Stopping microaggressions in the clinical learning environment

“Microaggression is a term used for commonplace verbal, behavioral or environmental slights, whether intentional or unintentional, that communicate hostile, derogatory, or negative attitudes toward stigmatized or culturally marginalized groups,” at least that is how Wikipedia puts it. “They are really not ‘micro,’” said Dr. Ezgi Tiryaki, a professor of neurology at the University of Minnesota, during her presentation at the International Conference on Residency Education (ICRE) in Halifax last weekend. She noted that when learners and doctors are slighted in this way it can have a big impact. Indeed, she said, because they are not at all really “micro” some want them to be called exclusionary behaviours instead. But what do you do if you see a colleague do or say a microaggression—or misgender a patient—in the hospital or clinic? Read: Repair and connect: Focusing on constructive solutions to microaggressions in healthcare In the presentation “It only takes 10 minutes: Use simulation to stop microaggressions in the clinical learning environment,” Dr. Tiryaki, who is also an associate chief of staff for education at the Minneapolis VA Medical Center, talked about how people need to notice and interpret a situation and then decide how to intervene. She spoke about how to us the “five Ds” to help deal with microaggressions. During the presentation, Dr. Tiryaki and her colleague played a video simulation from a hospital post-anesthesia care unit (PACU) where a patient called Alex wakes up after a successful multi-stage phalloplasty. In the scenario, the patient explained that they use the pronouns “they/them.” When the OR nurse enters she gives her report: “So this is Alex. He had a phalloplasty? Anyway, he has a drain by his, uh, parts. The drain is sutured and covered with a mepilex dressing.” The anesthesia provider said: “Quick thing. When Alex introduced themselves, I heard them say their pronouns were ‘they/them,’ not ‘he/him.’” The OR nurse, flustered, said: “Oh, sorry. My mistake.” The PACU nurse then asked: “Anything else for the report?” The OR nurse said: “No, that should be everything. He—(catching the mistake), they did really well for us. Anesthesia, you’re good to give report. Good luck with everything, Alex.” In the discussion in the room at the ICRE event, those in attendance were pretty forgiving of the misgendering at the end—mistakes happen and the OR nurse even caught her mistake—but several attendees felt like they’d have spoken up about the “uh, parts” comment. “So assuming that the person just wasn’t informed of the proper terminology of the procedure,” said Dr. Bich-Han Nguyen, a physiatrist from Montreal, “we could have led with, ‘oh, so what you mean is gender reassignment surgery in the form of phalloplasty’ and then stick to technical terms like ‘their drain is in so-so position.’” The goal she said is “to reframe what they said in a more objective way.” Dr. Tiryaki said the 5 Ds—distract, delegate, direct, delay and document—don't all need to be employed in a given situation. The best option(s), rather, should be used depending on the situation. “It really depends on the context, the power differential, the safety, the risk involved—even sometimes the physical risk—sometimes ‘delayed’ is the right thing, sometimes bringing somebody in and ‘delegate’ is the right thing. I think sometimes ‘direct’ is the most uncomfortable one, at least for me, so in the simulations that is the way we practice the most. The good news is you don’t have to say it in the moment, if you freeze” that is fine, she said. One attendee said she feels like it should be the 4 Ds plus ‘document’ because having a record of something is so important in the hospital setting—which got many nods from around the room.

Stopping microaggressions in the clinical learning environment

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