Effect of Long Duty Hours on Physical and Social

Dimensions of Young Doctors. A cross-sectional study

from Peshawar.

BATCH NO: 19

Patron in Chief:
Prof. Dr. Bushra Iftikhar
HOD
Supervisor:
Asst Prof. Dr. Imran Ullah
PROJECT DIRECTOR:
MUHAMMAD SHOAIB
Submitted By:
BATCH 19
Session 2022-2027

Department of Community Medicine

Khyber Medical College, Peshawar

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Declaration:
This report comprises of our original research work performed under the Department of

Community Medicine, Khyber Medical College, Peshawar. This work is the property of the

Community Medicine Department and can solely be published by them. Due citations and

acknowledgments have been made in the text and bibliography to all other material used.

This research proposal comprises of our original research idea and research question. We

declare that this topic has not been researched/published or submitted in any forum, and no

part of it has been plagiarized.

Muhammad Shoaib

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DEPARTMENT OF COMMUNITY MEDICINE AND PUBLIC HEALTH
KHYBER MEDICAL COLLEGE PESHAWAR
APPROVAL SHEET
It is stated that Batch No.19 of 4th year MBBS session 2022-2027 of Khyber Medical College

Peshawar is hereby given approval by the Department of Community medicine and Public

Health, Khyber Medical College Peshawar, to do the research work on the topic entitled

“Effect of Long Duty Hours on Physical and Social Dimensions of Young Doctors. A

cross-sectional study from Peshawar” under the supervision of the same department.

Patron in chief

Prof. Dr Bushra Iftikhar

Department of Community Medicine

Khyber Medical College, Peshawar

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DEPARTMENT OF COMMUNITY MEDICINE AND PUBLIC HEALTH
KHYBER MEDICAL COLLEGE, PESHAWAR

SUPERVISOR’S CERTIFICATE
This is to certify that Batch no.19 (session 2022-2027) has worked under my supervision for

the project “Effect of Long Duty Hours on Physical and Social Dimensions of

Young Doctors. A cross-sectional study from Peshawar.”

I checked the project and approved their efforts.

Asst. Prof. Dr. IMRAN ULLAH

Dated:...........................................................

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Acknowledgements:

Foremost, we would like to express our sincere gratitude to the Department of Community

Medicine and our esteemed teacher, Dr. Imran Ullah, for his encouragement and insightful

comments. We would like to thank Dr. Sidra Irfan for her motivation and continuous

support in research. Her mentorship, marked by sagacity, illuminated every path we traversed

in our quest for knowledge. In addition, Dr. Imran Marwat for his unwavering efforts and

help to make this research report the best it could be. We would like to thank the Departments

of Medicine, Surgery, Eye, ENT, Pulmonology, Dermatology, Urology, Gynaecology,

Psychiatry, Orthopaedic, Nephrology, Anaesthesia, Oncology, and Neurosurgery for allowing

us to conduct research in their respective departments and providing us help where we

needed.

Muhammad Shoaib

Project Director
Batch 19
4th year MBBS
(Session 2022-2027)

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 ORGANIZATION AND BATCH MEMBERS
Research Supervisor: Asst. Prof. Dr. Imran Ullah
Research Director: Muhammad Shoaib
Assistant Director: Asad Nawaz

Name Class number

Muhammad Shoaib 197

Asad Nawaz 248

Sidra Noor 57

Ahtesham Ul Haq 219

Kashif Mehmood 205

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 TABLE OF CONTENTS
Declaration …………………………………………………………………………………. 4
Acknowledgements …………………………………………………………..……………... 7
List of Tables ………………………………………………………………….………….. 10
List of Figures ……………………………………………………………………………..10
Abbreviations ...………...………………………………………………………………….11
Abstract ……………….…………………………………………………………………....12
Introduction ……………………………………………………………………………….. 15
Literature Review ………………………………………………………………………….22
Study Objectives ………………………………………………………………………….. 30
Operational Definition ……………………………………………………………………31
Material and Methods. .……………………………………………………………………33
Ethical Consideration ……………………………………………………………………...35
Results …………………………………………………………………………………..... 37
Discussions ………………………………………………………………………………. 45
Acknowledgment and Limitations………………………………………………………….49
Recommendation………………………………………………………………………….51
Conclusion …………………………………………………………………………….....53
References ……………………………………………………………………………….55
Questionnaire ……………………………………………………………………………. 61

