Characterizing Asian American medical students’ experiences with microaggression and the impact on their well-being

ABSTRACT

Purpose

This mixed-methods study quantified and characterized incidents of microaggressions experienced by Asian American medical students. The authors report on their impact and suggest improvements to create a more equitable and supportive learning environment.

Method

Quantitative and qualitative data were collected from 305 participants who self-identified as Asian American or Pacific Islander. An online, anonymous survey was sent to US medical students through the Asian Pacific American Medical Student Association (APAMSA). Questions explored incidence, characteristics of, and response to microaggressions. We conducted four focus groups to further characterize students’ experiences. Data were organized and coded, and thematic analysis was used to identify core themes.

Results

Racial microaggressions were prevalent among Asian American medical students. Nearly 70% (n = 213) of survey respondents reported experiencing at least one incident during their medical training to date. The most common perpetrators were patients (n = 151, 70.9%) and fellow medical students (n = 126, 59.2%), followed by professors (n = 90, 42.3%). The most prevalent themes included being perceived as a perpetual foreigner, the assumption of timidness, and ascription of the model minority myth. Students rarely reported the incident and usually did not respond immediately due to fear of retaliation, uncertainties about the experience or how to respond appropriately, and perception that they would bear the burden of advocacy alone. Experiences with microaggressions led to feelings of frustration and burnout and had a negative impact on mental health. Recommendations were made to improve the anonymous reporting systems in medical schools, and to increase diversity and inclusion in medical education and leadership.

Conclusions

Asian American medical students face high exposure to racial microaggressions during their medical education that adversely impact their mental health. Changes are needed in medical training to create a more equitable and inclusive learning environment.

KEYWORDS:

• Asian Americans
• medical students
• microaggression
• discrimination
• student wellness

Introduction

Over the past decade, United States (US) medical schools have become increasingly committed to diversity, equity, and inclusion (DEI) for students and faculty [1,2]. The extent to which this applies to Asian American groups is either unclear or frames Asian American groups with White or dominant groups. Increased xenophobia during the global COVID pandemic has resulted in greater attention on the incidence and rise in anti-Asian racism. Leaders in academic medicine have a renewed focus on addressing health inequities, structural racism, and lack of representation in medicine and healthcare. Accountability for climate, mistreatment, and the experience of trainees, faculty, and patients are requisite in all DEI initiatives.

Racial discrimination is the differential treatment of a person or group of people based on prejudices about their presumed race. In this study, we focus on commonplace and subtle discriminatory behaviors: racial microaggressions. The term ‘microaggression’ was initially coined in 1970 by Chester Pierce, a Harvard psychiatrist, to refer to the subtle yet damaging humiliations and indignities experienced by African Americans [3,4]. The term was broadened to include all persons from marginalized communities in 2007 by Derald Sue and he described them as, ‘brief, commonplace, daily verbal, behavioral or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults.’ [5] Studies have shown a dose-response relationship between experiences with microaggressions and anxiety or depression [6–8]. Furthermore, chronic exposure has been found to correlate with cognitive dysfunction, trodden self-esteem, and impaired productivity leading to poor academic performance in students [6,7,9–11].

Previously published studies have characterized experiences of microaggression faced by underrepresented minority (URM) groups in medical training [5,6,9,12–16]. It is generally accepted that African Americans and Latina/o Americans experience discrimination through both overt racism and racial microaggressions. However, the experience of Asian Americans¹ is less understood for a few reasons. First, students identifying as Asian represent the second largest group among medical students, comprising 28.7% of matriculants to US, MD-granting medical schools in 2022 [17]. The American Medical College Application Service offers 13 subcategories for Asian, which are largely reported in aggregate despite immense diversity that includes many distinct countries of origin. Despite robust representation at the student and trainee level, Asian Americans have lower representation within medical school leadership similar to many historically excluded groups [18]. Second, Asian Americans are often thought of as ‘successful,’ and therefore ‘immune’ to racism [19]. In discussions of racial discrimination and biased practices within medical schools, Asians are often categorized with their White counterparts and excluded from designations of underrepresented or people of color [13,20–23]. Asian Americans are often cast as the ‘model minority’ in which they are perceived as more academically and economically successful in society compared to other racial minorities [24–26]. This has been particularly harmful to marginalized groups within the Asian diaspora [27]. These perceptions have led to the exclusion of Asian American students from DEI efforts and support.

This article seeks to document the previously unheard voices of Asian American medical students on experiences of microaggressions in the training environment. We quantify and characterize incidents of microaggression and its impact on learning experiences.

