seX & whY Episode 7 Part 1: Concussions

Jeannette WolfePodcast Episodes

Show Notes for Podcast Seven of seX & whY, Part 1

Thank you for Alyson McGregor for correctly pointing out that although the NIH, as of January 2016, does require its basic scientists to include both males and female animals in their grant proposals it is not called the “Research for All Act”. The Research for All Act of 2014 is actually a bill sponsored by Congressman Jim Cooper of Tennessee that would require, among other things, that the FDA have access to subgroup analysis of data by sex prior to granting expedited approval of a new product. As of now, this bill has not passed.

Host: Jeannette Wolfe


Dr. Neha Raukar, Emergency and Sports Medicine Physician

Katherine Snedaker, Executive Director of Pink Concussions

Topic: Sex and Gender Differences in Concussions

Take home points

  • The research behind traumatic brain injury is rapidly evolving as technology advances are allowing us to better understand how the human brain works and the nuances between male and female brains
  • We still have a long way to go because most of the basic science surrounding traumatic brain injury has been conducted on male animals
    • In 2015 the NIH passed The Research for All Act that requires NIH funded basic science to include both male and female animals or be able to justify their exclusion
  • Men, compared to women, have an overall greater incidence of traumatic brain injury and this is likely associated with differences in risk tolerance and exposure to activities associated with potential injury
  • In situations in which risk exposure is the same- like playing basketball or soccer- after sustaining the same impact, women appear to have a lower neurobiological threshold to obtain a traumatic brain injury than men
  • Definitive/proportionate reasons for these differences are not fully understood, however possible factors include:
    • Weaker neck muscles
    • Decreased neurobiological threshold for injury
    • Hormonal differences
    • Reporting bias- this theory is quite controversial and it was emphasized throughout the podcast that many athletes, especially at elite levels- will underreport symptoms regardless of their biological sex
  • Hormonal influences- it appears that a woman’s vulnerability to traumatic brain injury may vary depending upon where she is within her menstrual cycle (with injury during the luteal phase leading to increased concussive symptoms) or whether or not she is on oral contraceptives (with some evidence that women on OCPs having decreased symptoms).
  • Symptoms of concussion can be broken down into different categories:
    • Cognitive- issues with memory/concentration/fogginess
    • Emotional- anxiety, irritability/sadness
    • Somatic- headaches/ light noise sensitivity/nausea and vomiting
    • Vesitibular/Ocular- balance, eye tracking
    • Sleep


Collins, C.L., Fletcher, E.N., Fields, S.K. et al. Neck Strength: A Protective Factor Reducing Risk for Concussion in High School Sports J Primary Prevent (2014) 35: 309.

Covassin T, Moran R, Elbin RJ. Sex differences in reported concussion injury rates and time loss from participation: an update of the National Collegiate Athletic Association Injury Surveillance Program from 2004-2005 through 2008-2009J Athl Train. 2016;51:189-194.

Wilcox, B. J., Beckwith, J. G., Greenwald, R. M., Raukar, N. P., Chu, J. J., McAllister, T. W., … Crisco, J. J. (2015). Biomechanics of head impacts associated with diagnosed concussion in female collegiate ice hockey players. Journal of Biomechanics, 48(10), 2201–2204.

Wunderle K, Hoeger KM, Wasserman E, Bazarian JJ. Menstrual phase as predictor of outcome after mild traumatic brain injury in womenJ Head Trauma Rehabil. 2014;29:

seX & whY Episode 6: New Rules for Women

Jeannette WolfePodcast Episodes

Show Notes for Podcast Six of Sex & Why

Hosts: Jeannette Wolfe and Dr. Anne Litwin PhD

Topic: New Rules for Women

In this episode, Dr. Anne Litwin PhD joined me to discuss the findings of her book New Rules for Women. This book highlights the results of her extensive research on the challenges women can face when working with other women in a professional environment. Dr. Litwin, through her in-depth interviews of women across the globe and working in different industries, began to notice a pattern of expectations or so called “friendship rules” that women often carry into the workplace and innocently set them up for inevitable conflict.

The key components of the rules are as follows:

  • Equality
  • Loyalty
  • Listening
  • Sharing Confidences

The real kicker, however, is that it is actually considered taboo to talk about them.  Litwin claims that as these rules are so deeply ingrained into females as young girls, that by the time they enter the workplace they are simply assumed truths.

