Jessica Bienstock was discussing with a colleague how Johns Hopkins can support LGBTQ+ trainees, explaining that she wanted to make sure people are comfortable no matter their “sexual preference.” At that moment, she didn’t think about what the word “preference” implies.

Her colleague’s response?

“He said, ‘Who I love is not a sexual preference. When you say that it’s sexual preference, it makes it sound like it’s something I can change,’” recalls Bienstock, the director of graduate clinical education and senior associate dean for graduate medical education. He continued: “It’s my sexual orientation, not my preference.”

Language is rife with terms that can result in microaggressions, even when there is no malicious intent.

(Microaggressions are verbal, behavioral or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory or otherwise negative prejudicial slights and insults toward an individual or group, particularly people who are culturally marginalized. View a glossary of related terms here.)

Equally important to what Bienstock’s colleague said was her reply. She didn’t brush off the remark or say she didn’t mean anything by it. Instead, Bienstock thanked her colleague for letting her know how she can be a better ally.

“It’s a growth mindset — the journey of anti-racism, anti-bias and allyship is something we all need to work on,” she says. “We are all products of our culture. We need to be able to say, ‘Yeah, I can do better.’”

Bienstock and her colleagues in the Office of Diversity, Inclusion and Health Equity (ODIHE) are on a mission to help ensure that conversations like this about microaggression happen at Johns Hopkins. They’ve been trained through Stepping in 4 Respect, a multisite collaborative study with UVA Health that aims to create a culture of respect and inclusion that can positively affect health care delivery as well as the environment at Johns Hopkins Medicine and other participating institutions.

Residents, fellows and faculty members now receive training on how to recognize microaggressions and how to be an active bystander, or upstander — someone who speaks in support of a person being attacked or bullied. This is done through the Stepping in 4 Respect workshop, a two-hour allyship training program designed to help health care professionals use a positive approach to address discriminatory behavior.

“It’s the idea of recognizing that something hurtful was said and stepping in so that the person who was the victim feels supported, or if it’s an unsafe situation, to allow them a way out,” Bienstock says. “If you don’t say something when you hear someone make a joke or say something disparaging, then the person who said that thing thinks you agree with them, as does the person who was the target of the microaggression.”

More than 250 incoming residents took part in the workshop in June 2021, led by school of medicine faculty and ODIHE leadership. The next class of residents will do the same in June of this year.

How to Respond

The workshop discusses prejudice, bigotry, disrespect and implicit bias (societal attitudes and stereotypes that unconsciously affect our understanding, actions and decisions). It teaches how to thoughtfully respond to situations through empathy and engagement.

Videos walk through common scenarios clinicians may encounter — a white patient doesn’t want to be treated by a Black doctor; a patient makes xenophobic remarks and asks a doctor how long he’s lived in America. In one video, a researcher jumps to a hurtful conclusion about a female lab assistant: that since she’s in a same-sex relationship, she won’t get pregnant and therefore won’t need to take time away from her work for maternity leave.

Bienstock says responding to microaggressions can be as simple as saying “ouch” or, “Did I hear you correctly?”

“‘Ouch’ can be enough because that conveys the message that you’re not just hurting the person who you aimed your microaggression at, you’ve hurt me personally now. That gives people a minute to reconsider,” Bienstock says. “I also like the language of, ‘Help me understand what you meant when you said that.’”

In addition to questioning, active bystanders can confront others directly by disagreeing and saying something like, “That’s not OK.” Bystanders can pivot the conversation — “Have you met my colleague?” Challenging the person diplomatically is another method: “I’m surprised to hear you say that. You’ve always supported equity.” Expressing emotions is another technique — “I’m really (uncomfortable/disappointed/surprised) by this comment.”

Sometimes, using humor or creating a distraction works. If the situation is dangerous, getting the person being targeted out of harm’s way is important. In a public place, creating a distraction such as spilling a cup of coffee or dropping change on the floor can be enough of a distraction to get a person out of a dangerous or uncomfortable situation.

While it can be hard to stand up in the moment, Bienstock encourages people to do something rather than nothing, knowing your reaction may not be perfect.

“It’s painful to be the only person of a certain race, nationality or sexual orientation in a room and have something aimed at you, and all these people who you think are your friends and colleagues laugh or smile,” she says. “That’s one of the reasons we’re trying to give people some language to use.”

She adds that there’s no “statute of limitations” on approaching both the person who committed the offense and the person who was the target — speaking with someone after an incident is better than not talking with them at all.

In addition to learning how to react to these situations, Bienstock recommends that people expand their worldview and social circles.

“Get to know people from different backgrounds and put yourself in situations where you might not feel the most comfortable and with people that you might not have grown up with,” she says. “It can be simple stuff like diversifying your Instagram page by following people different than you. You’ll hear different voices and it will help you grow.”

The Stepping in 4 Respect workshop is being rolled out beyond the residents — 50 fellows and faculty members have also participated in the program. The Johns Hopkins Clinical Fellows Council, which supports the needs of school of medicine fellows, will take the training in April. This workshop is an extension of the required one-hour live, virtual unconscious bias training curriculum for faculty members, students, trainees, postdocs and fellows, almost 2,200 of whom have taken the course since it launched in February 2021.

Beginning this year, the ODIHE will include diversity topics in the annual required training for the school of medicine and the Johns Hopkins Health System. This year’s content is a seven-minute video, Toward an Inclusive Culture: Acting Against Disrespect and Bias, which is based on the Stepping in 4 Respect curriculum.

“In addition to recognizing and mitigating our own implicit biases, which is the goal of our foundational unconscious bias training, we also want our leaders, faculty and learners to know how to address the microaggressions that result from biases. That is what allyship training does,” says Sherita Golden, vice president and chief diversity officer for Johns Hopkins Medicine.

While anti-racism training is a major pillar of this work, the ODIHE’s education training strategy uses an anti-oppression framework that includes addressing sexism, heterosexism, transphobia, xenophobia, ageism, classism and ableism (discrimination in favor of people who are without disabilities) in the workplace.

“The ultimate goal is to create an inclusive environment that supports all members of the community,” says Golden.

Bienstock adds, “If you want to address culture change, you have to make sure everybody feels included. It’s a heavy lift, but that’s our moral imperative.”

More resources are available on the Office of Diversity, Inclusion and Health Equity’s website.