Methods

Study design

We performed a mixed-methods study with the intention of quantifying and characterizing microaggression experiences of Asian American medical students in the US. Study participants were recruited through the Asian Pacific American Medical Student Association (APAMSA), the largest national organization for U.S. medical students to engage in Asian American, Native Hawaiian, and Pacific Islander (AANHPI) professional development, mentoring and health advocacy [28]. Recruitment was performed both in-person at the 2022 APAMSA National Conference, the largest annual APAMSA conference, and through e-mail via a nationwide listserv, which includes active e-mail addresses of members of the more than 120 APAMSA medical school chapter across the US [28]. The national conference served as a venue to collect candid data from the largest gathering of Asian American medical students in an environment that could be perceived as ‘safer’ and more culturally congruent than students’ own institutions [29]. All students who identified as AANHPI were invited to participate. Survey data was collected anonymously via Qualtrics (Qualtrics, Provo, UT), and incentives for completion consisted of ten raffled $20 merchandise cards. Volunteers for focus groups were recruited through an additional, separate survey question to maintain anonymity of survey responses. Four focus groups with four to seven participants were recruited, for a total of 26 participants. The institutional review board (IRB) of California University of Science and Medicine approved the study.

The survey included questions regarding demographics and personal experiences with microaggressions during medical school. Questions were designed to capture experiences of Asian American medical students with microaggressions (Appendix 1). The survey also included questions from two validated instruments, the Workplace Racial Microaggression Scale for Asians and Asian Americans [30] and the Racial and Ethnic Microaggressions Scale [31].

Focus groups consisted of semi-structured interviews based on aggregate responses to the survey and were conducted until thematic saturation was achieved (Appendix 2). Informal thematic analysis was conducted after each focus group, and no new themes were noted after the completion of the fourth focus group. We then employed formal inductive coding on the transcripts of the four focus groups which confirmed thematic saturation and the decision to not conduct additional focus groups.

Quantitative analysis

Descriptive statistics were calculated on survey data using IBM SPSS software (IBM Corp., Armonk, NY, USA). Frequencies were calculated on demographic and microaggression data. Means were calculated on the Likert Scale data, with comparisons between various subgroups performed using the Mann Whitney U test.

Thematic analysis

Qualitative analysis was performed through inductive coding by four of the co-authors (LZ, CA, JC, JP) with thematic checking with the remaining co-authors (SN, BL). Each focus group transcript was independently reviewed by at least two co-authors to generate initial themes, which were subsequently reviewed by four co-authors (LZ, CA, JC, JP) together to complete consensus coding. Two of the co-authors (CA, JC) are currently medical students and are both members of our population of interest. It was important to the study team to include medical students in the analytic process to ensure that the themes reflected their lived experiences as members of the population. By incorporating their positionality as medical students, they were able to leverage their own experiences with the experiences of our participants in a process of reflexivity. Each of the transcripts were also coded by a co-author who was not a medical student (LZ, JP), and checked with the remaining co-authors (SN, BL) to determine consensus. Codes were further broken down into themes and assessed by frequency.

Results

Demographics

We received 368 unique respondents to the survey. Sixty-three surveys were excluded due to incompleteness. A total of 305 survey participants were included in our analysis (Table 1). The majority of our survey respondents identified as women (n = 201, 65.9%). Almost 60% of the respondents were first (n = 82, 26.8%) or second (n = 97, 31.8%) year medical students, which reflected individuals in their pre-clinical years of medical school training and more likely involved in student organization activities. Notably, the majority of the survey participants self-identified as Chinese (n = 112, 36.7%), followed by multiracial (n = 45, 14.8%), Korean (n = 30, 9.8%), and Vietnamese (n = 30, 9.8%). While the majority of Asian-identified medical student matriculants in 2022–2023 were Indian (36.2%), the following highest identified Asian ethnicities include Chinese (17.3%), Korean (9.5%), and Vietnamese (6.5%), which is similar to our survey demographics [17]. APAMSA does not collect national membership data by Asian ethnicities.

Table 1. Characteristics of the survey and focus group participants.

Student characteristics:		Survey participants (n = 305)	Focus group participants (n = 26)
Gender	Man	91	5
	Woman	201	21
	Gender Diverse^a	10	0
	Preferred not to say	3	0
Age	20–25	174
	26–30	107
	31–35	15
	35 +	8
MS Year	First	82	4
	Second	97	8
	Third	65	5
	Fourth	44	5
	Fifth or higher	17	4
Generational Status	First	18
	1.5^b	67
	Second	196
	Third	15
	Fourth or higher	9
Location of medical school in US	East	46
	Midwest	145
	South	39
	West	68
	Preferred not to say	7
Self-identified race/ethnicity	Chinese	112	7
	Multiracial	45	2
	Korean	30	6
	Vietnamese	30	4
	Indian	25	2
	Taiwanese	21	1
	Filipino	17	2
	Other^c	24	2
	Preferred not to say	1	0

^aGender diverse gender identities include transgender man, transgender woman, non-binary individuals, and gender queer individuals.

^b1.5 generational status was defined as individuals born outside of the US and came to the US as a child (age 17 of younger).

^cOthers included: Bangladeshi, Cambodian, White, Japanese, Latino/a, Nepalese, Pakistani, Singaporean, Thai, Hmong, Burmese, Tongan, Samoan.

A total of 26 individuals participated in focus groups. Focus group participants were representative of survey participants.