These rules set up a catch 22 as the very nature of most work environments is competitive and hierarchical. As such, women may often find themselves in positions in which they are not “equal” and not able to unconditionally back each other up. The result is that the friendship rules will predictably get broken and if unchecked, potentially leave women feeling unsupported, backstabbed or disillusioned with other women.

Fortunately, there are a few suggestions to better manage these relationships.

  • Break the taboo and actual talk about the inevitable catch 22 of women working together.
  • Make a commitment to resist the temptation of indirect aggression and agree to handle conflict in a direct fashion.

Some suggested wordsmithing:

you are a strong woman and I want to support you, there are going to be times when due to our different job descriptions that we will inevitably face conflict, I ask that when this happens that we agree to work through them in a professional respectful manner so that we can continue to support each other and do our jobs to the best of our abilities.”

as we have different roles, there are going to be times in which I am going to have to put on my “professional” hat to do my expected job. To avoid confusion or misunderstanding, I will try and be as transparent as possible when I need to adopt that role.”

  • Pre-empt anticipated conflict such as:
    • competition for promotion
    • predicted disagreement during meeting
    • hierarchical roles on a team under stress

Try to discuss expectations up front and identify new ways, understanding the above constraints, in which you can continue to support each other.

  • Recognize and address blooming dysfunction early on (though it is usually helpful to wait until the emotional sting of a situation has passed). This helps to avoid the “stockpiling” of perceived wrongs and to hopefully realign the relationship.
  • Double check perceptions, it is possible that a woman may be acting in a way that is constrained by an organizational system and not necessarily their preferred choice.
  • In teams, be clear about the shared goals of the team and delineate specific ways in which members of the team are expected to behave and communicate to fulfill these goals.

Anne Litwin’s New Rules for Women
Joyce Benenson’s Warriors and Worriers
Douglas Stone’s Thanks for the Feedback

Check out my “X- the Skidmark Talk” from the archives of the 2017 Feminem FIX national meeting.

seX & whY Episode 5 Part 3: Stress Response

Jeannette WolfePodcast Episodes

Show Notes for Podcast Five of Sex & Why

Host: Jeannette Wolfe
Guest Host: Justin Morgenstern

Topic: Stress Response – Part 3

Tricks for optimizing performance under stress


  • Over train and begin to focus on how to recover from mistakes
  • Invest in mindfulness
    • Meditate
      • Increases your awareness of your own physiological stress response
      • Can help you train to go back and forth from narrow to broad focus
    • Be Awed
      • Have gratitude for what is going right
    • Use a transition mantra as you walk into work and move from your personal to your professional life
    • Appreciate the power of emotional contagion
      • Your mood influences your team’s performance
      • Acknowledge and celebrate team’s saves and successes
    • Create safe communities in which you can talk and walk through difficult cases without shame or judgement
  • Maximize environmental advantages
    • Have the right equipment and know where it is

In the moment

  • When you are becoming aware of stress- acknowledge its presence and recognize that you can face it as a threat or a challenge and then deliberately and emphatically choose challenge
  • Chunk down overwhelming situations into immediate next actions, when in doubt go to the head of the bed and check oxygen connections and monitor leads
  • Access mental crutches- simple pneumonics, resource cards, or a favorite app to jumpstart your thinking until your frontal lobe comes back on line
  • Consider cognitive reframing and brief emotional detachment
  • Keep a talisman in your pocket- use for either spiritual strength or physical distraction
  • Use Mike Lauria’s pneumonic BTSF (Beat The Stress Fool)
    • Breath
      • Tactical breathing and controlling the breath
    • Talk
      • Positive self-talk
    • See
      • Visualize successful completion of the task
    • Focus
      • Use a trigger word
    • Tips for breathing
      • Consciously slow your exhalation
      • Belly breath in which your abdomen expands with inhalation
    • Armor for negative thoughts
      • Thank your brain for trying to keep you safe
        • “Thank you brain for trying to watch my back, but I’ve got this”
      • Recognize your thoughts as being “just thoughts”
        • Change “I can’t do this” to “I’m having a thought that I can’t do this and fortunately most of my thoughts don’t equate actual reality”
      • Identify and label your patterns
        • “oh yay, I do this sometimes when I get stuck, but I can choose to do X, Y or Z instead” (repeating if needed.)
      • Internally shout at yourself (to snap out of an internal loop) and then remind yourself that you are trained and capable
      • Repeat a repetitive negative thought in a strange accent
      • Sing a repetitive negative thought
      • Refer to yourself as a third person
      • Touch something in front of you and describe its shape/temperature and texture
      • Acknowledge that you are stressed but decide to just do it anyways
    • Tricks for focus words
      • Consider single word describing next critical action (“drape”, “needle”)
    • After the stressful event
      • Anticipate parasympathetic backlash
      • Consider cognitive offloading
        • Have a check list
        • Use time outs
          • Creates a shared mental model of critical actions
          • Allows for information exchange
          • Reinforces value of team
        • Appreciate that cortisol spiking may subtly shift your tolerance for risk and could potentially impact clinical decision making
        • Take a break
          • Eat and drink something (preferably without caffeine)
          • Emotionally recharge
        • After the shift
          • Work Out
          • Play Tetras- (this was a new one for me and I’ve attached a reference below)

