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Working hours in Pakistan and maladaptive coping strategies

Posted by plosmedicine on 31 Mar 2009 at 00:11 GMT

Author: Pashtoon Murtaza Kasi
Position: Medical Graduate (Class of 2006, Aga Khan University)
Institution: Bolan Medical College
Additional Authors: Talha Khawar, Masoom Kassi
Submitted Date: July 31, 2007
Published Date: August 1, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

We would like to congratulate Kenneth R. Fernández Taylor for bringing up such an important but avoided issue in developing countries like Pakistan. [1] The growing debate regarding long working hours of postgraduate trainees has been receiving considerable attention recently.[2] This greater workload contributes to increasing stress and decreases the overall performance and the quality of the life of the affected individuals. [3,4]

In Pakistan, physicians, after having done a five-year medical degree course (M.B.,B.S.) course, are supposed to do their ‘internship’, or ‘house job’ as it is often referred to. The salaries speak a sorry tale as the typical salary of an intern starts from Rs. 8,000 ($ 129); even lower than what is mentioned by the author in El Salvador.

The author very rightly points out a typical tiring working week for an intern with little or no time for any educational activities. Some of the specialties are known and may even be proud of the fact (unfortunately) that their working hours are ‘killing’ for their residents and interns. The inhumane approach is not often criticized by the interns working in a hospital; probably because they are too tired at the end of a day or even 2-3 continuous days to do so. I know of 2 specialties (Neurosurgery and Urology) in which the on call team came on Friday and left on Monday morning (72 hours straight); the reason being no other team to cover up for them. And most of the time what an intern does is merely ‘clerical’ work, with little satisfaction.

We, as final year medical students, tried to bring attention to this issue by firstly documenting how many hours the interns and residents worked; and secondly if it led to negative coping strategies/mechanisms, which might further contribute to the stress of these individuals, rather than helping them in relieving it.

We found that long working hours were indeed leading to negative coping mechanisms such as Behavioral disengagement (e.g., "I've been giving up trying to deal with it"), Substance use (e.g., "I've been using alcohol or drugs to make myself feel better"), Denial (e.g., "I've been saying to myself, ‘this isn't real’ "), and Venting (e.g., "I've been saying things to let my unpleasant feelings escape"). The frequency of different coping strategies employed by the residents in the past 2 weeks was determined with the Brief COPE – 28.[5]

We also found significant levels of mild as well as morbid stress in the trainees of the hospital, with every second individual suffering from some degree of stress as well. Action indeed is needed.

Reduction of working hours is important. At the same time interventions, need to be planned at imparting knowledge, awareness and skills to cope with various kinds of stressors encountered by a trainee during his/her training. However, it would probably be far from now that such an intervention comes underway.

All the stakeholders should come forward in helping out the young interns and residents in the developing countries. The formation of the ‘Working Hours Task Force’ at our hospital when we were medical students last year, is an initial step in the right direction. However, such efforts have to be at a national basis and regulated by law as pointed out by the author. Countries who have been successful in designing humane working hours for their trainees should lend a helping hand to other countries in sharing their experiences and helping them design better working schedules than what are prevalent at the moment for the trainees.

Considering the attention the issue is receiving, hopefully positive things would come about.

1. Fernández Taylor KR (2007) Excessive Work Hours of Physicians in Training in El Salvador: Putting Patients at Risk. PLoS Med 4(7): e205 doi:10.1371/journal.pmed.0040205
2. Howard SK, Gaba DM (2004). Trainee fatigue: Are new limits on work hours enough? CMAJ 170(6); 975-976.
3. Howard SK, Gaba DM, Rosekind MR, Zarcone VP (2002) The risks and implications of excessive daytime sleepiness in resident physicians. Acad Med 77; 1019-25.
4. Parshuram CS, Dhanani S, Kirsh JA, Cox PN (2004) Fellowship training, workload, fatigue and physical stress: a prospective observational study. CMAJ 170(6); 965-70.
5. Carver, C. S (1997) You want to measure coping but your protocol’s too long: Consider the Brief COPE. International Journal of Behavioral Medicine 4; 92-100.

No competing interests declared.