A very paradoxical reality, but such is the dire situation of the healing fraternity in the Ministry of Health (MOH), Malaysia.
The recent doctor’s suicidal act in Penang maybe was totally unrelated to bullying at the hospital, as per the Rashomon Effect, but it surely has opened the Pandora’s box of the toxic work culture that is both chronic and perennial in the MOH.
There is a paucity of data on bullying in the MOH. Probably the first report of workplace bullying among junior doctors in Malaysia was a multicentre, cross sectional study of 1,074 house officers (HOs) in 12 MOH hospitals accredited for HO training. The six-month study from November 2017 till May 2018 showed a high workplace bullying prevalence of 13 per cent.
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 to be 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 7 times less odds 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 affect (behaviour), high degree negative affect, and high degree neuroticism had a 4.4, 13.7 and 3 times higher risks of being bullied compared to 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 MOH, DOBBS (Doctors Only Bulletin Board System) undertook an anonymous survey of their online community of 16,000 doctors in 2018.
Eighty per cent of junior doctors reported they experienced bullying. About 71 per cent experienced symptomatic bullying, with 17 per cent amongst them having suicidal feelings. About 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 cognisance of the seriousness of bullying in the MOH.
If outcome is used as an index of success, termination or simply put, sacking a Head of Department (HOD) of the most toxic working environment in 2018 by the previous Minister of Health, couldn’tbe any better deterrent for would be perpetrators. It raised a red flag to all leaders in the MOH to take the bullying cases very seriously. Obviously neither the rogues in the MOH nor health care leaders took a leaf from the Minister’s anti-bullying playbook.
When we were housemen, medical officers, paediatricians and sub-specialists in many years of service in the MOH, from 1977 to 1997, there was not a major report of bullying or harassment in the nation’s premier health care institution, let alone doctors jumping off the roof top of hospital quarters.
We doctors then enjoyed the firm and no-nonsense leadership of a director general (DG) of Health who walked the talk, apart from a working psyche of a baby boomer generation, much different from the present Gen Y.
Multiple factors contribute to the culture of fear and blame culture that are presently plaguing the MOH. Uppermost in the forensic audit is the failure of health care leaders to develop a work culture which promotes a safe and quality ambience for training and learning, essential to the delivery of quality health care 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 health care 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 Minister of Health, DG, DDGs (deputy director-general), state directors and HODs to be exemplary and promote a just culture in the MOH. All the health care leaders must walk the talk.
The TOR (terms of reference), SOP (standard operating procedures) and the playbook of a just culture in the workplace must be crafted, shared and amplified; and it must be embraced and operationalised by all leaders at all levels of the MOH
The prevalent blame culture must be eliminated. It has been the major source of a toxic MOH working environment apart from causing high numbers of medical errors.
A careful analysis of the available data on MOH bullying is pertinent and they must immediately address the gaps and the need for more contemporary research and data. Within this framework for action, there must be studies on poor morale, HCW fatigue, burnout, and workplace culture in the MOH.
They must establish a full-proof grievance mechanism for all staff to report bullying without fear of identification and further victimisation. There must be a strong support system for counselling bullied staff, especially those with suicidal thoughts.
An operational algorithm of investigating complaints from all levels of staff must be in place and must be undertaken thoroughly without fear or favour.
The MOH must work closely with the Ministry of Human Resources to submit legislations against workplace harassment.
With the Ministry of Higher Education, 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 medical schools.
The MOH 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 that are not up to the mark.
It is all too obvious that the Healthcare Work Culture Improvement Task Force (HWCITF) named by the Minister is not inclusive. This MOH exclusivity mindset was one of the major failures of health care leaders to tame the Delta wave from its onset in October 2020, until the inclusive team of the Greater Klang Valley Special 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 HWCITF – 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 Mohd Nordin and Prof Dr Azizi Haji Omar are paediatricians.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.