Microaggressions [Re-release] (8 Nov 2023)

SPEAKER_00 0:00

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SPEAKER_02 0:23

Hello, this is Tina Ryan. I'm a member of the RCPE Training and Members Committee. And for this podcast, we're very lucky to be talking to Dr. Rosie Baruja. She's an ICU consultant in Edinburgh, and she's going to be talking about microaggressions. I'll hand over to you to give a bigger explanation of what's made you interested in this and your professional background.

SPEAKER_01 0:45

Yes, so thank you for asking me to come and speak to you today. I'm a consultant in anaesthetics and ICM at the Western in Edinburgh, and I'm a fellow of the Royal College of Physicians in Edinburgh. And I came into reading about microaggressions through my work and my interest in gender equity in medicine and the effects that gender and implicit gender bias can have on the experience of people working within the NHS. And microaggressions are a term that people often see being sort of used in the media, but may not know what that means, and if that term has any relevance to them in their everyday lives. And hopefully, as a result of our discussion today, people will have a better grasp of what microaggressions are, that they are actually pretty common, and the potential consequences of either delivering or being the recipient of microaggressions and strategies for identifying and possibly tackling the problems that these acts can cause in the workplace.

SPEAKER_02 1:45

So I guess my first question is: what is a microaggression?

SPEAKER_01 1:50

So microaggressions were first described way back in 1970 by a psychiatrist at Harvard University called Chester Pierce. And his description was around the use of phrases in everyday life. And his particular interest was in race relations. So he defined this in terms of race relations. And his definition of microaggressions, and I'll just read out, are subtle, stunning, often automatic and non-verbal exchanges, which are put downs directed towards people of colour, because that was his area of interest, often automatically or unconsciously, that send denigrating messages, which may be more impactful to the recipient than more overt acts. And what he really means about that is that we now live in a society where we would hope, especially when dealing with each other as colleagues, that overt racism, sexism, homophobia, transphobia, I mean, these acts still occur, but most people would agree that they are unacceptable. And we all have a greater awareness than we did maybe 30, 40 years ago, about what is acceptable in the workplace when dealing with each other as colleagues. But it's quite possible accidentally, without you being aware of it, to make comments or act in ways that very subtly undermine the people around you based on their particular characteristics. So that can be social class, that can be gender, that can be sexual orientation, that can be gender identity, in a way that makes them feel excluded from the social group that is the workplace and can make their work lives harder than they need to be. Now, the terminology microaggression, I think, is one that's a little bit mystifying in several ways. As I say, this was coined in the 1970s. The word micro is meant to imply that these are very, very small acts. These are just throwaway phrases that people use or tiny things that they say that aren't meant to be over acts of discrimination. But the cumulative effect of being a person of a minority of some kind, getting these messages day after day, again and again and again, can actually be incredibly tiring and exhausting and just contribute to a feeling of not being included within the workplace. The fact they're called a microaggression is also a little bit difficult because these aren't overt acts of sexism, homophobia, racism. So, you know, the deliverer of a microaggression is not doing it as an act of aggression, hostility, and a deliberate attempt to exclude. So the term microaggression is perhaps not the most helpful one, but the uh the definition of it is these these subtle phrases or acts that can make people feel excluded. Again, one of the criticisms of microaggressions as a concept is that they're not something that are based in empirical psychological research. Um, it was sort of made up, but it was something that was developed by uh Chester Pierce and his group. And they're very subjective. So one person's idea of that that was a microaggression may not be another person's idea of it, both in terms of being a deliverer or a recipient, which again, you know, if something only exists in the experience of the person who's at the receiving end of it, is it real? But I think again, in the net in the last decade or so, we're really moving on from this feeling that bullying, for instance, has to be something that is just absolutely terrible and just so overt that no one can ignore it. Being bullying is something that that makes the person receiving it feel bullied. So the subjectivity of it is perhaps somewhat problematic, but hopefully in this discussion, people will become aware of how microaggressions can manifest and how they can be harmful and can make their own minds about about how they how they feel about it as a concept.

SPEAKER_02 5:43

So, why do you think these these happen? I always think of the NHS as quite uh, or at least trying to be an open workplace and accepting. Why do you think they happen within, particularly in the medical structure?

