CORR Insights®: The Majority of Black Orthopaedic Surgeons Report Experiencing Racial Microaggressions During Their Residency Training

Where Are We Now?

As a Black woman orthopaedic surgeon, I am accustomed to being asked, “what can we do to recruit more women and underrepresented minorities to the field of orthopaedics?” I am aware the person asking the question recognizes the importance of and need for greater diversity in our field. At the same time, it cannot be answered with an easy sentence or two, as the inquirer is often hoping. In the past 20 years, we have seen a decline in the number of Black residents we are training [7]. Why does this matter? To start, we have unprecedented healthcare disparities in the United States, including in the care of patients with orthopaedic illness [6]. Several studies looking at healthcare inequities have confirmed that a more-diverse workforce results in better care for underserved communities [2-4, 8]. We need orthopaedic surgeons to reflect the patient populations we care for more closely, so we bring all our tools to the table to promote better patient care.

When residency program directors and department chairs are asked why they are unable to recruit Black residents to their programs, the most-often cited reasons are a lack of Black faculty and not enough Black applicants [5]. We also have a more complex dilemma in which Black residents have a substantially higher rate of early termination or dismissal from a residency program [5]. We are not only failing to recruit Black medical students into our field, but we are also failing to keep them here once we do recruit them.

To further understand this problem, Brooks et al. [1] studied the extent of discrimination reported by Black orthopaedic residents during training, subtypes of racial microagressions, feedback Black residents receive during their training, and gender differences in the reported types of racial microagressions described by these residents. Unfortunately, most Black residents and Black orthopaedic surgeons described fairly consistent experiences of persistent microaggression in their training.

To address the findings in this study, program directors should start by acknowledging the existence of these microaggressions, because this builds an environment that feels welcoming to students and residents who have had this experience. Program directors should provide educational opportunities for faculty to be made aware of this environment, which will allow for faculty to consider ways they can reduce some of these microagressive events. Making faculty aware of the importance of clearly stating a resident’s title when introducing them to patients during office hours is a simple and clear way to potentially reduce such events. Specific training for faculty on providing nonexclusionary feedback is another direct action that can be initiated immediately in most residency programs. Other actions that could be beneficial in addressing the environmental experiences of underrepresented residents would be to ensure clear pictures of all residents are posted in a location where they may be frequently working with hospital and office staff. Including residents’ accomplishments on these postings would be a nice way to make everyone aware of how hard the residents have worked to get to this point and gives the residency program a chance to boast about their own ability to recruit such accomplished individuals.

Where Do We Need To Go?

The first place I suggest readers go is Table 4 in the paper itself [1]. The word “microaggression” is an unfortunate linguistic construction, and it may cause people who have not had these experiences to minimize the impact these narratives can have on a young professional. When a medical student hears something like “don’t worry about the match, you’re Black or a woman, programs are going to want you,” this substantially devalues that individual’s hard work, perseverance, and accomplishments. All readers should have a look at the paper by Brooks et al. [1] and make sure not to perpetuate these harms.

Ultimately, we who are training the next generation need to create an environment that is conducive to learning for all trainees and faculty. This means we need to work toward a low-microaggression environment for everyone. Implementing strategies such as faculty training about nonexclusionary and wise feedback, providing residents with ways to report concerns without the risk of retaliation, and simply acknowledging the existence of the problem to Black residents in a sincere manner are ways to improve the learning environment. Once these changes have been initiated, follow-up data showing implementation has improved the perception of microaggressions in the workplace for Black residents will be important. Long-term data showing an increase in Black medical students entering and completing residency training in orthopaedics would be a true sign the environment has become more welcoming.

How Do We Get There?

Unlike a lot of problems in orthopaedics, we are not going to research our way out of this one.

Brooks et al. [1] introduce the concept of wise feedback as the right approach to providing feedback. In providing critical feedback, it does not take much to let the recipient know that as an educator you have high standards and expectations and then provide ways for students to work toward those high expectations. In providing wise feedback, we also need to be aware of terminology that creates alienation. Telling an individual that he or she “doesn’t fit in” or that he or she is “intimidating” should play no role in constructive feedback. Adhering to some of these simple concepts gives us all an opportunity to improve as educators. Educator courses offered to program directors and others interested in education should focus on wise feedback. Such courses should also prioritize strategies that reduce alienation and improve the way we provide feedback to residents, particularly those from underrepresented groups.

The data in the current study [1] show that if an individual is both Black and a woman, she is likely to experience both more and more-severe microaggressions as a resident. Are we surprised this group is more likely to have this experience? I hope not. But knowing this information gives us a chance to talk about the intersectionality of living in a world where one must experience the compounding effects of both racism and sexism. It is also an opportunity for program directors and department chairs to become aware of this compounded stressor and provide early support and engagement to residents in this group. This support should include absolute protection and a suitable level of confidentiality for all individuals to express concerns about their experiences and receive advice and help when needed without fear of retaliation.

The current study [1] found that most microassaults come from patients, followed by attending faculty. I charge every attending who has interactions with residents to contemplate how they can fix this problem rather than cause it. This is the very least we can do as a group. This still leaves us with the 38% of microassaults that come from patients. That being so, we cannot stop with only fixing ourselves. We need to work on educating others. We need to correct patients when they make derogatory statements about residents. We need to let patients know we will not tolerate such comments in our practices and in our hospitals. We need to set that example for others.

Finally, we must not make the mistake of placing these perceptions of microaggressions in the category of hypersensitivity on the part of a Black resident or faculty member. This invalidates the real feelings of real people, which has sometimes been termed “microinvalidation.” Those who claim this is all just hypersensitivity need to ask themselves where that hypersensitivity stems from. This country has a history. And we must know that some of that history carries forward to the present. We need to reflect on the environment as it exists now and ask why it is less inviting for some, and do what we can to make it equally inviting to all who wish to join our profession.