The Cutting Edge: Values Affirmations in Surgical Training

• In Event: “Wise” Educational Interventions: How Understanding Stereotyped Students’ Subjective Construals Can Improve Motivation and Performance

Abstract

Stereotype threat, a psychological explanation for how performance may be affected by negative stereotypes of one’s group, has been extensively studied in academic settings. Values affirmations, exercises in which participants write about things that are important to them (e.g., family, art, religion), are thought to decrease the harmful effect that stereotype threat can have on performance. That is, by reinforcing the values that matter most, affirmations seem to put evaluative tasks, such as exams, in perspective, and thereby disrupt the connection between stereotype threat and performance.

In this study, we examined how values affirmations might be implemented in a high-stakes work setting. Specifically, we examined the stereotype that men are better surgeons than women. In an academic hospital, we surveyed 143 surgical residents (86% response rate) about the extent to which they perceive others around them, such as faculty and other residents, believe this stereotype. Residents were then randomly assigned to either the affirmation or no-affirmation condition. They performed writing exercises based on the condition to which they had been assigned (84% response rate). We collected evaluations of their on-the-job performance both before and after the intervention. We also collected test scores from their annual in-training examinations, which are multiple-choice, nationally standardized exams.

Although the residents spent only around 15 minutes doing the values affirmations, the intervention had long-lasting effects. When residents were evaluated on their delivery of patient care, medical knowledge, technical skills, professionalism, and other work-related qualities, women tended to actually be rated more highly than men. However, when they sat for the high-stakes national exam, women underperformed compared to men. If stereotype threat were a contributor to this discrepancy, we would expect women with a greater degree of stereotype threat perception to be most helped by the affirmations. The results supported this hypothesis: women who reported high levels of stereotype perception at baseline performed better at the end of the year if they were affirmed at the beginning of the year, compared to corresponding controls (Control: M = 21.7, SD = 19; Affirmation: M = 64.9, SD = 15; Cohen’s d = 2.5). This also eliminated the gender gap among such students. In addition, in a lab study, affirmations improved working memory for both men and women, presumably by reducing stress and cognitive load.

Hence, using the in-training exams as an evaluative criterion disadvantages women. Since these exams are similar to those that govern board certification at the end of residency, women may be at a disadvantage even after residency. There are already many fewer women than men who pursue surgical training, and women leave the field at a higher rate than men. It is therefore important to address the factors that may be contributing to these discrepancies. One of these factors may be a perceived performance difference between men and women. Interventions such as the values affirmations have promise as a way to improve performance in stressful situations and perhaps neutralize this difference. More importantly, they may contribute to improved patient care.

Authors

• Arghavan Salles, Stanford University

• Claudia Mueller, Stanford University

• Geoffrey L. Cohen L. Cohen, Stanford University