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After the Match

After the Match: Seeing the World as an ED Tribe

Cook, Thomas MD

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doi: 10.1097/01.EEM.0000456993.66969.6e

    I walk through the parking lot of our ED on my way into work to get an idea of who is visiting us. The trash tells the tale: liquor bottles, pizza boxes, chicken bones, countless cigarette butts, and even dirty diapers. It's fertile territory to study the lifestyles that have led many patients to our door. In the midst of it all, I am always struck by a simple question: Why? Why do people act in a way that is so far outside what most would consider appropriate behavior?

    The book, “Tribal Leadership,” by David Logan, PhD, from the University of Southern California, chalks it up to the concept that all humans form tribes. Stage One tribes make up two percent of the population. They believe that life sucks. These groups are comprised of gang members, prisoners, and many of the mentally ill. For them life is relentless unhappiness. This is the group responsible for the most egregious acts of violence that come to the ED. They do not even have the capacity to consider things like littering. They just do it.

    Stage Two tribes comprise the 25 percent who think life can be OK, but that their life sucks. This often manifests itself in passive-aggressive behavior like smoking in front of the no-smoking signs. Stage Two tribes throw around garbage as a form of protest for their unhappy lives. “Why should I care? My life is terrible.” The upside is that they can move to higher levels of function with guidance from skilled leadership.

    Stage Three tribes are the most common (48% of all tribes). They live by the motto that they are great, and you are not. Nearly all doctors are in this tribe, and they engage in never-ending competition for money, power, time, and prestige. Physicians are groomed from high school through medical school to compete with the person next to them to demonstrate why they are better. They have it mastered by the time they are attendings.

    Stage Four tribes make up 22 percent. Their motto is, “We're great.” This is the tribe for hospital administrators. They need the skills to take disparate lower tribes to higher levels. Their focus is on improving life for everyone in the organization through collaborative effort. These skills take years to develop and rely on making connections between different groups to achieve higher outcomes.

    Only two percent belong to Stage Five tribes. They think that life is great. These are the groups that innovate outside the box. They look for solutions to create success for society, and their experiences force the creative destruction needed to change the world for the better. Apple and Amazon are Stage Five tribes.

    An important aspect of all tribe behavior is that they can function at different levels on different issues. One physician group might be Stage Four in community service but Stage Two on creating equitable shift schedules that safeguard the health of the physicians and the quality of patient care.

    “As people see the world, so they behave. People will do anything to survive, even it is means disparaging other people,” Dr. Logan says in his TED talk. ( This sums up the plight of ED parking lots. Many of our patients exist in Stage One and Stage Two tribes, and for them to even consider responsible behavior is extremely difficult.

    It is important for emergency physicians to understand how lower tribes think and not allow themselves to become frustrated by the slow progress of change to move people to higher levels of function. Lower tribes will always exist, and ironically they are a major driver for the creation of our specialty.

    But tribe members must move away from competitive behavior and toward collaboration for organizations to achieve real success. ACGME is attempting to be a catalyst for educating residents in these skills by mandating resident participation in interdisciplinary committees, such as a hospital's trauma committee. Many residents might dread the loss of free time, but it is important for them to understand that these skills will be critical to their future success in health care.

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