SPEAKER_01 5:55

So there's a couple of reasons for that. Uh, we as doctors are still first and foremost human beings who have been born and grown in a society that gives us very fixed ideas about what certain groups of people are like. So, stereotypes are beliefs about a particular group or class of people, which are born of beliefs that are sometimes true, sometimes not true, and sometimes true just by process of repetition. And we learn about group identities just from the influence of our family, the influence of mass media, what we see on television, what we see on billboards, what we see in newspapers. So, for instance, if you open a newspaper, the most common use of a photograph of a black man is going to be as somebody who is suspected of or convicted of a crime. You won't see a black man as somebody who is necessarily in a position of authority, you won't see a black man in advertising. That will be the time you most often see a black man. And so there is now this stereotype born of this kind of saturation of what a black man is, of them being perhaps very aggressive, people you should be scared of, people who are perhaps more criminal or have more criminal tendencies. And then we see in stop and search rates from police that black people are far more likely to be targeted than white people. So we are as susceptible to those stereotypes as anybody else, regardless of the fact we have chosen to come into a profession where we swear an oath to treat people fairly, and regardless of the fact that we do our mandatory equality and diversity training, because all of these stereotypes are hardwired into our brains. You know, what is a man? What is a woman? Um, what does a woman in a hijab look like, behave like, act like? And there's no getting away from the fact that these are hardwired into our brains. Medicine is also an incredibly hierarchical profession. It's very sort of crazy military in the way that it's set. You know, we even talk about house officers and we have a doctor's mess. These are military terms. And as much as we like to think we have a flat hierarchy where anyone can speak openly to anyone else, I think all of us would agree that's probably not true. And again, people who are a rank or two above us can say stuff to people a rank or two below who do not have an equal right to say things back, regardless of how flat a hierarchy we think we have. And so I think there can be a perpetuation of standards of communication that can be quite pejorative of certain groups in society, and there's very little they can do or they feel that they can do to turn around and stop those things happening.

SPEAKER_02 8:30

I never made that association between house officer and doctor Smith with the military before, which seems really obvious now. So if a trainee does experience microaggressions from, let's say, their consultant, how should they go about managing that?

SPEAKER_01 8:44

So I think it might be helpful if I sort of give some examples of microaggressions so that you can get an idea of what I mean. So for example, uh you're training in in Glasgow, and I don't know, did you train at Glasgow?

SPEAKER_02 8:55

No, no, Dundee.

SPEAKER_01 8:57

Dundee. Well, Dundee, my sister trained in Dundee, and it's a very, I think, all the Scottish medical schools, a very sort of egalitarian medical school. I think it has a really good balance between state and private um school students. I think it it really does sort of seem like a very meritocratic medical school. I'm not throwing shade on anyone, but I went to Edinburgh Medical School and I went there a long time ago, but it has a very different, the university certainly has a very different demographic balance. And so, for example, if you're a boy who uh wants to go to medical school and you get into Edinburgh and that's where you go, but you're from a very working class background, and nobody else from your family has ever been to university, let alone um, you know, a prestigious course like medicine, and you speak with a really, really broad accent, um, right away you're going to go somewhere like Edinburgh and feel quite excluded from your peers, all of whom probably speak, and actually, you know, what vocabulary do we use for this? Who speak um more politely than you do in a more refined way, even the way that we describe kind of accents is loaded with a certain sort of uh prejudice. So, for example, if you are of that kind of background and um you're on a ward round and you're moving from patient to patient, and your consultant says, These widening access courses are great, aren't they? It's wonderful to see people like you at this medical school. It may well be that you had nothing to do with widening access programs, you just got straight A's in your hires like everyone else, but the assumption is you had extra help to get into medical school. And of course, I think actually that's a great thing because it's clear that if you go to a school that doesn't traditionally send people to university, you deserve some extra help and guidance. But the point is the assumption has been made that you are not academically as gifted as your peers, you need to that we extra help and hand up. So that's something that's meant benevolently, it's meant as just a passing comment. But if all your other peers are all talking about their skiing trips to Valdasier and you're known as the guy with the really strong accent who never goes to ski trips to Valdasir, and people are constantly making assumptions about your right to be there, having these comments again and again and again and again can make you feel really excluded as a member of your community of training. Same goes if, for example, you're a Muslim woman who's a who wears hijab. The assumption will be that, oh, are you comfortable to go and examine that male patient by yourself? And you know, maybe that's quite a kind thing to make sure that you're culturally happy with that. But surely we can expect somebody who does have particular cultural uh needs to make them known and sort of benevolently assuming, oh, I'll not send you in there because I don't want to offend you, because I know people of your culture can be very, very, you know, cautious about being alone with men, is in itself a cultural microaggression. You are making an assumption about this person, which could limit their training experience in a way that they have not asked you to do. And again, again and again and again, having these assumptions made about you can make you feel very excluded.

SPEAKER_02 11:46

That's one of my concerns. I realize I'm in a very privileged position. I am now a registrar, I'm a cis-white female from Scotland. I worry about making microaggressions. How can I ensure that I don't?

