Healthcare Demolition Derby: Why Doctors in Malaysia Must Break the Hierarchy Wars and Reclaim Meaning

By The Insight Circle (28th September 2025)

"He who fights monsters should look to it that he himself does not become a monster" - Friederich Nietzsche

The Pledge We Make, Unknowingly

Doctors ought to be careful what they wish for. The Hippocratic Oath is not merely a collection of words recited at the outset of a career—it is a moral covenant that transcends the routines of daily practice. To swear by an ideal is to cross the Rubicon, a point of no return where one makes a conscious choice to walk a path willingly and with full awareness of its weight.

Once we take up the pledge, there is little room to lament career choices, grow jaded, or project dissatisfaction onto others through grandstanding that merely masks insecurity about the path we have chosen. Implicit in that pledge is the understanding that doctors must embody virtues that hold them accountable for their actions and uphold an unwavering commitment to fostering respect and solidarity — one that serves both patients and colleagues in a spirit of mutual, symbiotic coexistence.

Reality Bites

Yet in Malaysia, the reality remains a contradiction to these ideals. The healthcare system functions in ways diametrically opposed to these values, straying far from the very principles that define the profession. Too often, doctors appear to have succumbed to a kind of selective amnesia, drifting further from the noble aspirations that once marked the beginning of their careers. Each day brings reminders of this decline: from the tragedy of a patient who exsanguinated while a doctor stepped out for a drink (New Straits Times, 2025), to bitter infighting within the fraternity (CodeBlue, 2025), and the crushing organizational stressors that drove a doctor to take their own life (CNA, 2024).

What drives doctors to do the unthinkable in our country? What force hijacks their minds, compels them to displace their frustrations onto others, and causes them to lose sight of their role in an environment where trust, self-sacrifice, and compassion are needed most? To answer this, we must confront the dangerous psychological contract that breeds distrust and sets the stage for psychological warfare within organizations meant to serve as exemplars of society.

Death of a Conscience

At their core, doctors aspire to save lives, yet they remain caught between what they “wish to be”—the benevolent healer—and what the system compels them to become. This tension is reinforced by entrenched hierarchies rooted in an archaic past, inequitable training opportunities, and persistent workplace power asymmetries.

In such an environment, doctors may come to mistreat or look down not only on allied health staff but, at times, on patients themselves. The erosion of their already fragile autonomy under high-stakes conditions only deepens this violation of professional identity. This sets off a chain reaction in which doctors become trapped in an identity crisis, paying the ultimate price—betraying their own conscience simply to survive within a suffocatingly toxic system, and regressing into primitive instincts of self-preservation.

Organizational Demolition Derby

It is therefore less a matter of individual malice than of a deeply institutionalized culture of hierarchy—one that has yet to awaken to the demands of a modern, collaborative healthcare paradigm. In this respect, Malaysia refuses to move beyond a certain threshold, clinging to a belief system or dogma fully aware of the friction it creates — obstinately defending inhospitable conditions in healthcare, choosing the discomfort of stagnation over the challenges of change, while doctors and healthcare staff slowly slip into a metaphorical coma, sustained only by life support.

Comparatively, many nations have already reached a stage of reconciliation among the various facets that constitute healthcare. Egalitarian societies such as Sweden, and even partly doctor-led systems like the UK and Australia, emphasize unity through organizational citizenship — a spirit of “all for one and one for all”. In these contexts, doctors do not dominate but instead form collaborative teams with other professional staff, creating collective yet pragmatic spaces for patient care. By contrast, Malaysia remains far removed from such organizational relationships, with its system still marked by status-driven, prestige-heavy, and collectively feudalistic patterns of patronage (Hofstede Insights, 2025).

The Steep Flight of Fancy

Despite a documented exodus and a reluctance to enter the workforce affecting approximately 40% of doctors nationwide since 2017 (The Star, 2025), and the unprecedented Hartal Doktor protest movement, policymakers remain unmoved by crises unfolding under their watch. As outlined above, there is little appetite to decisively confront the systemic deficiencies that have kept Malaysia’s healthcare system reeling for decades. It is increasingly evident that real help will no longer come from institutional reforms alone — and doctors must resist barking at the moon, relying on higher echelons to deliver changes that may never see the light of day.

What is needed is not another round of half-hearted, undelivered promises, but a fundamental shift in mindset — a reminder of who truly steers the ship: the frontliners themselves. And, sadly, the truth is that doctors must face a harsh reality – they are on their own, with no one taking a shine to them. There is no better time than now. If it is not already evident, doctors must wrestle with the uncomfortable truth that dismantling the old disorder and building a new order must begin from within — and this moment demands courage, voice, and united, decisive action.

A Cure Worse Than Poison

Systemic decay in Malaysia’s healthcare system makes it far harder for doctors to swallow the bitter pill that may lead to their salvation. In light of this, the solutions offered here are directed at those prepared to take the fight back to the heart of darkness and transform it into a brighter future — though not without the inevitable birthing pains such change will entail:

1.       Acknowledge hierarchical decadence — We must first acknowledge the reality on the ground: Malaysian organizations are shaped by a cultural narrative of passive aggression, marked by high power distance and a lack of self-reflection (Swarna Nantha, 2017). Unlike flatter hierarchies that prioritize collaboration and shared goals, this structure perpetuates division and undermines collective progress.

2.       Invert the hierarchical pyramid – Doctors often feel compelled to remain perpetually in the driver’s seat, dominating others so that only their point of view prevails. This behavior is partly rooted in the pressure to make the “right” decisions without what they perceive as excessive “noise”. Yet such a top-down approach creates friction within organizations, where shared care could otherwise lead to better outcomes. There is a pressing need to invert the power pyramid—shifting decision-making from the top to the bottom—and to build organizational structures that emphasize lateral rather than vertical integration.

3.       Cultural-specific organizational change – Doctors must call an immediate ceasefire — forging a truce with all health staff and working as a unified team, regardless of hierarchy, status, or qualifications. The Swedish concept of lagom—“just the right amount, not too much and not too little”—offers a guiding philosophy for organizational culture, emphasizing balance, moderation, and harmony. Embracing such ideals shifts decision-making away from rank, prestige, and material gain, while dismantling the extrinsic motivations that currently drive healthcare delivery.

4.       Protean-career in a changing world – The belief that the role of a doctor is fixed and unchanging is a fallacy. As artificial intelligence advances to become one of the greatest equalizers in human history, the traditional hegemony over knowledge is rapidly eroding. In response, Malaysia risks taking the wrong path by trying to reclaim this lost autonomy through an even tighter choke-hold on organizational relationships. Instead, doctors must recognize the enduring value of lived experience and remain open to reinvention, moving beyond traditional pathways that may soon lose viability. Success should no longer be defined by rigid organizational structures, but by personal goals, adaptability, resilience, and growth.

The Final Lap

Doctors must reclaim true autonomy while fostering genuine relatedness within organizations now rife with infighting that undermines unity. All health professionals should commit to cultivating an environment of “working without prejudice,” anchored in a shared vision of loyalty to the patient rather than to rigid organizational structures. Such a collective vision nurtures intrinsic motivation and, over time, can transform the healthcare landscape from within. Hippocratic Oath (Declaration of Geneva, 2017) reminds us in its opening line — “I solemnly pledge to dedicate my life to the service of humanity” — our work should, and always must, remain grounded in honouring this pledge.