Does physician gender have a significant impact on first-pass success rate of emergency endotracheal intubation?

Whei Jung, Joonghee Kim
American Journal of Emergency Medicine 2019 June 14

STUDY OBJECTIVE: It is unknown whether female physicians can perform equivalently to male physicians with respect to emergency procedures. Endotracheal intubation is one of the most critical procedures performed in the emergency department (ED). We hypothesized that female physicians are not inferior to male physicians in first-pass success rate for this endotracheal intubation. This study aimed to prove this hypothesis using a prospective airway registry.

METHODS: This was an observational study of a prospectively collected ED-based emergency airway registry. We analyzed orotracheal intubation performed on adult ED patients using direct laryngoscopy from Jan. 1, 2013 to Dec. 31, 2016. The primary outcome was first-pass success. Noninferiority was tested using a 10% noninferiority margin (1 in 10 attempts). We constructed multiple logistic regression models to adjust for covariates, such as clinical experience and department of the operator, patient age and sex, cause of ED visit, crash airway, rapid sequence intubation (RSI) and various difficulty indicators.

RESULTS: There were 1154 eligible cases with 409 (35.4%) patients intubated first by female physicians. The first-pass success rates of female and male physicians were 83.6% and 84.8%, respectively, with an absolute difference of 1.2% (95% CI, -3.1-5.8%; p = 0.587). The upper margin of the difference was under the noninferiority margin of 10%. In multiple logistic regression, physician-related variables associated with first-pass success included experience level and the department of the operator.

CONCLUSIONS: Female physicians are not inferior to male physicians in performing emergency endotracheal intubation.


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Hello readers,

I am the corresponding author of the study.
I deeply apologize to you and all the people who read the paper.

My original intention was to confirm that there is no physician gender effect on the first pass success rate. Now I know that I was so insensitive and had little knowledge on the subject. And I also admit such study is not required at all because the findings of the study were so obvious from the beginning. It was absolutely not my intention to offend or incite any gender-related issues (I have two lovely daughters, and the first author of the study is also a female medical student).

I will ask the journal editor about explanation/ clarification/ withdrawal of the paper.

I sincerely apologize to you and all the people who read the paper.

Joonghee Kim


Jessica Pelletier

As someone who grew up in a western society I had a visceral rejection of this paper, at first. However, this paper drives home the point that context is very important. In this case, cultural context is critical in understanding why this study is very reasonable and well done. For numerous cultures and countries sexual discrimination is normal. This paper helps provide ammunition for those who need to prove their non-inferiority over and over again in their respective societies.


Michael Seed

Dear Dr Joonghee, I apologise for my social media reaction to your paper. Please use the support we all are now giving you to keep the paper and write a supplement. It is now an important reference contributing to gender equality in medicine, more so when the comments here and the social media discourse is added. Your and others' social context makes it clear this is a very important and active issue in the Republic of Korea. Tweets point out this is also true of other countries eg India. I'm sure I can speak for many others that we will support you in using this experience to full advantage towards our common aim of gender equality for n medicine.


Christa Riley

There may be relevance of this study in non-Western countries but the American Journal of Emergency Medicine is a Western journal and therefore complicit in the suggestion that a "no difference" hypothesis even requires study. Furthermore, this study invites speculation about gender differences in all aspects and procedures of medical practice. What about central line placement, robotic surgery, arterial line placement, neurosurgery, foley catheter placement, epidural placement, etc? Any physician involved in training learning physicians knows that differences among trainees are multifactorial. Perhaps that is why this study is published in AJEM and not Anesthesiology.


Tudor Costachescu

This must be the most useless article I've seen in quite a long time...
The fact that it saw the light of day says a lot about the "peer reviewed" process this journal uses!
What in the world made you think that there could be any difference?!


Andrew Miller

The degree of vitriol this article has sparked is amazing. The cultural lenses most are viewing this through are largely that of western countries where this degree of sexism has subsided. Consider the possibility that the Korean culture is so strongly paternalistic in that female physicians not only experience a subjugation by their male counterparts but also by the very patients they have sworn to treat. As such, a study such as this becomes necessary to begin breaking down the psychological, cultural, and professional repression this article indicates exists.

We don’t want to admit that these issues exist, but they still do on this level throughout many Asian, Middle Eastern, and African countries. Attacking the authors for attempting to right a clearly identifiable wrong through what is arguably a most noble scientific endeavor is absurd. The AJEM editors failed the authors here for inappropriately framing the study. If anything, a supplementary clarifying statement should suffice.

I hope the authors see benefit from this study in their professional endeavors and that the gender biased climate they appear to live in shifts in a more appropriate direction.


Jill Cramer

The null hypothesis is that women are non-inferior to men for ETT is so obnoxious. I am galled that anyone felt this “study” was necessary to perform, let alone print. Shall we next prove that men are non-inferior to women when it comes to calming babies or baking brownies? When in the name of all things are we going to stop acting surprised that women can perform in medicine as well as men? You do know that we can vote, too, right?


Knut Taxbro

Seriously!!!??? Is AJEM being Trumpified?? IMO the authors should explore ways to improve first pass successrates instead.


Tim Stevenson

Seriously? Of all the hypotheses that you could have come up with to test, it had to be one that potentially adds division amongst medical staff? I’m sure the female physicians will be reassured to know they are not inferior to their male counterparts. What a ridiculous study - not well thought out at all IMO.


K Mansfield

Ugh Really?
My colleagues and I are appalled at the lack of insight and respect this study AND ITS PUBLICATION show.
Get your act together AJEM and issue an apology. This is 2019.


Aparajita Mitra

This is a ridiculous topic for a thesis. Utterly humiliating!


Diana Valcich

Maybe we should do a study that includes experience at a procedure versus being unburdened with a penis to interfere with visualization of the cords. Did this include if the male was erect and maybe had to stand away from the patient?


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