1. Introduction

A recent magazine article [1] described a situation at a White House Coronavirus Task Force press conference where President Trump called Dr. Anthony Fauci to the podium; followed by coronavirus response coordinator, Dr. Deborah Birx. Trump referred to him as Dr. Fauci; to her as Deborah. The author of the article was not happy! “This is part of a national occurrence - men in positions of power using language to subordinate women.” She went on to add, “reference to a woman in power’s first name is a stark reminder of her subordinate status. Women are called by their first name in professional settings because of a gender bias problem.” She concluded with, “for Dr. Birx, without the dignity of her title and last name, she’s stripped of the place she deserves in history.” I thought, wow, that seems like an extraordinarily strong response. Then I saw on Facebook that a physician friend had also hit the roof about this. I knew she was upset because her post, “IT’S DR. BIRX, NOT DEBORAH!” was written in ALL CAPS! These also remined me of a recent lecture by a highly regarded surgeon at a highly regarded institution describing the same scenario; she found it highly inappropriate being introduced as “Joan” instead of “Dr. Jones.” [name changed]. In her mind, women called by their first name in professional settings clearly indicates a gender bias problem.

An Indian PhD, journalist, TEDx speaker, and award-winning author, now living in the UK, wrote recently in Forbes magazine [2] about her experiences at professional conferences. She bemoans that the most common phrases she hears from people when they first meet her is: “I love Indian food,” “where are you from?” and “your English is very good.” She is not happy about these “microaggressions.” Making fun of someone's accent or ethnicity is not a joke, she says, adding that while the intent might not be malicious, it is borne out of ignorance, and reinforces differences and non-conformity of a minority community from the majority demographic. It is akin to being bullied. It is indicative of the insidious underlying implicit unconscious bias that exists in our society and has to be called out. We must exhibit empathy and reflect on the hurt our words might have caused. These comments perpetuate racism and sexism. Again, my initial reaction was - really? You got all of that from those few innocuous comments about your intriguing mixed accent and love of Indian food?

2. Cross-cultural Competence and Communication

Before discussing microaggressions, it is important to discuss the importance of cross-cultural competence and communication. On our diverse planet, the varied demographics (gender, income, race, ethnicity, etc.) and culture (language, religion, etc.) of our diverse societies significantly influence our behaviors. Cross cultural competence (CCC) is an acquired skill all successful 21st century global companies must help their employees develop in order to “do the right thing” and help maintain a competitive business advantage. CCC serves to create a more welcoming environment and improves the delivery of culturally appropriate customer service. It is increasingly important for the modern workforce to communicate effectively with people from various backgrounds. Effective CCC and communication can lead to increased co-worker productivity and morale as well as increased customer satisfaction.

Cultural competence is the behaviors, attitudes and policies that enable effective cross-cultural interactions. It is a prerequisite to providing compassionate and empathetic business practices. During cross-cultural interactions, inherent differences, diverging values and disparate communication styles may create misunderstandings or conflicts [3]. Interpersonal relationships and productivity may suffer. When an issue arises, one may not realize it is predicated on cultural differences. One may not even realize they have cultural differences from their colleagues. There are two components in essentially every organization: interactions among co-workers on a collaborative cross-cultural team and interactions of employees with their global customers.

We all have unconscious, implicit biases and explicit biases or prejudices. These, along with a genuine lack of knowledge and inherent cultural differences sometimes make it challenging to work with people from groups different than one’s own [3]. People judge, generalize, stereotype, categorize and oversimplify. Miscommunications occur. People are hurt - often unintentionaly. Personal cultures formulate, influence, guide, and shape how people view and interact with others, their sense of right and wrong, how they approach problems, reactions, and communication styles.

People approach the same situation very differently. Confounding this is the observation that communication styles also vary, extending beyond language to more subtle nonverbal cues (expressions, gestures, rate, volume, extent). Cross-cultural competence relies on effective open communication with active listening, carefully noting these cues. In some places, there is a tendency to avoid conflict and confrontation. Harmony is sought above all else. One may never really know where they stand. People “play their cards very close to the vest.” Emotion, sharing of personal information and probing questions are avoided. These workplace priorities make it difficult to “sell” diversity as a strategy in environments where harmony stemming from homogeneity is the preferred modus operendi. In other regions, people deal with conflict openly, directly, face-face, boldly. People leave a conversation knowing exactly where they stand. Diversity is an easier sell. It is ok to be different, and it is ok to discuss, debate; even argue.

To improve interactions and enhance effective communication among colleagues and customers, there needs to be awareness and mindfulness of the many cultural idiosyncrasies, variations and nuances that comprise any organization (4). Unfamiliarity should be interpreted as something that is “different” rather than “wrong.” Assigning value or making judgements must be mitigated. By recognizing that cultural differences contribute to uncomfortable situations, people can proceed thoughtfully and respectfully, not letting stereotypes and miscommunication alienate them from co-workers who could otherwise be valued colleagues or even friends.

Innovative strategies to overcome barriers start with self-awareness. People must reflect, evaluate, and question their own biases, prejudices, and stereotypes (5). As global organizations interact with people from different cultures, employees may find their own beliefs and values challenged. Peoples’ own norms are just as embedded and unique as those of any other culture. They are not necessarily best, nor should they be considered universal. Many will find it difficult to respect “foreign” customs and traditions (6). Yet, employees must avoid projecting their own feelings, especially as it relates to their customers.

Successfully managing situations with conflicting values requires training, nimble responsiveness, adaptability, and flexibility (6). It also requires respect, trust, humility, integrity, and the highest ethical standards. The value delivered by bridging cultural gaps is that everyone learns from one another, conflicts are reduced, and outcomes are improved. Customer and co-worker interactions and relationships become more successful, meaningful, effective, compassionate, and empathetic.

Cultural differences or variations are often at the root of workplace communication challenges. Without CCC, employees might not recognize important cues, for example that Orthodox Jews are not permitted to shake hands with the opposite sex, that many male-dominated patriarchal societies are guided by social and cultural traditions, not religious ones (6); or that the Amish may oppose technology or treatment, even when involving a very sick child [3].

Working across cultures and managing situations with conflicting values in multicultural organizations is challenging, but integral to success (4). Cross-cultural competence requires “perspective taking;” observing situations from another’s point of view (7). Asking “from your perspective, how can we improve?” brings diverse perspectives to teams and projects. The ability to see others’ perspectives allows for the ability to make better global decisions that are more likely to benefit an organization and create positive customer experiences. Successful cross-cultural competence and communication portend a competitive advantage.

3. Microaggressions

Microaggressions are brief, subtle, verbal (a comment or statement) or behavioral (an action or incident) indignities, slights or insults whose derogatory nature communicates prejudice, dismissal, denigration, hostility or negativity to a member of a socially or culturally marginalized group; especially racial or ethnic minority groups [8], but also gender, sexual orientation, and religion. They may appear indirect, casual, innocuous, and insignificant; particularly to someone not from a marginalized group. They are often unconscious, unintentional, and unnoticed by the aggressor. They may arise from underlying: prejudice, discrimination, oppression, explicit bias, or implicit unconscious bias toward the targeted group [2,9-10].

4. Point: It is a Real Problem

The underlying feelings of exclusion, marginalization (“I am less”), bias and discrimination are very apparent to those who experience it [10]. Naysayers must empathize, not minimize. They must see it from the other side and call it out when they see it [2]. We must all accept that it is inappropriate, especially in professional circumstances where it affects the people and the culture of the workplace. Repeated, cumulative exposure to such behavior affects performance, stress, confidence, well-being, burnout, and morale [11]. Promoting a respectful workplace that prioritizes collegiality and discourages bias will enhance inclusion, trust and belonging. We must raise awareness and educate ourselves to recognize, and then address and eliminate this potentially hurtful language.

5. Counterpoint: It is much Ado about Nothing

These are small, obscure acts of perceived injustice. In all likelihood, the “microaggressor” meant absolutely no negative intent whatsoever, may have actually been well-intentioned, and was certainly unaware of the potential resultant negative impact. Some of these are worth acknowledging and complaining about, but others may not be. Shrug them off as fleeting interactions; and move on. Perhaps the issue is over-reaction due to your own lack of confidence or hypersensitivity. Do you really find it necessary to insist on always being called Dr. XXX? Life is full of big stresses and big problems. Sure, we can try to eliminate all workplace “microaggressions” but then we would have to create a completely sterile workplace.

6. Conclusions

Microaggressions exist, especially against racial and ethnic minorities. Religion is not far behind. I too have been on the receiving end of microaggressions on numerous occasions. The most egregious recent example was, while describing his very frugal nature, a colleague (and I thought friend) said to me; “in fact …. I am even more Jewish than you are! True story. These days, politics is up there too. We see daily personal attacks on supporters of either side of the partisan divide. I have gotten several of those as well. Microaggression, or plain old, aggression?

So, if I introduce you as Joan, instead of Dr Joan Jones, or Dr. Jones, it is not because I think you are less, that your MD is less than John Jones’s MD, sexism or underestimating your abilities. It is because I am comfortable with you as a close colleague. I would probably even consider you a friend. That is it. No other reason. Also, feel free to call me by my first name. I do not need to be remined that I am a doctor.

If I ask you where you are from because I hear an accent; that comes from genuine curiosity. If you say Long Island, with a heavy accent, and I say, “no, where were you from before that?” That is curiosity. I am genuinely interested. It is my attempt at cultural competence – a good thing - not a microaggression.

If I say where did you learn to speak English so well. That is not a microaggression. That is me being interested in you; me complementing you. I am impressed. You see, my family emigrated from Czechoslovakia when I was 6. I spoke my first word of English in 1^st grade. My parents lived in the US for decades and their English never got all that great.

Keep an open mind. There may be factors you are not aware of. For example, Dr. Birx actually has her office in the White House. She and the President see each other every day, making for a perfectly reasonable explanation for being on a first name basis. Dr. Fauci, on the other hand is based in Bethesda, Maryland [12].

Rather than being negative or defensive, it would behoove us instead to assume that the other person is genuinely interested in you,or is working to improve their cross-cultural competence. Maintaining a broad perspective will allow us to have more meaningful interactions with one another. In our “new normal,” post COVID-19 world, this focus on positivity will be more important to society than ever before.