In Malaysia, doctor’s death shines spotlight on long-standing workplace bullying in public health sector

KUALA LUMPUR: When Dr Nurul (not her real name) was a houseman at a government hospital in Selangor a few years ago, being yelled at by some of her superiors in front of patients was the norm.
They told her she had “no brains” and had wasted her money and time studying medicine, recalled Dr Nurul, who is in her 30s.
Faced with such co-workers with a “god complex”, Dr Nurul said she contemplated quitting several times.
“But I knew I couldn’t because that meant they would win. The only thing you could do was to suck it up,” she said, adding that being berated in front of patients occurred daily during some of her postings.   
“I had several friends who were in the same boat and we could speak and cry out to one another about our situation. That helped me get through the difficult times,” the civil servant told CNA on condition of anonymity as she is not authorised to speak to the media.
While bullies form a minority, they cause a lot of damage overall, she added.
A recent suicide by a doctor in Sabah has once again highlighted the problem of workplace bullying in Malaysia’s public healthcare sector, prompting renewed calls to address the long-standing issue. 
On Aug 29, Dr Tay Tien Yaa, 30, who headed the Chemical Pathology Unit at Hospital Lahad Datu, was found dead in her rental home. According to family members, she had started working at the hospital in February and a senior colleague had allegedly “mistreated, oppressed” her.
The police do not suspect foul play, and Health Minister Dzulkefly Ahmad reiterated a zero-tolerance approach to bullying while calling for a thorough probe into Dr Tay’s death.
“All Health Ministry staff deserve a safe and just working environment,” he said in a series of tweets on Sep 16, after a Facebook post two days earlier by Dr Tay’s brother.
“I understand this toxic work culture still persists, so perpetrators just stop it!”
Experts say workplace bullying is a universal problem not confined to healthcare.
Although past studies do not show a higher prevalence of bullying in healthcare than other sectors, the experts believe it may be more pronounced or severe in healthcare due to a high-pressure environment where patients’ lives are at stake. 
Factors such as heavy workloads compounded by manpower issues and the lack of support systems contribute to endemic bullying, they believe.
The number of housemen at the Ministry of Health fell by about half between 2019 and 2023, from 6,134 to 3,271, according to official data reported by news outlet The Star earlier this year.
The lack of cardiothoracic surgeons – 14 in the seven public hospitals where heart surgery is performed in Malaysia – was also highlighted in July, when four graduates of a “parallel pathway” training programme with the Royal College of Surgeons Edinburgh in cardiothoracic surgery applied for a joint judicial review to contest the Malaysian Medical Council’s decision to deny their applications for the National Specialist Register, a database of specialist medical practitioners in the country. 
In the earlier news reports, experts flagged the need to tackle the shortage of doctors and warned of the potential impact on patient care.
Dr Tay’s death occurred about two years after a houseman at the Penang General Hospital reportedly committed suicide after experiencing workplace bullying.     
Back then, the government formed a Healthcare Work Culture Improvement Task Force (HWCITF) to investigate the death of the 25-year-old, as well as claims of a bullying culture prevalent within its health departments.
It listed intimidation, isolation, vilification, misgendering, inflammatory language, harassment, unfair compensation, unfair working hours and unfair workload as types of bullying.    
In its report that was released in August 2022, the taskforce found no strong evidence of workplace bullying in relation to the houseman’s death. But it noted that burnout, bullying and an unhealthy work culture were present in the Health Ministry at different levels, albeit not in all healthcare facilities.
The report also surveyed more than 110,000 workers in the Ministry of Health. About 30 per cent admitted to burnout while 7.5 per cent felt they had been bullied at work.
About a quarter of more than 20,000 respondents at the management or supervisory level admitted to acts of bullying at their workplace.
Of those who admitted to bullying, about 20 per cent said they engaged in “severe” bullying while the others said they were involved in “low”-level bullying. 
The report, which stated that the Ministry of Health had about 250,000 staff, also emphasised a significant shortage of doctors, nurses and other healthcare staff, especially in rural areas, who face excessive workloads leading to stress and burnout.
In a separate survey last year of 728 doctors, the Malaysian Medical Association (MMA) found that 30 to 40 per cent of doctors in the country have experienced some form of bullying.
The survey also found that victims are more likely not to file a complaint out of fear, or are unsure how to go about it. 
In comparison, a 2019 study found almost 40 per cent of Malaysian employees had experienced workplace bullying. 
The study, titled “Workplace bullying and psychological distress of employees across socioeconomic strata: a cross-sectional study”, surveyed more than 5,200 people from 47 organisations in Malaysia and was published in the BMC Public Health journal.
