This is the basic script that supported my presentation, “Breaking Down Tribalism”. I recently presented this at EMTA2018, the Emergency Medicine Trainees Association conference in Cardiff. It is a privilege to be allowed to be part of their tribe.
Tribes happen; they have to. They affect how we work, for good and for bad. Breaking down tribalism so that we understand it, will make for better care in health.
1.Tribes happen for good reasons
It’s Natural. Babies are not born racists, but there is clear evidence that they very quickly recognise people who are not from their tribe. Within 3 months of being born a baby will recognise people they are regularly around and if someone different (in colour or size) enters their experience they react negatively. Importantly, babies don’t know what they themselves look like, they are merely recognising difference. Even as babies we gain comfort from those we know and experience discomfort or challenge with people from outside.
There is clear psychological evidence1 that emotions are amplified if an experience is shared. Consider a major sporting event, religious celebration or even nowadays something on TV that is shared through Twitter, events shared are felt more deeply, both positively and negatively when shared. Happier events are happier, sadder events are sadder. If you like, “It was the best of times, it was the worst of times…” This builds connection. The literature demonstrates the benefits of connection are not associated with duration of time. 2 Benefits of connection can occur from very short interactions. Shared experience builds interpersonal closeness.
This makes sense when you consider that is what friendship, relationship even family is all about. The same is true of the people we work with. We recognise similarities. We share experiences. And we share emotion. All of this builds connection and this connection is “tribe”.
Tribe is valuable for many reasons. It builds happiness3, it gives meaning beyond the task itself4 and it builds a closeness of relationship that offers more than simply co-existence5 . Conversely, without this there are clear effects on mental health, productivity and even health itself. Tribe is valuable.
Tribe brings a strong identity, a unified purpose and a singular drive for success.
Tribe builds success. Tribe brings a strong identity, a unified purpose and a singular drive for success. We may inhabit the same jungle, or wear the same clothes or have the same approach to issues but we all identify with tribe. When we move jobs we very quickly establish where our new tribe is, how they behave and importantly, who is not in our tribe. It is because of tribe that functional units within hospitals develop. Disparate individuals are brought together often solely through chance of selection, interview or migration but they recognise and establish their identity within that space or task because of this occurrence. Tribe gives them identity, purpose and value and this translates into success beyond that which might be achieved by individuals. Tribe gives value back to those within the group more than the task itself and benefits patients by improved clinical care. Tribes are natural, valuable and successful.
2. Tribes cause problems
All of the powerful and positive attributes of ‘tribe’ are great however it is important to acknowledge that these are similar traits shared as terrorist organisations. Tribes by their very existence identify “ingroup” or “outgroup” status; “my” tribe and “NOT my tribe.” It is the need for commonality and awareness of difference that may create potential conflict. Not necessarily violence and desire for world domination but, like the babies, distrust of non group members with an antagonism towards their behaviour and intentions, so called motive attribution6.
Consider Jeremy Hunt. (Or any other politician in your personal sphere) Do you believe they wanted good things to happen to their area of responsibility eg the NHS? The fact that you don’t is motive attribution.
Let’s try a clinical example. Can you remember a situation in which you made a surgical diagnosis and the surgeon disagreed with you? Maybe a 7 year old who comes in with abdominal pain. You assess him. There is a good history of anorexia, vague abdominal pain that shifted now to severe pain in the right iliac fossa. On examination the child has marked tenderness and guarding. Clearly they need admitting as you feel this kid has peritonitis due to probable appendicitis. You call the surgeon, they eventually come down, disappear behind the curtain and within 2 minutes they are out rushing back to theatre, “There’s nothing wrong with the patient, send him home.”
Let’s consider the two options.
How did you feel when the surgeon made a completely different decision to you? How did you feel if the kid didn’t come back in the next day? (Why did you even think they would?) What about the opposite? Can you remember the situation where you were right? Yeah? YEAH! Maybe the kid came back the next day, rigid abdomen and peritonitis. And you got to call the same surgical registrar? How did you feel about it? Who did you tell? We share such stories within the tribe because of course this builds the tribe by shared experience and therefore deeper emotions. It builds our tribe and diminishes theirs.
“You’ll NEVER guess what The Surgeons did THIS time?!”
Studies have shown we actually get a little neuro-endorphins reward when we see an outgroup person fail. And let’s be honest, this is never about the patient. The kid actually suffered, potentially significantly and we are laughing about it and sharing that problem. How crazy is that? It’s much more about that point scoring thing, a way of building empathy, credibility and ingroup stability. And this cascades through the team at handover or in social discussion, for all the reasons that tribes are valuable.
Let’s consider again those two situations? If we were to make an error in diagnosis in deciding this was appendicitis, but it wasn’t, why did that happen? It is probably because it was due to a difficult history, an atypical presentation, early in the disease process. In the case when the surgeon was wrong why do we think that happened? – maybe they didn’t take a complete history, they were possibly not used to examining children, they were rushing and being stupid… The reason we made a mistake was excusable, a system level problem. The reason the surgeon made a mistake was about deficiencies of personality. She had it coming…
We tend to judge others on their behaviour not the reasons behind the behaviour.
We tend to judge others on their behaviour not the reasons behind the behaviour. Whether it is Jeremy Hunt or the Surgical Registrar. We have a lack of confidence in other people’s opinions and intentions not for the decisions but the reasons and behaviour behind their decision. We believe we want the best for the NHS but Mr Hunt is trying to privatise it. We were wrong because of difficulties of the patient but the surgeon was wrong because of their approach.
