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Background

Our profession needs more training on equity, diversity, inclusivity, indigeneity, and accessibility (EDIIA). A key topic of EDIIA instruction is microaggressions, which are subtle snubs or insults directed towards historically stigmatized or excluded groups that implicitly communicate hostility, disrespect and devaluation [1]. Individuals can experience microaggressions related to race, ethnicity, (dis)ability, gender identity, sexual orientation, age, class, education, profession, and more. Whether they are intentional or accidental, microaggressions are extremely common in medicine [2, 3].

In emergency medicine (EM), gender-related microaggressions are common. Recent studies demonstrate that despite equivalent or equal competence, nurses judge female EM residents as having lower ability and work ethic than their male counterparts [4], and that EM attendings provide lower evaluations of resident milestone attainment in female residents, resulting in a gender gap surrounding evaluations and progression [5]. Knowing that microaggressions affect performance, it is important to teach learners to address them. We designed an immersive curricular intervention to address gendered microaggressions using Kern’s model [6].

Purpose and rationale

We created a session for EM residents using simulation and discussion/didactics to teach allyship and tools for responding to microaggressions. Residents participated in a simulation scenario with embedded gender-related microaggressions, followed by a facilitated reflection and discussion on addressing these situations as an individual and as a bystander/ally.

Description

A need to address gender-related microaggressions through formal teaching activities was identified by a local “Women in EM” interest group comprised of residents and faculty. Residents considered simulation the best format and wrote a pilot simulation case [7, Appendix 1]. The specific microaggressions embedded in the case included assumption of inferiority (consultant questions female physician’s management), sexual objectification (patient comments on female physician’s appearance) and invisibility (paramedic provides handover to male nurse, ignoring female physician).

Faculty worked with the resident EDIIA lead to co-create a pilot session using this simulation case. A local EDIIA content expert provided further frameworks and tools. The overall goal was for residents to reflect on how it feels to be subject to, or witness, gendered microaggressions. Key objectives were recognizing situations where residents can intervene as an ally, and empowering residents with tools and frameworks.

Pre-readings were distributed to prime residents on real-life examples of microaggressions in medicine (Refs. [1,2,3, 8]).

A resident volunteer was recruited and pre-briefed on the case and the embedded microaggressions. For simplicity in launching this pilot, the patient actor was a session facilitator. Several other resident volunteers were asked to play allied health professional roles during the simulation.

All attendees received traditional simulation pre-briefing followed by discussions on safe, brave, and accountable spaces.

This pilot session used non-traditional simulation and debriefing experiences. The simulation scenario served as an immersive experience for trainees and triggered a robust reactions phase of debriefing. To avoid the debriefing’s analysis phase leading to the sensation of “calling out” [9] those involved, we opted to “call in” [9] by using participant reactions as a launching point for further reflection and discussion around allyship and microaggressions. Toolkits for addressing microaggressions were discussed, including O3 [10], Open The Front Door [2], the 5 D’s [11] or Call In/Call Out [9] which can be found in Table 1.

Table 1 Toolkits to address microaggressions
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After this session, an anonymous online qualitative survey was emailed to participants to collect feedback and assess key takeaways. Ten residents attended the session; the survey had a 100% response rate. The responses were overwhelmingly positive, including reassurance in knowing that they were not alone in their experiences of microaggressions. Suggestions for improvement included breaking up into smaller groups to involve those who may have a “quieter” voice, as well as hiring a patient actor to improve realism. Interest was expressed for a future session on responding to microaggressions related to race and sexual orientation. Key take-aways highlighted by participants included one-liners to respond with in difficult situations, the “5 D's”, recognizing opportunities for allyship, and asking coworkers before defending them if the situation allows.

Discussion

This pilot session on microaggressions was one facet of introducing formal EDIIA curricular content. As with all EDIIA work, we acknowledge that we have unconscious biases and perhaps these affected the session. While there were both male and female facilitators of this session, all openly identify as cisgender. Although we chose to start with gendered microaggressions, we recognize that highlighting a single category of microaggressions imperfectly addresses intersectionality.

It is important to highlight that individual experiences of microaggressions, discrimination, verbal harassment, and sexual assault were disclosed by residents. By fostering a safe space to share personal stories, this session emphasized that facilitators need familiarity with EDIIA and Trauma-Informed Practice to avoid inadvertently causing harm to residents by perpetuating problematic viewpoints. However, we must not wait until we have expert-only facilitators, or we will have waited too long to address society’s call to action. We should highlight that, aside from the resident EDIIA lead, none of our facilitators had any specialized training in EDIIA. We feel this is reflective of most departments. However, our facilitators feel passionately about addressing inequities, have lived experience with microaggressions, and were willing to engage in brave and open conversation.

After this successful pilot, next steps include creating sessions to address further microaggressions. As we build on these experiences, and more faculty embrace brave spaces, we envision one day being able to embed these conversations into simulation sessions offered as a regular and ongoing part of the curriculum. First, we must build a critical mass of facilitators who can engage in these conversations on a regular basis.

Summary

We created a targeted curriculum innovation to address gendered microaggressions in EM as part of a plan to teach EDIIA principles. Feedback from participants on this immersive simulation and reflection session was overwhelmingly positive and included practice-changing reflection. Critical elements for success are the use of pre-reading to prime learners, a pre-briefing that focuses on the definitions of safe, brave, and accountable spaces, and facilitators familiar with EDIIA principles and willing to engage in brave spaces. Others trying to integrate gendered microaggression training into their EDIIA curricula could model our innovation.