“When two tribes go to war, a point is all that you can score”-
Peter Gill, Holly Johnson and Mark O’Toole
Growing up, I remember hearing my dad singing this Frankie Goes to Hollywood classic on loop around the house. He used it to tell me about his own childhood in the 80s, about the heady influence of wartime politics on the world of music, giving us anti-war bangers like ‘Two Tribes’ and ‘Enola Gay’.
Now, years later, I wonder if the same message can be used to tackle the ‘us vs them’ problem of tribalism, which is so pervasive in healthcare. We see many cases of ‘two tribes’ clashing, including the PICU vs ED clash explored in the article.
Kanaris, C. (2025). Tribalism in healthcare: See it. Stop it. Sorted. Journal of Child Health Care. doi:https://doi.org/10.1177/13674935251366769.
The author’s reflections on tribalism were sparked by a conversation overheard between two PICU registrars. During this conversation, the registrars were frustrated with perceived inadequate documentation for a patient in the ED they were called to review. However, this frustration was expressed in a way that reinforced tribalism, as the registrars mentioned ‘standard ED operating procedure’ and ‘no time for vitals or a proper neuro assessment’, and made assumptions about ‘blood tests they definitely didn’t order’.
On the face of it, this is not an uncommon type of conversation (Mannix and Nagler reflect on a similar conversation about ED doctors) and may not initially appear to be harmful.
I’m sure we’re all familiar with tension between the ED and, well, pretty much every other department in the hospital, particularly PICU. As a medical student, you’re in the fairly unique position of rapidly switching between departments, being sent into one place for one day, then another the next and never actually finding your feet in one area. However, this means we learn about the inter-departmental conflicts from both sides.
We smile and nod while the PICU registrar complains about the shoddy ED handover, knowing that two days earlier, we were sympathising with the ED registrar about how hard it is to get PICU on board with their unwell patient. This teaches us tribalism, highlighting the tensions between teams rather than a mutual goal of high-quality patient care.
But what actually is tribalism?
As stated by Kanaris:
“The tribalism phenomenon arises when different groups within a healthcare setting strictly adhere to their own group identity, sometimes at the expense of broader team cohesion and family-centred care.”
Kanjee and Bilello note that grouping is something which comes naturally to humans. Belonging to a group can boost self-esteem and provide support, with healthcare grouping being no exception. However, they also highlight the negative impact this can have on clinical relationships between different groups and an implicit sense that groups to which we do not belong are inferior.
Tribalism is therefore, in this context, a clinical paradigm which creates an ‘us vs them’ mentality between healthcare workers, with a range of tribes forming both across departments and within departmental hierarchies. Tribes between specialities are common and, as explored in the article, particularly troublesome for holistic patient-centred care.
If PICU and ED are busy bickering with each other, who is prioritising the patient?
Why should I care? The patient safety impact
Tribalism isn’t just ‘banter’; it poses a real threat to patient safety.
Tribalism is a problem because it leads to communication breakdown. Poor communication has been recognised as a cause of adverse events, including fragmented information sharing and missed critical interactions. Missed critical interactions directly lead to harm and delays in patient care, risking ‘blinkered healthcare’ which decentres the patient from practice.
Furthermore, hierarchical tribalism creates communication problems within teams, where junior staff may be afraid to challenge their seniors.
Think back to moments across your own experience where you have questioned something- or maybe even known something was wrong- but held back from speaking up for fear of upsetting the status quo. Splitting the team into ‘seniors vs juniors’ primes us for conflict if we stick our head above the parapet rather than facilitating open sharing of ideas.
Psychological safety is important for patients and professionals alike, and a pervasive tribalistic paradigm keeps individuals from feeling truly safe. This all impairs open communication and collaboration, at worst, leading to unchecked errors.
Poor collaboration between teams due to tribalism can result in lower-quality care. Medically complex and critically unwell children often involve a range of specialists and allied health professionals in their care, making effective communication key to high-quality care.