Selected Resources

Meditation App- Insight Timer

Justin Morgenstern’s Performance Under Pressure blog:

Adrian Plunkett’s SMACC talk

Recent Tetra study: Horsch A, et al: Reducing intrusive traumatic memories after emergency caesarean section: A proof-of-principle randomized controlled study. Behaviour Research and Therapy, 2017

Lauria, M. J., Gallo, I. A., Rush, S., Brooks, J., Spiegel, R., & Weingart, S. D. (2017). Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress. Annals of Emergency Medicine.

Parkin, B. L., Warriner, K., & Walsh, V. (2017). Gunslingers, poker players, and chickens1 :Decision making under physical performance pressure in elite athletes. Progress in Brain Research (1st ed., Vol. 234). Elsevier B.V.

Markway B, Stop Fighting your Negative Thoughts, Psychology Today May 7 2013

seX & whY Episode 5 Part 2: Stress Response

Jeannette WolfePodcast Episodes

Show Notes for Podcast Five of Sex & Why

Host: Jeannette Wolfe

Topic: Stress Response

For Acute Care Medicine and Introduction to Sex and Gender Based Medicine CME Cruise Opportunity click here

Part 2 on biological sex differences in the stress response with special guest Justin Morgenstern

We started out with a discussion on different ways to frame potential sex and gender based research using a method described by  Dr. M McCarthy

A full discussion of this framework can also be found on my website

There appears to be a significant amount of individual variation in how some individuals respond to and recover from similar stresses. Some of these differences may be influenced by our biological sex. Understanding how we react and respond to stress and how this may perhaps differ from other individuals around us may help us better communicate and lead under stressful situations.

McCarthy MM et al, The Journal of Neuroscience: the official journal of the Society for Neuroscience. 2012;32(7):2241-2247.

Study #1

This was a follow up study to an infamous study the same team did three years before in which they looked at sex differences in reward collection on a computer balloon game (Balloon Analogue Risk Task or BART). In this game, players got 30 balloons and the farther they pumped them up the more points they got however, each balloon was also set to randomly pop somewhere between 1- 128 pumps and if the player popped their balloon before they cashed it in they lost points for that balloon. Study participants were randomized to control vs stress condition (placing hand in neutral versus ice water for 3 min) and then played the game. They found that in neutral conditions there was no significant difference in risk taking (number of pumps 39 for women versus 42 for men, but under stress women decreased their pumping to 32 while men increased to 48).

In this 2012 study, Lighthall’s group adjusted its protocol so that BART could now be played in an MRI scanner. Unfortunately, the new BART design subtly changed the game because now instead of going through 30 balloons, participants played the game for a set amount of time with unlimited balloons. This inadvertently added a second strategy to get lots of points as the new design allowed participants to get points by either pumping additional air into an individual balloon or rapidly moving through a greater number of balloons while pumping only a few pumps per balloon. Stress intervention was again either a cold or neutral temperature water bath and after submersion the researchers collected cortisol samples and scanned participants while they played the game.

Results- no difference in control conditions (room temp water) between men and women in number of balloon pumps or points earned

But under stress men acted more quickly and got increased rewards while women appeared to slow down their reaction time and decrease their rewards.

Men had higher baseline and stimulated cortisol but there was no difference b/w men and women in the amount of cortisol change between baseline and stressed condition.

Under basic non stress conditions- during the control testing it appeared that overall men and women utilized the same brain regions to complete the balloon task (i.e. suggesting that males and females approach the task by using similar neural strategies), however once stressed men and women seemed to use different areas of their brain. Men used their dorsal striatum and anterior insula more. Anterior insula has been associated with switching tasks from a riskier to a safer option (and in both sexes higher activity in this region correlated with higher collection rate) and the dorsal striatum is believed to be associated with obtaining predictable rewards and with integrating sensory, motor, cognitive and emotional signals.