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 LIST OF TABLES

TABLE 1: DEMOGRAPHICS......................................................................................
TABLE 2: OUTCOMES WITH RESPECT TO EACH WARD...................................
TABLE 3: OUTCOMES...................................................................................................

LIST OF FIGURES

Figure1: Number of participants in each ward …………………………………………………………….

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 Abbreviations
MVCs Motor vehicle crashes
HS House staff
ED Emergency department
BBFs Blood and body borne fluids
NSIs Needle stick injuries
OPD Outpatient department
HOs House officer
PGR Post graduate resident
MO Medical officer
SR Senior registrar
CCHF Crimean Congo hemorrhagic fever
ILO International labor organization
ACGME Accreditation council for graduate medical education
WHO World health organization
CVD Cerebrovascular disease
OBBFEs Occupational blood and body fluid exposures
OFEs Occupational fluid exposure

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 CHAPTER 01

ABSTRACT

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Abstract:

Background: Long duty hours can lead to deprivation of sleep, fatigue, and mental strain,

which can be associated with deteriorating doctor’s health. Long duty hours could be a

significant cause of percutaneous injuries and motor vehicle crashes among doctors. These

are also significant factors in restraining doctors from social interactions and managing their

daily activities. We aimed to assess the relationship of long duty hours on the physical and

social dimensions of doctors.

Objective: This study aims to investigate the relationship of long duty hours to the physical

health and social interactions of doctors.

Methods: A cross-sectional study was conducted among a sample of 384 doctors in three

tertiary care hospitals in Peshawar. The study duration was three months. Non-random

convenience sampling method was used to collect data from the participants by the

interviewee. All the doctors below the designation of assistant professor were included in the

sample population.

Results: There were 384 participants in this study, out which females were 104 (27.1%) and

males were 280 (72.9%). Out of 384, 130 (33.9%) were married and 254 (66.1%) were

single, while 149 (38.8%) were day-scholars and 235 (61.2%) were Hostilities. There were

24 (6.3%) in Anesthesia, 10 (2.6%) in Cardiology, 27 (7.0%) in Dermatology, 26 (6.8%) in

ENT, 20 (5.2%) in Eye, 34 (8.9%) in Gynecology, 66 (17.2%) in Medicine, 12 (3.1%) in

Neurology, 11 (2.9%) in Nephrology, 2 (0.5%) in Oncology, 20 (5.2%) in Orthopedics, 27

(7.0%) in Paeds, 11 (2.9%) in Pulmonology, 1 (0.3%) Radiology and 93 (24.1%) in Surgery.

There were 195 (50.8%) HOs, 32 (8.3%) MOs, 138 (35.9%) PGRs, 13 (5%). Mean

experience of every participant was 16.2 ± 21.54 months. Total weekly physical work hours

were 56.3 ± 12.47 h, while continuous work hours without sleep were 20.1 ± 5.66 h, outside

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work hours were 8.3 ± 7.46 h. The participants, on average, slept 3.5 ± 3.41 h at the

workplace while they slept 37.8 ± 19.77h outside the workplace in a whole week. Average

weekly rest days were 0.8 ± 0.4 days per week. 291 (75.8%) participants reported at least one

nod during work or study-related activity, while the average nods per week for the

participants were 2.6 ± 3.07. Out of 384, 53 (13.8%) faced crashes while they were diving,

131 (34.1%) had an OFEs while 88 (22.9%) caused OFE to patients, 111 (28.9%) participants

think that the safety measures in place were inadequate with 205 (53.4%) facing health

issues. Out of 384, 175 (45.6%) faced strains in their relationships, 218 (56.8%) think they

don’t have time for leisure activities, 154 (40.1%) had a hard time attending social gatherings,

and 131 (34.1%) think they don’t have a positive work-life balance.