A majority of Asian Americans medical students experience racial microaggressions

More than two-thirds (n = 213, 69.8%) of students reported experiencing at least one episode of microaggression during their medical school training. They reported the highest frequencies of microaggressions related to their race/ethnicity (n = 213, 100%), gender/gender-identity (n = 121, 56.8%) and size or physical appearance (n = 94, 44.1%) (Figure 1a). Most commonly, these microaggression encounters occurred with patients (n = 151, 70.9%) and other medical students (n = 126, 59.2%), followed by faculty supervisors in the classroom (n = 90, 42.3%) and in the hospital settings (n = 73, 34.3%) (Figure 1b).

Figure 1. Characterizing the microaggressions experienced by Asian American medical students by (a) theme; and (b) perpetrator.

Frequency from 213 surveys where participants had at least one experience with microaggression. Participants were able to select multiple choices.

To further characterize these experiences, we queried our focus group participants for examples of these encounters. The most frequent microaggressions towards Asian American medical students were categorized into the themes outlined in Table 2. The ‘perpetual foreigner stereotype’ was a commonly reported theme for many students [32]. Study participants recalled incidents where patients, fellow students, or supervisors asked, ‘Where are you from?’ implying that they were foreign-born and not American. Additionally, students mentioned incidents in which they were assumed to be ‘timid’ or ‘quiet,’ which led to assumptions of lacking confidence, interest, or competence. This was reported both by students who described themselves as quiet or shy and by students who described themselves as outspoken. Two examples included:

Attendings I’ve worked with commented that I sometimes seemed uninterested in what was going on because I was being very quiet. As a quiet person, I think that was just part of my personality, but they took that as a way of measuring interest. −4^th year multiracial medical student

People are taken off guard by my personality… they say, ‘I didn’t expect you to be so outspoken’ and those little digs … [I wonder] do you just expect me to meekly sit there and just follow along? – 2^nd year Korean-American medical student

Table 2. Themes regarding types of and students’ responses to microaggression experienced during medical training.

Topic:	Theme:	Description:	Frequency:
Microaggression based on:	Perpetual foreigner	Students are assumed to not belong where they are, either based on citizenship or profession.	15
	Assumption of timidness	Assumption is made about students as being quiet or timid and is reflected as lacking self-confidence in their interaction with patients.	9
	Model minority myth	The use of the model minority myth can be harmful when it diminishes the differing experiences of Asian American individuals.	8
	Misidentification as another Asian American individual	Students are mistaken for another Asian American, including other students.	7
	Intersectionality with gender identity	Students who identify as Asian American and female have an additional layer of discrimination against them.	6
	Relation made to the global pandemic	Students are associated with starting or spreading the COVID-19 pandemic.	4
How student responded to situation:	Decision that the most appropriate response is no response	Students refuse to allow the microaggression to impact the way they act in the interaction.	5
	Justification for the perpetrator	Students provide a justification for the perpetrator’s response as a way to process the situation.	4
	Outright identify the microaggression	Students immediately respond to the perpetrator by pointing out the microaggression as harmful and insulting.	4
Reasons why students did not respond to microaggression experience:	Fear of Retaliation	There is concern about impact on students’ grades or relationships with the individuals involved in the situation. Most students fear the impact it will have on their ability to get into residency if they were to respond outwardly.	18
	Lack of a safe space for Asian American students	Asian Americans are often not considered underrepresented minorities or people of color, which invalidates their feelings of discrimination.	16
	Uncertain if experience was a microaggression	Students describe a microaggression but then question if the experience is ‘severe’ enough to be classified as a microaggression.	7
	Uncertain about how to respond appropriately	There is a general lack of knowledge on how to respond to the situation.	7
	The overwhelming burden of advocacy	Students do not want to feel constantly responsible for educating others on how to interact with people of color.	4

The model minority myth undermined support for the academic struggles of participants. Despite positive intentions, the stereotype was sometimes used to justify higher expectations of the students by colleagues and supervisors despite actual lived experiences or lower socioeconomic backgrounds. For example, one student discussed how their academic struggles in medical school were ignored:

The perception of the model minority in terms of when you are struggling, or even if you’re not struggling but if you’re not making it look easy … – 3^rd year Indian-American medical student

Similar to our survey findings, the theme of intersectionality of racial and gender identity emerged from the focus group data. Students who identified as female felt an extra layer of complexity to their experiences with racial microaggression.

Students also shared stories of experiencing microaggressions related to the 2019 global pandemic. During the period of our data collection in 2022, there was a sharp rise in anti-Asian hate violence across the US [33]. Among our participants, these experiences most often involved patients whom students encountered on clinical rotations. A student shared:

“I was in rural Virginia… And, a patient outright asked for my ethnicity, and I said I identify as Chinese. And he said, ‘You’re here to kill us all,’ because of the pandemic. −3^rd year Chinese-American medical student

Asian American medical students lacked peer and institutional support to respond to acts of microaggression

The focus groups explored participants’ responses to incidents of microaggression. Among participants who had a clear reaction, a majority of them decided to not respond (Table 2). The students discussed considering the benefits and costs of an immediate response and felt that ‘brushing it off’ was the safest course of action. Less commonly, students rationalized justifications or understanding for the perpetrators’ or bystanders’ actions. For example, one student expressed empathy for her colleagues who were bystanders following an uncomfortable encounter:

Looking back, I feel like my attendings and residents may not have responded because they also did not know what to do … . I am not sure they were equipped to respond to patients saying mean things or using microaggressions. −3^rd year Chinese-American medical student

Lastly, some students also attempted to ‘retaliate immediately’ or at least to identify the incident as a microaggression when it happened.

