In lieu of an abstract, here is a brief excerpt of the content:Both Interpersonal and Structural Efforts Are Necessary for Healthcare Professionals to Avoid Committing MicroaggressionsChidiogo Anyigbo (bio)I commend Lauren Freeman and Heather Stewart for acknowledging that the final chapter of Microaggressions and Medicine (2024), chapter 7, which provides practical guide for healthcare workers to avoid committing microaggressions, is a work in progress. The authors primarily focus on "strategies that can be implemented on the interpersonal and environmental levels because (...) this is where we can all immediately make the most impact to reduce microaggressions and their harmful consequences" (189). Presumably, readers of Microaggression and Medicine will by and large be healthcare workers: physicians, nurses, and allied health professionals working in direct patient care settings, and presumably these individuals pick up a book like Microaggression in Medicine to apply it to their own practice. Therefore, it may seem logical to act at the level that is closest to us as readers.The authors highlight seven strategies for reducing microaggressions in the healthcare space:• diversify employees• hire local health advocates, activists, and consultants to offer feedback on clinic design and practices• incorporate micro-cues into medical practices• foster medical humility• practice ethical listening• collaborate with patients as epistemic peers• increase awareness and education for colleagues and staffSome of these strategies occur at a systems level, like diversifying employees, hiring local health advocates, and creating staff educational awareness. Others are intended as steps for individuals to take during patient encounters. All of [End Page 152] these points, however, show how structural and systemic changes are important to address concurrently with taking individual steps. For example, if one makes interpersonal efforts to reduce or avoid microaggressions but is at the same time still operating within systems and structures that reinforce microaggressions, not only will harm continue to be done, but there is also a risk of burnout for the individual trying to make strides despite these harmful systems (as Hambrick and Tang Girdwood [2024] discuss). This may lead individuals to view their interpersonal and environmental efforts as futile because they do not lead to widespread reduction in microaggressions.For example, these structural and systemic strategies can start with institutional and organizational policies, for example, regarding how to respond to patients who harass healthcare professionals or expectations patients can have regarding the care they receive. Not only do patients experience microaggressions from healthcare workers, which is the focus of Freeman and Stewart's book, but healthcare workers can also experience microaggressions from patients (as Hambrick and Tang Girdwood elaborate). Hiring a diverse staff at all levels can certainly help foster a more inclusive environment, but it is not sufficient, and it also can lead to healthcare workers from historically underrepresented groups being the target of microaggressions from patients, their surrogate decision-makers, or their families. Institutional approaches to diversifying the healthcare workforce also need to consider how to best support a diverse healthcare workforce.The authors rightly point out that people of marginalized backgrounds often face a "minority tax" and that they are often the ones expected to do the uncompensated work of calling attention to and leading efforts to address microaggressions in their organization by educating colleagues and staff. As this happens, these more diverse staff may not feel the psychological safety or support needed to stay in the organization. The efforts to develop and maintain psychological safety are led by structural and systemic action, not solely individual herculean efforts. Education is not sufficient if there are no systems and policies in place to support and reinforce the desired behaviors.The concept of choice architecture is often used in business and behavioral economics to describe how to influence the conditions in which people make decisions to reduce bias, oftentimes creating default options that improve well being for many (Meder, Fleischhut, and Osman 2018). For example, this concept has been applied to improving healthy eating behaviors in workplaces (Rantala et al. 2024). There may be similar opportunities to explore how such efforts can be applied to create default action that does not rely on individual action and vigilance to address microaggressions. Choice architecture strategies for addressing microaggressions could perhaps expand the Institute for Healthcare Improvement (IHI) framework used for systems-based efforts to be... (shrink)

We agree with McCullough, Coverdale and Chervenak1 that ‘medical educators and academic leaders are in a pivotal and powerful position to role model’ to counter ‘incivility’ in medicine, which can include ‘dismissing’ or ‘demeaning others’. They note that ‘women may be at greater risk for experiencing incivility compared with men’, as may other individuals who experience ‘patterns of disrespect based on minority status’. The authors promote ‘professionalism’ and ‘etiquette’ to foster civility within medicine. Yet theory and experience suggest that medical (...) educators and academic leaders are also in powerful positions to mobilise these concepts to perpetuate exclusions from, and biases within, medicine, upholding racist, sexist and ableist norms. Feminist methodology reveals how ethical theorising historically excluded views and experiences of marginalised individuals and groups and provides frameworks for interrogating supposedly universal norms. Presuming dominant values and experiences reflect universal ones can further marginalise already oppressed groups and individuals. A feminist analysis reveals how ‘professionalism’ or ‘etiquette’ are historically shaped by white or male identity and experience, including norms of attire, hair, accessories, speech or behaviour. Part of the hidden curriculum of medicine becomes intuiting how leaders implicitly or explicitly define ‘professionalism’. McCullough et al define ‘professionalism’ in medicine as ‘sustained commitments to scientific and clinical excellence… making the protection and promotion of health-related interest the physician’s primary concern …. (shrink)