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Residents' perceptions of work environment during their postgraduate medical training in Pakistan BI Avan1, Syed Ahsan Raza2, S Khokhar1, F Awan1, N Sohail1, S Rashid1, H Hamza31 Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan 2 Department of Surgery, Aga Khan University, Karachi, Pakistan 3 Department of Family Medicine, Aga Khan University, Karachi, Pakistan
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 16534158
Background: In Pakistan, there is a lack of information about the work environment of residency programs. This lack is a major impediment in their improvement. One of the approaches for improvement in these programs can be directed through the residents' own perception of their working conditions. Therefore, we collected data which would reflect working conditions of residents. Aim: To assess the perceived status of "work environment" in different specialities Materials and Methods: A cross-sectional survey was conducted in four teaching hospitals of Karachi from July 1999 to January 2000. Residents from selected programs were grouped into four broad groups: specialist, medical, surgical, and multidisciplinary. Responses of residents were obtained on a Likert scale of 0 to 4. Indices were formed for two components of work environment: academic and mistreatment. Statistical Analysis: Differences between residents' groups were assessed through analysis of variance (ANOVA) at 5% significance. Results: A total of 341 registered residents responded (response rate: 75%). Surgical residents were working more than 80 h/week and this was more than the other three groups. Medical residents were spending the highest actual time on research and teaching activities (10% and 14%, respectively). Academic index score was highest for surgical group (15.81, SD = 4.69) and lowest for multidisciplinary group (11.82, SD = 4.80). Medical group had the highest perceived mistreatment index score (5.56, SD = 4.57). Conclusions: In a study of work environment of residency programs, differential impact was found for the four groups on work environment perceptions. Most of the residents recognized undergraduate teaching, grand rounds, patient rounds, and seminars or workshops as contributing to their academic learning. Reporting of sexual harassment was low, indicating either underreporting or cultural dynamics of our setting. Keywords: Developing countries, environment, residency, sexual harassment, academic index, mistreatment index
Work environment of residency programs and its effect on residents have been subjects of interest in medical academia of developed countries.[1] Several factors have been recognized previously as components of residents' work environment affecting their working conditions. These include residents' working hours, faculty's academic contributions, and incidences of mistreatment or discrimination. [1],[2],[3] Residency programmes provide an educational and academic environment conducive to specialized clinical training. Within this environment, residents also learn through their colleagues' professional attitudes and behaviour.[4],[5] They learn their clinical skills and also the implicit messages about their colleagues' professional attitudes and behaviour.[6],[7],[8],[9],[10] These implicit messages can be interpreted by the resident's as their own perception of their environment and how they are being treated. Perceptions of learning environment and perceived satisfaction depend on their experiences during residency, which define their professional competency and identity, which becomes a lifetime valuable asset for them. Several studies have assessed the work environment of residents through impact of workload on their academic performance that provided substantial information about distribution of their work hours.[11],[12],[13] Work environment for residents was also evaluated by Strunk et al. who concluded that the laborious demands of direct patient care during residency training could have negative effects on their performance.[1] Harassment and discrimination negatively affect the performance, productivity and learning in professional and academic settings. Experiences of sexual harassment and mistreatment have been reported through various studies.[14],[15],[16],[17],[18] Komaromy et al. have reported experiences of sexual harassment and mistreatment in educational settings where 48% of the residents reported harassment at least once during their training.[19] Magnus et al. explained sexual harassment, and also reported gender and racial discrimination. It was also reported that harassment by instructors and supervisors occurred frequently.[20] In developing countries, there is a lack of scientific literature about work environment of residency programs. Improvement and changes in work environment can be directed through residents' own perception of their working conditions. Therefore, we collected information that would reflect these existing conditions, and made an effort to depict this environment as perceived by residents. These findings are not only important in planning future health policies concerning Postgraduate Medical Education (PGME) in Pakistan but would also open up new avenues and provide the opportunity of exploring and identifying weaknesses in this area, which have remained unrecognized.
