Microaggressions are a common experience for medical students and are associated with a positive screening for depression, lower medical school satisfaction, and a higher risk of contemplating transfer or withdrawal from medical school. Female students, Black students, and students with other minoritized racial identities are more likely to experience microaggressions, which are defined as intentional or unintentional verbal, nonverbal, and environmental slights that communicate hostile, derogatory, or negative messages to the recipient based on their marginalized group membership.
These are among the concerning findings of a recent study, The Association of Microaggressions with Depressive Symptoms and Institutional Satisfaction Among a National Cohort of Medical Students, published in the Journal of General Internal Medicine (JGIM) on April 30, 2021, by Nientara Anderson, MD, MHS and Dowin Boatright, MD, MBA, MHS from Yale School of Medicine (YSM), along with a team of collaborators. The findings of this study have important implications for students’ mental health and the diversity of medical schools and the medical profession.
While there is substantial research on the impact of overt discrimination on medical trainees’ mental health and on how discrimination affects physicians’ job satisfaction, Boatright explains "we don't have much data on the prevalence of microaggressions in academic medicine. We wanted to better understand students' experience with microaggressions and how this exposure influenced student wellness and medical school satisfaction."
Their study, involving 759 students from 120 medical schools, is the largest to date of the experiences, frequency, and effects of microaggressions on a national sample of US medical students.
The study was conducted by distributing a survey to listservs of the Student National Medical Association, the Latino Medical Student Association, the Association of Native American Medical Students, and the Asian Pacific American Medical Student Association, between July 2016 and October 2017. Survey recipients were free to forward it to peers. Respondents were 31.4% white, 29.2% Black, 23.6% Asian, and 12% Hispanic. Black and Hispanic students were significantly over-represented in the sample, as they comprise 7.3% and 6.5% respectively of US medical school students. Additionally, 69.2% of study participants identified as women, compared to 50.5% of the US medical school population.
Almost 99% of respondents reported experiencing at least one microaggression in medical school, and nearly 34% reported experiencing a microaggression almost daily. Sixty-one percent experienced at least one microaggression a week. Respondents cited their gender (64.4%), race/ethnicity (60.5%) and age (40.9%) as the most common reasons for these experiences. Students identifying as Black, Asian, Multiracial, and female were the most likely to have experienced microaggressions at least weekly.
The study also found that 14.2% of respondents had a positive screen for depression, and as the frequency of microaggressions increased, the likelihood of a positive depression screen also increased in a dose-response relationship.
Additionally, the participants who experienced microaggressions at least weekly were less satisfied with medical school than those with fewer experiences. For example, they were less likely to recommend their medical school to friends and less likely to want to stay at their institution for residency, while they were significantly more likely to consider medical school transfer and withdrawal.
Another finding is that higher exposure to microaggressions was associated with decreased satisfaction with their institution’s climate. Higher exposure respondents were less likely to believe their school was proactive in preventing microaggressions and more likely to view microaggressions as a normal part of medical school culture. Regardless of microaggression exposure, the majority of all respondents did not think their school had adequate teaching about implicit bias.
Given that medical students who identified as female, Black, or belonging to other minoritized ethnic groups were the most likely to experience a high frequency of microaggressions, this data suggests that microaggressions may create a substantial psychic burden and hostile educational environment for medical students from historically oppressed groups.
Nientara Anderson, MD, MHS
Reflecting on this data, Anderson states, “given that medical students who identified as female, Black, or belonging to other minoritized ethnic groups were the most likely to experience a high frequency of microaggressions, this data suggests that microaggressions may create a substantial psychic burden and hostile educational environment for medical students from historically oppressed groups."
The authors emphasize the significant implications of their findings for academic medical centers, national medical societies, governing bodies of undergraduate medical education, and advocates focused on combating bias and discrimination in medicine.
For example, the prevalence and frequency of microaggressions suggests microaggressions may be supplanting more pronounced acts of bias— “as social mores change, biases such as racism evolve and manifest in more socially acceptable, but similarly harmful ways,” the authors state in their study. They therefore argue that institutions trying to address bias towards medical students need to look at microaggressions, in addition to overt discrimination, when measuring institutional climate.
Another implication: the dose-response association between microaggression exposure and a positive screening for depression suggests microaggressions may have a significant influence on medical students’ mental health, important information for those working to address the alarmingly high rates of depression, suicidal ideation, and burnout among medical students. The authors point out that addressing microaggressions is not part of many medical schools’ wellness interventions and suggest this should change.
The results on institutional satisfaction also are relevant to the recruitment and retention of diverse medical students and, by extension, have broader implications for physician workforce diversity. The results also could impact accreditation, given the requirements to work to attract and retain diverse students.
Finally, the authors posit that the study suggests value in re-evaluating the word “microaggression.” Research shows that reviewers of reports of discriminatory behavior are less likely to call for mitigation of discriminatory acts associated with implicit rather than explicit bias. Accordingly, the authors believe the term microaggression may “unwittingly make medical schools less likely to take microaggressions seriously,” and suggest instead using specific terms such as racism and sexism. Moreover, they believe the qualifier “micro” “reflects the dominant-group perpetrator’s perception of the supposed innocuousness of microaggressions rather than the victim’s perspective” when, as their study shows, such behavior has a serious impact on victims.
Along with Anderson and Boatright, the multi-institutional collaborative study was co-authored by Emmanuella Ngozi Asabor, Mphil; Amanda Lynn Hernandez, MD, PhD; Max Jordan Nguemeni Tiako, MS; Tara M. Rizzo, MPH; Darin Latimore, MD; and Marcella Nunez-Smith, MD, MHS from YSM, as well as Elle Lett, MBiostat; Christen Johnson, MD, MPH; and Roberto E. Montenegro, MD, PhD.