Authors: Simi Ogunnowo (1.Pritzker School of Medicine, University of Chicago, Chicago, IL), Tanya L. Zakrison (2.Department of Surgery, University of Chicago Medicine, Chicago, IL), Brandon Baird (2.Department of Surgery, University of Chicago Medicine, Chicago, IL), Young Erben (3.Department of Surgery, Mayo Clinic, Jacksonville, FL), Elizabeth L. Tung (4.Department of Medicine, University of Chicago Medicine, Chicago, IL), Joyce P. Yang (5.Department of Psychology, The University of San Francisco, San Francisco, CA), Chelsea Dorsey (2.Department of Surgery, University of Chicago Medicine, Chicago, IL)
Categories: Article, Diversity, Inclusion, Health Equity, Discrimination, Microaggressions
Source: The Journal of surgical research
and Surgical Residents
Authors: Simi Ogunnowo, Tanya L. Zakrison, Brandon Baird, Young Erben, Elizabeth L. Tung, Joyce P. Yang, Chelsea Dorsey
Studies have suggested that experiences of gender and racial discrimination are widespread among surgeons and surgical residents. This study examines the relationship between experienced microaggressions and traumatic stress.
A one-time, de-identified survey was distributed over email to academic surgical societies. The survey consisted of 35 items including questions on prevalence of microaggressions, perceived job impacts as well as a shortened version of the Trauma Symptoms of Discrimination Scale (TSDS). Chi-square tests and an independence test for trends were utilized to determine significance.
We collected data from 130 participants with majority (81%) having experienced microaggressions in the workplace. On measures of worry (p<0.001), avoidance (p=0.012), anxiety (p=0.004), and trouble relaxing (p=0.002), racial/ethnic minority surgeons and trainees demonstrated significantly higher scores. With perceived job impacts, significant agreement was seen with occurrences of working harder to prove competence (p=0.005), gaining patient confidence (p<0.001), reduced career satisfaction (p=0.011), work-related negative talk (p=0.018), and burnout at work due to microaggressions (p=0.019). Among participants who underwent behavioral modifications, female surgeons were more likely to change their non-verbal communication styles (p<0.001) and spend more time with patients (p<0.001).
Experiences of microaggressions are associated with increased anxiety-related trauma symptoms in racial/ethnic minority surgeons and surgical trainees. Additionally, these experiences of microaggression can influence job satisfaction, burnout, career perceptions and workplace behaviors. As the field of surgery becomes more diverse, this study contributes to growing awareness of the role of implicit discrimination in the attrition and retention of racial/ethnic minority surgeons and female surgeons.
While explicit forms of discrimination have seemingly diminished over time, more subtle forms of interpersonal discrimination has persisted in the form of microaggressions.^1^ Within surgery, literature suggests that gender role expectations and racial discrimination, in both explicit and implicit forms, are widespread in training and practice. Surgeons who identify as racial and ethnic minorities experience microaggressions, but the content of those microaggressions differ based on background. For Black and African American surgeons, microaggressions centered on aspects of invisibility, criminality and perceived low achievement emerged as persistent instances of discrimination.^2^ Furthermore, Asian and Asian American as well as Hispanic and Latino surgeons are more likely to experience microaggressions in the form of being seen as a foreigner or not belonging within medicine. As a collective, racial and ethnic minority surgical residents are more likely to be mistaken for an individual of the same race, mistaken as a nonphysician and experience different standards of evaluation.^3^
Various studies also confirm the persistence of gender inequity despite an increase in the number of women in surgery.^4^ While there have been efforts to protect against gender discrimination on a systemic level, microaggressions still persist in the form of assumptions of inferiority, usage of sexist language and assumptions regarding traditional gender roles related to career, personality and leadership. With the intersection of race/ethnicity and gender, burnout was found to be higher among women and racial/ethnic minority surgeons with the highest rates reported by female surgeons who experienced both racial/ethnic and gender-related microaggressions.^5-6^ Specifically, those identified as female and underrepresented in medicine (URiM) experienced the highest prevalence and severity of burnout. These studies highlight the increased personal and professional stress experienced by surgeons of racial/ethnic minority backgrounds as well as the pervasiveness of discrimination within every level of surgical training and practice.