More frequently, students felt uncertain about how to respond to microaggressions. Common reasons for the lack of immediate response included: 1. fear of retaliation; 2. lack of safe space for Asian American medical students; 3. Uncertainty if the described experience was a microaggression; 4. Uncertainty about how to respond appropriately; 5. The overwhelming burden of being alone in advocating for self (Table 2). Our participants expressed the distressing thought processes that followed microaggressions and the difficulties in characterizing and responding to the situations. A common scenario described by participants was feeling undignified after experiencing a ‘small’ microaggression, then being unsure about those feelings, and then feeling embarrassed about being bothered by it after the moment had passed. However, students also described the frequencies of these ‘small’ microaggressions and how they can become cumulatively overwhelming. An example of one student’s confession:

I’m just thinking of all the little things that have happened when I’ve been uncomfortable. I don’t really know how to address it because it’s so small and I think sometimes in certain situations when I have questioned it or brought it up to the perpetrator. It’s more like, ‘Oh, you took it the wrong way.’ … I think in that way, what’s the point of bringing it up? − 2^nd year Pacific Islander-American medical student

These common fears and uncertainties were heard across different focus groups, ethnic backgrounds, and training years. Students also spoke about potential consequences of responding to microaggressions, including jeopardizing professional relationships on clinical rotations and deleteriously affecting residency recommendations and future career opportunities.

In the survey, students were queried about the formal reporting resources of their medical schools and, of those who experienced an incident of microaggression, only 15.4% (n = 47) indicated they made a report. A majority of those reported it to a clerkship director (n = 20, 42.6%) and/or a dean of the medical school (n = 11, 23.4%). Among those who did not report incidents, 34.9% (n = 90) ‘did not feel comfortable reporting the incident,’ 15.9% (n = 41) ‘did not know how to report the incident,’ and 13.6% (n = 35) ‘fear the repercussions if [they] reported it.’ Participants were allowed to give more than one reason why they did not report.

Taken together, we found that, following an experience with microaggression, participants tended to rationalize the action of those involved (i.e., the perpetrator, bystanders) and fixate on the consequences of verbally identifying or reporting the incidents. Among our participants, the potential consequences and the lack of institutional support for Asian American students dissuaded them from speaking up.

Experiences with microaggression led to feelings of anger, isolation, and burnout

Previously published literature has correlated experiences of racial microaggression with negative outcomes for learners [5,6,9,12–15,34], and we hypothesized the same would apply to Asian American medical students. We therefore explored the impact these experiences had on our participants, focusing on how our participants coped. Our participants discussed the emotional impact that microaggressions had on them (Table 3). Most commonly, students described feelings of anger and frustration, followed by feelings of ‘burnout.’ Feelings of anger were directed at having to manage these situations internally without support, likely reflecting the reported lack of support and safe space. Many students indicated not feeling welcomed in DEI spaces because the medical schools did not consider them underrepresented.

Table 3. Themes regarding the impact of microaggression Asian American medical students and suggestions for change in medical school training.

Topic:	Theme:	Description:	Frequency:
Emotional impact of microaggression student experience:	Anger and frustration	Students feel anger and frustration when encountering microaggression.	14
	Feelings of burnout	Students describe feelings of ‘burnout’ and express hopelessness after so many encounters with microaggression and often having to be the ones doing the advocacy work without seeing any effect in society.	8
	Impact on authenticity of self	Students are unable to act as themselves for fear of perpetuating stereotypes or eliciting experiences of microaggression.	6
	Apathy due to frequency of the experience	Students have developed fatigue from the high frequency of microaggression that it often does not bother them anymore.	5
	Negative impact on mental health	Students describe feelings of loneliness and isolation, particularly when seen as ‘perpetual foreigners’ and ‘exotic’. There is an increased level of anxiety and insecurity among students with multiple, repeated experiences of microaggression.	5
Suggestion to change the learning environment:	Supportive action from administration and faculty members	Students recommended more accountability and acknowledgement from the faculty members that they interact with, and this includes speaking up for AANHPI students. There is an emphasis in removing the onus from students to do the education and reparative work.	15
	Include Asian American experiences in medical school curriculum	Students suggested including AANHPI experiences within the curriculum, in two main areas: 1. Patient health outcomes and disparities; 2. People of color facing microaggression and racism.	12
	Include Asian identify in diversity, equity, and inclusion (D.E.I) Efforts	Asians should not be excluded as a minority group and should be included in the D.E.I. activities and conversations. This includes working alongside other student organizations that focus on other minority groups.	10
	Diversify the medical workforce	Students emphasized the need for advocacy within the medical field with individuals who understand the students’ experiences. In particular, there was a call for increasing Asian American visibility in leadership.	8
	Improve the students’ anonymous reporting system	Students lack trust in current feedback systems and suggest changes to the system to improve medical education experiences. Changes include honoring anonymity and seeing more action from administration.	8

