During a recent discussion the old adage about a frog and boiling water arose. People know the story so well it has become stale. It has lost its effectiveness as a metaphor because as soon as you start talking about the frog and the pot their eyes glaze over. The most interesting part is, like a lot of things in life, what we think we know to be a solid fact often isn’t true. Even heated slowly, at a certain point, if the frog can get out, it will. The problem is that our current science does not allow us to ask the frog how it feels about its environment, and given that we don’t even know what the hell human consciousness is all about, it is difficult to speculate on the level of self-awareness of our amphibian compatriots.
But people can tell us what they think and feel, and at a certain point in a deteriorating environment, hopefully before a critical maximum is reached, a revelation will occur, and people will try to escape.
In zoology we can study the critical thermal minima and maxima of different species, and we find that some are more cold or heat resistant than others. Red flat bark beetles (Cucujus clavipes puniceus) essentially have antifreeze in their tissues and can survive in temperatures as low as -58°C with their larvae able to survive to around -100°C. In the oceans Pompeii worms (Alvinella pompejana) can survive in water over 80°C, and on land the Sahara desert ant (Cataglyphis bicolor) thrives to a critical thermal maximum of 53.6°C.
But the king of resistance is the tardigrade (Hypsibius dujardini), also called the water bear. This little sucker can survive to almost absolute zero and up to 150°C. Considering it is less than 1 mm in length, it takes electron microscopy to reveal the cuddliness of this bear.
There are critical minimum and maximum points of governance, as well, but they are different for different people. Some people could thrive alone, with little to no supervision after a sufficient childhood learning period. Others require leadership and structure just to be able to survive. There are examples of people who were raised in the wild, without parents to teach them and with minimal human contact.
At the other end of the spectrum, theoretically everyone has a maximum point of governance, the point beyond which even the most law-abiding and submissive types will crack and rebel, but these thresholds are vastly different based on upbringing, environment, and political leanings. Call this the critical governance maximum (CGM).
Actually, the psychology of obedience to authority has been examined in a number of fascinating studies, and as with most things in life, the story is complicated. Probably the most famous research was done by Milgram in the 1960s and 1970s. In these classic experiments volunteer ‘Teachers’ were ordered to deliver electric shocks of increasing voltage to ‘Learners’ to ostensively try to improve memory tasks. In reality the shocks were fake, and the experiment was to see how far the ‘Teachers’ could be pushed. The disturbing finding of the study was just how compelling the authority figures could be – all of the volunteers delivered what were thought to be very painful shocks and two thirds were willing to go all the way to a dangerous 450V shock when told to do so. These studies have broken through to the popular culture – so much so, in fact, that the “Law & Order: Criminal Intent” rerun on while I was writing this post highlighted Milgram’s experiments as a motivation for the killer. D’Onofrio made that show, but I have to say that I like Jeff Goldblum as well…
The Stanford Prison Experiment (SPE) also delved into this territory, randomizing college student volunteers to be guards or prisoners in a mock prison in the basement of the Psychology Department. This experiment is often cited as an example of the abuse of power, but the reactions of the ‘prisoners’ are as interesting as the role-play of the ‘guards’. Despite being student volunteers paid for the study, the participants internalized their roles. The guards became brutal and on just the second day the prisoners revolted.
One of the main findings of these studies was an understanding of what led people in power to abuse that power. Arendt’s book about the trial of Adolph Eichmann, published in 1963, introduced the idea of the banality of evil. She had been struck by the fact that Eichmann did not come off as a monster during his trial, but as an almost disinterested bureaucrat. Later writings of Milgram from 1974, largely influenced by Arendt, attributed the actions of the ‘Teachers’ in his studies not to any prior sadistic tendencies or motivations, but to the subjects taking on the role assigned to them in the studies. He described this as an ‘agentic state‘, where
the essence of obedience consists in the fact that a person comes to view themselves as the instrument for carrying out another person’s wishes, and they therefore no longer see themselves as responsible for their actions
Zimbardo’s conclusions from the SPE also supported this idea. He thought that the guards’ brutality derived from the role that they were put in, not from personal characteristics of the volunteers. He argues that almost anyone, given the right situational influences, can be made to abandon moral scruples and cooperate in violence and oppression, a problem he termed the Lucifer effect.
The findings of Milgram and Zimbardo dominated social theory for decades, although they were not universally accepted. Some critics have felt that these theories excuse horrific war crimes by the Nazis, and also the abuses at Abu Ghraib, particularly by lower level officers and enlisted men because they could claim that they were “only following orders”.
