CASE: 

Rachel is a 10-year-old White girl with attention-deficit/hyperactivity disorder and a history of trauma who presented for evaluation by Dr. Narayanaswamy, a developmental-behavioral pediatrician. A pediatric resident observed the visit with permission from Rachel's parents.

During the visit, Dr. Narayanaswamy spoke to Rachel's case manager over the phone to advocate for a trauma-based day treatment program at her school. At the end of the call, the case manager asked the physician for her full name. Dr. Narayanaswamy responded with her name and asked the case manager, “Would you like me to spell it?” At that time, Rachel's father began to laugh, shook his head, and incredulously remarked, “Ugh, yeah you need to spell it.” Dr. Narayanaswamy ignored the comment and completed the phone call.

After the visit, Dr. Narayanaswamy explained to the resident that the father's derisive laughter was a microaggression. The resident appreciated the observation and, after a pause, asked why she chose not to defend herself when the microaggression occurred. Dr. Narayanaswamy reflected that she had refrained from responding to Rachel's father over concern that he would retaliate by providing low ratings on the postvisit patient satisfaction survey sent to all patients who received care at the institution. The granular survey results, comprising ratings in each survey subheading category for each clinician, are made public to members of her division each quarter, and low ratings are scrutinized by the leadership. Dr. Narayanaswamy thought it unfortunate that she felt inhibited in her response because this deprived the resident of observing ways to address microaggressions during an encounter, deprived herself the opportunity to respond directly to Rachel's father, and deprived Rachel from an instructive moment about racial empathy.

Dr. Narayanaswamy wrote a letter about the incident to the chief of clinical affairs to inquire what recourse clinicians had in these situations and whether certain patient encounters could be flagged to prevent the postvisit patient survey from being automatically sent. The chief responded that the incident was unfortunate and praised Dr. Narayanaswamy's restraint and professionalism but denied her request to have postvisit surveys blocked for certain encounters. He shared that if a clinician were to be dissatisfied with a visit satisfaction rating, the clinician could petition for a review, and a committee would subsequently determine whether the review could be removed.

How can health care professionals respond to microaggressions while maintaining a therapeutic alliance with the patient/family members and how can institutions support health care professionals in this endeavor?

中文翻译：

---

让我详细说明一下：微侵犯对医疗保健专业人员的影响

案件： 

Rachel 是一名 10 岁白人女孩，患有注意力缺陷/多动症，有外伤史，她前来接受发育行为儿科医生 Narayanaswamy 医生的评估。在雷切尔父母的允许下，一名儿科住院医师观察了这次探访。

在访问期间，纳拉亚纳斯瓦米医生通过电话与雷切尔的案件经理交谈，倡导在她的学校开展基于创伤的日间治疗计划。通话结束时，病例经理询问医生她的全名。Narayanaswamy 医生回答了她的名字，并询问专案经理：“您需要我拼写一下吗？” 这时，雷切尔的父亲开始大笑，摇摇头，难以置信地说：“呃，是的，你需要拼写它。” 纳拉亚纳斯瓦米博士无视了这一评论并挂断了电话。

探访结束后，纳拉亚纳斯瓦米医生向住院医生解释说，父亲的嘲笑是一种微侵犯。该居民对这一观察表示赞赏，并在停顿后询问为什么当微侵犯发生时她选择不为自己辩护。纳拉亚纳斯瓦米医生反映，她没有对雷切尔的父亲做出回应，因为担心雷切尔的父亲会在发送给所有在该机构接受护理的患者的就诊后患者满意度调查中给出较低的评级来进行报复。详细的调查结果，包括每个临床医生的每个调查小标题类别的评级，每季度向其部门的成员公开，领导层会对低评级进行审查。纳拉亚纳斯瓦米博士认为不幸的是，她在回应中感到压抑，因为这剥夺了居民在遭遇中观察处理微侵犯的方法，剥夺了自己直接回应雷切尔父亲的机会，并剥夺了雷切尔关于种族同理心的教育时刻。

Narayanaswamy 医生就这一事件写了一封信给临床事务主管，询问临床医生在这些情况下可以采取哪些手段，以及是否可以标记某些患者的遭遇，以防止自动发送患者就诊后调查。该负责人回应说，这一事件是不幸的，并赞扬了纳拉亚纳斯瓦米博士的克制和专业精神，但拒绝了她要求阻止对某些遭遇进行访后调查的请求。他分享说，如果临床医生对就诊满意度评分不满意，临床医生可以申请审查，委员会随后将决定是否可以删除审查。

医疗保健专业人员如何应对微侵犯，同时与患者/家庭成员保持治疗联盟，机构如何支持医疗保健专业人员的这一努力？