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Creating a Culture of Micro-Affirmations to Overcome Gender-Based Micro-Inequities in Academic Medicine

Published:February 01, 2019DOI:https://doi.org/10.1016/j.amjmed.2019.01.028
      A woman physician meets with the department chairperson and colleagues to discuss her project ideas. The group agrees that they have transformative potential. The chairperson says to her in front of the group, “With your looks and my brain, we'll be a great team.” Unable to muster a response to him, she laughs uncomfortably and changes the subject. Several weeks later, the physician presents a patient case at medical rounds. A new colleague mistakes her for a medical student and after realizing the mistake comments, “As a woman, you should be grateful to look so young!” As the physician's career progresses, she finds herself questioning her ability to lead projects and defers applying for career opportunities because she feels underqualified.
      This case vignette highlights an example of gender bias. While versions of these encounters have played out across the globe with growing attention to overt gender bias in the workplace, the more subtle forms of bias—the micro-inequities—are equally important to identify and correct to support women's advancement in medicine.
      Unconscious, or implicit, biases are stereotypes or associations outside of conscious awareness that may lead to a negative evaluation of a person on the basis of irrelevant characteristics, such as gender or race.
      • FitzGerald C
      • Hurst S
      Implicit bias in healthcare professionals: a systematic review.
      Research demonstrates that health care professionals exhibit similar levels of unconscious associations—both positive and negative—as the wider population, and that these biases may influence the quality of care administered.
      • FitzGerald C
      • Hurst S
      Implicit bias in healthcare professionals: a systematic review.
      • Dehon E
      • Weiss N
      • Jones J
      • Faulconer W
      • Hinton E
      • Sterling S
      A systematic review of the impact of physician implicit racial bias on clinical decision making.
      Unconscious bias becomes entrenched in hierarchies of training and clinical practice, insidiously takes root in the workplace, and creates a culture of disadvantage for women in academic medicine. Evidence suggests that unconscious bias regarding gender and race impacts both medical school admissions and workforce recruitment and retention.
      • Johnson TJ
      • Ellison AM
      • Dalembert G
      • et al.
      Implicit bias in pediatric academic medicine.
      Gender bias is particularly salient when women apply for positions historically occupied by men, and they experience negative stereotypes in the hiring process;
      • Isaac C
      • Lee B
      • Carnes M
      Interventions that affect gender bias in hiring: a systematic review.
      such biases may contribute to gender-discordant leadership and hinder women's success.
      Inequities—differences that are systemic, avoidable, and unjust—rise from unconscious biases related to gender, age, race, ethnicity, religion, class, occupation, and sexual orientation and identity, which may be intertwined and difficult to separate. There is robust literature on gender inequities in academic medicine,
      • Westring A
      • McDonald JM
      • Carr P
      • Grisso JA
      An integrated framework for gender equity in academic medicine.
      • Bates C
      • Gordon L
      • Travis E
      • et al.
      Striving for gender equity in academic medicine careers: a call to action.
      • Rochon PA
      • Davidoff F
      • Levinson W
      Women in academic medicine leadership: has anything changed in 25 years?.
      and is primarily focused on macro-inequities—often structural or systemic in nature—such as gender-discordant leadership, unequal compensation, or lack of flexibility for care-giving responsibilities outside of work. One striking example is the salary gap between women and men physicians in US public medical schools, even accounting for age, experience, specialty, faculty rank, research productivity, and clinical revenue.
      • Jena AB
      • Olenski AR
      • Blumenthal DM
      Sex differences in physician salary in US public medical schools.
      Less obvious, but equally important, is how micro-inequities influence academic culture and women's career trajectories.
      Micro-inequities are small events that are often ephemeral, hard to prove, covert, unintentional, frequently unrecognized by the perpetrator, and occur wherever people are perceived to be “different.”
      • Rowe M
      Micro-affirmations and micro-inequities.
      Similarly, micro-aggressions, often applied to racial inequities, are brief and commonplace verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative attitudes toward people of color.
      • Sue DW
      • Capodilupo CM
      • Torino GC
      • et al.
      Racial microaggressions in everyday life: implications for clinical practice.
      When micro-inequities and micro-aggressions infiltrate a workplace, they negatively affect how people perceive their potential to thrive at work. Research has shown that women's performance on math tests decreases when they are reminded of their gender.
      • Spencer SJ
      • Steele CM
      • Quinn DM
      Sterotype threat and women's math performance.
      Women in academic medicine reported greater vulnerability to negative stereotypes, more sensitivity to rejection, and more recognition of their gender than male counterparts.
      • Fassiotto M
      • Hamel EO
      • Ku M
      • et al.
      Women in academic medicine: measuring stereotype threat among junior faculty.
      In regard to inclusion within academic departments, women reported lower relative potential compared with colleagues, and lower sense of belonging than men.
      • Fassiotto M
      • Hamel EO
      • Ku M
      • et al.
      Women in academic medicine: measuring stereotype threat among junior faculty.
