Five myths about house officer issue

The issues surrounding the welfare of house officers (HO) have been there since I was a HO in the 1980s. We knew how to tread carefully around certain towering and dictatorial personalities. This issue is nothing new. Everyone knew it but no one did anything about it.

However, the tables have turned and it is time that we no longer tolerate such a culture of abuse, especially within the medical community, the guardians of our physical, social, emotional and mental health and wellness.

Yet, several misconceptions continue to persist and they reach the level of becoming almost mythological within our collective medical minds. These myths have become entrenched in our culture and are a barrier to progress. I can think of at least five of these myths.

Myth 1: The HO should talk to their superior when they have a complaint

It may be scary to think about this, but mistakes are inevitable in medicine. Do such mistakes lead to subsequent changes in clinical practice?

In 1991, The Journal of the American Medical Association published a paper where 254 house officers were surveyed and they found that house officers who accepted responsibility for their mistakes and discussed them were more likely to report constructive changes in practice.

The conclusion from this learned journal was that to promote learning, senior doctors should encourage house officers to accept responsibility and discuss their mistakes. The HO I talked to reacted with shock and horror at this very idea.

“Never admit your mistake,” she says, “that’s a sure ticket to hell on earth”. “Never complain either,” said another HO because, “well… we all know the drill by now. There will be an open meeting, no one would step forward with a complaint and the matter will end there. The administrators are happy, superiors are happy, while the HO is cowed under threat of an extension of the housemanship period.”

The culture of fear and of repercussion remains. Matter closed.

Myth 2: We need new strict SOPs and clear guidelines for senior doctors

Are existing guidelines not enough? Take a look at the oath that we took when becoming doctors. Take a look at the House Officer’s Handbook and the Malaysian Medical Council’s Code of Professional Conduct. They all provide the yardstick for the conduct and behaviour of doctors in all areas of professional activity.

Item 3.2.4 of the MMC Code of Professional Conduct states that “a practitioner must treat colleagues and staff with due respect and dignity at all times and avoid any act, verbal or physical, which may cause harm or injury, or which may be interpreted as harassment, including gender-related, aggressive pressuring or intimidating behaviour”.

The code and the guidelines discuss, not ideal behaviour, but the minimum standards of conduct expected of a registered medical practitioner and assessed by the Malaysian Medical Council. Yet these minimum standards seem difficult for some of us to attain.

We have enough guidelines. The world does not need more SOPs but we need better implementation of existing guidelines with the political will to conduct clear and transparent checks and balances.

Myth 3: We need to stop bullying our house officers

Is this the crux of the matter? Is this why a HO recently decided to end his life so dramatically? Was he bullied? I have to disagree, because words matter. The actual words we say and the way we choose to say them are very important. Our language can either degrade or demean, or it can encourage and empower.

Bullies exist in schools, homes and even hospitals. Yet, what our HOs are experiencing now is not bullying. It is outright abuse. We need to call it what it is. Abuse.

Is there a difference? Bullying and abuse are both forms of ill-treatment between which there lies a key difference. Bullying refers to the act of intimidating a weaker person. Abuse refers to all forms of ill-treatment of an individual.

Sexual harassment is abuse, not bullying; racial and religious insults directed at HOs are forms of abuse, not bullying; humiliating a HO for the slightest of infractions, each and every time in front of his patients and peers, is abuse, not bullying. We need to get our words right because words matter.

Myth 4: Our HOs are of poor quality, and can’t tolerate stressful situations in hospitals

I worked with the Malaysian Qualifications Agency (MQA) for a long time and their assessment of medical schools is more than stringent. Anyone who goes through five years of an MQA-certified medical school and passes the exams has more than enough knowledge to become a HO.

Each hospital has protocols and procedures unique to itself, unique to the whims and peccadilloes of the specialists and there is a learning curve for all house officers. Being thrown into the fray and expected to treat patients from day 1 is enough to scare the best of any HO.

We then throw them another curveball. Unlike my time as a HO, when I started immediately after graduation, today’s HOs may have to wait for almost a year or more before they can start. What happens to their practical skills?

Medicine is an apprenticeship. You learn by doing. Given enough time away from the practice of medicine, you forget everything. Is it entirely the fault of the HO or perhaps the powers above have also to shoulder some blame? Are our teaching methods outmoded? We don’t have newer methods of teaching? Those are nothing more than excuses.

HOs need proper apprenticeship and the later they start, the easier it is to fall behind and forget everything they were taught.

Since the time of the Greek and Muslim physicians, practitioners of medicine secured much of their training through an apprenticeship. The physician mentor provided instruction and became the guide and counsellor to the prospective doctor of medicine.

Through his preceptor, the latter came into actual contact with the practical details of medical practice. Have we forgotten the origins of the practice of medicine?

Myth 5: The task force will solve the problem

To be fair, the task force has not yet made known its terms of reference. What is certain is that it cannot change this work culture overnight, especially if it is a task force that lacks representation from those it seeks to protect.

To me, it’s a case of identifying abuse and preventing that abuse. Not to mix it up with looking at the training of HOs. The training is a separate issue. If they don’t make the grade, then they don’t deserve to be a medical officer (MO). The process and procedure are clear.

The issues to be addressed include: (1) how to prevent the abuse before it begins; (2) make it safer and easier for the HO to report abuse at the onset; (3) improve the response once the abuse comes to the attention of the administrators; (4) develop strategies for long-term reduction of abuse.

Those who work with domestic abuse victims are familiar with these four steps. It’s the same thing with workplace abuse. Nothing to do with the standard or substandard HO.

The specialist is not a demigod. He or she just happens to be higher up the ladder and in a position of power and experience. There is no excuse for passing off abuse as a teaching-learning experience. There never is.

Look at the four steps I mentioned above. Those are the reasons why we need junior doctor representation. They know what are the barriers to early reporting of abuse. They know the consequences of such reporting. Their work culture is so far removed from the specialist who just cannot understand why the HO won’t speak up in an open meeting. Strange, considering they were house officers once.

If we want solid strategies that work for the HO, then they need to be included in any such task force.

I welcome the setting up of the Task Force. Despite not being inclusive, it is a step in the right direction. It is still the early days but I am certain the task force will work with other stakeholders to map the current landscape of HO abuse and to look with fresh eyes at how we can both hold abusers accountable and ensure that we are providing smart and effective pathways to safety for the hapless house officer. We need the political will to do it right.

Enough said. It is time for action. - Mkini

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DR ZALINA ISMAIL is a former professor in Neurophysiology at the School of Health Sciences, Universiti Sains Malaysia and a Fellow of the Foundation for Advancement of International Medical Education and Research.

The views expressed here are those of the author/contributor and do not necessarily represent the views of MMKtT.