paper

THE TRIBE WITHIN THE TRIBE : Why the Greatest Divisions in Healthcare Often Exist Inside the Same Profession

Healthcare’s deepest divisions may exist within professions themselves. ISI examines hidden hierarchies, protection, power and their implications for accountability, organisational justice and patient safety.

Dr Alwin Tan, GAICD, MBBS, FRACS, EMBA (Melbourne Business School)

Nadra Gadeed BSc Psychology, MSc Forensic Psychology, MA Health Research

Founder and Strategic Advisor of Edify & Grow, a workforce risk advisory practice for boards and C-suite leaders in private healthcare across the GCC and Asia-Pacific. | NHS senior leadership experience spanning strategic, operational and clinical leadership. - 20 years experience - Combining expertise in Psychology, Forensic Psychology and Health Research |

Institute for Systems Integrity

“Healthcare does not merely decide who belongs. It quietly decides who deserves protection.”

Executive Summary

Healthcare is frequently described as divided by professional tribes, with distinct professional cultures and group boundaries capable of shaping communication, collaboration and patient safety (Hall, 2005; Weller et al., 2014).

Doctors.

Nurses.

Managers.

Allied health.

Yet this explains only part of the problem.

Within every profession exists another, largely invisible hierarchy.

A tribe within the tribe.

These informal structures influence who receives opportunity, credibility, mentoring, leadership, referrals and protection.

They also influence who becomes vulnerable to scrutiny, exclusion and retaliation.

Unlike formal organisational charts, these hierarchies rarely appear in governance documents.

Yet they may profoundly shape organisational learning, accountability and, ultimately, patient safety.

Contemporary patient-safety frameworks increasingly recognise organisational and system conditions—not only individual actions—as central to the prevention of avoidable harm (World Health Organization, 2021).

This paper proposes that hidden in-group dynamics should be recognised as a governance risk because they influence whose knowledge survives institutional decision-making—and whose does not.

Introduction

Healthcare often speaks about equality.

Professional standards.
Merit.
Objective decision-making.
Fair accountability.

Most organisations genuinely aspire to these principles.

Yet few clinicians would argue that everyone experiences healthcare organisations in the same way.

Some people seem naturally protected.

Others appear permanently vulnerable.

Some voices are heard immediately.

Others struggle to be believed.

Some mistakes become opportunities for learning.

Others become career-defining events.

Why?

The traditional explanation is individual performance.

This paper proposes something different.

Healthcare does not merely organise people into professions.

It organises them into social hierarchies within those professions.

The Hidden Hierarchy

Every profession contains two organisational structures.

The formal hierarchy.

Consultant.
Registrar.
Resident.
Intern.
Nurse Unit Manager.
Clinical Nurse Specialist.
Executive.
Board.

Alongside it sits another hierarchy.

This second hierarchy influences:

Who receives trust.
Who receives mentorship.
Who receives opportunities.
Who receives context.
Who receives forgiveness.
Who receives institutional protection.

Unlike the formal hierarchy, it is rarely acknowledged.

Yet it may exert enormous influence over organisational behaviour.

And it is not confined to clinical roles.

The same dynamics operate within management and executive teams, where influence, trust and protection may be distributed through tenure, relationships and proximity to power rather than job title alone.

A management tribe can protect its own just as a clinical tribe can.

In-Groups and Out-Groups

Social Identity Theory demonstrates that groups naturally distinguish between insiders and outsiders (Tajfel and Turner, 1979).

Healthcare is no exception: professional group identification can reinforce boundaries, shape perceptions of other groups and contribute to intergroup conflict (Bochatay et al., 2019).

Membership of the in-group is rarely written down.

Instead, it develops through:

shared training,
shared history,
shared reputation,
shared referrals,
shared committees,
shared friendships,
shared success,
shared loyalty.

The defining question quietly changes.

Not:

“Are you a doctor?”

But:

“Are you one of our doctors?”

Protection Is Unequally Distributed

One of the least discussed consequences of tribal identity is the unequal distribution of protection.

The same behaviour can produce entirely different organisational responses.

An insider’s complication becomes complexity.

