EP27 - Microaggressions in Medicine: The Triangle of Source, Recipient, and Bystander

In every operating room, in every ward, in every clinic, and every team meeting, a silent battle brews. Conflict, negotiation, identity. Welcome to the Scalpel and Sword podcast, where I, Dr. Lee Sharma, physician and conflict analyst, Explore the hidden negotiations behind modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision and power. You've spent years making careful decisions with lasting impact. When it comes to investing, the same principle applies. Lightstone Direct gives you access to institutional quality real estate investments. With decades of proven experience behind them. Invest directly, no middlemen, and a $12 billion plus AUM real estate firm in your corner. Visit lightstonedirect.com. All investments involve risk. Please visit lightstonedirect.com for a full list of disclosures. Hello, my peaceful warriors. Welcome to the Scalpel and Sword podcast. I am your host, Dr. Lee Sharma, physician and conflict analyst, and I am so thrilled to have on the podcast today Dr. Tracy McIntosh. Dr. McIntosh is the Associate Dean for Access, Belonging, and Community Engagement at the University of Central Florida College of Medicine. She has her Master's in Science, a Master's in Public Health, and she got her medical degree from Yale. She also completed her residency training there in emergency medicine. She then moved to Florida and became founding faculty for the UCF HCA Florida Emergency Medicine Residency of Greater Orlando. She has a passion for teaching. She loves her medical students and her residents, and it's really clear not only from her activities and her work but also from her awards that she definitely excels in that area. She's passionate about helping physicians, and learners in all areas be heard, valued, and respected. And I am so happy she's here today.

Hey, Lee, it's a pleasure to be here and have this conversation and maybe open some minds to having a more candid reflection on how we can communicate better with our peers and how we can stand up for our peers and support each other the best way possible, especially in the healthcare environment where it's hard. The days are long and some of the cases and the patients are really hard. And so how can we support each other as best as possible to do what we're all called to do, which is just to help one another, patients or peers?

100%. What sparked this passion in you? Because it's clearly something you very much care about.

For me, it's the comments and the experiences of peers, friends, folks around me, when we show up to work with our best selves, walk into a room, and then get hit with a comment from a patient that we don't belong there, that we're assumed to be the nurse, I'm assumed to be the patient care assistant. All amazing roles in healthcare. But when I show up with my badge that says MD, I introduced myself multiple times as Dr. McIntosh, and to have that disregarded, to have that undermined, some days it's easy to brush that off, but when you're having a really hard day, then those are paper cuts. And time after time, it takes a toll on even the best of us. And my goal is to help to bring these situations to light. for patients, for our peers, and so that we each have the voice to recognize that I can correct this behavior.

Yeah.

I can address it without being confrontational, without interrupting the patient-physician relationship, without seeming like I'm undermining my attending or a consultant, but that I can speak my own truth and that I can stand up for myself and say, hey, You know, those comments, that hurts me for this reason, and to help people to see that so that people can improve. And so that's my goal, is to have these conversations with my learners, with my colleagues, so that we can normalize that when things are said that are hurtful, that we can address it and that we can correct that behavior, and then it can stop. And that people can realize that there's a difference between intent an impact with our words and that we can create cultures in our learning environments where everyone can thrive and everyone can come to work and do the hard things of patient care without the harmful words and comments from peers, patients, and colleagues.

Yeah. One of the things I loved about the article that you published in 2022 in the HCA Journal of Medicine, when you open the article, the first paragraph talks about an intern named Isabel, and she's so excited, and she's happy to be there, and she's wanting to be challenged. And she walks into the room, and she's here to see the patient. And the first thing the patient says to her is, I don't want a doctor with an accent. And what I loved about starting the article with that is it made it very real. And for those of us who are physicians of color, who have walked into patient rooms and had people say, I have had patients say to me, I don't want a brown doctor. I've had this happen. It's really hard if you've never had that experience to understand how hurtful that is. And I, when you started the article with that, I feel like it really opened a lot of people's eyes to the fact that this is a commonplace experience. And this commonplace experience, unfortunately, has a profound negative effect on our healthcare workforce. What kind of negative things does this kind of commentary produce, not only in our learners, but like you said, our attendings?

