Disparities between women and men in medicine persist despite efforts to ameliorate them.1–3 While this could be due to concerted efforts to oppose change, it also could be due to subtle behaviors that have not been previously recognized. Data from the Association of American Medical Colleges (AAMC)1 show that women constitute 43% of assistant, 33% of associate, and 20% of full professors compared with 57%, 67%, and 80%, respectively, for men. These differences in rank are not explained by gender differences in productivity or attrition from the workforce.4 Wage (salary and bonuses) disparities between men and women have been well described, as have differences in resource allocation, such as space allocation and other professional incentives.5,6 Even of those in leadership positions, women are more likely to serve as clerkship, residency, or fellowship directors or in other educational roles,7 while men are more likely to serve in positions with more power, including as division chiefs, department chairs, and deans.8–13 Within the National Institutes of Health, women investigators are less likely to be awarded research dollars.14 Studies have shown that these disparities across academic medicine are not due to a lack of women physicians, as medical schools have trained equal numbers of men and women for many years.1 In addition, the percentages of men and women entering academia are roughly equivalent. It is safe to conclude then that gender disparities exist.15–21
In a national survey, women faculty expressed a need for an equitable workplace that promotes collegiality, collaboration, and is free of discrimination.21 In an effort to ameliorate perceived discrimination, policies and behaviors have been targeted. As a result, written or outright verbal expressions of gender preference are uncommon. However, disparities persist and now may be caused by known prejudices and hostilities that have become more subtle or by previously unrecognized factors. Subtle prejudices and unconscious biases can manifest as microaggressions that may contribute to the persistent disparities faced by women in medicine.
Microaggressions are subtle verbal or nonverbal behaviors that may arise from unconscious biases, covert prejudice, or hostility.22 In contrast to direct aggressions, microaggressions are fleeting, everyday occurrences that may be unconscious, unintentional, or unnoticed by the aggressor, and they are typically unacknowledged when they happen. On the surface, these everyday occurrences may appear innocuous and insignificant, particularly to someone who is not marginalized. However, to someone who is from a marginalized group, microaggressions are known to have a powerful effect on the psychological well-being of the recipient.
Cumulatively and over time, microaggressions can contribute to a pervasive state of discrimination and disenfranchisement. In fact, the minority stress theory posits that difficult social situations, like those caused by microaggressions, cause stress for members of minority groups that accumulates over time.23–26 This kind of stress is known to result in perceived discrimination,24 decreased performance, heightened stress responses, erosion of the recipients’ sense of confidence and well-being,27,28 and long-term health deficits.27 Unconscious biases might well be a missing link that helps explain the gender differences and discriminatory practices in medicine today,22,29 and the presence of microaggressions might help explain the erosion of wellness in women and minorities specifically.
Microaggressions, bias, and discrimination can happen to anyone in any venue irrespective of gender, race, and ethnicity. For the purposes of this article, however, we limited our work to the microaggressions reported by women in medicine. We specifically sought to identify common microaggressions reported by women faculty in medicine and to determine if specific demographic characteristics affect the reported frequencies of such behaviors.
We used a chain referral sampling approach (i.e., a nonprobability sampling technique where existing study participants recruit future participants from among their acquaintances) to confidentially collect real-life narratives related to microaggressions that women faculty in medicine experienced or witnessed in their professional environment. One of the investigators (V.S.P.) invited women through her peer network to initiate the chain referral sampling.
Of the numerous real-life microaggressions that participants reported, 34 unique experiences were identified and used to create representative scripts. For each of these 34 real-life microaggression scenarios (“treatment”), a corresponding fictional “control” version of the same scene was scripted. The control scenes depicted the same scenarios as the treatment scenes but without the specific microaggressions. Using professional actors, the scripts were enacted to create 34 pairs of microaggression and corresponding control videos (68 videos in total). All videos were scripted, directed, and produced by one of the investigators (V.S.P.). Next, the 68 videos were assessed by 7 senior faculty leaders (3 men and 4 women), who viewed all the videos and gave feedback on the video pairs. Their input was used to further edit and refine the final videos used in the study.
We used an online portal, hosted on a secure Stanford University School of Medicine server, to display the videos. The site was programmed to present the 68 videos in a random order to viewers.*
Investigators from each of the 4 study sites (Stanford University School of Medicine, University of Rochester School of Medicine, Harvard Medical School, Medical University of South Carolina) invited their faculty colleagues to participate using the same email invitation (created by V.S.P.). The study sites were specifically chosen to represent both private and public medical schools as well as different geographic locations. Faculty who agreed to participate watched each video and completed an online questionnaire. They were asked to assess each video using the following multiple-choice question:
Based on your own knowledge and experience and that of your colleagues and students at your institution and settings, is this scenario something that:
(a) Has never happened nor is likely to ever happen
(b) Happens rarely or will happen rarely
(c) Happens or will happen to a lot of people
(d) Affects every person sometime in their career
Participants could not proceed to the next video until they responded to this question for the previous video, and they could not submit their responses unless they answered all the questions. Participants were also invited to write additional comments regarding each video using a free-text feature. As the topic is a sensitive one and to foster frank responses, participants completed the questionnaire anonymously. Data were collected from 2016 to 2018.
