The transfer patient from an outside hospital rolls in with a hemoglobin of nine and a fresh unit of packed red blood cells infusing. The response is immediate, though largely unspoken. A few glances are exchanged. Perhaps an eyebrow is raised. There is no need for commentary; the message is understood. “They do not know what they are doing over there.”
But how do we know we are right?
Most physicians would point to the TRICC and TRISS trials as justification for restrictive transfusion thresholds. If pressed, they might mention mortality curves or oxygen delivery metrics. But in truth, very few of us have read these trials closely, and even fewer have explored the broader body of literature with the rigor one might expect for such a widely accepted practice. We transfuse at seven because that is what we were taught, and because it was presented to us as the hallmark of good medicine. The guideline was not merely recommended; it was modeled, rewarded, and internalized. Over time, it ceased to be a topic of discussion and became instead a matter of professional identity. One transfuses at seven because that is what good doctors do.
This is how medical culture operates. It is not dispassionately academic, nor is it wholly scientific. It is social. It is behavioral. For better or worse, it is tribal.
The Culture of Conformity
Medical training is intellectually rigorous, but it is also socially immersive. From the earliest stages of a physician’s education, there are both spoken and unspoken expectations, not only about what one must know, but about how one ought to think. The culture begins to take shape in medical school but is most fully formed during residency. There, under the constant supervision of attendings and senior residents, one quickly learns that being correct is not sufficient. One must also be seen to be correct by those in positions of authority.
The day-to-day work of residency involves long hours and constant exposure to judgment. Decisions are reviewed in real time. Handoffs are dissected. Clinical plans are challenged. It is not surprising, then, that residents gravitate toward safety, and not merely clinical safety, but social safety. The surest way to earn praise and avoid criticism is to adopt the prevailing practices of one’s environment. Over time, these practices become normalized, and then internalized, regardless of whether they are independently understood.
Conformity, in such an environment, is not the result of intellectual laziness. It is a coping mechanism.
The Academic Monoculture
Within academic medicine, a particular vision of correctness has emerged, one that cloaks itself in scientific rigor but is often shaped as much by institutional consensus as by empirical evidence. Leading institutions establish clinical standards, publish guidelines, and disseminate best practices. These are undoubtedly informed by research, but their acceptance is often mediated through reputation and authority.
Once these standards are adopted, they acquire the weight of moral authority. To object to them is not simply to express skepticism. It is to position oneself outside the bounds of what is considered professionally sound. In many cases, the result is not a scholarly rebuttal but a form of professional distancing. The physician who questions a widely accepted practice is viewed with suspicion, not because their argument lacks merit, but because their dissent is itself a kind of deviance.
In this way, academic consensus becomes self-reinforcing. Beliefs are elevated not only by data, but by social cohesion. Dissent is minimized not by superior reasoning, but by subtle forms of exclusion.
The Mechanics of Social Enforcement
This process is enacted daily in hospitals and residency programs across the country. The primary mechanism is informal judgment. Physicians frequently speak of colleagues, trainees, and outside providers with an evaluative tone. The object of discussion is often a clinical misstep, a judgment call that differed from the local norm, or a perceived failure to meet expectations.
These judgments are rarely delivered with cruelty. More often, they are cast as wry observations or quiet criticisms. “I cannot believe they ordered that test.” “He started antibiotics for that?” “She transfused at nine?” The point is not simply to note the deviation. It is to reaffirm the speaker’s own alignment with the standard. These conversations serve a dual function: they reinforce communal norms while offering psychological reassurance to the speaker.
This is not limited to students and residents. Attendings, fellows, and academicians all participate. The culture of evaluation extends indefinitely upward. Social enforcement persists even when formal evaluation has ended.
Patterns of Groupthink
This dynamic becomes particularly dangerous when it intersects with large-scale public health controversies. Consider the use of hormone replacement therapy. Despite mounting evidence supporting the careful use of estrogen in postmenopausal women and testosterone in men with clinically significant deficiencies, many academic institutions continue to treat these interventions with suspicion. The reason is not evidentiary but cultural. Hormone therapy has become associated with non-academic “wellness” medicine, and by extension, with a perceived lack of rigor. Testosterone and HRT are peddled by telemedicine hacks, wellness gurus, and Joe Rogan guests, not good doctors. That stigma is remarkably difficult to dislodge, regardless of how the evidence evolves.
The response to COVID-19 illustrated this phenomenon even more clearly. Remdesivir, a medication with limited and uncertain clinical benefit, was rapidly adopted as standard of care. Meanwhile, repurposed older medications, most notably hydroxychloroquine and ivermectin, but also azithromycin, zinc, quercetin, and others, were subject to widespread condemnation. The criticisms may have been justified, but the intensity of the response often exceeded what the evidence warranted. These drugs were not simply questioned; they were ridiculed, and the physicians who advocated for their study or use were ostracized. In many cases, studies appeared to be designed not to explore clinical utility, but to discredit the possibility that these medications could be beneficial.