When tribalistic ideas become deeply entrenched biases, there is a lack of respect and trust between teams, which can be another barrier to holistic patient-centred care. This tribal conflict is the last thing a critically unwell child and their family need as they are transitioned from ED to PICU.
Moreover, tribalism creates a blame culture, described in the article as ‘a detrimental environment characterised by the misattribution of fault’. Blame culture facilitates fundamental attribution error, a tendency to pin blame on an individual, especially if they are perceived to belong to a different group.
This type of culture discourages open reporting and discussion of mistakes, risking errors not being addressed early and making it difficult for an organisation to learn from its mistakes. Instead, we should aim for a ‘culture rooted in genuine inclusion and mutual respect’ since this supports staff wellbeing and has been shown to reduce errors, helping patients overall. This involves tackling the tribalism problem.
Now what? Tackling tribalism head-on
We have a collective responsibility to address tribalism. As noted in the article:
“Silence is never neutral, it is a declaration of complicity.”
Let’s be honest, no one is immune to tribalism. We’ve all experienced the bonding moment of complaining to a colleague about the typical shortcomings of another speciality, of rolling eyes at the referral from that speciality, which might as well be written in crayon, because it is something that brings us closer in the moment.
We must aim to rebuild a sense of belonging and safety without relying on our tribes for support. We must break the cycle of tribalism to make a meaningful difference, and in doing this, our actions will recentre the patient in our practice (rather than ourselves and our differences).
Achieving these goals requires active engagement and building awareness of current problems contributing to tribalism. I’m well aware that this is easier said than done. Luckily, others have already done the work to create frameworks we can use to structure our actions and make intervention possible. Thanks, social scientists!
In the moment, the bystander is vital. The author challenged the overheard conversation using the LIFT model, as explored by Govrindraj et al., which provides a memorable framework to empower individuals to intervene without creating conflict.
L is for ‘Lights on’, inviting us to bring microaggressions to light in the moment without creating confrontation.
I is for ‘Impact vs Intent’, shifting the focus to the potential harm resulting from what may initially seem to be a benign interaction.
F is for ‘Full stop’- immediately stop the behaviour and redirect conversation.
Finally, T is for ‘teach’. We can use moments such as this to educate and develop understanding of the problems surrounding tribalism, allowing personal and team growth.
This allows us to learn from our implicit biases rather than creating tensions and assigning individual blame.
Individual action is important but we should also think about system-centred approaches. After all, tribalism is about bad systems, not bad people; we’re united by the goal of high-quality patient-centred care. We’re aware that ED doctors are time-pressured and that PICU doctors haven’t got the bedspace or staffing to accept every single referral. Let’s redirect our attention to the mechanisms leading to these stresses rather than fixating on specific shortcomings.
Tribalism is kept alive by systemic stressors in the workplace and Patterson and Wears argue that communication failure is not an explanation of error, but rather a symptom of systemic vulnerabilities.
We must direct attention beyond the confines of tribes within healthcare towards the level of management to collaboratively address the systemic issues which feed tribalism. Frameworks such as clinician-led governance models and a focus on organisationally supported teamwork may provide structure for this.
Doctors are used to finding and treating causes rather than symptoms alone- let’s use these problem-solving skills on the ‘us vs them’ problem of tribalism.
There’s still hope! A medical student’s perspective
If you, like me, had minimal medical experience before setting foot into university, you may well have been similarly unaware of the Mean Girls-esque tribal stereotyping within the medical world. This naivety seems a lifetime away, even as someone who hasn’t made it out of medical school yet. These professional divides between ‘tribes’ are not inescapable but they are taught- before even starting clinical rotations, we quickly learn negative stereotypes such as ‘surgeons have massive egos’ and ‘midwives have it out for doctors’.
