The report on bullying of junior doctors in July 2018 embarrassed at best, and at worst, shamed the medical profession.

In a study of 535 doctors, 79.63% experienced bullying that was severe enough to cause symptoms in 71% of respondents. Of those bullied, 16.9% felt suicidal at some point.

Work place harassment, which is much more serious, was experienced by 44.6% of respondents.

Another study of 426 respondents in Sarawak hospitals, comprising 45.5% nurses, 37.8% doctors, and 16.7% medical assistants and midwives, reported that 20.7% of respondents had been bullied. Twenty-two point five percent had depression and 8.5%, low self-esteem.

The factors associated with bullying were “younger age group, shorter length of service, shifting work, non-managerial position and designation as a doctor”. (Source: Med J Malaysia Vol 72 Supplement, Aug 1, 2017)

Bullying occur in healthcare organisations globally. In an analysis of 24 countries, prevalence rates of 11-18% were reported.

Defining bullying

There are various terms used, often indiscriminately, but they are different.

Bullying has to be distinguished from admonishments when there are mistakes or errors in healthcare delivery that affect patient safety and quality of care.

The World Medical Association states: “Bullying is behaviour that is repeated over time or occurs as part of a pattern of behaviour, rather than a single episode.

“Unreasonable behaviour is what a reasonable person in the same circumstances would see as unreasonable.

“It includes behaviour that intimidates, offends, victimises, threatens, degrades, insults or humiliates. Bullying can take psychological, social and physical forms. It is not the perpetrator’s intention, but the victim’s perception, that is key to determining whether bullying has occurred.

“Harassment is unwanted, unwelcome or uninvited behaviour that makes a person feel humiliated, intimidated or offended.

“Harassment can be related to a person’s ethnicity, gender, sexual orientation, disability or other factors such as whether a person has made a complaint.”

Bullying may be by an individual against an individual or groups of individuals.

It may be obvious or insidious. and takes one or more of these forms: verbal abuse; threatening, intimidating or humiliating behaviours (including non-verbal); and work interference, which prevents work from getting done (Workplace Bullying Institute).

The recognised categories of workplace violence are threat to professional status (public humiliation); threat to personal standing (name-calling, insults, teasing); isolation (withholding information); overwork (impossible deadlines) and destabilisation (failing to give credit where credit is due). (A summary review of literature relating to workplace bullying. Journal of Community & Applied Social Psychology, 1997;7:181-191)

Consequences of bullying

The links between bullying, patient safety and quality of care are universally recognised. Effective teamwork and communication, and a collaborative work environment are critical to quality healthcare.

Bullying is associated with disruptive and corrosive behaviours that inevitably lead to a dysfunctional work environment, medical errors and preventable adverse outcomes with patients suffering ultimately.

According to the Royal College of Surgeons of Edinburgh, healthcare professionals have attributed disruptive behaviour in the perioperative area alone to 67% of adverse events, 71% of medical errors and 27% of perioperative deaths.

The effect of bullying on a healthcare facility include lower morale and productivity, increased absenteeism, rapid and increased staff turnover, which compromises patient safety, and a negative impact on the facility’s reputation.

It also exposes the facility to litigation by its staff and actions in negligence by patients.

The estimated annual cost of bullying to organisations in the United Kingdom was £13.75bil (RM71.86bil). No local data are available.

Action needed

Employers have a legal duty to ensure the health, safety and welfare of their employees. The underlying principle has to be zero tolerance for bullying.

The Health Minister is to be lauded for taking the initiative to address this serious problem.

As there is limited local data, it is worthwhile considering the experiences of others.

According to Clare Marx, past president of the Royal College of Surgeons of England, the bullying culture in the UK National Health Service starts at the top.

She said: “I think attitudes and behaviours in healthcare come from the top. We all hear about bullying cultures. I’m ashamed to say that I don’t know a chief executive who isn’t bullied from the top, and I think that is passed down.”

Is the local situation different, and if so, how different? Unfortunately, the deafening silence leads to negative perceptions.

A compassionate leadership is critical for building a culture of improvement and empowering staff to raise concerns.

The statement by Martin Bromiley, Chair of the Clinical Human Factors Group, is relevant for leaders at all levels.

“Think about this: ‘Am I creating the right conditions for people to speak up to me? Am I reacting to people in a way that tells them I want to hear what they have to say?’ Remember it’s what’s right – not who’s right – that counts.

“By all means be decisive – be a leader, push and challenge those around you – but make sure you listen and acknowledge people, and NEVER frighten or devalue those around you.

“You’ll have already lost the respect of those same people, and your situational awareness will never be complete again.”

That there is a trust deficit between junior doctors, and their seniors and employer, is reflected in the media disclosure of bullying.

Many remember the treatment meted out to a doctor who disclosed the unsatisfactory conditions in the Orang Asli hospital in Gombak. (The doctor was transferred to Kedah.)

An independent, accountable and fair system is required to address bullying of junior doctors, nurses and other healthcare professions. This would be within the remit of a Health Ombudsman as the Health Minister cannot be expected to address the problem all the time.

There are good global practices that have reduced the prevalence of bullying in healthcare organisations.

The interventions could be adapted for local use for the Health Ministry; Malaysian Medical Council and other health professionals’ regulators; healthcare facilities; departments and teams; and individuals, both victims and perpetrators.

It is useful to learn from the UK General Medical Council who, following a review of bullying and undermining in medical education and training in 2014, reported that the key factors contributing to positive workplace behaviour and a supportive training environment were valuing doctors in training; departmental cohesion and leadership; workload and stress for doctors in training and consultants; communication with doctors in training and recognising undermining and bullying; and the need for effective senior leadership.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.