Postgraduate Medical Training: Residents education

400 Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (6): 400-404
INTRODUCTION
The rapidly growing body of scientific evidence as well
as public opinion have effected revolutionary changes in
the health care system and working standards of the
doctors.1,2 In the developed countries the working and
training conditions of doctors are frequently evaluated
scientifically, but there is dearth of such work in
developing countries like ours.3,4
Residency involves learning in the context of providing
clinical services to the patients. The relationship
between working environment, workload and learning is
highly complex and has been debated for long in the
developed countries. It still continues to be debated with
the aim to ensure safe and productive working and
learning environment for residents.1,5
Several variables that influence the learning during
residency, have been identified by published research
works. These include residents' workload, working
environment, support and supervision by faculty,
appraisal and constructive feedback by mentors,
financial incentives, and work related other problems
such as mistreatment or harassment etc.6,7 Also the
colleagues' professional attitude and behaviour
constitute an important source of insensible learning
during residency.8 The role of surveys entailing
residents’ perceptions of their residency experiences
has been under continuous scrutiny and greater
attention revolves around their utility as feedback for
identifying and rectifying deficiencies in residency
training.
The present cross sectional survey was undertaken to
determine the current working conditions of the
residents at PIMS and hence obtain actionable
information to effect meaningful changes in the working
conditions and well being of the trainees.
METHODOLOGY
This cross-sectional survey was undertaken at the
Department of Medical Education, Pakistan Institute of
Medical Sciences (PIMS), Islamabad, during September
and October 2008.
PIMS is a tertiary care hospital and is one of the
country’s leading medical institutions, various post-
graduate residency programmes including FCPS, MS,
MD, MCPS and M.Phil. in different clinical specialties.
ABSTRACT
Objective: To determine the residents’ perceptions of their current working conditions by measuring their level of
satisfaction with the existing pattern of workload, working environment and residential/ financial standards.
Study Design: Cross-sectional survey.
Place and Duration of Study: The Department of Medical Education, Pakistan Institute of Medical Sciences (PIMS),
Islamabad, during September and October 2008.
Methodology: Residents of different specialties who had been undergoing residency training at PIMS for no less than one
year were included. A questionnaire was employed which addressed three components of residency programme including
workload, working environment and financial/residential aspect of training. Supplemental questions regarding impression
of the overall working environment was asked. A five point response scale was used to rate responses to the questions in
each of the three components of residency programme.
Results: Response rate was 73%. Among the 109 respondents, 74 (68%) were males while 35 (32%) were females.
Seventy three (67%) were pursuing FCPS and 36 (27%) were pursuing other degree programmes including MS, MD,
MCPS and M.Phil. The age range was 25 to 41 years with a mean of 31.60 ± 4 years. Working environment was the
highest rated area with index score of 67%. Financial and residential aspect of training was the lowest rated area with a
score of 37%. Workload ‘s index score was 46.78%. The overall working index score was 26.23%.
Conclusion: Residents perceived marked problems with their working conditions as indicated by their unfavourable ratings
of the various components of the residency programme. There were problems with workload, duty hours, working
environment, income and accommodation. Further research is needed to confirm and improve upon these results.
Key words: Residency. Postgraduate medical education. Duty hours. Workload of doctors. Working environment.
Department of Medical Education, PIMS, Islamabad.
Correspondence: Dr. Muhammad Saaiq, Room No. 20, MO
Hostel, PIMS, Islamabad.
E-mail: msaaiq@yahoo.uk.com
Received March 30, 2009; accepted Febraury 22, 2010.
Residents’ Perceptions of Their Working Conditions During
Residency Training at PIMS
Muhammad Saaiq and Khaleeq-uz-Zaman
SURVEY REPORT