Did not find that men had increased risk taking in this study but it may have been masked in that there was now a lower risk strategy available to them that still was associated with an increased reward (pumping balloon a small amount and quickly cashing in to get to next balloon).

Concept discussed is that under stress men may possible go into type one systemic thinking (automatic) while women may favor type 2 (deliberate cognitive inquiry).

Lighthall, N. R., Mather, M., & Gorlick, M. A. (2009). Acute stress increases sex differences in risk seeking in the balloon analogue risk task. PloS One, 4(7), e6002.

Lighthall, N. R., Sakaki, M., Vasunilashorn, S., Nga, L., Somayajula, S., Chen, E. Y. Mather, M. (2012). Gender differences in reward-related decision processing under stress. Social Cognitive and Affective Neuroscience, 7(4), 476–84.

Study #2:

Goal to determine if:

  • Under equal subjective sensations of stress (i.e. men and women objectively rate their subjective level of stress the same on a 1-10 point scale) do men and women use the same brain circuitry to process stress or do they use different circuitries.

What they did:

  • Collect cognitive, psychiatric, and drug use assessments on 55 men and 41 women aged 19-50
    • Exclusions TBI, psychoactive meds, history of substance abuse, preg, DSM-IV mental health disorder and currently menstruating or oral contraceptive use (to try and mitigate additional hormonal influences)
  • Over course of 2-3 sessions put them into a MRI scanner and asked them to visualize neutral or stress inducing images (this technique has previously been validated and involved the subjects own audiotaped accounts of stressful –rated as greater than 8 on 1-10 Likert scale- or neutral experience) which was later played back to them in MRI scanner
  • Asked them to rank their level of stress
  • Looked to see which areas of the brain lit up under different conditions


Men and women appeared to have different strategies for guided visual tasks in general regardless of whether listening to neutral or stressful recordings:


More likely to light up areas associated with motor processing and action.

Caudate, midbrain, thalamus, and cingulate gyrus and cerebellum


More likely to light up areas associated with visual processing, verbal expression and emotional experience

Right temporal gyrus, insula and occipital lobe

Women were also more likely to increase their HR regardless of condition (likely from having increased autonomic arousal- though other studies suggest that women have increased HR at baseline compared to men in general)

Under stress men and women had firing in opposite directions:

Men dampened while women increased firing in:

Dorsal Medial pre-frontal cortex, parietal lobes (including inferior parietal lobe and precuneus region) left temporal lobe, occipital area and cerebellum.

Believed functions of these different regions

Dorsal medial frontal cortex – executive functioning of cognitive control, self-awareness of emotional discomfort, strategic reasoning, and regulation

Precuneus– part of the parietal lobe associated with self-referential and self-consciousness

Inferior parietal lobe– cognitive appraisal and consideration of response strategies (also area often associated with mirror imaging)

Left temporal gyrus– processes verbal information

Occipital area– processes visual information

Cerebellum– besides coordinating motor movement also is involved in emotional and cognitive processing

“Taken together, the observed differences in these regions suggest that men and women may differ in the extent to which they engage in verbal processing, visualization, self-referential thinking, and cognitive processing during the experience of stress and anxiety.”

They also suggest that under stress men may feel anxious due to “hypoactivity” while women may feel stress due to “hyperactivity” in above noted regions.


  • Men and women use different neural strategies under stress even with similarly reported stress levels

This research is still clearly in its infancy but suggests that under stress some men, may turn down activity in areas of their brains involved in executive functioning and that this might increase their vulnerability to impulsivity. Conversely, under stress some women may actually turn up activity in these regions that could lead to excessive rumination and possibly depression. The authors then extrapolate their data to suggest that men and women might possibly benefit from different stress reduction techniques in that some men might benefit more from cognitive behavioral therapy which enhances frontal lobe firing and some women from mindful meditation which dampens it.

Seo, D., Ahluwalia, A., Potenza, M. N., & Sinha, R. (2017). Gender Differences in Neural Correlates of Stress-Induced Anxiety. Journal of Neuroscience Research, 125, 115–125.

