For decades, American medical schools and academic centers have worked to incorporate cultural humility into the educational curriculum.1 It was a necessary move for two reasons: (1) to better prepare healthcare providers to treat a progressively more diverse patient population and (2) to meet the needs of a slowly diversifying physician workforce.2,3,4 Calls to improve physician diversity have come from some of the largest, most influential professional organizations in the country, such as the American Medical Association.5,6,7,8 Subsequently, diversity and inclusion have become buzzwords used when recruiting medical students, residents, and physicians. However, the push to increase diversity and representation in medicine seems to overlook the decades of systemic oppression and discrimination experienced by various groups in the USA. Micro- and macroaggressions do not cease to exist simply because an individual enters the medical profession.

Microaggression is generally recognized as “rooted in (implicit or explicit) prejudice and/or racial, ethnic, gender, sexuality, religious, disability, or other stereotypes and that are directed at and subsequently harm members of marginalized groups.”9 Macroaggression, though not an entry in traditional dictionaries, is listed in Wiktionary as a “Large-scale or overt aggression toward those of a certain race, culture, gender, etc.”10 Survey data shows that micro- and macroaggressions are prevalent in medicine.11,12,13

Past studies have shown individuals underrepresented in medicine, across all stages of the medical career, face stereotype threats and emotional challenges based on racial microaggressions.14,15,16,17 Qualitative interviews on this topic have largely focused on a single specialty, level of training, race, or type of microaggression.14,16,17,18,19,20,21 Furthermore, few studies have engaged providers and trainees for their opinions on what interventions, if any, could help curb these incidents and foster a culture of support.

This study sought to hear directly from physicians of all levels and specialties about their experiences with micro- and macroaggressions in their job or training.

METHODS

Study Design

For this qualitative study, semi-structured, one-on-one, virtual interviews were conducted at a tertiary, urban, academic medical center from February 2021 through September 2021. Interviews focused on participants’ experiences with micro- and/or macroaggressions from patients, colleagues, and staff. We used the Consolidated Criteria for Reporting Qualitative (COREQ) guideline to report our findings. See appendix 1 for the full checklist with additional details. The Medical College of Wisconsin Institutional Review Board approved the study.

Participants and Recruitment

This exploratory study included faculty physicians and trainees, from medical students to fellows, and was open to all specialties. Participants were recruited through the institution’s intranet homepage; departmental, residency, and medical student meetings; campus organizations; and snowball sampling. Respondents completed an online form to volunteer to be interviewed. Interviewer and interviewee dyads were matched by level of training to ensure no hierarchical differences. An informed consent letter was emailed to participants prior to the virtual meeting. Participants received no incentive for participating.

Interview

A semi-structured interview guide was created based on literature review and past guides used for sexual harassment and microaggression surveys15,22 (Appendix 2). J.B. (White female), C.K. (Asian female), S.T. (Black female), J.W. (White female), and N.Y. (White female) conducted and audio-recorded the interviews from a private location. All interviewers were trained in qualitative methods and conducting semi-structured interviews. Participants did not review the transcriptions. Recruitment continued until thematic saturation was reached.23

Analysis

Interviews were transcribed verbatim through the online video platform’s integrated transcription service. Interviewers then reviewed the transcripts to ensure accuracy and removed all identifiers prior to analysis. Three study team members (J.B., C.K., N.Y.) analyzed all transcripts. Based on grounded theory, J.B., C.K., N.Y. created a code book through an iterative process. Each of the three members independently analyzed the first six transcripts and created preliminary codes. They then met to review, refine, and finalize the coding structure to develop a codebook. Utilizing a constant comparative method, the three members coded the remainder of the transcripts. Once all transcripts were coded, the codes were developed into themes and subthemes. Saturation was reached when no new codes emerged.

RESULTS

A total of 14 interviews were conducted, lasting between 20 and 51 min. Of the participants, five were faculty, two were fellows, five were residents, and two were medical students. Three participants identified as men, and the remaining identified as women. Four self-reported as White (Table 1). Participants spoke about their personal experiences with micro- and macroaggressions. Four themes emerged: definitions of micro- and macroaggression, the moment an aggression is experienced, aftereffect of an aggression, and education and training for micro- and macroaggressions, with some containing subthemes (Table 2). Examples of micro- and macroaggressions as described by participants are provided in Table 3.