SPEAKER_01 12:01

Personally, and this is just my opinion, I think it's not possible to not do that. As people who have just grown up in the societies in which you've grown up in, these are little solicisms we will make all the time. I think as reflective human beings, what we do is when we do make them, you think, oh, that's really interesting. I wonder why I did that. If you think you've caused harm by it, having a discussion. And I can go through a kind of a framework for this kind of thing later on. And then just reflecting on why did I think that? What made me make that assumption? And you know, this isn't so much of a microaggression as such, but so often at work, I'll go up to a surgical ward and somebody will come and speak to me and I'll assume she's one of the nurses and she's actually one of the surgical registrars. And I just do that all the time. It's and again, it doesn't mean that I'm a horrible sexist bigot. It's just because we are just taught to think, think surgeon, think male. So don't beat yourself up, just think this is a product of how I've been socialized, what can I do to make it better? And think of the person to whom you may have accidentally delivered this microaggression to, and what discussions could you have with them?

SPEAKER_02 13:02

So let's say if I have accidentally said something to somebody and they've been hurt by that, how would I approach that and apologizing and kind of going through it?

SPEAKER_01 13:12

So, what I can do now is go through a system that's been written by Yvonne Coghill. She works in England, she's a nurse by training, and she has sort of expertise in race within the NHS and racial equity. And she talks about allyship, which is kind of what you're talking about here, in that you know, we all forgive ourselves for being human because we are all human, but what can we do to make ourselves better and make lives for our colleagues better? So she talks about the seven A's of authentic allyship. Number one is appetite, and I think you know, the fact that you've you've become involved in this podcast and you're showing an interest in this means that you do have the appetite, and she defines it as the appetite to immerse yourself in the complex emotive world of race equality. And we could transfer that to sort of gender-based equity or class equity or any other kind of thing that make people feel marginalized and like they don't belong. Because it is work, isn't it? It's so much easier to not worry about this stuff and just carry on the way you are. But I think you've demonstrated that you do have that appetite because you're engaging. Her second A is ask. So ask questions about race, be curious, read, learn, and educate yourself. And again, I think in British society it's really interesting. We're uncomfortable about mentioning people's skin colour. You know, if you're describing a reg who's come to do a review on your ward, oh, who was it? Oh, right, but they're five foot, five foot-ish and yeah, black hair and yeah, maybe kind of um like olive skinned, and just to say the word, oh, they were black, it just seems rude, but it's not, you know. So again, just making ourselves comfortable with just the concept of ethnicity. I think we have a lot of work to do in the United Kingdom, and that's not our fault. I think that's just the way that our society has these kind of really um underdeveloped vocabularies for talking about race and of difference compared to, for example, America, which is founded um in a very, very different way and has a very different sort of social structure. Number three is accept, accept that there really is a problem and that more data isn't needed, and that you know, people who do have um identities that aren't typical, that you're describing your own identity, might have a different experience to what you have. And I know myself that even though you know I'm ethnically Indian, um, and British Indians are very sort of overrepresented in the NHS compared to how we are in the population, and we are, I think, quite a privileged group compared to, say, an international medical graduate or a working class white person from a gypsy or traveller background, who I think will find themselves very excluded. The fourth A is acknowledge. So openly acknowledge the problem needs to be dealt with. Number five, I think, is the most important, and it's an A for apologize. And I think the apologizing here isn't just if you think you've said something that may have been inadvertently harmful, but also, for example, if one of your trainees comes up to you and says, That patient refused to speak to me because I was female or because they don't like black people, or they they said they couldn't understand my accent, even though you know your trainee doesn't even have an accent, rather than just being saying, Oh, well, do you know they're just of a generation that are like that, or oh well, just put a smile on, you'll be fine. Actually, say that must have been really, really rubbish and really quite upsetting. I'm so sorry you had to have that experience. It's not an experience you should have to have. And I think a lot of the time, through benevolent intent, we try and minimize these experiences to think, oh, if you minimize it, then you can just shrug it off and carry on with your day. But if you've grown up in society for whatever reason with an identity that kind of targets you a little bit. So, for example, if you spoke to any of your colleagues who are not white about their experiences of racism, they'll give you, like for me, it was always the number 45 bus from the centre of Glasgow back to where I grew up in Bishop Briggs. There'd always be someone who'd get on, who'd start a big rant about immigrants and asylum seekers, and you'd be sat there just like, you know, your face kind of bright red, just hoping they didn't sort of come and directly start attacking you. Um, you know, everybody has experiences like that. And so when you have another experience, it's not an experience in isolation, it's one that is built of many, many, many exposures to unpleasant situations. So apologizing that they even have to go through that because it's not fair can actually be such a powerful act of allyship and make people feel that they are heard, that they are understood, and that they are not alone and that they are seen, which I think is such an important thing because minimization, even if done with benevolent intent, can really be harmful. Your feelings and your perceptions don't matter. I don't see what you're going through, I don't think it's important. That might not be your intention by telling them just to shrug it off, but that can sometimes be how it feels. Number six is assume, but it's don't assume, but instead develop informed views by seeking to understand people. And seven is action, which is taking demonstrable steps to establish equality and be accountable. And again, I think that action includes education, which hopefully this podcast can be part of, involves monitoring. So, you know, does your organization have a good monitoring for any kind of discriminatory acts? Do you do you have a trainees group where people feel that they can go and take their concerns and take their experiences? What kind of demonstrable actions does your organization have to allow people to feel that they can speak up, be supported for other people, for allies to become educated and more knowledgeable about these kinds of issues? And the fact that the RCPE, which is you know an organization that's been around for 500 years, is now pushing out podcasts on microaggressions, goes to show that you are an organization that's very much of the 21st century that wants your members to understand what these issues are.

