How to upgrade an organisation’s tribal culture

Immature tribal cultures create silos and distrust, and sustain undesired behaviours. How can we change a dominant culture and become more effective?

My mother spent years of her childhood in Tjideng, a Japanese internment camp for women and children run by the cruel Captain Kenichi Sone.

She was born in the former Dutch East Indies, now Indonesia. The Dutch occupied and exploited the country for over four hundred years, but in 1942 things changed dramatically as a result of the Invasion by the Japanese imperial army.

The women in the Japanese internment camps are sometimes called the ‘forgotten women’ of the war in the East. These camps, as well as Dutch colonialism, are some of the worst examples of tribalism.

Tribalism comes of course in many shapes and forms including, as we all know, in the medical world.

Tribes & organisations

Most leaders know that tribal cultures are a key factor in the performance of organisations. Some leaders are experts at creating close-knit cultures, but only a few can change a culture that doesn’t perform optimally.

Tribalism is the natural way we organise ourselves into social groups. Our ‘tribes’ are part of who we are. They offer support, security and a sense of belonging an there’s nothing wrong with that.

However, tribalism can also refer to a false sense of superiority, sometimes leading to exclusion, bullying and discrimination.

We can change a dominant tribal culture and upgrade our organisations to more collaborative, healthy stages. History shows that goal-oriented groups and organisations that work well with others are more successful.

5 tribal cultures

In the book ‘Tribal leadership’, Professor David Logan et al describe five stages of tribal culture. As he points out, the medical profession is only half way, at stage three of five.

Five tribal cultures
The five tribal cultures. Source: Tribal leadership. David Logan, John King, Halee Fischer-Wright 2011

Logan’s tribal stage one is the mindset of gangs and war criminals – people who come to work with weapons. There is hostility and violence and no cohesion.

People working in a stage two culture may have coffee mugs with slogans like: “I hate work,” or “I wish it was Friday”.

There is often a high suspicion of management and authority in general, and team-building efforts are not effective in this culture.

Stage three is the dominant culture in almost half of all organisations, including many professional workplaces. Quite often doctors fall into this category. In stage three it is all about personal success and being the smartest. Stages four and five are the collaborative cultures.

Let’s have a closer look at the most common culture, stage three.

I’m great (and you’re not)

The mantra of stage three is ‘I’m great’, often followed by the unspoken words ‘and you’re not’. There’s a long history in medicine of stage three cultures with a strong focus on individual expertise and success.

Anatomy lesson
The Anatomy Lesson of Dr Nicolaes Tulp, by Rembrandt. Source: Rembrandt Huis.

One of the earliest examples I could find is this well known Rembrandt painting titled, ‘The anatomy lesson of Dr Nicolaes Tulp.’

Dr Tulp was a highly respected surgeon in Amsterdam in the seventeenth century; he is clearly the central figure in this painting. He’s the only one wearing a hat. Sadly but not surprisingly there are no women present.

You could argue that this scene demonstrates the dominant culture of the exclusive Amsterdam Guild of Surgeons. These days, almost four hundred years later, the dominant culture in medicine hasn’t changed all that much.

Professionals working in a stage three culture are often very good at what they do as individuals but what they don’t do is bringing people together.

They may think they are. Interestingly people in stage three often think that they are at one of the collaborative stages. They may talk about collaboration and teamwork – hallmarks of stage four and five – but their actions firmly put them in stage three.

The issue with a stage three culture is that it cannot be fixed – it can only be abandoned. The solution is to move your tribe to the next stage, stage four.

How to upgrade

People working in a stage four culture don’t talk about themselves. They first start listening. It’s no longer about being the smartest or about personal success.

There’s a move from ‘expert’ to ‘partner’. The language used is not “I’m great” but “We’re great”. There’s tribal pride.

Eventually, later in stage four, organisational boundaries become less important and cross-pollination between organisations may occur.

So how do we upgrade our culture from stage three to the more collaborative stage four? Logan describes several principles, including:

  • Focus your team on tribal success instead of personal success
  • Point out the superior results of stage four tribal cultures
  • Describe role models in the organisation that show stage four behaviour, for example people who are talking about ‘we’ instead of ‘me’
  • Encourage transparency and sharing of knowledge & information as much as possible.