Exposure to traumatic events can increase the risk of significant physical health problems, negative health behaviors and/or mental health problems such as posttraumatic stress disorder (PTSD) and depression.^7^ Traditionally, incidents of overt discrimination and violence fit the DSM-5 criteria of trauma—a situation that requires psychological and/or physiological distress to the stressful situation. When individuals experience violence, are targeted by hate crimes or are sexually assaulted, clinicians are likely to assess for symptoms of PTSD. Alternatively, when individuals experience persistent gender-based or racial discrimination in their daily lives, these incidents are usually not labeled as trauma.^8^ Despite this, ongoing racially discriminatory events can have a cumulative effect that may increase hypervigilance and avoidance as well as contribute to PTSD symptoms. Due to its associated emotional and mental injury, racial discrimination has recently been conceptualized as a race-based traumatic stressor rather than as a simple negative experience.^9^ As a form of racial discrimination, microaggressions and the cumulative stress associated with “everyday racism” could be a significant source of traumatic stress.
Within the surgical workplace, there has been minimal research assessing the relationship between gender and racial microaggressions with the functioning and well-being of practicing surgeons and surgical trainees. In this study, the authors sought to examine the impact of microaggressions on traumatization in surgeons and surgical trainees through the administration of validated survey assessing the impact of microaggressions on various career dimensions.
In this IRB-exempt study, the authors sent a one-time, de-identified survey to surgeons and surgical trainees. The survey was sent via email with an introductory script explaining the goals of the study, assuring confidentiality, reiterating the voluntary nature and no known risks to participation as well as the exempt status of the study. Both practicing surgeons and surgical trainees were asked to respond to the survey in order to ascertain whether the frequency, content and/or responses to microaggressions changed depending on the level of surgical experience. Notably, the survey was primarily distributed to racial and ethnic identity-based surgical society listservs including the Medical Organization for Latino Advancement, the Latino Surgical Society, the Society of Asian Academic Surgeons, Asian Society for Vascular Surgery, and the Society of Black Vascular Surgeons. Permission was obtained from each society to use the listserv for this study. These societies were selected in an effort to adequately encompass data from those of major racial/ethnic minority categories; given the nation-wide reach of these surgical societies, we wanted to ensure a breadth of different experiences. The survey was also sent through the authors’ home surgical department for additional data collection. Study data was collected and managed using REDCap electronic data capture tools hosted at the University of Chicago.
The survey consisted of 35 questions (Supplementary A1) adapted from various validated measures including the Trauma Symptoms of Discrimination Scale (TSDS), a scale developed to measure anxiety-related trauma symptoms surrounding the experience of discrimination. Additionally, components of the Hackman and Oldham Job Satisfaction Scale and the Maslach Burnout Inventory were utilized in the survey. The survey was developed based on prior microaggressions studies and is not validated in its entirety; the derivation and scoring of each survey component are presented in Table 1. Participants were also asked demographic questions, including self-identified gender; race; indication of Hispanic and/or Latino origin; level of training (resident/fellow or faculty/attending); and surgical specialty.
Descriptive and comparative statistics were used to analyze participants’ demographic information, measures of trauma symptoms and measures of perceived job impacts. For analysis, we looked at the differences between male/female genders and “Non-Hispanic White/Non-Hispanic Black or African American/Non-Hispanic Asian or Asian American/Hispanic and/or Latino” categories. For purposes of analysis, all participants who selected “Hispanic and/or Latino” for ethnicity were placed in a separate category regardless of self-identified race. From this point on, respondents will be characterized as Non-Hispanic White, Black/African American, Asian/Asian-American and Hispanic/Latino. Survey responses were converted to corresponding numerical scale for analysis. Pearson chi-squared test were used for comparison between our gender categories, while an independence test for trends was used for our race/ethnicity categories. Scores for behavioral modifications were arranged in crosstabulations and analyzed via the Pearson chi-square test. Statistical significance was defined as p ≤ 0.05 and all statistical analyses were performed in IBM SPSS Statistics 27. For our free text comments, themes were generated via coding by two independent coders.
