By Matt Skoufalos
In every social encounter, there’s an opportunity to connect, and a risk of miscommunication and of being misunderstood. Social interactions carry the weight and differences of class, race, gender and sexuality, age, and ability level between speakers.
In any circumstance where the power dynamics among both parties are significantly differently weighted – such as in the workplace – one party enters the interaction at a disadvantage. When that disadvantage is exploited, whether intentionally or unintentionally, it can have the effect of reframing the discussion in terms defined by the higher-status individual, be they a supervisor, coworker, or simply a member of a majority class to which the other party does not belong.
In simple terms, these can be understood as institutional or unconscious biases; when these biases inform remarks that harm, slight, or undercut another person on the basis of their individual identity, they are referred to as microaggressions. Micro, because they’re smaller or more insidious than an overt insult or attack, and aggressions because they nonetheless put one party on the defensive from another.
The phrase “microaggressions” was defined in 1977 by Harvard University psychiatrist Chester M. Pierce in a study critiquing how Black Americans were depicted in TV commercials at the time. Pierce’s writings on the subject described the “subtle and stunning” ways in which presumptive language had been used to denigrate Black Americans, including himself.
That work is regarded as a seminal piece of research in the field, upon which additional writings by other researchers on the subject have built over the intervening decades, including those of Jessica Leschied, associate professor of radiology and radiological sciences at Vanderbilt University Medical Center in Nashville, Tennessee.
Leschied is a diversity, equity and inclusion (DEI) advocate who worked on the Justice, Equity, Diversity and Inclusion (JEDI) Taskforce for the Graduate Medical Education office at Henry Ford Hospital in Detroit, Michigan, where she also headed a networking group for women in radiology. Leschied said she’s experienced different treatment as a woman in a field that’s dominated by white men.
“I think I was pretty naïve in terms of how few women and minorities go into radiology,” Leschied said.
In mentoring some of the woman residents at Henry Ford, Leschied said she discovered that she and they all had comparable experiences of different treatment than their male peers. Some of them endured comments about their cultural backgrounds, others about whether they were presenting as friendly enough to the group, or whether they should “smile more.” A third-generation American medical student of Asian heritage was complimented on how well she spoke English. Leschied, an international medical graduate, was told, “you’re not our usual candidate.” Other men struggled to remember their female peers’ names, called them by the names of other women in the group, or by their first names, when they would refer to their male counterparts by their surname and doctor honorifics.
“These are microaggression, which are subtle – sometimes not-so-subtle – comments that make the recipient feel that they don’t belong or that they’re unusual in that specialty,” Leschied said. “It’s part of our unconscious bias, but if you become educated on what your unconscious biases are, you can become more aware of them, and change the things you say and do.”
Leschied said that she believes the educational health care space is “often a couple years behind the business world” in terms of culture change, and that it may take more time to see improvements in these areas, especially among older health care professionals whose viewpoints may include turns of phrase that have become unacceptable in the workplace.
“They’re very commonplace, and they can have disastrous consequences for an individual in our profession,” Leschied said. “The worst case is that the [victims] leave our profession, and take their unique perspectives with them, when what we need is them to have a seat at the table.”
Her solution is for people to develop a comfortability with self-advocating in the moment; letting their colleagues know when their comments have become degrading, insulting, or ignorant, and giving them a chance to acknowledge their mistake.
“I have said to colleagues before, ‘Maybe you can be more intentional about changing your behavior, and acknowledge how it affects the recipient,’” Leschied said. “We don’t focus on the intention of the aggressor; we focus on how the comment affected the recipient.”
“None of us is perfect; we all make mistakes,” she said. “We are not here to spend time on these mistakes. I think one of the ways that I find effective in teaching this is admitting that I’m not perfect, and saying, ‘I made that mistake before.’ There’s lots of ways of doing it without becoming accusatory; the problem is if it becomes repeated behavior, you have to escalate the reporting to higher-ups.”
Leschied also encourages people to seek out whether their organizations have put language around DEI values into their mission or vision statements; things like, “We want to be a workplace that’s inclusive of everyone’s viewpoints, or creates a sense of belonging,” and whether those aspirations are put into practice in the culture of the workplace.
“One of things I pushed for is a good, anonymous reporting tool for residents, so people feel like they at least have an avenue for reporting their grievances,” she said. “Power dynamics makes reporting very challenging. It also makes it easier for these things to happen.”
Above all else, Leschied said it’s important to remember that behavior change comes slowly, but that with constant guidance, intentionality, and coaching, it is achievable.
“We need to acknowledge that we can be better, and we’re works in progress,” she said. “The small things that happen every day, if we can all find our courage to say, ‘I didn’t like that comment,’ or, ‘You might not have meant this, but,’ we can make some changes.”