There’s one main problem with stage four, reflected in the unspoken sentence that often follows “We’re great,” and that is: “… and you’re not,” referring to other groups or organisations. That’s where stage five comes in.

Stage five is the dominant culture in two percent of work places. In this stage there is no ‘they’.

‘Them & us’ thinking has gone out of the window and there is a focus on inspiring purposes. These are often universal values, taking away the need to compete.

People working in stage five cultures can work with any group that has a commitment to universal core values – even if these values are different from their own.

Effective followership

More collaboration in medicine has many benefits, including for direct patient care, mental health of doctors and healthcare reform.

We always talk about leadership but effective followership is just as important.

Effective followers don’t blame their leaders when things don’t go as planned; instead they offer support and gently, but persistently, steer their leaders in the right direction to help them achieve the organisational goals.

What the medical profession needs is people who build bridges.

I’d encourage you to review your own organisation(s) and look for opportunities to collaborate. Don’t accept non-collaborative cultures.

Find role models and like-minded people, people who talk about ‘we’ instead of ‘me’, and together take your dominant culture to the next level.

This is an adaptation of a presentation given at GPDU18.

Tribes, tribulation and the elephant in the room

If we want to change bullying and abuse within the profession we have to move our tribal cultures to the next level.

The medical profession has come a long way in the past 25 years, but sadly seems to have difficulties eradicating issues of humiliation and abuse of colleagues and medical students.

One option to fix the problem is to make junior doctors and students more resilient, which seems like a good principle that is currently being applied by other organisations in other areas. Fore example, Beyond Blue has released a practice guide for professionals to help children deal with the adversities they experience early on to prevent mental health conditions later in life.

But teaching resilience alone is not enough.

Another option is to increase awareness and understanding among senior doctors and educate them about bullying, discrimination and sexual harassment. A good example is the mandatory education module, ‘operating with respect’, from the Royal Australian College of Surgeons (RACS).

Elephant in the room

The elephant in the room, however, is our culture – or at least certain aspects of it.

David Logan, a professor at the University of Southern California, said it a few years ago in his New York Times bestseller ‘Tribal leadership’: on the tribal culture scale of 1-5, most professionals around the world score a meagre three. This includes lawyers, doctors and professors.

According to Professor Logan and fellow authors John King and Halee Fischer-Wright, a stage-three culture or tribe is built around knowledge, personal accomplishments and individual expertise. The emphasis is often on winning. Although there may be talk of teamwork, the group interactions usually resemble those of a master-servant relationship.

The mantra of a stage-three culture is, ‘I’m great’. The language used is often along the lines of, “I’m good at my job,” “I try harder than most,” “Most people can’t match my work ethic,” and key pronouns used are ‘I,’ ‘me,’ and ‘my’.

This creates several problems. Professionals operating in this type of culture often feel unsupported, undervalued and frustrated, and those around them feel like a support cast.

Stage-three cultures cannot be fixed, but they can be abandoned. The answer is to upgrade the culture and move away from the ‘I’m great’ mantra to ‘We’re great.’

The next level

Instead of relying on personal achievements and expertise, at stage-four it becomes all about the accomplishments of the group. Partnerships, communication and transparency are recognised as essential ingredients for success. This is a healthier environment, in which people feel more valued and supported.

Professor Logan’s top level is stage-five. Highly functioning teams focus on maximising achievement – not in competition with other groups or tribes but with what’s possible. Stage-five teams can work with anyone.

Australian research has shown that hierarchical and stereotype behaviours largely dissolve when health professionals are working in a more collaborative, multidisciplinary environment.

Resilience training and anti-bullying education are essential, but if we really want to make a difference we have to move our tribal cultures to the next level.

This article was originally published in newsGP.

Overcoming tribalism in healthcare

When I was preparing this session I thought I’d start by telling a joke:

Five doctors went duck hunting one day. Included in the group were a general practitioner, a pediatrician, a psychiatrist, a surgeon and a pathologist.

After a while, a bird came winging overhead. The first to react was the GP who raised his shotgun, but then hesitated. “I’m not quite sure it’s a duck,” he said, “I think that I will have to get a second opinion.” And of course by that time, the bird was long gone.

Then another bird appeared in the sky. This time, the paediatrician drew a bead on it. He too, however, was unsure if it was really a duck in his sights and besides, it might have babies. “I’ll have to do some more investigations,” he muttered, as the creature made good its escape.

