Medical Examiner

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.

Afriend recently put me on to a classic demonstration of the phenomenon–the Robbers Cave study. In 1954, some experimental psychologists randomly divided 24 sixth-grade boys into two groups and took them to Robbers Cave State Park, Okla., for summer camp. Initially, the two groups were kept apart and unaware of each other. Almost instantly, kids in each group formed bonds of loyalty and group identification. Then, when the groups learned of one another’s existence, the boys immediately drew lines in the sand. They spoke of “our guys” and “those guys.” Each group named itself–one the Eagles and the other the Rattlers. Name-calling began at their first interaction. For example, the Eagles called the Rattlers the “nigger campers,” even though all the boys were white. At common meals they glowered from separate tables. Cabin raids and fistfights ensued.

People discriminate even when it’s against their own self-interest. In a 1970 study, teen-age boys were asked their preferences among paintings by two “foreign painters.” Afterward, the boys were told that their choices divided them into a “Klee group” and a “Kandinsky group.” In fact, they were assigned to these groups at random. Then, each boy was taken aside and asked how he would divide up rewards among individual boys from “your group” and “the other group.”

The results were depressingly consistent. The boys gave more money to those in their own group. Furthermore, when the options were fixed so that a boy could not give his group more without sacrificing profits for both groups, the boys still chose to maximize the difference in rewards between groups. Although they knew each other from school; although their groups were defined by flimsy, irrelevant criteria; and although self-interest was not served; they discriminated faithfully.

In an influential 1995 paper, the social psychologists Roy Baumeister and Mark Leary reviewed all such studies and concluded that we have an instinctive “need to belong.” Given the advantages that would have come to our ancestors from banding together in groups, this is plausible. Might prejudice–the hatred between the Rattlers and the Eagles, the Klees depriving the Kandinskys, the surgical residents’ disdain for meddies–be instinctive too? I spoke with Leary, and he wasn’t ready to go that far.

Given the pessimistic findings, however, we might ask why groups aren’t always at war with one another. Fortunately, it turns out that despite how easily group hostility forms, it’s not that hard to damp it down. Sociologists have documented many methods–for example, fomenting competition within a group, even moral suasion. At Robbers Cave, animosity rapidly disappeared when the “counselors” created common tasks, for example, fixing a broken water tank. Also, these experiments–like residency–artificially isolate individuals from families, outside friends, and other social ties that produce bonds outside group lines.

In fact, one of the difficulties I have keeping up my aversion to meddies is that I’m friends with a few from my medical school class. (Why can’t other meddies be like you? I ask them.) It seems that given the chance, we are legions ready to mass against one another. Fortunately, we keep getting distracted.