Death by a Thousand Paper Cuts  by Richard Akintayo  

Black History Month

To mark Black History Month 2023, we present an article written by the Chair of the Ethnic Minority Staff Network and Consultant Rheumatologist, Dr Richard Akintayo, on the subject of microaggression.

In the first few months after I moved from Nigeria to the UK, and for the first time in my career as a doctor, I lived close enough to walk to work, and I was quick to fall in love with my daily commute. When I shared the positive impact of this routine physical exercise with a work colleague, they seemed surprised and asked, ‘So in Nigeria, did you always drive to work?’  

‘Yes, and I’m really enjoying the walks now,’ I answered.  

‘That’s interesting, considering all the news we always hear of people walking several kilometres to fetch water in Africa,’ was this colleague’s reply.  

Reading about this experience may make a neutral person feel upset that I got treated that way. However, the truth is that various degrees of statements like this – and often subtler ones – slip their way into everyday workplace interactions, and many people don’t even see them as grossly inappropriate. Even those at the receiving end of treatments like this often come to accept them as normal. Sometimes, the person treating you that way may even have good intentions. This is microaggression. If someone is holding a dagger menacingly whilst talking to you with disgust on their face, it’s not hard to see the danger. But it’s a different story if all they wield is paper and a smile (or sometimes disgust) yet are cutting you now and again with the paper – whether they mean to or not.  

A subtle act of exclusion  

The term microaggression is used to describe everyday, thinly veiled hostility towards a group of people, usually people belonging to a marginalised group. Microaggression takes the form of verbal, behavioural or environmental slights – basically subtle acts of exclusion. Unfortunately, many incidents of microaggression are driven by unconscious negative reactions. Even when microaggressions are unintentional, however, their impact on individuals and organisations can be significant.  

Microaggressions are especially common in the workplace, and they deliver unfriendly meta-communications in which their targets are made to feel excluded or demeaned. They can be verbal acts like saying, ‘The best person should get the job regardless of their race,’ implying that institutional racism does not exist and people don’t miss opportunities because of their race. Saying to a person of colour, ‘Everyone can succeed in this society, if they work hard enough’ suggests that laziness is the only reason some people don’t reach the peak of their potential; and saying, ‘As a woman, I know what you go through as a racial minority’ implies that the racism you suffer is not worse than my gender oppression; therefore, I’m just like you and cannot be racist.” Attempting to dismiss the injustice which black people face by saying, ‘All lives matter’ in response to the Black Lives Matter movement is like going to a campaign against prostate cancer to agitate that all cancers should be talked about.  

Behavioural microaggressions are things like avoiding getting in a lift because a person of colour is there. Or hurriedly clutching your bag if you were already in the lift when the person of colour enters. Environmental microaggressions include having a leadership rank that doesn’t include persons of colour, despite having a significant number of competent ethnic minorities among the staff. Microaggressions are a manifestation of implicit bias and may be seemingly invisible despite their rifeness in a workplace that is not challenging them.  

Put-downs that put us all down  

Although members of the Western workplace now report being more accepting of people of colour than, say, before 1807 when the slave trade was abolished in the British empire, there is still a significant gap between what people claim to believe and how they act towards ethnic minorities. A PhD thesis published by the University of Georgia shows that not only are the recipients of microaggressions hurt, teams and organisations equally suffer from the impact of these behaviours. (1) Employees at the receiving end of microaggression are more likely to report experiencing negative emotions than the control group but are not necessarily more likely to respond aggressively in order to avoid conforming to unhelpful stereotypes such as the ‘angry Black person’. Team efficacy has also been shown to be diminished in an environment harbouring microaggressive behaviours, and there is an overall decline in self-esteem and increased burnout.   

Similarly, microaggressions damage trust in coworkers, management and the organisation. Immigrant professionals, many of whom are ethnic minorities, make up a significant proportion of the NHS workforce, and the system relies on the proper delivery of service by all the professionals within it to deliver its goals. Yet, evidence around the pervasiveness of racism in the NHS continues to emerge. For example, in a recent British Medical Association national survey, 76 per cent of respondents said they had experienced at least one incident of racist behaviour in the preceding couple of years and 17 per cent stated that they experienced it regularly. (2)  

Whereas the impact of a single episode of microaggression might not stand out menacingly, unending barrages of various forms of this pattern of hostility can very well damage the confidence and career prospects of the victim and wreak huge harms on the service itself. Holding a dagger to the figurative neck of a person’s career is obvious in its intent to kill, but subjecting that same career to endless injuries from microaggression is like delivering death by a thousand paper cuts. 

How on earth did we get here?  

Evolutionary theorists have suggested that some of our discriminatory behaviours towards other races may be linked to documented historical reactions to outgroups as seemingly constituting inherent threats. A 2015 study published in the Journal of International and Global Studies posits that the mainspring of outgroup prejudice is a triggered sense of distrust and caution. Early humans relied on heightened levels of vigilance and suspicion to protect themselves and their offspring from intruding dangers, including those posed by other humans. In essence, prejudice is a product of a self-preservation outlook rather than a specific attribute of any given outgroup.(3) Evolutionary psychologists Carlos Navarrete and colleagues argue that racism itself is not so much based on the ingroup innate preconception of risk posed by the outgroup but is strongly determined by established cultural and social norms.(4)   

A powerful pointer against the normalisation of racial prejudice driven by intergroup biases is reducing this bias through common motivation with people of other races—for instance, when a mixed-race group must work together to achieve a goal that all members believe in and are keen about. Suddenly, the bias either goes away or is significantly reduced due to the common group identity.(5) In other words, the acceptance of ‘the other’ as ‘same’ can eliminate conscious and unconscious racial biases and likely race-based microaggressions, even the ubiquitous ones that have been seen as nearly innocuous. This suggests that racially discriminatory behaviours may have been learned and can very well be unlearned.  

The danger of the inactive bystander  

Racism and microaggression continue, at least in part, because the perpetrators have the instinctive conviction that other people of their race will back them up, protect them from facing the consequences of their action or even punish the victim further if they raise an issue. Many people of colour have had people they’ve known and worked with harmoniously for a long time suddenly refuse to help them when they receive a racially motivated attack, whether subtle or overt. Sometimes, the victim even ends up thrown under the bus and the weight of evidence is twisted around to paint them as the hostile one.   

Everybody must think about themself first. Many people cannot afford to risk being thrown out by their own tribe for accepting the moral responsibility of taking a nonconforming stand to help someone who’s been mistreated. Unfortunately, this type of self-preservation effort simply sustains the culture of marginalising the ethnic minority and undermining the principle of social justice that many organisations like to associate with – all the more reason why an organisation’s prevailing culture is ultimately the responsibility of its leadership.   

If we choose to adopt tactical neutrality when complaints of microaggressions are made, or we find a way to silence the complainant, we’re providing negative reinforcement for the action of the aggressor, who in turn sees no need to change. In fact, it’s like injecting dopamine, the biological currency for reward and pleasure, into the brain of the perpetrator to see the victim ignored, gaslighted or blamed for making an issue of the incident. As the ultimate management principle says, you get what you reward. We may well have created an environment for victims of microaggressions to live in fear of the toxic culture they work in. A true fear of career death by a thousand paper cuts and maybe a dagger stab at some point.  

In our highly politically charged world, words like injustice, discrimination and microaggression may trigger people in different ways. They may lead us to take an emotion-driven stand on any discussion that follows and spend our logical reasoning defending a position we chose based on emotion. It may even make us resolve to actively oppose any argument that suggests that neutrality is complicity, because we take offence at reasoning that we interpret as trying to guilt us into taking sides. However, it is not merely being pressured to take sides if we indeed have the power to make a positive difference on an issue that we fundamentally agree, and probably openly profess, is wrong. Choosing to not lift a finger in such a situation is simply empowering the aggressor, and it does send a message.  

Who does see no evil, hear no evil help?  

The workplace often encourages people to conform to certain types of behaviour that serve to promote what the organisation sees as professionalism – but this can also encourage not making a mountain out of the mole’s hill of micro-injustice. In other words, having to keep your human face (and whatever burden of morality you carry around) a little bit masked. The culture of being afraid of getting into trouble for rocking the boat of a system that looks away from microaggression is likely ensuring a perpetual succession of patterns of behaviour that can damage employee morale. Some ethnic minorities may even learn a dysfunctional coping strategy of kicking down on other ethnic minorities and kissing up to the establishment to signal that they don’t want to be considered part of ‘the other’.   

If what it would take for a person of colour to not be held back by the well-documented differential attainment trend between white employees and employees of colour is to enthusiastically play the office politics that may harm the wellbeing and career prospects of other ethnic minorities, even they might have no problem keeping mum at the sight of microaggression. After all, that may be what it takes to properly blend in. This means, of course, that if everyone goes around pretending not to notice the mistreatment of their colleagues or is too afraid to help the victim in any way, the perpetrator benefits and has no real reason to change. Sadly, if you help an aggressor cover up racially motivated hostility today, you can also expect them to do the same for you when you also kick down an ethnic minority. That is how to use the race card without using the race card. 

