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A Building Block for Organizational Change

Halem, Jessica, MBA

doi: 10.1097/MLR.0000000000001009

Harvard Medical School, Boston, MA

The author declares no conflict of interest.

Reprints: Jessica Halem, MBA, Harvard Medical School, 260 Longwood Avenue, Suite 252, Boston, MA 02115. E-mail:

Just a few weeks into their first year of medical school, the anatomy professor told 2 male students to help the female student cut the ribs open on the body donor since “women are too hesitant to cut” and she should pay attention since “she won’t always have a man around to open the door for her.” All 3 medical students went silent, and the professor walked away. The students told me the story and the impact it had on all 3 of them almost a year later. None had ever spoken directly to that anatomy professor about what was said. They were deflated, angry, and sad. Their relationship with a faculty member felt irreparably severed. The professor is still teaching and has no idea students are still talking about his sexist behavior.

The anatomy professor had perpetuated a stereotype rooted in perceived sex differences onto a new group of students, quickly and thoughtlessly. Perhaps the professor had encountered female students in the past who were hesitant, or maybe he relayed a stereotype passed down from his own mentor. Why did the professor see “hesitation” and conclude it was about gender when it was just as likely they were being thorough and cautious because they were new students? No matter the intent of the professor, the impact was negative. Today, female and male medical students alike are attuned to sexism and negative sex stereotypes and are surprised when encountering them from those they are told to trust.

The professor’s sexist comment was a microaggression. Microaggressions are understood by scholars and advocates alike as: “brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative” slights.1 First defined in relation to racial bias, the concept of a microaggression helps to illuminate how race, gender, sexual orientation, and other nonmajority status people experience subtle (and sometimes not so subtle) hostility in schools, the workplace, and beyond.

This scenario portrays some of the barriers to successful engagement, which the scoping review tells us is necessary, for health systems’ change. What seems like a minor incident becomes of greater importance when we consider that the review claims that engagement itself is the cornerstone of “health system transformation.”2 The scoping review defines the term “engagement” in health care as a “positive, fulfilling work-related state of mind.” With recent attention being paid to physician burnout and suicide, this review of the characteristics that enable successful physician engagement is especially timely. The authors found that both younger physicians and physicians with extensive experience were both highly engaged, suggesting that mid-career physicians were at the greatest risk of burnout. Aside from individual characteristics, the study also showed how the work environment can influence physician engagement. Hospitals can positively nurture physician engagement by providing more autonomy, constructive feedback, and better schedules. These practices can be cultivated in medical school where many habits and traits are first enshrined between the students and faculty.

Cultivating faculty and student engagement in diversity efforts in our medical school and hospitals has been my mission for the past 4 years. The research in the article highlights that one part of the secret sauce for engagement is optimism. But, with moments like the one described above, it is no wonder that our optimism gets chipped at everyday, making our full engagement at work impossible. I spent an hour with the anatomy class scenario and a group of new medical students workshopping other ways through which this difficult moment could have been addressed. I believe that all medical students come to medical school firmly in the camp of “optimists” and, as that personal attribute gets tested, they have the opportunity to tap into their ability to effect change and take care of themselves and each other.3 Optimism isn’t a rosy view of situations4 but a sense of your own ability to be a change agent, whether it is a patient prognosis, a demanding studying schedule, or a broken health system. They wouldn’t have chosen medicine or made it all the way here if they didn’t have a strong sense of their ability to make a difference.

I believe that optimism can be taught. Or more specifically, remembered and conjured when needed. Finding ways to deal with these difficult moments requires us to engage our own personal mix of optimism, resilience, and self-efficacy. And the very act of using these personal attributes in small ways everyday can actually build up our reserves and make those necessary muscles stronger. The beauty of resiliency isn’t found in the ability to keep taking the hits, but in the bouncing back part.5 Every time we bounce back, we get stronger and wiser. The bounce can get faster, and the hits can sink in less deeply.

But the students in the anatomy class took the hit, got deflated, and didn’t bounce back. They absorbed it. We can teach or at least workshop together, strategies for bouncing back. Because we know the hits are coming. Together, almost 80 of us brainstormed ideas for alternative endings to the story. We practiced engagement. We tried on different personalities. We heard ideas ranging from the funny to the serious to the practical: how to actually stand-up in the moment and practice our optimism in the face of adversity. I believe these difficult moments are at the heart of workplace conflicts and have a far-reaching impact greater than a few sexist words.

The act of engaging requires involving ourselves in these everyday difficult moments, in our institutions, and in each other’s work. But how do we engage in a way that doesn’t assume intention and also allows for space to speak about and then heal the negative impact? How can we take time to catch our breath, ask for clarification, and see if we heard correctly? How can we engage in ways that boost our relationships and not sever them more? How can we teach each other the impact of their words and reveal the pain caused? How can we self-reflect on our own biases and history that can result in not seeing people as individuals but as stereotypes?

In their study of stress and resiliency among LGBTQ health care professionals, Eliason and Streed found “using humor to deflect a potentially threatening situation as a positive approach.”6 Remaining positive in the face of negativity can be practiced. Those of us who are LGBTQ often find ways to reframe difficult moments, so people in positions of power can hear us. Yes, this can be extra work on our parts. But, with practice, we can learn to use humor to help point out absurdities or even bias7 in the moment while keeping the meeting on track and work on moving ahead. It actually can get easier the more we practice. But we need to practice.

I spent the morning teaching the medical students how to cultivate their own sense of humor and how to imagine a response to the anatomy professor’s sexist comment. We found ways for the male students to step-up first and ask the professor to clarify what was meant by the comment. Or perhaps go right for the obvious gender joke and find a way to poke fun at the idea that women are made from one of Adam’s ribs. “Professor, we were overwhelmed with the idea that we would finally see where women come from.” Finding the humor in the situation allowed them to tap back into their natural optimism and hope. Sure, part of it was about blowing off steam. Retreating during a difficult moment can be a way to stay safe, but it also takes us all further away from engagement.

Medical students and faculty members have shared their stories of bias, stereotyping, and marginalization with me for years. More often than not, they remained silent for fear of repercussions: a bad grade, severed relationships, or a reputation for being “difficult.” But silence has its own consequences: detachment (which can also lead to a bad grade and severed relationships), pessimism, and career detours. It’s time to try a different path—the path of engaging in these difficult moments. Let’s practice harnessing our natural optimism, resilience, and self-efficacy. And tell the anatomy professor that he’s wrong.

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