Microaggressions in anesthesiology and critical care: individual and institutional approaches to change

Microaggressions are subtle verbal or nonverbal insults that convey derogatory and negative messages to and about people who belong to oppressed groups. Microaggressions reflect structurally and historically perpetuated societal values, which advantage some groups of people by considering them to be inherently more worthy than others, while simultaneously disadvantaging others. While microaggressions may seem innocuous and are often unintentional, they cause tangible harm. Microaggressions are commonly experienced by physicians and learners working in perioperative and critical care contexts and are often not adequately addressed, for a multitude of reasons, including witnesses not knowing how to respond. In this narrative review, we provide examples of microaggressions towards physicians and learners working in anesthesia and critical care, and offer individual and institutional approaches to managing such incidents. Concepts of privilege and power are introduced to ground interpersonal interventions within the larger context of systemic discrimination, and to encourage anesthesia and critical care physicians to contribute to systemic solutions.

Abstract Microaggressions are subtle verbal or nonverbal insults that convey derogatory and negative messages to and about people who belong to oppressed groups. Microaggressions reflect structurally and historically perpetuated societal values, which advantage some groups of people by considering them to be inherently more worthy than others, while simultaneously disadvantaging others. While microaggressions may seem innocuous and are often unintentional, they cause tangible harm. Microaggressions are commonly experienced by physicians and learners working in perioperative and critical care contexts and are often not adequately addressed, for a multitude of reasons, including witnesses not knowing how to respond. In this narrative review, we provide examples of microaggressions towards physicians and learners working in anesthesia and critical care, and offer individual and institutional approaches to managing such incidents. Concepts of privilege and power are introduced to ground interpersonal interventions within the larger context of systemic discrimination, and to encourage anesthesia and critical care physicians to contribute to systemic solutions.
Keywords allyship Á equity Á microaggressions Á privilege Á racism ''You don't even have an accent.'' ''I won't try to pronounce your name because I'll get it wrong.'' ''This must be a tough specialty for a woman.'' ''You're pregnant again?'' ''You are being overly sensitive.'' Though most physicians believe themselves not to have biases, we all carry varying degrees of unconscious bias. 1 By definition, these biases influence us without our knowledge and despite our best intentions, 2 and affect our decisions and communication. 1 Indeed, it is often this lack of conscious ill intent on behalf of the perpetrator that make microaggressions so difficult to deal with. 3 The above are a few examples of microaggressions that we as anesthesia and critical care physicians have faced, witnessed, and perhaps unknowingly engaged in.
These are not rare instances; literature suggests that microaggressions towards physicians and physicianlearners are common. In surveys, approximately 70% of women in cardiothoracic anesthesia 4 and orthopedics report experiencing microaggressions. 5 Another survey of surgeons and anesthesiologists found that 91% had faced sexist microaggressions and 84% racial microaggressions. 6 The environments in which anesthesiologists and critical care physicians work-such as the operating room, intensive care unit, and birthing suite-are dynamic, complex, time-pressured, and stressful. 7 In these situations, not only are medical errors more likely but also implicit biases may be increased, 1,7 leading to more microaggressions.
While microaggressions from patients and their family members are frequent, physicians and trainees in perioperative and critical care environments also commonly face microaggressions from colleagues, including physicians, nurses, and other team members. [8][9][10] Studies also report that, among all women physicians, surgeons and anesthesiologists in particular experience bias and harassment. 4,11 A survey of women in cardiothoracic anesthesiology found that perpetrators of microaggressions were most often surgical and anesthesia faculty members (64.4% and 35.6%, respectively). 4 This paper is a narrative review of the literature on microaggressions towards physicians and medical learners. We contextualize microaggressions in the broader scope of systemic discrimination, give examples of how microaggressions may manifest in anesthesia and critical care, and offer individual and institutional approaches to preventing and managing such incidents. We draw upon Nixon's coin model of privilege 12 (Figure) to anchor suggested approaches to microaggressions within larger systems and concepts, including critical allyship. The authors, all anesthesiology and/or critical care clinicians from equity-seeking groups, recognize that a single approach or intervention is inadequate to tackle the manifestation of a systemic and pervasive problem. Our intent is to provide anesthesiology and critical care physicians who witness microaggressions, with a framework to respond in the moment, as well as an understanding of the roots of microaggressions in systemwide biases.

