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February 2012, Volume 62, Issue 2

Letter to the Editor

Going beyond the resident duty hours in Pakistan

Madam, we have read" Resident duty hours: Globally accepted standards and the situation in Pakistan" by Juma and Hosein1 with interest. We think that they have highlighted an important problem which is usually brushed under the carpets as it doesn\'t affect the senior faculty and policy makers in the Pakistani health care system. But duty hours are only part of the problem that residents face in Pakistan.
The residents/trainees are the vital pillars of Pakistani health care system. They do most of the clinical work, work in long shifts without breaks, bear the brunt of the patients (and their relative\'s anger) in case they are unsatisfied and are frequently academically exploited by consultants. This is in addition to the poor pay system, current socio-political unrest and burden of fulfilling their responsibilities towards their families. The sad part is that when these residents qualify their exams and cross over to other side of the line joining the consultants, they forget the mistreatment they suffered and engage in the same unhealthy (and often unethical) behavior towards residents.
The Accreditation Council for Graduate Medical Education (ACGME) which evaluates and accredits medical residency programmes in the United States overlooks more than 8,500 residency programmes and > 100,000 residents all around the USA.2 It has a separate section dedicated to the resident\'s duty hours,3 which has extensive resources about resident duty hours, its financial implications, glossary and frequently asked questions. The salient features of the revised 2011 guidelines for resident duty hours are as follows.4
* Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
* Residents must be provided with one day in seven free from all educational and clinical responsibilities, averaged over a four-week period, inclusive of call.
* Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call.
* The programme must ensure that qualified faculty provides appropriate supervision of residents in patient care activities.
In Pakistan apart from the long duty hours, residents have to face other problems as well. A resident is dependent on his supervisor /Consultant for his/her experience certificate, approval of dissertation, and maintenance of log book. Unfortunately many of the consultants do not fulfill their responsibilities towards their residents and the residents are unable to express themselves for the fear of repercussions in form of not getting their experience certificates and log books signed. It is not uncommon for senior faculty to ask the residents to write articles for them and some go beyond all limits to force them to include their family members as co-authors.5
Bullying of junior doctors including residents is another neglected and underreported issue.6 A large cross sectional survey demonstrated that 63% of the junior doctors faced bullying with consultants being the main culprits (51.6%).6 Most of them (73.4%) did not even lodge a complaint as they were afraid of the consequences (23.3%). The most common bullying behaviour reported was persistent unjustified criticism and persistent attempts to disregard and undermine their work.
Poor work conditions for the residents are another thorny issue. While senior medical administrators and consultants have their well furnished and air conditioned offices, residents are often seen sweating in the OPD and hanging around in patients cafeterias. The resident rooms are often poorly maintained and residents themselves have to arrange the basic amenities. Poor working and hygienic conditions of residents have been cited as one of the reasons for migration to train abroad7 and they also act as a demotivator.8
Dissertation writing, a mandatory part of the fellowship training is also, a hurdle for many residents.9 Majority of the trainees have no experience of medical writing and research at the undergraduate level. With a busy routine, OPDs and night calls it sometimes becomes difficult to learn this science. Many a times trainees then indulge in shortcuts and unethical practices of plagiarism and data fabrication. When such practices are present in the system, the quality of trainees and trainers is compromised.
There is a need to address these problems of the residents who are the back bone of the clinical management system of the patients. Pakistan Medical and Dental council along with College of physicians and surgeons of Pakistan should take steps to tackle these problems which are never voiced or acknowledged. We propose that like trainee evaluation by the supervisor, a supervisor feedback evaluation by the trainee should be introduced and it will facilitate to strengthen the training programme. Faculty should be more proactive in guiding the residents and involving them in the clinical and academic activities to enhance their learning experience. The hospital administrations should facilitate the on call residents.
Unless we admit the truth and work hard towards better residency programmes we will see more and more young doctors and residents leaving the country for the greener pastures, never to return.
Disclaimer: Neither of the authors is a current resident. Both are qualified and happily practicing /teaching faculty members in their respective fields.
 
Farooq Azam Rathore,1 Fareeha Farooq2
Rehabilitation Medicine, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi,1 Park View Town, Park Road, Islamabad.2

References

1.Juma AAM, Hosein S. Resident duty hours: Globally accepted standards and the situation in Pakistan. J Pak Med Assoc 2011; 61: 1253.
2.The Accreditation Council for Graduate Medical Education at a Glance. (Online) (Cited 2011 Nov 29). Available from URL: http://www.acgme.org/acWebsite/newsRoom/newsRm_acGlance.asp.
3.ACGME duty hours. (Online) (Cited 2011 Nov 29). Available from URL: http://www.acgme.org/acWebsite/dutyHours/dh_index.asp.
4.ACGME Task Force on Quality Care and Professionalism. The ACGME 2011 Duty Hour Standards: Enhancing Quality of Care, Supervision, and Resident Professional Development . 2011 Accreditation Council for Graduate Medical Education (ACGME) Chicago, IL.
5.Pakmedinet discussion forum: Pakistani Medical Journals. (Online) (Cited 2011 Nov 29). Available from URL: http://www.pakmedinet.com/ forum/viewtopic.php?TopicID=1695.
6.Imran N, Jawaid M, Haider II, Masood Z. Bullying of junior doctors in Pakistan: a cross-sectional survey. Singapore Med J 2010; 51: 592-5.
7.Imran N, Azeem Z, Haider II, Amjad N, Bhatti MR. Brain Drain: Post Graduation Migration Intentions and the influencing factors among Medical Graduates from Lahore, Pakistan. BMC Res Notes 2011; 4: 417.
8.Malik AA, Yamamoto SS, Souares A, Malik Z, Sauerborn R. Brain Drain: Motivational determinants among physicians in Lahore, Pakistan. BMC Res Notes 2010; 201.
9.Haider J. Problems encountered by post graduate trainee during dissertation writing. Pak J Med Sci 2009; 25: 520-1.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: