Background: Microaggressions are subtle, indirect words or actions that create hostility, communicate disrespect, or imply a sense of exclusion. Over time, these microaggressions can contribute to physician burn-out and negatively impact well-being. Although studies have found that a majority of physicians have been subjected to these deleterious comments by patients, many physicians have never received training on how to address these situations. This is in part because such training is difficult–-simulation with practice and feedback is necessary to train these complicated skills.

Purpose: We sought to identify how many of our trainees had experienced or witnessed microaggressions. We then created a curriculum and simulation exercise to help them address these in real-time.

Description: A simulation workshop was created for Internal Medicine residents as part of their didactic curriculum. An online pre-survey was administered weeks prior to the workshop to gauge the prevalence of microaggressions that they had observed over the course of their training, their beliefs regarding how best to address these behaviors, and their confidence to do so. Residents participated in four unique standardized patient scenarios, enabling them to develop their skills. Although planned as an in-person workshop at the Simulation Center, due to Covid-19, this was transitioned to an online simulation format. A survey was administered to residents after completion of the workshop, again assessing their confidence addressing microaggressions. We had a 57% response rate (85/150) for the pre-survey. Gender-related microaggressions were reported by 65% (18% reported frequent occurrences), ethnic microaggressions by 60% (7% reported frequent occurrences), and class-related microaggressions by 60% (5% reported frequent occurrences). Only 7% of trainees reported being very confident to manage microaggressions personally experienced, and only 6% felt very confident managing observed microaggressions. Females were more likely to report having experienced gender-related microaggressions, Mann Whitney U = 244, N = 85 (50 males, 35 females), p < .001. Similarly, URG (Black/Hispanic) trainees were more likely to report ethnic-related microaggressions, Mann Whitney U = 283, N = 85 (15 URG, 70 Others), p = .003. After the workshop, 65% of participants said that they would address microaggressions they experienced (up from 53%), and 83% would address ones they witnessed (up from 75%). Trainees also felt more confident in addressing these. Sample qualitative comments from the post-survey included: a) “I learned…how to nip in the bud small things like a patient calling you ‘honey.’”, b) “I have learned that setting boundaries is okay/encouraged. While trying to find that fine line between not straining the patient/physician relationship and respecting ourselves will likely still be something I need to develop, I feel more empowered to stand up for myself when appropriate.”

Conclusions: Our project demonstrates an innovative way to address an important problem faced by our trainees using simulation. A majority of our trainees have observed and/or experienced microaggressions, and our simulation-based training was designed to better empower them to manage these behaviors. Specifically, using a practice-and-feedback approach over several vignettes in small teams with trained faculty facilitators, residents learned strategies for communicating when confronted with microaggressions.

IMAGE 1: Figure 1. Presurvey results showing perpetuators of microaggressions and who respondents considered responsible for addressing microaggressions

IMAGE 2: Figure 2. After the simulation session, respondents indicated that they were more likely to address microaggressions, and they felt more confident doing so.