Who is the Doctor?

#Heforshe is a hashtag that has spread across Twitter as a way to encourage male allies to support their female colleagues. While not unique to healthcare, it has been embraced by #medtwitter to advocate for a more inclusive and diverse workplace.

#HeforShe has been applied to a number of situations, one of which is being an active bystander to address microaggressions: slights based on stereotypes. While microaggressions are often unconscious on the part of the transgressor, the implications and cumulative effects are negative.

For example, some physicians—typically female and/or minority—repeatedly have to clarify that they are indeed physicians. When this confusion comes from a patient, it can have a detrimental effect on the physician-patient relationship as well as physician moral. @Choo_ek once wrote that she has to use her title 5 times before patients remember she is their doctor.

For women physicians, patients may identify the male medical student, resident, or nurse in the room as the physician, even after introductions have been made.

While there are many ways to handle this microaggression, the psychological principles of positive and negative emotional attractors (PEA/NEA)—a framework I learned from John Schaffner during my MBA coursework—can help explain why bystander intervention is such a successful method. This framework refers to the relationship between emotional stimuli and neurotransmitters of the autonomic nervous system. While NEA can make one defensive, anxious, guilty, and result in a decrease of executive functioning, PEA can make one hopeful and enhance resonant relationships.

Applying this idea to the microaggression above, one can appreciate that the physician’s response can quickly, and easily, create a NEA environment if they have to correct the patient about their role. One solution is described in this tweet from @BromoSouthern.

Rather than passively watching the patient dismiss the attending, he jumps in and defers the authority placed onto him to the attending physician, where it should have been directed originally.

This deference of authority is humbling, like politely turning down a compliment, and prevents the environment from becoming overtly negative, which was a risk if the attending was forced to correct the patient herself.

In this manner, the bystander was able to subtly address the patient’s comment as being inaccurate while maintaining a PEA environment with appropriate diction and the complement of her expertise. Additionally, it could be argued that this allows for the establishment of trust between the attending and the patient; a crucial aspect to the patient-physician relationship. The patient was never made to feel defensive and as though they themselves were trying to be overtly rude or disparaging.

While there are many ways to handle this microaggression, bystander intervention supports one’s colleague, clarifies the confusion, and allows the patient to learn, all while potentially maintaining a PEA environment. This may be why bystander training has been found to be more effective than implicit bias training at affecting workplace culture. As medicine works to address the implicit and systemic biases within health care, more hospitals and residency programs should consider implementing bystander training at all levels and across disciplines.