The Halstead/Gervais Principle

Residency is one of the most unique and maddening experiences a person can go through. Picture a massive nationwide cohort of high achievers, top of their class, hard-workers on the verge of starting one of the most lucrative and sustainable careers, forced into a truly bizarre secondary class of apprenticeship and cheap labor within a massively complicated hospital system, making the salary of an entry level software sales associate; and that’s Residency. These are primarily young, bright MD’s and DO’s, entering into a multi-year contract with little to no ability to select their program, change programs should the experience not be ideal, or enact change to the overall structure from within. Your typical resident, had they not chosen to pursue a medical or surgical practice, would likely have already landed a coveted corporate or high-earning job. In fact, there are numerous high profile consulting companies that absolutely love getting their hands on MD’s, often handing out jobs with starting salaries in the $200k+ range. 

But you know this already. We’re not here to simply complain about the archaic structure of residency programs, we’re here to offer a framework for maneuvering within the system. To give you language to describe and digest all that might be happening around you, and to begin to understand the dynamics at play that govern a hospital and the departments that hold so much power over you.

‍The Gervais Principle is a theory of organizations proposed by Venkatesh Rao, modeled after the popular UK and US TV show, The Office. In it, Rao uses various characters and premises from the show to illustrate inherent principles behind business decisions and organizational hierarchy. We’ll start by summarizing The Gervais Principle, then explain how it can be applied to residency and hospital culture at large.

The Gervais Principle suggests that organizations are inherently pathological, creating a culture of “individualistic Darwinism”, or more plainly, a dog-eat-dog rugged capitalism. Within these organizations are 3 levels of employees; Sociopaths, Clueless, and Losers. Rao’s stated principle is as follows:

‍Sociopaths, in their own best interests, knowingly promote over-performing losers into middle-management, groom under-performing losers into sociopaths, and leave the average bare-minimum-effort losers to fend for themselves.

Let’s first expand upon these 3 layers before diving into its application to residency.

‍Sociopaths are the people at the top of the organization. Per Rao,

‍The Sociopath (capitalized) layer comprises the Darwinian/Protestant Ethic will-to-power types who drive an organization to function despite itself.

‍The Clueless are the middle managers, the ‘Company Man’, those that occupy the middle between the leaders and the lower level workers.

‍The Losers are not ‘losers’ in a social sense, they may in fact be the ‘coolest’ or most well liked people in the organization. They are Losers in an economic sense, meaning they have entered into a bad economic deal, giving up high earning potential for a steady paycheck. They have either willingly entered into this agreement or been forced to, due to circumstances financially or culturally. They are the producers, the laborers who actually deliver a service or goods, but are not compensated relative to the value that they produce (sound familiar?). 

How do these 3 layers of individuals relate to each other? The Sociopath exhibits the highest level of freedom, entering and exiting organizations on their own terms, doing whatever necessary to come out on top. They look out for themselves, and often only themselves. The Losers rarely have true loyalty to an organization, but may have loyalty to individuals, especially within the same Loser class. They are typically at the mercy of macro-economic trends and of the organization themselves. The Clueless are often former high achieving Losers, who, unable to maneuver to the top of an organization due to a lack of skills, are destined to a career of intense loyalty to the organization. Organizations will not show the same loyalty to them, but they must hold on until the bitter end in order to sustain themselves. 

Let’s start with the Losers. Losers have 3 options; do the bare minimum, do less than the bare minimum, or over achieve. Each potential decision leads to a different outcome. Losers, as mentioned, have entered into a bad agreement. The logical thing would be to do the bare minimum, as they are being compensated at or near the bare minimum. Going above and beyond for no more compensation, potentially due to a misplaced sense of loyalty to the organization, will land Losers straight in the Clueless class. Doing less than the bare minimum opens up a Loser to one of 2 things; potential promotion into the Sociopath class, or getting fired. If a Loser has the competence to sustain the high pressure situation that comes with doing less than the bare minimum, they may show an awareness of the inherent unfairness of the system, thus landing themselves firmly on the radar of the Sociopaths. This may seem counterintuitive, but essentially if a Loser is wily and confident enough to both assess the situation correctly and refuse to toil in obscurity, they may just have what it takes to vault right past the Clueless and into Sociopath territory. Alternatively, they may just be truly incompetent and find themselves without a job. For ‘Office’ fans, classic Losers are Kevin or Stanley, showing up every day to work but distracting themselves by playing in a band or doing crossword puzzles. 

The Clueless, while incapable of driving forward an organization on their own, play a pivotal role in the hierarchy. They are the buffer between the Sociopaths and the Losers, taking the blame but never receiving the glory. They may have actually been high producing Losers at one point, but were unable to translate that ability into their own economic gain, ultimately taking on a role of middle management. Inherently, the Clueless exhibit worse decision making skills than the Losers, yet are often promoted because of this exact trait. They can be counted on to remain loyal despite being forced to carry out the pathological policies of the Sociopaths and organization as a whole. The most classic example of a Clueless is none other than Michael Scott.

The Sociopath is likely a well-known figure to anyone who has worked in an organization. It is almost impossible to make it to the top of a modern company without being ‘slightly evil.’ A Sociopath may not be quite as ill-meaning as their title would suggest, but rather understands that the correct approach to take in order to maximize their earnings, status and career, is to operate in a high-risk, high-reward manner. This could ultimately lead to actual cruelty and a slew of unethical practices, but is undeniably effective in navigating modern capitalistic society.  