Defining the problem
Gianakos et al. define microaggressions as ''verbal, nonverbal and/or environmental slights, snubs, or insults that are intentional or unintentional, which convey hostile, derogatory, or otherwise negative messages to target persons based upon their membership in a structurally oppressed group.'' 5 Microaggressions can be subcategorized into microassaults, microinsults, and microinvalidations. 13 Microassaults are verbal or nonverbal expressions of biased attitudes towards minoritized groups, such as telling a racist joke and then saying, ''I was just joking.'' Microinsults are behaviours that express stereotypes or insensitivity that demean someone based on their identity, such as ''You don't seem gay.'' Microinvalidations exclude, negate, or nullify the perceptions of lived experiences of minoritized groups, such as ''When I look at you, I don't see colour.'' 13 While microaggressions may seem innocuous and are often unintentional, they cause tangible harm. Outcomes for health care workers who experience microaggressions include undermining their identity and belonging, avoidance of pursuit of a particular specialty, attrition from academic medicine or a specialty, lower self-esteem, reduced trust in colleagues, hypertension, poor sleep, and mental health conditions, including burnout, anxiety, depression, chronic stress, and increased risk of suicidal thoughts. 4,5,8,14 Surgeons and anesthesiologists who are targets of sexist microaggressions, as well as racial/ethnic minority women physicians who experience both sexist and racist microaggressions, are more likely to report burnout than White male colleagues are. 6 Further, conditions that affect physician health 15,16 and sense of belonging in the workplace have the potential to compromise patient care. The mental load required to process microaggressions, which by their nature tend to contain at least some degree of ambiguity of intent, reduces the available cognitive capacity of clinicians and trainees to conduct the work of providing care for patients. 17 The 2022 Canadian Anesthesiologists' Society Guidelines to the Practice of Anesthesia call for ''building of departments that are culturally safe and have appropriate mechanisms in place to deal with workplace harassment and bullying, with zero tolerance policies for discrimination based on gender, race, culture, sexuality, or disability.'' 18 To create a safe and healthy workplace and learning culture, microaggressions cannot be ignored, and those targeted must be supported. 5 Dr. Chester Pierce, a Black psychiatrist, coined the term ''racial microaggression'' in the context of anti-Black racism: ''The offensive mechanisms used against blacks often are innocuous. The cumulative weight of their neverending burden is the major ingredient in black-white interactions.'' 19

While
Pierce's original conceptualization of microaggressions focused on racial microaggressions, Sue et al. extended the concept, understanding the harms of insidious and repetitive negative interactions along axes of gender, sexual orientation, and disability. 13 Critics have suggested that the term microaggression minimizes the impact of chronic discrimination, and in particular, minimizes the role that systemic discrimination plays in these experiences. 20 While we unequivocally agree that systemic discrimination must be named for what it is, 21 we would note a few points regarding this critique. First, manifestations of systemic discrimination, whether they be racism, sexism, ableism, transphobia, homophobia, or others, take on many forms; specifying a subtype can be helpful in describing the experiences of people subjected to these forms of discrimination. Second, ''micro'' is not meant to minimize these experiences, but rather to emphasize the often subtle contexts in which they occur. In particular, ''micro'' reflects that these interactions are difficult to pin down, so that recipients of microaggressions experience doubt regarding their reactions 17 -a phenomenon less common with more overt forms of discrimination. Third, the invisible (to the perpetrator) nature of acts of aversive racism prevents perpetrators from realizing and confronting (a) their own complicity in creating psychological dilemmas and unsafe spaces for minoritized colleagues and learners, and (b) their role in contributing to disparities in employment, health care, and education. 13 Naming these acts as microaggressions can therefore draw attention to their existence and begin the conversation in addressing and preventing these instances.
Most people find it challenging to address microaggressions. 22 Barriers to addressing microaggressions include fear of overreacting or retaliation, negative impact on personal relationships and career, perceptions of lack of repercussions for the perpetrator, power differentials between learners and faculty, disillusionment, and lack of institutional reporting mechanisms. [23][24][25] Targets of microaggressions have to weigh the risks of being perceived as disruptive or overly sensitive against the need to address repeated experiences of harm, all while maintaining relationships and their own safety in an hierarchical and evaluative environment. Given the harm of microaggressions, particularly when chronic and cumulative, it is imperative to acquire skills to intervene in these situations. Training improves the ability of those witnessing microaggressions (bystanders) to respond, [25][26][27] and there is increasing recognition that antiracism and antidiscrimination training, and the creation of culturally safer spaces in health care, should be foundational. 28,29 Such training cannot be done in isolation. Self-reflection and an understanding of the systems of power and privilege that give rise to systemic discrimination, and thus to downstream microaggressions, are also necessary for sustained change.

Privilege, oppression, and the coin model
In Western society, 30 systemic discrimination is perpetuated through the Eurocentric worldview that White, cisgender, heterosexual, able-bodied men are the default ''normal'' model professional. 21 Groups considered ''normal'' have privilege, social power, and often institutional power. The definition of privilege in this context is unearned benefits or lack of barriers; and privilege is characteristically invisible to people who have it. 31 Institutional power is the ability or official authority to decide what is best for others, along with the power to determine access to resources and exercise control over others. 31 The combination of privilege, prejudice, and institutional power creates a system that discriminates against (oppresses) some groups and benefits (privileges) other groups. Privilege and oppression are the results of social systems, and are reinforced by binarized, normative hierarchies that categorize certain identities as superior and their supposed opposites as inferior. 31 A foundation in these ideas of privilege and oppression is necessary in understanding how and why to address microaggressions and create change at both interpersonal and systems levels.
To help ground the ''in the moment response'' framework we offer later in this paper, we use Nixon's coin model of privilege to help provide this foundation. 12 (Figure).
In the coin model, multiple metaphorical coins each represent a system of inequity (e.g., racism, ableism, sexism) with upper and lower faces of the coin representing privilege and oppression. In this model, each coin can be thought of as a category (i.e., socioeconomic class, ability, sexuality), with those who are advantaged by those norms occupying a place at the top of the coin, and disadvantaged individuals occupying a place at the bottom of the coin.
For example, a racialized, cisgender woman with economic privilege would find herself at the top of the coins of heterosexism and socioeconomic class, but at bottom of the coins of gender and race. As noted by Crenshaw's influential work on intersectionality, 32 individuals experience oppression and power through the lenses of multiple intersecting and interconnected identities. As such, individuals may find themselves on the top of some coins, and the bottom of others. It is imperative that we examine our privilege in relation to the multiple coins that exist and take action to intervene at both interpersonal and systems levels; Nixon refers to this as ''critical allyship.'' 12 As coins necessarily have two surfaces that are part of the same whole, the coin model encourages us to consider how systems of inequality interact to produce complex patterns of unearned disadvantage and advantage. The metaphor of multiple coins encourages us to recognize that there are systemic forces at play that privilege some social groups over others. When we view issues of discrimination as problems solely for those at the bottom of the coin, Nixon reminds us that our ''responses will ignore the complicity of the corollary groups who receive unearned and unfair advantage from these same structures.'' 12 It is crucial to accept that the system that gives unearned privilege to some groups is the same system that gives unearned disadvantage to others (those on the other side of the same coin).
We are using the coin model to highlight microaggressions as one of the symptoms of the existence of these ''coins.'' Some examples to illustrate how systems of inequity manifest as microaggressions are given in Table 1.
The coin model helps guide our work because, while people who experience microaggressions must certainly be supported, support is not enough. Unless we exercise critical allyship to examine and address the structures that perpetuate inequality in our own workplaces, the idea will be perpetuated that the people at the bottom of the coins are responsible for changing those systems themselves. This reinforces the existing hierarchies that have empowered people to commit microaggressions in the first place, and leave witnesses free of any sense of responsibility to intervene. 9 Those of us who find ourselves on the top of many coins have an ethical duty to our colleagues, learners, and patients to act.

Allyship and interpersonal intervention frameworks
Interpersonal interactions in which an individual intervenes in moments of discrimination are often the focus of calls to ''be an ally.'' 12 Allyship has been defined as an ''active, consistent, and arduous practice of unlearning and reevaluating in which a person of privilege seeks to operate in solidarity with a marginalized group of people.'' 33 Allyship and upstanding require practice and should be viewed as skills that can be developed. An upstander (compared with a bystander) is ''a person [who] will use their privilege, to actively stand up in the fight against oppression by speaking up against the oppression (while being careful not to speak for the person or groups experiencing oppression).'' 34 Finding a way to be an upstander when witnessing a microaggression, without speaking over or on behalf of the person who is the target is not always straightforward. Determining the appropriate timing can also be challenging. While egregious examples should be interrupted immediately, this often doesn't occur, as witnesses prefer to offer support to the victim privately after the interaction. This approach is generally inadequate, particularly when the exchange occurred in public such as a meeting or clinical setting, because the harm is not only the actual interaction but also the silence of witnesses. 3 That said, addressing a microaggression briefly in the moment, and offering further discussion with the perpetrator at a later time may be a reasonable strategy in some contexts. Notably, while some frameworks for intervention prioritize the recipient's perspective of a microaggression in determining how it should be addressed, it can also be helpful for witnesses to address an incident on a systemic level without requiring targets to invest further energy in the incident. 23 Several frameworks have been proposed to support clinicians and medical learners in building skills to address microaggressions in the moment. These are often focused on particular circumstances in which microaggressions originate from patients or family members, colleagues, or those in positions of power (and evaluation). The general principles of these frameworks involve cultivating a degree of curiosity and openness in responding to the behaviour or statement, along with an expression of how the witness/ recipient may have perceived the microaggression and a suggestion of how to move forward. 16,23,27,29,35 The framework we have selected for the examples we provide in this paper is the ''observe, why, think, feel, desire'' (OWTFD) framework 35 (Table 2). It was developed to support individuals in intervening, with an emphasis on increasing their confidence and ability to respond to microaggressions.
We favour the OWFTD framework for a number of reasons. First, it integrates factual observations and emotional responses. The role of emotional discomfort in successful conversations about discrimination cannot be minimized. Thus, a framework that acknowledges emotional responses and supports those involved in navigating their own and others' reactions is useful. Second, the OWTFD framework uses the concept of allyship, which can be applied at a systems level and interpersonally. Third, while the framework focuses on race and ethnicity, training using this framework increases comfort in initiating and having discussions on other diversity-related topics. 35 Finally, the framework emphasizes that response to a microaggression does not have to be confrontational. 3 In Table 3, we provide an example of racial microaggressions in critical care and anesthesia practice, how the OWTFD framework can be applied, and how systems level change may be enacted. In the Electronic Supplementary Material eTable, we expand this to other types of microaggressions. We strongly encourage readers to reflect on the content in these tables and build skills to respond when similar microaggressions occur in their own contexts.