Table 1 Characteristics of Participants
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Table 2 Themes and Subthemes with Representative Quote
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Table 3 Examples of Micro- and Macroaggression as Described by Participants
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Definitions of Micro- and Macroaggression

Participants identified microaggression as less overt than macroaggression. Many characterized microaggressions as subtle, “commonplace,” and can be “unconscious.” A few mentioned its association with an individual’s identity. One participant defined microaggression as “…either spoken or unspoken hostility toward a kind of uncontrollable part of your identity.” “[Microaggression] serves to like undermine you in some way or whatever identity that you have.”

The definition participants had for macroaggression was more universal. It was a “deliberate” act or an “intentional thing” that is clear to observers. Some linked it to “terms of racism” but noted it “can also be used in terms of a lot of other different areas in discrimination.”

The Moment an Aggression Is Experienced

Impact

Participants reported feeling the immediate effects of micro- and macroaggressions. For microaggressions, some emotions participants experienced were “shocked,” “stressed,” and “frustrated.” Some were uncertain with what had just happened. One participant described microaggression as being “disguised as a compliment or an opinion.”

Multiple participants did not view the microaggression as a problem with the aggressor. Instead, some felt it was how they received it: “I think he was…trying to be funny,” “…maybe she didn’t mean to be that abrasive.” Additionally, some viewed the microaggression as a reflection of larger societal issues, one in which stereotypes are “…really ingrained in people’s minds.”

Some participants found microaggressions particularly troublesome due to the invalidation of their response. “…[T]he denial of [my] initial answer of ‘Where are you really from’, the part that negates my answer…or cannot be accepted because I look like I am not from the United States—that’s the microaggression to me.”

The immediate impact of micro- and macroaggressions was dependent on where the individual was in their training or career. Those early in their training, such as medical students, described their emotions as “very taken aback” and “shocked.” While those well into their training and careers, such as residents and faculty, though “angry” and “bothered,” often felt the need to move quickly beyond the incident “…because it’s like you have so many other things that [you] can’t carry all this stuff.”

With macroaggressions, some participants needed physical space to regroup: “I had to like step away and go to the bathroom and just like breathe.” Others felt that “macroaggressions are much harder to handle…at the time that it’s happening.” The macroaggressions “made me feel like embarrassed” and “made me feel like a, you know, berated a child.”

Response

The decision to respond to micro- and macroaggressions was related to multiple factors: level of training or point in career, specialty, and institution. The reasons to respond also varied. Some chose to address the situation to change the culture: “If you don’t address it, the more you create an environment that this is ok.” Some mentioned that their response was to make people aware of “what they’re actually asking. And if they get embarrassed, then I think they have realized that what they have asked was perhaps inappropriate.” Faculty from all specialties felt obligated to respond if a learner was present. “In my role as a faculty member I think it’s important…if I see it happen to a trainee [I] …approach them and ask… ‘Are you okay?’ Like ‘That wasn’t right.’” Many commented that responding was an obvious choice if it affected patient care or could directly affect other providers.

Reasons not to respond were equally variable. Some noted: “I don’t really feel like it’s my role to change my patients.” The participant’s level of training at the time of the incident and their perceived status within the medical system impacted their ability to respond. Medical students noted that “…I didn't really know how to respond in a situation like that” and “this is like my first attending [who] grades me…I was kind of like concerned…, if I did say something.” Additionally, some participants chose not to respond if the offender was a patient with a cognitive or psychiatric condition: “…Persons like an elderly dementia patient who…makes some stupid comment…and it’s like well,... this is not even worth it… to address it.” Many also stated that they were more concerned about “…trying to move the clinic appointment [along]” than responding. Some did not have the energy to respond: “…is it worth the effort to try to like correct it? … to expend that energy to try to correct whatever it is.”

Those that chose to respond often utilized humor, diversion, and clarifying questions. Some were direct in their response, based on their comfort and training level. Participants learned their responses through personal experiences, colleagues and others who have similar identities, professional groups, and didactics.