Conclusions: This study provided important information regarding the physical and social

aspects of the lives of young doctors in relation to the long duty hours, but it was unable to

find any association between long duty hours and their impact on the physical and social

dimensions of the lives of young doctors. But it also brings to light the grim situation of the

residents and doctors in Pakistan.

Key words: long duty hours, physical dimension, social interactions, motor vehicle crashes,

occupational fluid exposure, work-life balance, leisure time.

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 CHAPTER 2:
INTRODUCTION

Introduction:

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Enduring long duty hours alongside the social and physical challenges they accompany has

become an unyielding challenge of the modern-day world and society. The healthcare system

has been revolutionized ever since it has started, bringing happiness, joy and healing for the

humanity. It has been a blessing for the human race, but on the flip side, it was never possible

without the sacrifices of those who are there for others regardless of the time. One can access

the healthcare system even at night or during the wartime.

Industrialization has certainly been the greatest marvel of the human history, which has made

many luxuries possible. It was only possible due to the adaptation of the scientific method

and that same method killed the former medicine and paved the road for a more evidence-

based medicine(1). The lifetime discoveries of many scientists have led to the rapid rise of

modern interventions, increasing the average human life by more than 30 years than it was in

the preindustrial era. Emergency medicine has reduced the number of deaths from fatal

injuries compared to what they used to be previously.

It won’t be wrong to say that healthcare has become a pivot in the modern society and

economy. We might need more improvements, yet the results are at all time high. This has put

a lot of burden on the doctors and paramedical staff of the hospitals. Young doctors are

especially prone to this due to their long working hours, which start with their graduation and

continue until they complete their training and reach a certain level of maturity in their

practice. Data from different departments in USA have indicated that the prevalence of

MVCs among residents and HS stand between 7.9% - 24.6%(2) which translates to be ¼th of

the junior doctors. Another study on the residents of ED in USA stated that 8%(3) of the

residents reported crashes while 58%(3) reported to involved in any sort of near crashes.

OFE is a major concern in the field of medicine, causing the spread of many serious

infections, including HIV, Hep-B, and Hep-C from patients to doctors and vice versa. A study

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conducted at the University of Gondar, Ethiopia, it was claimed that 58.5% of participants

were exposed to BBFs, while it was 42.2% of the participants were exposed to NSIs at least

once in their lifetime.

Times are changing, and the field of Medicine is evolving too. A doctor who was once

expected to just cure the disease of a patient is now considered to be an all-round performer,

treating illnesses, updating knowledge regarding the new discoveries, publishing his/her own

new research observations from case reports and cohorts, and even conducting clinical trials

for newer drugs and interventions. At the same time, a young doctor has to perform long-duty

hours for the sake of learning and research; publishing and electives are also there just for the

sake of career advancement, not to mention the vast amount of knowledge they have to

absorb each day.

Long hours also pose many health-related challenges to the young doctors, including fatigue,

sleep deprivation, stress, burnout, sedentary lifestyle, and substance abuse. The prevalence of

substance abuse among American physicians stood at 12.9% and 21.4% for males and

females, respectively (4) which ultimately leads to depression, suicidal thoughts, and lack of

career satisfaction. It also has a strong association with recent medical errors (p = 0011) (4).

Apart from the health hazards during the job, the work hours are ridiculously high for the

junior doctors, especially House Officers. Some might even work more than 100h/d(5) with

mere compensation money along with many continuous hours of sleep deprivation, toxic

work culture, and rigorous workload. Due to this toxic work environment, poor performance

of the economy, lack of reforms, unemployment among medical graduates, many graduates

and young doctors leave the country for better prospects in countries like the USA, UK, or

even Middle Eastern countries. The recent trend has been alarming, as 800,000 Pakistanis

leaving the country, including 100,000 doctors, nurses, Engineers(6). Situation might not get

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good for those graduates even in those countries as a report from BMJ stated that British

hospitals exploit those foreign graduates(7).