Data collection A cross-sectional survey was conducted in four teaching hospitals of Karachi between July 1999 and January 2001. The selection criteria for these accredited institutions were availability of a comprehensive infrastructure for major residency programs on their premises and their location in a politically stable area of Karachi.[21],[22] The administrative structure of Karachi at the time of survey was divided into five districts, and hospitals were selected from each district with one hospital excluded owing to its location in a troublesome area. Participants The target population for the study was all residents registered for postgraduate training ( N = 455). Three hundred and forty one residents (75% response rate) in 1-5 years of residency programs responded to the survey questionnaire. The residents were selected from internal medicine ( n = 41), family medicine ( n = 5), pediatrics ( n = 45), neurology ( n = 20), psychiatry ( n = 13), community medicine ( n = 12), general surgery ( n = 48), obstetrics and gynaecology ( n = 46), orthopaedics ( n = 26), urology ( n = 12), neurosurgery ( n = 8), pediatric surgery ( n = 4), anaesthesiology ( n = 21), pathology ( n = 33), and radiology ( n = 7). Family medicine and community medicine in Pakistan are different training programs since the former has a focus on primary care with major clinical components whereas the later is a public health speciality with minimum clinical components. Survey instrument A detailed questionnaire used previously[21],[22] to assess different aspects of residency programmes was used to analyze the domain of "work environment" for this study. This self-administered questionnaire was given to the resident who was requested to fill it in the presence of one of the coauthors. Three components of the questionnaire were used to explore the work environment as perceived by the residents. These components included residents' working hours, academic learning through various modes, and mistreatment during training. Responses of residents were obtained on a 0-4 Likert scale[23] and questions about specific attributes of two components: academic and mistreatment were rated by residents on a scale of 0-4. For academic component, the residents rated their learning through contributions for different modes from "0 = no contributions" to "4 = great deal of contribution." Nonclinical activity was defined as time spent at work or within proximate call without direct patient contact, for example, drinking tea and having lunch or dinner in addition to having time to rest or sleep. Nonspecific activities included all other activities in which the case resident was requested to specify other activities and then rate it on Likert scale. The scale for mistreatment component ranged from "0 = never" to "4 = always," and residents were asked questions on humiliation, i.e., instances where they felt losing their self-esteem; sexual discrimination for encountering behavior with one-sided sexual connotations affecting their well being; sexual discrimination that excluded their gender in favor of the other genders, and for instances where they felt that others took their credit. The survey instrument was reviewed after pretesting on interns at one of the hospitals and they were not part of target population. Analysis Data were analyzed using the statistical package for social sciences (SPSS version 11.0). Descriptive statistics were computed for demographic, educational, and working hours of residents. Residents from selected programs were distributed into four broad groups: specialist, medical, surgical, and multidisciplinary. The division of residents into these groups was done on the basis of their functional association and liaison.[24] Therefore, analysis of work environment was done according to the programs that have almost similar goal of delivery system, e.g., residents from neurology, pediatrics, psychiatry, and community medicine, were included in the specialist group; internal medicine and family medicine residents in medical group; residents from general surgery, neurosurgery, orthopedics, and urology, and obstetrics and gynaecology in surgery group; and anaesthesiology, radiology, and pathology in multidisciplinary group. Indices were formed for two components of work environment: academic and mistreatment. Mean scores and their standard deviations based on responses from 0 to 4 Likert scale were obtained for each attribute of these components. These mean scores were added to form total index scores and compared across four groups of residents. Median scores were also reported for some attributes where standard deviation was more than the mean value and where the distribution was skewed. Group differences were statistically assessed through analysis of variance (anova). All analyses were done at 5% significance.
Resident's demographics Sixty-six percent of the residents in the study were males. Male residents were almost twice in number than females in all the four groups. The proportion of female residents working in the medical group was the highest (39%) and it was the lowest in multidisciplinary group (28%). Mean age for the residents in all the four groups was not significantly different with highest age observed in medical group (31, SD = 12.30). The majority of residents belonged to surgical group (42.23%). Number of dependents was more among the multidisciplinary residents (Mean = 1.54, SD = 1.79 [median = 1], P = 0.03). The average interval between graduation and start of residency was largest for internal medicine residents (4.3 years, SD = 4.69, [median = 3 years], P = 0.03). Surgical residents had the highest average working hours per week (82.03, SD = 30.68) [Table - 1]. Work hours Weekly work hours [Table - 2][Table - 3] of residents were divided into seven activities: Direct patient care, teaching medical students or junior colleagues, research activities, reading medical journals, administration-related activities, leisure time, and nonspecific activities. Residents were spending most of their time in direct patient care and significant differences were present between the four groups ( P <0.05 give actual P values). The specialist group was spending more time in direct patient care (59.86% of average work hours per week) and multidisciplinary group spending the least (39.10% of average work hours per week). Actual weekly working hours were also compared with the ideal weekly hours as perceived by residents (paired t -test) and all groups were of the opinion that time spent in direct patient care should be reduced and increased in research and teaching activities. Group differences were statistically significant for both direct patient care and research activities for both actual and ideal work hours. Academic index scores Academic index was made up of components that residents thought were contributing to their academic growth. Mean scores [Table - 4] were computed on a scale of 0-4 for faculty members, colleagues, undergraduate teaching, routine rounds, grand rounds, lectures, and seminars or workshops. Total academic index was highest for surgical residents (15.81, SD = 4.69). Specialist group residents achieved highest mean academic score for faculty members (1.52, SD = 1.02). Medical group residents gave highest scores to undergraduate teaching (2.09, SD = 1.26), lectures (2.48, SD = 1.15), and seminars or workshops (2.61, SD = 1.06). Highest mean academic contribution scores given by surgical residents were for resident colleagues (2.33, SD = 0.98), routine patient rounds (2.74, SD = 1.07), and grand rounds (2.53, SD = 1.28). Group differences were also significant for undergraduate teaching, patient rounds, grand rounds, and seminars. Mistreatment index scores Information for five attributes of perceived mistreatment during past 1 year was obtained from the residents. Mean scores [Table - 5] were obtained for humiliation, sexual harassment, sexual discrimination, ethnic discrimination, and for due credit not given. The highest mistreatment index score was reported from medical group residents (5.56, SD = 4.57). Group differences were significant for sexual harassment in medical group ( P = 0.01). Residents from internal medicine achieved highest mean scores for most of the mistreatment sources [Table - 6]. Specialist group residents gave highest mean scores for nurses (1.06, SD = 1.13) and patients (1.16, SD = 1.12) as sources of mistreatment. Significant differences were present between four groups of residents when the source of mistreatment was patient ( P = 0.01).