The survey was sent to more than 800 surgeons, with one hundred thirty participants completing the survey. Respondents who identified as female represented 53.2% of those surveyed. Forty-three (34.9%), 27 (21.9%), 23 (18.7%) and 30 (24.4%) respondents identified as Asian/Asian American, Black/African American, Hispanic/Latino and Non-Hispanic White, respectively. Exclusion from analysis due to small sample numbers included one participant who identified as Non-Hispanic “American Indian or Alaskan Native”, three as Non-Hispanic “Other” and three as Non-Hispanic “Two or More Races.” For other demographic questions i.e. gender, age, and level of training, those who chose the option of “prefer to not disclose” or left the section blank were excluded from analysis (Table 2). Most of the respondents were practicing surgeons (n=93), with majority working in an academic practice (n=74). Two practicing surgeons chose not to disclose setting of practice.
Overall, 81% of respondents stated that within the past 12 months, they had experienced microaggressions in the workplace. Compared to male surgeons, female surgeons were experiencing microaggressions at significantly more frequent rates; 87.7% of female surgeons experienced workplace microaggressions about once a month or higher (few times a month, once a week or more) compared to 44.8% of male surgeons (p=0.029). Additionally, female surgeons were more likely to receive these microaggressions from patients (p=0.005) and patients’ families/friends (p=0.048). Compared to their Non-Hispanic White counterparts (n=30, 70%), 96% of Black/African American (n=27), 86% of Asian/Asian American (n=43) and 70% of Hispanic/Latino individuals (n=23) stated having experienced microaggressions in the past 12 months (p=0.03). Additionally, Black/African American (74%), Asian/Asian-American (51%) and Hispanic /Latino (57%) participants were significantly more likely to receive these microaggressions from their colleagues compared to 33% of Non-Hispanic White participants (p=0.022).
Level of agreement to TSDS scores were compared on the basis of race/ethnicity and gender, with a higher level of agreement representing increased frequency of experiencing associated trauma symptoms due to microaggressions. Analysis was based on the percentage of each racial/ethnic group who indicated that they often or sometimes experienced trauma symptoms due to past microaggressions. As shown in Table 3, in comparison to Non-Hispanic White counterparts, Asian/Asian American, Black/African American, and Hispanic/Latino individuals were more likely to worry too much about things due to past experiences of microaggressions (p<0.001), go out of their own way to avoid certain situations (p=0.012), experience increased anxiety around certain people (p = 0.004) and have trouble relaxing due to past experiences (p=0.002). With gender, significance was found with having trouble relaxing; 35% of female surgeons endorsed often or sometimes having trouble relaxing due to past experiences compared to 20% of male surgeons (p = 0.008).
Survey responses concerning agreement towards various career dimensions e.g., job satisfaction, burnout, patient satisfaction, and confidence were converted to a corresponding numerical scale for analysis (1= strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree). As shown in Table 4, compared to Non-Hispanic White counterparts, Asian/Asian American, Black/African American, and Hispanic/Latino individuals were more likely to work harder to gain patient confidence (p < 0.001) and to be seen as competent (p=0.005). Additionally, for these racial/ethnic minority groups, microaggressions were more likely to cause reduced career satisfaction( p=0.011), contribute to burnout (p=0.019) and result in increased negative work-related talk (p =0.018). With gender, women were more likely than men to report having to work harder to gain patient confidence (p = 0.006) as well as to be viewed as a competent physician (p = 0.006). Additionally, microaggressions were more likely to reduce career satisfaction ( p = 0.05) and contribute to burnout at work (p=0.037) for female surgeons compared to male surgeons (Table 4). For race, no statistical significance was found with S1, S3, S4, B1, B2, B4, B5, I3 (see Supplementary A1). For gender, no statistical significance was found with S1-S4, B1-B5, I3, I5 (see Supplementary A1).
