Tribalism in Medicine

The Tribal Nature of Medicine

Dr Victoria Brazil recently gave a Key Note speech at SMACC 2014.


Entitled “Tribes and STEMI”, this (effortlessly excellent) talk, timed to perfection, discussed healthcare teams.  Dr Brazil outlined the concept that teams in healthcare can form “Tribes”.

An Uncontacted Tribe

These functional healthcare tribes create powerful bonds with each other.  A good example of a bonded tribal team is an Emergency Department staff group.  In the ED we are multidisciplinary. We are in it together – standing against the world (and the rest of the hospital).

While a well bonded ED tribe has advantages in terms of cohesion, this may come at a cost.  Excluding outsiders or using ‘put downs’ against opposing tribes is common place in a typical hospital.  We build our team by highlighting our differences and flagging our unique identity.   In our experience, ‘opposition to outsiders’ advances the ED team’s state of togetherness by highlighting that ‘our tribe is the best’.

Of course, in reality all the teams in the hospital have the same opinion about their own tribe:

We all think we're the best doctor...
We all think we’re the best doctor…

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While gentle ‘banter’ or friendly rivalry between teams can be productive, it is important to realise that ‘slagging off’ your colleagues can have damaging consequences. In fact, deleteriously putting down colleagues (even if in jest) may even effect patient care. Tribalism can jeopardise effective handover and in-patient referral.

Tribal War on Facebook

 Med Reg

There are many examples medical tribalism seen in everyday practice as well as online (illustrated above on Facebook).  Classic Combatants include:

  • ED versus Surgery
  • Anaesthetics versus Orthopaedics
  • Medicine versus Surgery
  • Paediatrics versus Everyone Else
  • ICU versus The Hospital

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Tribal Teams

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So is this Tribal thing all bad?

According to the book Tribal Leadership by Dave Logan there are various levels of teams – some are more effective that others.  Tribal Leadership states that there are ‘5 Levels’ of functioning team.  At the bottom of the effectiveness ladder are teams that undermine each other.  At a higher level are the tribal teams we see commonly see in healthcare. The tribal team can be quite effective, succeeding through bonding and competition:

5 Levels of Team - Tribal Leadership

Team Culture

It seems we shouldn’t despair too much.  Healthcare tribes can be considered ‘high performing‘. Indeed, being in a tribe can feel good and lead to good outcomes:

Level 4 Team (Tribal Pride)
Level 4 Team (Tribal Pride)

So, most teams are Level 4 (or below) – but can we do better in healthcare?

In healthcare, the “us” against “them” mentality can help build a team but may also be destructive.  Developing and reenforcing the “us against them” mentality will stop us moving to becoming a “Life is Great Level 5 Team”.  Higher level teams don’t require tribal bonding to work well – they are teams of ‘innocent wonderment’.  All very well – but how do we get to be a level 5 team?

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What does the Level 5 Team look like?

  • Shared Values
  • Outward Worldview
  • Stated Outcomes
  • Knowledge of Strengths
  • Knowledge of Team Resources
  • Performance Management
  • Planned Behaviours
Level 5 Team
Level 5 Team

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Take Home Points

Suggestions to reduce Tribalism in your healthcare team

  • Avoid outbursts on social media when frustrated
  • See other healthcare teams’ point of view
  • Understand the features of highly functioning teams
  • Use Conflict Resolution strategies
  • Communicate, Communicate, Communicate
Use a Chair - Communicate!
Use a Chair – Communicate!
  • Final Thought – Dr Brazil suggests using a chair when talking to patients & colleagues this may help break down barriers. A study by Swayden (2012) suggested patients perceive you spent longer with them and cared more when you sat down at the bedside…