      First steps are to recognize when these micro-inequities and micro-aggressions occur, name them, and hold people accountable. The subtle everyday norms and practices within the workplace make it difficult to name gender bias explicitly.
      • Soklaridis S
      • Kuper A
      • Whitehead CR
      • Ferguson G
      • Taylor VH
      • Zahn C
      Gender bias in hospital leadership: a qualitative study on the experiences of women CEOs.
      We may fail to address micro-inequities out of fear of repercussions, lack of understanding, or acceptance of them as workplace norms. Furthermore, it can be challenging for both targeted individuals and bystanders to find appropriate language to respond to micro-aggressions in the moment.
      Building awareness of unconscious bias and micro-inequities sensitizes all individuals—recipients, allies and bystanders—to the power of spoken and unspoken language in our daily interactions. Case-based unconscious bias trainings address underlying micro-inequities, potential impact on both the recipient and workplace, and solutions.
      Cornell University
      Diversity training tackles unconscious bias and micro-inequities.
      In addition to identifying micro-inequities, trainings should focus on activating cognitive “system 2” reactions (slower, deliberative, controlled thinking) in response to micro-inequities and overcoming cognitive “system 1” reactions (rapid, intuitive, impulsive, and error-prone thinking), so that people can catch themselves prior to or immediately after a micro-inequity occurs.
      • Kanheman D
      Thinking Fast and Slow.
      A cluster randomized-controlled trial demonstrated that a workshop on gender bias awareness within an academic department resulted in faculty reporting improvement in gender-equity-promoting behaviors, greater perception of fit and value, and comfort in raising personal and professional conflicts.
      • Carnes M
      • Devine PG
      • Baier Manwell L
      • et al.
      The effect of an intervention to break the gender bias habit for faculty at one institution: a cluster randomized, controlled trial.
      However, efforts should be sustained throughout the department or institution and at every aspect of the employment life cycle, such as staff orientations, annual meetings, and leadership trainings.
      • Ross H
      Diversity best practices: proven strategies for addressing unconscious bias in the workplace.
      In addition to identifying micro-inequities, another solution is to transform workplace culture through micro-affirmations, defined as small acts, which are often ephemeral and hard-to-see, often unconscious efforts to help others succeed.
      • Rowe M
      Micro-affirmations and micro-inequities.
      Micro-affirmations recognize and validate individuals in ways that empower them to thrive in an environment where they may feel marginalized.
      • Rowe M
      Micro-affirmations and micro-inequities.
      When applied in the workplace, micro-affirmations foster inclusion and support for people who may feel unwelcome or invisible.
      • Powell C
      • Demetriou C
      • Fisher A
      Micro-affirmations in academic advising: small acts, big impact.
      When micro-affirmations become frequent, intentional practices, they communicate to others that they are welcome, visible, and capable of performing.
      • Powell C
      • Demetriou C
      • Fisher A
      Micro-affirmations in academic advising: small acts, big impact.
      When academic culture improves, everyone benefits; however, groups with less power, such as women and people of color, gain the most in relation to inclusion and advancement.
      • Pololi LH
      • Civian JT
      • Brennan RT
      • Dottolo AL
      • Krupat E
      Experiencing the culture of academic medicine: gender matters, a national study.
      Cumulative micro-affirmations have the potential to foster individual and collective growth and allow everyone to thrive. Examples of micro-affirmations include:
      • Rowe M
      Micro-affirmations and micro-inequities.
      • Appreciative inquiry: “What is something you are working on that you are excited about?”
      • Recognition and validation of experiences and feelings: “I know that not getting the grant is a disappointment or having a patient complication is challenging.”
      • Reinforcing and rewarding positive behaviors: “Congratulations on your publication!” Departments can develop academic incentive plans to reward faculty members for teaching, administrative, and research productivity.
      • Intentional inclusion in professional settings (meetings, conferences, presentations) and information networks: “There is an upcoming prestigious meeting that I think you should attend. I'll forward your name to the organizers.”
      • Introducing team members by name and role: “This is Dr. _____, a resident working on your care team.”
      • Diverse representation in public spaces: departments or institutions can ensure that portraits of successful women and people of color are displayed in meeting spaces.
      In addition, critical actors—individuals who lead workplace culture transformation through role modeling and encouraging others to advance gender equity—are pivotal to spreading and sustaining micro-affirmations.
      • Helitzer DL
      • Newbill SL
      • Cardinali G
      • Morahan PS
      • Chang S
      • Magrane D
      Changing the culture of academic medicine: critical mass or critical actors?.
      The case vignette demonstrates the power of gender-based micro-inequities to prevent women from achieving their full potential by eroding their self-confidence at work. As a call to action, recipients and bystanders of gender micro-inequities need to identify when they occur, make the underlying biases explicit, and take a stand against the inappropriate nature of these micro-inequities. Everyone is responsible for holding each other accountable to ensure gender-equitable communication and action. Further, all members in the workplace should strive to make micro-affirmations an intentional practice. Only then will we begin to dissolve deeply-rooted gender biases entrenched in academic medicine and create a culture of optimal engagement and performance for all.

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