Study #3

This study literally looks at what conditions men and women might seek out increased physical interaction with their dog after an agility competition. The background here is that in 2000 Dr. SE Taylor questioned whether the flight of fight response which has classically been described as a “universal” stress response, was actually applicable to both males and females. She questioned how realistic it was for a female who might be physically smaller and less muscular than her male peer to successfully fight or run away from a potential attacker. She suggested an alternative response of “tend and befriend” which suggests that under stress that women may naturally migrate towards their children as well as others within their intimate circle with the belief that a larger group may offer protection and a pooling of resources. Additional support for this theory is the idea that oxytocin, which has receptors throughout the brain and is usually found in higher amounts in women, may be released during this affiliative behavior and help to dampen the physiological cortisol stress response.

This study was done to see if men and women seek out physical contact with another being (in this case their dog) in similar fashion when they are stressed. They chose to study human contact with a dog versus an interaction with another human to try and mitigate the influence of any “gender expectation” violations. Which in English means that if Rob would normally seek out Carol when he is stressed, he might decide not to do so in public (and in this case being videotaped) because he doesn’t want to appear “less masculine”. As public affection with one’s dog is considered less gender biased, the authors chose this interaction as a marker for affiliative behavior.

What they did: Videotaped and took cortisol saliva levels from 93 men and  91 women after they had run their dog through a competitive agility course. Recording and samples were taken as participants waited for their official score (although subjectively most participants pretty much already knew whether or not their dog had scored high enough to move on.) The researchers measured cortisol levels and how much participants petted their dog while waiting for this score.


  • 36 of results excluded because dogs did not finish course and were disqualified
  • Overall there was no sex difference in total affiliative behavior
    • Of first 180 seconds of video tape women petted dog on average 27 seconds and men 25 seconds
  • When men and women perceived they lost, their cortisol level increased more than those who perceived they had advanced.
  • Differences occurred however as to when men and women were more likely to pet their dogs
    • Women petted them more when they sensed defeat– an additional 12 seconds compared to women who had won
    • Men petted them more when they sensed victory– an additional 7 seconds when compared to men who had lost

 Conclusions: women sought out affiliative behavior when they lost, men sought it out when they won.

Justin and I use this paper as a discussion point as to understanding how two people may get exposed to the same stressor and respond quite differently and importantly how they sort of bounce back from a stressful situation may also differ. This paper suggests that emotional debriefing after stressful experiences may be more helpful to some individuals than others.

For more on the stress response please see Justin’s new post on First10EM

Sherman G, Rice L, Shuo Jin E, et al: (2017) Sex differences in cortisol’s regulation of affiliative behavior. Hormones and Behavior 92, 20- 28

seX & whY Episode 5 Part 1: Stress Response

Jeannette WolfePodcast Episodes

Show Notes for Podcast Five of Sex & Why

Host: Jeannette Wolfe

Topic: Stress Response

This Podcast focuses on the basics of the acute human stress response. Please see Dr Morgenstern’s excellent write up:

Performance Under Pressure Review:

Components of stress response

  • Trigger
  • Speed of activation
  • Magnitude of response
  • Time to return to baseline

Things that affect cortisol response

  • time of day
  • health
  • genetics
  • personality
  • early pre-natal/childhood stressors- epigenetics can change DNA expression
  • current stressors
  • smoking
  • if female- where you are in cycle or use of OCP
  • interaction with testosterone

Sensation of psychological stress is not always associated with physiological stress (i.e. cortisol stress response)

Conversely in psychological studies in which subjects get exogenous steroids (i.e take a hydrocortisone pill) although there are often associated behavioral changes from the steroids participants rarely feel anxious.

Somewhat ironic that women report more psychological stress but that men die on average 7 years earlier

Things that reliably trigger physiological stress:

Demands >>> Resources

  • Unpredictability
  • Uncontrollability
  • Novelty

Learning on stress is U shaped curve

  • A little stress helps things stick more
  • As stress increases harder to draw

Some suggested sex differences:

In general women have higher baseline HR than men (despite this, women are believed to have a higher parasympathetic baseline tone)


  • Men may be more vulnerable to stressors that trigger dominancy/hierarchy
  • Women may be more vulnerable to stressors that trigger social isolation

Free Cortisol is the active form and men appear to have higher free cortisol levels

Women may be more sensitive to acth- similar cortisol level with less trigger.

Men more likely to respond to threat of hierarchy, women social exclusion

Stress resiliency:

Time to respond, magnitude of response time until return to baseline

To what, how quickly, how much, how long.

Studies discussed in podcast

Alexander, G. M., Wilcox, T., & Woods, R. (2009). Sex differences in infants’ visual interest in toys. Archives of Sexual Behavior, 38(3), 427–33.