SPEAKER_02 18:51

And well, my final question is how do I call these out? Because a lot of the time I'm in the position where I'm a fairly senior registrar and I probably wouldn't I would never have confidence to do it as an FY1, even though I maybe should. How do I say this is actually inappropriate, even if it's not directed at myself?

unknown 19:10

Yeah.

SPEAKER_01 19:11

So again, this kind of harks back a little bit to the hierarchy of medicine, um, because exactly like you say, what can you say as an FY1 compared to what you can say as a ST7, compared to what you can say as a consultant of eight and a half years, which is what I am, compared to what you can say as, you know, the most senior consultant of a department, I think is very different in the way that you feel that you can speak out and the way that you feel you will be heard and how you will be received. I think direct confrontation is quite a high-risk strategy, and nobody likes to be told if they have done something inadvertently and unintentionally, oh, you're being really horrible, you you've you've done a microaggression thing, you know, it right away, I think, just puts people's backs up. You know, no, I wasn't. I was just asking where he was really from, because he's clearly not from Dundee, because you know, he he he looks Indian. So, you know, people can do things but that they don't necessarily realize are not helpful. So I think taking the discussion away from the actual event is often helpful because that allows people to save face in a degree. Because what you really want to do is engage people in meaningful discussions that might help positively change their behavior, not confront them in a way that might make them defensive and even less likely to engage in the future. So I think that's fine if you're saying a consultant talking to another consultant because you both have that same kind of badges of authority as consultants. I think doing it up the hierarchy gradient is near enough impossible. And in that case, I think all you can do is speak to a consultant colleague that you trust about what you saw, what the implications of that are, and is there something that could happen in terms of a friendly, a friendly chat that can make that person just reflect on what happened and the effects whatever that interaction had on the individual that you saw being quite upset or distressed. I think if it's you as an ST7 leading a word round, say one of your core trainees makes a comment to one of the medical students about um the length of her skirt that you think is meant to be a bit jokey, a bit banterist, but she you know does that thing where she goes bright red and blotchy and you can tell she's very uncomfortable. Again, maybe just a quiet let's move on. And then afterwards, little stop phrases like, I don't think that was as funny as you thought it was. How do you think that made her feel? And just ask them to put themselves in that person's place. And then if need be, a little follow-up about, you know, this is what is okay to talk about in a work situation, this is what not, this is what isn't. Um, and again, with medicine, because I think we often work in the same place we were trained, you start at age 18, you go through it's almost a little bit infantilizing that you forget that this is a place of work that is bound by the uh rules of engagement and behaviors that that workplaces are, and you can't be, you know, the banter king of edginess on a ward round the way you can when you're in the pub. Yeah. So I think if you're in a more senior position, again, taking people aside and just just exploring with them how do you think that person felt when you said that thing? I will caveat all that with saying that it's an incredibly brave, effortful, uh fraught with difficulty thing to do. And it's far easier to pretend you just haven't heard anything. And I would absolutely include myself in the category of people who just often gloss over it and carry on because it's it's really, really difficult, I think, to take that step to take people aside and and talk to them about issues like this. I think it is really challenging, and I hope as I carry on in my professional career, I will talk the talk and walk the walk because I think the former is a lot easier than the latter. So I I would say that I I completely um acknowledge and accept that doing these things is really difficult.

SPEAKER_02 22:40

That's really reassuring, actually, because it is reassuring that you find it difficult. And that's great. Thank you so much for chatting. Is there anything else that I've missed or you want to tell people about?

SPEAKER_01 22:53

No, I think we've gone over most of what microaggressions are, and just to try and get people to understand that just because you're not seeing conscious, deliberate acts of bigotry, it doesn't mean that people in your work circle aren't receiving little acts every day that just chip away constantly at their sense of belonging within the professional sphere that they've chosen to try and belong in. And it happens all the time. And if you start looking out for it, you'll start seeing these little acts, but they are committed without any any malign intention, which is what makes them particularly tricky to try and eradicate from from our workplaces. But I guess just becoming aware of the concept in itself is hopefully useful to people, and I hope they find this conversation useful.

SPEAKER_02 23:44

That's brilliant. Thank you very much for all your help.