Dr. Tapan Kavi is a husband, father, and Assistant Professor of Neurocritical Care. He currently practices with the OhioHealth Physician Group in Columbus, Ohio.
The Pre-brief
Despite other primates displaying rudimentary abstractions of us/them-ing, human beings occupy a stratosphere of uniqueness.1
“Us-versus-Them” refers to the human predisposition for tribalism, which, seen through the lens of evolutionary neuropsychology, describes a complex set of neural machinery, predisposing humans to group distinctions that likely allowed for the in-group’s increased gene transmission. Tribalism may have once been a feature that maximized one’s ability to pass on genes, but the Us-Versus-Them schema can be harmful in the modern world. What was once adaptive is now maladaptive, and varying degrees of in-group and outgroup predispositions exist across the spectrum of countries and cultures.2
Indeed, tribalism assumes many forms: Marxists versus capitalists, liberals versus conservatives, Christians versus Muslims, Eagles fans versus Cowboys fans, Frequentists versus Bayesians (even statisticians are not immune!), and arguably the most toxic, racial divides. As a physician, I have observed that the hospital is no exception to group demarcations. The medical profession includes medical and surgical doctors, each area having many subspecialties. Although most specialists’ interactions are likely civil, toxic interactions are more likely to occur between a cardiologist and a nephrologist than within either specialty. I argue that the same neural machinery contributing to political divides is partly responsible for the toxicity between medical specialties.
We are all physicians. We all took the Hippocratic oath. We would never let something as petty as tribalism cloud our judgment. Right? Even though human beings are remarkably diverse, we share many common evolutionary predispositions. Doctors are human. Thus, to deny Us-Versus-Them thinking within the medical profession is to be incredibly naïve. Tribalism is not relegated to religious or political divides; these (basic) demarcations can be rapidly replaced with new ones. It has been experimentally demonstrated that common divides can be diminished by newly imposed coalitions, termed “coalitional manipulation.”3 Cosmides et al. describe a human state of continuous evaluation of coalitions that can change due to something as trivial as t-shirt colors. An example would be sports fans; any prior group divisions (race, religion) can often be replaced by donning a sports jersey. Coalitions can form in settings of group coordinated action, cooperation, and competition.4 I am a critical care physician. I go to critical care conferences. I attend critical care faculty meetings, where we discuss common goals to advance the cause of our specialty and our department. My fellow intensivists and I form a coalition not immune to possible consequences of tribalism.
To understand those potential consequences, we have only to turn on the news; tribalism-related animosity is ubiquitous. But what is the neural machinery that makes in-group and outgroup hostility so pervasive? To answer this question, we divide the brain into two parts: the subcortical structure known as the amygdala and the prefrontal cortex (PFC). The amygdala is active during times of emotion, whereas the PFC handles complex cognitive tasks. Amygdala activation, or priming, predisposes humans to relatively more primal behavior, whereas the PFC can allow for complex moral analysis. Robert Sapolsky eloquently describes the PFC as the part of the brain that “allows us to do the right thing when it is the harder thing to do.” This dichotomization of the mind into the PFC and the amygdala (limbic system) has also been described as manual and automatic,5 rider and elephant,6 and System II and System I.7 Us-Versus-Them thinking is stronger in situations during which the amygdala is primed, and PFC function diminished. Sleep deprivation and stress are constants in medical practice, and they happen to be primers for the amygdala.8 So what is the big deal? So I called the surgeon a jerk–is this harmful to my patient? Are there consequences to dichotomizing specialties as Us-Versus-Them?
The answer is a resounding “Yes!” Patients are more complicated than ever. Specialties are becoming increasingly complicated to the point that diagnostic and therapeutic languages within each specialty are diverging at rapid rates. Simultaneously, multigroup pro-sociality and communication are more critical than ever in optimizing our patients’ care. In a relaxed and calm state, most physicians say that the information source is irrelevant if it leads to the best patient outcome. But is rational thinking maintained during stress? Tribalism leads to an in-group elevation while simultaneously minimizing the outgroup; this sort of thinking is more common when the amygdala is primed. “Mistakes By Us are more likely to be forgiven than Mistakes By Them.”9 Therefore, it stands to reason that tribalism can negatively affect multidisciplinary hospital care.
So, what is the solution? Sadly, there is no panacea, but given the relative ease of coalitional manipulation, I believe there is hope for looking beyond subspecialty divides. When doctors are tired, hungry, stressed, or overwhelmed, we are likely to be tribal, but optimizing physicians’ mental and physical health might reduce tribalistic tendencies. The education of young doctors and medical students about the concept of metacognition might also be helpful.10 In fact, mindfulness meditation has been shown to reduce the amygdala’s size and activation.11 Regarding divisive opinions between specialties, Joshua Greene, author of Moral Tribes, offers a lofty recommendation, “When it is Me versus Us (in-group), think fast. When it is Us versus Them, think slow.”5
If left unchecked, any behavior that is a remnant of ancient survival conditions can be toxic. This diatribe is not an attack on any specialty but rather a commentary on the human predisposition toward tribalism, to which medical professions are not immune. Tribalism diminishes cross-specialty respect and, consequently, hinders multispecialty care. Sub-optimal multispecialty care does a disservice to our patients. How can we overcome the blind spot concerning other tribes? The first step is to recognize the problem.
The Debrief
- Tribalism exists across all spectrums of human life.
- Physicians are not immune to the tribalistic tendencies.
- In-group and Out-group hostilities of medical subspecialties likely diminishes the quality of patient care.
- Improving physician mental health may reduce the toxic behaviors that stem from tribalism.
References
- Sapolsky RM. Doubled-Edged Swords in the Biology of Conflict. Frontiers in psychology. 2018;9:2625.
- Kurzban R, Tooby J, Cosmides L. Can race be erased? Coalitional computation and social categorization. Proceedings of the National Academy of Sciences of the United States of America. 2001;98(26):15387-15392.
- Cosmides L, Tooby J, Kurzban R. Perceptions of race. Trends in cognitive sciences. 2003;7(4):173-179.
- Pietraszewski D, Cosmides L, Tooby J. The content of our cooperation, not the color of our skin: an alliance detection system regulates categorization by coalition and race, but not sex. PloS one. 2014;9(2):e88534.
- Greene J. Moral Tribes. New York: Brilliance Audio.
- Haidt J. The happiness hypothesis : putting ancient wisdom to the test of modern science. 2015.
- Kahneman D. Thinking, fast and slow. 2015.
- Motomura Y, Kitamura S, Oba K, et al. Sleep debt elicits negative emotional reaction through diminished amygdala-anterior cingulate functional connectivity. PloS one. 2013;8(2):e56578.
- Sapolsky R. Behave : the biology of humans at our best and worst. London: Vintage; 2018.
- Medina MS, Castleberry AN, Persky AM. Strategies for Improving Learner Metacognition in Health Professional Education. American journal of pharmaceutical education. 2017;81(4):78.
- Taylor VA, Grant J, Daneault V, et al. Impact of mindfulness on the neural responses to emotional pictures in experienced and beginner meditators. NeuroImage. 2011;57(4):1524-1533.
- Baldwin DC, Jr., Daugherty SR. Interprofessional conflict and medical errors: results of a national multi-specialty survey of hospital residents in the US. J Interprof Care. 2008;22(6):573-586.