Aftereffect of an Aggression

Sequelae

Aside from the immediate effect of an incident, long-term impact was also noted. Most well into their careers were still “stressed” by these aggressions. Many noted the cumulative effects of such events throughout their careers: “…It’s funny, like one negative interaction with a family can sort of taint your whole experiences…and I’ve had many…almost 20 years into practicing, I’m exhausted.” For some, the years of aggressions “…just eats at your soul” and “…made me into a more jaded person.” Some participants mentioned how repeated microaggressions could raise self-doubt and possibly hinder promotion in the future: “…this constant like invalidation of who you are, it does like wear on you that you start to feel like, ‘Gosh, am I like a good doctor?’” Of note, experiencing a microaggression may also propagate stereotypes. One participant, after a microaggression, thought to herself “this is what old white men are like in rural Wisconsin.”

Support

Support, or lack thereof, contributed to the impact felt by participants. Participants noted the absence of institutional polices:

“…true support is like when there are policies and things in place that says…if a patient does this, this is the action that we’ll do…emotional support that’s nice, but like there’s no consequence for patients’ bad actions…there’s no recourse and that’s not support.”

Concurrently, participants conceded that: “…I want policies and things, but…realistically…how can you punish patients when…you’re supposed to be there to help them.” Leadership and the institution were another source of support. Some participants were “…surprised by some of our leaders, in terms of how woke…they are” and felt that the “… [institution] is working on [aggressions] and trying, and that has been something more active in the last year or two.” Others felt differently: “We’ve had people in our department say… you’re just not resilient enough that’s why that’s upsetting to you.” Few participants voiced that they “…don’t feel comfortable overall with the [residency] program” and “don’t trust the system enough to side with me.” The importance of diversity to feel supported was also identified by multiple participants: “I only share [micro/macroaggressions] with others who I believe are…dealing with the same issues.” A participant described the lack of diversity as “…I’m just like a little island on my own over there.” For others, “…an acknowledgement that what I was feeling was okay, was helpful.” Colleagues, friends, and family were examples of support.

Coping

How individuals cope and process the incidents were wide-ranging. Many reported sharing their experiences with family and colleagues. Some tried to forget it, used journaling, therapy, and educating oneself. A venue to discuss such incidents was also suggested, as “I don’t think that [residents]… get that space. To be able to talk about their experiences…has far more reaching…impact for them.” A participant who experienced and witnessed macroaggressions was compelled to form a group with a colleague to better support others. Another participant’s research interest stemmed from her experiences: “…this upsets me, so I’m just going to be upset or maybe do something about it, so like let’s do something about it.”

Reporting

One participant made an effort to report gender microaggressions to leadership “to make them aware of like how common it is.” No participants ever reported a non-gender microaggression, often deeming them as “[not] so egregious.” Two trainee participants reported a macroaggression when a superior was verbally offensive. Most participants were unsure if there was a system in place to report such incidents. “Who do we talk to? It’s a traumatic situation, so knowing who to speak to would be helpful.” Many stated that they knew who they could report to on colleague and staff issues, but “If it’s coming from a patient, I have no idea.”

Education and Training for Micro- and Macroaggressions

Participants believed education was essential and should include the entire spectrum of physicians, from students to faculty. As such, “one hat fits all bureaucracy does not work…You can’t teach everyone the same.” Nonetheless, the need for education and training for all, even those belonging to a marginalized group, was highlighted by a participant who reflected that, “I have white women friends who understand ‘male privilege’ but can’t understand ‘white privilege.’ They could understand why they can’t get on Uber at 2 AM, but [not] why I’d be afraid when a police officer approaches me.” Participants also felt that “in general, [education in micro- and macroaggression], seems to be led by trainees.” Specific areas that were identified for education were: “…the opportunity to practice standing up for each other” and “how to deal with things professionally. How to recognize it, how to address it and who to talk to.” They acknowledged that education, to “completely rewire thinking without putting in some work,” was not realistic. One participant pointed out that “the underlying source of all of this comes from understanding others and understanding diversity, which is not something that should be started in medical school. That’s something that should be started much, much younger.” Several participants referenced some of their institution’s campus-wide programs to create an open dialog about race as a positive. Additionally, upstanders were mentioned as potentially being helpful.

