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Glass Slippers and Glass Cliffs

Fitting In and Falling Off

Krishnan, Nithya FRCP, MD1,2; Biggerstaff, Deborah PhD3; Szczepura, Ala DPhil4; Dolton, Monica PGCertMgmt5; Livingston, Sondra BComm6; Hattersley, John PhD1; Eris, Josette PhD7; Ascher, Nancy PhD8; Higgins, Robert FRCP1; Braun, Hillary MD8; Wood, Kathryn PhD5; Raymond, Neil MSc1

doi: 10.1097/TP.0000000000002603
Original Clinical Science—General
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Background. A glass ceiling effect exists for women in male-dominated professions. Recent studies also show a glass-cliff effect where senior women can more easily fall from positions of leadership. Transplantation remains a male-dominated specialty. This study investigated gender and the perception of adverse clinical incidents in transplantation.

Methods. Prospective randomised web-based survey involving five clinical scenarios presenting two versions of episodes with errors or mistakes, with either a male or female as a randomly named protagonist (Set1 and Set2). To address unconscious bias, the study was described as examining actions following clinical adverse incidents in transplantation. Each scenario was followed by 2 closed questions: (1) clinical performance rating and (2) selection of action required. Reasoning was invited (open-text comments). Responses were analyzed using quantitative and qualitative methods.

Results. One hundred ninety-one invitees responded; 134 completed questionnaires. There were no statistically significant differences (P > 0.05) in responses between sets for performance ratings or recommended actions. However, for “first solo laparoscopic surgery” scenario, there was some indication that “No Action” was more likely if surgeon was male (P = 0.056). Male responses rated female performance as significantly worse (P = 0.035) for the laboratory-based scenario. One hundred two participants provided open-text comments. Thematic analysis identified 7 themes. Acceptable levels of risk theme demonstrated engendered leadership beliefs, that is, when clinical judgment proved incorrect, males described as forceful but females as needing support. In cases where things went wrong, respondents were more likely to comment females should not have decided to proceed.

Conclusions. While gender may no longer be an overt issue in perceived performance of senior staff in transplantation, respondents’ use of language and their choice of words display elements of unconscious (covert) engendered views.

1 Renal Unit, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom.

2 Centre for Innovative Research Across the Life Course, Coventry University, Coventry, United Kingdom.

3 Mental Health and Wellbeing, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom.

4 Enterprise & Innovation, University of Coventry, Coventry, United Kingdom.

5 Transplantation Research Immunology Group, University of Oxford, Oxford, United Kingdom.

6 Director of Operations, The Transplantation Society, Montreal, QC, Canada.

7 Renal Transplantation, University of Sydney, Sydney, Australia.

8 Transplantation, University College San Francisco, San Francisco, CA.

Received 10 August 2018. Revision received 29 November 2018.

Accepted 10 December 2018.

Statistical work was funded by Coventry Kidney Research Fund and LINC Medical Systems Ltd, United Kingdom.

The authors declare no conflicts of interest.

N.K. conceived original idea based on clinical work; developed survey tool and vignettes used; organized online survey distribution; and contributed to data analysis, writing, and approval of final version of the paper. D.B. co-developed survey tool and vignettes used, analyzed qualitative data from survey, and contributed to writing and approval of final version of the paper. A.S. co-developed survey tool and vignettes used and contributed to data analysis, writing, and approval of final version of the paper. M.D. reviewed survey tool and vignettes used; helped with online survey distribution; and reviewed and approved final draft version of the paper. S.L. helped with online survey distribution and reviewed and approved final draft version of the paper. J.H. set up randomization of the survey and reviewed and approved final draft version of the paper. J.E. reviewed survey tool and vignettes used. N.A. reviewed survey tool and vignettes used; helped with online survey distribution; and reviewed and approved final draft version of the paper. R.H. reviewed survey tool and vignettes used and reviewed and approved final draft version of the paper. H.J.B. reviewed survey tool and vignettes used; helped with online survey distribution; and reviewed and approved final draft version of the paper. K.W. reviewed survey tool and vignettes used; helped with online survey distribution; and reviewed and approved final draft version of the paper. N.R. analyzed quantitative data from survey and contributed to writing and approval of final version of the paper.

Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.transplantjournal.com).

Correspondence: Nithya Krishnan, FRCP, MD, Renal Unit, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom CV2 2DX. (nithya.krishnan@uhcw.nhs.uk).

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