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Martin McKneally
Martin McKneally

Most people believe that civil society is organized by jurisdictions and corporations, and governed by councils, parliaments and boards. While formally true, I believe there is a more important fundamental unifying element. Primitive and powerful tribal organizations preceded these structures, and tribalism persists today, influencing our decisions and trust relationships. The tribes are not limited to the "tribal areas" of the developing world. We all live in tribal societies, where values, beliefs and codes of conduct are socially inherited and learned through close contact. The knowledge- intensive work of surgery involves tacit knowledge -- "task specific experiences that cannot easily be articulated or stored in documents" (1). This knowledge is difficult to share without first hand experience through close contacts. People who share these experiences are more likely to trust each other, based on a variety of qualities and characteristics. Demographic and social-contextual factors that led to their co-location and group membership reinforce the shared experience that binds them to their tribes.

Tribal instincts rather than rational analyses can lead to suspicion or even hostility between tribes. As a resident at the University of Minnesota, my occasional clandestine Saturday trips from Minneapolis to the Mayo Clinic to watch the gifted O.T. Clagett perform thoracic surgery were viewed as seditious by my tribal chief, surgery chairman Owen Wangansteen. Corporate mergers between Cornell and Columbia in New York City, or Massachusetts General and "The Brigham" in Boston did not extinguish tribal boundaries maintained and guarded by their surgeons.

Canadian surgeons are more collaborative than those in the US, where entrepreneurial marketing enhances institutional and personal incomes. Nevertheless, tribal boundaries are palpable. Residents quickly adopt the customs and biases of the service they are on - to gain acceptance as initiates and accelerate their progress toward increased responsibility and operative experience. Fellows who are recruited to the faculty help break down barriers as they scrub in and operate, especially when hired across tribal boundaries.

When Andy Smith was taking the message to surgeons across Ontario that "negative nodes in colon cancer means twelve or more nodes were resected and all are negative," he encountered resistance. (see page 7 at http://www.surgicalspotlight.ca/Shared/PDF/Winter07.pdf ) So he hung his clothes in their lockers, put on the tribal


greens of their hospitals and operated with local surgeons. The policy was widely adopted because of trust based on "first hand experience through close contact", not through evidence and rational argument presented on Powerpoint slides in a formal conference room.

In their book on Tribal Leadership, David Logan and his colleagues (2) describe the taxonomy and characteristics of five levels of tribal development. Click on his excellent TED TALK ( http://www.ted.com/talks/david_logan_ on_tribal_leadership.html ) to see how effective leaders "nudge tribes forward" from "we're great; you're not" to more advanced levels of reconciliation and unity.

Best wishes to all for joyful holiday celebrations from the Surgery Department and the Spotlight staff.

Martin McKneally

1. Polanyi, M. 1967 www.infed.org/thinkers/polanyi.htm
2. Logan, David. Tribal Leadership. Harper Collins, 2008



From "Tribal Leadership", by Dave Logan et al.
Harper-Collins, 2008, p.181

  • There are two ways to seek core values. The first is for a Tribal Leader to tell a value-laden story, which triggers others to tell similar stories about their values.
  • The second way is to ask questions such as "What are you proud of?" and ask three to five open-ended questions.
  • The Tribal Leader's goal is to find shared values that unite the tribe.
  • A noble cause is what the tribe is "shooting for". There are two ways to find a tribe's noble cause. The first is to keep asking, "in service of what?"
  • The second way is to ask the Big Four Questions of people in the tribe. They are "What's working well?" "What's not working?" "What can we do to make the things that aren't working, work?" and "Is there anything else?" These questions capture a group's current assessment of its situation and its aspirations about what should change and why. The noble cause will often emerge out of people's answers to the questions.
  • The goal of determining values and a noble cause isn't agreement; it is alignment, which produces coordinated action married with passionate resolve.

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