From Dr Musa Nordin and Dr Azizi Omar
A paradoxical reality, but such is the dire situation of the healing fraternity in the health ministry.
The recent doctor’s death in Penang may have been totally unrelated to bullying at the hospital, as per the Rashomon effect, but it surely has opened a Pandora’s box of the toxic work culture that is both chronic and perennial in the health ministry.
There is a paucity of data on bullying in the ministry. Probably the first report of workplace bullying among junior doctors in Malaysia was a multi-centre, cross-sectional study of 1,074 house officers (HOs) in 12 government hospitals accredited for HO training.
The six-month study from November 2017 to May 2018 showed a high workplace bullying prevalence of 13%.
Complaints from the HOs included being ordered to do work below their level of competence, being ridiculed, humiliated, shouted at, and being the target of their superior’s anger.
HOs from Eastern European medical schools were 2.8 times more likely of being bullied when compared to local graduates.
HOs in surgical-based rotations were 1.8 times at risk of being bullied versus those in medical-based rotations.
HOs with good proficiency in the English language had seven times fewer chances of being bullied as compared to those with poor English proficiency.
Careful analyses of the sample of 1,074 junior doctors further showed that moderate negative effect (behaviour), high degree negative affect, and high degree neuroticism had a 4.4, 13.7 and three times higher risks of being bullied compared with their counterparts.
Following a report by a junior doctor against a senior doctor and a former minister’s determination to end the toxic work culture in the health ministry, DOBBS (Doctors Only Bulletin Board System) undertook an anonymous survey of their online community of 16,000 doctors in 2018.
The survey showed 80% of junior doctors had experienced bullying, while 71% experienced symptomatic bullying with 17% among them having suicidal feelings. Also, 45% of junior doctors experienced harassment at work.
DOBBS proposed a grievance mechanism for junior doctors to report bullying without fear of being victimised, a support system for counselling bullied doctors, especially those with suicidal thoughts, and to lobby for legislation to outlaw workplace harassment.
These two studies are enough reasons for the healthcare leaders to take cognisant of the seriousness of bullying in the health ministry.
If the outcome is used as an index of success, then the termination or sacking of a head of department (HOD) of the most toxic working environment in 2018 by the previous health minister, couldn’t be any better deterrent for would-be perpetrators and it raised a red flag to all leaders in the health ministry to take bullying cases very seriously.
Obviously, neither the rogues in the health ministry nor the healthcare leaders took a leaf from the former minister’s anti-bullying playbook.
No-nonsense leadership
When we were housemen, medical officers, paediatricians and sub-specialists with many years of service in the health ministry, from 1977-1997, there was not a major report of bullying or harassment in the nation’s premier healthcare institutions, let alone doctors jumping off the roof of hospital quarters.
We doctors then enjoyed the firm and no-nonsense leadership of a health director-general (DG) who walked the talk, apart from a working psyche of a baby boomers generation, much different from the present Gen Y.
There are multiple factors contributing to the culture of fear and blame culture that are presently plaguing the health ministry.
Uppermost in the forensic audit is the failure of the healthcare leaders to develop a work culture which promotes a safe and quality ambience for training and learning which is essential for the delivery of quality healthcare, and which enhances patient safety.
This is the paradigm of a just culture, a contemporary systems thinking, whereby medical errors are to be examined holistically: responsible factors may be related to a faulty organisational culture, systems errors and are not merely attributable to the healthcare worker (HCW).
Targeting solely the HCW involved in the error is prevalent in a blame culture. An individual may be at fault, but frequently the system is also at fault.
Punishing the HCW without transforming the faulty system only perpetuates the problem rather than solving it.
A blame culture creates a climate of fear that results in poor patient safety culture where errors tend to be hidden rather than spoken about openly.
A poor safety culture and the blame culture perpetuate poor performance, which in turn becomes a “justification” for labelling juniors as incompetent and of poor quality. A vicious circle is thus established.
Based on the unprecedented case, we implore those highest in office, the health minister, DG, deputy DGs, state directors and HODs to be exemplary and promote a just culture in the health ministry. All the healthcare leaders must walk the talk.
The terms of reference, standard operating procedures, and the playbook of a just culture in the workplace must be crafted, shared and amplified. It must also be embraced and operationalised by all leaders at all levels of the health ministry.
The prevalent blame culture must be eliminated. It has been the major source of a toxic health ministry working environment apart from causing high numbers of medical errors.
A careful analysis of the available data on health ministry bullying is pertinent and they must immediately address the gaps and the need for more contemporary research and data. And within this framework for action, there must be studies on poor morale, HCW fatigue, burnout and workplace culture in the health ministry.
They must establish a grievance mechanism for all staff to report bullying without fear of being identified and further victimised. There must be a strong support system for counselling bullied staff, especially those with suicidal thoughts.
An operational algorithm for investigating complaints from all levels of staff must be in place and must be undertaken thoroughly without fear or favour.
The health ministry must work closely with the human resources ministry to submit legislation against workplace harassment.
Working with the higher education ministry, they must together ensure that the affective domain of learning is given due emphasis and attention; and any mental health issues are promptly addressed in the medical schools.
The health ministry must give regular feedback to the Malaysian Medical Council (MMC) on the quality of graduates from the many medical schools so as to empower it to credential or act otherwise against medical schools which are not up to the mark.
It is all too obvious that the task force, named by the minister is not inclusive. This exclusivity health ministry mindset was one of the major failures of the healthcare leaders to tame the Delta wave from its onset in October 2020 until the inclusive team of the Greater Klang Valley Task Force took over command and flattened the Covid-19 pandemic trajectory within a short space of time.
The failure to incorporate professional medical organisations and NGOs in the Task Force, but to just listen to them from a distance, instead of sitting them on par at the crisis table, only deals a disservice to the bullying crisis at hand. The legal adage echoes – justice must not only be done but must be seen to be done.
Dr Musa Nordin and Dr Azizi Omar are consultant paediatricians.
The views expressed are those of the writers and do not necessarily reflect those of FMT.