This study was reviewed and approved by the Stanford University institutional review board in 2015 and subsequently by the institutional review boards at the University of Rochester School of Medicine, Harvard Medical School, and the Medical University of South Carolina.
The Mann–Whitney–Wilcoxon test was used to compare the responses of men versus women respondents. For each video, P values and effect sizes are reported. Two equivalent effect sizes are reported: area under the receiver operating characteristic curve (AUC) and success rate difference (SRD). AUC is the probability that if a man and woman view the same video clip, the women will report a higher frequency of microaggressions than the men. Thus, if AUC = 0.7, for example, 7 out of 10 times the women will report a higher frequency of microaggressions than the men. The null value of AUC is 0.5 when men and women report equal frequencies of microaggressions. SRD rescales AUC to a null value of zero, which is the probability that a woman reports a higher frequency minus the probability that a man reports a higher frequency (i.e., SRD = 2AUC - 1). SRD = (+1) means a woman will always report a higher frequency; SRD = (−1) means a man will always report a higher frequency. SRD = 0 means men and women report equal frequencies. Thus, the sign of the SRD clearly shows the direction as well as the magnitude of the male–female difference. The data were analyzed using SAS 9.4 (SAS Institute, Cary, North Carolina).
As part of a post hoc analysis, we identified which microaggressions were most common and grouped them into themes.
A total of 124 faculty members (79 women and 45 men), from diverse racial and ethnic backgrounds, various age groups, and academic ranks, participated in the study (see Table 1 for their complete demographic characteristics). The median time of employment in medicine for both women and men was 15 years.
Women reported much higher frequencies of the microaggressions depicted in 33 of 34 microaggression videos (see Table 2 and Figure 1) than men (P value range < .001 to .042 and AUC range: 0.60–0.69). In stark contrast, men reported these microaggressions to be uncommon. There were no such male–female differences seen in the responses to the control videos.
We compared participants’ responses to the videos to determine if other key demographic factors including age, race/ethnicity, academic rank, or number of years in medicine influenced the results, but we found no significant effects.
We identified the most common microaggressions and grouped them into themes. The resulting themes from this post hoc analysis of the 21 microaggressions identified by the women participants, in the order of frequency of occurrence, were (1) encountering sexism (6 videos), (2) encountering pregnancy- and child care–related bias (5 videos), (3) having abilities underestimated (4 videos), (4) encountering sexually inappropriate comments (3 videos), (5) being relegated to mundane tasks (2 videos), and (6) feeling excluded/marginalized (1 video).
Through this study, we identified 21 commonly occurring microaggressions reported by women faculty in medicine. Furthermore, we demonstrated the significant differences between men and women faculty in their perceptions of the prevalence of these microaggressions. It is remarkable that women across the 4 study sites reported a high prevalence of microaggressions, while men from the exact same environments were far less likely to recognize the existence of these microbehaviors.
The ability of all faculty to flourish depends on a nurturing professional environment. Health care settings that are structured to reduce identity-related threats and deliberately promote a sense of safety, belonging, and equity for everyone regardless of their group-based and personal status are critical to empowering women and minorities. Environments that are impartial, consistent with a person’s values, and that convey belongingness, engender trust.30,31 Microaggressions, over time, may cause the recipients to feel isolated, may undermine trust, and likely will have a lasting negative effect on well-being and morale. They may even cause the recipients to disengage from their work and eventually leave academia. This attrition of women from academic environments will result in a shortage of women role models and mentors and may worsen gender disparities in the future.9,32,33
In addition to the effects on the recipients, microaggressions also have a secondary effect on witnesses, who may draw conclusions about what is institutionally condoned behavior from the behaviors they witness. In fact, it is known34 that a majority group can implicitly stimulate convergent thinking (from the perspective posed by the majority) on what is socially acceptable behavior toward underrepresented groups, and this may be a key reason why microaggressions often go unnoticed and unchecked. Though the recipients of microaggressions (and in many cases the witnesses) often recognize these behaviors immediately, they may feel an internal pressure to conform to the social norms imposed on them, refrain from vocalizing their concerns, and learn to expect and silently tolerate these behaviors. It behooves all professionals, irrespective of their personal characteristics or professional role in the organization, to become aware of microaggressions, identify them when they occur, and actively seek to prevent them.