There's some amazing work coming out of the surgical residency literature led by Hu et al., and they really characterize and quantify for us in real terms what is the human cost to these comments from patients, from nurses, from colleagues that are often in jest. In the case of the patient, that comment there that's happened many times to my colleagues and my learners, it's not in jest. It's— that's intentional. But even comments that are in jest, the consequences are that folks who experience it are disproportionately from underrepresented groups in medicine. So groups that are already in low numbers in healthcare, they're more likely to experience these kinds of comments, discrimination, and harassment, frank harassment in the workplace. They're more likely to have thoughts of burnout. So that means we're less engaged in patient care, we have less empathy. That's how burnout manifests in our workplace.

Yeah.

More likely to have thoughts of attrition. That means leaving medicine. That means people that we recruited because of their passion for helping others, for improving the quality of care. People that we recruited to our residency programs because we knew they would add so much, they're more likely to want to walk away from medicine, maybe from our program and to another program, which is still a loss, but to leave medicine altogether. And unfortunately, there is an association with thoughts of suicide and self-harm. And so, this is a tremendous cost, and we're very invested in making sure that we prevent all those outcomes.

And we know that having physicians who are underrepresented minorities, not only is that so important to improve our culture in our medical house, but it's also very important for patient care. We know that patients resonate with physicians who look like them. That's well documented. It's going to help them feel like they're accessing a common system, and we want patients to feel comfortable in the system. And the fact that we are letting these microaggressions, these statements, the things that sometimes people will try to laugh off, and yet they're so hurtful, and we're not finding an active way to address that, it's hurting how we care for patients, but it's also hurting the clinicians in such a profound way. And if they don't have a way to work through it, if they don't have a way to address it, you're right, they may just want to walk away. And what a terrible loss. One of the things I love in this article Is that you actually talk about a structured way to approach this, that if these are happening, let's say for the sake of argument, let's say that you have an attending who's got a male medical student and a female medical student, and he calls the male medical student by his name, whatever, and the female he calls sweetie, honey, and this happens over and over on rounds. And we have somebody who's making the statement, we have someone who's hearing the statement, but we also have the bystander. We have another person who's a witness to this. And you talk about this in the article, that there is actually a triangle in this process. Tell us more about that.

Yeah, this is from Ackerman-Barger. And I like to use this because so often we're found in situations where it happens, it's uncomfortable, We see it happening, we're right there, it's unfolding, and we're frozen, just caught off guard. And so by having these workshops, by having these conversations, and by giving examples of scripting, my goal is that once I've set it in this protected environment in a workshop, once I've had a chance to role-play with a colleague, then when it happens the next time, I have an idea of how I, what feels good to me, what feels normal and natural for me. which could be different than what feels normal for you, Lee. And so sometimes in the moment, I'm going to want to interrupt it, and I'm going to want to speak up and point it out right there and then. Other times, it may not feel comfortable, and I'll want to just say something to the recipient of that ugly joke or that frank form of discrimination outside the patient's room or in the physician lounge. And so I want to give folks permission—

Right.

To address it in the way that feels comfortable for them. And sometimes it's gonna be an email, sometimes it's gonna be in an anonymous survey at the end of the semester for a student because they're worried about retaliation. But the goal here is that everyone feels empowered to speak up when you feel it's uncomfortable for you, and that you can let your colleague know that you also were not okay with what just happened, that you saw it happen. And that it was hurtful to them and it's hurtful for you, and you're not the kind of person that wants that just to be swept under the rug. And so by having different perspectives on the situation, I hope to empower folks to speak up and to address it. And there's an example that we give where sometimes I have a joke that falls the wrong way. Sometimes I'm the source of it. I'm human and I make mistakes. And I have some scripting for when somebody says, hey, Dr. McIntosh, the way that joke came across, it really, it hurt my feelings, or it could come across in this way. And so I put some words to that. Oh yeah, I'm sorry. You're right. I never thought of it like that, which is often just what it is. I never thought about that different perspective and to thank the person for bringing it to my attention and to allow me to have some time for growth. If I'm the recipient, when I'm in the room and a patient says, I don't want a Black doctor, when that's happened, My instinct is to come from curiosity. I like to give people grace. That is inherently who I am. And so for me, the reflex is to come from curiosity. Oh, why do you say that? And then I generally reassure them with my credentials. Not every doctor has to do this. It is a function of some of my identity that I get called out more than somebody else having to defend myself. Oh, I went to Yale Medical School and I've been practicing for 15 years, but I give people grace. And I understand that patients are in pain and then they react in ways that may not be their best moment, but not everyone is gonna wanna have that grace for a patient. I can understand that when you feel beaten down over and over again and people keep saying the same things, you may not feel that's where you wanna come from, but I offer that as one strategy. And then the third perspective is the bystander. When you're in the same room and how do you support your colleague so that they're not burdened so much just on their own? Because you can imagine when this comment that belittles you, that undermines your value and your experience, it sticks with you and you're mulling it over in your mind.