It is said to be the first to report the prevalence of workplace bullying and its association with socioeconomic factors and psychological distress in a large sample of Malaysian employees recruited from multiple organisations. 
The study did not identify the organisations or industries they belonged to, but found those who had been bullied at work to be specifically associated with being female, drawing a higher income, and with greater psychological distress.
Bullying in healthcare may not necessarily be more prevalant than in other sectors, but it may be more severe because of a high-stress operating environment that deals with life-and-death situations, said Dr Andrew Mohanraj, president of the Malaysian Mental Health Association.
He explained that senior doctors may feel stressed because they have to take the flak if things go wrong, and may take it out on the junior doctors.
“One small mistake can be irreversible and result in morbidity or mortality. Under the guise of being cautious, bullying becomes institutionalised and accepted,” he said. 
“This means that in the medical sector, bullying is often justified to prevent errors, leading to a culture where it is tolerated and even expected,” added Dr Andrew, a psychiatrist.
As a result, nurses, junior doctors, and other support staff could find themselves being bullied by their superiors.
“While bullying is a universal problem, specific work environments may be more susceptible due to factors like hierarchical structures, high-pressure settings, and job instability,” he explained.
That said, a senior doctor who has been in the public sector for more than 30 years felt shouting in a stressful situation did not necessarily constitute bullying.
“Sometimes, things are said in the spur of the moment but it isn’t supposed to be personal,” he said. “I believe that not everyone is cut out to be a doctor, even though you can have the highest scores in the exams.”
Mr Manvir Victor, one of the nine members of the HWCITF, agreed the high-stakes healthcare environment could contribute to workplace bullying.
In addition, the “archaic system” in which healthcare workers operate plays a role, he said. For instance, many tasks are still manually done, from note-taking to the process of discharging someone.
“We speak about bullying but the system bullies doctors and healthcare workers as well,” he said.   
“These are the people who are taking care of the healthcare of the nation. It is essential that their wellbeing is taken care of in the first place,” he added.  
In the wake of Dr Tay’s death, Hartal Doktor Kontrak – an informal group that represents doctors in the country – has called for immediate reforms including a transparent, independent and accessible reporting system for all healthcare workers.
 
“There must be concrete steps to enforce anti-bullying policies and hold those responsible for workplace harassment accountable, regardless of their position within the hierarchy,” it said in a press statement on Sep 16. 
It also said there must be a stronger focus on the mental health of workers. Support services should be made available to all healthcare professionals, particularly those in high-stress or remote environments, it said.
“Dr Tay’s death serves as a painful reminder of the urgent need for reforms to address chronic understaffing and overburdening, which exacerbate stress and mental health concerns,” it said.
All sectors should put in place stricter, zero-tolerance policies on workplace bullying, said Dr Andrew.
Punishment should be enforced to drive home the point that consequences can be severe, and to make everyone responsible for creating a safe and respectful work environment, he said.
“Bullying not only leads to a drop in work performance and higher absenteeism but also results in high staff turnover and reduced job satisfaction. 
“This should be a cause for concern and a strong motivation for all sectors to implement stricter policies and laws against workplace bullying, not just as a public relations exercise but as a necessity for maintaining productivity,” said Dr Andrew.
The HWTICF said in its report that while there were already policies and rules when it came to complaints in the ministry, there was a need to improve confidentiality for the complainant.  
Mr Manvir believes the authorities should also tackle the overstretched public healthcare system that sees long waiting times for appointments, overcrowded hospitals and overworked professionals.
Even specialists face undue burden, having to teach and be involved in administrative duties such as the approval of claims, in addition to taking care of patients, he noted.
Hospitals could adopt digitalisation and other tools to help ease the burden of healthcare workers, he suggested. “These tools are needed to help the workers to be more efficient and to be able to work faster.”
Professionals like Dr Nurul feel that despite a lengthy debate about the issue, little has changed.
“While there is more awareness about this in general, bullying is deeply ingrained in the structure of the system. It is going to require a lot of political will in the system to solve this problem,” she said.   
Now working at another public hospital in Kuala Lumpur as a medical officer, she still witnesses some housemen getting scolded daily. This, according to some of her peers, is necessary to toughen up the young ones. 
“They see it as a rite of passage for all doctors and (having the) right to verbally abuse the juniors. It seems that this behaviour is normalised at times but not everyone can take it,” said Dr Nurul. 
When interacting with her juniors, Dr Nurul remembers the kind doctors who went out of their way to help in her younger days.
“I have had experience in several places and the working environment really depended on the people who were there,” she said.