Discrimination 911: A novel response framework to teach bystanders to become upstanders when facing microaggressions

Mgbechi Ugonna Erondu, MD, MFA and Nancy L. Glass, MD, MBA, MLS, MFA

Our goal for the PAADs is to keep them short, 5-7 minute reads, and to make them more than simple summaries/abstracts.  Today’s PAAD is a bit longer but I think well worth your time and effort to read.  It provides a lot of food for thought and discussion.  The authors of today’s PAAD, Drs. Erondu and Glass are thought leaders in our profession and relatively new PAAD reviewers.  Further, as way of full disclosure please note that both have worked with the authors of today’s article in the Palliative Care Section at Texas Children’s Hospital.   Myron Yaster MD

Original Article

Rubenstein J,Rahiem S, Nelapati S S, Arevalo Soriano T, Tatem A.  Discrimination 911: A Novel Response Framework to Teach Bystanders to Become Upstanders When Facing Microaggressions. Academic Medicine, 2023;98: 800-4.   PMID: 36795599

This week’s PAAD addresses an all-too-common situation facing medical teams:  discriminatory statements made by patients or family members toward minoritized members of the team.  If you are like me (NLG), these comments feel hurtful to me as a team leader and a white person, but I’ve not always known what to say.  Address it in the moment or go back later to talk with the family—and what should I be saying to the individual attacked?  How I wish I had received training about how to better support my colleagues and trainees!

Rubenstein and colleagues studied the DEI literature and developed four algorithms for addressing such comments, focusing on 1) levels of discriminatory language 2) suggested responses by bystanders on the team, 3) supporting and validating the minoritized person immediately after the event, and 4) returning the conversation to the medical care of the patient.  Examples of discriminatory language included microaggressions, overtly discriminatory language, discriminatory requests (for example excluding a team member from the patient’s care team based on bias) and mistaken identity (assuming a person of color is the housekeeper, etc).  After developing these algorithms for response, using a format analogous to CPR algorithms, the team offered three-hour workshops for hospital providers with didactics about systemic racism and DEI.  Following didactics, participants practiced role-playing with different scenarios.  Of note, in each of the workshops, the facilitators acted as the aggressors in the scenarios, to decrease the level of trauma for participants.

I (MUE) must say that when I first began reading this article I worried about the three-hour workshop as potentially re-traumatizing for minority participants. As an early career physician who experienced numerous microaggressions throughout my training, such situations can have a devastating impact on one’s sense of inclusion, belonging, even safety.  I (MUE) am curious about the specific scenarios used in the workshops and whether these came from real experiences. I also wonder who acted the role of recipient and feel that this also might best have been filled by a facilitator.

You might be asking yourselves…this is all well and good on the wards—how does it apply to me in the operating room? 

Although these algorithms and the associated workshops were devised to respond to microaggressions of patients and family members, the skills acquired could be adapted to other scenarios encountered in our clinical work. Many of us have witnessed microaggressions from our surgical colleagues across the drape or in interactions with other perioperative staff.  It is possible patient family members have made requests for another anesthesiologist based on gender or other biases.  Or perhaps we might find ourselves hovering or lingering a bit longer to help in another colleague’s operating room and might later need to consider whether there is underlying bias based on their age, race or gender.  Oso et. al. (2021) took an anonymous pilot survey of anesthesiology residents in the United States and found that women and minorities experienced greater instances of microaggression and reported that this decreased their likelihood to pursue academic medicine.

In thinking about how to apply this to my (MUE) practice, what is most helpful to me about all four algorithms suggested by the authors is the identification of whether the patient is medically stable or unstable.  Inappropriately timed upstanding can make the discriminatory interaction even more traumatic. Next most helpful is the “ready to respond” step where an upstander takes their own pulse (in a sense) and decides whether they are emotionally able and have the language or the institutional support to respond to the microaggression.  Examples of useful language cited by the authors include: “did anyone else notice…” and “that made me feel uncomfortable” which names the behavior and gives permission for witnesses to speak up against the aggression.  Another useful response is that a person from a non-marginalized group might perform the inappropriate request (e.g. taking out the trash) while also clarifying the mistaken identity: “Let me clarify something, this member of your care team is…”

We were asked to select one figure to include in our review. Interestingly, NLG chose algorithm 1 and MUE chose algorithm 4.  While this training is an excellent place to start, a three-hour workshop is not enough time for individuals from unmarginalized groups to see and identify what persons of color have experienced over lifetimes (e.g microinsults, microinvalidations, overt discrimination, etc.) and to apply the algorithms to distinguish the level of discrimination. The authors’ suggestion to refocus on the care of the child by saying something like “Let’s focus on why we’re here. How can we help you or your child?” is a wonderful pivot in those moments followed by finding an open space for conversation with the recipient of the aggression as demonstrated by algorithm 4.   

This is a terrific preliminary report about an innovative tool for our workplaces, applicable in both academic hospitals and community settings.  Early feedback from workshop attendees was overwhelmingly positive; the authors plan additional workshops and longer-term follow-up to assess the degree to which the workshop training/intervention changed the participants’ responses to such scenarios in the course of patient care.  As usual, the devil is in the details—finding support for faculty time/effort and the necessary workforce for rolling this initiative out in a large health system are daunting challenges, but we believe this early report deserves your attention.  I (NLG) would have loved to have this training early in my career, so that I could have been a more effective supporter—an “upstander”—for my colleagues. And for me (MUE), what rings truest for upstander training is the acknowledgement and support of colleagues.  I think of the MLK quote, “In the end, we will remember not the words of our enemies, but the silence of our friends.”

May we all become upstanders.

References

1.      Rubenstein, Rahiem, S., Nelapati, S. S., Arevalo Soriano, T., & Tatem, A. (2023). Discrimination 911: A Novel Response Framework to Teach Bystanders to Become Upstanders When Facing Microaggressions. Academic Medicine, Publish Ahead of Print. https://doi.org/10.1097/ACM.0000000000005171

2.      Oso, Murira, A., Nwokolo, O. O. (2021). Perceptions of microaggressions: A pilot survey of anesthesiology residents. Journal of Clinical Anesthesia 68 (2021) 110094.

https://doi.org/10.1016/j.jclinane.2020.110094

3.      Osseo-Asare, Balasuriya, L., Huot, S. J., Keene, D., Berg, D., Nunez-Smith, M., Genao, I., Latimore, D., & Boatright, D. (2018). Minority Resident Physicians’ Views on the Role of Race/Ethnicity in Their Training Experiences in the Workplace. JAMA Network Open, 1(5), e182723–e182723. https://doi.org/10.1001/jamanetworkopen.2018.2723

4.      Ostrander, & Slater, G. N. (2023). REALIGN-RESPOND-REPAIR: Responding to Discrimination with Your Interdisciplinary Team (FR203B). Journal of Pain and Symptom Management, 65(3), e272–e273. https://doi.org/10.1016/j.jpainsymman.2022.12.068