Work-life balance amongst residents in surgical and non-surgical specialties in a tertiary care hospital in Karachi

Objective: To assess work-life balance among medical residents at a tertiary hospital. Methods: The cross-sectional study was conducted from September to December 2016 at a private-sector tertiary care hospital in Karachi, and comprised medical residents working at the facility. A standardised, self-administered questionnaire was developed on the basis of Canadian Mental Health quiz and a study in literature. The questions aimed at assessing satisfaction with work as well as emotional and personal life of residents in various medical and surgical specialties. SPSS 20 was used for data analysis. Results: Of the 275 residents, 129(46.9%) were males and 146(53.1%) were females. The overall mean age was 28.19±2.194 years. Of the total, 13(4.7%) participants thought they had work-life balance; 165(60%) felt their job had negatively affected their private lives; 118(42.9%) felt worn out; 109(39.6%) expressed moderate dissatisfaction with work-related factors; 119(43.3%) were dissatisfied with life outside work; and 93(33.8%) were dissatisfied their health. Conclusion: There was minimal work-life balance among the residents.


Introduction
Work-life balance (WLB) can be defined as the management of the actual and desired proportion of one's work and private life activities. 1This refers to the time actually spent on work and private life compared to the time one hopes to spend on such activities. 1 The outcome of work-life imbalance and its effects on health and satisfaction are well-known. 2,3Work-life imbalance and long working hours are associated with significant burnout. 4Studies in various parts of the world have demonstrated a link between a poor WLB and healthcare issues, such as hypertension, depression, stress, anxiety and substance abuse. 2,3,5national survey of medical students, residents, and physicians in practice for less than 5 years in the United States (USA) revealed statistically higher rates of burnout and depression when compared to peers in the general population.6 This coincides with literature revealing poor WLB amongst nurses and doctors.1,[6][7][8][9] A further cause of concern is the association between burnout and an increase in errors by healthcare professionals.10,11 Residency years represent a time of stress due to an ever-increasing workload which must be balanced with the attainment of new skills in a specific specialty.This makes WLB an important issue amongst residents. Crrent literature reveals an alarming incidence of burnout and work-life conflict amongst residents in surgical as well as non-surgical specialties.[12][13][14] The current study was planned to assess WLB among residents at a private-sector tertiary hospital.

Subjects and Methods
The cross-sectional study was conducted from September to December 2016 at a private-sector tertiary care teaching hospital in Karachi, and comprised medical residents working at the facility.All the residents were approached for participation and those who furnished informed consent were enrolled.The questionnaire was a modified version of what was used by a study to assess WLB amongst surgeons in Hong Kong. 15The Canadian Mental Health Association's quizon WLB was also utilised in designing the questionnaire. 16The final questionnaire involved elements from both sources.The questionnaire and the study protocol were approved by the ethics review committee of Aga Khan University (AKU), Karachi.The questionnaire (Appendix) contained 4 sections.The first section had questions on socio-demographic factors, such as age, gender, marital status, medical school and year of graduation.Participants were also asked if they had ever heard of WLB and to assess whether their life had WLB.
The second section assessed satisfaction levels of the respondents.This included satisfaction related to work, outside work, and with their general health condition.
The third section included questions on various aspects of work life, including the ability of the respondents to cope with the amount of work they were dealing with on a daily basis and overall attitudes related to their workplace, their satisfaction with the faculty and questions related to the emotional status of the respondents.Finally, the respondents were asked to give suggestions for improvement in WLB.
Data was coded and analysed using SPSS 20.Mean and standard deviation (SD) were calculated for continuous variables.The questionnaire also asked the respondents if they felt their life had WLB.This was considered a discrete parameter and reflected levels of WLB amongst the respondents.Hence, correlations between this parameter and other discrete parameters, such as marital status, were analysed using Chi-squared test.P<0.05 was considered significant.Correlations were calculated using Pearson's correlation.
Overall, 146(53.1%)subjects said they seldom had the opportunity of learning new things via patient care, and 89(32.4%)felttheir work was sometimes appreciated.In emotional aspects, 165(60%) residents felt their job had negatively affected their private lives, and 118(42.9%)felt    stressed the need for a friendly faculty (Figure ).
The satisfaction with WLB did not differ between genders, specialties, or any other element (Table -3).The only elements significantly associated with WLB were pay scale (p<0.001) and the level of postgraduate training (p=0.034).

