The Pecking Order

Social Dominance Orientation (SDO) is a socio-political theory first proposed by Jim Sidanius and Felicia Pratto as a component of their Social Dominance Theory (SDT)

SDO is a measurable personality trait which predicts social and political attitudes and correlates an individual's preference for hierarchy within any social system and the domination over lower-status groups. Put another way; it is a predisposition toward anti-egalitarianism within and between groups.

Closely related to SDO is System Justification Theory (SJT), which is a theory that proposes that a group’s underlying needs can be satisfied by the defense and justification of the status quo, although the system may be disadvantages to other groups with less power.

Dr. Dan Martin and his colleagues at the Stanford Center for Compassion, Altruism Research and Education published a recent paper about the relationship between SDO, SJT, and compassion among business students.* The article discusses their findings that demonstrate a statistically significant inverse correlation between SDO and compassion. In other words, the more one believes in domination over lower-status groups, the less compassionate one is.

Before reading the paper, I had never heard about social dominance orientation. However, I could quickly see its relevance to the healthcare industry. It is straightforward to see that there is an acknowledged social pecking order within the Healthcare system, organized by degree or specialty. For instance: MD above RN (which is the nursing degree). Alternatively, between specialties (surgery above primary care) or even within specialties: cardiothoracic surgeons above general surgeons.

For those practitioners who embrace the social hierarchy in healthcare, I think the question arises: do they have less compassion? I think from a stereotypical standpoint that might make sense. I can imagine the prima donna “old-school” physician, who cares little for the feelings or emotions of their coworkers, and also feels little for the patient regarding compassion or their suffering, and views each patient as a project or a disease to be defeated and not a person. Often this portrayal is used in modern TV and movies. A good example is the 1991 movie "The Doctor" starring William Hurt. In this film, the main character is an arrogant, wealthy, and self-centered surgeon who suddenly learns to deal with his battle with cancer, and becomes more humanized and compassionate towards his patients as a result.

In my work with simulation, we view most medical errors as caused by lack of sufficient Teamwork. To have good Teamwork, one needs to have a flattened hierarchy. Proof of this comes from some of the research done with commercial flight crews, in which pilots used to have a palpable social hierarchy. This culture led to numerous problems in the cockpit, most notably the 1977 crash at Tenerife in the Canary Islands involving a KLM jumbo jet. The aircraft crew misinterpreted the instructions from the control tower, and while attempting take-off, plowed into another stationary plane standing on the runway. In that particular situation, the Captain of the aircraft considered himself to be infallible. The junior officers knew that there was an issue, but were reluctant to communicate that to the Captain out of fear of reprisal or criticism. As a result, they withheld relevant information. This factor was one of several that eventually led to the collision and the deaths of almost 600 passengers.

As insurance companies are looking towards reimbursement based on patient experience, there is a higher premium placed on compassion and physicians these days. Perhaps in the past, the public would have tolerated a doctor who cares only for the procedure and the outcomes in that for the patient's emotional needs, but in modern-day, this sort of attitude does not really fly anymore. Nobody these days wants to be treated by a physician who lacks compassion or empathy. Furthermore, when complications occur, it is well-documented that patients who feel their doctors do not care about them are more likely to seek legal action if there is an adverse outcome.

I think it would be fascinating to apply the metrics of SDO to the Healthcare setting and investigate thoughts and beliefs regarding hierarchy and social dominance. One might seek to look for a correlation between patient satisfaction scores (tied to empathy), which are kept track of, and SDO metrics.

*Martin, Daniel, et al. "Multiple facets of compassion: The impact of social dominance orientation and economic systems justification." Journal of Business Ethics 129.1 (2015): 237-249.

© Edwin T. Ozawa 2017