By AMY LANGRIDGE
Micro aggression is a relatively new term (circa 1970) and although discussed as a way of articulating the act of subtle and unconscious racism by Pierce et al  the concept has evolved to include sexism, homophobia, ageism and many other aspects of aggression that are experienced by marginalized groups within society. The very notion that microaggressions are unconsciously emitted without intent to cause harm by the perpetrator makes it a troubling concept to remedy or even prevent but what does this mean for paramedic practice and how do we attempt to address this as leaders within the profession? When I consider microaggressions within the spaces of paramedic practice, all the above subcategories have played their part in experiences I have had in practice, from patients, the accounts of my staff at the time, and me personally. With this in mind, I would like to broach this covert aggression as a way of depicting how peer microaggressions have been witnessed by myself and experienced or shared by others.
As a paramedic, I always found it easier to hide the varying facets of my own personal identity, especially my sexuality, behind the uniform. In the almost ritualistic process of preparing for a shift, the uniform became my shield and projected identity as discussed by Flugel  in as early as 1940 and again by Sterman  in 2011. I always knew that the uniform gave a merely perceived sense of security within which I was safe and could not be harmed, yet what is more troubling is the thought that someone would want to cause harm to a paramedic, after all, we are there to help. This ability to help, I always felt was of higher value to my staff and my patients above anything else, even above aggression. Fundamentally, there were times when I felt maybe it was microaggression filtering through, however, only now when I truly reflect, do I realize they were microaggressions and consider the negative and positive impact this had on myself, my practice and my identity.
As paramedics, we are uniquely positioned: in that we are invited into people’s lives, often at times of greatest need and vulnerability, yet there are concerning instances whereby paramedics are the vulnerable ones, with multiple historic occasions of violence and aggression directed towards crews discussed by Bingham et.al 2014 . Could the unconscious violence of microaggression be considered a part of this too? As a paramedic, must we fall into the trap of having to hide our own vulnerability and feelings of fear during practice when the direct patient and peer contact positions us in this way? Moreover, as an operational manager or leader in the field, how can we as leaders find the balance over the needs and perceptions of clinical staff versus the expectations of patients and perceived notions of what is simply’ ‘okay by me’. As an example, if a male paramedic member of your staff received a complaint over exposing a female’s chest to perform an ECG, although consent was given at the time of treatment, later the patient feels as though there was an unconscious judgement of her as a female – who do you appease? Whilst neither party is technically wrong for the opinions, feelings and actions which followed, the gaps in communication and understanding perhaps reveal that we should we be less focused on apologising and place more emphasis on education and research.
During my paramedic training in the UK, I vividly remember having a whole day dedicated to communication skills and cultural sensitivity. We were taught to be prepared for patients and relatives who may react differently and to be sensitive to others’ cultural and religious beliefs and practices. One such example I recall, is that in Arabian culture it is considered rude and disrespectful to hold eye contact with women, or ask a male questions regarding any female members of their family, especially his wife. This of course becomes difficult in medical practice and exceptions are generally made by the patient and/or relatives. Nevertheless, the fact a paramedic may appear ignorant of this knowledge can be considered a microaggression, or when the patient or family appear more receptive to a male counterpart of a crew in attendance may be perceived by the female paramedic as a form of microaggression towards them. Is this microaggression or more a mismatch of cultural understanding?
Perhaps it is a significant aspect of my personality to be able to deal empathetically with people regardless of their actions that made it easier to deflect or set boundaries with patients and colleagues. Except upon reflection now, this raises more questions, such as; Is it any easier to act impartial or compassionate when you are seen as a mere vessel for medical provision or do we see past gender, race, age, sexuality and individual identity at times of emergent medical crisis? Quintessentially, is it only at the point of greatest vulnerability that we cling to the only true constant, the fact we are all human beings.
