Common Sense

The Tribe

Issue: November/December 2018

Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense


“We have a strong instinct to belong to small groups defined by clear purpose and understanding — ‘tribes.’ This tribal connection has been largely lost in modern society, but regaining it may be the key to our psychological survival.”

— From Tribe: On Homecoming and Belonging by Sebastian Junger

In my last article, I discussed the sadly common feeling of despair in our specialty related to the sense that we are no longer in control of our jobs or specialty. The character of Howard Beale from the movie, Network, is representative to me of this feeling and I hope you spent a few minutes looking at the movie scene I mentioned in my last article. What is important to me is how we deal with this sense of anger and frustration. Turning this anger inwardly is certainly self destructive and each of us needs to learn our own constructive way to direct the negative aspects of emergency medicine towards a constructive path which can help us cope and prosper in our professional lives.

The sense of belonging to something bigger than oneself can lead to fulfillment and satisfaction even while dealing with difficult patients, administrators, or consultants. Certainly, this sense of belonging, which I am speaking about, can be felt on multiple levels and they are all important and have different levels of meaning to each of us. Some of us have developed this sense of purpose and meaning from organized religion, family, friends, hobbies, social organization, activities, etc. All of us need to focus on whichever combination of these works to make us feel whole and in which we feel like you belong to a group whether that is to a faith, country, family, group, or professional society. For some people, one of these is paramount and seemingly is enough to move us up Maslow’s triangle (remember that) towards self-actualization, but for most of us we need a combination of strategies. The level of importance of each of these will change depending on time and situation.

However, I think what we are increasingly lacking in emergency medicine is the sense of a “tribe” or belonging to something special or important. Speaking to emergency physicians across the country I do not often sense the level of pride in our specialty, which I believe it deserves. This is not to me reflected in emergency physicians’ thoughts and feelings related to the actual clinical practice of emergency medicine. Emergency medicine has made huge strides within the medical community in the past thirty years. Our specialty is now sought after by residency applicants and these residency slots are filling even as the number of residencies continues to grow. What disheartens many of us is that we feel alone while working in our emergency department. We have a need to feel that even if times are dark whether related to stroke alerts, patient satisfaction scores, chronic pain patients, your current CMG boss or whatever we are facing, that each of us as board certified emergency physicians are special and members of something that is important and that the “tribe” cares for you.

The book mentioned above, Tribe — On Homecoming and Belonging, is short and I certainly suggest that you read it. The author stresses the importance of belonging. Maybe this stems from our hunter-gather origins, but we all have a need to feel like we are a member of something, which is unique and special. The book uses many military examples but stresses the sensation of safety, which is derived simply by being in and with your clan. He gives an example of the utter sense of safety and security one can feel as long as others surround you who are fighting the same fight and who have your back and you have theirs. This blanket of safety can make you feel secure no matter how tired, hungry, or dirty you are and it does not matter how desperate the situation can feel. Why don’t we feel this way related to emergency medicine? Don’t you feel at times that you are involved in trench warfare while working an extremely busy shift? Do you feel that your fellow emergency physicians, hospitals, leaders, or professional societies have your back and if not why not and more specifically what are you going to do to feel safe and become a member of a “tribe?” This is the component, which we need to work on together.

I am troubled by the increasing loss of the control we have over our careers but more importantly the sense that we do not need to be in control. While flipping through emergency medicine journals and magazines look at the ads for jobs. Are you looking at the advertisements of the smiling young doctor carrying the surfboard? Many young emergency physicians now never even consider the type of practice environment in which to work and just look for a place they want to live and how much money they will earn. This sense that the business aspect of our profession is beyond their control and should be left to others can lead to mere servitude. Many of these younger physicians have never developed or have quickly lost any interest in the business and collegial side of their practice. The hired gun mentality or the sense that you are trapped working for whichever CMG is currently holding the contract this year leads to a compartmentalization of our “job” from our professional life. Of course, many of us have no choice except to work in clinical jobs where we have no control due to the seeming geographic domination by CMG’s. Working towards the right balance between family, friends, etc. can lead us to compromising on the type of job we accept. It would be great if each of us could choose between several democratic groups where your opinion mattered and was sought in making decisions related to “your” practice. This is not the reality today and our settling for less than desirable practice conditions does not make us bad people.

The sense of belonging to a profession (the tribe of emergency medicine) is something we all need to work on to be able to help the individual practitioner with their sense of well-being no matter in what practice environment in which one is practicing. There are many paths to this and we each need to find one, which works, for us as individuals. I ask each of you to think about this no matter your practice situation. This does not matter if you work for a corporate management group, government agency, military, academic, independent group or whatever your practice environment. I think you need something in your professional life, which makes you feel like a doctor and not a “provider.” This may mean taking a leadership role in your group, joining a hospital committee, seeking medical staff leadership at your hospital, teaching residents, becoming active in organized emergency medicine via AAEM or ACEP or whatever, find something which makes you think you are the professional which you trained to become. You are not an extender or provider. Remember that you are the emergency physician who will be trusted caring for the most injured and sickest members of our community.

Organized medicine hopefully will become part of your plan to thrive in your career in emergency medicine. In this regard you have many choices including county, state, and national organizations. This leads me to discussing the different approaches of AAEM and ACEP. Each has advantages and many emergency physicians become proud members of both organizations. AAEM’s new motto is the “champion of the emergency physician.” This simply and clearly emphasizes the commitment of AAEM to the individual doctor. I personally need to feel that I am represented professionally by an organization, which shares my values and concerns. Please find an organization, cause or committee through which you can express your sense of what it means to be a doctor. Please reflect on what is important to you and what you think you need to be part of a “tribe” and act on it. Don’t be the guy in the ad carrying the surfboard. No matter what the CMG may want you to believe you do need to care about your practice and feel that you are a proud member of the “tribe” of emergency medicine and not a just filling a hole in a schedule.

Last, it is disturbing to hear that some emergency physicians who work for CMG’s think that they should not join AAEM because they feel that they have already sold their soul to the devil. This is simply not the case and exactly the opposite of what AAEM wants for these physicians. AAEM wants them to know that the organization still cares for their individual well-being and wants to do what it can to make their practice life better and more fulfilling. We all make choices in life and have to compromise. The key is making the most of the situation and working to improve it. Certainly, many of us work in settings, which do not make us feel like a true professional. Our opinions are neither sought nor heard. Corporate overlords can dictate from on high and make you feel belittled and simply labor and not the professional. You have struggled and worked until you were thirty years old to reach your impressive level of expertise and training so please do what it takes to make the most of your professional life. Become active in something in organized medicine!


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