Yeah.

And instead of being focused on the labs and the next thing to do, you're stuck. And then for my learners, that's being stuck sometimes manifests as not being engaged, not participating.

Mm-hmm.

But you're just mulling over and you're stuck in this moment of feeling the imposter syndrome is there. And on top of this, the patient just said this to you, or the nurse just said this to you, and you're feeling like you don't belong and you're feeling like you're not worthy. And then there's a cycle that you're not engaged and you're not participating, and people think that you're aloof because you're bogged down by what just happened. And so, those are all the reasons that it's so important that we have conversations about it and that people realize that at our core, we want training environments where everyone can thrive. And this is one of the tools that we wanna give our learners and our peers and our colleagues to be able to make it better.

Oh my gosh, there's so much beauty in that, and I wanna really get into this. One of the things that you talked about Being the recipient, because that's such a hard role when you especially, and I love how you bring in the fact that if we already are carrying relative imposter syndrome in our jobs, which I think we all do, and then someone makes a negative comment like that, it compounds and jumps on that imposter syndrome. And sometimes I think the first knee-jerk reaction we all have, especially walking into that kind of conflict, is to defend. We want to defend ourselves. We become a Preservational creature, and I love how you talk about we really want to respond from curiosity because being curious about why that statement was made actually does so many things. It creates a space to have that conversation, and you actually become more powerful because you are letting that conversation take place, and you're able to say, "I would love to know why you made that statement." That's very empowering, and most of the time, I think if you open the door to that, not only is the patient going to get a different perspective or whoever has made this comment to you, but you're also going to be able to take it out of a space of taking it personally. And I love how you're giving people that strategy. I also love how you talk about the process of scripting these responses, because in the moment, it's such an emotional process that if we don't have something already that we've thought about it, that we've prepared ourselves, that it's very easy to get into that headspace of being distracted. And we're distracted by the comment. And as you say, we suffer personally, clinical care suffers. And I think with that idea of scripting comes the idea of it's not an if, but when. And so you're already, I think, preparing your learners for the possibility that this may happen. And in a sense, in many ways, it's not a possibility, it's a probability. Do you find that when you practice scripting with them, they become more confident in entering these conflict situations?

Yeah, I, I do see that in our workshops, and when I offer an opportunity for learners especially to share experiences, then they're able to see how pervasive it actually is, and folks are able to identify how these situations impact their peers. And so it's really powerful to do the scripting, to give us some concrete examples. From people that they really respect and people that they really want to have their backs and make sure that they all make it through training and they all make it to the other side whole.

Yeah. Another thing that you talked about is if there is somebody who is making the comment or making the microaggression, when this is brought to that person's attention, we're not trying to create a culture of finger-pointing, that we're actually trying to create a space that is, we're here to grow, we're here to get better. I'm going to make mistakes. We're all going to make mistakes. We're all going to say things. And there's a lot of, as you said, being able to extend grace to ourselves as well as extending grace if we happen to witness something like this. Do you find that also doing this kind of work that you're doing, these workshops, doing the scripting, I'm sure that is making huge strides in creating this culture where you are?