The study population was constituted by all the
residents undergoing residency training at the institute
for a period of over one year. The data of residents in
different residency programmes was initially obtained
from the hospital’s official record. The target was to
cover half of the residents from all specialties and
residency programmes. They were randomly approached
face-to-face, with the help of a team of junior doctors
detailed for questionnaire distribution among residents
of different specialties.
A self-administered questionnaire was employed for the
survey. A good deal of effort and consideration went into
designing the questionnaire in order to cover all the
important aspects of residency training and to generate
a representative data, that would serve as a valid
outcome variable.
The questionnaire was reviewed after initial pre-testing
on a group of 15 residents from different specialties and
various residency programmes. The questions were
rephrased in such a way that an agreement/satisfaction
with the accepted standards got higher score while
disagreement/dissatisfaction scored low. Also new
questions were added to the questionnaire in the light of
the suggestions, frequently made by the subjects of the
pre-test group. The questionnaire comprehensively
addressed 3 components of residency programme namely;
workload, working environment e.g. mistreatment etc.
and financial and residential aspect. Supplemental
questions regarding impression of the overall working
and learning environment were asked. Any additional
suggestions for further improvement of the existing
situation were also invited.
A 5 point response scale was used to rate responses to
the questions in each of the 3 components of residency
programme; with 5 points for strongly agree, 4 for agree,
3 for neither agree nor disagree, 2 for disagree and 1
point for strongly disagree. No response was considered
as zero point. Results for each of the measures of all the
included residents were added up, and an average was
calculated and scaled to a score out of 100 to form the
‘Index Score’ of the given component. In this way the
residents’ level of agreement or disagreement with the
questioned statement was measured from ‘strongly
disagree’, (0%) to ‘strongly agree’, (100%). Response
scale for the overall impression of working and training
environment was also of similar five points. i.e. from 0%
to 100%.
The data were analysed through SPSS for Windows
version 10. The nominal variables were reported as
frequency and percentages. The numerical data were
reported as mean ± S.D. The average of the responses
to the questions in each of the 3 components of
residency programme, was taken as the Index Score
(IS) for the respective component. The average of the
responses to the overall impression of working
environment was taken as the Overall Working Index
Score (OWIS).
RESULTS
In the target population of 150 residents contacted, 109
returned the questionnaires duly answered. The
response rate was thus 73%. Among the 109
respondents, 74 (68%) were males while 35 (32%) were
females. Majority of respondents (67%) were pursuing
FCPS while 36 (27%) were undergoing other degree
programmes including MS, MD, MCPS and M.Phil. The
age range of the respondents was 25 to 41 years with a
mean of 31.60 ± 4 years.
The workload of the residents was assessed with the
help of questions covering 6 important aspects namely;
Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (6): 400-404 401
Residents’ perceptions of their working conditions during residency
Table I: Residents’ perceptions of the workload (n=109).
Questions and responses No. (Percentage)
My weekly duty hours are less than 80 hours
Strongly disagree 33 (30.27%)
Disagree 17 (15.59%)
Neither agree nor disagree 28 (25.68%)
Agree 23 (21.10%)
Strongly agree 3 (2.75%)
Not answered 5 (4.58%)
I usually avail enough hours of un-interrupted sleep when on call
Agree 8 (7.33%)
Significant proportion of my on-call time is not spent on non-clinical/
managerial work
Strongly Disagree 34 (30.27%)
Agree 11 (10.09%)
I prefer 24 hours On-call system over 12 hours shifts
Agree 18 (16.51%)
My hospital work allows me sufficient work---life balance
Agree 13 (11.92%)
When on--call I am not overworked with direct patient care duties. (Also
indicate the number of new patients, admissions or surgeries I perform)
Agree 14 (12.84%)

weekly duty hours, necessary sleep when on-call,
managerial work, work-life balance, magnitude of direct
patient care duties and preference for 24 hours on-call
over 12-hours shift.
Majority of the residents worked for over 80 hours per
week. Most of them reported inability to avail sleep when
on-call. Majority reported involvement in managerial
work as well as excessive direct patient care duties.
Work-life balance was also unfavourably rated. Majority
preferred 24 hours on-call system over 12-hours shifts
(Table I).
Working environment was assessed with the help of
responses to 5 important attributes i.e. perceived
mistreatment, discrimination, harassment, dignified
treatment and any special un-ethical behaviour (e.g.
sexual harassment). Majority of the residents reported
absence of various negative elements in their working
environment (Table II).
The attributes towards the financial and residential
aspect of training included; regular salary/stipend,
reasonable amount of salary, need for any part-time job,
status of residential facility and overall satisfaction with
income and residence.
Majority of the residents reported receiving salary/
stipend on regular basis, but unfavourably rated all other
related attributes (Table III).
Working environment was the highest rated area with IS
of 67%. Financial and residential aspect of training was
the lowest rated area with a score of 37%. Workload’s IS
was 46.78%. The overall working index score was
26.23%.
DISCUSSION
Majority of the residents reported working for more than
80 hours per week and also could not avail enough
hours of un-interrupted sleep while on call. A recently
conducted Karachi based study also showed that for
most of the residents, working hours were very long in a
number of departments,9 exceeding the internationally
agreed limit of 80 hours per week. The study also found
Table II: Residents’ perceptions regarding working environment
(n=109).
I don’t come across any mistreatment
Agree 31 (28.44%)
Not answered 0
My seniors don’t show any discrimination towards me
Agree 32 (29.35%)
Not answered 0
I am not subjected to any harassment
Agree 43 (39.44%)
Not answered 0
Overall I am treated with respect and dignity
Disagree 9 (8.25%)
Agree 33 (30.27%)
Not answered 0
Overall there is no un-ethical behaviour/sexual harassment etc.
Strongly disagree 0
Disagree 7 (6.42%)
Agree 61 (55.96%)
Not answered 0
Table III: Residents’ perceptions regarding financial and residential
issues. (n=109 ).
I receive stipend/ salary on regular basis
Agree 49 (44.95%)
My stipend is sufficient for my family needs
Agree 1 (0.91%)
Strongly agree 0
Not answered 0
I do not need a part time job to fulfill my needs
Agree 14 (12.84%)
Not answered 0
I have a decent residential facility for living
Agree 7 (6.42%)
Not answered 0
Overall I am satisfied with my income and residence
Agree 0
Strongly agree 0
Not answered 0

Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (6): 400-404 403
Residents’ perceptions of their working conditions during residency
significant levels of mild as well as morbid stress among
the trainees, the chance of stress being more among
those with longer hours of work. In the developed
countries there is growing recognition of the fact that
long working hours of postgraduate trainees lead to
fatigue and sleep deprivation10,11 which ultimately
results in overall poor performance, owing to compro-
mised judgment, impaired manual dexterity and errors in
medication orders.12,13
Currently there exist no prescribed standards or official
limits of duty hours for trainee doctors in Pakistan. This
is in sharp contrast to the developed countries where
duty hour standards have evolved after a long
experience and careful consideration over the last 3
decades.14-16 In June 2002, the Accreditation Council for
Graduate Medical Education (ACGME) approved new
duty-hour standards for residency programmes in all
specialties. These limit the duty hours in all specialties to
80 hours a week and require a rest period between duty
periods. Continuous duty is limited to 24 hours, with an
added period of upto 6 hours for continuity and transfer
of care and didactic activities.17 In Canada the famous
PAIRO–OCOTH agreement (Professional Association of
Interns and Residents of Ontario-Ontario Council of
Teaching Hospitals agreement) was okayed in 2000.
This agreement limits residents to a maximum of 7
in-house, on-call periods of upto 24 hours (plus a
handover period) in 28 days. Call periods are non-
consecutive, should not include more than 2 weekend
days in the 28-day cycle and are followed by "relief of
service until the next working day."18
Although we could not determine an exact estimate of
the sleep time that a resident avails during the 24 hours
call, most of them reported inability to avail enough
hours of un-interrupted sleep while on call. Further
studies into the residents’ sleep patterns and require-
ments are needed.
Residents reported investment of significant time on
non-clinical and managerial duties such as arranging
bed, blood, theatre items etc. for patients, Since
residency training relies on learning in the context of
providing clinical service to the patients, there is dire
need to redesign the working pattern in such a way that
all the residents have a reasonable opportunity to
participate in the formal educational events.
Most of the residents preferred the 24 hour on call
system. Tait et al. also noted that the shift system was
less safe, harmful to training, and worse in terms of
work-life balance.19 By and large the partial shifts are
not conducive to high quality training. They are
associated with lack of continuity with patients and staff.
However, there is no all-encompassing standard
solution which can work across all medical specialties
and settings, therefore, a flexible approach to working
patterns should be adopted.
Residents also reported overwork regarding their
experience of direct patient care duties. There were
wide differences in the number of new patients they
attend when on-call, new admissions they handle and
emergency surgical procedures they perform. Haney
et al. found that residents feel more challenged with
increase in the total number of patients they care for
(case volume), with more patients whose diagnoses are
new to them (case variety) and who are more sick
(acuity).20
Working environment was the highest rated area. There
was no report of sexual harassment in this study. This
may reflect a healthy socio-cultural milieu of mutual
respect, however, further detailed studies are warranted
to conclude whether sexual harassment really does not
exist in our institutions or it exists, but is denied or not
disclosed. Not surprisingly experiences of sexual
harassment and mistreatment are not infrequent in the
West and studies have attempted to explore sexual
harassment in academic settings, because it is
responsible for an environment that creates negative
impact on the residents' individual performance and
reduces their productivity.21
Financial and residential aspect constituted the lowest
rated area. This study’s findings provide a compelling
rationale for redesigning the pay structure and financial
incentives for the trainee doctors. Low salaries, poor
service structure etc. have also been identified by other
published local studies as one of major sources of
dissatisfaction among Pakistani doctors.7, 22-24
This survey has some limitations. Only the most
important aspects of 3 attributes of residency training
were probed. Relationship between residents’ working
conditions and learning is highly complex and influenced
by many factors. Further research is needed to evaluate
the various components of residents' workload in
particular. With better understanding these components
with meaningful interventions can be instituted to
optimize the learning environment. In fact no
questionnaire can be an all encompassing one and each
one has its own limitations and deficiencies. Since
research is a dynamic process we may need to redesign
the questionnaire in future in light of the ongoing
experience. Moreover, other researchers may customize
it to meet their survey objectives in a particular context.
CONCLUSION
Residents perceive significant problems with the
working conditions of their training as indicated by their
unfavourable ratings of the various components of the
residency programme. There are problems with
workload, duty hours, working environment, income and
accommodation. Further research is needed to confirm
and improve upon these results.

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G G G G G *G G G G G

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