In April 2022, a junior doctor working in Penang Hospital fell to his death from his residence. In response, the police have classified it as “sudden death”, the Ministry of Health (MoH) has convened a Healthcare Work Culture Improvement Task Force (HWCITF) and various doctor groups have expressed their concerns about a “bullying culture” at MoH hospitals and clinics.
Needless to say, workplace bullying at MoH hospitals is unacceptable. Bullying harms individuals and indirectly threatens public health as it may lead doctors, nurses and other healthcare professionals to leave MoH. The working conditions are already challenging, with low salaries, high workloads, large amounts of soul-crushing paperwork, precarious contracts and few opportunities for career advancement. A work environment that is hostile, toxic or bullying may be the last straw that sees health professionals leaving MoH.
Bullying is a serious issue with impact on individuals and our health system. In this article, we look at bullying through the lens of public policy. We will examine what constitutes bullying, why bullying happens at MoH hospitals and what we can do to resolve this issue. It is crucial that the ministry creates a safe and nurturing working environment in hospitals, to lead other ministries and private companies by example.
What is bullying?
According to the American Psychological Association, bullying is “a form of aggressive behaviour in which someone intentionally and repeatedly causes another person injury or discomfort”. There is usually a real or perceived power imbalance in bullying, with power usually manifesting in physical (“I’m bigger than you”) or authority (“I’m your boss”) terms.
Bullying can take place among those as young as nursery-age children or as old as senior citizens in nursing homes. Evidently, bullying also exists in professional settings such as among doctors working in critical public hospitals in Malaysia. Bullying can be categorised into various forms, including verbal (like teasing or name-calling), social (like embarrassing someone in public) or physical (like hitting or punching). In the modern world, cyber-bullying (like trolls on social media) can be a distinct fourth category.
There are countless ways of bullying, and they cannot be fully listed here. However, for the purposes of this column, it would be helpful to identify three categories of workplace bullying that are completely unacceptable. One, all illegal acts like sexual harassment, unwanted advances or bodily harm must be firmly prosecuted in the justice system. Two, all unprofessional acts that break the Malaysian Medical Council’s Code of Professional Conduct must be firmly addressed by the MMC. And three, all unethical acts that break the Malaysian public service Code of Conduct, General Orders and human resources (HR) policies must be firmly addressed by relevant leaders and departments. These illegal, unprofessional or unethical acts are completely unacceptable and cannot be condoned.
But after leaving aside these obviously illegal, unprofessional or unethical bullying acts, what else constitutes bullying? Is the “tough love” dispensed by a senior doctor considered bullying, if it is intended to improve patient safety and is well received by a junior doctor? What if it is the exact same tough love dispensed to a group of 10 junior doctors, and is actively welcomed by two, passively tolerated by six, but considered hostile bullying by the last two?
This is not to condone or encourage “tough love” as the best way to educate, inspire and motivate junior doctors, but to illustrate the grey areas that laws, regulations and professional codes simply cannot be exhaustive enough to cover.
Why does it happen?
There are multiple reasons for workplace bullying in MoH hospitals, and no “single reason to bully”. Different bullies use different justifications for different acts when bullying different people at different times and in different situations in MoH hospitals, but there are three common themes.
One, bullies have a complex psychology. For example, they are likely to be insecure and unable to manage work pressure or their emotions. Two, bullies use the system to enable their acts. For example, senior doctors may weaponise the Sasaran Kerja Tahunan (Annual Work Targets) performance assessment against junior doctors. And three, bullies use a moral cover for their acts. For example, harsh words are justified with claims of wanting to improve the junior doctor’s performance or a desire for patient safety.
Each of these themes have deeper causes that are worth examining. Let’s start with the complex psychology. Medicine is similar to other professions with its fair share of people who are unable to manage work pressure, their emotions or their interpersonal relationships. The legal profession has its fair share of allegations of uncomfortable workplaces or outright bullying, and so does accounting, banking, start-ups and so on.
