After a Penang Hospital houseman died last April, Health Minister Khairy Jamaluddin made the bold move of setting up an independent task force to review the Ministry of Health’s (MOH) work culture.
His decision was triggered not just by the trainee doctor’s death, but also complaints by staff in the public health service beyond house officers about workplace bullying.
Khairy’s terms of reference for the Healthcare Work Culture Improvement Task Force (HWCITF) headed by former Ministry of Science, Technology and Innovation secretary-general Prof Siti Hamisah Tapsir were clear: to evaluate not just the work culture of health service staff in general, but also house officers specifically.
Yet, HWCITF’s investigation ended up covering all 30 service schemes across the entire MOH workforce – from medical practitioners to drivers – with very little analysis of specific workplace issues faced by junior doctors, including bullying.
Medical practitioners in grades 41 and above only comprised less than a quarter (23 per cent) of the 110,411 respondents in HWCITF’s online poll of MOH staff; merely about one in 10 respondents were housemen or junior medical officers in grades 41 to 44.
HWCITF’s 162-page report – lazily just titled “Report” and lacking an executive summary – contains multiple errors (see pages 23 and 41), including a major discrepancy on the number of respondents reporting being bullied (see pages 43 and 51).
The presentation on women comprising the majority of self-confessed workplace bullies at the management or supervisory level in MOH (page 49) and Perak having the highest number of bullies (page 50) is misleading and devoid of analysis on the prevalence of bullies by gender or state. Three quarters of total survey respondents were women and the highest number of respondents came from Perak.
The n value, which indicates the sample size, is completely absent from all statistical graphics in HWCITF’s report. Some charts also do not have labels of percentages or absolute figures (see pages 49 and 51), besides mismatched graphic labels and legends (see page 41).
Beyond these sloppy mistakes, the fundamental flaw in HWCITF’s report is its failure to confirm whether or not workplace bullying is a real problem faced by junior doctors – the very question that sparked the creation of the task force.
When you fail to identify the problem, you will fail to identify the solution.
After poring through HWCITF’s laborious 162-page report, I still have no idea what MOH’s work culture is like, which should have been easily described in a single sentence.
What’s The Prevalence Of Bullying Among Junior Doctors?
HWCITF’s report states that those who reported experiencing workplace bullying or harassment are housemen or junior medical officers in grades 41 to 44, as well as medical officers and specialists in grades 47 to 56, who work in hospitals and public health clinics.
Yet, no specific figures are provided. We don’t know whether the majority (or all) of respondents who reported workplace bullying are doctors. And we don’t know if bullying prevalence among medical practitioners, particularly housemen or junior medical officers, is high, ie: did most medical practitioners who took part in the survey say they suffered bullying?
Even though only 7 per cent of total respondents report experiencing workplace bullying or harassment, and just 18 per cent see their work culture as negative, these figures dilute the pervasiveness of bullying of junior doctors (if the problem is indeed common in this group).
HWCITF’s report also fails to name specific hospitals with rife workplace bullying. Instead, the task force simply concludes that bullying in MOH is of “different levels” and not occurring in every single public health care facility.
Of course workplace bullying is highly unlikely to take place in all MOH hospitals or clinics, just like how bullying of students doesn’t happen in every single school. But identifying problematic facilities is crucial to target specific interventions, instead of trying to cover everything with limited resources.
What Exactly Is Bullying?
After news of the Penang Hospital house officer’s death broke and horrifying anecdotes of workplace bullying in public hospitals, including sexual harassment, were tweeted by Hartal Doktor Kontrak, many doctors wrote to CodeBlue about bullying, including those who defended MOH and those who said the system perpetuates bullying.
This indicates that bullying is perceived differently by different medical practitioners in MOH.
Yet, HWCITF doesn’t define bullying in its report, including “severe” or “low-level” bullying, or explain how bullying is perceived differently by junior doctors versus senior physicians.
Despite using Speak Up Malaysia’s definitions of nine forms of workplace bullying in its survey, HWCITF’s recommendations do not include using these definitions in MOH. Neither does HWCITF propose a suitable alternative of the definition of bullying or guidance for MOH’s use, despite the presence of human resource experts in the task force.
Instead, HWCITF proposes an overly prescriptive set of acceptable behaviours for clinicians and medical practitioners to get an “accurate set of behaviours”.
Missing Qualitative Data Analysis Despite Receiving 14,000 Pages Of Comments
Since HWCITF held engagement sessions with various medical groups – including the Malaysian Medical Association, Malaysia Medic International, and Hartal Doktor Kontrak – besides speaking to a few hospital directors and officials from MOH’s medical development and human resource divisions, among others, their verbal feedback could have helped to fill the wide gaps in the task force’s poor quantitative analysis.
Yet, despite receiving a whopping 14,000 over pages of comments, suggestions, and views, HWCITF’s report contains only a single page on this tremendous trove of qualitative data that doesn’t even state the main problems cited by respondents.
Instead, page 54 merely lists general themes like “work culture”, “team work”, or “workplace environment” that HWCITF arbitrarily concludes as showing needed renewal of MOH’s work culture.
Feeding the data to a word cloud would easily identify the most common issues.
A rigorous qualitative data analysis – including powerful anecdotes of workplace bullying or excessively long working hours for trainee doctors – could have answered key questions on what causes bullying; the risk factors of bullying; at what stage of a doctor’s career does she or he turn into a bully; what kind of bullying practices are tolerated by the system; gaps in setting job expectations, supervisory feedback, and performance reviews; or if senior doctors feel they are supervising too many people, beyond their ideal number of reports.