The word ‘burnout’ was used by students across different focus groups, and it was used in the context of burnout around advocacy within medical school and around the recent sentiments of ‘anti-Asian hate’ [33]. Students felt largely ignored by their administration and this led to discouragement. For example, a student stated,

Sometimes you get a little bit of advocacy burnout because you don’t necessarily know if the school administration will really do anything about it. −2^nd year Filipino-American medical student

Students also spoke about the negative environment created by these microaggressions and its impact on their mental health. Our participants described a sense of loneliness and isolation during their medical training. Many students voiced a sentiment of defeat in their attempt to overcome these experiences:

I have to be the person to sacrifice myself and put that target on my back because no one else is educated about this topic … That’s been a very isolating experience. −4^th year Chinese-American medical student

Asian American medical students in our study suffered from incidents of microaggressions largely without support from their medical school administration. The combination of feelings of uncertainty about the experience itself, the fear of consequences if reported, and the feelings of isolation and burnout around the experiences of microaggression impacted the mental health of Asian American medical students in the focus groups. To understand ways to mitigate this, we asked students to suggest changes that they hoped to see within medical schools to improve the experiences of a diverse student population.

A call for increasing the visibility of Asian experiences in DEI efforts

Focus group participants shared suggestions to create a more inclusive and equitable learning environment, and these were categorized into themes shown in Table 3. They had suggestions about their immediate environment but also recognized changes in the healthcare workforce and medical school curricula that could have more long-term and lasting benefits. The students advocated for more support and action from their administration and faculty members as well as improved anonymous reporting systems for students to use when they encounter microaggressions in professional and education settings. They also expressed that it was important to further educate their peers regarding the disparities and challenges faced by Asian Americans in society by including it in the curricula and by specifically including Asian identified students and faculty in DEI initiatives. Lastly, in alignment with their feelings of ‘advocacy burnout,’ our focus group participants emphasized increasing Asian American visibility in leadership.

Support from administration and faculty remained most important to our participants. The students wished that medical school faculty would ‘just listen’ and try to understand their experiences. One student stated,

[Asian students] feel like, by speaking up, they’re going to make a mountain out of a molehill. When really, it’s like we’re just surrounded by a million mole hills like we can’t go anywhere without stepping on one. And so, it really helps to have someone who recognizes the burden that microaggressions play in your day-to-day life. −3^rd year Indian-American medical student

Changes in medical school curricula were mentioned in all focus groups. Students thought that including the Asian American ‘lived experience’ in diversity training would help others understand their perspectives. Others advocated to include Asian populations in discussions of health care disparities to educate their colleagues to be ‘more welcoming to the [Asian American community].’ They proposed that these changes could lead to debunking the ‘model minority myth.’ Participants hoped that, with changes in the curricula, their supervisors in clinical rotations might also treat them with more respect.

In addition, participants suggested increasing Asian American representation in DEI efforts, such as within the diversity offices of their medical school and in collaboration with other race-affinity student organizations (i.e., Student National Medical Association (SNMA) and Latino Medical Student Association (LMSA)). For example, one student discussed how she felt unsure if she could take advantage of the resources offered by her school’s office of diversity:

I definitely agree with the idea about being Asian and dealing with [the] Office of Diversity. The people there are great, but I don’t know if I am allowed to go there. −2^nd year Korean-American medical student

The focus group participants believed that increasing Asian American representation in academic leadership would also mitigate their current dilemmas. The students voiced that having representation in leadership would give students more support. For example:

My school doesn’t really have any advisors or Deans or people [who] are Asian, who Asian students can turn to and [say], ‘I know you’re probably experiencing similar feelings that I am with the pandemic and all the hate crimes and everything,’ − 4^th year Vietnamese-American student

Overall, our participants felt that increased education regarding the diversity of histories and communities of Asian Americans within medical academia is needed to create a more inclusive environment for Asian American medical students.

Discussion

Our study is among the first mixed methods study that establishes the prevalence of microaggressions experienced by a large cohort of Asian American medical students during their training in US medical schools. We found that there is a high incidence of microaggression experienced by Asian Americans in medical school, and that these experiences have profound impacts on students’ well-being. While there has been a critical effort to recruit diverse student populations to medicine, the recognition of the importance of diversity is not sufficient to create an inclusive and supportive student culture. Medical schools must focus on creating safe and equitable spaces in which all students can thrive. Our study findings suggested that vital changes are needed in medical school to facilitate more inclusive environments.

