Manning the Hospital Barricades
Why do groups--even groups of doctors--instinctively hate each other?
If you walk into the cafeteria at my hospital--or, I suspect, at any other academic medical center--you'll find a medical Bosnia. We surgical residents sit at one end of the cafeteria, the medical residents--or "meddies," as we call them--at the other. God knows where the psychiatrists sit. In the hundreds of meals I've eaten there over the last three years, I don't think I've sat down with the meddies more than half a dozen times.
I remember one such time, when the surgery table was full.
"Mind if I sit here?" I asked.
The pack of meddies eyed me in my green scrubs suspiciously. Someone grunted, "OK," and cleared a corner of the table for me. It was my own little Bantustan. The pack ignored me and resumed a boring conversation comparing how many "hits"--patient admissions--each had and how little sleep each was functioning on. Among surgeons, it's a point of pride verging on arrogance that we work harder than anybody else. So I ate my meal silently, looking faintly bemused at their complaints. Who wanted to talk with those do-nothing, pill-pushing, pointy heads anyway?
Later I took my share of ribbing from fellow residents for "going meddie" at dinner. Next thing you know, someone said, you'll be wearing a dog collar. Meddies, you see, wear their stethoscopes around their necks. Surgeons, should we need anything besides our bare hands, keep our stethoscopes coiled up in a pocket of our white coats like forgotten but occasionally necessary detritus. Like admitting you're tired, being caught wearing a dog collar is embarrassing. It diminishes you.
This all seems childish, I know. Why all this sniping along the medical front? These are educated, professional people, right? If you pushed surgeons to explain, I suspect the response would be that the animosity is functional, that patients would not want surgeons accepting other specialties' softer values.
Surgery is not like other fields in medicine where it is commonly accepted that nature may defeat doctors' efforts. Because surgery is so violent, surgeons generally do not undertake it unless they expect to succeed. So surgical training inculcates the view that nothing must be allowed to go wrong. One learns to take responsibility for almost any unwanted "surprise"--not just death but an unexpected infection, a dressing applied carelessly, anything. Once, I had a patient who refused to get out of bed after surgery and soon developed a clot in his leg. Medical residents might have thrown up their hands and said, "What could we do?" But the chief resident gave me hell for it. It didn't matter that the patient wouldn't cooperate. Why, she asked, didn't I figure out a way to make the patient cooperate?
As the argument goes, surgical residents quite naturally disparage specialties with less rigid--dare I say less virtuous--priorities, because our values are central to what we do. So we seldom gripe about cardiologists, because they share our ethic of personal responsibility and keep our long hours. But pimple poppers (dermatologists)? Forget it. Here's a joke we tell: How do you keep a dollar bill from a radiologist? Pin it to a patient.
This theory of discrimination's functionality doesn't quite add up, though. Why not simply accept that our group has a certain set of skills and values that fit our needs, while others have theirs? If we were sensible about it, we shouldn't need to beat the meddies down.
It turns out, however, that to social psychologists there is nothing at all surprising about this antagonism. In numerous studies, they have documented a deep paradox about human relations--persons get along, but people don't. Encounters among individuals are generally positive, supportive, and rewarding, but those among groups are ordinarily unpleasant and confrontational. What's more, they observe something called "the minimal group effect." Even if people are randomly divided into groups, the groups will automatically discriminate against each other. It seems we can't help ourselves.
Atul Gawande, a surgical resident in Boston, is a staff writer on medicine for The New Yorker and author of the new book Complications: A Surgeon's Notes on an Imperfect Science.