Gender, Power and Leadership: the Effect of a Superior’s Gender on Respiratory Therapists’ Ability to Challenge Leadership During a Life-Threatening Emergency

Pattni N, Bould MD, Hayter M et al.

British Journal of Anaesthesia 2017; 119 (4): 607–702

Aim of Study

“To understand if gender impacts a respiratory therapists’ (RTs – approximately equivalent to ODPs – operating department practitioners – in Britain) ability to challenge authority in a simulated crisis situation, when faced with clinical management they know to be incorrect and endangering patient safety”.


Design & Location

Single-blinded randomised intervention study, Ontario, Canada.



Random assignment of 29 RTs to either a male or female anaesthetist in a simulated Can’t Intubate Can’t Ventilate scenario. The anaesthetists were confederates in the study and would badly manage the situation in accordance with a strict script. RTs behaviour was video recorded, which was then analysed by two independent raters. Challenges by the RTs were counted and assessed using a modified advocacy inquiry score (mAIS).


Primary Outcome

Best mAIS compared by gender of anaesthetist.


Secondary Outcomes

Best mAIS compared by gender of RT. Best mAIS compared by same or different sex pairings. Number of challenges.



Main outcomes were compared using the Mann-Whitney U test. Raters’ scores were compared using interclass correlation coefficients.



The female anaesthetist was challenged more strongly (higher mAIS) and more frequently than the male anaesthetist. The RTs’ years of experience (ranging from 1 to 29 years) did not correlate with maximum mAIS.



Juniors’ willingness to speak up and challenge their seniors’ actions may be affected by the sex of their seniors. This could imply a need to include specific training on the effect of gender on team hierarchies in medical education.


Stated Limitations from the Study

Small study size, which also had some video data lost. Despite attempts to standardise the male and female anaesthetists in everything other than gender, other intangible factors may also have affected RTs’ interactions with them. Results from this study may not be generalizable to other situations.


Discussion from Journal Club Meeting

It might be difficult to reverse centuries of patriarchal power imbalance in communication skills classes for medical students or ODPs. Male anaesthetists should be aware of juniors’ possible reluctance to challenge sub-optimal practices, but could try to adopt those female traits that do make juniors feel able to speak up, thereby encouraging collaborative problem solving and improving patient safety.

Summary by Dr T Wedgwood. Journal Club 02 November 2017. 

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