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. 2021 Mar 24;156(5):e210265. doi: 10.1001/jamasurg.2021.0265

Prevalence and Nature of Sexist and Racial/Ethnic Microaggressions Against Surgeons and Anesthesiologists

Neha T Sudol 1,✉, Noelani M Guaderrama 1, Pamela Honsberger 2, Jennifer Weiss 3, Qiaowu Li 4, Emily L Whitcomb 1
PMCID: PMC7992024  PMID: 33760000

Key Points

Question

What are the prevalence and nature of sexist and racial/ethnic microaggressions against female and racial/ethnic–minority surgeons and anesthesiologists?

Findings

This survey study of surgeons and anesthesiologists in a large health maintenance organization found a 91% prevalence of sexist microaggressions and an 84% prevalence of racial/ethnic microaggressions, with a significant association between microaggressions and physician burnout.

Meaning

These findings suggest that a high prevalence of microaggressions exists that stigmatize female and racial/ethnic–minority physicians and contribute to unhealthful surgical workplaces and physician burnout.

Abstract

Importance

Workplace mistreatment can manifest as microaggressions that cause chronic, severe distress. As physician burnout becomes a global crisis, quantitative research to delineate the impact of microaggressions is imperative.

Objectives

To examine the prevalence and nature of sexist and racial/ethnic microaggressions against female and racial/ethnic–minority surgeons and anesthesiologists and assess the association with physician burnout.

Design, Setting, and Participants

This cross-sectional survey evaluated microaggressions and physician burnout within a diverse cohort of surgeons and anesthesiologists in a large health maintenance organization. A total of 1643 eligible participants were sent a recruitment email on January 8, 2020, 1609 received the email, and 652 replied, for a response rate of 41%. The study survey remained open until February 20, 2020. A total of 588 individuals (37%) were included in the study after exclusion criteria were applied.

Exposures

The Maslach Burnout Inventory, the Racial Microaggression Scale, and the Sexist Microaggression Experience and Stress Scale.

Main Outcomes and Measures

The primary outcomes were prevalence and nature of sexist and racial/ethnic microaggressions against female and racial/ethnic–minority surgeons and anesthesiologists using the Sexist Microaggression Experience and Stress Scale and Racial Microaggression Scale. Secondary outcomes were frequency and severity of microaggressions, prevalence of physician burnout, and associations between microaggressions and physician burnout.

Results

Data obtained from 588 respondents (249 [44%] female, 367 [62%] racial/ethnic minority, 224 [38.1%] 40-49 years of age) were analyzed. A total of 245 of 259 female respondents (94%) experienced sexist microaggressions, most commonly overhearing or seeing degrading female terms or images. Racial/ethnic microaggressions were experienced by 299 of 367 racial/ethnic–minority physicians (81%), most commonly reporting few leaders or coworkers of the same race/ethnicity. Criminality was rare (18 of 367 [5%]) but unique to and significantly higher for Hispanic and Black physicians. Individuals who identified as underrepresented minorities were more likely to experience environmental inequities (odds ratio [OR], 4.21; 95% CI, 1.6-10.75; P = .002) and criminality (OR, 14.93; 95% CI, 4.5-48.5; P < .001). The prevalence of physician burnout was 47% (280 of 588 physicians) and higher among female physicians (OR, 1.60; 95% CI, 1.03-2.47; P = .04) and racial/ethnic–minority physicians (OR, 2.08; 95% CI, 1.31-3.30; P = .002). Female physicians who experienced sexist microaggressions (racial/ethnic–minority female physicians: OR, 1.84; 95% CI, 1.04-3.25; P = .04; White female physicians: OR, 1.99; 95% CI, 1.07-3.69; P = .03) were more likely to experience burnout. Racial/ethnic–minority female physicians (OR, 1.86; 95% CI, 1.03-3.35; P = .04) who experienced racial microaggressions were more likely to report burnout. Racial/ethnic–minority female physicians who had the compound experience of sexist and racial/ethnic microaggressions (OR, 2.05; 95% CI, 1.14-3.69; P = .02) were more likely to experience burnout.

Conclusions and Relevance

The prevalence of sexist and racial/ethnic microaggressions against female and racial/ethnic–minority surgeons and anesthesiologists was high and associated with physician burnout. This study provides a valuable response to the increasing call for evidence-based data on surgical workplace mistreatment.

This survey study examines the prevalence and nature of sexist and racial/ethnic microaggressions against female and racial/ethnic–minority surgeons and anesthesiologists and assesses the association with physician burnout.

Introduction

Workplace mistreatment is implicit and explicit, akin to microaggressions and macroaggressions (overt racism, sexism, and abuse), respectively. Microaggressions are subtle, insulting, discriminatory comments or actions that communicate a demeaning or hostile message to nondominant groups.1 The negative implications of microaggressions are severe and lead to long-term psychological distress.2 Although data on the deleterious impact of workplace macroaggressions exist, research exploring the potential role of microaggressions in physician burnout is lacking.

Physician burnout is a global crisis, with prevalence as high as 80%.3,4 The Maslach Burnout Inventory (MBI), a validated survey and the criterion standard for measuring physician burnout, proposes that burnout is a product of long-term workplace stressors.5,6 Thus, it is conceivable that microaggressions play a major role.7 Templeton et al8 emphasized the urgent need to investigate the intersection of burnout, age, sex, and race/ethnicity as potential contributors to female physician burnout. Similarly, an editorial3 in The Lancet called for institutional-level action toward negative work environments surrounding specialty, sex, and race/ethnicity that impact physician burnout.

Surgeons are some of the highest at risk for burnout, with those who experience mistreatment being most susceptible.9,10 Specifically, burnout among female surgeons is consistently higher than in their male counterparts, with sexism as a primary contributor.11 Although the body of literature on sexist microaggressions is increasing, there is an urgent need to understand the impact of racial/ethnic microaggressions and whether both of these issues are associated with physician burnout.12

Thus, we sought to report the prevalence, frequency, nature, and severity of sexist and racial/ethnic microaggressions against female and racial/ethnic–minority surgeons and anesthesiologists within Southern California Permanente Medical Group (SCPMG). We also explored the association between microaggressions and physician burnout. We hypothesized that there is a high prevalence and severity of microaggressions toward female and racial/ethnic–minority surgeons and anesthesiologists compared with male and racial/ethnic majority surgeons and anesthesiologists. In addition, we postulated that these microaggression experiences are associated with burnout.

Methods

We conducted a cross-sectional survey from January 8 to February 19, 2020, of all surgeons and anesthesiologists within SCPMG. Eligible participants were active SCPMG surgeons and anesthesiologists, identified using the current email distribution list for each specialty. All data were deidentified. The study was approved by the SCPMG Institutional Review Board and was funded by a Regional Research Committee grant. The study followed the American Association for Public Opinion Research (AAPOR) reporting guideline.

An anonymous electronic survey was sent to all eligible participants on January 8, 2020. Reminder emails were sent at weeks 2 and 5. Consent was implied on accessing the survey link, and respondents received a $10 Amazon gift card for participation. The complete survey included self-reported demographics, the MBI, the Racial Microaggression Scale (RMAS), and the Sexist Microaggression Experience and Stress Scale (Sexist MESS) (eTables 1-3 in the Supplement). The demographic questionnaire queried nonbinary gender and race/ethnicity, defined by the investigators and classified by the participants, to inform selection of the appropriate surveys assessing sexist or racial/ethnic microaggressions (eFigure in the Supplement).13 All participants completed the demographic survey and the MBI (eTable 1 in the Supplement).

The validated Sexist MESS assesses frequency and severity of sexist microaggressions using 7 subscales (eTable 2 in the Supplement).2 Subscale scores are obtained from a mean response to individual questions using a 4-point Likert scale, with 0 indicating never occurring and 3 indicating occurrence most of the time. The RMAS uses a similar format with 6 subscales (eTable 3 in the Supplement).14 We defined the prevalence of sexist or racial/ethnic microaggressions as at least 1 mean subscale score for a frequency of 1 or greater, correlating with the microaggression occurring at least a little or a few times.

The MBI assesses physician burnout with individual questions grouped into 3 subscales (emotional exhaustion [EE], depersonalization [DP], personal accomplishment [PA]), using a 7-point Likert scale, with 0 indicating never and 6 indicating every day.5 Burnout was defined as an EE score of 27 or higher or a DP score of 10 or higher, correlating with experiencing these feelings a few times a month or more.4 Unlike the EE and DP, which directly correlate with burnout, an increasing PA score is inversely related and represents wellness.

Our primary outcome was the prevalence and nature of sexist and racial/ethnic microaggressions against female and racial/ethnic–minority surgeons and anesthesiologists as measured by responses to the Sexist MESS and RMAS. Secondary outcomes included frequency and severity of microaggressions, prevalence of physician burnout, and associations between microaggressions and physician burnout.

Statistical Analysis

We anticipated a 30% response rate. Categorical data (demographics and prevalence) are reported as numbers (percentages) and compared using χ2 tests or Monte-Carlo estimates. Continuous data (frequency and severity) are reported as means (SDs) or medians (interquartile ranges [IQRs]) and compared using the Kruskal-Wallis test and/or Wilcoxon rank sum test.

Logistic regression models determined the odds ratios (OR) and 95% CIs on the Sexist MESS, RMAS, and MBI as well as associations between microaggressions and physician burnout. These models intended to control for demographic variables that met statistical or clinical significance. Analysis was performed using SAS statistical software, version 9.4 for Windows (SAS Institute Inc) with a 2-tailed statistical significance level set at P ≤ .05.

Results

A total of 1643 eligible participants were sent a recruitment email. Of 1609 who received the email, 652 replied, for a response rate of 41%. Data analysis was performed for 588 individuals (37%) after exclusion criteria were applied (Figure 1).

Figure 1. CONSORT Diagram.

Figure 1.

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Cohort demographics are reported in Table 1. The self-reported sex distribution was binary, with 259 (44%) identifying as female and 329 (56%) identifying as male. A total of 367 individuals (62%) identified as being in a racial/ethnic–minority group, with an equal distribution of female and male individuals. The most common racial/ethnic–minority group was Asian, of whom 75 of 189 (39%) identified as female. A total of 58 of 588 individuals (10%) identified as being in an underrepresented minority (URM) group (Black, Hispanic, or Hawaiian/Pacific Islander) and primarily identified as female (39 of 58 [67%]).

Table 1. Demographic Characteristics of the Study Participants.

Characteristic No. (%) of participants
Female (259 [44%]) Male (329 [56%]) Total (588 [37%])
Age, y
20-39 88 (34) 62 (18.8) 150 (25.5)
40-49 99 (38.2) 125 (38) 224 (38.1)
50-59 58 (22.4) 92 (28.0) 150 (25.5)
≥60 14 (5.4) 50 (15.2) 64 (10.9)
Race/ethnicity
White 97 (37.5) 124 (37.7) 221 (37.6)
Hispanic 18 (6.9) 13 (4.0) 31 (5.3)
Asian 75 (29) 114 (34.7) 189 (32.1)
South Asian 17 (6.6) 30 (9.1) 47 (8.0)
Middle Eastern 11 (4.2) 28 (8.5) 39 (6.6)
Black 19 (7.3) 4 (1.2) 23 (3.9)
Hawaiian/Pacific Islander 2 (0.8) 2 (0.6) 4 (0.7)
Multiracial 20 (7.7) 14 (4.3) 34 (5.8)
Specialty
General surgery 18 (6.9) 41 (12.5) 59 (10)
Neurosurgery 0 4 (1.2) 4 (0.7)
Obstetrics and gynecology 163 (62.9) 55 (16.7) 218 (37.1)
Ophthalmology 12 (4.6) 20 (6.1) 32 (5.4)
Orthopedic surgery 9 (3.5) 68 (20.7) 77 (13.1)
Otolaryngology 10 (3.9) 35 (10.6) 45 (7.7)
Plastic and reconstructive surgery 7 (2.7) 15 (4.6) 22 (3.7)
Urology 5 (1.9) 31 (9.4) 36 (6.1)
Anesthesia 29 (11.2) 51 (15.5) 80 (13.6)
Podiatry 6 (2.3) 9 (2.7) 15 (2.6)
Fellowship trained
Yes 92 (35.5) 181 (55) 273 (46.4)
No 165 (63.7) 145 (44.1) 310 (52.7)
Not applicable 2 (0.8) 3 (0.9) 5 (0.9)
Operating time, d/wk
0-1 135 (52.1) 80 (24.3) 215 (36.6)
1-2 82 (31.7) 132 (40.1) 214 (36.4)
2-3 19 (7.3) 63 (19.1) 82 (13.9)
3-4 3 (1.2) 12 (3.6) 15 (2.6)
>4 20 (7.7) 42 (12.8) 62 (10.5)
Gender environmenta
Female 164 (63.3) 128 (38.9) 292 (49.7)
Male 23 (8.9) 23 (7) 46 (7.8)
Equal number female and male 72 (27.8) 178 (54.1) 250 (42.5)
Relationship status
Single, never married 39 (15.1) 14 (4.3) 53 (9)
Married or domestic partnership 201 (77.6) 293 (89.1) 494 (84)
Divorced 17 (6.6) 17 (5.2) 34 (5.8)
Separated 2 (0.8) 3 (0.9) 5 (0.9)
Widowed 0 2 (0.6) 2 (0.3)
Parental status
Yes 200 (77.2) 289 (87.8) 489 (83.2)
No 59 (22.8) 40 (12.2) 99 (16.8)
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a

In response to the question, “Which gender comprises the majority of the people you work with on a daily basis?”

Sexist Microaggressions

A total of 245 of 259 female respondents (94%) experienced sexist microaggressions (Table 2). A total of 123 of 259 (47%) experienced cumulative microaggressions or microaggressions across all 7 survey subscales. The most commonly experienced microaggression was environmental invalidations, described as overhearing or seeing degrading terms or images about females (222 of 259 [86%]). The next most common microaggression was leaving gender at the door, described as feeling pressure to overcompensate, hide emotions, or intentionally appear less feminine at work, which occurred in 188 of 259 female respondents (73%). Sexual objectification was reported by 114 of the 259 female respondents (44%) and was highest for those in URM groups (24 of 39 [61%]; P = .02).

Table 2. Prevalence, Frequency, and Severity of Sexist Microaggressions Among Female Physicians Using the Sexist MESS.

Variable Median (IQR)a P valueb
White Hispanic Asian South Asian Middle Eastern Black Hawaiian/Pacific Islander Multiracial Total
Survey subscale, No. (%) 97 (37.5) 18 (7) 75 (29) 17 (6.6) 11 (4.2) 19 (7.3) 2 (0.8) 20 (7.7) 259 NA
Leaving gender at the door
No. (%) 69 (71.1) 15 (83.3) 52 (69.3) 13 (76.5) 7 (63.6) 12 (63.2) 2 (100) 18 (90) 188 (72.6) .47c
Frequency 1.3 (0.8-1.8) 1.8 (1.3-2.3) 1.3 (1.0-2.0) 1.8 (1.0-1.8) 1.3 (0.5-2.0) 1.3 (0.5-2.0) 2.0 (1.5-2.5) 1.7 (1.3-1.9) 1.5 (1.0-2.0) .16
Severity 1.3 (1.0-1.8) 1.8 (1.3-2.3) 1.5 (1.0-1.8) 1.5 (0.8-1.8) 1.5 (1.4-1.8) 1.0 (0.5-1.8) 1.3 (1.0-1.5) 1.4 (1.2-1.8) 1.3 (1.0-1.8) .16
Sexual objectification
No. (%) 44 (45.4) 8 (44.4) 24 (32) 7 (41.2) 4 (36.4) 14 (73.7) 2 (100) 11 (55) 114 (44) .03
Frequency 0.9 (0.8-1.3) 0.9 (0.6-1.5) 0.8 (0.5-1.1) 0.8 (0.8-1.0) 0.7 (0.4-1.6) 1.1 (1.0-1.4) 1.4 (1.0-1.8) 1.1 (0.9-1.4) 0.9 (0.6-1.3) .04
Severity 1.0 (0.5-1.4) 1.2 (0.6-2.0) 0.9 (0.5-1.5) 1.1 (0.9-1.4) 0.6 (0.3-2.0) 0.9 (0.6-1.5) 1.1 (0.4-1.8) 1.2 (0.6-1.8) 1.0 (0.5-1.5) .75
Environmental invalidations
No. (%) 88 (90.7) 17 (94.4) 55 (73.3) 15 (88.2) 9 (81.8) 16 (84.2) 2 (100) 20 (100) 222 (85.7) .03c
Frequency 1.5 (1.3-2.0) 1.5 (1.0-2.0) 1.3 (1.0-1.8) 1.3 (1.0-1.5) 1.5 (1.3-2.0) 1.5 (1.3-2.0) 1.5 (1.5-1.5) 1.5 (1.3-1.8) 1.5 (1.3-1.8) .18
Severity 1.3 (1.0-1.8) 1.8 (1.0-2.0) 1.5 (1.0-1.8) 1.3 (0.8-1.8) 1.5 (1.0-1.5) 1.0 (0.8-1.4) 2.0 (2.0-2.0) 1.4 (0.9-1.8) 1.4 (1.0-1.8) .39
Invalidation of the reality of women
No. (%) 41 (42.3) 9 (50) 18 (24) 6 (35.3) 3 (27.3) 4 (21.1) 1 (50) 4 (20) 86 (33.2) .10
Frequency 0.8 (0.5-1.3) 1.0 (0.5-1.3) 0.7 (0.2-1.0) 0.6 (0.5-1.2) 0.7 (0.4-1.0) 0.7 (0.3-0.9) 0.8 (0.3-1.3) 0.6 (0.4-0.9) 0.7 (0.4-1.2) .04
Severity 1.1 (0.7-1.7) 1.5 (0.9-2.0) 0.8 (0.4-1.7) 1.2 (0.7-1.6) 1.0 (0.7-1.2) 0.9 (0.6-1.4) 1.4 (1.4-1.4) 1.0 (0.5-1.5) 1.0 (0.5-1.6) .53
Traditional gender roles
No. (%) 46 (47.4) 10 (55.6) 36 (48) 8 (47.1) 4 (36.4) 15 (78.9) 1 (50) 9 (45) 129 (49.8) .33
Frequency 0.8 (0.3-1.5) 1.0 (0.7-1.5) 1.0 (0.5-1.5) 0.8 (0.3-1.8) 0.7 (0.3-1.5) 1.5 (1.3-1.8) 1.3 (0.8-1.7) 0.8 (0.4-1.5) 1.0 (0.5-1.5) .21
Severity 0.8 (0.5-1.3) 0.7 (0.5-1.5) 0.8 (0.5-1.3) 1.0 (0.3-1.5) 0.4 (0.3-1.5) 1.0 (0.5-1.3) 1.0 (0.2-1.7) 1.0 (0.2-1.7) 0.8 (0.5-1.3) .99
Expectations of appearance
No. (%) 45 (46.4) 6 (33.3) 18 (24) 7 (41.2) 3 (27.3) 6 (31.6) 0 (0) 6 (30) 91 (35.1) .12
Frequency 0.7 (0.3-1.3) 0.7 (0.0-1.0) 0.3 (0.0-1.0) 0.7 (0.0-1.0) 0.2 (0.0-1.0) 0.7 (0.0-1.0) 0.5 (0.3-0.7) 0.7 (0.0-1.0) 0.7 (0.0-1.0) .28
Severity 1.3 (0.7-2.0) 1.2 (0.9-1.7) 1.0 (0.7-1.7) 1.3 (1.2-1.9) 2.0 (1.2-2.5) 1.3 (0.3-2.0) 0.5 (0.3-0.7) 1.7 (1.3-2.0) 1.3 (0.7-2.0) .16
Inferiority
No. (%) 53 (54.6) 12 (66.7) 28 (37.3) 8 (47.1) 5 (45.5) 8 (42.1) 2 (100) 9 (45) 125 (48.3) .18
Frequency 1.1 (0.6-1.7) 1.4 (0.9-1.7) 0.8 (0.2-1.2) 0.8 (0.4-1.2) 0.9 (0.3-1.1) 0.9 (0.6-1.2) 1.1 (1.0-1.1) 0.9 (0.7-1.2) 1.0 (0.4-1.6) .04
Severity 1.5 (0.8-2.0) 1.8 (1.0-2.6) 1.2 (0.6-1.9) 1.3 (0.6-1.7) 1.3 (1.0-1.7) 1.2 (1.0-2.1) 1.2 (0.6-1.8) 1.4 (1.0-2.0) 1.3 (0.8-2.0) .29
All 7 subscales
No. (%) 49 (50.5) 11 (61.1) 27 (36) 9 (52.9) 5 (45.5) 10 (52.6) 1 (50) 11 (55) 123 (47.5) .48
Overall frequency 1.0 (0.8-1.4) 1.1 (0.9-1.4) 0.8 (0.6-1.2) 1.0 (0.6-1.2) 0.9 (0.6-1.4) 1.0 (0.8-1.5) 1.2 (1.0-1.4) 1.0 (0.8-1.2) 1.0 (0.7-1.3) .16
Overall severity 1.0 (0.6-1.4) 1.1 (0.9-1.7) 0.8 (0.5-1.3) 1.0 (0.6-1.3) 1.0 (0.5-1.1) 0.8 (0.5-1.5) 0.9 (0.3-1.4) 1.0 (0.8-1.3) 1.0 (0.6-1.4) .55
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Abbreviations: IQR, interquartile range; NA, not applicable; Sexist MESS, Sexist Microaggression Experience and Stress Scale.

a

Median comparisons were determined by the Kruskal-Wallis test for more than 2 comparison groups. Medians are reported for 245 physicians (those with microaggression prevalence).

b

P value determined by the χ2 test unless otherwise indicated.

c

P value determined by the Monte Carlo estimates for exact test.

The overall median frequency of sexist microaggressions was 1.0 (IQR, 0.7-1.3), and the overall median severity was 1.0 (IQR, 0.6-1.4). These findings correlated with microaggressions occurring a few times and being minimally stressful. The median frequency and severity were higher for environmental invalidations (frequency, 1.5; IQR, 1.3-1.8; severity, 1.4; IQR, 1.0-1.8) and leaving gender at the door (frequency, 1.5; IQR, 1.0-2.0; frequency, 1.3; IQR, 1.0-1.8), occurring many times and trending toward moderately stressful. The frequency of sexual objectification was higher for Black (1.1; IQR, 1.0-1.4) and Hawaiian/Pacific Islander (1.4; IQR, 1.0-1.8) physicians compared with those of other races. Hispanic female physicians experienced invalidations of the reality of women (1.0; IQR, 0.5-1.3) and inferiority (1.4; IQR, 0.9-1.7) at the highest frequency.

In adjusted models, physicians working at SCPMG for less than 3 years (OR, 70.0; 95% CI, 1.10-4655.80; P = .04) and those who reported working primarily with men (OR, 5.50; 95% CI, 1.10-30.31; P = .04) were more likely to experience environmental invalidations. Female physicians who reported working primarily with men (OR, 5.42; 95% CI, 1.45-20.10; P = .02), URM physicians (OR, 2.49; 95% CI, 1.11-5.63; P = .03), and divorced, separated, or widowed female physicians (OR, 3.10; 95% CI, 1.00-9.62; P = .04) were more likely to experience sexual objectification.

Racial/Ethnic Microaggressions

Racial/ethnic microaggressions were experienced by 299 of 367 racial/ethnic–minority physicians (81%). A total of 67 of 299 (18%) experienced cumulative microaggressions across all 6 RMAS survey subscales (Table 3). Within this subset, 47 of 67 individuals (70%) were female, and although these individuals were primarily Asian (25 of 67 [37%]), 12 of 31 (39%) of all Hispanic and 14 of 23 (61%) of all Black respondents met the criteria for this group. Female physicians experienced a significantly higher prevalence of all microaggressions compared with male physicians, except for criminality. The most commonly reported microaggression was environmental or few role models, authority figures, and coworkers of the same race (246 of 367 [67%]). This microaggression was significantly higher for female physicians (120 of 162 [74%]), those who identified as being in a URM group (52 of 58 [90%]), and South Asian physicians (33 of 47 [70%]). The foreigner subscale, feeling targeted for being “not a ‘true’ American” or being a “foreigner,” was the next most common microaggression (187 of 367 [51%]) and occurred more commonly in female (94 of 162 [58%]), Asian (108 of 189 [57%]), South Asian (28 of 47 [60%]), and Middle Eastern (21 of 39 [54%]) physicians. The criminality subscale, being perceived as scary or aggressive or being singled out by law enforcement because of race/ethnicity, had the lowest frequency (18 of 367 [5%]) but was unique to and significantly higher for Black (11 of 23 [48%]) and Hispanic (3 of 31 [10%]) physicians. Racial/ethnic sexualization occurred in 58 of 267 racial/ethnic–minority physicians and was primarily reported by female physicians in this cohort (47 of 58 [81%]). This microaggression was also more prevalent among Hispanic (10 of 31 [32%]), Black (8 of 23 [35%]), and multiracial (9 of 24 [27%]) physicians.

Table 3. Prevalence, Frequency, and Severity of Racial/Ethnic Microaggressions Among Racial/Ethnic–Minority Physicians Using the RMAS.

Variable Median (IQR)a P value Median (IQR)a P valueb
Female Male Hispanic Asian South Asian Middle Eastern Black Hawaiian Pacific Islander or other Multiracial Total No.
Survey subscale, No. (%) 162 (44.1) 205 (55.9) NA 31 (8.4) 189 (51.4) 47 (12.8) 39 (10.6) 23 (6.7) 4 (1.1) 34 (9.2) 367 NA
Foreigner
No. (%) 94 (58) 93 (45.4) .02 10 (32.3) 108 (57.1) 28 (59.6) 21 (53.8) 5 (21.7) 2 (50) 13 (38.2) 187 (51) .004
Frequency 1.0 (0.7-1.7) 1.0 (0.7-1.3) .14 0.7 (0.3-1.0) 1.0 (0.7-1.3) 1.0 (0.7-1.7) 1.0 (0.3-1.7) 0.3 (0.0-0.7) 0.9 (0.4-1.2) 1.0 (0.7-1.0) 1.0 (0.7-1.3) <.001
Severity 1.0 (0.3-1.3) 0.7 (0.0-1.0) .01 0.9 (0.2-1.5) 1.0 (0.3-1.3) 0.9 (0.3-1.3) 1.0 (0.0-1.3) 0.3 (0.0-0.7) 0.7 (0.0-1.0) 0.7 (0.3-1.0) 0.7 (0.3-1.3) .56
Criminality
No. (%) 11 (6.8) 7 (3.4) .14 3 (9.7) 2 (1.1) 0 (0) 2 (5.1) 11 (47.8) 0 (0) 0 (0) 18 (4.9) <.001c
Frequency 0.0 (0.0-0.3) 0.0 (0.0-0.3) .63 0.0 (0.0-0.3) 0.0 (0.0-0.0) 0.0 (0.0-0.3) 0.0 (0.0-0.3) 0.8 (0.5-1.3) 0.0 (0.0-0.0) 0.0 (0.0-0.3) 0.0 (0.0-0.3) <.001
Severity 0.8 (0.5-1.4) 0.5 (0.3-0.8) .01 1.0 (0.5-1.8) 0.3 (0.3-0.8) 0.5 (0.3-0.8) 0.5 (0.5-1.0) 1.4 (0.5-2.4) 0.0 (0.0-0.0) 0.5 (0.3-1.0) 0.5 (0.3-1.0) <.001
Sexualization
No. (%) 47 (29) 11 (5.4) <.001 10 (32.3) 25 (13.2) 5 (10.6) 1 (2.6) 8 (34.8) 0 (0) 9 (26.5) 58 (15.8) <.001c
Frequency 0.3 (0.0-1.0) 0.0 (0.0-0.3) <.001 0.3 (0.0-1.0) 0.3 (0.0-0.7) 0.0 (0.0-0.3) 0.0 (0.0-0.3) 0.3 (0.0-1.0) 0.3 (0.3-0.5) 0.3 (0.0-1.0) 0.3 (0.0-0.7) .02
Severity 1.0 (0.3-1.7) 0.3 (0.0-0.7) <.001 1.0 (0.3-1.3) 0.5 (0.2-1.0) 0.3 (0.0-1.0) 0.2 (0.0-0.3) 0.9 (0.0-2.0) 0.2 (0.0-0.3) 1.5 (0.3-2.0) 0.3 (0.0-1.3) .01
Low achieving
No. (%) 56 (34.6) 35 (17.1) <.001 15 (48.4) 38 (20.1) 8 (17) 5 (12.8) 16 (69.6) 1 (25) 8 (23.5) 91 (24.8) <.001
Frequency 0.7 (0.3-1.3) 0.4 (0.3-0.9) .001 1.1 (0.6-1.9) 0.6 (0.3-1.0) 0.4 (0.2-0.7) 0.4 (0.2-0.7) 1.4 (0.8-1.9) 0.6 (0.4-1.2) 0.6 (0.3-1.0) 0.6 (0.3-1.0) <.001
Severity 0.7 (0.2-1.3) 0.3 (0.1-0.7) <.001 1.2 (0.2-1.9) 0.4 (0.1-0.8) 0.3 (0.1-0.7) 0.3 (0.1-0.7) 1.4 (0.8-2.3) 0.2 (0.1-1.0) 0.4 (0.2-1.1) 0.4 (0.1-1.0) <.001
Invisibility
No. (%) 45 (27.8) 24 (11.7) .001 9 (29) 30 (15.9) 7 (14.9) 4 (10.3) 13 (56.5) 1 (25) 5 (14.7) 69 (18.8) <.001c
Frequency 0.6 (0.3-1.1) 0.3 (0.0-0.6) <.001 0.6 (0.1-1.6) 0.5 (0.1-0.9) 0.3 (0.1-0.8) 0.1 (0.0-0.4) 1.0 (0.6-1.5) 0.5 (0.2-1.1) 0.1 (0.0-0.6) 0.5 (0.1-0.9) <.001
Severity 0.9 (0.5-1.5) 0.5 (0.1-0.9) <.001 1.0 (0.5-1.9) 0.7 (0.3-1.1) 0.5 (0.3-1.1) 0.5 (0.1-0.9) 1.1 (0.6-2.0) 0.5 (0.3-1.6) 0.6 (0.1-0.8) 0.8 (0.3-1.3) .02
Environmental
No. (%) 120 (74.1) 126 (61.5) .010 26 (83.9) 115 (60.8) 33 (70.2) 23 (59) 23 (100) 3 (75) 23 (67.6) 246 (67) .003
Frequency 1.6 (1.2-2.0) 1.2 (1.0-1.6) <.001 1.8 (1.2-2.2) 1.2 (1.0-1.6) 1.2 (1.0-1.8) 1.4 (0.8-2.0) 2.0 (1.8-2.6) 1.6 (0.8-2.3) 1.4 (1.2-2.0) 1.4 (1.0-1.8) <.001
Severity 0.7 (0.2-1.0) 0.4 (0.0-0.6) <.001 0.9 (0.4-1.4) 0.4 (0.2-0.8) 0.4 (0.0-1.0) 0.0 (0.0-0.6) 1.0 (0.4-1.4) 0.4 (0.1-1.4) 0.4 (0.2-0.6) 0.4 (0.2-1.0) <.001
All 6 subscales
No. (%) 47 (29) 20 (9.8) <.001 12 (38.7) 25 (13.2) 6 (12.8) 4 (10.3) 14 (60.9) 1 (25) 5 (14.7) 67 (18.3) <.001c
Overall frequency 0.8 (0.5-1.2) 0.5 (0.4-0.8) <.001 0.8 (0.5-1.4) 0.6 (0.4-0.8) 0.5 (0.4-0.8) 0.5 (0.3-0.7) 1.3 (0.8-1.6) 0.6 (0.4-1.0) 0.7 (0.4-0.8) 0.6 (0.4-0.9) <.001
Overall severity 0.7 (0.4-1.2) 0.3 (0.1-0.6) <.001 0.8 (0.3-1.3) 0.4 (0.2-0.7) 0.3 (0.2-0.8) 0.3 (0.1-0.6) 1.0 (0.5-1.8) 0.3 (0.1-0.8) 0.4 (0.2-0.7) 0.4 (0.2-0.8) <.001
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Abbreviations: IQR, interquartile range; NA, not applicable; RMAS, Racial Microaggression Scale.

a

Median comparisons were determined by the Kruskal-Wallis test for more than 2 comparison groups. Medians are reported for 299 physicians (those with microaggression prevalence).

b

P value determined by the χ2 test unless otherwise indicated.

c

P value determined by the Monte Carlo estimates for exact test.

The overall median racial microaggression frequency was rare at 0.6 (IQR, 0.4-0.9) and associated with a little stress or severity (0.4; IQR, 0.2-0.8). However, environmental microaggression frequency was significantly higher for racial/ethnic–minority female physicians (1.6; IQR, 1.2-2.0), and URM physicians (1.8; IQR, 0.8-2.2), occurring a moderate amount. Increased severity or stress were seen among Black (1.4; IQR, 0.5-2.4) and Hispanic (1.0; IQR, 0.5-1.8) physicians reporting criminality and for Black (0.9; IQR, 0.0-2.0), Hispanic (1.0; IQR, 0.3-1.3), and multiracial (1.5; IQR, 0.3-2.0) groups reporting racial/ethnic sexualization.

In adjusted models, racial/ethnic–minority female physicians were more likely to experience feeling like a foreigner (OR, 2.89; 95% CI, 1.62-5.17; P < .001) and racial/ethnic sexualization (OR, 6.11; 95% CI, 2.70-13.80; P < .001) compared with racial/ethnic–minority male physicians. Although findings of increased sexualization in non–male-dominant fields did not persist, female physicians who reported working primarily with women were more likely to experience feeling like a foreigner (OR, 2.04; 95% CI, 1.18-3.53; P = .01), to experience racial/ethnic sexualization (OR, 2.30; 95% CI, 1.06-5.09; P = .03), and to experience environmental inequity (OR, 1.93; 95% CI, 1.11-3.37; P = .02). Identifying as being from a URM group was protective against the foreigner subscale (OR, 0.19; 95% CI, 0.09-0.39; P < .001); however, increased association with criminality (OR, 14.93; 95% CI, 4.50-48.50; P < .001) and environmental inequity persisted (OR, 4.21; 95% CI, 1.60-10.75; P = .002) compared with those from other racial/ethnic–minority groups. Physicians older than 50 years were more likely to experience the foreigner microaggression (OR, 6.60; 95% CI, 2.10-20.66; P = .001) compared with younger physicians.

Physician Burnout

The overall prevalence of physician burnout was 47% (280 of 588 physicians), with highest rates among ophthalmologists (18 of 32 [56%]), urologists (20 of 36 [55%]), and obstetrician-gynecologists (115 of 218 [52%]) and the lowest rates for plastic surgeons (5 of 22 [23%]) and anesthesiologists (30 of 80 [38%]) (P = .06). Prevalence was higher for female vs male physicians for burnout (140 of 259 [54%] vs 140 of 329 [43%], P = .01), EE (118 of 259 [46%] vs 108 of 329 [33%], P = .002), and DP (107 of 259 [41%] vs 94 of 329 [29%], P = .001). When stratified by race, PA was higher for White physicians (185 of 221 [84%]) compared with racial/ethnic–minority physicians (266 of 367 [72%]) (P = .002).

The median frequency of burnout experiences was a few times per month (3.6; IQR, 3.2-4.1). Emotional exhaustion occurred a few times per month (3.7; IQR, 3.1-4.4), DP occurred once per month (2.4; IQR, 1.8-3.2), and PA occurred on a weekly basis (4.6; IQR, 3.9-5.1).

In adjusted models, being a plastic surgeon was protective against burnout (OR, 0.30; 95% CI, 0.10-0.91; P = .03) and EE (OR, 0.14; 95% CI, 0.03-0.60; P = .01). Although not protective against overall burnout, being an anesthesiologist was protective against EE (OR, 0.15; 95% CI, 0.03-0.62,; P = .01). Being single or not married was associated with DP (OR, 2.18; 95% CI, 1.10-4.60; P = .05) and low PA (OR, 2.4; 95% CI, 1.14-5.42; P = .03). Female physicians were more likely to report burnout (OR, 1.60; 95% CI, 1.03-2.47; P = .04), EE (OR, 1.61; 95% CI, 1.02-2.53; P = .04), and DP (OR, 1.80; 95% CI, 1.17-2.77; P = .001). Racial/ethnic–minority physicians were more likely to experience low PA compared with White physicians (OR, 2.08; 95% CI, 1.31-3.30; P = .002).

Intersection Between Microaggressions and Physician Burnout

An analysis of the association among sex, race/ethnicity, and physician burnout was performed (Figure 2). Female physicians who experienced sexist microaggressions (racial minority group: OR, 2.28; 95% CI, 1.40-.3.71; P = .001; White group: OR, 2.45; 95% CI, 1.42-4.25; P = .001) were more likely to experience burnout compared with White male physicians. Racial/ethnic–minority female (OR, 2.32; 95% CI, 1.41-3.82 P = .001) and male (OR, 1.82; 95% CI, 1.12-2.94; P = .01) physicians who experienced racial/ethnic microaggressions were more likely to report physician burnout compared with White male physicians. When adjusting for demographic variables, this finding only persisted for racial/ethnic–minority female physicians (OR, 1.86; 95% CI, 1.03-3.35; P = .04). Racial/ethnic–minority female physicians who had the compound experience of sexist and racial/ethnic microaggressions were more likely to experience burnout compared with racial/ethnic–minority (OR, 1.60; 95% CI, 1.01-2.42; P = .05) and White male physicians (OR, 2.50; 95% CI, 1.51-4.14; P = .001). In adjusted models, this finding persisted when compared with White male physicians (OR, 2.05; 95% CI, 1.14-3.69; P = .02).

Figure 2. Associations Between Microaggressions and Physician Burnout.

Figure 2.

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A, Unadjusted estimates. B, Estimates adjusted for age, specialty, fellowship, operating time, gender environment, relationship status, parental status, years in practice, and years at Southern California Permanente Medical Group.

Discussion

In this survey study, there was a high prevalence of sexist and racial/ethnic microaggressions against surgeons and anesthesiologists. Racial/ethnic–minority female physicians, specifically URM physicians, experience the highest prevalence and severity. Furthermore, sexist and racial/ethnic microaggressions were associated with physician burnout.

