Gender, hierarchy and implicit bias: An interdisciplinary pilot simulation study

Background: Interdisciplinary collaboration and team dynamics play critical roles in patient safety, especially in the management of airway emergencies. However, these interactions can be influenced by implicit biases, which are often heightened in emergency scenarios in which Type 1 thinking predominates. This study aimed to understand the complex relationships of gender bias and hierarchy in a simulated airway emergency. Methods: Using the validated modified Advocacy-Inquiry Score (mAIS), we designed a simulation focused on the interaction between otolaryngology residents and anesthesiology attendings when deviation from the emergency airway management algorithm was introduced. A total of 15 otolaryngology residents were recruited. mAIS values were compared between female and male residents (self-identified gender) and by PGY-level. Results: The mean mAIS in female versus male participants was 4.11 (SD 0.44) versus 4.41 (SD 0.51) (p=0.12), respectively. There were no statistically significant differences in mean scores based on either gender or PGY-level. Twelve participants demonstrated male association with career and female association with family on the Implicit Association Test while three were neutral. Results from our debriefing sessions indicated that females were challenged more and spoke up less than their male counterparts, even when they were clinically more experienced. Conclusions: This pilot study prompted conversation within our institution’s departments of otolaryngology and anesthesia about training and empowering residents to employ cognitive and interpersonal skills to challenge a superior when appropriate. Our simulation design fosters recognition and discussion of implicit biases related to gender and hierarchy and is adaptable to numerous other specialties and fields in healthcare.