This novel case comes from Drs. Melissa Bouwsema, Tia Warkentin and Erin Brennan.
Drs Bouwsema and Warkentin are Emergency Medicine Residents at Queen’s University in Kingston, Ontario, Canada. Dr. Brennan is an attending Emergency Physician at Kingston General Hospital and Emergency Medicine Residency Program Director at Queen’s University.
Read more about this case in the Canadian Journal of Emergency Medicine: Education Innovation
Why It Matters
This case aims to address microaggressions using simulation. Microaggressions are defined as daily, subtle snubs, slights, and insults directed towards historically stigmatized, oppressed or excluded groups that implicitly communicate hostility, general disrespect and devaluation. This case focusses specifically on microaggressions women commonly experience as health care providers.
Clinical Vignette
A 60-year old man comes to the ED from home with two days of confusion and urinary symptoms. He is febrile, tachycardic and hypotensive on arrival to the resusciation bay.
Case Summary
The resident team leader has 3 minutes to organize her team. She has 2 male RNs available. As the case progresses, she will encounter multiple gendered microaggressions.
A paramedic goes to a male nurse asks if he is the staff taking care of this patient (gender stereotype 1).
Once the resuscitation begins, the mildly confused patient comments on the resident’s appearance “lucky me to get such a good-looking doctor” (gender stereotype 2). Once the patient is more settled, he asks the resident for warm blankets and ginger ale.
The patient is stabilized and the resident contacts the internist on call. The consultant comes down and asks “who is in charge of this patient”. He begins questioning the management and asks to speak to the staff (gender stereotype 3).
Debriefing Notes
This case, in many ways, serves as a launching point for conversation. It is not a traditional simulation case; instead of having the debriefing and discussion concentrate on medical management and individual participants’ actions, facilitators intentionally describe the microaggressions that occurred and guide the discussion to focus on concrete actions that can be integrated into clinical practice. The case involves many actors. The role of the actors is essentially to commit the microaggressions toward the resident managing the case. Because this case can be triggering, especially for individuals having experienced previous microaggressions, careful selection of actors and participants, as well as pre-briefing the resident leading the case far ahead of time are crucial. When we ran this case with our residents, one of the case authors volunteered ahead of time to be the resident managing the case. This means she was aware beforehand that she would be having this experience. The other trainees watched the case.
We all know that simulation is a useful tool; it’s impact and utility depend on who is using it and how well they know how to operate it. This is particularly true for this case. In addition to normal pre-briefing information about safe spaces, this case requires the explicit discussion of brave spaces. It also requires that the facilitators have taken the time to learn about microaggressions and their impact. For this session to have positive impact, the facilitators must also be versed in discussing ways that we can be allies to those experiencing microaggressions. The real value here is in educating each other through conversation. A skilled facilitator is required to ensure biases are not perpetuated. We would also recommend that the facilitators should be of diverse background – both those who have experienced microaggression (in this case, those identifying as cisgender women) and those who have not.
Download the Case Here
Additional Learning Resources
If you are interested in learning more about microaggressions and their impact on health care professionals, we recommend reading this article by Samina Ali or this fantastic review article from Annals of Emergency Medicine.
For those looking to learn more about how to be an ally or how to respond when witnessing microaggressions, we would recommend resources such as O3, Open the Front Door, the 5 D’s or Call In/Call Out. These resources are a bare minimum for facilitators looking to incorporate a session like this one into their curriculum.
References
- Torres MB, Salles A, Cochran A. Recognizing and Reacting to Microaggressions in Medicine and Surgery. Chicago: JAMA Surg; 2019 Sep. 1;154(9):868-872. doi: 10.1001/jamasurg.2019.1648
- Ali, S. Be Polite. CJEM. 2022 Oct 5; 24:88-89. doi: 10.1007/s43678-021-00208-6
- Molina MF, Landry AI, Chary AN, Burnett-Bowie SM. Addressing the Elephant in the Room: Microaggressions in Medicine. Dallas: Ann Emerg Med; 2020 Oct. 76(4):387-391. doi: 10.1016/j.annemergmed.2020.04.009
- Tavares W, Eppich W, Cheng A, Miller S, Teunissen PW, Watling CJ, Sargeant J. Learning Conversations: An Analysis of the Theoretical Roots and Their Manifestations of Feedback and Debriefing in Medical Education. Acad Med; 2020 Jul. 95(7):1020-1025. doi: 10.1097/ACM.0000000000002932
- Interrupting Bias: Calling Out vs Calling In. Seed the Way; 2018. [cited 2022 April 26] Available from: http://www.racialequityvtnea.org/wp-content/uploads/2018/09/Interrupting-Bias_-Calling-Out-vs.-Calling-In-REVISED-Aug-2018-1.pdf
EM Sim Cases 