Keywords
Key points
- •Implicit bias is an unconscious, automatic association that is either disadvantageous or favorable toward a person or group.
- •A microaggression is an intentional or unintentional statement or action that is perceived as discriminatory against a marginalized community, emanating as the product of bias.
- •Intersectionality is a concept that describes the exponential discrimination toward individuals who belong to more than one marginalized group, such as their racial and ethnic group and gender affiliation.
- •Implicit bias and microaggressions that negatively affect marginalized groups are ubiquitous in medicine (including Hand Surgery), which contribute to health and health care disparities for patients, as well as poor representation and burnout of marginalized groups within the medical community.
- •Although awareness is the first step to combating bias and microaggressions, active steps should be taken to minimize the negative effects of these phenomenon, starting with taking an implicit bias test to understand your own biases.
Introduction
Implicit bias and microaggressions are well-established principles in psychology supported by increasing amounts of empirical evidence.
1
,2
Researchers have investigated several different environments to reveal how implicit bias affects large-scale organizations, business ventures, and interpersonal relationships across a variety of settings.3
,4
Research on health care disparities has grown significantly in recent years, revealing consistent themes of inequalities in access to care and clinical outcomes associated with racial and ethnic minority groups, individuals of lower socioeconomic status, and residents of defined geographic areas.
5
,6
Within medicine, findings of disparities related to race, gender, and sexual orientation have also been found in the training environment. One of the main factors contributing to these findings is underlying bias.7
Societal standards have transformed biases in our daily lives to be less explicit, manifesting instead as implicit bias and microaggressions and other more subtle forms of discrimination and bias.8
Implicit bias has been shown to affect patient care decision making in physicians with correlation of levels of bias and lower quality of care.9
Hand Surgery, with an eclectic patient mix and a group of providers who are often working in multidisciplinary teams, also has evidence of disparities in patient care and education that is founded in bias. Academic societies are in the process of focusing on addressing these issues for practicing surgeons and trainees.
10
The authors aim to provide definitions and enhance awareness of implicit bias and microaggressions, highlight areas in Hand Surgery that manifest these issues, summarize relevant literature, and provide a practical evidence-based framework to guide surgeons in their practices.
Definitions and background
Implicit bias is an unconscious, automatic association that is either disadvantageous or favorable toward a person or group. Although prejudice is not a new concept, implicit bias defines biases that are uncontrollable, intuitive, and irrational. Implicit bias can present itself as a preference, leading to outcomes that undermine trust. Although societal standards have evolved to disfavor explicit bias, implicit bias is harder to recognize even by the recipient.
8
There is evidence that implicit bias favoring in-groups and dominant groups and also disfavoring out-groups develops as early as 6 years old.11
,12
A microaggression is a statement or action, conscious or unconscious, that is perceived as discriminatory against a marginalized community, the product of implicit bias. Originally defined in 1970 by Dr Chester Pierce to describe subtle forms of racism in the post-Jim Crow era,
13
it has evolved as discrimination has become more subtle, and it spans across multiple target groups, whether based on race, gender, sexuality, or other marginalized groups.8
Microaggressions are admittedly difficult to navigate because they can be subjective in nature and interpretation. There are 4 defined forms of microaggression that are summarized in the following discussion, and in Table 1 where examples are provided14
,15
:- 1.Microassault: Discriminatory action or comment that is intentionally performed/spoken; however, it may not be meant to be offensive.
- 2.Microinsult: Unconscious verbal or nonverbal subtle rudeness or insensitivity that demeans a person’s identity.
- 3.Microinvalidations: Unconscious acts or words that negate, undermine, or nullify the feelings and reality of a marginalized person/group.
- 4.Environmental microaggressions: Systemic rules or physical environments that exclude, underpin vulnerability, and perpetuate inequity.
Table 1Types of microaggressions
| Type | Definition | Examples |
|---|---|---|
| Microassaults | Discriminatory action or comment that is intentionally performed/spoken; however, it may or may not have been meant to be offensive |
|
| Microinsults | Unconscious verbal or nonverbal communications that convey subtle rudeness or insensitivity that demeans a person’s identity |
|
| Microinvalidations | Unconscious acts or words that negate, undermine, or nullify the feelings and reality of a marginalized person/group |
|
| Environmental Microaggressions | Systemic rules or physical environment that excludes, underpins vulnerability, and perpetuates inequity |
|
Implicit bias and microaggression by themselves or in combination affect the individuals involved and the relationship between them. Regardless of who is affected, in the context of Hand Surgery, patient care can be compromised.
The term intersectionality was first coined in 1989 by Kimberlé Crenshaw, a Professor of Law at Columbia University, and a distinguished Professor of Law at the University of California, Los Angeles.
16
Intersectionality is a concept that describes the exponential discrimination toward individuals who belong to more than 1 marginalized group, such as their racial and ethnic group and gender affiliation. These individuals are often the subjects of prejudice on a larger scale due to the existence of their multiple realities. For example, a black woman who is discriminated against for being black and for being a woman will suffer more discrimination and inequity than a Black man or White woman.17
Discussion
Hand surgeons experience multiple types of interpersonal encounters across a variety of environments. These encounters include varying levels of power and authority and situations that capture biases and microaggressions. The patient-surgeon, surgeon-peer, surgeon-staff, and surgery training environment all afford their own unique sets of challenges when it comes to addressing biases in the workplace (Table 2).
Table 2Summary of bias and clinical microaggression for the hand surgeon
| Environments | Examples of Implicit Biases | Examples of Clinical Microaggression |
|---|---|---|
| Surgeon-patient | Disfavor for patients who make below the federal poverty line Preference for males |
|
| Surgeon-peer | Disfavor for Black community Preference for neurotypical |
|
| Surgeon-staff | Preference for White Preference for males Disfavor of homosexuality |
|
| Training environment | Disfavor for heterosexuality Preference for males Disfavor for Latino/a community |
|
Abbreviations: ADHD, attention-deficit hyperactivity disorder; OR, operating room.
Patient-Surgeon Relationship
Within the Hand Surgery clinical sphere, the patient-surgeon relationship is essential in diagnosis, surgical decision-making, overall care delivery, and complication prevention and mitigation. Multiple treatment options can be available based on the condition being treated. The development of trust between the patient and surgeon is crucial in finding the care plan best suited for the patient.
Socioeconomic status has been found to affect access to hand specialty care in the United States,
18
with less access to hand trauma and congenital hand care in underserved areas.19
,20
Large-scale studies of implicit bias in health care have found evidence of health care providers displaying bias that favors patients of upper socioeconomic status,- Kalmar C.L.
- Drolet B.C.
Socioeconomic Disparities in Surgical Care for Congenital Hand Differences.
Hand (N Y). 2022; (15589447221092059)https://doi.org/10.1177/15589447221092059
21
by surgeons and nurses22
,23
; this cultivates a system whereby hand surgeons at tertiary referral centers facilitate care for this population.Race-related disparities in health care are also documented in patient counseling,
24
timing of operations,25
and perception of pain and prescription of opioids.26
,27
Unsurprisingly, patients are more likely to choose racial- and ethnic-concordant physicians28
and are also more likely to follow their physician's recommendations if they are of the same race and ethnicity.29
Implicit bias and microaggressions are multidirectional and often occur from the patient to the physician. These “contra-power" microaggressions can lead to burnout among physicians.
30
In addition, these biases are reflected in patient satisfaction scores. Metrics like these, such as Press-Ganey scores, often influence physician compensation and promotion, worsening the impact of disparities in academic medicine.31
Surgeon and Peers
Within the surgical community, implicit gender bias is well documented. Large cohort implicit association test (IAT) has found that among surgeons, men are associated with surgery and women with family medicine as specialties. Furthermore, cumulative implicit bias can have an impact on personnel hiring decision making. Downstream effects of such decisions are thought to contribute to underrepresentation and disparities in access to mentorship and leadership opportunities. Within Hand Surgery, documented downstream disparities in research,
32
,33
society leadership,34
and hand fellowship directorship35
have been noted.- Schiller N.C.
- Spielman A.F.
- Sama A.J.
- et al.
Leadership trends at hand surgery fellowships.
Hand (N Y). 2022; (15589447211073977)https://doi.org/10.1177/15589447211073977
Surgeon and Staff
As a surgeon in the health care environment, one interacts with many types of staff as an integral part of the operating room team. A recent validated survey study found that surgeons’ leadership behaviors affected intraoperative team performance, particularly negative behaviors.
36
Both in and out of the operating room, hand surgeons encounter administrative, nursing, technical, cleaning, and supply chain team members on a daily basis. Members of each of these groups have their own separate dynamics and propensity for biases.Studies on operating room staff characteristics that were predictive of surgeons being written up have found that the likelihood of writing up the surgeon was predicted by role, with technologists, nurses, and assistants reporting surgeons at higher frequencies.
37
Furthermore, the age/generation of operating room staff and how they interpreted surgeons’ behavior has revealed that older generations were more likely to find behaviors of impatience, tardiness, and swearing to be inappropriate compared with younger generations who found fault with deviation from rules and regulations such as the surgical time out.
38
The microaggression of mislabeling a physician from a marginalized group as someone who has less training (mistaking a female attending for a nurse, or a black resident as the janitorial staff) occurs frequently. However, the physician is faced with a dilemma because speaking up about the microaggression may be perceived as disrespect for the nonphysician staff and their profession.
30
At the crux of these observations is the lack of insight into one’s own biases. For instance, survey studies of nurses at an academic hospital found that whereas 71% of those surveyed believed they had no implicit bias, in actuality, only 14% displayed no implicit bias after taking an IAT regarding clinical vignette scenarios.
23
Often, being the leader of their team during these times, hand surgeons must be aware of role-specific, generational, race, ethnicity, and socioeconomic biases and microaggressions.
Training Environment
The academic training environment has lent itself to several studies regarding the presence of both bias and microaggressions, providing insight into training programs within medical settings. Although most studies have unanimous themes, the frequency and consistency may provide evidence that biases are being encouraged and facilitated within our training programs.
Several recent reports have found disparities and bias manifesting in Hand Surgery letters of recommendations
39
and Orthopedic Surgery residency interviews.40
A recent survey study of Plastic Surgery trainees found that 69% of trainees reported experiencing microaggressions within the past year, with females, racial, and sexual minorities having higher odds of reporting such experiences.41
Furthermore, there is some consensus that as a trainee, the risk of reporting racial discrimination is not worth the reward of potential equity.
42
Hence, as leaders of a training program, surgical team, operating room, or administrative teams, one must be increasingly aware of how their actions may be interpreted.Intersectionality has been shown to be relevant in the graduation rates of General Surgery residents. A study by Keshinro and colleagues
17
demonstrated that the increase in women graduates of General Surgery residencies is attributed in most part to the increase in White and Asian women, and not black and Latina women; this occurs despite an increasing number of black and Latina women applicants to General Surgery residency.17
Attrition of trainees from surgical training is more common in women and racial/ethnic minorities.
17
,43
,44
This attrition has been reported to be associated with burnout that is secondary to implicit bias and microaggressions.45
,46
The attrition of trainees with minority backgrounds perpetuates the deficiency of diversity among the ranks of practicing surgeons and is detrimental to patient care.Action Plan
At an institutional level, many organizations are incorporating Diversity, Equity, and Inclusion committees or including curricula within medical education to prepare health care providers to be more aware and trained regarding implicit biases.
47
These organizations can be great resources to find and take an IAT, provide training for one’s teams, and gain exposure through events and lectures. However, ultimate change must come at the individual level, and these are the efforts on which the authors focus, with strategies summarized in Table 3.Table 3Strategies to combat implicit bias and microaggressions
| Strategy Source | Explanation | Useful Link |
|---|---|---|
| Project Implicit 49 | Take an IAT | https://www.projectimplicit.net |
| APA’s recommendations for the target, bystander, or microaggressor 50 |
| https://www.apa.org/monitor/2017/01/microaggressions |
| APA’s Inclusive Language Guidelines 51 | Consciously avoid using language that may be perceived as a microaggression, regardless of the intent | https://www.apa.org/about/apa/equity-diversity-inclusion/language-guidelines |
Abbreviation: APA, American Psychological Association.
For those striving to work through strategies to reduce implicit biases and microagressions in the workplace, definitions and evidence of existing problems only help to some extent. Although there is no true way to eliminate implicit bias from our decision making, minimizing its negative impact on others is an achievable goal. Although awareness is the first step to solution, implementing change to reduce bias is often harder than it seems.
In psychology literature, it is well known that small changes in behavior can cumulatively bring about change. For example, it is encouraging to note research establishing that implicit bias is a habit that can be broken. Devine and colleagues
48
developed an intervention to reduce implicit bias and showed that it is possible to retain this gain over a 12-week period. The American Psychology Association has a concise outlined plan for the parties involved in any microaggression and is summarized in Table 3. The following section lists the action steps or behaviors that health care providers can practice to reduce the potential for displaying implicit bias and microaggressions.Clinics care points
- •
- •
- •Ask patients “What’s going on in your world right now and how is your hand problem affecting it?” instead of “How’s your hand doing”?
- •At the end of any encounter, ask patients if they feel comfortable instead of asking if they understand what you are saying.
- •Offer a second opinion and be open to patients not wanting to seek care with you. Everybody is not for everybody.
- •Facilitate a training session for team members and trainees.
- ○Provide scenarios that do and do not depict implicit bias and ask respondents to react and differentiate between the 2 scenarios.
- ○Provide scenarios of different types of implicit bias/microaggression and ask the respondent to select from options about how the target should respond.
- ○Vary the scenarios so that the recipient of the bias/microaggression has more power or less power (eg, staff member on surgeon).
- ○
- •Listen to others and explore why something was perceived as hurtful or demeaning, even if that was not the intention.
- •Strive to use inclusive language to avoid conscious and unconscious microaggressions (see Table 3),
Summary
The existence and detriment of implicit bias and microaggressions is becoming more and more recognized in medicine. Awareness of these psychological attacks is not enough to mitigate or stop them from occurring, or prevent the progression of their downstream effects. As hand surgeons, we can be leaders in our medical community and actively work to eliminate these learned but entrenched views of others. Resources are available to guide and support us through this process and spearhead a culture change within our subspecialized field of medicine.
References
- Measuring individual differences in implicit cognition: The implicit association test.J Pers Soc Psychol. 1998; 74: 1464-1480
- Microaggressions in everyday life: race, gender, and sexual orientation.John Wiley & Sons, Inc., Hoboken, NJ2010
- Measuring individual differences in implicit cognition: the implicit association test.J Pers Soc Psychol. 2003; 85: 197-216
- Microaggressions and “evidence”: empirical or experiential reality?.Perspect Psychol Sci. 2017; 12: 170-172
- A systematic review of health disparities research in plastic surgery.Plast Reconstr Surg. 2021; 147: 529-537
- Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients.J Gen Intern Med. 2007; 22: 1231-1238
- How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States.J Womens Health (Larchmt). 2021; 30: 270-273
- Microaggression and Implicit Bias.Am Surg. 2021; 87: 1727-1731
- Implicit bias in healthcare professionals: a systematic review.BMC Med Ethics. 2017; 18: 19
- Microaggressionsin Clinical Training and Practice.PMR. 2019; 11: 1004-1012
- The development of implicit intergroup cognition.Trends Cogn Sci. 2008; : 248-253
- The development of implicit attitudes. Evidence of race evaluations from ages 6 and 10 and adulthood.Psychol Sci. 2006; 17: 53-58
- Black psychiatry one year after Miami.J Natl Med Assoc. 1970; 62: 471-473
- Racial microaggressions in everyday life: implications for clinical practice.Am Psychol. 2007; 62: 271-286
- Recognizing and Reacting to Microaggressions in Medicine and Surgery.JAMA Surg. 2019; 154: 868-872
- Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doc-trine, feminist theory and antiracist politics.Univ Chic LegForum, 1989: 139-167
- Examination of intersectionality and the pipeline for black academic surgeons.JAMA Surg. 2022; 157: 327-334
- Inequalities in Specialist Hand Surgeon Distribution across the United States.Plast Reconstr Surg. 2016; 137: 1516-1522
- Tennessee emergency hand care distributions and disparities: Emergent hand care disparities.Hand (N Y). 2013; 8: 172-178
- Socioeconomic Disparities in Surgical Care for Congenital Hand Differences.Hand (N Y). 2022; (15589447221092059)https://doi.org/10.1177/15589447221092059
- Estimating implicit and explicit gender bias among health care professionals and surgeons.JAMA Netw Open. 2019; 2: e196545
- Implicit Bias in Surgery-Hiding in Plain Sight.JAMA Netw Open. 2019; 2: e196535
- Unconscious race and class biases among registered nurses: vignette-based study using implicit association testing.J Am Coll Surg. 2015; 220: 1077-1086.e3
- Patients with limited health literacy ask fewer questions during office visits with hand surgeons.Clin Orthop Relat Res. 2017; 475: 1291-1297
- Socioeconomic disparities inbrachial plexus surgery: a national database analysis.Plast Reconstr Surg Glob Open. 2019; 7: E2118
- Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.Proc Natl Acad Sci U S A. 2016; 113: 4296-4301
- How to Be An Antiracist Hand Surgery Educator.J Hand Surg Am. 2021; 46: 507-511
- Do patients choose physicians of their own race?.Health Aff (Millwood). 2000; 19: 76-83
- The service patterns of a racially, ethnically, and linguistically diverse housestaff.Acad Med. 2001; 76: 1232-2124
- Are you really the doctor? Physician Experiences with Gendered Microaggressions from Patients.J Womens Health (Larchmt). 2022; 31: 521-532
- Physician gender is associated with press ganey patient satisfaction scores in outpatient gynecology.Womens Health Issues. 2018; 28: 281-285
- Sex bias in hand surgery research.J Hand Surg Am. 2018; 43: 1026-1029
- Gender disparity trends in authorship of hand surgery research.J Hand Surg Am. 2022; 47: 420-428
- Gender diversity in hand surgery leadership.Hand (N Y). 2022; (15589447211038679)
- Leadership trends at hand surgery fellowships.Hand (N Y). 2022; (15589447211073977)https://doi.org/10.1177/15589447211073977
- The impact of positive and negative intraoperative surgeons' leadership behaviors on surgical team performance.Am J Surg. 2018; 215: 14-18
- Predictors of the response of operating room personnel to surgeon behaviors.Surg Today. 2019; 49: 927-935
- Effect of operating room personnel generation on perceptions and responses to surgeon behavior.Am Surg. 2021; 87: 1934-1945
- Racial and gender discrimination in hand surgery letters of recommendation.J Hand Surg Am. 2021; 46: 998-1005.e2
- Is There unconscious bias in the orthopaedic residency interview selection process?.J Surg Educ. 2022; (S1931-7204(22)00017-4)
- Assessing the prevalence of microaggressions in plastic surgery training: a national survey.Plast Reconstr Surg Glob Open. 2021; 9: e4062
- The risk and reward of speaking out for racial equity in surgical training.J Surg Educ. 2021; 78: 1387-1392
- National orthopedic residency attrition: who is at risk?.J Surg Educ. 2016; 73: 852-857
- Association of time to attrition in surgical residency with individual resident and programmatic factors.JAMA Surg. 2018; 153: 511-517
- Race, gender, and residency: a survey of trainee experience.J Natl Med Assoc. 2021; 113: 199-207
- Prevalence and nature of sexist and racial/ethnic microaggressions against surgeons and anesthesiologists.JAMA Surg. 2021; 156: e210265
- A framework for integrating implicit bias recognition into health professions education.Acad Med. 2018; 93: 35-40
- Long-term reduction in implicit race bias: a prejudice habit-breaking intervention.J Exp Soc Psychol. 2012; 48: 1267-1278
- Project implicit.(Available at) (Accessed June 15, 2022)
- Did you really just say that?.in: Monitor psychol. 48. 2017 (Available at:) (Accessed June 15, 2022)
- Inclusive language guidelines.(Available at:) (Accessed: June 15, 2022)
Article info
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