As of 2017, there were 89,904 medical students in training, and 50.7% of them were women.35 Medical schools and teaching hospitals have the solemn responsibility of training future doctors to be respectful and compassionate toward their colleagues, patients, and families. All institutions have some policies that prohibit unlawful discrimination on the basis of race, color, national or ethnic origin, sex, age, disability, religion, sexual orientation, gender identity or expression, veteran status, or other protected characteristics. While these policies may prevent overt expressions of bias, they may not be entirely effective in preventing microbehaviors that manifest from subtle prejudices, including microaggressions. Institutions that allow gender-based and other microaggressions to go unnoticed and unchecked will be less successful in improving the congeniality and collegiality of the professional work climate for all employees, but more specifically for marginalized groups.
The AAMC recommends unconscious bias training for search committees and promotion and tenure committees and the assessment of institutional culture and climate as strategies for institutions to recruit, retain, and advance women in the health care workforce.36 Broad and nonspecific unconscious bias training per se may be less likely to result in lasting behavior change. Unconscious bias and subtle prejudice manifest as specific microbehaviors in the workplace. The 6 microaggression themes we identified in this study provide a basis for designing bias prevention training that is specific to the behaviors that faculty encounter in their professional environments and may be useful in designing training that targets real-life experiences.
In examining these common themes, we found that microaggressions related to sexist and sexually inappropriate comments and behaviors are interpersonal in nature and require solutions that target individuals who demonstrate these behaviors. Recipients of these types of microaggressions should have a confidential and anonymous way to report these behaviors, and institutions should adopt a zero-tolerance policy and act expeditiously to stop them from occurring.
Pregnancy- and child care–related bias can be mitigated by having explicit institutional policies that safeguard the rights of women and by educating all employees about these issues. Solutions to mitigating pregnancy- and child care–related bias include implementing a parental leave program that allows several weeks to months of paid leave for all new parents, regardless of their gender, and fosters personalized career planning to meet both career and life goals. Doing so while concurrently promoting team success will mitigate work–life and work–work conflicts.37,38
Microaggressions that involve underestimating the abilities of women, relegating them to mundane tasks, or excluding them from teams, events, and opportunities can be prevented by instituting specific training, especially for institutional leaders and supervisors. All faculty members also need training39 and coaching to learn how to respond appropriately in real time when they encounter microaggressions, to become effective advocates for their own rights. Passive bystanders should be trained to identify microaggressions and become active upstanders (someone who recognizes when something is wrong and acts to make it right) in providing real-time support to those subjected to microaggressions. This kind of sensitivity training should target the entire workforce, including administrators, deans, chief executives, and members of boards of trustees. Dramatized real-life scenarios, as shown in our videos, might be used to teach these individuals what microaggressions really are. Identifying and eliminating microaggressions are the collective responsibility of everyone in academic medicine, not just those who are the recipients of such behaviors. Ultimately, enduring change is possible only if institutions truly value equity, parity, and a respectful workplace for all and if they build accountability and transparency into the workplace.
Our study has a number of limitations. It is a cross-sectional study with volunteer participants. However, the sample size was adequate to detect differences by gender in our findings, as demonstrated by the stark differences between responses to the microaggression videos between men and women. We intentionally included 4 geographically diverse sites and 2 private and 2 public medical schools to increase the diversity of our participants and their settings. In addition, though the women from our chain referral sample did not report any anecdotes of microaggressions perpetrated by other women, we acknowledge that microaggressions toward women can come from both men and women. Future work in this area should focus on understanding the relevance of the scenarios in the videos we created in a broad variety of settings. Another limitation is that we focused only on microaggressions where women were the recipients. To understand the full extent of microaggressions in medicine, we need to collect and study vignettes that include women as the generators of microaggressions and both men and women as the recipients. We also need to identify microaggressions that occur in a variety of venues and settings, including the clinical arena, community-based practices, and elsewhere, as well as those experienced by different groups, including racial and ethnic minorities; lesbian, gay, bisexual, transgender, and queer individuals; persons with disabilities; and other vulnerable groups in medicine.
Privilege is often invisible to those who have it, while bias and discrimination are readily apparent to those who experience it. Subtle prejudice and unconscious bias can manifest as microaggressions. In this study, we found that women in medicine, compared with their male counterparts, reported that microaggressions were much more common in the workplace. We identified 6 common types of microaggressions that can be the targets of creative individual, interpersonal, and institutional solutions. Promoting a respectful workplace that prioritizes collegiality and discourages bias will lead to a sense of trust and belonging in all faculty and serve to mitigate disparities in medicine.
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