Coping With Microaggressions and Gaslighting in the Surgical Learning Environment

Authors: Daryn Nguyen, Nikhitha Thrikutam, Christie Bialowas

Abstract

Plastic surgery and plastic surgical training programs are institutions rife with rewards. However, these rewards can be tempered by general physical and psychosocial stressors inherent to a surgical specialty. Although progress has been made in addressing the physical demands of training, less attention is given to the psychosocial and interpersonal challenges faced by plastic surgeons and trainees. Two key stressors are microaggressions and gaslighting. Microaggressions are generally unintentional but highly impactful expressions of bias, whereas gaslighting involves deliberate psychological manipulation. The purpose of our article is to explain the influence of microaggressions and gaslighting on plastic surgery providers. Most importantly, we aim to provide a framework for recognizing and addressing them professionally.

INTRODUCTION

The structure of surgical education is steeped in hierarchical dynamics. This framework has been cited to reflect the complexity of medical and procedural knowledge surgical trainees are responsible for, the importance of ensuring patient safety, and the need for effective training and apprenticeship.^1^ Surgical trainees, including those in plastic surgery, are expected to navigate the demands of clinical practice while managing intricate psychosocial relationships, which can lead to burnout and compromised mental health.^2,3^

Cultivating a learning environment that mitigates psychological stressors for surgical trainees has become a goal of many plastic surgery residency programs.^4^ A 2019 study of plastic surgery trainees reported that 39.2% of plastic surgery residents experienced verbal abuse during their training, with 64.5% of harassment coming from supervising physicians.^5^ Unfortunately, the stress surgical trainees face in their education can be escalated when they experience differential treatment based on race, ethnicity, sex and gender, sexual orientation, and religion, which adds an extra layer of complexity for minority trainees. This ultimately can result in greater attrition rates among minority surgeons and leads to a less diverse plastic surgery workforce.

Microaggressions and gaslighting are 2 overlooked phenomena that complicate the learning relationship among surgical colleagues.^6,7^ A 2021 article by Fraser^8^ defines this experience of gaslighting between medical professionals as “medlighting” and describes how it contributes to power struggles, prejudice, and lack of confidence for those affected.

This discussion will give readers tools to identify microaggressions and gaslighting as well as be an effective bystander. It will also illustrate the complex relationships of how these phenomena interplay in interactions with patients, students, and colleagues in the surgical field.

DEFINING GASLIGHTING AND MICROAGGRESSIONS

What Are Microaggressions?

Microaggressions, including microassaults, microinvalidations, and microinsults, are various forms of subtle yet impactful expressions of bias and discrimination that pervade interpersonal interactions in the workplace verbally, behaviorally, and systemically.^9^

• Microassaults are the most overt and explicit form of microaggressions, often involving acts of bigotry, discrimination, and prejudice such as the casual use of slurs, name-calling, racial preferences, and expressions of homophobia. These acts undermine the dignity of marginalized individuals and make them feel unwanted.
• Microinvalidations involve the unintentional dismissal or negation of an individual’s lived experiences and identities. Expressions such as “I don’t see color” or “sexuality is a choice” and repeatedly using the wrong pronouns after numerous corrections for a transgender or gender-diverse individual are invalidating and leave individuals feeling invisible and frustrated.
• Microinsults target an individual’s heritage, background, or cultural identity. Statements like “You sound white” or “You’re pretty for a Black girl” are demeaning and leave individuals questioning their sense of self-worth and cultivate feelings of otherness.

Microaggressions are often unintentional reflections of implicit biases and societal conditioning. As a result, people outside of minority groups may be unaware of them. Unlike gaslighting, which involves deliberate manipulation, microaggressions can go unnoticed by both the perpetrator and the recepient.^9^ In the workplace, they undermine self-worth, affect mental health, and perpetuate power dynamics that create hostility and fear of retaliation.^10^ Although federal and institutional policies address overt discrimination and prejudice, microaggressions remain covert and legally unprotected. Though an attending’s comments may not directly hinder a resident’s education, they are mentally taxing and contribute to burnout over time.