For the behavioral modifications portion of the survey, respondents were asked to mark any/all checkboxes concerning the ways in which work-related microaggressions has impacted their behavior as a physician. When stratified by race/ethnicity, a significant difference was seen with individuals changing their verbal communication style (p =0.015). Compared to Non-Hispanic White counterparts (27%), Asian/Asian-American (63%), Black/African American (52%) and Hispanic/Latino (61%) endorsed changing their verbal communication style in response to microaggressions. Female surgeons were more likely to change their physical appearance (p=0.018), verbal communication styles (p= 0.036), non-verbal communication styles (p < 0.001) and spend more time with patients (p < 0.001) (Table 5).
While our qualitative portion (“Describe how your experiences facing microaggressions in the surgical workplace has effected your professional development in the field”) was not meant to be robust, three themes were identified: negative experiences due to perceptions and/or stereotypes; limited perceived or real opportunities for advancement and subsequent instances of impaired psychological safety. Quotes have been added to illustrate findings.
and stereotypes about their appearance, race/ethnicity, and gender.
Participants described experiences of being perceived as incompetent due to their appearance and/or stereotypes associated with their racial/ethnic group or gender. One participant mentioned, “I had a lot of comments from patient’s families asking my age or asking about it in roundabout ways, by asking the duration of my education, Doogie Houser references…” Other participants mentioned having to fight against perceptions of Asian Americans as simply “good worker bees for white men” while some Black female identifying participants stated a hyperawareness of being portrayed “as having an attitude or [the] angry black woman.” Many participants have tried to combat these perceptions by changing their clothing style or manner of behavior e.g., changing how they stand or speak as well as even adjusting their choice of music in the operating room.
for advancement
Many participants mentioned experiences of being regarded as a junior member of the team, passed over for leadership positions or changing their attitudes about goals towards advancement. One participant mentioned being “frequently tasked with service-oriented roles rather than leadership roles” as well as frustrations regarding their opinion not considered in their field of expertise. Another participant stated that the lack of Asian men considered for promotion in leadership was depressing and part of their “daily existential crisis.” Some participants have accepted a sense of hopelessness regarding advancement stating that they “may have reached a ceiling because of [their] ethnicity.”
psychological safety due to past experiences with microaggressions.
As a consequence of past experiences with microaggressions, participants have mentioned needing to adjust to a poor surgical culture—often to the expense of their mental and emotional well-being and safety. One participant stated having to keep “looking around […] all the time instead of enjoying the moment.” Another participant described the continuation of emotional strain from the workplace to their personal life. Others brought up the persistent feeling of frustration, detachment, and burnout due to ongoing harassment and being passed over despite hard work. To combat the psychological injury from microaggressions, one participant mentioned that you “know it is time to take a vacation and recharge” when it “eat[s] away at you slowly and manifests as anger.”
This current study broadens our understanding of microaggressions in the surgical workplace by examining the relationship and demonstrating a significant association between experienced microaggressions and trauma symptoms. Results indicated a high prevalence of experienced microaggressions across racial and gender identifiers, but the frequency of associated trauma symptoms were significantly higher for those who identified as Asian/Asian-American, Black/African American and Hispanic/Latino. Due to microaggressions, these racial minorities are experiencing symptoms associated with psychological trauma i.e., increased anxiety, avoidance, and worry. Additionally, it adds to the literature on race- based traumatic stress by highlighting the traumatic impact of cumulative racial discrimination in a population (Asian/Asian-American surgeons) typically under-researched in discrimination work. Furthermore, this study also identified significant associations between racial microaggressions and self-reported experiences of burnout e.g., talking about work negatively and needing more time to relax and feel better. Racial/ethnic minority respondents also showed reduced career satisfaction and felt that they needed to work harder to be viewed as competent and gain patient confidence. This is consistent with previous studies and helps to explain literature concerning increased attrition rates among non-white surgical trainees and academic surgeons as well as increased reported burnout in physicians who have experienced racial/ethnic microaggressions.^6,10^