An outsider’s complication becomes competence.

An insider challenging authority demonstrates leadership.

An outsider demonstrates disruption.

An insider receives context.

An outsider receives scrutiny.

Organisational justice literature has long examined inconsistent procedural and interpersonal justice (Greenberg, 1990; Colquitt et al., 2001).

Healthcare rarely examines the same phenomenon through a governance lens.

Yet this inconsistency reveals something deeper.

Protection creates debt.

When institutional goodwill, credibility or tolerance is disproportionately extended to one person, someone else may carry the consequences.

Whose account is treated as credible by default—and whose requires corroboration—may track status more reliably than evidence.

An established, well-regarded colleague raising a concern may be heard as offering insight.

The same concern, raised by someone newer, more junior or simply less embedded in the in-group, may be heard as a complaint to be managed.

This is the beginning of what this paper calls protection debt.

The Protection Gradient™

Protection is not random.

It follows patterns.

Individuals possessing greater organisational influence frequently receive:

greater credibility,
greater discretion,
greater advocacy,
greater tolerance,
greater rehabilitation.

Those possessing less influence may experience:

greater surveillance,
greater procedural scrutiny,
greater reputational vulnerability,
greater isolation.

This paper proposes the Protection Gradient™:

The closer an individual sits to organisational influence, the greater the institutional tendency to interpret their behaviour sympathetically.

Trauma psychology provides an important parallel through the concept of institutional betrayal, in which an institution’s response to wrongdoing can protect institutional interests rather than the person harmed (Smith and Freyd, 2014).

The Protection Gradient™ is therefore not unique to healthcare.

It can emerge wherever removing or challenging a high-value individual is perceived as more organisationally costly than tolerating their behaviour.

Institutional Gravity

Not all individuals exert equal influence over organisations.

Some clinicians become centres of institutional gravity.

They generate significant:

activity,
revenue,
research,
prestige,
leadership,
political influence,
referral networks.

The organisation gradually begins adapting around them.

This is rarely conscious.

It is systemic.

Just as gravity bends physical space,

institutional gravity bends organisational judgement.

Boards and executives may tolerate behaviour that would be unacceptable elsewhere because challenging or removing the individual appears organisationally costly.

The consequence is unequal accountability.

This is not merely theoretical.

The independent inquiry into the malpractice of a surgeon found that colleagues raised concerns about his practice over many years, yet those concerns were inadequately followed up or shared between organisations within a culture described by the inquiry as one of avoidance and denial (James, 2020).

Paterson’s high patient volume across NHS and independent-sector settings illustrates the type of institutional dependency described here.

The lesson is not that institutional value inevitably produces protection.

It is that organisational dependence can alter the perceived cost of challenge.

And when challenging someone appears more costly than tolerating them, protection debt can accumulate.

Commercial Protection

Healthcare is also an economic system.

Financial sustainability matters.

However, financial importance can unintentionally reinforce tribal protection.

High-volume proceduralists.
Major referrers.
Prestigious departments.
Commercially significant services.

These individuals and groups may become increasingly difficult to challenge.

Not because governance intends corruption.

But because systems naturally protect what sustains them.

This paper proposes the Commercial Protection Gradient™ as a governance construct describing the relationship between institutional value and organisational tolerance.

The underlying dynamic is well recognised beyond healthcare governance.

An extensive review of conflicts of interest in medicine found that financial relationships can influence professional judgement even where individuals do not believe their judgement has been compromised (Institute of Medicine, 2009).

Commercial protection therefore does not require bad faith.

It requires only that an organisation begins to value someone’s continued contribution or goodwill more highly than the discomfort of examining them closely.

Nor is this dynamic limited to clinicians who generate referrals or procedural volume.

It may apply equally to executives and managers who control budgets, vendor relationships, strategic knowledge or access to the board.

A commercially or institutionally powerful executive can become just as difficult to challenge as a commercially powerful surgeon.

The structural reason is the same:

the organisation has learned to depend on them.

There is also a reputational dimension.

Eccles, Newquist and Schatz (2007) describe the reputation-reality gap—the distance between what an organisation is believed to be and what it tolerates internally—as a significant organisational risk.