Discussion
Work-life balance is important for keeping an individual productive.There is an increasing realisation of the importance of WLB in various professions.][19] Realisation of the importance of WLB in medicine came much later.Work-hour reforms in 2002 can be considered a realisation of the impact of burnout and work-life imbalance.
Most of the work on physician burnout and WLB has been done in the West, particularly the United States.Physicians in developing countries tend to carry more stress as physician-to-patient ratio is amongst the lowest in the world. 20Physicians in developing countries are also frequently underpaid.Trainee physicians or residents are therefore highly vulnerable to burnout and exhaustion.Despite its significance, WLB has not been studied adequately in developing countries.
The current study presents the views of a large group of residents from different specialties and showed that 95.3% of them were dissatisfied with their WLB.This figure is much higher compared to 42% in a similar study from Canada 21 and 32% in Switzerland. 22Post-graduate level of training was significantly associated with WLB.Residents in second and third years of training were more dissatisfied with their WLB.Of the 141 residents in year II and III, only 1 was satisfied with his WLB.Most residents were dissatisfied with the pay scale, and suggested an increase in pay to improve WLB.While an improvement in the pay scale would not change the amount of time spent on social activities, it may lead to a greater appreciation of their work and quality of time.Several other studies support these findings. 12,21,22is is further illustrated in a study comprising obstetrics and gynaecology residents in Canada.It was clearly seen that a desire for an improvement in WLB amongst residents had a key influence on future decisions related to their profession. 23study on Swiss residents showed no impact of gender or choice of specialty on WLB, which is consistent with the observations of our study. 22owever, various studies have listed down gender as an important factor.Men who are married tend to look forward to and are happier at work compared to women. 24,25Moreover, women are more likely to be unmarried and have fewer children overall compared to men. 24Spousal support is thought to be a protective factor against burnout. 12Hence, this may explain why women are more likely to experience burnout compared to men. 12 Female residents are also at a higher risk for emotional exhaustion compared to their male peers. 12,24,25st residents suggested a reduction in work hours and increment in salary.Long work hours are a major cause of burnout and higher grades of burnout are negatively related to WLB as seen in a study on otolaryngology residents in the US. 12 Another study focusing on the impact of the Accreditation Council for Graduate Medical Education (ACGME)'s duty hour restrictions on general surgery interns in the US reveals a different perspective. 26Some residents reported dissatisfaction with aspects of their work life.In particular, it was believed that the rules had negatively affected continuity of care and time spent in the operation room (OR). 26Moreover, less than half the respondents believed that there had been a reduction in their fatigue levels after the new duty hour restrictions. 26esides, 32% still reported "very poor" or "not great" WLB. 26 One in seven respondents also expressed a desire to give up their career in surgery on "at least a weekly basis." 26Similar results were also seen in a review of the pros and cons of duty hour restrictions. 27These restrictions appear to have resulted in an increase in emotional exhaustion and stress amongst residents. 27his shows that a simple reduction in work hours may not be enough to improve satisfaction with work life and WLB in general.
Improving WLB would require a combination of measures, such as a reduction in work hours, greater mentorship and support from respective departments as well as their faculty.Clarity of assignment and learning outlines are also relevant issues as seen from our results.Mentorship is necessary for professional growth, especially in developing countries with lessthan-ideal training facilities and growth opportunities. 28,29ere are several limitations to the current study.Despite the large sample size, the response rate to the questionnaire was 57.29%.One reason could be the length of the questionnaire.Some of them said that filling such a questionnaire won't change anything.The other limitation is that the data relates to a single centre which may not be generalisable.The sample size was also not pre-calculated as we wanted to reach out to the maximum number of residents in different specialties.Yet, we believe that our study has raised an important and relevant issue that we intend to take forward.
WLB is a serious problem in developing countries that needs the will and the motivation of physicians, mentors, hospital administrations and policy-makers.

Conclusion
There was a lack of WLB in most of the responding residents.This imbalance appeared multifactorial and would need increased efforts from physicians, mentors and hospital administrations.Disclaimer: None.

Figure :
Figure: Suggestion given by resident for improvement in WLB.
. A. Khan, M. Waqas, M. Siddiqui, et al Is your work recognized and appreciated by faculty?Are treated fairly at your workplace?Does your work have clear objectives?Do you know exactly what is expected of you at work?To what extent would you say that your immediate superior gives high priority to job satisfaction?To what extent would you say that your immediate superior is good at patient care?How often is your nearest superior willing to listen to your problems at work?How often do you get help and support from your nearest superior?Regarding your work in general.How pleased are you with your job as a whole, everything taken into consideration?Do you feel that your work drains so much of your energy that it has a negative effect on your private life?Do you feel that your work takes so much of your time that it has a negative effect on your private life?Can you trust the information that comes from the faculty?Does the management trust the faculty to do their work well?Are conflicts resolve in a fair way?Is the work distributed fairly?How often have you felt worn out?How often have you been emotionally exhausted due to work?How often have you been stressed because due to work?How often you have been irritable due to work?
J Pak Med Assoc254 S

Table - 1
: Characteristics of the participants.

Table - 2
: Resident's response to questions on work hours and satisfaction.
* Chi-square test, other values measured using correlation.