Yeah, I hope it is because the workshops and the conversations I have It's very affirming for folks to realize that they're not alone. It's unfortunate when I share the data about how pervasive it is. It's good and bad. Good for them to know they're not alone and that what they're experiencing has a name, has been studied, and interventions to address it. But of course, bad because it is so prevalent. And again, our surgical colleagues have been shedding light on these issues and trying to improve the training environments, Specifically for general surgery, every year after their in-service training exam, they have surveys for every single surgical resident to understand how many folks are going through this. And one of the criticisms that I hear from folks about having these conversations, putting a name to these insults, discrimination, and harassment is, oh, are these millennials and Gen Zers are just too sensitive? They're just too sensitive. But then when I present the data of the prevalence, that close to half to two-thirds of female surgical residents are experiencing sexual harassment.

Yeah.

That maybe close to half of Black African American surgical residents are experiencing racism, discrimination. These are the toughest residents, the surgical residents, and they're all experiencing it. So it's not that they're too sensitive, it's just that there's too many of them going through it. And it's really a call to action for us.

Going through, I went through OB-GYN residency in the '90s and I trained at Parkland Hospital. And of course we knew all the surgical residents as well. And one of the things that I really think about now is going through that process, I think we had a lot of toxicity in our programs. I think it was all there, and I think the reason why I am just now thinking about what that experience was like for me was because I just accepted the fact that I was going to get beat on and harassed. And it didn't occur to me that there was anything different. But more importantly, and actually frighteningly, I didn't think it was anything wrong. It was, this is the nature of training. This is the nature of training in a big university hospital. You were going to have these comments made. You just learned to deal with it. You sucked it up. You kept going. You really didn't want to say anything because you might get tossed.

Yeah.

And It was literally almost trained out of us to think about whether or not environment was toxic or not. And I think that's such a fascinating perspective. So hearing you talk about how we have the millennials and the Gen Zers who are actually saying this is not appropriate behavior is promoting that change. And I love the fact that a lot of this literature is coming out of the surgical residencies that people are saying that having this kind of interaction Is not only detrimental to us; it's detrimental to patient care. It's dividing our attention. We're spending more time thinking about the aggression than we are thinking about doing the case in front of us. That's so terrifying that we are asking them to divide themselves in that way, and being able to have an environment where we can actually educate people because we want to educate, we want to learn, we want residents to leave training programs feeling competent and ready to go out. and practice on their own, but understanding that we have to create an environment to do that. One of the things that I loved in the article as you're talking about helping people learn about these interactions is helping them to learn to do this in a non-confrontational way, actually creating that space to do that. How do you show resident staff how to do that?

We know that very— a small percentage of residents will report it because they're so worried about retaliation. And so in our onboarding for our learners at our institution, we share with them all the different ways that we want to hear about their experiences. We have anonymous reporting strategies. We have our program directors. We have different levels of administrators who will be able to address these issues, provide coaching, feedback, and closed-loop communication so that the learners can know what actions were taken.

Yeah.

And so, those are the main things that we reinforce for our learners, that we're not trying to fire great doctors. Our goal is to provide feedback and coaching and support. And so, that's really how we address it. So, early on in training and throughout the years, we provide avenues for disclosing, for reporting, and if it needs to be anonymous because people are worried about retaliation, that's one of the mechanisms That is so powerful.

You are giving them such a sense of security, literally psychological safety in creating this kind of mechanism. And that's something, unfortunately, I think that it's really, it's so needed. We don't have that right now in so many locations in just medicine in general. We're needing to really find that because it's lacking so much, especially right now. I feel like one of the things that we talked about before we jumped on Was the idea that this is not just about preserving mental health for our physicians and our learners, our medical students and residents. This is about preserving a workforce.

Absolutely. Yeah, you know, I talked about the thoughts of attrition. That was 1 in 8. That was for the surgical residents. But we extrapolate that to other specialties, and we have an expected shortage of physicians AAMC put out a report earlier this last year that is up to 86,000 doctors that we'll need in 10 years. And so we need to do everything we can so that doctors are staying in medicine for the love of medicine and not just for a paycheck. And so this is just one of the strategies that we have to make sure that folks can stay in love with the work. And especially for us as a training site, My goal is to have the residents love our hospital, love our community, and love our patients and want to be a part of it for the long haul.

Wow. As you are working through this process of teaching them how to recognize, approach, and deal with microaggression in such a way that it becomes a learning experience and something that becomes a part of their education just as much as clinical practices, you are giving them a life skill. Do you give them any kind of specific acronyms, tools, something that they can use to remember how to process all of this?