Ali, Amir; Subhi, Yousif; Ringsted, Charlotte; Konge, Lars. Gender differences in the acquisition of surgical skills : a systematic review. /I: Surgical endoscopy, Vol. 29, Nr. 11, 11.2015, s. 3065-3073.

Deane, R., Chummun, H., & Prashad, D. (2002). Differences in urinary stress hormones in male and female nurses at different ages. Journal of Advanced Nursing, 37 , 304–310.

Shane MD, Pettitt BJ, Morgenthal CB, Smith CD (2008) Should surgical novices trade their retractors for joysticks? Videogame experience decreases the time needed to acquire surgical skills.
Surg Endosc 22:1294–1297

Theorell Tores, On Basic Physiological Stress Mechanisms in Men and Women: Gender Observations on Catecholamines, Cortisol and Blood Pressure Monitored in Daily Life. Psychosocial Stress and Cardiovascular Disease in Women, DOI 10.1007/978-3-319-09241-6_7  Published 2015 pp 89-105

Turecki, G., & Meaney, M. J. (2016). Effects of the Social Environment and Stress on Glucocorticoid Receptor Gene Methylation: A Systematic Review. Biological Psychiatry, 79(2), 87–96.

Yael, Sofer, et al. “GENDER D. S. F. C. H. L. I. M. . E. P. (2016). (2015). Original Article GENDER DETERMINES SERUM FREE CORTISOL: HIGHER LEVELS IN MEN EP161370.OR. Endocrine Practice.

White MT, Welch K (2012) Does gender predict performance of novices undergoing fundamentals of laparoscopic surgery (FLS) training? Am J Surg 203:397–400

seX & whY Episode 3: Priming and Performance

Jeannette WolfePodcast Episodes

Show Notes for Podcast Three of Sex & Why
“Behavior” Pod
Hosts: Jeannette Wolfe and Simon Carley

Topic: Unconscious Bias

Major Question: Can unconscious cues cause changes in behavior and performance?

Riskin Study

Examined the effect of rude statements on team diagnostic and procedural performance.

What they did: Had NICU providers (nurses and doctors) first go through a simulation and then attend a workshop on team “reflexivity” (i.e. team training). The workshop was taught by a neonatologist who said that he was “collaborating” with an American expert who was ostensibly watching via webcam.

At the end of the workshop, the coordinating neonatologist told the teams that the expert wanted to greet them and he then “dialed” up the expert (in reality this triggered a prerecorded message). The groups were randomized to hear either a neutral message in which the expert commented that he had been working with a lot of Israeli hospitals, or a rude message in which the expert commented that he had “observed a number of groups from other hospitals in Israel and compared with the participants he had observed elsewhere, he was not impressed with the quality of medicine in Israel.”

Both groups then underwent a standardized written and procedural simulation case involving a neonate with rapidly progressing necrotizing enterocolitis. Ten minutes into the simulation the American “expert” spoke again with the control group hearing another neutral comment and the rude group hearing that although the expert liked some of what he saw during his visit to Israel that he hoped that he would not get sick in Israel and implied that most “wouldn’t last a week” in his own department. The teams then continued to complete the case.

The simulations of both the control and rude teams were then evaluated by blinded observers who reviewed written documents and team videos. Participants were rated on diagnostic performance, procedural performance, information sharing and help-seeking.

Results: 33 NICU providers were randomized to control group and 39 to rude statement group forming a total of 24 teams.

Diagnostic and procedural performance along with information sharing and help seeking behavior declined statistically significantly in the rude group.

Table 1

Statistically significant differences in procedure performance

Procedure Control-neutral phone calls

Mean (1-5 scale)

Intervention- rude phone calls P value
resuscitation performed well 3.05 2.49 .002
Verified tube placement well 3.56 2.85 .0005
Ventilated well 3.43


3.01 .002
Asked for right lab tests 3.78 3.24 .01
Good general technical skills 3.17 2.61 .002
Overall procedure 3.26 2.77 .0002



Table 2

Statistically significant differences in diagnostic performance

Variable Control- neutral phone calls Intervention-rude phone calls P value
Diagnosed shock 2.88 2.08 .003
Diagnosed NEC 3.08 2.62 .041
Diagnosed deterioration 4.05 3.54 .006
Suspected bowel perf 2.6 1.94 .012
Diagnosed cardiac tamponade 3.18 2.15 .001
Overall Diagnostic 3.18 2.65 .0003

Theory behind findings- At individual level rudeness can impair access to working memory (which is important for analysis, planning, and execution) which can then contribute to suboptimal task execution. At the team level, performance is further decreased because less information is shared (potentially limiting diagnostic considerations) and procedures may become more difficult because individuals stop asking for help.

