PERSPECTIVE: “Us” and “them” in medical culture
Brian Goldman, MD
Empathy is the capacity to see things from another person’s point of view. In some health care settings, empathy and kindness are lacking. One factor in the lack of empathy toward both patients and colleagues is the tendency to see others as the enemy. Although humans are hard wired to be kind and empathic to one another, under conditions of stress, they are also hard wired to decide whether another individual is friend or foe. Some medical cultures are defined by conflicts between in-groups and out-groups and a resultant lack of empathy. One way to restore friendliness and empathy is to address the underlying sources of stress.
KEY WORDS: empathy, kindness, in-groups, out-groups, stress
“Sorry to intrude,” says Susan, a paramedic with 15 years of experience, as she approaches a triage nurse standing behind a counter in the emergency department. Her partner Jeff stands beside a stretcher bearing a young man whose shirt is covered in vomitus.
“John is a 22-year old male who got intoxicated with alcohol and did a face plant while attempting to hop three steps at a time down the concrete staircase just inside the entrance to the subway,” Susan tells a triage nurse named Fraser. The nurse stares for a moment at John and then Susan before glancing at the more than 60 patients, family members, friends, and bystanders who have crowded into the waiting room.
“You again?” Fraser asks sarcastically while motioning to the sea of impatient humanity on chairs, stretchers, or leaning against the walls. “This is your fifth drop off this evening. Are you telling me we’re the only emergency department that’s open in the entire city?”
Susan sighs as she slinks away to stand closer to John’s stretcher. She turns her head to meet the eyes of her partner, who nods his head in sympathy. He’s the only other person in the room who knows what it’s like to be blamed for doing their job.
Fraser retreats behind the counter at the triage desk and sits down to record vital signs on John’s ED chart.
“Glad you spoke up,” another triage nurse, Amanda, shoots Fraser an approving look. “Those paramedics know we don’t fight back when they keep bringing us patients. They get a much chillier reception at the ED across the street.” Top
This exchange is typical of a kind that occurs not infrequently at some hospitals. In this paradigm, the paramedics see themselves as members of what psychologists refer to as an in-group and the triage nurses as members of an out-group. Likewise, the triage nurses view themselves as the in-group and the paramedics as the out-group.
What’s striking about this encounter is that members of the in-group have abundant empathy for one another, but little if any empathy for their perceived opponents.
The empathy gap in health care
“Empathy is the feeling that ‘I might be you’ or ‘I am you,’ but it is more than just an intellectual identification; empathy must be accompanied by feeling. Sympathy brings compassion, ‘I want to help you,’ but empathy brings emotion. Without feeling, there is no empathy.”1 Empathy is defined as the ability to imagine what it’s like to stand in someone else’s shoes and see things from their perspective.
Evolution has equipped our brains with cells known as mirror neurons.2 These cells are active, both when we are carrying out an action and when we are observing someone else carry out the same action. This enables humans to see things from both perspectives at the same time. Although it hasn’t been proven that mirror neurons are the seat of empathy, having these specialized brain cells most likely facilitates empathy for others. Top
Many experts in medicine and psychology have decried the lack of empathy in modern health care. System issues that may interfere with empathy include stress, time pressure, technology, fragmented care, and the increasingly complex needs of patients. These factors can overwhelm health professionals with competing priorities that distract them from empathizing with patients.
Individual factors can also impair the capacity for empathy. One of these is compassion fatigue, a gradual lessening of concern for, or frank indifference to, the suffering of patients and others who need our help. Another is known as moral distress, which is defined as holding a moral obligation to act in a specific clinical situation, but feeling constrained from acting because rules, regulations, or customs make such action impossible without risking professional repercussions. Top
Moral distress and compassion fatigue are risk factors for burnout. The 2018 National Physician Health Survey found that 30% of Canadian physicians had burnout.3 High rates of burnout exist among nurses too.4 Studies have shown a consistent negative association between burnout and empathy, although a causal link has not been established clearly.5
Another factor that impairs the capacity for empathy and is seldom noticed, let alone talked about, is the tendency to see working in health care as a battle between in-groups and out-groups. The basis for this behaviour is known as social identity theory, resulting in “us” versus “them” scenarios. Top
Us and them
In 1979, the Polish social psychologist, Henri Tajfel, proposed that the social groups to which people belong bestow upon them a sense of self-esteem and social identity.6 The latter has been defined as a person’s sense of who they are, based on the groups to which they belong. Surveys by social psychologists have shown that humans regard members of their in-group as loyal, industrious, generous, charitable, kind, and empathic. They regard members of out-groups as the polar opposite.