What Is Gaslighting?

Gaslighting is a form of psychological manipulation wherein individuals in positions or pseudopositions of authority sow seeds of doubt in their victims, causing them to question their own perception of reality.

In essence, gaslighting is a form of bullying and sometimes retaliation, where the perpetrator undermines the victim’s sense of self. Abramson^11^ defined a gaslighter as “someone who aims to destroy the possibility of disagreement by so radically undermining another person that [he/she/they] have nowhere left to stand from which to disagree.” Though gaslighters are often people of authority and trust, they can also be people who self-assert into higher positions. Not unexpectedly, the hierarchical structure of surgery creates an environment where gaslighting is free to thrive if not properly identified and checked.^12^

Gaslighting often unfolds in stages, starting with an idealization stage where interactions seem normal but are intermixed with vague complaints and subtle criticisms. This progresses to the devaluation stage, which is marked by accusations, fault-finding, and baseless complaints. The victim begins to doubt themselves, becoming defensive in an effort to fix the situation. Finally, in the discarding stage, the victim internalizes the negative narrative imposed upon them, despite experiencing internal cognitive dissonance.^13^ In medical settings, gaslighters may be unaware of their harmful impacts, often justifying their behavior as being in the best interest of patient care.

Consider the following scenarios.

Scenario Microaggression

A female chief resident in a long white coat and a taller male medical student walk into a patient’s room for a postoperative check following a deep inferior epigastric perforator flap procedure. She introduces herself as “Dr. X” and the medical student as “medical student Y” and begins examining the patient. She notes significant venous congestion of the flap and informs the patient that a reoperation is necessary. She explains the procedure thoroughly and answers all of the patient’s questions. At the end of the conversation, the patient turns to the male medical student and asks, “So I really need to go back?” The medical student points to the female resident and says, “She is the doctor, please address your questions to her.” Despite this, the patient continues seeking clarification from him.

Explanation: This is a gender-based microaggression. Despite multiple clear indicators that the female resident is the senior provider—her long white coat, introduction as “Dr. X,” and leadership in the discussion—the patient directs questions to the male student. The patient’s behavior suggests that they have an implicit bias favoring male authority. In this scenario, the male medical student, acting as an effective bystander, appropriately redirects the patient to the female resident physician.

Scenario Gaslighting

A junior attending, up for promotion after 5 years of service, initially receives strong verbal support from the chief of their division through the evaluation process and begins the required paperwork. However, in a follow-up meeting, the senior chair of the department unexpectedly halts the process, citing the lack of “leadership presence.” When the junior attending states that in previous evaluations, they have been praised for their leadership skills, the chair states, “You must be misremembering those evaluations.” The junior attending leaves the meeting feeling disoriented and questioning their own memory.

Weeks later, the junior attending is accused of unprofessionalism, with unspecified “complaints” against them, which they are not allowed to view due to “confidentiality.” This lack of transparency leaves them feeling vulnerable and anxious. The chair mandates professional coaching, which the junior attending complies with and takes months to complete. Upon readdressing the promotion, the chair claims the surgical technicians harbor negative feelings toward them, despite the junior attending’s established positive rapport with the staff. This accusation further isolates the junior attending, leaving them to grapple with self-doubt and insecurity about their professional relationships.

Explanation: This is an example of gaslighting. The sudden denial of the promotion, followed by vague accusations and demands for remediation, reflects a manipulative pattern. As in all situations of gaslighting, the chair’s true motivations are unclear, heightening the sense of confusion that many victims of gaslighting experience. Rational disagreement occurs whenever a gaslighter has an explanation or a reason for anything that happens. The attending’s logical counterarguments and requests for evidence are ignored, leading them to internalize unfounded allegations and question their own reality.