While much of this chat is framed as banter, there is a hidden meaning- ‘we’ are better/friendlier/more important than ‘them’, so stick to your own. Every positive real-life interaction with a surgeon, or a midwife, or someone outside of your chosen tribe, is the exception that proves the rule, rather than a challenge to your mindset. I know I’m guilty of this, entering surgical placements with a sense of dread about ‘typical surgeons’ and longing for the comfort of the friendly, welcoming paediatricians, even when I do then have great interactions with surgeons in clinic and in theatre. Mindset changes are hard.
We can celebrate good qualities and have pride within our groups without putting down others.
For example, the stereotype of paediatricians being friendly is not an unwelcome one and does not need to be rejected, provided that we understand it does not mean that those outside of paediatrics are unfriendly, nor that a paediatrician is inherently friendly.
Likewise, we can challenge negative experiences of non-technical skills such as communication without relying on stereotyping.
We must be better learners and role models, taking individual responsibility to avoid teaching tribalism to those new to the system and learning how to challenge our own biases. Importantly, we can open up the conversation surrounding tribalism to bring awareness as to why it should be a concern and what we can do about it.
Tackling a deeply entrenched phenomenon such as this is not easy but I hope that our action can erode tribalism.
The Bottom Line
-Tribalism in healthcare has serious consequences for patient safety
– It’s up to individuals to start ‘shining the spotlight on tribalism’ using methods such as the LIFT framework
– We need systems-level interventions too- communication failure is a symptom, not a cause
– Our action can lead to positive culture change and redirection of focus to patient-centred care
References
Kanaris, C. (2025). Tribalism in healthcare: See it. Stop it. Sorted. Journal of Child Health Care. doi:https://doi.org/10.1177/13674935251366769.
Mannix, R. and Nagler, J. (2017). Tribalism in Medicine—Us vs Them. JAMA Pediatrics, 171(9), p.831. doi:https://doi.org/10.1001/jamapediatrics.2017.1280.
Kanjee, Z. and Bilello, L. (2021). Leadership and Professional Development: Specialty Silos in Medicine. Journal of Hospital Medicine, 16(6). doi:https://doi.org/10.12788/jhm.3647.
Weller, J., Boyd, M. and Cumin, D. (2014). Teams, Tribes and Patient Safety: Overcoming Barriers to Effective Teamwork in Healthcare. Postgraduate Medical Journal, 90(1061), pp.149–154. doi:https://doi.org/10.1136/postgradmedj-2012-131168.
Govindraj, R., Binda, D.D., Harris, A.C., Ananthakrishnan, S., McGrath, M.E., Kuohung, W., Hsu, T.-Y., Siegel, J. and Yadavalli, G. (2024). Responding to Interprofessional Microaggressions: Bystander Training—A Virtual Simulation Curriculum for Internal Medicine Residents. MedEdPORTAL. doi:https://doi.org/10.15766/mep_2374-8265.11435.
Braithwaite, J., Clay-Williams, R., Vecellio, E., Marks, D., Hooper, T., Westbrook, M., Westbrook, J., Blakely, B. and Ludlow, K. (2016). The basis of clinical tribalism, hierarchy and stereotyping: a laboratory-controlled teamwork experiment. BMJ Open, [online] 6(7), p.e012467. doi:https://doi.org/10.1136/bmjopen-2016-012467.
Patterson, E.S. and Wears, R.L. (2009). Beyond ‘Communication Failure’. Annals of Emergency Medicine, 53(6), pp.711–712. doi:https://doi.org/10.1016/j.annemergmed.2008.07.014.
Bolous, N.S., Graetz, D.E., Ashrafian, H., Barlow, J., Bhakta, N., Sounderajah, V. and Dowdeswell, B. (2022). Harnessing a clinician-led governance model to overcome healthcare tribalism and drive innovation: a case study of Northumbria NHS Foundation Trust. Journal of Health Organization and Management, 37(9). doi:https://doi.org/10.1108/jhom-05-2022-0157.
