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.