I am writing this letter in response to a previously published piece written by an anonymous doctor currently working with the Ministry of Health (MOH).
The summary of the statement, from what I have gathered, was that bullying does exist within the MOH, but the MOH has come up with a response, so let’s be fair and say that there was some action, and that the junior doctors themselves are problematic, so they need to buck up first.
Universally, everyone agrees that bullying has no place in any workplace. Forgive my sense of grandiosity, but in a noble profession such as ours, if we cannot create a healthy environment, how can we then expect to promote health and wellness? I believe we wouldn’t find anyone who would disagree.
However, I am scratching my head wondering why there is such an opposition to change.
The typical arguments given are usually fourfold:
- “Scolding” is good, not bullying.
- Long work hours are expected, we went through it ourselves.
- The junior doctors themselves can’t cut it – they have mental health problems or they need to have a better mindset.
- There are “good apples” and “bad apples”, so we should not criticise the system for the “bad apples”.
Scolding Vs Teaching
Education is an art form by itself, and doctors have not mastered it. It should be a skill that we continue to master, just as how we focus to improve our techniques on operating on people, or dissecting history and physical examinations to create a complete differential diagnosis.
The author inserted a quote questioning whether it is wrong to scold a doctor for a repeated mistake, despite gentle reminders, or by putting their patients’ lives at risk.
I would say, yes, it is wrong. We are yelling because we get frustrated, we do not know what else we can do. We feel helpless and powerless.
If we are calling for systemic change to improve the quality of house officers, let’s work on improving the ability to calmly teach. If it’s a repeated mistake, then bring up the issue to a disciplinary board.
There is no need to yell, scream, or abuse the person. There is always a reason to abuse — parents start smacking their kid around because they don’t clean their rooms, or a coach starts hitting his players with a bat because they didn’t win a game. Having a reason to yell, scream, or “scold” does not justify the action itself.
If you argue that there are a few house officers that “we just cannot teach”, then I would bring up the author’s argument that let’s not shame all house officers because of the few rotten apples. Let’s focus on building a conducive and fruitful community that prioritises learning and improvement.
Expecting Long Hours
No one thinks being a doctor is easy. It’s a popular notion that even before you become a doctor, medical school is supposed to be one of the most, if not the most, rigorous training in terms of higher education.
I suspect most medical students realise, by watching the news and shows, and listening to friends, that they come into this expecting long hours.
I would like to make a point here that those protections mentioned by the author are usually not followed, with them needing to come in earlier before 7.00am (and this occurs for all levels of medical professionals, including house officers, medical officers, and specialists).
The author then states this is because of their own choice, not the departments, but fails to acknowledge that if they come in at 7.00am, they will be ridiculed and “scolded” by their supervisors for being lazy and given the speech of “back in my day, I come in at 5.00am”.
They would be marked as “a problematic houseman” or “problematic medical officer”, and would be harassed. There is no point in stating that there is some rule or regulation in place if no one practises it; it is in fact then ineffectual or it simply does not exist.
Length of time also does not measure competence. A lot of arguments on social media would discuss how you need to work very long and hard hours to be competent, but I would argue that the lack of competence is because of the lack of guidance and opportunity given.
There exists such a variance in experience given in hospitals that there are no standard expectations for when a house officer completes their training.
Even a medical officer in a specific department might not obtain the opportunity to be hands on for procedures or to treat a certain patient segment, just because the consultant or specialist in a department refuses to take them or is not good at training them.
We are essentially hoping that with “enough time”, they could then have some sort of chance to get some experience, whereas the goal should have been to create a specific system that sets appropriate goals in mind, then guaranteeing that these opportunities are given.
If a house officer is expected to deliver five babies or be first assist for two cesarean sections, let’s schedule them in and not bank on the hope that they somehow either meet a good senior or that they have to come in past their scheduled work hours and beg for the chance at one. How is that considered good training?
If they are not competent even when appropriate chances are given, then extension or additional remediation would make sense, not before.
‘It’s The Junior Doctors Who Can’t Make It’
I struggle with this probably the most, as I myself train juniors and I understand the frustration that comes along with it. As stated in the book The House of God by Samuel Shem, “show me a medical student that only triples my work, and I will kiss his feet”. I think this applies to all trainees.
However, I disagree that this should have any standing in why we should stop bullying. Adding this point to any argument about bullying is essentially advocating for victim blaming. It is the same action as bullies who say it’s the people who are bullied who are at fault, or that people who were raped shouldn’t wear skimpy clothing.
Could better decisions be made? Could they just not come into the medical field? Sure, but that does not change the fact that we should focus on improving our field of medicine and not focus on trying to reduce the chances of people coming into this field.
There are three aspects to mental health: biological, psychological, and social. The psychological (having a strong mindset), whilst important, is far from being the only component. We need to ensure there is good social health as well.
Telling a poor person to just “work more shifts” for more money doesn’t improve their lives, but teaching them, educating them, helping them upskill, and showing them the way works better.
Giving people overwhelming work and then expecting them to finish it within a scheduled amount of time that’s unreasonable is not appropriate. I think in Japan, they call such corporations “black companies”. When they cannot, they get victim-blamed and are told they are not competent.
If the data quoted by the author is true, then a sacking of the 20 per cent might be warranted, but it should not justify the bullying and has no place in an argument about stopping bullying.
I do agree with the author’s suggestions for medical schools to improve their programmes to produce healthier and more wholesome graduates, but that’s neither here nor there when it comes to us tackling bullying.
‘Unfair For The Good Apples’
I quote the author when she or he states: “It is most unfair and unwarranted for the public to go on bashing most of our medical officers and specialists who are not in the bullying category.”
Another quote would be: “The only thing necessary for the triumph of evil is for good men to do nothing.”
Is it unfair if we are upset at a passerby when someone was stabbed, and they did nothing? They are not at fault for the stabbing, but we would hope they would have said or done something.
Sure, their name is smeared, when we say there is rampant bullying, but herein lies the problem — at what stage would it be enough to say that there is a problem? When 90 per cent of the seniors are bullies? Fifty per cent? Or would the author be generous to give me 25 per cent?
If this schema or way of thinking is appropriate, then we should not need to change anything about the house officers, since apparently only 20 per cent are exhibiting atrocious behaviors and attitudes.
There are good seniors. I hope most of us are, but to ignore our colleagues who are bullies and say, “we are good, so please don’t criticise us”, is unfair also.
While I am glad the author spoke up to defend the MOH, I can’t help but wonder about our mentality about the current system. A lot of our colleagues would not speak up or if they do, they reminisce about their past experience as some sort of struggle they have gone through (and so should our juniors), and even fantasise about how well they have done despite the challenge.
I wonder if this is a version of Stockholm syndrome, where we feel we are guilty of not appreciating what we have if we were critical of the current training system. We have spent too much time like this — that this is our culture, and to be critical is to be bad.
Just like victims of kidnapping, they try to understand their captor and try to appreciate the reason they were kidnapped. “It’s a trial by fire”, “It’s for my own good”, “It’s how we become strong specialists”, “You just need a strong mindset”.
I think we can do better. I wish we could improve the system without criticising it publicly, but internally complaining about bullying has not worked. It has now become rampant enough.
Some medical officers were noted to be proud of how well they’ve bullied people to the point their juniors needed to see a psychiatrist.
Enough. Stop. Let’s not justify bullying and claiming that there is legitimate and illegitimate bullying. Bullying is bad. Period.
CodeBlue is publishing this letter anonymously because of the author’s fear of retaliation towards himself or his family members currently in the Ministry of Health.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.