“Ultimately, people want to come to work in a place where they can be their authentic selves and voice opinions, and if you don’t create a workplace that allows for those things, it can lead to bad patient outcomes, and detrimental emotional health issues in our trainees or the recipient,” she said.
Health care operations consultant Nicole Dhanraj, an expert on microaggressions, said that although their effects reverberate throughout the profession, she is particularly concerned about how quietly they persist.
“While those on the receiving end may recognize and internalize these microaggressions, the broader health care community often fails to acknowledge their presence or significance,” Dhanraj said. “I think this occurs because not enough people on the receiving end speak up about it to truly make a movement of change on this.”
“While some individuals may vocalize their experiences, these conversations frequently lack understanding, perpetuating misunderstandings, and exacerbating tensions between employees,” she said.
When those on the receiving end of microaggressions remain silent, often out of a fear of retribution, or a desire to keep the peace in the workplace, the negative treatment persists; when they speak up, such discussions may be emotional to the point of being unproductive, Dhanraj said.
“Patients, too, are not immune to the impact of microaggressions,” she noted: “biased language and assumptions regarding their background, their medical history, or conditions frequently occur. This often erodes trust from them in the health care world.”
“I was a victim of microaggressions probably for the first 10 years of my career,” she said. “Always a comment about being female, an immigrant, my skills, my race; so many things. I didn’t speak up for various reasons, but as I became more confident in myself, I started educating people about their comments.”
The only way conditions may improve, Dhanraj said is through improved education and awareness on the subject, “and a commitment to promote a culture of inclusivity and respect.”
“I think sometimes we think we know what those two words mean, but they are often far from a common understanding,” she said. “In the work environment, when people are educated, they are able to call out the behaviors. The recipient should also be aware of what they are experiencing – oftentimes people tell me they thought this was in their head!”
As imaging operations manager at the Dallas, Texas-based UT Southwestern Medical Center, Tricia Trammell, CRA, aims to eliminate microaggressions in the workplace by creating an institutional culture of psychological safety. Trammell believes that by helping her staff feel psychologically safe enough to bring their true, authentic selves to work every day, it fosters an environment of acceptance, which eliminates microaggression.
“It takes constant work, not just from leadership, but commitment from the team,” she said. “It has to be taught to the team, it has to be modeled, and it has to be a constant reminder. I cast a vision for what I want our work culture to be, and I’m constantly reminding them what I want our culture to be.”
Trammell’s trainings focus on fostering civility in the workplace by helping her team to embrace who they are at their core, and support their colleagues in doing the same.
“Obviously, we all have different versions of ourselves,” she said. “We have various emotions that we engage with at work, but the true heart is feeling truly genuine. I want everyone to behave in a way that feels truly genuine for them instead of behaving in a way that feels superficial.”
“I think people do know what it’s like to be themselves,” Trammell said. “I think the truth is, most of the time, people don’t necessarily feel comfortable to be themselves because they feel like people will reject that. You have to be pretty vulnerable to be your authentic self.”
“What I’m encouraging in my workplace is that you’re safe to be who you are,” she said. “Be that person, and come to work, and work with people who care about you.”
Trammell believes that the various attitudes and emotions that people embrace in the workplace may be derived from fear, anxiety, or a desire to not be seen as the weak link of their teams. Sometimes that behavior is superficial; in many workplace cultures, there’s an attitude that leadership compels aggressive behavior to instill compliance and stifle dissent, for example. Trammell said it requires constant work from both staff and their bosses to remind their teams that everyone is safe and can be their authentic selves.
“We can trust each other, and we’re all going to accept each other at face value, as whatever you are,” she said. “That doesn’t mean that rude behavior is acceptable, but if someone is an introvert, an extrovert, a silly person, we’re going to accept that; we’re not going to change anybody. The diversity on the team creates a really beautiful and fun culture. It makes it really interesting.”
In the two years that Trammell has honed her approach with her current work group, the team appears to be performing as a cohesive unit. Employee engagement surveys show vast improvement in engagement scores for the workgroup. In 2022, the first-year engagement was measured after Trammell started working with this team, the overall engagement score increased 12 points from the prior year, which was 10 points over the institutional benchmark. The biggest increase came in how her team members rated their ability to “speak my mind” at work, which climbed 32 points from the prior survey, and 17 points over benchmark.
“That’s important because ‘speak my mind’ is one of the measures that many health care organizations struggle with, so we have made it one of our focuses,” Trammell said.
In 2023 when engagement was measured in the same workgroup, the overall engagement score showed marked improvement again, significantly over the institutional benchmark. It was the highest engagement score of all imaging work groups in the organization.
“I’ve been working on this approach with this workgroup for about two years,” she said; “I’ve found it to be extremely effective.”
