Gender and Code Leadership

Kelly Tighe, Josie Acuna, Anchal Ghai

Resuscitation skills are the cornerstone of Emergency Medicine, with cardiopulmonary resuscitation comprising a fundamental element of this skill set. Effective leadership is frequently cited as the most important aspect of a successfully run cardiopulmonary resuscitation (“code”). A wealth of research has found no difference in the effectiveness of male & female leaders, and multiple studies have examined leadership during CPR and found no gender difference in outcomes. However, individual traits such as gender can affect the status of team members, code team dynamics, and the code leadership experience. A recent article by Kolehmainen and colleagues1 published in Academic Medicine explores these issues, examining which medical behaviors residents associated with effective code leadership and how gender influences their experiences. The authors of this study conducted interviews with 25 residents (16 women, 9 men) from nine United States internal medicine residency programs. After analysis of all interviews, the authors organized the data into four recurrent themes:

  • Leadership defines code success:  Most participants described a code as successful if it was controlled and had effective leadership. One participant said that he thought “less about the actual patient outcome” and more about his “control” of the room.  Another resident described a code that ended when the “patient was getting better and was wheeled away,” but because the room was chaotic said “it wasn’t a good code.” Poor leadership was consistently cited as the major contributor to a chaotic code.

  • Ideal code leadership behaviors: Most participants described the ideal code leader as a person with an authoritative, assertive & strong presence; speaks with a deep, loud voice; uses clear, direct communication; and has emotional control. Both male and female participants agreed that “the most important thing” was to “establish yourself as a leader.”  One participant described accomplishing this by being “the focal point in the room … you know that I’m running the code because I’m the one who’s talking and I’m the one who’s standing at the foot of the bed and telling people what to do.” Participants also described the leader as the “chaos control factor,”  projecting a composed demeanor to “help calm other people down.” They described often being “panicked” but trying to appear as the “calmest person in the room.” One participant likened his behavior to a duck, saying “If you’ve ever watched a duck on a pond, it looks as though it’s floating effortlessly across the lake but if you’ve ever looked underneath at a duck’s feet, they’re paddling feverishly.”

  • 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.

  • Integrating conflicting identities: Female participants described various strategies to assist in assuming code leadership, including “wearing a white coat, wearing a physician’s badge, and carrying the code pager.” Several female participants talked about the importance of mentally preparing before a code to “assume a code persona.” Physical signals of such included tying hair back and adopting a powerful posture including a wide stance with arms crossed (“code stance”). In respect to being directive and assertive, most female participants felt able to suspend their usual “niceties” during codes, although one resident said that she is “super apologetic afterward.” Another resident felt differently, encouraging women to “feel ok about dropping the ‘pleases’ and ‘thank yous’.”

The male and female residents in this study expressed similar levels of confidence in their abilities to lead. Cultural stereotypes about men and women are well known, and reinforcement of these stereotypes throughout life leads to implicit rules about how men and women should and should not behave. “Agentic” behaviors, including being assertive, dominant, forceful, and acting as leader are socially more acceptable for men, whereas “communal” behaviors, including being cooperative, warm, soft-spoken, and polite, are socially more acceptable for women. The ideal code leader is typically described in highly agentic terms. Although both men and women expressed the need to become more assertive during a code, women more often expressed the need to modify their “normal day-to-day” behavior to adopt the more direct and agentic behaviors required to enact code leadership. In adopting these behaviors, females frequently expressed their discomfort in violating prescriptive gender norms. This may stem from women’s experience that they can suffer social penalties from engaging in behavior that is too agentic. A study by Koch2 found that even when viewed as more competent than men in leading a group, women elicited more nonverbal displays of negative affect from other team members. Rudman and colleagues3-4 named the social censure women receive from counterstereotypical behavior as “backlash” and noted that women express a fear of this backlash. In this study, only female participants voiced stress from needing to behave in the agentic, stereotypical male manner required for code leadership. To overcome this, the female residents employed various strategies to better integrate the competing identities of code leader and female gender. In the future, residency training should acknowledge how female gender stereotypes may conflict with the behaviors requires to enact code leadership and offer strategies, such as those used by female residents in this study, to help women integrate these dual identities.

Check out the full article by following the link below:


  1. Kolehmainen C, Brennan M, Filut A et al. Afraid of Being “Witchy With A ‘B’”: A Qualitative Study of How Gender Influences Residents’ Experiences Leading Cardiopulmonary Resuscitation. Academic Medicine. 2014;89(9):1-5.

  2. Koch SC. Evaluative affect display toward male and female leaders of task-oriented groups. Small Group Res. 2005;36:678-703.

  3. Rudman LA, Glick P. Prescriptive gender stereotypes and backlash toward agentic women. J Soc Issues. 2001;57:743-762.

  4. Rudman LA, Fairchild K. Reactions to counterstereotypical behavior: The role of backlack in cultural stereotype maintenance. J Pers Soc Psychol. 2004;87:157-176.

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