The aim of the study was to assess work environment of residency programs as perceived by residents enrolled in postgraduate medical education program in Karachi, Pakistan. We analyzed three components of residency work environment, which included the distribution of their work hours, academic contributions through different modes, and mistreatment during training. The results of this study have provided objective information about work hours of residents and activities performed during that time. Surgical residents were working more than 80 h/week, an arbitrary limit based on recommendations and regulations of the residents' working hours by the American Medical Association.[25] However, there has been no official limit and monitoring of work hours of residency programs in Pakistan. Scant information is available in medical literature about the number of hours that residents work in a developing-country setup. This information is critical for the improvement of PGME in Pakistan and to propose rational reforms for work hours. Although sleep deprivation is considered a relevant variable in research related to work hours in residency training affecting the quality of life of the resident.[26],[27] We were unable to document the amount of time available for sleep in this study. Therefore, further exploration is clearly needed to identify variations in individual personality characteristics that make some residents liable to reduced performance owing to disrupted sleep. Clearly, fatigue owing to lack of proper sleep affects the safety of the patient.[28],[29],[30] However, this issue at present is not openly discussed in the Pakistani medical academia. Faculty's contribution to teaching is crucial because residents tend to have positive feelings for those teachers who not only focus on routine patient care but also give more emphasis on their education.[9] The low scores given to faculty by residents [Table - 4] to some extent is suggestive of the faculty's lack of interest in teaching and more emphasis on the volume of work that the residents accomplish. Residents gave relatively more importance to their resident colleagues, routine patient rounds, grand rounds or journal clubs, and lectures as contributors to their learning. The highest academic index score achieved by surgical residents indicates that surgical residency training programs are providing a relatively better academic environment. This may also be owing to an extensive variety of procedures learned not only in the operation theater but also through academics throughout the 5-year surgical residency programs under supervision of faculty. Studies in developed countries 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.[2],[31] Our results are in sharp contrast with studies that reported high response rate of sexual harassment in developed countries, suggesting that it is a common experience.[15],[16],[17],[19],[20] Reporting of sexual harassment and discrimination from our study was low [Table - 5], indicating either under-reporting or actual low incidence. Under-reporting could also be owing to cultural dynamics of our setting, in which sharing experiences of sexual harassment could have damaging effects. Limitations Since self-administered survey questionnaires are susceptible to some bias in responses, we believe that there might be slight under-reporting (e.g., mistreatment) or over-reporting (e.g., academics) in some of the attributes. Studies of this phenomenon indicate that such under-/over-reporting is usually small depending on the conditions under which the survey is administered and the questions being asked.[32] Although these limitations may have a small effect on the quality of the data reported here, for the most part they are inherent. One way to increase the accuracy of this survey in future is to use better established measures, which have been demonstrated to be both reliable and valid. Whenever possible, this was also attempted in the current survey. Questions relating with the component of mistreatment were not qualitatively assessed; therefore, careful quantitative interpretation is needed on our perception-based questionnaire. We pretested the questionnaire on interns as a dry run to uncover defects in questions and to identify the practical snags. However, these interns are likely to differ from residents because of their recent graduation from medical school. Comparison between too many specialty categories ( n = 15) confused and obscured the interpretation; we merged them together so that the scaling can accommodate broad groups on the basis of some similarity in their patient-care delivery. Therefore, all the specialties were categorized into four groups to carry out the assessment of different attributes, though some specialties might be less pertinent for comparison such as procedure-based anesthesiology with investigation-based radiology and pathology. In summary, work hours, academic contributions, and mistreatment form an important part of the work environment of residency programs in developing countries. As a result of this study, we have found that the residents' perceptions of their work environment can give program directors information that may aid in the improvement of workplace learning environment. An infrastructure should be developed by the PGME to regularly obtain the views of residents. This would enable the faculty and program directors of the residency programs to address inadequacies and to develop infrastructure appropriate to the primary purpose of their training. Whether sexual harassment contributes to the environment in our setting is a matter that should be further explored. A learning supplement in training curriculum is also required in these programs for fostering an understanding of the patients' needs and social environment directly with their care[Table - 7].
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7]
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