Rosie is the Chair of the WICM group. She is a consultant in critical care and anaesthesia at the Western General Hospital in Edinburgh. With WICM she aims to promote ICM as a female-friendly specialty to women in all stages of their medical training, from undergraduate level upwards.


October 2018: Confidence in confidence?

On February 6th next year, WICM will host our first ever one day meeting. “Critical Care without Ceilings.” We are really excited about the programme (although clearly very biased!), which is very much aimed at what are sometimes described at ‘soft skills’ in ICU – leadership, time management, and challenging personal interactions. I have been a consultant now for 6 years, and I can tell you that the greatest challenges for me haven’t been dealing with the patients or dealing with families – although I have encountered plenty of challenges there – it’s been dealing with other people, and dealing with myself.

Until recently I was my unit’s Faculty Tutor (I’ve given this up to become Clinical Lead, so by the time you read this I may be hiding out in a Highland bothy, having cracked and gone rogue.) FICM Faculty Tutors have to sign off all anaesthetic Higher CUT forms for our more senior anaesthetic trainees, and this involves examining all the evidence attached to the form.  Confidence – and the abundance or lack thereof, is frequently commented upon, particularly for female trainees. My hackles rise when I read ‘needs to be more confident,’ or ‘very confident – needs to be aware how this comes across.’ How is a trainee, or anyone, meant to improve their performance based on comments like this?

What do we mean by ‘confidence’, anyway?

Let’s take a common clinical scenario for trainee doctors - a cardiac arrest. To be an effective leader at a cardiac arrest, you need to know how to manage cardiac arrest – there is a clear requirement for that basic level of knowledge. You have to be audible – if you happen to have a very quiet voice and no one can hear you, you are going to struggle to lead effectively, regardless of how effective a leader you are. But beyond this, how much does confidence impact on leadership effectiveness?

A 2014 paper, “Afraid of Being Witchy with a ‘B’[i]explored US medical residents’ perceptions of and experience of:

  • Leadership during cardiac arrests

  • What behaviours these doctors in training associated with effective cardiac arrest leadership

  • How gender influenced their experiences

25 trainee volunteers (16 women, 9 men) were interviewed about their experiences, these were analysed and broken down into themes. 

What did they find?

All participants thought that effective leadership led to a controlled situation, and this made the situation successful even if the patient outcome was not. In turn, poor leadership was consistently cited as the major contributing factor to poor quality arrest management.

The participants were asked about what their ‘ideal’ cardiac arrest team leader looked like – and this is where it gets interesting. Both men and women described this hypothetical ideal as “a person who has an authoritative presence, speaks with a loud, deep voice, uses clear, direct communication and has emotional control.”  Several participants added ‘being tall’ as a key attribute of effective leadership.

So, you will not be in the least bit surprised about the relationship between effective leadership and gender as perceived by the study participants. Both male and female participants thought that men and women could be equally effective leaders. Both described the same ideal leadership behaviours, as described above.  The need to ‘act’ this role was described much more frequently by female doctors. This is a sample of quotes from the paper:

I just try my best to look authoritative…but its stressful”(female participant)

It can come off as bossing people around. Whereas I never felt that way when I see a male run a code – it just seems natural” (female participant)

Anyone who tells you that being a male with a deep voice who’s a little taller is not an advantage to being perceived positively, or perceived as in control, would be lying” (male participant)

The authors conclude that female trainees should be taught strategies to help them become more ‘leaderly’ in these high-stress, high-stakes situations, to help them suspend gender expectations and adopt ‘highly agentic behaviours’ while leading arrests.

I have to say, I don’t agree with this and wouldn’t advocate this as a strategy for female trainees.


Agentic behaviours are the counterpoint to communal behaviours.

Agentic behaviours include being:

  • Independent

  • Ambitious

  • Outspoken

  • Confident

Communal behaviours include being:

  • Supportive

  • Helpful

  • Friendly

  • Collaborative

Most people will exhibit a mixture of these behaviours, but agentic behaviours tend to be more stereotypically male, and communal behaviours more typically female.

In the ICU, we are often expected to work in a team, in a way that allows the strengths of each team member to be maximised, and which allows each team member to feel that they can voice concern. Strongly agentic leadership is less likely to allow this shared ownership of responsibility to flourish. Yes, the situation requires a leader but if we are trained to be good followers, a more balanced, communal style may be more effective and safer than traditional medical models of leadership.

I won’t – and don’t – advocate for women to adopt a persona which is inauthentic to them and which may not bring out the best in their team. What we should promote is clinical proficiency. Beyond this, ‘confidence’ shouldn’t be conditional on having a loud voice or being tall (DOI am 1.56m short) but instead should come from the belief that we, as teams, work best when we feel that we are being led by someone who is proficient in their clinical skill and is able to listen to the concerns of all the team members. Maybe what is required isn’t for women to change themselves but for us – all of us – to change our view of what leadership and confidence actually looks like. Perhaps if ICM adopts a more balanced model of ideal leadership, we will find that we begin to attract a more diverse workforce.

If you want to see a glittering line up of amazing, confident, leaderly colleagues talk about issues like this, come to the meeting in February. You’ll hear inspiring talks, take part in genuinely useful workshops and meet and network with like-minded people. See you there!