TRIBALISM

The healthcare professions have been described by several authors as behaving in a tribal manner Dearden (1985), Pietroni (1994), Atkins (1998), Beattie (1995). Pietroni (1994) looked at the history and development of interprofessional teamwork in hospitals; general practice and community care in the U.K. He cites Bligh (1979) as explaining that “each profession acts in a sense like a tribe” and he goes on to identify several of the tribal features that exist in the health professions. These include having their own leaders; imposing sanctions on non-members; developing their concepts in exclusive gatherings; and being nurtured in distinct ways.

Beattie (1985) in Soothill et al (1995) describes the use of the word tribalism as a “vivid anthropological metaphor” and gives some historical context to the tribal boundaries that have built up in the healthcare professions. He suggests that the professions evolved separately due to the class divisions and gender barriers that existed in Victorian Britain. He also goes on to explain that the boundaries reflected

“…prevailing cultural codes surrounding social selectivity, sponsorship and patronage.”

In order to understand the development of this tribal mentality it is necessary to explore the origins of a profession and make explicit the pressures and determinants of professional status. The author’s profession of radiography provides a useful example of the interaction between radiologists, the medically qualified doctor, radiographers, degree qualified independent practitioners and also includes some contribution from the profession of engineering during the chronological development of these professions. This historical perspective also highlights the effects of government and medical organisations.

2.4.1 The Emergence of the Radiographic Profession

After the discovery of x-rays in 1895 by Professor Wilhelm Conrad Roentgen, a physicist, a society was soon set up to look after its affairs. This was The Roentgen Society (1987) and was largely organised by medical doctors. However at their second meeting they decided to admit some non-medical members so physicists and engineers were invited to join (Reynolds 1956). Although there was no exclusive medical association with x-rays at this time, Larkin (1983) observes that:

“…medical proprietorship of x-rays developed very quickly” p 63

He goes on to layout the early evidence for the view that the radiographer was subordinate to the medical practioner. At the time there were no radiographers rather these workers were referred to as laymen. Larkin offers the following quote from the British Medical Journal of 1903:

“There is no reason for professional prejudices against the practice of radiology by laymen, so long as they confine themselves to the mere mechanical act of producing a picture and abstain from assuming a scientific knowledge of the bearings of their radiography on diagnosis and prognosis. Of those engaged in x-ray work only qualified practitioners are entitled to undertake the treatment of disease.”

BMJ (1903)

This signifies that the debate regarding role boundaries between the radiological and radiographic factions had begun. Larkin explains how the medical profession put forward reasons why there should be medical control of x-ray diagnosis. As was known at the time x-rays were unsafe and therefore the medical profession would be guardians of this dangerous discovery. They would also be able to guarantee competence in its use. However little was known about the safety issues in the early twentieth century so competence and safety were not guaranteed. Larkin goes on to cite examples where doctors had overdosed patients and staff. So many of the reasoned arguments put forward by the medical profession were weak.

The outbreak of the First World War led to great advances in x-ray technology and many lay people were trained in the use of taking x-rays for army and civilian benefit. Once the war was over there was the prospect of many radiologically experienced doctors, who were not radiologists, and lay men returning from the war keen to secure a job and exploit their new talents. Many of these people had been trained in the taking and reporting of x-rays by radiologists.

There was also pressure on radiologists at this time who were battling with their medically qualified colleagues trying to get their work status recognised. In 1916 Dr T. Holland, President of the Roentgen Society, complained that prominent physicians and surgeons were sending their patients to radiographers to avoid consulting a radiologist (Larkin p 66). So the issue of role conflict was affecting the radiological as well as radiographic professions.

In 1917 the British Medical Association recommended that radiography be placed under the direct instruction and supervision of medical practitioners. In addition medical doctors suggested an initiative to set up an organisation for ‘lay assistants’ in radiology in order to limit and control the work of the lay radiographers (Larkin 1983). This organisation became the Society of Radiographers, which was formed in 1920. Its committee was composed of six doctors and six engineers. Subsequently six selected radiographers from the London area were added to it. Dr Hernaman-Johnson drew up the Society’s by-laws and a qualification was developed for radiographers which was a condition of membership of the society.

