seX & whY Episode 2: Code Leadership and Gender

Show Notes for Podcast Two of seX & whY Code Leadership and Gender “Behavior” Pod Hosts: Jeannette Wolfe and Simon Carley Major Question: Are there potential unique gender challenges associated with stepping into traditional code leadership roles? What we know- importantly there is no evidence that men and women differ in competence of running actual resuscitations (Wayne 2012). This discussion is based on whether unique gender associated variables should be considered when learning and then running resuscitations. Streiff Study This study looked at a code simulation run by randomized groups of three Swiss fourth year medical students. Before participating in the simulation, students filled out basic demographic information and then took tests that evaluated for certain personality traits and for basic resuscitation knowledge and experience. The authors main objective was to see which variables were associated with code leadership by using “leadership statements” as a surrogate marker.  Leadership statements were statements made by participants that could be categorized into one of four areas: what should be done; how it should be done; who should do it; direction/command to another person that prompted action or change of action. Results: 237 students Variables that were associated with leadership statements were: Male sex, extraversion and low scores on agreeableness personality trait. Factors not associated with leadership statements were: height, experience or(most concerningly) fund of knowledge. Study implications:

• Individuals with the most knowledge might not actually be the ones taking charge/ speaking up in critical situations
• Individuals who are less concerned with typical social conformity (tact, modesty) may be more comfortable stepping up to lead in short term emergencies
• There are likely gender specific factors that need to be considered when teaching providers to become effective code leaders. (d = 0.38)

Kolehmainen’s study

• Qualitative study on resuscitation perspectives
• 25 residents from 9 internal medicine programs
• Semi-structured telephone or in-person interviews

Men and women both shared that effective code leadership was extremely important for patient care and team cohesion and that the most effective code leaders ran codes in a classic “agentic” style (i.e. loud, direct and authoritarian). Women found it much more stressful to step into this style of leadership and were concerned about potential backlash from team members who assumed they were acting “witchy with a b”. The authors contend this is a legitimate concern because when women step into code leadership they are bucking implicit bias around cultural stereotypes that expect men to be more aligned with agentic roles and women to be more aligned with communal ones (i.e. cooperative and soft spoken) “Leadership and gender: All participants thought that men and women were equally effective leaders, and both described the same ideal leadership behaviors and their struggles to achieve them. However, the larger majority of female participants expressed their discomfort and stress in acting more assertively during codes. One female participant observed that “tall men with a deep voice may naturally appear more authoritative.” A male participant confirmed this advantage, saying “Anyone who tells you that being a white male with a deep voice who’s a little bit taller is not an advantage … would be lying.” Another female participant said, “I act differently during a code … you’re trying to assume this persona of being in charge and I think that’s probably a little more stressful (for women).” Almost half of the female participants described their apprehension in appearing “bossy” when leading codes, whereas no male participants expressed this concern.” Kolehmainen’s tips to help women cognitively prepare for running a resuscitation.

• Establish “Identity safety”
  • Remind them there are no gender differences in code competencies

Validate potential awkwardness

• Acknowledge that transitioning from one’s typical communication style can be difficult but it is also necessary for running effective resuscitations

• Practice “Enclothed cognition”
  • Use pager and white coat as external symbols that validate leadership role
  • Consciously transition by tying hair back
• Adopt “Embodied Cognition”
  • Take advantage of body positioning
    • Stand elevated at head of bed
    • Use power stance
    • Deepen voice
  • Debrief (and possibly acknowledge awkwardness of leadership role) afterwards

Other tips from podcasters: Reframe resuscitation scenario- advocate for patient, optimize their outcome Liberal use of time outs- this allows summary, direction and formally solicits input

• Consciously creating a space that empowers others in the room to have the opportunity to speak up is paramount to patient safety

Bottom line of these two studies:  it is important to consider the potential of gender specific issues and possibly gender specific consequences associated with traditional code leadership. Kolehmainen c, Brennan M, Filut A, Issac C, Carnes M” Afrain of being “witchy” with a “b”: a qualitative study of how gender influences residents’ experiences leading cardiopulmonary resuscitations. Academic Medicine: 2014 89 (9) 1276-81. Wayne DB, Cohen ER, McGaghie WC. Leadership in medical emergencies is not gender-specific. Simul Healthc 2012;7:134. Streiff S, Tschan F, Hunziker S, et al. Leadership in medical emergencies depends on gender and personality. Simul Healthc 2011;6:78Y83. Tool to understand Cohen’s d effect graph: Magnussen, K: http://rpsychologist.com/d3/cohend/ In gender associated research the following d effect size  is commonly used (d 0.10) or small (0.11 d 0.35) range, a few are in the moderate range (0.36 d 0.65), and very few are large (d 0.66–1.00) or very large (d 1.00).