Scenario Simultaneous Microaggression and Gaslighting

A female plastic surgeon performs a skin-only cosmetic procedure under spinal anesthesia. Postoperatively, the patient becomes hypotensive with headaches and upper extremity numbness, unresponsive to fluids and blood products. The male anesthesiologist administers Levophed, and after discontinuing the spinal, the patient stabilizes. Scans show no evidence of bleeding or hematoma.

The surgeon attributes the complication to the spinal, but when she tries to discuss this with the anesthesiologist, he dismisses her saying, “Honey, it was from the bleeding.” Despite no tachycardia, he attributes the issue to the fact the patient was wearing an abdominal binder and “orthostatic tachycardia.” When the head of the surgery center becomes involved, he supports the anesthesiologist. No matter what the surgeon tries to explain, she is stonewalled. She is then quoted an irrelevant article on abdominal binders and orthostatic tachycardia, which further confuses her, leading her to accept fault.

Explanation: This situation delineates both gaslighting and microaggression which occurred in tandem. The term “Honey” is an example of a microaggression that undermines and belittles the female surgeon’s authority, while her clinical judgement is dismissed despite objective medical evidence. Providing her with an unrelated article serves to further confuse and undermine her credibility, gaslighting her and leading her to doubt herself. Though no explicit sexism is evident, the subtle devaluation of her expertise suggests biases rooted in her gender. To understand this, it is helpful to question if the same judgment would be placed upon a nonminority individual. For instance, would a male surgeon have faced the same treatment in this scenario?

DISCUSSION

Tactics to Address Microaggressions and Gaslighting

Microaggressions and gaslighting are unfortunately abundant in academic medicine and the surgical learning environment. If unaddressed, individual events may become part of a broader pattern of behavior that persists within professional environments.^13^ Recognizing and addressing these behaviors requires collective action from bystanders, recipients, and sources of such behavior.

Effective bystander intervention is key to creating a safe surgical learning environment.^14^ Microaggressions tend to be based on implicit biases that many people are unaware still exist. For example, many male surgeons who respect their female colleagues may be unaware that female surgeons are being treated differently by the same surgical staff. Therefore, the first step to addressing microaggressions is simply to understand that they exist.

The Microaggressions Triangle Model, developed by Ackerman-Barger and Jacobs^15^ for application in nursing academia, is 1 possible tool to help identify and address microaggressions in medical settings. This model encourages thinking about microaggressions from 3 the recipient, the source, and the bystander (Fig. 1).

When an individual encounters microaggressions, they should identify what was intended, elicit their emotions, and take ACTION. These steps are outline

• Asking a clarifying question. For “Would you like me to go over the procedure again since he is a medical student?”
• Coming from curiosity, not judgment. For “Maybe when I introduced ourselves, you didn’t hear he was a medical student?”
• Telling what you observed in a factual way. For “I noticed that you called me ‘Honey.’ That is not appropriate.”
• Exploring impact. For “When you called me ‘Honey,’ you devalued my training as a surgeon.”
• Owning your own thoughts and feelings. For “It is difficult to be ignored as the physician after introducing myself as such.”
• Following next steps. For “I would be happy to explain more about this to you at a later date if you would like.”

During the heat of an interaction, it may be difficult for a victim to address the microaggression immediately. Revisiting the encounter later affords the recipient time to process and properly convey the emotional strain the microaggression caused.

Most people, unintentionally, have committed a microaggression during their lives. If you have been made aware that you committed one, instead of becoming defensive, this model^15^ suggests you ASSIST

• Acknowledging your bias. For Engage in self-directed learning. Once aware of your innate biases, you are more likely to recognize them and stop before you say something hurtful.
• Seeking feedback. If you are unsure of what you did wrong, ask for feedback. It takes bravery to speak up. Terms that may have meant one thing years ago may take on different meanings now.
• Saying sorry and meaning it. It is important to recognize someone else’s pain, but not burden the recipient to comfort you.
• Recognizing your impact, not intent. Acknowledge that even good intentions can have negative impacts.
• Thank the informant for the feedback.