Rao’s full Gervais Principle is an expansive 6-part series, closely examining the relationships between each layer and the potential mobility and exploitation available for each class. We won’t go too much further into detail however, as residency creates a unique situation that ultimately prevents mobility, to a certain extent, within the resident class. So while academic hospitals do operate similarly to any other organization, there is inherently a hierarchy that remains immovable. A nursing supervisor could never become the Chair of Surgery, much like an attending would never be doing the work of an intern. However, a Sociopath nursing supervisor could in fact be promoted to CEO of the hospital one day, and a resident with the right moves could eventually stay at the same hospital and be the Chair of a department later in life. So it’s important to recognize that while certain structures cannot necessarily be changed, there are legitimate ways that people can act in order to better their position.

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So how does this relate to residency? Why should a resident care? If a resident is having a rough time, the classic advice is to ‘keep your head down and wait it out.’ But is that all that a resident can do? Does that advice help when dealing with complicated interpersonal issues either relating to attendings in the department, consulting services, or staff and nurses? Having an understanding of people’s motivations and the way in which they are viewed by an organization at large can help someone at the resident level navigate this complicated world and better position themselves to come out relatively unscathed on the other side.

In the strict sense of the Gervais Principle, residents are Losers. They have entered into a bad economic deal. 3-7 years of low pay with 0 mobility and only the hope that they will graduate and land that high paying job. They are at the mercy of the organization. As previously stated, this leaves 3 options:

1. Do the bare minimum
2. Do less than the bare minimum
3. Over achieve

Residents are being paid the bare minimum, so logically they should do the bare minimum in return. Doing less than the bare minimum, in the care of residency, is in fact much more risky than say, working at Dundler Mifflin. If Jim had done less than the bare minimum and was fired, he could simply find another sales job. If a resident is fired, it will be extremely difficult to find another residency position. However if one’s aspiration is to be the future Chair of Surgery, this likely won’t happen by actually being the best at performing surgery. You would need to start to position yourself in a way that catches the attention of the current Chair of Surgery, or another similarly powerful player, by perhaps diverting some of your time from writing extensive clinic notes or performing administrative tasks to taking on leadership roles or engaging in research in their preferred field. You obviously wouldn’t be promoted right from resident to Chair, but down the line having the trust and recommendation of your former Chair could certainly help in making that ascension.

Most likely though, you are just trying to make it through residency and find a solid job. In this scenario, you will still want to lean towards doing the bare minimum. What would over achieving lead to? The option to stay on and do a chief year? (No offense to those that have done a chief year, but it is objectively one of the worst economic arrangements available). Being ‘the best resident’ does not equate to landing the best attending job. Much like your Step and Board exams, you simply need to pass. Residency itself is a test, and you need to demonstrate that you understand the rules and know how to play the game.

Ultimately, you want to act like Jim Halpert. Jim understands the game. He shows up to work each day and treats it like work. He does just enough to get by. He is neither the best salesman, nor the worst (Dwight is the best, and is firmly and forever in the Loser class). He pretends to take Michael Scott seriously, all while staring incredulously into the camera knowing that Michael yields no actual power. He often lets Michael ‘win’ the little battles and knows who to align himself with. Jim is not loyal to Dunder Mifflin as an organization, but is loyal to certain others in the Loser class, like Pam (being loyal to other residents is obviously not necessary to ‘win the game of residency’, but we’re not here to say you shouldn’t have friends). 

Jim stays out of the office drama and demonstrates to David Wallace (main Sociopath character) that he understands how to handle things. The best example is when David Wallace is trying to learn more about Michael and Jan’s relationship, and he flat out asks Jim what he knows. Jim neither snitches on Michael, nor shies away from the question, but answers vaguely in a winking manner that yes, something weird might be happening. Ultimately Jim turns down the opportunity to move into Corporate, but continues in his sales role, still maintaining freedom to explore his passion and start his own sports agency business.

How can this be translated into residency speak? On the surface, it is critical to stay out of the weeds. Engaging in the day to day drama of the hospital only serves to suck up your already diminishing, precious free time. It also demonstrates to attendings that you don’t have your eye on the prize. You’re wasting time focusing on residency and not training to become a practicing physician. 

This principle can also be applied to senior residents and program directors. In some sense, both of these groups are Clueless. An attending has a problem. Do they seek out the intern and tell them exactly how to fix it? No, they call the senior resident, chew them out and tell them to take care of it. That senior resident may then pass on that vitriol to their junior. It’s easy to harbor hatred for a nasty senior resident, but remember - organizations are pathological. Yes, that senior resident may in fact be a rotten person, but ultimately they are the middle man. They have very little real power in this scenario.

A quick Office aside, later in the show Charles Miner (Idris Elba’s character) appears, and immediately dislikes Jim. At the very end of Charle’s run on the show, he tries to push Jim out in favor of Dwight, but David Wallace insists that Jim remain in place. By laying the groundwork early with the person in real power (David Wallace), Jim is able to escape the punishment of Charles, the middle man. Am I saying you should always go around your senior resident and appeal directly to the department Chair? No, but this is meant to give some context to what is really happening. You are being yelled at by a confused, hurt middle man.

So then how do you actually deal with the senior resident giving you a hard time? Obviously you can’t simply ignore it, and I would refer you to various DBT interpersonal effectiveness skills in order to learn how to deal with these interactions directly, but at the end of the day the senior resident can not fire you. Let them ‘win’ this battle, complete the tasks assigned, but do it on your own terms and in a way that maintains your own self respect and integrity. Find your way to ‘smile into the camera’, accept, and keep your eye on the prize.

‍This is just scratching the surface of the Gervais Principle. I would encourage everyone to read the entire series. But also stay tuned for additional parts of the adapted Halstead/Gervais Principle.