Bioethics Forum Essay

The Other July Effect: Tribalism in Medicine

Every summer, our household lives through “the July effect.” The mate, an internist, spends extra time at teaching rounds with his brand new residents, hoping they will beat the odds and not hurt patients disproportionately with their greenness. Our son, now 10, tightens his bike helmet a little extra, telling his friends, “This is not a good month to end up in the hospital.” And me, I watch my dear former students turn into real doctors.

And yet I don’t really watch – not usually. My “kids” are so deeply immersed in their terrifying, exhilarating transition to real medical care that I won’t hear from them for months, sometimes even for a year. It always reminds me of the moment in Apollo 13 where the crew has to slingshot around the moon, so that they are out of radio contact with Earth for several minutes, while all on Earth hold their breath.

But I broke radio silence with one of my kids a few weeks ago. I happened to be in a city where he had just started his residency, and happened to hit a night between post-call and call, and so I took him out to dinner. This is a great kid – one I’ve known for years. Smart, scientifically-minded, ethical, socially-oriented.

For years, he wasn’t sure he wanted to be a doctor because he wasn’t sure he could do enough good in the world that way. He has talked about being one of those Doctors Without Borders types when he’s done training, or maybe setting up a clinic somewhere in the developing world. I love this kid.

We ordered a bottle of wine, and I had one glass. He downed the rest. I had never seen this kid drink like that, nor make reference to getting drunk with colleagues as he now did. He told me, with a mixture of anxiety and excitement, about the horrific cases he’d had to deal with so far in a burn unit.

He’d had to tell families of deaths, of impending deaths, of the choice to invite Death to arrive a little early. I listened, struck again by the sense that I have no right to criticize doctors. It reminded me of the time I had come home, when my own mate was in residency, and I complained for a good half hour about mind-numbing committee work and immature students before I asked him how his day was. “I lost a patient,” was all he answered.

Now Dr. Kid whipped out his cell phone to tell me a funny story. He had been doing a procedure on a patient and was all scrubbed in, so of course his phone was off in the next room with the rest of his personal stuff. He was doing the procedure, with the patient unconscious, when this practical joker of an attending grabbed Dr. Kid’s phone and started teasing him, telling Dr. Kid that she was texting other attendings with various inappropriate messages from the kid’s phone, as if the messages were from the kid.

The kid thought this was so funny, and thought it was even funnier that the attending had decided to take a picture of this whole scene. Dr. Kid showed me the picture of himself taken by the attending. Dr. Kid was barely recognizable to me, in complete scrubs and mask. Two other residents stood next to him. And an unconscious man lay on the table, his face just visible enough to look like a black man.

I suddenly wished he had not drunk all the wine. I needed another glass.

Flash forward a while, to Nashville, where I had the honor of giving the keynote at the Androgen Insensitivity Syndrome Support Group’s meeting. I had already decided long before seeing Dr. Kid that I’d hit on a theme that I always hit with medical support groups, and that’s how to take care of yourself in a medical setting. As part of that, I said to them what I always say – that the most important thing they need to keep in mind is this: doctors are human.

But as I said it, I found myself having one of those split-speaker moments, where my mouth was saying one thing – doctors are human – and my brain was criticizing my delivery. My brain was saying this: “When you say doctors are human, what they’re hearing is doctors make mistakes sometimes, medical mistakes, and that’s true, but what you mean is something more subtle. What you mean is that doctors evolved like the rest of us, and this means they react in ways that aren’t always in the patient’s best interest, even though they are really good people.”

Then my brain launched into a meta-critique, as somehow my mouth stayed on message. The meta-critique consisted of a complaint that I was suddenly sounding like an evolutionary psychologist, and even one who was happy to commit the naturalistic fallacy of thinking that what evolved is what must still be. And yet, there I had, in my mind, my picture of the kid on the other side of the table, showing me the cell phone photo and laughing. . . .

I slowed down and tried to explain to the Nashville audience what I really meant: Doctors, like all of us, respond to rewards and punishments, particularly rewards and punishments perceived as immediate. As a consequence, they might sometimes put the “need” for another publication or a shorter office visit or a colleague’s approval before your or your child’s long-term best interests.

And, I went on, doctors take care of the people they are with the most. They are tribal, as are we all. And it is impossible for you to be there enough to count as part of the tribe the way the colleagues, the office staff, and even the drug reps do. I told them about the recent article in JAMA, on “Physicians’ Perceptions, Preparedness for Reporting, and the Experiences Related to Impaired and Incompetent Colleagues.” That paper concludes, “Overall, physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report.”

The same study also showed that “Underrepresented minority physicians were significantly less likely than other physicians to report, as were international medical graduates compared with graduates of U.S. medical schools.” Of course; these are the people who are already on the margins of the tribe. Can they really afford to report? (And by the way, Dr. Kid just happens to be an underrepresented minority in the field he chose. I thought of the black man lying unconscious.)

I tried to impress upon the people at the support group meeting that we cannot expect doctors to be superhuman. Their work is so very stressful much of the time, it is hardly surprising that they would succumb to natural coping strategies, including taking care of the people closest to them. The key is to understand the way medicine functions, and to protect yourself within those structures. I recommended that the support group make sure every team dealing with their condition have a named liaison from the group who meets regularly with the team, in the hopes of having a key relationship develop between a knowledgeable patient advocate and the overwhelmed medical professionals.

And I quietly wondered to myself what we do if that liaison becomes accepted as a member of the tribe.

How much of taking care of perfect strangers do we each really have in us?

A couple of days ago, it was time for me to go to sleep, and yet I could not stop thinking about this essay, about the green tribalism of July’s medicine. So to distract myself, I made the mistake of looking at the New York Times homepage. The top headline had shifted since last I looked, to the horrifying news of the 10 international medical workers killed in Afghanistan by the Taliban. One tribe against another. I found myself shot-through with a visceral maternal fear for Dr. Kid, involuntarily praying he would give up his dreams of brave aid work abroad, and stay home, safe, with Dr. Practical Joker, far away from places where his cell phone would not work when he ran into someone who doesn’t understand you don’t kill doctors. Please, please, not my kids.

Alice Dreger is a professor of clinical medical humanities and bioethics at Northwestern University’s Feinberg School of Medicine.

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