Yeah, one shortcut is just to focus on I statements. So this is good communication 101 for any kind of conflict resolution and any kind of difficult conversation. And it just to start with, I feel this way because of this, as opposed to You are racist. You are sexist. You are anything. That is very difficult for the recipient of that type of statement to open their ears and heart to a conversation. But if I start with, I'm curious why you don't want a doctor who looks like me. Did you really mean to say that? Because I'm here to provide the best possible care for you. So I just focus on the I statements when I don't know what else to say. But finger-pointing and calling other people out, it— that my guard is way up and the tension is going to be way up, and it's going to be hard for me to recover that relationship. Patient-physician, or colleague-to-colleague, consultant to emergency attending. It's going to be really hard.

Oh, amen. The idea of finding a way to start that conversation where you're not immediately putting somebody on the defensive, that's so powerful. Because that's such a place that if you walk into that with the you statement immediately, especially somebody who hasn't been through the training, who hasn't been to the workshops like you guys are doing, the natural knee-jerk response is to react, not respond. And unfortunately, this is where you get escalation. And rather than opening a dialogue, you're going to close a door. And that's the opposite of what you want. Brené Brown has a beautiful way of working with this in her books, Daring Greatly, all, she's just so amazing with her work with leadership. But one of the phrases that she uses that we will use a lot as well, and it's still a you statement, but the whole kind of interaction is framed around when you say this, I hear this. And so you're not telling the person, your ex, that's not the point, but it's explaining to the person that I understand that what you said may not be what you intended to communicate. And that's a huge place of awareness for a lot of us as communicators, isn't it?

Oh, absolutely. And so that really requires us to come to our work, to the hospital, to our clinics with our cup full, because it really takes a lot to do those types of statements.

Yeah.

And I don't discount what that requires, and especially when it's different levels of training, an intern, it's hard for them to have that confidence to have these types of conversations. But, oh yeah, scripting and giving them permission to feel the way that they feel and to know that they don't need to be anybody's punching bag. That's so important.

I love how you use that phrase, to feel the way they feel, because This is something that I think has been so sorely lacking in medicine that as we are learning more about conflict, as we're learning about microaggressions, we are understanding that it's okay to feel. It's okay to have emotions as we come into our job, and we can be professional and sometimes even be better professionals if we're aware of what's in our cup, if we're aware what we're bringing into the workplace.

Mm-hmm.

Because that's not something in terms of a self-awareness or a, any kind of mindfulness practice of what's going on with us. That's not really something we had as trainees. We were not encouraged to do that. So I love the fact, as you're going through this process, inherent in it is doing some introspective work to know what we're bringing in with us when we walk in the door to the clinic, the ER, the OR, wherever we happen to be.

Yeah, absolutely.

I love that so much. Have you found since you started doing these programs that your attrition rate or The reported mental and psychological health of your residents and learners has improved as you've been doing these programs?

I haven't been tracking the outcomes. What we track is, in our healthcare systems, the rates of discrimination, and that hasn't changed too much, but I have so many variables and confounders, so I'm not too discouraged, and I will still continue on with these workshops, but I'm Looking forward to some really incredible work coming out of the surgical literature where they have done randomized controlled trials. They have implemented a suite of workshops and programs and resources in order to really see, does this make a difference? I'm in a world where doing these workshops, it feels right. We're having meaningful conversations. I get a lot of great feedback, but there's still opportunities for us to see What are the actual evidence-based strategies to have real outcomes improve for our learners? So that's still the second trial, and that's still on the horizon.

Oh, I'm so glad. I'm fairly confident that as you continue to do this work, I think you're going to see better reporting when it comes to mental health. I think we're going to start to see less attrition. I think we're almost getting into a critical space with healthcare. In terms of keeping people we've invested in as learners, but also the people who are in their careers. These are also physicians that maybe have a few more years of clinical practice that may also be leaving because they were never given these tools, and we want to include them as much in this learning workshop world that you are presenting as much as our learners are. Because honestly, sometimes as I start to talk to doctors who graduated from other countries who. Maybe they do speak with an accent and they just put up with it their whole lives. And no one's ever given them the tools. No one's ever given them the permission to say, it's really not okay for this to happen. We wanna put our arms around you and support you.