Next to spy a bird was the sharp-eyed psychiatrist. Shotgun shouldered, he was more certain of his intended prey’s identity. “Now, I know it’s a duck, but does it know it’s a duck?” The fortunate bird disappeared while the fellow wrestled with this dilemma.

Finally, a fourth fowl sped past and this time the surgeon’s weapon pointed skywards. BOOM!!

The surgeon lowered his smoking gun and turned to the pathologist beside him and said: “Go see if that was a duck, will you?”

The tribal jungle

Two years ago our keynote speaker was the amazing Dr Victoria Brazil, emergency physician and medical educator from the Gold Coast. She spoke about tribalism in our profession and said:

“I think we actually work in a tribal jungle in healthcare.”

She was right. We make jokes about the characteristics of the other tribes, like I just did, but tribalism is still one of our biggest challenges today. We are concerned about fragmentation in healthcare – but what about the divisions within our own ranks?

Part of what makes general practice attractive is its diversity, but it is also a weakness. Think, for example, of the stereotypical dichotomies: generalists vs partialists, private practice versus corporates, rural versus metropolitan etc.

I’m not saying we should be one big happy family, but why not focus more on what we have in common?

There is hope: participants of groups like United General Practice Australia and, here in Queensland, the GP Alliance, have shown a desire to put aside tribal differences and work towards common goals. This is a start, and initiatives like these must further strengthen the voice of general practice in the near future.

Investing in general practice

With the Federal Budget due to be handed down this coming Tuesday, this weekend also serves as a timely reminder of the RACGP’s advocacy campaign to reverse the freeze on Medicare rebates. As part of our pre-budget submission to the Federal Government, we outlined 4 key strategies that will improve quality-led patient care.

In order to provide quality healthcare services, MBS rebates must be in line with the cost of doing so. More than 80% of the Australian population is seen by GP’s each year but only 8% of Government healthcare spending is allocated to general practice.

New data presented in the flagship report from the National Health Performance Authority released this week, shows that people who do not see a GP have a 30% higher chance of visiting an emergency department.

Investment in primary care will result in long-term health savings and reversing the freeze on MBS indexation is a must. The College will continue to represent our members and lobby the government on this very important issue.

A challenge 

The theme of this RACGP Queensland Conference is ‘the future’. So here’s a challenge for you:

You don’t have to go duck hunting with your colleagues, but what can you do to reduce tribalism?

If you decide to take up this challenge, do one thing, one little thing, and start this weekend while you are amongst your peers.

If we want the future to be different, if we want to see different results, we should do things differently.

Opening speech given at RACGP Queensland’s 59th Clinical Update Weekend: iGP, General Practice into the future. Source joke: Nursing Fun

If only we worked together (instead of competing)

Many GPs feel disempowered in the current climate of cuts and freezes. It is indeed hard to comprehend why governments slash funding to the most efficient and cost-saving part of the health system.

We are all concerned about the lack of continuity of care and increasing fragmentation in our healthcare system, but what about the divisions within our own ranks?

Part of what makes general practice attractive is its diversity, but it also makes general practice prone to divisiveness. Think, for example, of the stereotypical dichotomies: generalists vs partialists, private practice vs corporates, rural medicine vs metropolitan general practice, etc.

GPs are highly respected in the community, but have become an easy target because of marginalisation and fragmentation. It is a well-known secret that governments play different GP groups off against each other, choosing to include or ignore organisations in their deliberations and negotiations.

Lack of unity also opens the door for disruption by third parties.

Our culture

It is clear that general practice needs an urgent cultural change. Just like surgeons are working on improving the bullying culture, we must address the disharmony and division that afflicts us.

How good would it be if practices worked together instead of competing? If GPs could get together and agree on issues important for their area? If peak bodies would team up and better coordinate strategy, policy development, campaigns, conferences and membership services?

There is a whole generation of GPs that don’t understand why we have so many representative organisations. These young doctors are concerned about the disadvantages. Why don’t general practice organisations support each other, why are there multiple memberships and so much duplication? I believe they are right.

We have much more in common than what sets us apart, so why are we so tribal?

Why tribalism?

I can think of a few reasons. The first that comes to mind stems from social psychology; our brains may be programmed to organise us into small tribes because of evolutionary advantages, such as social bonding and survival.