Ultimately this study suggests that when an attribute (in this case being an Israeli physician/nurse) is challenged, behavior can be impacted. This has huge implications for how physician professionalism can directly affect patient care.

Shih Study:

This study is wonderful in its simplicity, it takes individuals who possess two attributes that are associated with opposing stereotypes (in this case Asian and female) and asks if their behavior (performance on a math test) is able to be manipulated depending upon which attribute is subtly cued.

Shih asked a group of Asian college females to take a math test. Prior to taking the test she randomized the women into three groups.  In the first group, participants were subtly primed to identify with their “female” identity by asking them gender demographics and targeted questions about single sex versus coed dorm living. In the next group, women had their ethnic identity triggered by asking about relatives and languages spoken at home. And in the final group women were asked generic questions that avoided implicit triggering of either gender or ethnic attributes. The measured outcome was accuracy= number of test questions right/number attempted

Results: Women who had their Asian identity triggered scored highest on the tests, the neutral group scored in the middle and the female identity primed scored the worst with statistical difference (p<.05) between ethnic and female triggered scores.   (Of note, the mean SAT scores for Asian women in the study was 750 with the general average scores that year being 508)

Importantly in this study results showed:

  • the women were unaware of both the specific attribute that was being primed or the purpose of the study
  • no difference in motivation (i.e. Asian group did not consciously try harder)
  • no difference b/w the three groups in believe of how well they did
  • no difference b/w the three groups in their overall assessment of math competency

Maass study:

This is one of my favorite studies because it objectively shows that subtle gender cues or “primes” can actually trigger significant differences in performance.


What they did:  had chess players matched by ability level play three games of internet chess. Each pair was composed of a man and women who (unknowingly) played all three games of chess against each other. In the control game, each player was given a gender neutral name, in the second and third games players were given a priming statement about international chess being a male dominated game and that the researchers were evaluating potential contributing factors. Players were then told that in the last two games one game would be played against someone of their same sex and the other played against someone of the opposite sex.


42 pairs of men and women

Control game and primed game in which players believed they were playing against someone of same sex- games essentially split (i.e. no statistical difference in who won.)

Primed game in which women believed they were playing against a man: women lost 75%

So what happened here? Were men positively primed by information that suggested a natural advantage (receiving a  “stereotype lift”) and then able to play up and crush women? Or conversely, were women underperforming because they were negatively primed (experiencing a “stereotype threat”) and because in their minds the game’s stakes suddenly got raised as their performance would ultimately be compared to the stereotype? Well, the researchers believed that the differences were not because men changed their playing tactics but because women altered their game style. Instead of playing to win (goal directed), they began to play not to lose (failure avoidance) which is actually believed to be a separate motivational system. Ironically, playing more cautiously actually caused women to lose more games.


What we can learn from these studies: Subtle cues can affect behavior and team performance.  Unconscious bias is real and there are ways to mitigate it.

What is unconscious bias?

– A deeply rooted subliminal belief that reinforce the norms of the

dominant majority within a society

– May be at odds with conscious beliefs

– Is ubiquitous (affects both men and women)


A cue that triggers either a conscious or unconscious awareness of a specific attribute and that can subsequently affect behavior positively, negatively or not at all.

Priming variables:

Specific situation

Salience of prime:  blatant, subtle or simply “in the air” (ubiquitously present)

Number of different attributes being triggered (gender versus gender and race)

Who is triggering threat (self, in group, outgroup)

If threat is directed specifically toward self or larger group

If threat is believed to be “fixed”- (this comes out of Carol Dweck’s  Mindset work in which individuals who have a fixed mindset believe that certain abilities are innate and you either have them or don’t, versus a “flexible” mindset in which it is believed that abilities can be obtained through deliberate and consistent effort)

*** Somewhat ironic, stereotype threat appears to be most powerful in individuals who have deep associations with the specific triggered attribute and in those who are most motivated to do well.

(Hoyt 2016)

Examples of priming:

Asking demographics before testing

Comment about lack of diversity when you are only individual with specific attribute at meeting

Adverse effects of stereotype threat-

  • Underachievement

–   Loss of confidence

–   Disengagement/Avoidance

–   Adoption of “reactance” response, purposefully acting directly opposite of the expected stereotype (this may or may not be adaptive depending on situation i.e. blatantly priming can trigger a I-see-what-you-are-doing-and-I’m-not-going-to-let-you-get-away-with-it performance boost, or it can backfire as seen in some studies in which women try to negotiate similarly to men.