Previous studies have found high rates of microaggression among URM medical students [13,16]. A majority of these studies focused on historically underrepresented racial groups, and this distinction usually excluded Asian American students. In a number of studies, Asian-identifying students were categorized as non-URM and combined with White-identifying perspectives [13,21,22]. Positioning Asian American students as equivalent to the White majority perpetuates the model minority myth and ignores vast racism and discrimination, leaving students without support. Despite their proportional over-representation (when reported in aggregate) in medical student bodies, the challenging learning environment experienced by Asian American medical students is often overlooked by medical schools.

The racial microaggressions experienced by our study population were based on themes that have been previously reported among US medical students [6,13,35,36]. Our study noted that Asian American experiences with racial microaggressions are similar to those experienced by students from underrepresented racial groups despite prevailing assumptions of Asian immunity to racism. To address these discrepancies and challenges, our students suggested increasing visibility of the Asian identity in curricula by including Asian health disparities and targeting academic career development resources to increase representation among leadership. Similar findings of lack of visibility were identified in a recent qualitative study of Asian American medical students and their experiences with racism [36]. Students at the Medical College of Wisconsin developed a comprehensive curriculum, the ‘Health Advancement for Asian Pacific Islanders through Education (HAAPIE)’ initiative, that addresses these concerns and could be incorporated into the medical school curriculum [37]. Inclusion of data on Asian health disparities could counteract the ‘model minority myth’ and help students understand the vast diversities and intersections among the sub-ethnicities under the Asian American umbrella.

The intersectionality of Asian race and female gender was an unexpected, yet consistent finding in both the quantitative and qualitative data. The majority of our participants were female and potentially emphasized the prevalence of gender-based microaggressions. However, previously published studies also identified gender differences in trainee discrimination and report that women experience microaggression at higher frequencies [38–40]. Women of color may experience microaggressions and other forms of discrimination more frequently due to the confluence of racial and gender identities. Our study revealed that Asian American females experienced microaggression based on their race and their gender and, often, these experiences overlapped leaving our participants uncertain if the incidents were race- or gender-based or a combination of both. The intersectionality of races and gender warrants further exploration as it pertains to experiences of medical trainees.

There are numerous studies that correlate experiences of racial microaggression to negative outcomes for learners, including impact on mental health [5,6,9,12–15]. Similar to these findings, we characterize the negative impact on an individual’s self-reported wellbeing because of their experiences with microaggression. There was an alarming frequency of descriptors such as ‘anger,’ ‘sad,’ ‘isolation,’ or ‘lonely’ among focus group participants. Participants discussed the ‘burden’ of doing their own advocacy, a description of what is known as the ‘minority tax’ [41,42]. The minority tax has been defined as a tax of extra responsibilities placed on minority faculty under the premise of active efforts directed toward improving diversity [42]. Students hoped to see more education and resources for faculty to become allies and to support diverse medical students in addressing detrimental impacts of microaggressions. To fill the gap in understanding how to best address microaggression in the clinical learning environment, Bullock et. al used focus groups to explore ideal supervisor responses to incidents of microaggression from the perspective of clerkship medical students and developed the ‘Bystander Microaggression Intervention Guide’ [43]. This resource addresses some of the needs identified by study participants and would be a helpful addition to medical school curricula.

Lack of Asian American representation among senior faculty and clinical and academic leadership further exacerbates the plight of Asian American medical students. While Asian-identifying students represent over one-fourth of matriculants to US medical schools in the 2022–2023 academic year [17], in 2021, Asian individuals made up only 3% and 9% of assistant and associate deans in US medical schools, respectively [18]. Prevalent experiences of microaggressions are consistent with the notion that subtle yet impactful discrimination and bias starting early in medical training likely persists in advanced training and early career development and may ultimately affect professional advancement to leadership positions. Diversity within leadership in academic medicine is needed to advocate for diverse students and provide concordant mentorship [29].

Lastly, the high incidence of microaggressions experienced by Asian American medical students is often goes unaccounted and undocumented. Little is known about resources for reporting microaggressions at medical schools, but reporting of medical student mistreatment is low in general compared to actual incidents [44] and therefore, it is reasonable to suspect that similar underreporting occurs with regard to microaggression incidents. Our study identified barriers such as discomfort with reporting, fear of retaliation, and not knowing how to report. In a similar study of US surgical residents, one-third of residents who reported incidents of microaggression experienced retaliation due to reporting [35]. Focus group data revealed that students feared the potential repercussions of actively responding, and this fear is likely not unrealistic given extant literature on the topic. Improvement of the anonymity of the reporter, greater accountability practices, and more support from faculty might increase the likelihood of reporting for all students.

Our study explored in-depth the impact of racial microaggressions on Asian American medical students in US medical schools. Over two-thirds of Asian American medical students faced racial microaggression during their medical education from multiple sources including patients, peers, and faculty. The qualitative analysis from focus groups demonstrated that experiences of microaggression had a profound impact on student wellbeing and undermined their confidence as budding professionals. The participants provided suggestions on how to improve the overall equity and inclusion in medical schools.