There are also economic motivations, for example, GP clinics currently compete for patients. Our peak bodies are based on membership and need to offer benefits; this encourages competition rather than collaboration.

Reform fatigue may be another reason why some of us have stopped caring about achieving common goals. Experienced GPs can tell us the tales of the many system changes they have witnessed over the years; reform comes and goes and often disrupts our day-to-day practice. The risk is that we become cynical about what our profession can achieve in Canberra.

Perhaps there is also a selection bias. It is possible that GPs prefer more autonomy than our hospital colleagues, and although we work increasingly in teams, we may be less group-oriented or prefer smaller tribes.

Finally, doctors are trained to be leaders. We’re masters in problem solving and good at making difficult decisions, often in challenging and stressful situations.

We’re independent thinkers, skilled at arriving at our own conclusions and giving strong opinions. But we are not a profession of followers. The success of organisations depends on how well their leaders lead and how well their followers follow.

More unity

United General Practice Australia (UGPA) could connect the dots here. It’s an umbrella group for all the main groups, including the RACGP, ACRRM, AMA, RDAA. Those taking part have shown a desire to put aside their differences to a certain extent.

However, the status and governance of UGPA is somewhat vague. There is also no website or official spokesperson. But it is a start, and I would love to see this organisation be given the opportunity to grow and represent us all.

Lastly, we need to find common ground and partner with patient health organisations, as governments listen to the public more than they do to doctors.

The time has come to stop and think about where we want to go. More unity would require a cultural shift, excellent skills in following others, trust and willingness to compromise — not just from our leaders, but from all of us.

This article was originally published in Australian Doctor Magazine.

Tribalism: The real enemy in healthcare

Tribalism: the real enemy in healthcare
Image: Pixabay.com

Five doctors went duck hunting one day. Included in the group were a general practitioner, a paediatrician, a psychiatrist, a surgeon and a pathologist.

After a time, a bird came winging overhead. The first to react was the GP who raised his shotgun, but then hesitated. “I’m not quite sure it’s a duck,” he said, “I think that I will have to get a second opinion.” And of course by that time, the bird was long gone.

Another bird appeared in the sky thereafter. This time, the paediatrician drew a bead on it. He too, however, was unsure if it was really a duck in his sights and besides, it might have babies. “I’ll have to do some more investigations,” he muttered, as the creature made good its escape.

Next to spy a bird flying was the sharp-eyed psychiatrist. Shotgun shouldered, he was more certain of his intended prey’s identity. “Now, I know it’s a duck, but does it know it’s a duck?” The fortunate bird disappeared while the fellow wrestled with this dilemma.

Finally, a fourth fowl sped past and this time the surgeon’s weapon pointed skywards. BOOM!!

The surgeon lowered his smoking gun and turned nonchalantly to the pathologist beside him and said: “Go see if that was a duck, will you?”

Source: Nursing Fun

What’s great about this joke is not just the stereotype behaviour of the five doctors – which most people working in healthcare immediately will recognise. What is wonderful here, is the different disciplines doing some team building. They may not be very efficient as a team yet, and they could have picked a different activity, but at least they have found a common goal: hunting.

In the real world of medicine we sometimes seem to have forgotten our purpose. The inconvenient truth is that we’re often acting as a dysfunctional team where every member’s main goal is to finish their own little task, and where other team members and disciplines are sometimes regarded as ‘the enemy’.

A while back I was privileged to hear Dr Victoria Brazil speak at a conference of the Royal Australian College of General Practitioners in Brisbane. Dr Brazil is an emergency physician and passionate about the topic of medical tribalism. Instead of the more primitive tribal behaviour – characterised by hostility towards other tribes and the unwillingness to take responsibility for a bigger cause – we should move to a kinder tribalism driven by mission and purpose, without common enemies, she argues.

Dr Brazil reminds us that we cannot achieve the best patient outcome without other disciplines. Building relationships, communicating and networking are the key to success. This sounds obvious but it’s not very often that we make time to sit down and have a yarn with members of other teams.

You don’t have to go duck hunting together, but next time you talk to someone belonging to a different tribe, maybe just introduce yourself and ask how they’re going.

If you would like to know more about this fascinating topic: In the video below Dr Brazil, who is also a gifted speaker, addresses a room full of medical tribes (but with a common interest in emergency medicine). She explains how we can overcome the dark side of medical tribalism. Enjoy.