You cannot believe everything you think  

That everyone has good intentions is one of the key presuppositions of neurolinguistic programming, the study of the structure of our subjective experience. This implies that altruism, benevolence and even verbal slights and violence can all be thought of as behaviours geared towards pursuing a primary outcome which the person believes is positive. From the point of view of promoting tolerance and increasing the chance that we might consider the point of view of the other person, this is all reasonable. However, more than a hundred years since the abolition of slavery, sometimes we all need to examine the unconscious beliefs and values that drive our outgroup prejudice and inform our biases. We are living in the best time in the history of humankind – socially, economically, technologically. After millions of years of humans and about 300,000 years of our species, some of the lessons from our ancestral environments may no longer serve us very well. This is why we need to heed the warning of Carl Jung, the Swiss psychoanalyst who advised that if you don’t make the unconscious conscious, it will direct your life and you’ll call it fate. There are ample reasons to be optimistic for the future, but optimism can be active or passive. It is passive when we believe that things will get better, but it is even more potent in the active form when we believe that we can make things better.   

How does this make you feel?  

We all have a role to play in creating a work environment where each of us can flourish. It takes courage to go against our usual pattern of behaviour the next time we witness microaggression that is not directed at us, but seeing the situation for what it is and reminding ourselves that we all have a responsibility to stand for a positive change is a good place to start. It may even take an unexpected amount of energy to restrain yourself the next time you want to say or do something demeaning to a colleague, if this has been your habit. Our emotions, negative and positive, are always trustworthy signals to us about ourselves and our values. Reading this article, for instance, may have triggered some form of feeling within you. Anger, disgust, pleasure, guilt, fear, annoyance, compassion, surprise, shame or maybe even horror; whatever it is, it’s worth reflecting on why you might be feeling what you’re feeling. I bet that at the deep end of that feeling is some call to action.  

  1. Alinor M. Reacting to Racism: Examining the Emotional and Behavioral Outcomes Related to Racial Discrimination: University of Georgia; 2021. 
  2. https://www.bma.org.uk/news-and-opinion/racism-an-issue-in-nhs-finds-survey  
  3. Kaya, Serdar Ph.D. (2015) “Outgroup Prejudice from an Evolutionary Perspective: Survey Evidence from Europe,” Journal of International and Global Studies: Vol. 7: No. 1, Article 2. Available at: https://digitalcommons.lindenwood.edu/jigs/vol7/iss1/2  
  4. Navarrete, C.D., Fessler, D.M., Fleischman, D.S. and Geyer, J., 2009. Race bias tracks conception risk across the menstrual cycle. Psychological Science, 20(6), pp.661-665.  
  5. Kurzban, R.; Tooby, J.; Cosmides, L. (2001). “Can race be erased? Coalitional computation and social categorization”. Proceedings of the National Academy of Sciences. 98 (26): 15387-15392.  

Who/what is a SAS Doctor? by Shona Donaldson

It can be a confusing title. We aren’t in the Special Forces but we are sometimes as skilled in negotiation, hostage rescue, and covert reconnaissance!

SAS stands for Specialist, Associate Specialist and Specialty Doctors, we were initially called Staff Grade doctors, and over the years this has changed to describe the level of independent working we do. We are around 10% of the medical workforce in Scotland. We haven’t been through the challenging training of the consultants in the UK but have often done so overseas or worked in a medical field for some time and achieved similar qualifications.  I have been working as a Staff Grade, then Associate Specialist in care of the elderly for over twenty years and have seen the health service and the hierarchy change significantly in that time.

My job was initially a “service provision”, to help steer us through the challenging time of junior doctor hours negotiation and to provide continuity to departments and patients. Gradually we have been given more opportunities to develop skills, work independently and develop extended roles.

We have the SAS Charter to support and develop the role of the SAS doctor as a valued and vital part of the medical workforce in Scotland. We also had a new contract for Specialty Doctors at the end of 2022 with a new post of Specialist Doctor which can be advertised, if appropriate, for those with ten years postgraduate experience, 6 of those in their chosen field. This could open up exciting opportunities for the future, allowing a degree of autonomy only previously available to consultants. The Associate Specialist grade is closed, allowing no new positions, there are a few of us left, with senior positions in various departments.

I am privileged now to work as the Education Adviser for SAS doctors in Dumfries and Galloway, with support from a fantastic team at NES (NHS Education for Scotland). I aim to help with educational opportunities for our group of around 60 doctors who don’t fit into the training grades’ teaching group but are keen to keep learning. Some of our group are aiming to become consultants in the UK through CESR (Certificate of Eligibility for the Specialist Register) and others are developing special skills for clinical application using the Development fund from NES. We have local education meetings with lots of opportunities nationally.

We are everywhere, you may not have noticed us. We have SAS in lots of roles, such as chair of Medical staff committee, Specialty Team Leads, education leads and Associate Medical Director, to name but a few. NES has always encouraged us to use our skills to the maximum and develop leadership qualities alongside our clinical practice. Dumfries and Galloway has many successful SAS doctors, who have been and still are an inspiration to me.

This week (9-13th October) is SAS doctors’ week, raising awareness of our grade and understanding who we are. I hope this helps clarify who we are and what we do.

Dr Shona Donaldson is an Associate Specialist in Care of the Elderly and SAS Doctors Education Advisor for NHS Dumfries and Galloway