inferiority and issues with imposter syndrome.³ Imposter syndrome can limit engagement and encumber professional advancement.⁴ Microaggressions contribute to the “leaky pipeline” for women and minorities, particularly in academic medicine.^5,6 A cross-sectional, national survey by Nunez-Smith et al found that workplace discrimination was a significant factor associated with high job turnover on multivariate analysis.⁷ Aside from the mental and professional toll endured by marginalized individuals, evidence shows that there may also be a toll on one’s physical well-being.⁸ Racial battle fatigue is described as the cumulative result of repeated assaults of microaggressions on one’s overall health.⁴

Responding to microaggressions can be difficult for the target, especially if a power differential exists between the offender and target. Bystanders are often in a powerful position to intervene because their third-party view can offer further perspective for the offender. Bystanders and allies have an important role in combating microaggressions and supporting marginalized groups. In contrast, their silence compounds the negative impact of workplace discrimination. When responding to microaggressions, it is important to separate the offender from the behavior. Disarming the offender’s natural defense mechanisms when confronted is paramount in educating and changing the behavior.

Methods to combat microaggressions include asking the offender to clarify the comment or action, directly highlighting the underlining assumption and/or expressing how the offense makes the target feel. Make the “invisible” visible by using nonjudgmental language and body tone. For the offender, it is natural to feel defensive or embarrassed when confronted. Focusing on one’s intent over the impact is often a defense wielded by offenders. However, offenders should focus on the injured party and remember the offense does not make them inherently bad. Dr. Sue and his colleagues describe several practical microintervention strategies, with the ultimate goal being to help the offender recognize the implicit bias or stereotype and acknowledge the impact.⁹

Tackling workplace microaggressions as an institution starts by recognizing its pervasiveness, with an unwavering commitment to confront it in all aspects. Improving the workplace environment starts with leadership. Organizations frequently focus singly on diversity in hiring but not in culture. It is simply not enough to have a diverse workforce and not invest in a culture of inclusion. Inclusion and equity cannot occur without honesty and accountability. Leadership must engage and solicit honest feedback from their diverse workforce. Organizations should work toward achieving diversity in their leadership and incorporating different voices in the decision making process. Cultural sensitivity and competency training should be compulsory and assessed regularly. Ultimately, a truly inclusive and supportive health care environment yields a happier workforce and will lead to better outcomes for the increasingly diverse patient populations we serve.