Conclusion

The Asian American medical students’ experiences serve as case studies of the ongoing, often subtle, discrimination that people of color face early in their medical training. Representation alone cannot ensure an inclusive learning environment, as especially evident in the experiences of Asian American medical students. With the increasing diversity among medical school classes, we must continue to cultivate medical school learning environments that are inclusive, supportive, and safe for all students to learn and thrive.

Authors’ disclosures

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Acknowledgments

Special thanks to all the participants in this study. The authors are grateful for the support that the Asian Pacific American Medical Student Association (APAMSA) has given to conduct this research.

Disclosure statement

B.U.K.L. has received consulting fees from Takeda (not relevant to the current manuscript). No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2023.2299534

Additional information

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Notes

1. Asian American refers to diverse Asian groups such as Chinese, Filipino, Korean, Japan, Asian Indian, and other Asian groups living in the United States of America. In this paper, we refer to individuals who self-identify as Asian Americans.

Appendix 1.

Survey questions

Q1. Which of the following best describe(s) your race/ethnicity? (check all that apply)

• African American/Black

• Bangladeshi

• Cambodian

• European American/White

• Chinese

• Filipino

• Guamanian

• Hawaiian

• Indian

• Indonesian

• Japanese

• Korean

• Laotian

• Latino(a)/Hispanic

• Malaysian

• Middle Eastern/North African

• Mongolian

• Native American

• Nepali

• Pakistani

• Pacific Islander

• Singaporean

• Sri Lankan

• Taiwanese

• Thai

• Tibetan

• Vietnamese

• Prefer to specify

• Prefer not to say

Q2. Age (in years):

Q3. What is your gender/gender identity? (Check all that apply)

• Man

• Woman

• Transgender man

• Transgender woman

• Non-binary

• Gender queer

• Two spirit

• Prefer to self-describe

• Prefer not to say

Q4. What is your generational status?

• 1st generation (born outside of US and came to US as an adult (18 years or older))

• 1.5 generation (born outside of US and came to US as a child (17 or younger))

• 2nd generation (born in US)

• 3rd generation (born in US, at least one parent born in US)

• 4th generation or greater (born in US, grandparents/great grandparents etc. born in US)

Q5. Are you a native English speaker?

• Yes

• No

Q6. Do you think you speak English with a noticeable accent?

• Yes

• No

• Unsure

• Prefer not to say

Q7. Which of the following degrees are you pursuing?

• MD

• DO

• MD/PhD

• MD/MBA

• MD/MPH

• Other, please specify

Q8. What year are you in medical school (as part of your MD/DO program)?

• 1st

• 2nd

• 3rd

• 4th

• 5th+

Q9. Where is your medical school located?

• Northeast

• Mid-Atlantic

• South

• Midwest

• Northwest

• Southwest

Q10. “Microaggressions are the brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial, gender, sexual-orientation, and religious slights and insults to the target person or group. Perpetrators are usually unaware that they have engaged in an exchange that demeans the recipient of the communication.”

Taken from: ‘Microaggressions in Everyday Life. Race, Gender, and Sexual Orientation’ by Derald Wing Sue.

Keeping in mind the above definition have you ever experienced microaggressions during your time in medical school?

• Yes

• No

• I am not sure

Q11. I have experienced microaggressions related to my… (check all that apply)

• Race/ethnicity

• Gender/gender-identity

• Sexual orientation

• Immigration status

• Size or physical appearance

• Spoken language (i.e., accent, word choices)

• Communication styles

• Religion

• Disability

• Other, please specify

• I have not experienced any microaggressions

Q12. During my medical training, I have experienced microaggression from… (check all that apply)

• Professors or teaching assistants in didactics/classroom settings

• Staff or administration in medical school

• Medical supervisors (i.e., attendings) in the hospital

• Supervising residents/fellows in the hospital

• Ancillary staff (i.e., RNs, PTs, RTs) in the hospital

• Advanced practice providers (APPs)

• Fellow medical students

• Patients

• Patients’ relatives/guests in the hospital

• Others (please specify)

Q13. How did these microaggression incidents make you feel at the time? (check all that apply)

• I did not recognize it as a microaggression at the time

• It did not bother me

• It bothered me inside, but I kept my feelings to myself

• It bothered me for a long time after the incident

• It affected my behavior and mood for a long time after the incident (i.e., change in sleep and attitude)

Q14. How did you react to these microaggression incidents? (check all that apply)

• I kept my feelings and thoughts to myself

• I changed my behavior (i.e., spoke or engaged less/more) at the time

• I shared the incident with a significant other, friend, or fellow medical student

• I spoke up and countered the microaggression at the time

• I spoke up and countered the microaggression at a later time

• If you would like, please elaborate on your answer:

Q15. Do you think any of these microaggression incidents may have affected your grades?