Bystanders that witness gaslighting or microaggressions in action should ARISE and

• Awareness. Raise awareness of how a comment or action could have been perceived.
• Respond with empathy and avoid judgment. We all have implicit biases; it is necessary to understand that some people mean no harm.
• Inquire about the source. For “Why did you tell the surgeon she was wrong for attributing the complication to the spinal anesthesia?”
• Statements that start with “I.” For “I noticed that you interrupted her while she was trying to explain the cause of the patient’s symptoms.”
• Educate and engage. It is important to create a discrepancy between the source’s intent and the impact and demonstrate a willingness to educate about their harmful behaviors.

Bystanders can redirect the culture of the surgical workplace by serving as intermediaries between perpetrator and recipient. Because they are not emotionally targeted by the microaggression, they are equipped to intervene and educate the source about the negative impacts of their comments.^14^ In addition, as with any allyship, having someone there for support can greatly impact the well-being of the recipient.

For victims of gaslighting, however, it is often difficult to have bystander support due to the long-standing, and often discrete, relationship between the gaslighter and victim. If a victim becomes suspicious that they are being gaslit, they should remain focused on their emotions and self-validate their beliefs with affirmations. Escobar-Soler et al^16^ found that self-affirmation interventions are useful and effective strategies that allow victims of gaslighting to maintain a positive self-view in the face of social prejudice or identity threat.

When dealing with gaslighters, conversations should remain brief, straightforward, and objective, avoiding emotional engagement. Christensen and Evans-Murray^13^ recommended always requesting written documentation and never relying solely on the gaslighter’s word. Keeping a detailed record of interactions with time-stamped notes about the conversation will provide concrete evidence to address the gaslighter’s actions later. Additionally, having a witness at every meeting can help mediate conversations and reaffirm the victim’s experience.

Griffin and Clark^17^ found that after role-playing and rehearsing a confrontation, nurses were more effective at addressing workplace bullying. Therefore, unlike the Microaggressions Triangle Model which suggests taking an empathetic approach,^15^ confronting gaslighting may require reviewing and rehearsing the documented facts and leaving emotions out of the discussion, as the gaslighter has already caused the victim to question their own perceptions.

Finally, boundary setting is key to promoting physician wellness and formulating an effective exit plan.^18^ Because these interactions present victims with the choice to leave or stay, shifting the ultimatum onto the perpetrator empowers victims to reclaim their experiences. For instance, as in a gaslighting scenario like scenario 2, a possible response could “If my request to review the complaints against me continues to be denied, I cannot continue to grow in this environment.” This approach returns agency to the victim and offers a pathway to exit the toxic situation (Fig. 2).

Reminders for Maintaining a Nontoxic Surgical Workplace

Gaslighting is psychologically harmful. Although bystanders may not be able to directly intervene, they play a crucial role in helping victims recognize when they are being manipulated. Providers should be mindful of gaslighting and trust in their own value and abilities in such situations. Similarly, leaders, especially those in positions of power, must regularly assess their relationships with their juniors to ensure they foster a supportive, nontoxic environment.

With microaggressions, both the recipient and perpetrator must first acknowledge the incident. The recipient may not always respond immediately, and when confronted, the perpetrator should reflect on their biases and accept the fault rather than retaliate. Allyship entails lifelong learning and a commitment to recognizing and dismantling implicit biases, prejudices, stereotypes, and discriminatory practices. When victims offer perpetrators a chance for accountability, it is an act of care. No matter how antiracist, open-minded, or socially conscious an individual perceives themselves to be, a true ally must remain open to reviewing and unlearning hidden biases.

CONCLUSIONS

In the context of the surgical learning environment, gaslighting and microaggressions significantly contribute to feelings of inadequacy and self-doubt among plastic surgery trainees. These covert yet toxic behaviors can occur individually or simultaneously, often going unnoticed by others despite their significant impact on provider well-being. Although these interactions may seem isolated, they compound over time and reinforce power dynamics which negatively affect the learning experience for all trainees. Thus, being able to identify and address these stressors in practice is imperative to ensure the success of all plastic surgical trainees and practitioners.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.