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In Conclusion, Word Choice Matters: Female Physician Leadership and Cardiopulmonary Resuscitation Outcomes.

To the Editors: We read with enthusiasm the article recently published in Critical Care Medicine by Meier et al (1), describing differences in cardiopulmonary resuscitation (CPR) efforts and outcomes when led by female versus male physicians. They demonstrated that traditional measures of CPR quality were equal and that survival to hospital discharge was improved when CPR was led by female physicians. This work provided important follow-up to an earlier study by Amacher et al (2) examining CPR efforts led by female versus male medical students. The current investigation studied resident physicians rather than medical students, and it employed objective metrics of performance and outcome of actual rather than simulated cardiac arrest events, providing a more realistic environment from which to draw conclusions about gender-related performance in CPR. We were surprised, however, to note the differences in language and tone when comparing the conclusions presented by these two studies. The study by Meier et al (1) identified a statistically significant improvement in survival to hospital discharge when CPR efforts were led by a female versus male physician (odds ratio, 1.53; p < 0.01) after adjusting for multiple patients and environmental factors influencing outcome, as reflected in the article title. However, the authors conclude that “female physician leadership ... is not associated with inferior outcomes [emphasis added].” Contrast this to the “important gender differences” described in the study by Amacher et al (2), which observed worse adherence to traditional measures of CPR quality for simulated efforts led by women. Those authors concluded that their results demonstrated “inferior cardiopulmonary resuscitation performance, which can partially be explained by ... inferior female leadership.” The seeming lack of enthusiasm for positive findings associated with female leadership of CPR efforts in the study by Meier et al (1), or even willingness to conclude that outcomes associated with female CPR leaders appear to be better than those associated with male leaders, contrasted with the readiness to attribute poor CPR performance to inferior female leadership in the study by Amacher et al (2), concerns us as a possible example of implicit bias against female physicians. As observed by the authors of both studies, bias occurs across the career trajectory. Systematic differences exist as early as residency, where men receive more positive evaluations (3) and more useful feedback (4) and are granted greater autonomy (5). Female physicians report similar overall job satisfaction but experience difficulties in accessing mentoring and departmental support (6), which likely contributes to disparate rates of attaining objective measures of academic success (e.g., ongoing grant funding, leadership positions, and promotion) (7–9). A medical culture that allows implicit bias to persist creates unwarranted, damaging stress for a large proportion of physicians that may also negatively affect patients and families. The authors of both studies importantly reference measures that individuals and institutions can employ to counteract this problem, which affects all physicians—men and women—and the community we form as a whole. In addition to these discrete measures, we would add that closely examining our language, as a reflection of our core values, might also help us identify and counteract implicit bias against half of those within our community. Dr. Zimmerman’s institution received funding from the National Institutes of Health; Immunexpress, Seattle; Elsevier Publishing (royalties for co-editing the textbook Pediatric Critical Care); and the Society of Critical Care Medicine (partial salary support for serving as President and reimbursement to attend board meetings). The remaining authors have disclosed that they do not have any potential conflicts of interest.