The authors reply

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We thank Sell et al (1) for their letter regarding our research study (2), recently published in Critical Care Medicine. Indeed, we share their concern about misinterpretation of our findings by some media. We also thank them for pointing out reasonable explanations why female students may show inferior leadership behavior in this specific setting.
Our study (2) was a randomized, controlled trial, and outcome was assessed by videotaping techniques. All communication was transcribed word-by-word, and a trained (male) observer coded each leadership statement. A second (female) senior observer assessed the transcripts in a blinded fashion, and eventual disagreements were discussed until consensus was found.
Although simulation research has limitations, it also provides an important research venue that allows rigorous assessment of complex interactions during emergency situations in a realistic and controlled yet safe environment (3, 4). A further advantage of simulation methodology is that unlike in real emergency situations, a controlled, standardized experimental situation can be created and interventions can be compared head to head. Video recording that are partly blinded facilitates in-depth analysis of team interactions. Thus, simulator studies have become an important research instrument and can complement studies from real-life settings (4). Still, these findings need validation in real-life study settings. Also, while we focused on students, validation in more experienced rescuers will be important.
We also agree with the authors about differences in assertiveness between female and male students. In fact, we have found similar results in a prior study (5). This study found that leadership behavior as assessed by the number of leadership statements was determined by gender and personality and not by knowledge or experience. Of note, we did also assess assertiveness in our students participating in the trial and will report these data in a separate article.
As pointed out in our article (2) and in the setting of relatively unexperienced rescuers, we found a difference between male and female students in regard to leadership and unsolicited cardiopulmonary resuscitation measures with poorer performance of female rescuers. We did not in all detail explore reasons why these differences exist, which warrants further research and clarification. Still, we believe that future training should focus on encouragement of female students to show strong leadership behavior. Focused leadership training of female students may help to dissolve the differences between gender in regard to leadership and potentially assertiveness. Thus, it is time to include gender research in medical education.
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