• Not at all

• Possibly, but not sure

• Not in the numeric assessment but was reflected in the comments about my performance

• Both in the numeric assessment and in the comments about my performance

• Both in the numeric assessment and in the comments about my performance. I have challenged my grade

• due to it

• Not applicable; no incidences of microaggression involved a supervisor

Q16. Have you ever reported any incident of microaggression to a supervising attending, clerkship director, or administrator?

• Yes

• No

Q17. If you have reported an incident of microaggression, who did you report it to? (check all that apply)

• A resident

• An attending

• A clerkship director

• A dean in the medical school

• A dean of minority students

• A D.E.I. (diversity, equity, and inclusion) officer at the medical school

• The office of mistreatment/A mistreatment officer at the medical school

• Other, please specify

Q18. If you did not report these incidents of microaggression(s), why not? (check all that apply)

• I have not experienced any incidents of microaggression

• I did not feel the need to report the incident

• I did not feel comfortable reporting the incident

• I did not know how to report the incident

• I feared the repercussions if I reported it

• My school does not have a reporting system for microaggression or mistreatment

• Other, please specify

Microaggression Measures

Q19. Please rate the following statements on the Likert scale from 1 (never) to 5 (most of the time). Thinking about your experiences in medical school, how frequently did your supervisor, co-students, patients, or other staff members…

Table

	Never	Rarely	Sometimes	Usually	Most of the time
… assume you were going to school for a different career (i.e., nursing, other healthy profession) based on your race?
… expect you to work harder than other students because of your race?
… expect you to do more work than other students in similar positions because of your race?
… assign you to projects that did NOT require interpersonal skills because of your race?
… receive feedback that you lacked social skills because of your race?
… imply that you were submissive because of you race?
… note that you were someone who always complies because of you race?
… label you as a follower (vs. leader) because of your race?
… describe you as shy or too quiet because of you race?
… delegate you work that does NOT require writing skills because of you race?
… give you work that does NOT utilize your speaking skills because of you race?
… tell you that your English is “good” because of you race?
… mistake you for another Asian person?
… call you by another Asian person’s name?
… brought up Asian cultural events or experiences in order to relate to you, but it was an ethnicity other than your own?
… associate you with the COVID-19 pandemic in a derogatory way because of you race?

Q20. Please rate the following statements on the Likert scale from 1 (never) to 5 (most of the time). Thinking about your experiences in medical school, how frequently did your supervisor, co-students, patients, or other staff members…

Table

	Never	Rarely	Sometimes	Usually	Most of the time
… look away from you when you were speaking?
… ignore your ideas in meetings?
… ignore your suggestions?
… not take your recommendations seriously?
… attribute your comments to someone else?
… tell you were quiet even though you speak as must as other people?
… did not provide the opportunity for you to speak up after others have shared their thoughts?
… give more credit to your co-student (non-Asian) than you even though you both contributed equally?
… provide you less recognition for similar work done by others at the same level?
… call you by a nickname that was synonymous to something Asian (e.g., ninja or tiger mom)?
… mention your race in a conversation when it wasn’t relevant?
… imply you were brought onto a committee because of your race?
… ask you to speak-up in meetings?
… question your silence?

Appendix 2.

Focus group guide

Hello and welcome to the focus group. Thank you for agreeing to participate in this group discussion. My name is _____________. I am part of the research team for this study that aims to better understand the experiences of Asian American medical students with microaggression during their training.

You have been asked to participate in this focus group because you are a medical student who self-identifies as Asian American. For the next 45 to 60 minutes, we want to learn about your experiences of microaggressions during your medical training. We will ask you to provide personal experiences with it and how they made you feel. We will also discuss ways to improve the learning environment to be more inclusive and equitable.

As a reminder, we will audio record this interview as this allows us to accurately review the information you share with us. The audio recordings will be destroyed after the interview is transcribed. You can refuse to answer any questions at any time. If results of this study are published, we will not use your name and strive to keep your identify anonymous. Your responses will not be shared with anyone outside of this research team, therefore you can feel free to be open. Please turn off your cameras and change your name to a pseudonym of your choice, your MS year, and your gender identity. When you speak, please introduce your pseudonym prior to your answer. For example, “This is [], and I think that … ”

We will now start recording.

I would like to start by defining microaggression. As defined by Dr. Derald Wing Sue, microaggressions are the brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial, gender, sexual-orientation, and religious slights and insults to the target person or group. Perpetrators are usually unaware that they have engaged in an exchange that demeans the recipient of the communication.

• (1) Have you experienced microaggressions in your role as a medical student? If so, please describe the circumstances including where and from whom?

• (2) Describe the feelings you had when you experienced microaggressions. What impact have microaggressions had on you?

• (3) What were/are your responses to incidences of microaggression?

  • (a) If you did/do not respond to these incidences, why not?

  • (b) If you did/do respond, how effective were/are your responses?

• (4) If others were present when you experienced microaggression, how did they respond? What are your thoughts or feelings about how they responded, or failed to respond?

• (5) Visualize the ideal inclusive environment at your institution. What would need to change in interactions and relationships to improve this environment? What would need to change structurally or organizationally to create an inclusive environment?