seX & whY Episode 3: Priming and Performance


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Can unconscious cues cause changes in behavior and performance? Can subtle cues can affect behavior and team performance?

Show Notes for Podcast Three of Sex & Why

“Behavior” Pod

Hosts: Jeannette Wolfe and Simon Carley

Topic: Unconscious Bias

Major Question: Can unconscious cues cause changes in behavior and performance?

Riskin Study

Examined the effect of rude statements on team diagnostic and procedural performance.

What they did: Had NICU providers (nurses and doctors) first go through a simulation and then attend a workshop on team “reflexivity” (i.e. team training). The workshop was taught by a neonatologist who said that he was “collaborating” with an American expert who was ostensibly watching via webcam.

At the end of the workshop, the coordinating neonatologist told the teams that the expert wanted to greet them and he then “dialed” up the expert (in reality this triggered a prerecorded message). The groups were randomized to hear either a neutral message in which the expert commented that he had been working with a lot of Israeli hospitals, or a rude message in which the expert commented that he had “observed a number of groups from other hospitals in Israel and compared with the participants he had observed elsewhere, he was not impressed with the quality of medicine in Israel.”

Both groups then underwent a standardized written and procedural simulation case involving a neonate with rapidly progressing necrotizing enterocolitis. Ten minutes into the simulation the American “expert” spoke again with the control group hearing another neutral comment and the rude group hearing that although the expert liked some of what he saw during his visit to Israel that he hoped that he would not get sick in Israel and implied that most “wouldn’t last a week” in his own department. The teams then continued to complete the case.

The simulations of both the control and rude teams were then evaluated by blinded observers who reviewed written documents and team videos. Participants were rated on diagnostic performance, procedural performance, information sharing and help-seeking.

Results: 33 NICU providers were randomized to control group and 39 to rude statement group forming a total of 24 teams.

Diagnostic and procedural performance along with information sharing and help seeking behavior declined statistically significantly in the rude group.

Table 1

Statistically significant differences in procedure performance


Control-neutral phone calls

Mean (1-5 scale)

Intervention- rude phone calls

P value

resuscitation performed well




Verified tube placement well




Ventilated well




Asked for right lab tests




Good general technical skills




Overall procedure




Table 2

Statistically significant differences in diagnostic performance


Control- neutral phone calls

Intervention-rude phone calls

P value

Diagnosed shock




Diagnosed NEC




Diagnosed deterioration




Suspected bowel perf




Diagnosed cardiac tamponade




Overall Diagnostic




Theory behind findings- At individual level rudeness can impair access to working memory (which is important for analysis, planning, and execution) which can then contribute to suboptimal task execution. At the team level, performance is further decreased because less information is shared (potentially limiting diagnostic considerations) and procedures may become more difficult because individuals stop asking for help.

Ultimately this study suggests that when an attribute (in this case being an Israeli physician/nurse) is challenged, behavior can be impacted. This has huge implications for how physician professionalism can directly affect patient care.

Shih Study:

This study is wonderful in its simplicity, it takes individuals who possess two attributes that are associated with opposing stereotypes (in this case Asian and female) and asks if their behavior (performance on a math test) is able to be manipulated depending upon which attribute is subtly cued.

Shih asked a group of Asian college females to take a math test. Prior to taking the test she randomized the women into three groups. In the first group, participants were subtly primed to identify with their “female” identity by asking them gender demographics and targeted questions about single sex versus coed dorm living. In the next group, women had their ethnic identity triggered by asking about relatives and languages spoken at home. And in the final group women were asked generic questions that avoided implicit triggering of either gender or ethnic attributes. The measured outcome was accuracy= number of test questions right/number attempted

Results: Women who had their Asian identity triggered scored highest on the tests, the neutral group scored in the middle and the female identity primed scored the worst with statistical difference (p

28 episodes