DISCUSSION

As seen in our study, micro- and macroaggressions affect physicians of all levels. The themes identified span the entire medical training and post-graduate continuum. To our knowledge, our study is one of the few to focus on microaggression and macroaggression experienced by physicians at all levels, from student to faculty, and of various specialties. We found that these experiences are not unique to any one group. Many faculty recalled experiences that happened during their training, which have influenced their responses and reactions to subsequent events. This reinforces past studies that note microaggressions can be particularly detrimental to those early in their training.14,19 The long-term impact can be damaging, not only emotionally and mentally, but professionally as well.24,25,26,27 Additionally, our participants’ interpretation of microaggressions aligns with past work that describes how microaggressions can be meant as a compliment, but their impact is, by far, more consequential than the intent.28

The decision to respond to a micro- or macroaggression depended on numerous factors. Participants in this study voiced many of the same reasons for responding or not, as noted by prior literature on medical students and people of color, such as uncertainty of the act, knowledge, and context.14,29,30,31 Furthermore, responding requires time, confidence, and effort on the part of the victim.32 Similar to a pediatrics study, faculty in this study spoke about the importance of speaking up when trainees were involved and debriefing after the event.33 Coping strategies offered by participants, such as self-care and having a support network, also reflect those of published literature on black women and medical students.14,34 Participants had varied goals for their response, a concept not discussed in previous work on this topic. Some felt responsible to help change the culture, while others felt obligated to be a role model to others. Interestingly, many participants did not fault the aggressor, which could make understanding the objective to respond in these instances particularly important.

Many participants noted representation of one’s identity within the institution as critical for support. Participants acknowledged feeling isolated without individuals similar to themselves at their institution, which corroborates previous studies.14,15,16,21 It may not be possible for those who have never experienced these aggressions to truly understand their impact. Thus, a sense of shared background or characteristics can help facilitate trust when discussing incidences of micro- and macroaggressions. This reinforces the importance of representation and inclusion in medicine and underscores the need for diverse leadership to promote confidence and inclusivity.25,35

The perception of diversity, inclusion, and institutional culture varied among participants. While institutional support through campus-wide programs was viewed favorably, some participants were wary. As one of our participants expressed, simply being in one marginalized group does not necessarily confer awareness of all forms of discrimination. This emphasizes the need for better education. Indeed, our participants recommended education both at institutional and individual levels, similar to a prior study.33 Participants felt institution-led education should be mandatory for every member although they noted that education on this topic ideally should begin far before medical training. The need for micro- and macroaggression policies was also mentioned, which echoes published literature that stressed both a policy and its enforcement were crucial.12,36

LIMITATIONS

This study has several limitations. First, as it was done at a single institution, results may not be generalizable. However, our faculty and trainees often work and rotate at the associated hospitals, and our findings reflect prior work done in other specialties. We also interviewed trainees of all levels and faculty of various specialties and feel trainees and faculty at other institutions may share similar responses to our participants. Next, there could be a selection bias, given the voluntary nature of the study, and a response bias as racial concordance between interviewer and interviewee was not always possible. Additionally, lack of coder reflexivity and assessment of inter-coder variability could have impacted transcript interpretation. Finally, the study did not define micro- or macroaggression for the participants. This was designed to allow participants freedom in sharing experiences based on how they personally defined the terms. While the definitions of both were broadly similar among participants, some might have missed the essence of each term. Many macroaggressions shared by participants were verbal offenses without a clear indication that they targeted the participants’ gender, race, or other identifying characteristic. The specific inclusion of a marginalized group in the definitions of micro- and macroaggression is important and essentially distinguishes them from general unprofessional behaviors. Without it, one might view these encounters as mistreatment, instead of macroaggressions.

CONCLUSION

In this qualitative study, physician trainees and faculty responses highlight that microaggressions and macroaggressions are not limited to level of training or specialty and have varying degrees of impact. Suggested interventions included both institution-wide policies and education although participants acknowledged the myriad of challenges involved with implementing such measures. Establishing an understanding of the definitions of micro- and macroaggressions serves as a key point in distinguishing these from general mistreatment.