Using case studies of best-practice and worst-practice MOH hospitals on workplace bullying would help management and staff understand what a healthy or toxic work culture looks like.
Without any explanation, HWCITF omits the names of individuals that it interviewed – including a former Health deputy director-general, a retired surgeon from Seberang Jaya Hospital, and a mysterious “Chief Consultants from 4” – implying a culture of fear and secrecy in MOH that extends beyond active service.
For a report of this significance, all experts consulted must come on record. If they can’t, then HWCITF should explain their reasons and state if this is precisely the problem in MOH that leads to bullying.
Recommendations Without Data Or Evidence
Due to HWCITF’s failure to properly describe or identify the extent of workplace bullying in MOH, particularly in key jobs like medical practitioners, the resulting recommendations and conclusions from the task force are made without any real basis.
For example, HWCITF states on page 80 that “analysis shows there is solid evidence to prove that elements of bullying exist in MOH”. Yet, a preceding table summarising the current and hoped for work culture doesn’t mention bullying at all, as it merely states needed improvements in general terms, like “equal treatment”, without showing any evidence of unequal treatment of staff.
The task force claims that MOH staff are afraid of reprisals should they report bullying and that staff believe the current complaints mechanism does not sufficiently protect anonymity. However, HWCITF does not provide anecdotal evidence on such concerns or verify if these fears are justified, in that certain complainants had suffered actual consequences from reporting bullying, like unwarranted transfers.
HWCITF also fails to identify the resolution rate of MOH’s complaints mechanism, ie: out of X number of complaints received, how many were successfully resolved within a certain period of time?
Or, for example, MOH received X number of bullying-related complaints in a certain hospital or state, but HWCITF’s survey shows a higher number of bullying cases, which could indicate under-reporting and ineffectiveness of MOH’s complaints channel.
Without data, despite good intentions, HWCITF’s recommendations to improve MOH’s complaints mechanism are essentially baseless and may even be unfair to top management in the ministry who believe that they fairly and thoroughly examine all complaints received.
HWCITF recommends screening medical students and trainee doctors through psychometric tests before entry into medical school, as well as pre-placement interviews and a licensing exam before appointment as a house officer.
Yet, HWCITF does not provide evidence if there is a significant portion of housemen who aren’t actually interested in medicine, or if they are indeed incompetent or perceived to be incompetent by their superiors.
Expecting both MOH and the Ministry of Higher Education (MOHE) to implement these sweeping recommendations, without substantive data, may be a waste of taxpayer-funded resources.
Don’t Change MOH’s Vision, Mission, Core Values
Perhaps the most jarring recommendation by HWCITF is to change MOH’s vision, mission, and core values.
Without any justification whatsoever, the task force simply says that these fundamental principles should be changed to make them “more relevant, effective, and easily understood, and to be in line with current times and to remain relevant for the future”.
What’s wrong with MOH’s core values of compassion, professionalism, and teamwork, or its vision of working together for better health? Being professional means resolving workplace conflicts without bullying.
MOH’s mission to help people achieve their full potential in health and to ensure a high-quality health care system – guided by compassion, respect for personal dignity, and community involvement – sounds very good to me.
Surely these principles are evergreen, irrespective of technological advances (which, by the way, is explicitly mentioned in MOH’s current mission).
HWCITF’s suggestion of a vision for MOH to build an “internationally recognised” health care system is disputable. Just because a particular health care system isn’t “recognised” by other countries doesn’t necessarily mean it’s bad.
The task force’s proposal to revise MOH’s mission to “ensure continuous supply of competent health care professionals to meet the needs of the nation” isn’t even exclusively within MOH’s jurisdiction, since it’s the Finance Ministry that determines MOH’s budget, the Public Service Department that determines postings, and MOHE that determines the quality of medical students.
If there is a problem with how MOH’s vision, mission, and core values are translated on the ground (which HWCITF doesn’t mention), then the solution should be to educate staff on how to better inculcate these in their work, instead of arbitrarily changing decades-old principles without consultation with not just MOH’s workforce, but Malaysians at large.
HWCITF’s proposed mission for MOH of “building a healthy nation and enhancing the wellness of Malaysians” also sounds slightly xenophobic. Khairy recently told the Health Policy Summit 2022 that anybody on Malaysian soil, regardless of immigration status, has the right to health care and that MOH practises a no-wrong-door policy.
How To Save HWCITF’s Report
If HWCITF wants to ensure that its hard work for the past three months doesn’t go to waste, the task force should produce another report that focuses exclusively on medical practitioners, particularly house officers, as per its terms of reference.
All HWCITF needs to do is to extract the minority subset of survey respondents of grades 41 and above. This sample size of nearly 25,000 doctors is large enough for a good analysis.
The additional report should include personal testimonies, case studies, and proper qualitative analysis of the voluminous and, presumably rich, verbatim feedback contained in the 14,000 pages received by HWCITF.
It’s not only Khairy and MOH’s top management that invested time and money in HWCITF to conduct a thorough investigation and to produce a good report with practical solutions to workplace bullying.
Tens of thousands of junior and senior doctors had similar hopes and expectations after spending their precious time completing HWCITF’s extremely long 23-page survey, and speaking and writing to the task force.
Their feedback should not just be kept in a drawer somewhere, unseen by MOH’s workforce, the medical fraternity, or the general public.
Khairy had the courage to go against powerful vested interests in the bureaucracy by seeking to expose and resolve the problem of workplace bullying in the public health care profession.
HWCITF should not leave the minister’s noble endeavour unfulfilled.
Boo Su-Lyn is CodeBlue editor-in-chief. She is a libertarian, or classical liberal, who believes in minimal state intervention in the economy and socio-political issues.