I am personally skeptical as to whether drugs like chloroquine or ivermectin have any actual benefit in the treatment of COVID-19, but both drugs are widely used, well studied, and clearly quite safe. That is what makes the intensity of the backlash so striking. The CloroCovid-19 trial, an early and widely cited study, effectively sealed the fate of chloroquine as a potential COVID-19 therapy by associating its use with significant cardiac toxicity including fatal arrhythmias.1 However, that study administered doses that were fifteen times greater than those typically prescribed for rheumatoid arthritis, and approximately forty times greater than the standard dosing for malaria prophylaxis, the drug’s most common indication. It is difficult to avoid the conclusion that such a design was intended to produce harm. Whether or not chloroquine was ever a viable treatment option, the effort to discredit it appears to have been driven by more than dispassionate scientific inquiry.
The rollout of COVID-19 vaccines followed a similar trajectory. Initial data supported their use in high-risk populations, and widespread adoption was appropriate. However, as newer data suggested increased adverse effects such as myocarditis and limited protective utility in younger, lower-risk groups, the discourse around vaccination grew more rigid. Rather than welcoming debate, the establishment closed ranks. To question the evolving cost-benefit profile of universal vaccination was to risk professional censure, regardless of the data one might present.
The Physician’s Interior World
I do not offer this criticism from a place of detachment. I speak from experience. Medicine has been the central focus of my adult life. From undergraduate studies to medical school and then residency, I followed a path that demanded complete immersion. Residency, in particular, is a world unto itself. One’s friends are fellow residents. One’s entire social existence is shaped by the hospital. Conversations do not stray far from the wards. There is no separation between professional and personal identity.
Within that environment, the dominant mode of discourse is evaluative. Residents speak constantly about one another, especially when the subject is not in the room. They recount missed diagnoses, procedural complications, and poor decisions. The commentary is rarely generous. Judgment is the common currency. It is not uncommon, even years later, for these conversations to resume at weddings, reunions, or social events. The old group reforms, and the stories continue. “Did you hear so-and-so got sued?” “That guy works for a telemedicine company now.” “She had a terrible complication.” “He lost his license.” “Can you believe this guy is now peddling hair loss pills?” These anecdotes are presented as cautionary tales, but also as affirmations of group identity. The commentary is constant, judgmental, and deeply rooted in the belief that what matters most in our professional world is not clinical excellence as an abstract virtue, but the avoidance of embarrassment or deviation from what our culture deems acceptable.
This culture arises, in part, from the structure of medical training. From the earliest stages, doctors are conditioned to strive for perfection. We must build flawless résumés, avoid red flags, impress mentors, and conform to institutional expectations. Admission to medical school requires not only academic performance but deference, polish, and strategic presentation. Once inside the system, advancement depends entirely on how others perceive you. This dependence on reputation creates an intense sensitivity to the opinions of other physicians. The fear of professional judgment is cultivated long before one ever steps into the clinical world.
The insecurity is magnified in internship, where no one, regardless of intelligence or preparation, feels truly competent. Intern year is a baptism by fire, and the resulting vulnerability is rarely acknowledged aloud. In the absence of confidence, many cope by finding fault in others. We criticize, we gossip, we elevate ourselves by pointing to the perceived shortcomings of our peers. Insecurity breeds harsh judgment, and since the hospital is our entire world, there is no outside perspective to moderate these instincts. We have no connection to popular culture, no hobbies, no time. We inhabit a closed system in which the only available form of status is reputation within the tribe.
The way we learn medicine reinforces these patterns. Medical school is largely didactic, but residency is immersive. While medical school provides a scientific foundation, the actual craft of doctoring is learned through cultural transmission. We do what our senior residents did. We emulate our attendings. We perform procedures the way we were shown. We make decisions the way we were told is correct. Over time, these patterns of behavior are internalized, not through deliberation or independent review of the literature, but through immersion and repetition. The result is that we come to believe in certain practices not because we have analyzed the evidence ourselves, but because they were reinforced by the people we respected and needed to impress.
This dynamic shapes not only what we do but who we believe we are. Our identities become bound to a set of practices and assumptions we did not create but inherited. We build our sense of professional worth around conformity to these norms. To question them is not only to risk being wrong. It is to risk no longer belonging.
For doctors, few things are more painful than professional exile. We are, almost to a person, deeply invested in the esteem of our peers. We may believe we are independent thinkers, but the structure of our training and the culture make independence difficult to sustain. We are conditioned to fear being perceived as outliers, even when our reasoning is sound.
It is not easy to come to terms with this. It requires us to examine not only how we practice, but how we think, and how we learned to think. It calls for a quiet reconsideration of the sources of our certainty, and an acknowledgment that some of what we hold as clinical truth may reflect cultural inheritance more than deliberate judgment. While we strive to be guided by evidence, we are also influenced, often subtly or even unconsciously, by a natural desire for belonging, for affirmation, for the comfort of knowing we remain in step with those we respect. Perhaps the most difficult kind of intellectual honesty lies in recognizing how little of what we believe was ever fully our own.
Borba MGS, Val FFA, Sampaio VS, et al. Effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: a randomized clinical trial. JAMA Netw Open. 2020;3(4):e208857. doi:10.1001/jamanetworkopen.2020.8857. Available from: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2765499