The aims of the society to control the practice of radiography was not successful and there was still role conflict and blurring of professional boundaries between radiologists and radiographers. Larkin (1983) states that in 1923 there were still radiographers reporting on x-ray images and advertising these services to doctors. Further professional conflict occurred between the engineers and the medical doctors within the Society of Radiographers. The GMC tried to amend the articles of association thus removing reporting from the role of non-medical practitioners namely radiographers and engineers. Many of the engineers where in private practice and this would have affected their income so they withdrew their membership of the Society en mass in 1925.

The inter-war years’ records of the Society of Radiographers mostly reflect, according to Larkin (1983), its desire to improve standards and restrict the role of the radiographer. The admission of the Society to the Board of Registration of Medical Auxiliaries added a further dimension to the medical dominance of radiography.

The interprofessional relationship between the radiologist and the radiographer was demonstrated by recounting the view of a radiologist that was published in the Journal of the Society of Radiographers in 1952. On the subject of the “Ideal X-ray Technician” a radiologist stated :

“One attribute which will quickly assist the technician in gaining the radiologist’s approval is the habit of good listening. Pay rapt and undivided attention when he is giving advice or instruction…a technician who cannot feel a real deep loyalty after a reasonable time should seek employment elsewhere.”

Radiography 1952:133 in Larkin 1983 p90

This form of occupational dominance described above runs counter to the modern day principles of teamworking espoused by West and Slater (1996), World Health Organisation (1984) and Miller et al (1999). The historical pressures on the radiographic and radiological professions highlight the competitive environment within which each must function. They need to compete for precious resources and status to ensure their professions survive and develop. The division of x-ray work into the judgmental and the mechanical has been at the heart of the interprofessional rivalry between the two professions. Yet the experiences of the author during ten years of professional radiographic practice would suggest that there is considerable teamworking and co- operation between the professions at the coal face despite the competitive element that still exists.

The occupation dominance described above is also reported by Larkin (1983) to exist in chiropody, physiotherapy, nursing, midwifery, and ophthalmic opticians. He goes on to define the relationship from a sociological perspective as ‘medical imperialism’.

An important development for the professions was the setting up of the 1960 Professions Supplementary to Medicine Act (PSM act). This gave a degree of autonomy and a much-needed recognition of status for several professions. The role of the BMA

as the professional body for the medical profession has been significant in the domination of the professions. This organisation controlled the Board of Registration of Medical Auxiliaries and had subjugated the professions but this Board contributed eventually to the setting up of the PSM act.

In 1949 the Cope Committee was set up to report to the health ministry on the supply, demand, training and qualifications of medical auxiliaries employed in the NHS. This influenced the PSM act which provided for seven professions, chiropody, radiography, physiotherapy, dieticians, remedial gymnasts, occupational therapists and medical laboratory technicians. Its main purpose was with the protection of title and supervision and control of training. This enhanced the developing autonomy of the professions and was, as Larkin identifies (p176) disliked by the BMA. However this was a halfway house because although the medical profession no longer solely controlled the role definition, education and other affairs of the paramedical professions, the paramedical professions didn’t control them either as this had been handed to the Council for the Professions Supplementary to Medicine. This council consisted of seven auxiliaries (paramedical professions) seven doctors and seven ‘others’.

This example of the development of the radiography profession, the control exerted over it by the medical profession and the tribalism apparent is mirrored across other professions. Atkins (1998) cites research by social psychologists, sociologists and social anthropologists which provide an example of why this tribalism might be perpetuated. He describes the impact of specialist training schools e.g. medical schools, schools of radiography, nursing etc as transmitting a unique professional culture.

This tribalism between professions is considered one of the key factors that can affect teamworking. If the professions could consider that they belong to one ‘healthcare tribe’ with one goal teamworking would be likely to improve. Unfortunately there are many examples of poor interprofessional working and some of these will now be discussed. The chapter will conclude with a list of factors hewn from these examples, and from those earlier in the chapter, which have hindered or prevented successful interprofessional working.