The novelty of these findings lies in the intersection of sex, race/ethnicity, and physician burnout, whereby a crucial association between microaggressions and physician burnout is demonstrated. The rate of physician burnout is consistent with national estimates of approximately 50%, as well as higher rates among female compared with male surgeons.15,16,17 These findings indicate that female physicians who experienced sexist microaggressions were more likely to report burnout, and racial/ethnic–minority female physicians who experienced sexist and racial/ethnic microaggressions were more likely to report physician burnout compared with their White, male colleagues. The study did not find a difference among female physicians, irrespective of race/ethnicity, which corroborates published findings on the significant impact of female sex on physician burnout. Potential sex-based contributors to burnout include minority status in male-dominant fields, dual-role responsibilities, gender judgment, and different pressures or challenges in the workplace compared with male colleagues.11,18,19 Although we are unable to assume causality, the association of physician burnout with sexist and racial/ethnic microaggressions provides a valuable response to the call to further investigate this intersection.3,8

Our high prevalence of microaggressions is consistent with published reports11,20,21 that surgical environments are wrought with sexism and racial/ethnic bias. Barnes et al11 reported that all their female surgeon participants experienced gender bias or discrimination during medical training. We found that female physicians who reported working primarily with men were more likely to experience sexist microaggressions and female physicians who reported working primarily with women were more likely to experience racial/ethnic microaggressions. This finding speaks to the lived experience of many female surgeons who report differential treatment by both patients and staff. The finding also highlights the disadvantages for female surgeons identified by Brubaker20 and intensifies the concern that these realities will worsen in light of the coronavirus disease pandemic. These findings echo the marked inequity of female leadership in surgery, despite increasing rates of female surgeons overall.21

Although similar inequities for those in URM groups have been documented, the data are still emerging.22,23 This study found that male and female URM physicians had a consistently higher prevalence of racial/ethnic microaggressions compared with other racial/ethnic minorities. Furthermore, URM female physicians were twice as likely to experience sexist microaggressions, and racial/ethnic–minority female physicians, in general, were more likely to experience racial/ethnic microaggressions than their male colleagues. Thus, this study confirms the association among racial/ethnic–minority surgeons and anesthesiologists with a high risk of discrimination and mistreatment and further proposes that microaggressions contribute to the pervasive workplace inequity they face.

Varying definitions have been used to measure the prevalence of sexist and racial/ethnic microaggressions; however, their negative impact appears clear.12 The definition of sexist and racial/ethnic microaggression prevalence in the current study intentionally captured any degree of microaggressions. This approach is based on the notion that people process discrimination differently; whereas one person may be keenly aware and recognize the effect, another person may deny its existence, despite similar or worse impact.24 Because of the cumulative effect of microaggressions and the tendency for individuals to minimize these experiences, we argue that the frequency definition used in this study accurately reflects the lived experience and supports our belief that microaggressions that occur a few times are a few times too many.

Strengths and Limitations

This study has strengths and limitation. Its strengths lie in the representation of a diverse group of surgeons and anesthesiologists across all surgical subspecialties, consistent with Kaiser Permanente’s history as a leading organization in diversity and inclusion.25 Although the number of female and racial/ethnic–minority respondents was expectedly higher than nationally reported averages, the number was consistent with available SCPMG physician demographic data.26 The use of validated, quantitative questionnaires to assess both sex and racial/ethnicity bias adds further strength to the study.

Study limitations are those attendant to any cross-sectional survey within a single health care system and the bias introduced by a 41% response rate. In addition, we did not query all potential variables that may inform sexist and racial/ethnic microaggression experiences or physician burnout (ie, sexual orientation). Similarly, we queried the respondents’ gender using nonbinary, transgender-inclusive terms; however, the results were binary and based on the biological sex construct (male and female), which may be inconsistent with prior publications that use the terms woman and man. Future studies should attempt to align the language used to study sex and gender and include sexual orientation in relation to burnout.

Of importance, we are uncertain whether we measured the sexist and racial/ethnicity microaggression experiences themselves or the chronic effect of these experiences. Although we asked respondents to reflect on their workplace experience, the Sexist MESS and RMAS are not specific to physicians and do not require a temporal report. Thus, the microaggression experiences measured here are likely to reflect the microaggression experience beyond SCPMG because these issues are widespread in medicine.

Conclusions

These results suggest that there is a high prevalence of implicit bias or microaggressions that stigmatize female and racial/ethnic–minority physicians and contribute to unhealthful20 surgical workplaces and physician burnout. These findings highlight the gaps in empathy and compassion within the medical community and society at large. Although focused awareness on implicit sexism and racial/ethnic bias within our medical institutions is increasing, efforts must address these issues within the context of society’s structural sexism and racism. Individuals and medical organizations play an active role in mitigation of these experiences and associated burnout, and future research should assess both perpetrators and allies. At an individual level, value and respect should be placed on addressing microaggressions in a nonaccusatory manner, as proposed by the GRIT (gather, restate, inquire, talk it out) mnemonic.27 Systemic algorithms, such as the #BeEthical 6-step process of investigation, implementation, and publication of institutional efforts toward gender equity, should extend to racial inequity and be prioritized to the same degree as medical research.28 As we continue our work on these important topics, we place a call to action to our medical community to prioritize this imperative.

Supplement.

eFigure. Survey Branching Logic

eTable 1. Demographic Survey

eTable 2. Sexist Microaggression Survey (Sexist MESS)

eTable 3. Racial Microaggression Survey (RMAS)

Click here for additional data file. (400KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eFigure. Survey Branching Logic

eTable 1. Demographic Survey

eTable 2. Sexist Microaggression Survey (Sexist MESS)

eTable 3. Racial Microaggression Survey (RMAS)

Click here for additional data file. (400KB, pdf)

Articles from JAMA Surgery are provided here courtesy of American Medical Association

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