Yeah. And I feel like our skin gets tougher as we go on in training, but it's still, we're still human beings. And unfortunately, you and I know that the rates of suicide are way too high for physicians. And so we're not immune to anything. We just bury it and we hide it and we have strategies that are not healthy coping strategies that we employ. But I think there's so many opportunities for us to get to the root of what makes medicine so hard. And this is just one of the things that makes it hard. Having difficult conversations with colleagues, Where we're not built up by each other, we're not being encouraged by each other, by instead the words and the actions by our colleagues sometimes in and of itself are belittling. And having a voice to speak up and to report them to the CMO if that's what we want to do. But what's better is to just have conversations with colleagues and to let them know our perspective and how the words affect us. I think that's the best way for us to move forward.

You said something really amazing, and I want to really bring this out, which is that this is something that happens to a lot of us, if not all of us. It's not something because we have over time developed, as you said, this thicker skin, we've just let it go. Someone makes a comment to us and we just let it pass. We may overhear a comment and not have the tools to bring it up and to let that colleague feel alone. They received that comment and we let them suffer with it.

Yeah.

And rather than having these conversations or giving them that support, it's like, I'm really sorry that you had to deal with that. Let me talk with you. Let us sit down together. Let us figure out how we can address this so it doesn't happen to you again.

Yeah. Is there something that I can do to help you? But let them help. Let them guide you on what's comfortable for you and for them.

And this is one of the things I think is great about us even having this conversation in the first place. Is that if you start to think about the number of times you've had these comments made to you, and then you think about how that made you feel, would you ever want a colleague to feel that way? Of course not. And if you have the agility and the ability to actually help to make an intervention and raise somebody's awareness, I think that the majority of the time when you raise somebody's awareness to the fact that they made a comment that was hurtful, And especially in among medical professionals, I think the vast majority are going to be really shocked and very sad that they had that effect on somebody. But you do want to open the door in such a way that they don't feel attacked, that they don't feel canceled. You want them to feel very open to that. I think it's only going to build solidarity and it's only going to build that. And I keep coming back to this term, but psychological safety. We need that desperately.

Yeah, we do. The work is so hard as it is. We need to know that our spaces are safe. And the term toxic, that is what describes so much of training in the past, and we're hoping to change, shift the tide on that. I talk to my learners and my colleagues that medicine is supposed to be hard. It's hard. The cases that we take care of, the outcomes, it's really hard, but it's not the toxic part. That's what we can control. And that's what we really want to improve on for the here and now, and especially going forward.

Absolutely. Tracey, I love the work that you're doing. Your learners are so lucky to have you. Your patients, your fellow colleagues, they're so lucky to have you as well. If people wanted to reach out to you and learn more about the work that you're doing, how would they best do that?

The best way is to get ahold of me by email. It's tracey.macintosh. And I'm at the University of Central Florida, ucf.edu. I would like, yeah, I can share our workshop materials so that you're not reinventing the wheel and be happy to coach you through anything. The most important thing is to lay the framework that it's an open discussion and that really I have specific slides that I'm not trying to point fingers and there's no good or bad. We're trying to create better Healthcare spaces for all of us.

The work that you're doing is amazing, and I'm so thankful that you are doing it.

Thank you, Lee. It's been great to have this conversation, and it's overdue for us to make these conversations more normalized. And just to remind folks, we're not trying to get rid of great doctors. We're not trying to kick patients out of practices. We're trying to make the spaces positive.

100%. I thank you so much, Tracy, for your time. Thank you for being here. We will definitely put your email in the show notes. But it's been wonderful. I really appreciate it.

Thanks. It's been great to talk to you, Lee. Nice to connect on this issue.

100%. Thank you so much. For all of our peaceful warriors who have joined us on The Scalpel and Sword, thank you so much for being here. And until next time, be at peace. Every episode is an invitation to speak, to negotiate, to choose. I'm Dr. Lee Sharma. Join the dialogue by subscribing to Scalpel and Sword. Until next time, peaceful warriors, may your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict resolution. The Scalpel and Sword is not intended as medical or legal guidance. For personal matters, please consult a qualified professional.