But medicine is different from other sectors. It is a high-pressure profession, with life-and-death decisions taking a psychological and emotional toll on doctors and nurses. The selection process of medical students skews towards those with high IQ, not high EQ and social skills, even adjusting for the fact that EQ and social skills are impossible to measure in objective ways. And the training and education process for medicine is notoriously left-brained, even if medical school curricula have included “communication skills” in recent years.
Additionally, the current system allows ample formal opportunities for bullying. For example, senior doctors decide on small matters like the on-call roster for who works on weekends, decide on mid-sized matters like who gets extended for each posting (with each extension being considered a black mark), and influence large matters like who gets a permanent post and who should stay as a contract doctor. This does not include the hundreds of informal daily interactions of routine ward work and patient interactions.
Seniority is important in the Malaysian public service. A person is conferred a senior role simply by reporting for duty just one working day earlier than another person. This seniority carries forward for as long as the person remains in service. The outsized importance of seniority amplifies the already significant power of formal decisions and informal interactions that belong to senior doctors.
Finally, senior doctors who bully may often hide it under a moral cover. Medicine has many moral covers readily available, but there are three very common ones: patient safety, quality of training and quality of healthcare. Bullies can invoke patient safety or the need for urgent action to “save lives” when scolding a junior doctor for being slow. Bullies may also invoke the infamous “back when I was a junior doctor” line when justifying that they had it worse than the Gen X, Gen Y or Gen Z. And if all else fails, bullies may invoke “I’m just doing my job to preserve high standards” as a way to explain their actions.
What can we do to resolve this issue?
As the causes of bullying in MoH hospitals are multifactorial, the solutions must be multifactorial too. We can divide the solutions according to the three broad categories of improving leadership skills, power dynamics check-and-balance, and building new systems and skills to achieve the original intentions of training junior doctors and improving patient care.
First, all doctors must receive additional training to teach them how to manage workplace pressure and also their own emotions and psychology. In this way, MoH (in particular) and the civil service (in general) must take a leaf from large companies, with their own learning and development philosophies, frameworks and tools. This lifelong learning must start in medical school and continue through continuous professional development (CPD) for the rest of their careers.
There could be new criteria for emotional intelligence (EQ) and social skills to select who goes to medical school, to specialist training and becomes a department head or administrator. The performance criteria for specialists and department heads are already quite comprehensive and probably do not need more criteria, so the emphasis should be on consistent and disciplined enforcement.
Second, the power dynamics within MoH should have a check-and-balance element. The practice of medicine and public healthcare must have a hierarchy, because a completely flat structure may not be suitable for training young doctors and ensuring patient safety. In other words, senior doctors should retain some power and the ability to exercise judgement and discretion over junior doctors.
But this power should be checked and balanced, and not absolute. Two principles come to mind. One, the private sector does 360° performance reviews, where feedback is obtained from everyone, including a person’s direct reports and subordinates. Two, major decisions (like extensions and permanent posts) should have an independent, speedy and transparent appeals process. Utilising both principles (360° reviews and a robust appeals process) may check and balance the power of senior doctors.
Third, we must provide the systems, incentives, tools and training for senior doctors to achieve their three stated moral intentions, but in constructive and healthy ways. Patient safety, quality of training and quality of healthcare are all important, and must never be compromised. Junior doctors are there to learn to be senior doctors, and not to be mollycoddled or treated like precious objects.
But there are better ways to inspire, motivate and encourage junior doctors, by providing them with a working and learning environment that is healthy and constructive. “Tender love” must be accompanied by “tough love”, with judicious use of appropriate disciplinary action and remediation that is fact-based, proportionate, well-intentioned and with second chances built into the system.
The MoH probably doesn’t need another set of anti-bullying guidelines because there are already many. Instead, what is needed is consistent and disciplined enforcement of existing guidelines, while building the EQ skills of senior doctors, ensuring power dynamics check-and-balance, and building a system that encourages high-performing teams.
Dr Khor Swee Kheng is a medical doctor who specialises in health policies and global health