The Forward Movement: Recognizing the Gravity of Subtle Indignities

Narratives about overcoming racism are nearly always told after the fact, with the benefit of hindsight. This retrospective lens lends itself to certain biases and distortions. One can be misled to believe the outcome of success was inevitable, as if society is bound on an inexorable upward trajectory toward racial equality. In actuality, the pathway of American society is more accurately described as sinusoidal, dictated by the struggle between champions of progress and those who would rather maintain the status quo. There is no guarantee that we will reach the promised land; it is the dedication and sacrifice of courageous individuals that make such aspirations possible.

Another dangerous distortion in the way we frame racism narratives lies in the way we characterize individuals who are affected. These accounts frequently emphasize the exceptional force of will required to triumph over insurmountable odds. Indeed, those embodying such resilience deserve the highest praise and commendation. But even as we celebrate the human spirit, we must take care not to dehumanize the deeply personal aspects of the struggle against discrimination. The story does not end when the battle is won. There are profound psychological implications to personal engagement with systemic racism that all too often go unnoticed in tales of triumph.

To this point, every Black orthopaedic surgeon I know has personal anecdotes of how he or she overcame racial discrimination to achieve his or her current position. Unfortunately, this is not something that stops once we have “made it.” While the nature and context of repeated affronts may evolve over time, they do not disappear as one’s career progresses. Nevertheless, the offenses experienced during residency carry a particular poignancy that we need to acknowledge [1]. There is a distinct vulnerability that is unique to medical training for any individual, and this is only compounded for trainees of historically marginalized backgrounds. The daily experience of routine exclusion, disregard, underestimation, and belittlement under the guise of casual interaction transforms the innately challenging experience of residency into a nigh unbearable one.

These supposedly casual daily slights are frequently described as microaggressions, a concept initially defined by psychiatrist Dr. Chester Pierce and further characterized by law professor Peggy Davis as “stunning automatic acts of disregard that stem from unconscious attitudes of White superiority and constitute a verification of Black inferiority” [2]. While the term has become increasingly mainstream, the original intent of the concept has become distorted with time. A misconception exists that microaggressions (whether formally defined or otherwise) represent small hurdles and obstacles, ones that can be overcome by adequate “grit” on the part of the victim. This unfortunate misconception often leads to unconstructive advice and misguided guidance: Keep your head down. Ignore the indignities. Endure. Just get to the other side.

In the first place, advice like this fails to account for the sense of uncertainty that many Black residents experience. After all, we know that Black residents are dismissed from training programs much more commonly than their White counterparts [3], a fact that many of us are acutely aware of during training. It therefore borders on the absurd to advise patient endurance of indignities in anticipation of a promised future career, when it is entirely possible that future will be unjustly denied.

Moreover, such advice fails to validate the deeply personal struggle that arises when one experiences daily or near-daily discrimination. That advice counsels resiliency in the face of adversity, while overlooking the exhausting task of being forced to assert one’s humanity again, and again, and again.

Considering the body of research documenting the psychologically damaging effects of microaggressions [4], we can conclude that there is nothing small about these interactions [5]. To be clear, the only “micro” part of a microaggression is the duration of the exchange. The cumulative impact of ostensibly innocuous acts of degradation is unequivocally macro. We must eradicate the expectation that minority residents should just endure such systematic dehumanization. We must alter the training culture from one that values fortitude in the face of adversity to one that validates, heals, and restores dignity.

We cannot expect daily indignities to disappear overnight. What we can do is adopt a more direct approach to supporting Black residents. Graduate medical education has placed increasing attention on mental health and wellness in recent years. As we continue to develop these programs, specific attention needs to be paid to the experience of marginalized minority groups. There must be dedicated resources for counteracting the detrimental effect of microaggressions, a task that will inevitably require specific coordination with mental health professionals who have expertise in this field. Whether this manifests as specific resource centers, support groups, or even one-on-one mentoring will depend on the specific needs of the training program, but the underlying theme for this paradigm shift must be one of validation.

It is possible to recognize an individual’s resilience while still acknowledging and nurturing his or her humanity. In fact, if our goal is to create a diverse field of empathetic and compassionate surgeons, it is an absolute necessity.