Many examples of social identity are at play in everyday life. Among social classes, these include designations, such as middle and working classes. In politics, Canadians identify with political parties, such as the Liberals, Conservatives, and the New Democratic Party. In sports, we have the Toronto Maple Leafs and the Montreal Canadiens or the New York Yankees and the Boston Red Sox. In the former Yugoslavia, there are Bosnians and Serbs; in Northern Ireland, Catholics and Protestants. Top
It’s not a stretch of the imagination to suspect that such group distinctions exist in medical culture. At some hospitals, emergency physicians and consultants see themselves as opponents in a battle over patient referrals. In the operating room, surgeons and anesthesiologists may be in a perceived conflict over which profession controls time, the flow of patients, and income. Sometimes, internists and cardiologists disagree over which service should admit the elderly patient with congestive heart failure and dementia.
These dyads can shift depending on the circumstances. Physicians who typically see themselves as rivals may at times also see themselves as fellow members of a larger in-group in opposition to allied health professionals, such as nurses. Not infrequently, it’s health professionals in general versus patients and families. Top
This may come as a surprise, but just as we are hard-wired to empathize with others, we are also hard-wired to categorize others as friend of foe.7 In as little as 30 milliseconds, human beings distinguish between in-groups and out-groups. A photo of a member of an out-group activates the amygdala, which signifies an emotional response to the recognition of a potential enemy. In contrast, a photo of a member of an in-group does not lead to activation of the amygdala. This is tangible proof that human beings exhibit implicit racial bias. Thirty milliseconds is well below the 525-millisecond threshold required for conscious processing of images and activation of the frontal lobes. The latter executive function nullifies implicit racial bias; without it, the processing speed of the amygdala would allow its us-versus-them reaction to always win. Top
In the scenario above, Fraser and Amanda saw themselves as sticking up nobly for triage nurses. At the same time, they implied that paramedics, Susan and Jeff, took the easy way out of a potential conflict with staff at a nearby ED by overburdening the ED at which they worked. However, an instinctive survival strategy that is well-suited to the “kill or be killed” times of yesteryear is not particularly appropriate in modern life or, in particular, modern hospitals. So, why do some medical cultures spend a lot of time seemingly dividing colleagues into us and them? Although it hasn’t been studied, we can make some educated guesses.
Hospital environments are stressful. Time and productivity pressures and scarcity of resources, such as beds, personnel, and operating room capacity, together with budgetary cutbacks exacerbate the situation. These circumstances likely put humans into “survival” mode. In the brain, they would be expected to activate primitive emotional centres, such as the amygdala, thus fostering the tendency to divide the world into friends and enemies. Such conditions would also tend to deactivate the frontal lobes, thus depriving those affected with the capacity to reason past their primitive biases.7 Top
In a system in which us versus them predominates, there is little value in admonishing health professionals to be more empathic toward one another. It’s probably more fruitful to address first the factors that have led to stress and scarcity.
It’s important to remember that scarcity of time may not be improved by an increased financial budget. A better fix might be to address and remove unnecessary yet onerous responsibilities that make the work itself stressful.
The next step might be to encourage dyads of in-groups and out-groups to spend time together to find that what they have in common. That might entail meeting professionally or socially. Another way to address the gap in empathy would be to have members of in-groups and out-groups switch places with one another for a day or two to allow them to see the challenges of the opposite group from its point of view.
The idea behind all of this would be to diminish the role and perceived value of us and them and, in so doing, create one great big us. Top
1.Spiro HM, Peschel E, McCrea Curnen MG, St James D (editors). Empathy and the practice of medicine: beyond pills and the scalpel. New Haven: Yale University Press; 1993.
2.Keysers C. The empathic brain. Chicago: University of Chicago Press; 2011.
3.CMA National Physician Health Survey: a national snapshot. Ottawa: Canadian Medical Association; 2018. https://tinyurl.com/ubtd4s3 (accessed 23 Dec. 2019).
4.Dragan V, Miskonoodinkwe Smith C, Tepper J. More than a third of nurses have PTSD symptoms; a third of doctors are burned out. What are we doing about it? HealthyDebate 2018;27 Sept. https://tinyurl.com/qwttpv2 (accessed 23 Dec. 2019).
5.Wilkinson H, Whittington R, Perry L, Eames C. Examining the relationship between burnout and empathy in healthcare professionals: a systematic review. Burn Res 2017;6:18-29. DOI: 10.1016/j.burn.2017.06.003
6.Tajfel H., Turner JC. An integrative theory of intergroup conflict. In Austin WG, Worchel S (editors). The social psychology of intergroup relations. Monterey, Calif.: Brooks/Cole; 1979. pp. 33-47.
7.Molenberghs P. The neuroscience of in-group bias. Neurosci Biobehav R 2013;37(8):1530-6. DOI: 10.1016/j.neubiorev.2013.06.002
Brian Goldman, MD, FCFP(EM), FACEP, is a staff emergency physician at the Schwartz Reisman Emergency Centre at Sinai Health System in Toronto and the host of White Coat, Black Art on CBC Radio One. His latest book, The Power of Kindness: Why Empathy is Essential in Everyday Life, was published in 2018.
This article has been peer reviewed.