Published April 27, 2021
Student Admissions Ambassador, Midwestern University Arizona College of Osteopathic Medicine
President, Asian Pacific American Medical Student Association
Associate Professor (Breast Imaging), Vice Chair for Education, Radiology Residency Program Director University of Massachusetts Medical School/UMass Memorial Medical Center
Associate Professor (Clinical Radiology and Otolaryngology), Director of Head and Neck Imaging,
Vice Chair of Education, Radiology Residency Program Director MedStar Georgetown University Hospital
Professor of Radiology and Radiological Services, Radiology
Vice Chair of Education Vanderbilt University Medical Center
Resident Physician, Radiology
Harvard Medical School/Massachusetts General Hospital
Chair, ARRS Diversity, Equity, and Inclusion Committee
Associate Clinical Professor (Neuroradiology)
Icahn School of Medicine at Mount Sinai/Mount Sinai West Hospital
Advisor, ACGME Office of Diversity and Inclusion
Proper communication in a health care setting is vital to delivering quality care to patients. Without it, the quality of health care would be compromised, leading to greater overhead costs and, ultimately, negative patient outcomes. It is well-established that good communication requires basic health care literacy, intercultural competence, and language translation, when needed. But what about communication between providers? Towards nurses? Medical technicians? Medical students? It is easy to forget that patient care is a team effort, which entails cooperativity. While direct aggressive behavior is seldomly seen nowadays, subtle negative attitudes are often projected into biased mannerisms and come across as indignant, derogatory comments. Both these behaviors are unprofessional, but the latter is witnessed much more—to which it seems many prefer to turn a blind eye. Eventually, it becomes the status quo. Such comments sting for a moment but can be ignored; however, repetitive comments are damaging and lead to self-confidence issues and mental health conditions, such as anxiety and depression. These are microaggressions. It is imperative that microaggressions are addressed promptly and professionally to avoid escalating tension in the health care team.
A microaggression is a comment or action that subtly and often unconsciously or unintentionally expresses a prejudiced attitude toward a member of a marginalized group. These types of comments are usually due to underlying implicit bias. Microaggressions are not just harmless side comments; they have significant psychological and physical consequences to the recipient. Microaggressions can be both verbal or nonverbal. Examples of verbal microaggressions include one attending saying to another attending, who is Asian in appearance (but is actually Korean): “We have a Chinese patient and need an interpreter. You speak Chinese, right?” Or a male saying to a female radiologist: “You are too pretty to be a radiologist and sit in the dark. You should be in pediatrics.” Nonverbal microaggressions could be a store owner following a black customer around the store, or a manager ignoring an idea when a female employee presents it, then praising a male employee for saying the same thing. When such examples are experienced as isolated events, they can cause the recipient to become angry or frustrated. When someone is the recipient of microaggressions repeatedly, these events become dehumanizing and can lead to anxiety, lack of self-worth, depression, as well as physical distress.
Difficult conversations at work have additional complexities because of factors such as rank, seniority, perceptions of power within the organization, and perceived threats to work identity, which is often more deliberately crafted than the identity of our private lives. Difficult conversations can be unsuccessful because we bring assumptions and narratives about the intentions of others to the table, without being mindful of the fact that these assumptions are fabricated from our experiences in the world.
Mindfulness is the practice of bringing your attention to the present moment without judgment. Mindfulness is a skill that, when learned, will hopefully lead to equanimity and the ability to respond, rather than react1Harris D. 10% Happier: How I Tamed the Voice in My Head, Reduced Stress Without Losing My Edge, and Found Self-Help That Actually Works—A True Story. It Books, 2014. Mindfulness is a key element in using the Most Respectful Interpretation (MRI) method of responding to others. Instead of automatic negative assumptions about someone else’s actions or intentions, you are deliberately mindful, assuming the most generous intentions for that person. Bringing mindfulness to a difficult conversation allows you to arrive with compassion and empathy, but without judgment. Doing this will make the other person less defensive and more open to deeper and richer conversation. The threats to identity and ego are diminished, and you allow space for someone else’s perspective to be true.
A difficult conversation involves anything that is uncomfortable to talk about. Examples include confronting a supervisor making suggestive comments, a colleague unaware of their microaggressions, or coworkers with a conflict. Three questions to ask when contemplating a difficult conversation are:
- What do I really want?
- What do I want for others?
- What do I want for the relationship?2Stone D, Patton B, Heen S. Difficult Conversations: How to Discuss What Matters Most. Illustrated, Penguin Books, 2010
There is a tendency to avoid difficult conversations because they can make us feel uncomfortable, vulnerable, and anxious about challenging responses. However, unaddressed issues often simmer and can eventually erupt into an emotionally charged confrontation focused on blame and assumed intentions. Approaches to handling a difficult conversation well include shifting to a learning/curiosity stance, disentangling impact from intention, and moving from a blame frame to understanding contributions to the problem from both sides. Effective conversation skills include inquiry, active listening, paraphrasing, acknowledgement, reframing, and contrasting3Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations: Tools for Talking When Stakes Are High, 2nd ed. McGraw-Hill Education, 2011
Ho CP, Chong A, Narayan A, et al. Mitigating Asian American bias and xenophobia in response to the coronavirus pandemic: how you can be an upstander. J Am Coll Radiol 2020; 17:1692–1694
DeBenedectis CM, Jay AK, Milburn J, Yee J, Kagetsu NJ. Microaggression in radiology. J Am Coll Radiol 2019; 16:1218–1219. The goal is to move from a difficult conversation to a learning conversation with mutual understanding and purpose.
Microaggressions can often be addressed with curiosity. For example, one could say, “I’m sorry, could you repeat what you just said? I’m not sure I understood what you said.”
The timing of one’s intervention should be considered. We should consider “calling in” in private rather than “calling out” in public.
New or renewed attention on how workplace and institutional culture and behaviors impact marginalized communities can be challenging. Most people do not receive training throughout their careers on these topics, and the cultural or societal implications they may bring up can be challenging. As education is a central pillar to the ARRS, it was determined necessary to establish a Diversity, Equity, and Inclusion (DEI) committee to help provide teaching and resources to members and the public on relevant topics.
The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.