‘The individual has always had to struggle to keep from being overwhelmed by the tribe.’
Friedrich Nietzsche (1844–1900)
Getting in with the in-crowd
It’s well established that in-group loyalties are strong in Homo sapiens. We lived in small groups for many thousands of years and we are hardwired for it. It is ridiculously easy to get people to form group-based loyalties, to create their ‘in-group’ and become more hostile towards the ‘out-group’. We’re super-sensitive to social structures and studies have shown that completely arbitrary allocations can result in a change in our behaviour. Being allocated to a group on the basis of a toss of a coin is enough to change how we interact with the newly-perceived out-group.1 It is little wonder that we find ourselves at loggerheads with the tribes in secondary care.
In-group favouritism makes us more likely to attribute positive qualities to our own group and generalise negative ones to the out-group. Even when we meet that good consultant who treats us well, we treat them as the exception, in an example of ultimate attribution error.
Social identity theory was developed by Bristol-based social psychologist, Henri Tajfel. He was born in Poland and his entire family and most of his friends were killed in the Holocaust. He had a remarkable story, training in France and serving in their Army, and surviving WWII prison camps (though alarming evidence has just emerged that he sexually harassed female students2).
The other side of denigration
There’s a lot of talk about denigration and there has been, quite rightly, efforts to push back against a harmful phenomenon that has damaged general practice.3 When GPs and general practice are denigrated by consultants and hospital-based specialists we are outraged. However, and rather obviously, we are just as prone to out-group hostility ourselves. We’re hostage to our internal wiring.
There can be few of us who haven’t derided our local hospitals at times in some aspect. Even within recent months I’ve heard senior GPs make feeble after-dinner jokes about orthopaedic surgeons.
Internecine conflicts are also commonplace in primary care — I know I can name several practices who have bitter relationships characterised by conflict. And consider the pejorative ‘noctors’, used to describe healthcare professionals who are not doctors. It’s a shameful denigration of healthcare professionals with whom we work alongside in primary care. Paramedics, nurse practitioners, and physician associates have all met with toxic opposition at times from GPs. Debates around diversification in the primary care workforce often feel like thinly veiled attacks on these professionals, with evidence being bounced around to disguise underlying out-group hostility from GPs.
The Einstellung effect
Abraham S Luchins was a psychologist who, in 1942, asked participants to solve a series of simple mathematical problems involving water jars in the fewest possible steps. The initial tasks had similar solutions but when presented with a later problem, which had a far simpler answer, the participants stuck to the tried and tested, if inefficient, solution. He called it the Einstellung effect from the German word for attitude or mindset. It’s the problem where the very first solution that comes to our minds prevents us from seeing a better, simpler option.
General practice over run and under pressure? We need more GPs, more practices, more appointments! Yet, we need to be careful because out-group hostility and limited thinking can squeeze out the new and innovative. More GPs isn’t a bad plan but, as it was put by Bilalić and colleagues, good thoughts block better thoughts.4
We’re more prone to the Einstellung effect when we are fatigued, and working in groups helps protect us from it. The combination of the Einstellung effect and in-group favouritism can be a formidable barrier to change. We shouldn’t underestimate our own tribalism.
- © British Journal of General Practice 2019