Theories as to why there are behavioral changes associated with unconscious bias and stereotype threat:

  • Physiological stress- decreasing working memory
  • Increasing anxiety
  • Increasing thought intrusion
  • Overthinking previously automatic behavior

Ways to decrease stereotype threat

For individuals

  • Simply recognize
    • Understanding that situational anxiety may reflect stereotype threat and not incompetence (Maas study showed that under right mindset women could perform on par with men.)
  • Separation of attribute from task
    • “X” is challenging for everyone no just people with specific trait
  • Identify with individuals with same attribute who have been successful
    • Demonstrate that success is possible
    • Buffers threat (though in certain cases can backfire if the individual cannot realistically identify with the role model leading to feelings of inadequacy.)
  • “Positively” prime yourself
    • Remember a personal experience that was associated with professional success
  • Consciously embrace a flexible mindset

For organizations

  • Validation that individual is qualified to do task
  • Create external environmental cues that welcome inclusion and create “identity” safe environment
    • Encouraging people to volunteer for “easy” leadership opportunities, emphasizing no experience is needed
    • Emboldening jr residents to step up to care for critical patients reminding them they will receive appropriate back up if needed
  • Commit to breaking down silos- in medicine this is critically important, as different identity groups often take potshots at each other which can ultimately lead (at least in medicine) to decreased collaboration and increased medical errors
    • it should not be “us versus them” rather “us with them to take care of patients”.
  • Increase diversity- having a single individual with a specific trait in a group is quite different than having several other group members also share that same trait. When there is just a single individual, other group members may unconsciously process that individual’s suggestions as being aligned with or opposed to associated stereotype versus seriously considering its stand-alone legitimacy.


More Specific Gender Examples

Gender examples:

(Murphy 2007) women attending a major STEM conference in which gender imbalance was subtly primed felt isolated and disengaged at meeting

(Cheryan 2009) Stated interest in computer science decreased if women were exposed to a stereotypical male computer science environment (room with Star Trek poster and video games) than if exposed to more gender neutral space.

–   Distancing self from identification of attribute (women being unsupportive of other women)

Success story of positive priming

Harvey Mudd College’s computer science experience

Maria Klawe, president of Harvey Mudd University wanted to increase gender balance amongst computer science majors so she did three things

  • Affirmation
    • Personally contacted high potential female students women who were accepted into Harvey Mudd
  • Created enhanced opportunity in non-threatening environment
    • Required every freshman to take a computer science class but importantly divided students into two classes depending upon whether or not they had had previous experience (thus avoiding having novices feel out of their league if seated next to an expert)
  • Promoted exposure to role models
    • Invited women considering a computer science major to attend the national Grace Hopper conference so that they young women had first hand exposure to successful women programmers.
  • Results: Harvey Mudd increased percentage of female programmers from less than 15% to 40%

To test you own unconscious gender bias go to

Cheryan, S., Plaut, V. C., Davies, P. G., & Steele, C. M. (2009). Ambient belonging: how stereotypical cues impact gender participation in computer science. Journal of Personalityand Social Psychology, 97(6), 1045–60.

Hoyt C, Murphy S: Managing to clear the air: Stereotype threat, women, and leadership. The Leadership Quarterly Vol 27, Issue 3 June 2016 pp 387-399

Maass, A., & Ettole, C. D. (2008). Checkmate ? The role of gender stereotypes in the ultimate intellectual sport, 245(April 2007), 231–245.

Riskin, A., Erez, A., Foulk, T. A., Kugelman, A., Gover, A., & Shoris, I. (2015). The Impact of Rudeness on Medical Team Performance : A Randomized Trial, 136(3).

Shih, Margaret, Pittinsky, Todd L and Ambady, N. (n.d.). Stereotype Susceptibility: Identity Salience and Shifts In Quantitative Performance. Psychological Science January 1999 vol. 10 no. 1 80-83

  • Wayne N, Vemillion M, Uijtdehaage S, Gender differences in leadership amongst first-year medical students in the small-group setting Academic Medicine, 85 (8) (2010), pp. 1276–1281

Harvey Mudd Experience (NY Times April 2, 2012)


seX & whY Episode 2: Code Leadership and Gender

Jeannette WolfePodcast Episodes

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:

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).