Why Medical College Work Culture is So Horrible

A number of junior residents at Jipmer have raised allegations of mental and physical harassment against the head of department, medicine, and called for action against the senior faculty.
In recent complaints lodged with the Jipmer Dean (Academics), the residents alleged they were subjected to various forms of harassment at the hands of the department head during the three-year PG residency. They sought re-examination of the results of the exit examination on December 23 as they suspected they were deliberately failed in the practical segment by the faculty member.

This is from The Hindu a couple of days ago.

This is just one among the many thousands of such incidents across medical colleges. It would be really difficult to find a medical college which doesn't have harassment and bullying.

When this came up for discussion in a WhatsApp group I am part of, there was an interesting debate. While everyone acknowledged that there is a hierarchical culture in medicine and that this needs to be rectified, there was a slight disagreement on the exacts of how and why.

One argument was that the medical college culture is an extension of the casteist culture outside and that it will go away only when caste based discrimination disappears. To this some disagreed a bit and said it is not the same in institutions like nursing colleges.

Today morning I tweeted: "If you apply the corporate workplace harassment standards to medical colleges, you'll have to fire *all* doctors. That's how horrible that culture is."

I do think there're more issues that lead to the culture in medical colleges apart from casteism. I list down the potential causative factors here.

As you might know, I believe in intersectionality and in the contribution of all these causes (including causes that's not mentioned here) to the problem. The listing here is by no means a suggestion that "X is the reason ABC happens". If you remove X, you'll still have Y, Z, and so many other issues.

There is a lot of work to be done in medical colleges

A medical college (especially in government settings) has a lot of things happening at once. There's out patient department and the rush of patients. There are new admissions being made. There are existing in-patients who need follow-up care. There are constantly new developments (new symptoms or worsening of symptoms, new investigation results). There are plenty of learning requirements to be met. There are procedures to be performed. There are resources that need to be mobilized. There is paper work to be done. There are a lot of people talking to each other, lots of communication and miscommunication. There are duty rosters and handovers. There are emotions and sickness playing beneath all of this.

Almost everything requires to be done as soon as possible too, if not stat.

There is a lot of gap in resources

Often (especially in government settings) the resources required for getting a lot of work done is simply not there. This could be things like medicine, dressing equipments, and suturing material. Or this could be human resources like nurses, specialists, doctors, cleaners, attenders, pharmacists, and technicians.

There is poor spending on healthcare in Indian budget

As a country, India spends much less than what it should on healthcare.

The science of medicine is imperfect and the art of medicine is really hard

Medicine as we practice it has only evolved in the last few decades or so. We still have no idea what's going on in a lot of situations. It's an imperfect science. Biology has a lot of secrets.

Add to that we're dealing with human beings. The art of handling sickness and patient care is always complicated by the intensity of emotions.

Who wants to work hard?

I've left hospital based practice long ago. And I've not been even doing clinic based practice in the last couple of years. Because it is a lot of work.

When there's a lot of work, some people find ways to make it fun. They focus on the learning and growth. Or they focus on the people they're serving. If you can make hard work fun, you can do it for a while.

But it is not possible to do it forever.

Medicine is not fun

After a point, you get a lot of similar patients. There's plateau in learning and drudgery in work.

Even when you find ways to enjoy some of that, you can't enjoy death. People literally die. Despite all of what we do. How do you make death fun?

There are not many options for a change in scenery

It's the same kind of work from the end of MBBS till retirement. You go to hospital. You see patients. Medical college faculties don't even get transfer. You're stuck in the same department of the same building for your entire career.

Lack of skills leads to insecurities

We established that medicine is hard. Many doctors lack skills - be it in the clinic, or in their life. They are sometimes aware of their incompetency too. And some of this manifests as insecurities.

Everyone loves delegation

The best way to get something done while hating it is to delegate it. Patient care is complicated. If it can be delegated, it is less of a headache.

Delegation requires power structures

The easiest way to ensure you can always delegate work is to ensure that there are people "below" you who can do your work at your command. Maintaining a hierarchy is essential for delegation.

Hierarchies are easy to maintain in a hierarchical society

How do we build a hierarchy? We just need to belittle others. There are numerous ways to belittle others when the society has trained many people in things like:

• caste
• gender
• language
• physical appearance

In medical colleges there is a much easier way to belittle people - using their years of experience. Someone who is "junior" can be belittled easily as they will have that much lesser experience.

Individuals can't fight the hierarchy

Because medicine is hard no individual can do it alone. You can't run a hospital by yourself. Especially if you're a junior doctor who is still learning, you absolutely would be terrified of doing patient care without support from seniors. How can you fight someone whose support you need for your work?

There's always something more urgent

There is no space for conflict resolution in medical colleges. Patient care always comes up. There's no time for cooling down. There's no time for empathy.

The individuals who get in are of questionable merit

Most doctors are doctors who have gotten good marks in an entrance examination. This is a test of their memory and cognitive skills in a very narrow domain. This makes the selection process to medical colleges be highly skewed. The skills in various other domains - like social skills, emotional intelligence, empathy - are not regarded at all.

Without these other skills, it is very difficult to even acknowledge when something wrong is happening.

There are not many role models for better culture

Where does one find examples of good work culture in healthcare in India? Very few "alternative" healthcare institutions provide such an exposure. This is not accessible to a wide variety.

Medicine is mostly seen as a job, and not as a passion by many

There aren't a lot of people who think in terms of quality improvement, safety, etc in medicine. For many it is a job. A way to make money and live.

And hundred other reasons

These are what I quickly wrote down. I've not gone to a medical college in a powerless position since about 7 years. I do go to medical colleges very often as an "external" "senior" instructor. I've used this "power" to understand some of the power structures within medical colleges from up close. That has led to some of the insights above.

There are possible many other things that contribute to the mess. Some of the ones above could be wrong too. There are possibly many interventions one can do on many of these problems.