In fact, detailed examination of both Milgram’s experiments and the SPE do not entirely support their own conclusions. Milgram found substantial resistance by some subjects in his studies to carrying out shocks, and he did not publish his results until he had gone through many revisions of the experiment. The events divulged showed that while some ‘teachers’ resisted strongly and refused to carry out more severe shocks, other participants seemed to enjoy subjecting the ‘learners’ to pain, carrying out the shocks with zeal and even joking about the process. Milgram himself admitted that his study was as “as much art as science.”
The SPE had similar aspects which seemed to contradict the ultimate conclusions. Some of the guards were much easier on the prisoners than others, while the most sadistic guard, nicknamed ‘John Wayne’, seemed to take great pleasure in coming up with creative ways to punish the prisoners.
These reexaminations as well as more recent works in social identity theory have begun to challenge the idea that people will passively conform to authority. Current theories identify an in-group, or “tribe”, that people associate with, and instead of passive obedience, what is observed is an engaged followership. The authors of the BBC Prison Study (BPS) say:
people’s willingness to accede to the requests of others is predicated upon social identification with them, and an associated sense that they are legitimate representatives (emphasis mine) of shared group goals, values, and aspirations.
A main idea that has emerged from the BPS is that individuals need to come to identify with their group and its leadership before acting in a tyrannical way. Haslam and Reicher say that in order to carry out evil acts, people need to be able to justify their actions as ‘good’ in some way, a process that is easy for some people – those who may have more antisocial or sadistic tendencies – but more difficult for others. Peoples’ own identities converge with their group identity.
This new theory also better explains the fact that while some Nazi concentration camp guards took to their tasks eagerly and energetically, others were hesitant and only acted under direct orders. They had actually convinced themselves that they were acting for ‘the greater good’. This has been noted not only in holocaust memoirs by prisoners such as Frankl, but also in the Nazi’s own notes, where they categorized guards as cooperative or difficult.
So now we have discussed social identity theory and what drives people in power to tyrannical acts as well as what drives those under them to obey or resist authority. Besides being of general interest, what does this have to do with anything – specifically, why are we talking about this here?
The analogies to the Maintenance of Certification (MOC) system should be clear. First of all, this program has been put into place through long and convoluted arguments that MOC is ‘good’ for physicians. Despite the assertions of the American Board of Medical Specialties (ABMS) and the American Board of Internal Medicine (ABIM), for whom this program represents a major conflict of interest, there has been no general outcry by patients for this program, and despite some political posturing there has been no real proposal for Congress to put such a system in place. There is also no proof that this program serves any purpose for the benefit of patients, while the evidence of the harm of this time- consuming, expensive, and demoralizing system is clear. In fact, the only ‘benefit’ of the system seems to be the great financial benefit to the non-practicing physicians and bureaucrats who run the system – this is cronyism at it’s worst.
We can therefore say that this system is not ‘good’ for patients or physicians, but represents an ‘evil’. Only through self-serving justifications have our ‘leaders’ deluded themselves that this cronyism is for the ‘greater good’, and convinced us that it is a necessary evil.
So, if this system is so obviously bad and corrupt, why have doctors accepted this program and are only now starting to object to it?
Like the frog in the warming water we have only now realized that it is getting hot and we are trying to get out. Unfortunately, the bureaucrats have devised a pot so tall, steep, and slippery that we are finding it difficult to escape. For years we have obeyed authority, partially because this is the role that we have been placed in, partially because this is how we have been trained to act through years of having to follow authority without question, and partially because we have accepted our physician leaders as part of our in-group, acting in the group’s self-interest.
It is only recently that we are recognizing that our ‘leaders’ are no longer part of our in-group, but represent their own new group of non-practicing robber barons. Practicing physicians do not get high six figure salaries, reimbursement for spousal travel, and chauffeur driven limousines for little or no work. Practicing physicians do not get to commit tax fraud with impunity. Practicing physicians do not get to lose millions of dollars, and then demand money from their colleagues to cover up their incompetence.
So now we see that the ABMS and the ABIM are no longer our legitimate representatives. It is time for all physicians to refuse to participate in MOC. We must lobby our legislatures to pass bills such as in Oklahoma, giving us the right to work free from the MOC tyranny. For all of those who argue that we have no choice because the hospitals and insurance companies require it, we must stand collectively. We have more power than you might think – the medical system in this country cannot operate without us. There is no need to succumb to weakness and ignorance. Support the NBPAS, and do not send another cent to the ABIM, or any of the other ABMS bureaucracies.
For those of you close to recertification you may have to give in to keep your job, because the system has a lot of momentum, and many hospitals and insurance companies have not yet seen the light. But for all of you who are years away – please, please do not send any more money to these corrupt organizations. The only way to kill this monster is to starve it of its food – no more money.