Deadly bias: a call for gender diversity in cardiac life support simulation training

Simulation in medical education teaches students to recognise patterns that can be life-saving. As an emergency medicine (EM) resident (LSS) and a medical educator (RF), we witness the ways in which patterns in the medical curriculum shape our future medical providers. The recognition of a dangerous pattern has brought us together to call for increased gender diversity in one of the most fundamental skills medical learners must master: cardiac life support training.

EM resident perspective

As an EM resident, I (LSS) am the clay being shaped by the medical system. In the emergency department (ED), where I hope to spend my career, chest discomfort, nausea and diaphoresis set a series of actions into motion. I am taught to fear missing a classic presentation of myocardial infarction (MI) and to keep high suspicion for life-threatening conditions. MI in women often presents with symptoms other than chest pain, which the American Heart Association (AHA) details on a page separate from general MI symptoms.¹ The page emphasises that symptoms in women can be subtle and are often overlooked as acid reflux or the influenza, making recognition of MI in women especially difficult.

In the ED, over two-thirds of physicians are men.² “I am a woman in medicine” is an inescapable part of my daily inner monologue. I feel a solidarity with my female patients. I pay attention to how I approach their pain and I look for the ways in which women downplay their symptoms. It was initially easy for me to rationalise the 2018 study findings that women treated by male physicians were more likely to die than women treated by female physicians after a heart attack.³ I thought that female physicians could more easily piece together the ‘atypical’ symptoms of MI through increased communication and questioning. The study also found that working with female colleagues makes men more effective at treating female MI patients.³ I believed that the presence of female attendings could change the culture of the ED, thereby narrowing the gender disparity in MI survival. Surely, I thought, we just need more women in emergency medicine.

As I progress in my training, however, my sense of optimism that the gender disparity in MI survival will dissipate as more women enter emergency medicine is fading. I still believe in the importance of gender diversity among ED physicians, but I have begun to notice ways in which my training has changed the patterns I look for and the symptoms I consider significant. The problem is bigger than the under-representation of female physicians—the problem is the under-representation of women in the interconnecting systems that comprise medical education, including in the systems that use simulation in healthcare training.

I recently earned my Advanced Cardiovascular Life Support (ACLS) certification from the AHA. The online course first walked me through the various ECG waveforms that I must quickly recognise as pathological and finished with a series of computer-animated simulations where I was responsible for directing an ACLS code. By the end of the course, I felt cautiously competent. The course had provided me with nine different patients for whom I must rapidly recognise MI or initiate a lifesaving ACLS code. However, alongside ST-elevations and a smoking history, I realised that a masculine face had worked its way into the constellation of signs I looked for to identify MI patients. Out of a total of nine virtual patient simulations, not a single one featured a woman.

Medical educator perspective

As a medical educator, I (RF) note the systemic issues in medical education that leave our students underprepared for the realities of the clinical environment. The previously described ACLS course indicates a failure of the systems intended to prepare students to save lives, and particularly the lives of women. I hoped that this omission was an anomaly, but discussions with other students revealed a similar gap in simulation cardiopulmonary resuscitation (CPR) trainings, where high-tech manikins help students build the muscle memory needed to resuscitate a human. My students note that during these trainings, they never once practised on a manikin with breasts.

A cursory online brand comparison illustrated this disparity. Many manikin manufacturers advertise realistic features, including rib cages, hearts and lungs. They advertise that manikins can be adjusted for children and even extreme facial realism. However, not a single one incorporates a manikin with breasts. This may suggest that the gender disparities in ACLS and CPR training are not merely oversights by our institutions but rather failures of both the medical education system and the medical industry writ large.

The omission of gender-diverse simulation training can have deadly consequences. The AHA recently published findings that women receive out-of-hospital CPR less frequently than men. Among the reasons cited for this disparity were the fear that CPR might cause women physical injury, the perception that breasts make CPR challenging or sexually inappropriate, and the belief that women are less likely to experience cardiac arrest.⁴ All of these misperceptions could be overcome with gender-competent training. As a medical educator who teaches medical students about physicians and social responsibility, I feel a responsibility to help my students build patterns of practice that are not only lifesaving but also just and equitable.

Call to action

Achieving gender-inclusive simulation training could be easy. Among nine virtual ACLS patients, the AHA should include at least four women to reflect the demographic of MI incidence. When conducting in-person CPR trainings, manikins already in a school’s possession can easily be modified with new technology to emulate breasts, helping break down notions that breasts change the mechanics of chest compressions.⁵ In medical education, we need to teach our students to look for bias: even if we begin to include women in ACLS simulations, MI research centering or even including women has historically been sparse and bias surely exists elsewhere.

To overcome bias in medicine, we must hold the healthcare system accountable, from individual educators to the powerful professional societies that set training standards for physicians and non-physicians alike. There are tools to address biases in education. For example, The Upstate Bias Checklist (https://tinyurl.com/UpstateBiasChecklist) can be used to look for bias in eight domains, including gender, disability and immigration status, among others.⁶ In the case of ACLS training, it could call attention to the unintended consequences of omitting a diverse presentation of symptoms.

As a medical educator and an EM resident, we understand the pressures to conform to the ways in which medicine has historically been taught and practised. We understand the limitations of time, the available research and funding, and the pressures to keep momentum in a system that seems to be working. However, it is clear that the system is not working for everyone. We owe it to our female patients to make sure that systemic sexism is not the reason that we recognise MI in women less often than we recognise MI in men. Together, we call for a system that both takes responsibility for the historic absence of women from ACLS research and education and conducts simulation training that does not build injustice into our practices. Acknowledging the existence of bias in educational materials is a good first step, but it will accomplish little without intentional and significant systemic change in medical curricula.