A response when your patient says ‘You don’t look like a doctor’

May 13, 2025, Scott Wilson (Kansas City, Mo.) — If it’s possible for someone to become an instant mentor to 200 family physicians, Nanette Lacuesta-Kimmel, M.D., did it with her plenary at the AAFP’s 2025 National Conference of Constituency Leaders, “Anger to Advocacy: Practical Tips for Advocating for Yourself and Others.”

Lacuesta-Kimmel went on: “Along the way, I realized that one of the biggest gaps for our learners, for our medical students and our residents, was that there was bias in evaluations and in their experiences in the hospital. Because of this, maybe they were not getting the same level of opportunities or evaluations as some of the majority counterparts.”

This realization, she said, has informed her work as well as her approach to personal advocacy and conflict resolution — talents she laid out as vital to learning how to lead.

“You’re going to leave here with actual skills,” she said, “starting with recognizing microaggressions and how they negatively impact your clinical learning environment — and pretty much any environment that you will be leading in — and you're going to formulate a plan to respond to microaggressions.”

Facts, Not Feelings

Lacuesta-Kimmel listed some typical microaggressions she’s heard from patients: You don’t look like a doctor. That foreign doctor was already in here asking me these questions. You remind me of that little girl who does my nails. Many in the audience nodded their heads in recognition.

The micro in microaggressions — defined in publications Lacuesta-Kimmel cited in her slides as subtle expressions of bias or discrimination directed at marginalized groups — isn’t about the scale of the trespass. It’s about how commonplace the experience is for the target. You know it when you hear it.

“You may have also heard this analogy, that a microaggression is a little bit like a papercut or a mosquito bite,” she said. “One is kind of inconvenient or annoying. But if you got them every day, that would be a totally different experience. And it is. Understanding the impact of these microaggressions in the workplace, identifying them and then interrupting them, is going to be a skill that all of you as leaders are going to need to practice.”

That ability to meaningfully interrupt a microaggression is the self-advocacy at the center of Lacuesta-Kimmel’s talk, and she said it starts with managing “crucial conversations.” Taking cues from the book Crucial Conversations: Tools for Talking When Stakes Are High, Lacuesta-Kimmel called such exchanges “necessary, emotionally charged and high stakes” and said they’re also marked by varying opinions.

The formula she identified for mastering crucial conversations has a simple shape but, she explained, takes practice:

• Share your facts (not your emotions).
• Say why the facts concern you (leaving out your emotions).
• Ask: “Can you help me understand?”

‘Be a dead fish’

“How many of you know you’re getting into a crucial conversation and start with, ‘I feel like…’?” Lacuesta-Kimmel asked. “It happens all the time. Well, guess what? Unless you have a relationship with the person you’re talking to, do you think they care about your feelings? No. No, they don't. So go dead inside. Be a dead fish.”

The audience laughed, and she went on: “Take away the emotions. When you hear yourself start with ‘I feel like you…,” stop! Feel nothing!

“Your facts, your concern, not your emotions. And then ask for understanding. That's it. It’s easier to imagine an alternate point of view, the other person’s perspective, if you keep emotions neutral. So take some deep breaths and repeat after me: facts, facts, facts. I am concerned. Help me understand.”

Lacuesta-Kimmel offered an example from her home, where she said she’d put her technique into practice and set an example for her kids.

“My son, age 4, said to me one night, ‘Mommy, I noticed that for the last three nights you've not read to me. I'm concerned that if you don't read to me at night, I'm not going to learn how to read and then I won't be able to do basically anything. Can you help me understand why you're not reading to me?’

“Who can argue with you when you're asking for understanding? It's, like, so chill, right? Like, I'm not confronting you, but can you help me understand? It's collaborative.”

That same collaborative spirit animated the rest of the talk, which included questions and stories from several in the audience alongside Lacuesta-Kimmel’s call-and-response exercises. Attendees standing at one of the room’s microphones practiced recognizing the facts in the cases she laid out, then tried some neutral-sounding ways to express concern.

‘What Do You Mean by That?’

Lacuesta-Kimmel laid out frameworks for dealing with her sample scenarios, echoing the crucial-conversation structure.

“First, we can respond with curiosity,” she said. “The patient says you don’t look like a doctor. You can ask, ‘Well, what do you mean by that?’ And you can use your facts and point out that you have your white coat on, your ID badge, your stethoscope. Facts.

“You hear, ‘That foreign doctor was already in there asking me these questions.’ Maybe you say, ‘You use the word foreign to describe the other doctor. What do you mean by that?’ Or you pivot and say, ‘I can see how having to answer questions multiple times could be frustrating.’”

Yes, a patient did once tell Lacuesta-Kimmel, “You remind me of that little girl that does my nails.”

“I said, ‘Oh really? How so?’ I was super curious,” she said.

“At a time like that, you can give the person an out: ‘Can you repeat what you just said?’ You might hear a never mind. You ask a question that makes them stop and think. What do you mean by that? Give space for the person to think about intent. Because guess what intent is? Invisible. You don’t know what someone's intent is until it is stated.”

This step, she said, is about forcing the other person in the crucial conversation to reflect. It requires a little silence the self-discipline not to assume intent or make an excuse for the aggressor.

In the wake of that silence, Lacuesta-Kimmel said, “You could tell the person how the microaggression sounded to you, starting with ‘I’m hearing you say.’”

Then comes the advocacy.

When the crucial conversation is over and the microaggression and its negative effects are in the open, she said, is where the call for improved understanding or policy comes in.

“Inspire them to do the self-work next time,” Lacuesta-Kimmel said. “You can say, ‘I make mistakes. We all make mistakes. We all need to improve, OK? What can we do better next time?’

“And maybe something like this is going to inspire somebody just to have a little bit of empathy for what my experience has been or what someone else's experience has been.”