Breaking the ceiling: considering gender disparity in emergency care

Sex, a biological construct, and gender, existing on a sociocultural spectrum, are two very important patient variables that have the capacity to impact all aspects of medical care, including in the acute care setting of the emergency department (ED). The study by Vromant et al. [1] explores specifically whether ‘gender’ impacts emergency physicians’ treatment ceiling on decision to intubate in a specifically provided simulated scenario, that being geriatric respiratory distress. Responses from over 3000 emergency physicians across Europe led the authors to ultimately conclude that, given the same clinical vignette, women patients are less likely to be intubated than their male-gendered counterparts. (While sex and gender are not interchangeable terms, given the limitations of a survey-based scenario without additional qualifiers, for purposes of discussion we have included both ‘sex’ and ‘gender’, defaulting to the verbiage utilized by the respective authors, when appropriate.) As a main takeaway, an initial reaction to the study’s conclusion may elicit concern that women appear, at least in a scenario-based format, to receive different, perhaps even inferior emergent care; however, as the authors relay in their own discussion, lower rates of intubation do not necessarily infer second-rate care. The decision to intubate can be a complex process, often influenced by a number of factors, which may not be easily replicable by a survey-based vignette. Existing published research reflecting clinical data on actual disparities in emergent intubations by sex or gender is sparse and somewhat dated. A 2007 Canadian retrospective review (utilizing data from 2001 to 2002) suggested that among older patients (greater than 50 years of age), women were less likely to receive life-supporting treatments, including intubation and mechanical ventilation [2]. Similarly, a 2011 retrospective review from Taiwan (utilizing data from 2005 to 2007) also concluded that gender differences existed with regard to provision of mechanical ventilation with again, women being less likely to receive [3]. More recent studies suggest less or no disparity. A 2019 retrospective review of an Austrian level 1 trauma cohort (utilizing data from 2000 to 2017) demonstrated no sex differences in critical care, including mechanical ventilation [4]. Finally, a 2024 publication from Switzerland, inclusive of neurocritical care patient data from 2018 to 2021, found no sex-based differences in the frequency of emergent or planned intubations [5]. Of course, none of the clinical settings described in these prior manuscripts are exactly identical to the ED or the simulated case presented by Vromant and colleagues; however, similar to the scenario proposed by Vromant and colleagues, they challenge the reader to consider the impact of real or potential gender-based biases, which may impact physician decision making. The outcome noted by Vromant and colleagues deserves particular reflection as it underscores the potential of underlying gender biases that may impact life-saving (or life-ending) treatment approaches. Addressing these biases is crucial to ensure equitable healthcare delivery. Gender-based differences in diagnostic and therapeutic interventions or procedures (e.g. in the setting of acute coronary syndrome or acute pain management, as noted and cited by the authors) have been well documented, suggesting the need for increased awareness and standardized treatment protocols. In the case of intubation specifically, a handful of prior studies have explored sex-based anatomical considerations that might result in clinically important differences for the emergency physician. Female patients may present unique anatomical challenges during intubation, such as smaller airway dimensions, potentially influencing the decision to intubate [6]. While explicit feedback on the clinicians’ decision to intubate (or not) was not reported by Vromant and colleagues, might prior sex-specific experiences related to these anatomical differences influenced physician decision? As has been suggested by others who have previously reported on sex-specific anatomic differences, do we perhaps need sex-specific intubation guidelines to help standardize care and reduce disparities? It is important to acknowledge the limitations of this study. Specifically, these include the inherent limitations of a survey that utilizes a relatively static scenario-based format versus real-life interactions, which impart massive influence (note, half of the surveyed physicians changed their treatment plan after a patient prompt suggested a desire to ‘not suffer’). Also, this vignette did not state a reason for respiratory failure (potentially reversible versus not) or attempt to reenact/consider the potential impact of family interaction. A prospective observational study could offer deeper insight into the complexities of care that surround the decision to intubate, particularly in a geriatric patient cohort with variable functional capacity. Despite these limitations, the study by Vromant and colleagues suggests and highlights that gender-related biases may exist with regard to the decision to intubate in the ED. Identifying, acknowledging, and exploring these differences further will be important to promote optimal care for all. Future research in this space should consider real-world clinical scenarios as well as broader factors, such as race and ethnicity. Since 2016, the National Institutes of Health has recognized sex as a biological variable, emphasizing its significance in all aspects of medical care. This study serves as a reminder that we must continue to scrutinize how sex and gender impact treatment decisions in emergency care settings. Acknowledgements Conflicts of interest There are no conflicts of interest.

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