Protecting a commercially valuable individual may appear to close that gap in the short term by avoiding scrutiny.

In reality, it may widen it.

Because when tolerated behaviour is eventually exposed, the reputational cost may be far greater than the cost of confronting it early.

When Loyalty Exceeds Integrity

Professional loyalty is essential.

Healthcare depends upon trust.

The danger emerges when loyalty begins overriding curiosity.

When questioning colleagues becomes betrayal.

When protecting professional reputation becomes more important than examining uncomfortable evidence.

Organisational silence then becomes socially reinforced.

The tribe protects itself.

Reality becomes progressively filtered.

This is not simply a cultural description.

It can be seen in what professionals actually do.

In one large-scale survey of physicians, approximately one-third of those with direct personal knowledge of a significantly impaired or incompetent colleague had not reported them, despite most agreeing that reporting was a professional responsibility (DesRoches et al., 2010).

The gap between what professionals believe they should do and what they actually do when a colleague is involved is therefore not merely an individual ethical issue.

It is a governance signal.

Governance Implications

Protection debt is not simply a cultural phenomenon.

It is a governance blind spot with material workforce and patient-safety consequences.

Attrition.

Disengagement.

Psychological safety.

Leadership opportunity.

Professional isolation.

These are not abstract concepts.

They can leave observable organisational patterns.

Psychological safety is particularly relevant because people are more likely to learn, question and take interpersonal risks when they believe doing so is safe (Edmondson, 1999).

High-reliability scholarship similarly emphasises the importance of remaining attentive to weak signals and emerging patterns before they become obvious failures (Weick and Sutcliffe, 2015).

Yet boards rarely ask:

Who receives protection?

Who receives second chances?

Who receives context?

Who consistently receives scrutiny?

Who quietly disappears from leadership pathways?

Who benefits from existing referral structures?

Who influences decisions without formal authority?

Who is quietly paying the protection debt for someone else’s continued standing—through exclusion, disbelief, stalled opportunity or departure?

And perhaps most importantly:

Does the board apply the same scrutiny to its own executive team that it expects clinical governance to apply to clinicians?

Until these become governance questions,

tribal dynamics remain largely invisible.

Conclusion

Healthcare does not simply contain tribes.

Every tribe creates insiders.

Every insider system creates outsiders.

The governance challenge is not to eliminate professional identity.

It is to ensure that organisational justice, accountability and patient safety are never determined by informal membership of the tribe.

The strongest organisations are not those without tribes.

They are those whose governance remains stronger than them.

Protection debt does not remain on one person’s balance sheet.

It moves.

Organisations rarely recognise it as a single event because it rarely looks like one.

It may look like several unrelated departures.

A clinician who quietly leaves.

A manager who stops speaking.

A junior colleague who abandons a leadership pathway.

A concern that is never raised again.

Each event acquires its own plausible explanation.

Each disappears into ordinary organisational data.

What a board reads as routine turnover may, in some services, represent something more consequential:

a protected group closing ranks, one quiet exit—and one unpaid debt—at a time.

The governance failure is not simply that protection exists.

Human systems will always form relationships, loyalties and tribes.

The failure occurs when governance cannot detect when those relationships begin determining whose evidence is believed, whose behaviour is tolerated, whose voice survives—and who ultimately pays the price.

References

Bochatay, N., Bajwa, N.M., Blondon, K.S., et al. (2019) ‘Exploring group boundaries and conflicts: A social identity theory perspective’, Medical Education, 53(8), pp. 799–807.

Colquitt, J.A., Conlon, D.E., Wesson, M.J., Porter, C.O.L.H. and Ng, K.Y. (2001) ‘Justice at the millennium: A meta-analytic review of 25 years of organisational justice research’, Journal of Applied Psychology, 86(3), pp. 425–445.

DesRoches, C.M., Rao, S.R., Fromson, J.A., Birnbaum, R.J., Iezzoni, L., Vogeli, C. and Campbell, E.G. (2010) ‘Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues’, JAMA, 304(2), pp. 187–193.

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