Fatima, an intern, just finished a long day in the emergency department. It was a busy shift with many sick patients. One patient in particular, an 84-year-old with heart failure, stuck with her as she walked home. This gentleman was brought in by paramedics in acute respiratory failure. In the ED they had started the usual treatments: positive pressure ventilation, frusemide, and GTN. He seemed to improve before they referred him off to cardiology for ongoing management. She thought they had done a decent job. On the way out of the hospital she overheard the cardiology registrar and staff discussing the case.
“Can you believe that the ED only gave him 20mg of frusemide?” scoffed the cardiology consultant.
“Yeah haha, they might as well have given a homeopathic dose…” cracked the registrar.
Both laughed and the banter continued.
“When are they going to learn to manage heart failure down there? He clearly has a preserved ejection fraction and could have tolerated far more diuretic. Took them long enough to get him to us too, lucky he didn’t cork it while he was in the department. He was basically still drowning by the time we got involved! Good thing we are on speed dial.” Both laughed.
When Fatima got home she tossed in her laundry and did some cooking. As she went about her chores, she reflected on the conversation she overheard and was left feeling quite confused. Tomorrow the new term started and she would be out of the ED. In fact, she was joining the cardiology service for a few months. Maybe there she’d learn about the “right” way to treat heart failure.
Fatima hadn’t yet decided what type of medicine she wanted to pursue. She had been considering emergency medicine and enjoyed the diversity in presentations but maybe she did want to be “the expert”. She was in awe of the certainty with which these cardiologists were speaking. Maybe that would be her place. At the same time, she was a bit put off by the way they were denigrating ED. She’d spent a few months getting to know the staff and registrars there – they were good people, doing their best, even if they didn’t always get it right. She was as uncertain about her future as ever.
The professional socialization of doctors has been of interest to social scientists for years. How does one go from being a lay person to a physician? Yes, there is the acquisition of knowledge but there is also the adoption of a set of values, beliefs, and practices that lead to a change in self-identity and result in a position of belonging within a group (Philips & Clark 2012; Pitkala & Mantyranta 2003; Becker et al. 1961). Most studies of the medical socialization focus on transition from medical student to physician but do not explore the impact or process of specialisation within the profession itself. The ever increasing complexity of our healthcare system has resulted in more groups or “tribes” of physicians. Each of these groups, while sharing many fundamental similarities, do have cultural differences that surely affect the career decisions of medical trainees. We might consider, how does one go from being a doctor to being a certain type of doctor?
Socialization is a term used to describe the process by which individuals take on the ideas and behaviours of a particular society. Traditionally, socialization focuses on how children learn to belong. This process of socialization is involuntary and results in the transmission of culture (values, behaviours, beliefs) from one generation to the next. The ultimate purpose is to create a stable society whereby all involved understand the rules and norms, resulting in harmony and propagation of a group’s culture. There are two types of socialization:
So let us return to Fatima’s situation and apply the concept of socialization to her experience in medicine. Professional socialization first started for her in medical school within the confines of the classroom – technically this is a form of secondary socialization. She was instructed about the norms and values of the profession as a whole. She learned from professors and with peers about the basics of belonging and functioning within medical society. The beginnings of a professional identity began to form. Then, when Fatima entered the clinical environment, further professional socialization occurred. This could be thought of as tertiary socialization. Through exposure to different medical specialties she began to learn the different values, beliefs, and practices of subgroups within the profession. These are often colloquially termed the hidden curriculum, which can have both positive and negative connotations. In an effort to survive early training, Fatima is likely adept at adapting to different groups – rapidly undergoing socialization to fit in to whatever rotation she is currently on with hopes of belonging. But eventually, she must stop being a cultural chameleon and select a specific training pathway. She will eventually become fully socialized into that group. What role does the tribal nature of medical specialties play in this process?
Tribalism and career choice
Tribalism is best described as a strong loyalty towards one’s own social group. Often this is beneficial and results in high team functioning. In the narrative provided, the cardiology resident and consultant are clearly bonding over their position on the cardiology team. Their shared jokes may result in a strong relationship which allows them to work well together. However, their loyalty comes at the price of putting down their emergency medicine colleagues which may result in tension when these two groups have to work together down the road. The potential effects of this conversation on Fatima’s professional socialization are significant. She does not yet belong to a particular tribe. The transmitted values and behaviours of groups she comes into contact with – formally and informally – will impact who she feels most inclined to gravitate towards as her career unfolds and along the way they may even reshape her own values and beliefs system. The order of her rotations, the staff and registrars she works with, the cases she has, and the conversations she is involved in, will affect her understanding of medicine, the subgroups within it, and herself. While socialization is an involuntary process of cultural transmission, an awareness of its existence may allow Fatima to reflect on whether the values and beliefs of a group are in line with who she is and who she hopes to become. She is left considering, not just what type of medicine interests her, but also where she feels she most belongs.
Tribalism and patient care
Whether trainees or consultants, doctors’ ‘tribal behaviour’ can have profound consequences on patient care. It is both an outcome and antecedent of hospital or practice culture. Overt rudeness affects team performance (Riskin et al. 2015), but more subtle ‘put downs’, and demarcation of ‘in group/ out groups’ can be even more insidious. Fatima witnessed this behaviour, which is often more obvious to outsiders. The relative toxicity of tribal behaviour is often related to time pressure and clinical workload, as well as perceived powerlessness. There can be a fine line between a gentle tease about a specialty stereotype and a hurtful insult.
David Logan’s (2008) book Tribal Leadership describes the impact of organizational culture on behaviour. Doctors have or will likely work in different organizational settings and might recognize these stages from his framework ….
“ • Stage Two: The dominant culture for 25 percent of workplace tribes, this stage includes members who are passively antagonistic, sarcastic, and resistant to new management initiatives.
• Stage Three: 49 percent of workplace tribes are in this stage, marked by knowledge hoarders who want to outwork and outthink their competitors on an individual basis. They are lone warriors who not only want to win, but need to be the best and brightest.”
Better workplaces, including hospitals, are marked by an ability to transcend those stages …
“ • Stage Four: The transition from “I’m great” to “we’re great” comes in this stage….. ensuring (relationships) are based on values, advantages, and opportunity.”
• Stage Five: Less than 2 percent of workplace tribal culture is in this stage … this group is in competition with what’s possible, not another tribe….”
Complexity is the hallmark of 21st century healthcare. The ability to celebrate professional identity while respectfully navigating tribal interfaces is critical for future doctors. All of us can take some responsibility for moving from ‘I’m great” to “we’re great”.
To continue thinking about socialization and tribalism in medicine consider reflecting on the below questions:
For junior trainees (interns and junior house officers/residents)
For senior trainees (senior house officers and registrars)