This is fundamental attribution error. We need the world to be as we perceive it. We need it to be this way to reduce threats, to give us security and ultimately to give us meaning as an individual and also as a tribe. Our default is to believe that the other tribe is wrong and not wrong for logical or technical reasons, wrong because of deficiencies of their personalities, because that’s how surgeons are! Assholes! Worse than that, we mostly judge other tribes by our perceptions or stories shared amongst the tribe of their stereotype. I mean surgeons are all assholes, aren’t they? The ‘pods only care about bones and neurosurgeons? Don’t get me started…
When we do this, we build our own tribe but on the method of destroying trust and confidence in others. We tell other stories that reconfirm previous stories, we laugh about how they don’t care, shout at people and are always somewhere else. It builds the story of the stereotype, it builds us within our sense and value of our tribe and further destroys the credibility of other tribes. I mean, they’re bad, but not as bad as the bloody physicians! Test test test and STILL no closer to a diagnosis. Up themselves like a forest plot.
Tribalism builds tribalism.
And we all recognise that this affects patient care and staff wellbeing. Because those teams aren’t as caring as we are… It means difficulties in making referrals because “they” are always trying to avoid work…. It means arguments about management…have they not read the latest research?? it means delays in treatment… “they” never get here before the clock ticks over…it means complications… because “they” just wouldn’t listen. Again. And it makes working in our departments even harder… if it wasn’t for those assholes we would have a happy shop. And it’s all their fault. We must do something about their tribalism.
3. How to break down tribalism for better care
The first step is in accepting that there is a problem. That bad stuff affects patient care. And actually it affects self care. All this bitching and fighting? It really is not good for any of us.
It is not about blame and it is not about getting “them” to start first. I have intentionally written this to highlight your tribalism, looking outward from your point of view. Tribalism affects us all because we all are tribal. The problem does not lie solely with “them.”.
We need to recognise and begin to call out issues of negative tribal behaviour at all levels; ward rounds, handover, coffee breaks and of course social media. I’m not suggesting for a moment that this will be easy or that the changing of expression of views out loud in itself stops those opinions. If we look and see how far things have come in terms of racism, sexism and xenophobia it would never be acceptable to say:
“Women are so stupid, they can only hold one thought in their mind at a time”.
Yet we can substitute one word and
“Orthopods are so stupid, they can only hold one thought in their mind at a time”
This somehow appears humorous? It even becomes accepted knowledge. It is not true, nor is it acceptable to say this or laugh at it. Thoughts, change words, change actions.
We have already considered the issues of motive attribution and of fundamental attribution bias now we must also consider perspective. So much in life is changed by a different perspective. Think about the issue of why surgeons rush in and out of ED. Have any of you actually been the on call surgical registrar? Your understanding of what that job involves is perspective affected. Do you know what challenges the surgeon has currently has on this shift? Is it possible they have just come from a 6 hour procedure and haven’t even eaten? Has their boss maybe just ripped them a new one because of the death of a patient on the ward. Have they been up all night writing their thesis or not slept because their partner and new born baby haven’t slept either?
Now, let me stop you there. Your immediate response to that statement is highly likely to have been an example, once again, of fundamental attribution error. Did you justify your opinion on actions you have observed? (well we are only trying to get the best for the patient) and instead comment on the behaviour of the surgeons? (Surgeons are just so rude/arrogant/distracted) . This is why it is difficult. Consider the alternative perspective.
The wonderful Liz Crowe taught me many things. One phrase that sticks with me is that “no-one comes to work deciding to be an asshole that day.” Something usually changes to make that happen. And if we don’t know what that was, we probably won’t understand fully the reason behind the action. We just see the behaviour.
One of the most valuable lessons I have learned recently in feedback is the concept of advocacy with enquiry. Within that discussion comes an understanding of whether (or not) that thing was wrong and most importantly why it occurred. For so many things in tribalism understanding the perspective, the “why,” would provide a really useful starting point towards improvement.
When you move hospitals to commence working in a new ED department, you immediately become part of the new tribe. If you move to Anaesthetics or Intensive Care as part of your training, you become part of that tribe. Sadly sometimes, they take that opportunity to educate you about the bad in your previous tribe from their perspective of shared experiences. Rather than trying to break down tribes, how about if we intentionally form tribes, and change the boundaries? Something as simple as #onetribe. After all, we do have a singular purpose: the health of the patient.
#onetribe. Be the change you want to see.
The tiniest step is of course the hardest in the beginning. Let’s be clear too, these steps are only the beginning in a long journey and culture of change. I encouraged the audience at EMTA and followers on Twitter last week to consider what initial steps they could make towards reducing the negative attributes of tribalism. There were interesting responses.
- Try using personal names during discussions and referrals
- Pop round to X-ray WITHOUT a referral card
- When something goes wrong in another team be supportive not critical
- Organise joint social events that may play with the competitive edge of tribes
- Commit to calling out tribalism in casual conversation.
- Seek opportunities for mixed discipline interaction not simply within the ED.
- Join cross disciplinary committees.
- Consider how others are coping with their shift and even just mention that in referral.
- Build one tribe. Us against the disease. For the patients. We go this #onetribe
None of these are about being sycophantic, becoming the snack service to the hospital or excusing anyone’s behaviour for the lack of these things. Change takes time and sometimes that is what we have very little of. We won’t change tribalism overnight but we can make a start. As Vic Brazil said in her talk at SMACC on the topic, simply sitting down at the same desk to make a referral to a colleague rather than phoning it in or standing over them can be the beginning.
Tribalism happens. It is good and makes work better. It delivers better patient care. But it brings with it odd ways of treating and thinking about people we consider outgroup that directly affect patient care and self care. We need to address the negative side of this and we must start that change by being the change we want to see. Build a unified identity, drive and purpose: better care for both you and your patient. #onetribe
Ross Fisher @ffolliet
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