As a medical professional, we are taught to communicate, treat and represent a professionalism that fits with the expectations of our profession, employers, industry, colleagues, patients and public. Meeting our patient’s expectations can be enough of a challenge, yet we are often required to add an additional layer of social awareness that, I admit, sometimes takes a back seat when within the moment of treating a patient. Would it then be fair to say that we too as paramedics see past race, gender, sexuality and identity and simply see ‘the patient’. This too can be a form of microaggression when you consider how it feels to be seen as a condition or ailment first and not as the person with a character, history, culture and personality of the human we are treating.
The impact of microaggressions should not only be something we consider the impact of when thinking about our relationships with patients and the public. Molina  indicates that peer to peer microaggression between physician and nurse is still prevalent, additionally from my own experience, I can say the same for peer clinical levels within Paramedicine. For example, how often have we lived the experience where you are receiving a patient handover and yet the attending clinician continues to direct their attention to a paramedic of greater positional power, the one with the stripes or stars on the epaulets, or higher designation level? This intersects with boundaries of gender, race, age and sexuality and sadly all too often in my practice, I have had to redirect a fellow professionals’ attention back to the actual attending clinician, whether that be myself or a fellow colleague. Even within leadership teams of external medicine, I have experienced professional peer microaggression within interdisciplinary teams for being a paramedic officer in a room of executive board leaders and NHS officials. So as the minority, whether you are the elephant in the room or you are indirectly assuming there is one, it is disheartening that this form of microaggression is still occurring, yet only through revisiting these experiences have I conceded that action is required to disrupt or change these practices.
So do we work with microaggression or against it? Personally, I have found microaggressions have occurred as part of my own unconscious bias and furthermore as part of my intrinsic cultural background. To be British, Caucasian, female, homosexual, an immigrant, a paramedic, a leader or a mentor, are not mere labels I define my experiences by, nor does the fact that all the above labels apply to me mean that I have an all-encompassing understanding of how microaggressions are experienced by all the aforementioned subcategories. Just because you belong to a certain demographic or gender doesn’t mean all your experiences or values are shared across fellow members. Even now, at a time where gender and sexuality are understood to be more fluid, there needs to be greater understanding rather than assumption that an exterior representation may not be a true reflection of how that person identifies and would think, feel and react to perceived ideas of inclusion or exclusion.
So how does this impact our profession? Are microaggressions something to which we deal with personally and inter-professionally, or something to which we are conscious of only when treating patients? Additionally, shouldn’t we expect the same respect and courtesy from our patients? To practice medicine in any speciality, we do so with the intention to cause no harm, yet if microaggression is widely perceived as a means to inflict or sustain unintended harm, regardless of the fact it may be unconsciously done, harm is caused and we should all be acting accordingly to eradicate it. Perhaps, for Paramedicine a more focused approach towards respect and inclusion rather than tripping over unconscious microaggression is the best way forwards and the use of strategies as outlined by Herrick “Cricket” Fisher, MD MPhil Microaggression Response Toolkit  may well be a stepping stone towards this.
Essentially, I would argue that we should all be striving towards an inclusive way of practicing Paramedicine and fully living in our identities. If inclusion refers to; active, intentional and ongoing actions that create a community where all feel like they belong with their unique perspectives, backgrounds, skills and beliefs respected, welcomed and valued, this would need everyone to be acting in intentionally inclusive ways. Whilst the world we live is a place of widely varied cultures, religions, social structures and all of us having our own needs to be perceived as inclusive, it feels as though this may mean significant work must be done to be individual and inclusive at the same time. Only by bringing the unconscious bias and harm into the spotlight can we hope to pave the way for a better understanding and more inclusive working culture.
- Pierce, C. M. et al. (1977) ‘AN EXPERIMENT IN RACISM: TV Commercials’, Education and Urban Society, 10(1), pp. 61–87. [Cited 11.03.2021] doi: 1177/001312457701000105.
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- Fisher, H.N., Chatterjee, P., Shapiro, J. et al. “LET’S TALK ABOUT WHAT JUST HAPPENED”: a Single-Site Survey Study of a Microaggression Response Workshop for Internal Medicine Residents. J GEN INTERN MED (2021).[Cited 19.03.2021] https://doi.org/10.1007/s11606-020-06576-6
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