Previous research suggests that gender bias is pervasive in health care and has deleterious effects on treatment outcomes for patients. When developing and improving training on gender bias, we need to further our understanding of how such topics arise and are sustained in conversations between healthcare professionals (HCPs). The aim of this study is to analyse the influence of patient gender in HCP decision-making by analysing how they surface, discuss and manage topics around gender.
What this study adds
This study uses a novel approach to examine healthcare staff interactions through an ethnomethodological approach.
It adds to existing research about discrimination within healthcare settings using simulation as a research tool.
This study demonstrates the ways in which bias is co-created and given meaning within staff interactions and, in turn, affects perceptions and treatment of patients.
Findings indicate potential avenues for improvements to current antidiscrimination training initiatives which incorporate awareness of how bias appears through language and non-verbal communication.
Discrimination continues to be an issue within health care globally, affecting both patients and staff [1–2]. For example, staff from minoritized groups with intersecting marginalized social statuses (a person’s social and political identities) within the National Health Service (NHS) are increasingly reporting discrimination to a greater extent than their White staff counterparts . In relation to patients, research has consistently demonstrated that discrimination among marginalized groups can affect care, for example, acting as a barrier towards accessing healthcare services [3–4]. There is also evidence that discrimination affects the care offered to people, and that this may be manifested within interactions between staff and patients as well as between staff in clinical decision-making. In relation to race, evidence suggests that systematic differences in communication patterns between healthcare professionals (HCPs) and patients from marginalized and advantaged social statuses can impact patient care and decision-making through differential diagnoses . Gender, also considering inclusively gender identity, continues to be one of the leading causes of discrimination . Whilst discrimination is particularly evident for individuals occupying more than one disadvantaged social status, gender is one main category that impacts the care of patients with mental health illnesses with research attesting to the relationship between mental health and perceived gender discrimination . Gender discrimination is pervasive across health care, for example, a review by Samulowitz et al.  found gender biases, in that male and female patients received differing treatment for chronic pain. In another study, African American women faced various stereotyping relating to their gender identity that presented barriers to accessing appropriate treatment care . It is, therefore, understood that gender discrimination in health care across diverse settings has negative consequences on mental health and overall patient well-being.
Discrimination can be minimized through training around communication strategies involving interactions amongst HCPs . However, few studies focus on patient perception of stigma and discrimination or long-term interventions in this area. The lack of research leads to increased miscommunication between patients and HCPs regarding treatment options . As a result, it is unclear how topics of gender and gender bias are surfaced, discussed and managed between HCPs either in isolation or within an intersectional framework, and thus a void in knowledge exists. Before considering communication strategies in this field, it is thus critical to explore the question: how do HCPs discuss and manage topics around gender and gender bias?
One way to explore this gap is by examining verbal interactions between HCPs. Whilst there are other approaches to analysing the construct of gender, we seek to examine how HCPs communicate gender-related issues during simulation debriefing where topics of gender and gender bias in relation to simulated exercises occur. This study specifically examines gender and gender bias in debriefing conversations in a mental healthcare simulation training setting undertaken at the Maudsley Hospital, which is the largest mental health training institution in the United Kingdom and has a dedicated research centre. It is part of the South London and Maudsley NHS Foundation Trust and works in partnership with the Institute of Psychiatry, Psychology & Neuroscience at King’s College London.
Methodology: ethnomethodology, discursive psychology, and conversation analysis
To understand the ways in which these topics are introduced and managed by participants through discourse, we must examine interactions directly. Ethnomethodology is an approach to understand how members (in this case, HCPs) undertake an activity, such as ‘managing discussions of gender . The approach seeks to uncover the everyday ‘methods’ (such as conversational patterns and techniques) participants use within a culture to achieve the said activity. For example, a doctor-patient consultation (the activity) occurs through the roles which each participant takes, such as asking and answering questions, listing complaints, and offering treatment options . The analysis reveals patterns within conversations that form the interaction. Thus, the turns of talk have constructed the immediate social context – a typical doctor-patient consultation – and analysis of the discourse reveals the methods participants evoke to achieve the activity.
Within this methodological framework, conversation analysis (CA) is an approach that examines interactions in fine detail. Conversation analysts seek to elicit participants’ understanding of the ongoing conversational activity Patient gender in healthcare professional decision-making 3 (comprised of what is being communicated and the ongoing interaction) by looking at subsequent turns of talk. Analysis of turns of the talk will display, empirically, what the participant understood (or their display of understanding) regarding the previous turn, the ongoing activity that they are themselves co-constructing, and the wider social context. CA is thus characterized by analysing conversations between speakers and the meaningful impact these have in wider social practices  and in constructing the immediate context.
CA has been applied to explore interactions within institutional settings  and combined with the approach of discursive psychology (DP) in the empirical analysis [14,15]. DP is an approach that reveals how psychological themes manifest in conversations and the function of patterns in conversations. Moments of interactions can thus be observed in debriefs when HCPs discuss gender through a CA and DP lens, to analyse the discursive methods participants are involved in to achieve a social activity, namely the discussion of gender and gender bias.
CA has been researched for healthcare purposes such as in family therapy  and in medicine . Additionally, CA and DP have been studied alongside each other in psychological research . CA has also been used in research about educational institutions [19,20], which is pertinent, as the data analysed were extracted from the simulation training centre at the Maudsley Hospital.