System-level interventions and the importance of leadership
While frameworks like OWTFD-which focus on a given microaggression and the individuals at the delivering and receiving ends-are helpful, it is critical to frame these interventions as part of a wider antidiscrimination strategy.
Literature on workplace discrimination has underscored the necessity of policies, anonymous reporting systems, and accountability for perpetrators, as well as frameworks for individual intervention. 26,36,37 It is also crucial that the groups creating these policies centre the leadership of people with lived experiences of discrimination. This means leaders must listen with humility and curiosity to those who have experienced discrimination and ensure that whatever solutions are created are acceptable to those with this lived experience. One example of an institutional policy which includes many of the above elements is the Mayo Clinic's SAFER model for responding to bias incidents. 37 Policies alone, however, will not change willingness to report-institutional culture change is also necessary. While culture change is a complex topic, the brief recommendations below may support the beginnings of change in a given institution.
While diverse recruitment has historically been emphasized, organizations must endeavour to recruit and retain Black people, Indigenous people, people of colour, lesbian, gay, bisexual, trans, queer, Two-Spirit and intersex (LGBTQ2SI?) people, and people living with disabilities, including at a leadership level. Cluster hires-hiring a number of people from an under-represented group vs one   person in isolation-should be considered. Advantages of this approach include better retention, increased representation, allyship and peer support communities, and greater comfort for individuals to speak up. 38 It can also be helpful to use a quality improvement lens, using a data-driven approach to measure implementation of interventions and frameworks. 36 Collecting diversity data, institutional metrics, and measuring stakeholder engagement can support implementation success. Embedding antiracism mandates within the institutional quality plan may help identify early barriers to implementation and decrease a ''one size fits all'' approach at a systemic level. 36 Leaders should rolemodel inclusive behaviours, nurture trust, and overcome reluctance to address these sometimes difficult conversations. Investing time and resources is vital to ensure the sustainable success of interventions. Equity, diversity, and inclusion experts, as well as those with lived experience, should be cocreators when designing and implementing systems change. 37 A full discussion of mechanisms for organizational systems level change is beyond the scope of this paper; however, we do offer some suggestions in Table 4. LGBTQ2SI? = lesbian, gay, bisexual, trans, queer, Two-Spirit and intersex

Conclusion
The first step towards change, whether institutional or personal, is assessing the current state of affairs. Physicians and trainees working in anesthesia and critical care continue to experience and perpetuate microaggressions that may not be ill-intentioned, but which nonetheless cause harm and potentially affect patient care. A key responsibility of all clinicians is to develop skills of allyship and upstanding and frame them as part of a lifelong journey of learning. In describing the concept of microaggressions and suggesting interventions at both interpersonal and systemic levels, we have provided readers with tools to recognize these interactionswhether witnessing or enacting them-along with the courage to intervene with curiosity and compassion. We encourage individuals to self-educate regarding the systemic harms and inequities faced by minoritized physicians and learners in our medical culture and to recognize and exercise their privilege to advocate for and create systemic change. Becoming aware of our privilege and being accountable for our own inevitable mistakes, while leveraging that privilege to work in solidarity with those most affected, is crucial. We must all contribute towards creating spaces where we are as comfortable and committed to speaking up regarding microaggressions and systems of inequity, as we are around other safety issues that impact clinician health and thus patient care.
Author contributions Saroo Sharda and Kat Butler contributed to all aspects of this manuscript, including conception and design, literature review, drafting and editing of the article. Maha Al-Mandhari contributed to literature review and editing the article. Geeta Mehta contributed to study conception and design, and drafting and editing of the article.
Disclosures Dr. Geeta Mehta is a Guest Editor of this month's Special Issue on Equity, Diversity, and Inclusion in Anesthesiology and Critical Care of the Canadian Journal of Anesthesia/Journal canadien d'anesthe´sie; she had no involvement in the handling of this manuscript.

Funding statement None.
Editorial responsibility This submission was handled by Dr. M. Ruth Graham, Editorial Board Member and Guest Editor, Canadian Journal of Anesthesia/Journal canadien d'anesthe´sie.