While burnout is multifactorial, it has been defined as a triad of emotional exhaustion, depersonalization and a decreased sense of personal achievement.^11^ Even if a particular surgeon or trainee does not explicitly identify their experience of burnout, this study shows that racial microaggressions in the workplace contribute to a sense of emotional exhaustion and decreased sense of achievement i.e., putting in extra energy to be viewed as reaching a level of achievement. This study also demonstrated that racial minorities were more likely to change their verbal communication style e.g., speak in a deeper voice and provide more authoritative responses, to prevent future microaggressions. While there has been no explicit link between race and voice modulation, research has demonstrated that low sounding (deeper) vocalizations predict increased perceptions of physical dominance in male listeners.^12^
Furthermore, female surgeons also indicated needing to work harder to be viewed as a competent physician and to gain patient confidence. This concept was also validated behaviorally, with female surgeons more likely to cope and prevent future microaggressions by changing their physical appearance, verbal communication styles, non-verbal communication styles and spending more time with patients. These findings echo concerns from numerous studies that have shown that female surgeons have lower rates of career advancement, receive fewer referrals and suffer more professional consequences after surgical complications when compared to male counterparts.^13^ For female surgical residents, they are more likely to leave medicine early and not recommend the profession to other trainees or family members due to bias.^14^ While the proportion of female surgical residents has been increasing across surgical subspecialties, female residents have a 16% increased risk of undergoing attrition compared to their male counterparts.^10^
Under the broader category of racial and gender-based discrimination, microaggressions can be seen as pervasive and a stressor to the mental and emotional health of surgeons and surgical residents. Previous bodies of research have demonstrated the association between a lack of racial diversity in medicine and the propagation of healthcare disparities as well as the benefits of racially concordant medical care e.g., increased access and improved communication.^15^ As in other medical disciplines, racial diversity is lacking in surgery and negative experiences in surgical training and practice may contribute to a persistent lack of racial/ethnic minorities in surgery. The added burden of having to navigate and find ways to combat microaggressions further increases the difficult nature of graduate medical education and surgical practice.^15^ These challenges may contribute to the higher rates of withdrawal from racial/ethnic minority trainees and the eventual absence of mentors within surgery.
There are limitations that should be considered in the interpretation of these findings. One limitation of this study comes with the recruitment of surgeons and residents through academic surgical societies; in sending the survey via email listservs, an exact response rate is difficult to measure as well as distribution was done through third-party email coordinators. Given the nation-wide reach of these surgical societies, for some of our findings, our sample size may be too small to detect differences. The authors also acknowledge the limitations that come with sampling from only racial/ethnic-oriented professional surgical societies, specifically a lack of information regarding the experiences of racial majority individuals. But given the lack of racial/ethnic minority surgeons, we wanted to ensure a relatively balanced sample distribution. Another potential limitation that exists is the reliance on self-reported measures, which are subject to report bias as participants may under report experiences of microaggressions. Future research is needed to fully explore the ways in which microaggressions experienced by racial/ethnic minority surgeons and surgical trainees translate into trauma symptoms in order to inform and shape decisions regarding effective interventions.
While there has been a growing awareness of the impact of racial and gender-based microaggressions on practicing surgeons and surgical residents, this study is one of the first to explore the relationship between microaggressions and traumatic stress in surgery. Our findings demonstrate that, due to microaggressions, racial/ethnic minority surgeons and surgical trainees are experiencing trauma symptoms at significantly higher rates compared to their white counterparts. But awareness and recognition are not enough; as surgery is becoming more diverse, it is imperative for the field to begin the process of breaking the cumulative stressful effects of microaggressions by preventing microaggressions and supporting affected individuals. A strategy to counter microaggressions warrants an intentional and multidimensional approach; one that requires surgical leadership and national organizations to commit to a cultural change, meaningful diversity training, mentorship and sponsorship as well as individual efforts to reflect on personal biases and actively question and counter stereotypes.^16^ Committing to a culture of inclusivity and equity is more than just an annual climate survey or the creation of a diversity committee. To achieve change, there must be an investment in resources and staff to perform internal measures, adopt transparent policies and procedures as well as implement safe reporting mechanisms.^17^ To fully understand the impact of microaggressions and race-based traumatic stress, it is necessary to employ a system-focused perspective to ensure a more equitable future.