According to The DAWN (8), in the KPK province of Pakistan, young doctors might even

stay in the wards for more than 48h. This doesn’t reflect the weekly work hours but the

continuous time they have to be in the wards attending almost 8 patients at a time, excluding

their OPD duties. Many hospitals are severely understaffed, and they depend on the HOs for

even basic tasks. According to a study (9), the prevalence of sleep deprivation among the

undergraduates, including the PGRs and HOs turned out to be 79%. This can be directly

attributed to their rigorous and hard job.

Covid-19 has had a major impact on the lifestyle, habits, and mental status of people around

the globe. But doctors were the professionals who were directly affected by it including the

obvious hazards due to handling the covid patients resulting the unfortunate deaths of many

doctors but also indirect effects it had on their mental peace. There was also a lack of

protective gear(10) for the doctors, increasing the risk of direct exposure to a deadly bug. The

situation remains almost the same for the post –COVID time in Pakistan with doctors still

getting neglected for the infrastructure and safety equipment. Recently, 11 healthcare

providers from Quetta were infected while treating two patients with CCHF, and one of them

died while being transported to Karachi (11).

The demanding nature of modern healthcare requires the presence of doctors round the

clock to provide essential care to the patients. While the doctors are devoted to their

profession, the impact these long hours leave on their physical and social well-being is a

matter of growing concern. This research delves into the relationship strain among doctors, a

phenomenon that is aggravated by extended working hours. As they spend most of their time

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at work, they have a less time for their non-duty activities, family responsibilities, and

commitments, which in turn affects their health and well-being, social relationships, and

family life. These parameters have a negative effect, which can lead to their relationship

strains and may also affect their clinical assessment. A study shows that 11.6% (12) of the

variance in the work-family conflict may be explained by working hours.

Work-life balance, as defined in the Cambridge Dictionary, is the amount of time you spend

doing your job compared with the amount of time you spend with your family and doing

things you enjoy. So, if the demands of the work increase there would be less time to handle

other responsibilities. Thus, achieving a healthy work life balance is vital for the well-being

of young doctors (13). Thus, proper balance ensures that doctors can recharge, which would

lead to improved job satisfaction, enhanced patient care, and maintaining family

relationships. In the case of doctors, the work requirements are the professional culture,

exams, on-call commitments, and patient care stressors, while their enjoyment may include

their social life, which consists of family and friends, hobbies, relaxation, and fulfillment of

personal needs. Thus, maintaining all these with extended duty hours is somewhat difficult,

and doctors face challenges in their balance.

Leisure time is significantly important in maintaining a healthy lifestyle. Thus, prolonged

working hours will eventually lessen the amount of leisure time, affecting their ability to

engage in outside activities. This then leads to stress, fatigue, and a feeling of burnout. As a

result of less leisure time, the doctors might struggle in maintaining a healthy lifestyle, which

consists of regular exercise and adequate sleep. Thus, enough leisure time allows doctors to

engage in activities that bring them joy and happiness. These then act to reduce stress and

promote mental and emotional well-being. Healthcare systems need to recognize the

importance of leisure time to lessen the negative effects that are generated due to these long

duty hours. Certain policies must be introduced, like regular breaks between duty hours and

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decreasing the duty hours so that doctors can also enjoy their lives and maintain a healthy

lifestyle as well.

There is a shortage (14) (15) of doctors in Pakistan, which significantly impacts long duty

hours. As there are fewer doctors, so the doctors that are already working have to do extended

shifts in order to cope with the rising diseases and ailments, and the number of patients. This

then leads to prolonged and exhausting shifts that have a negative effect on the physical and

social dimensions of these doctors. This shortage leads to delayed patient care and

compromised quality of services. Thus, the doctors working overtime would get less leisure

time and less sleep duration, which would significantly lead to their deterioration of health

and overall well-being. Thus, by increasing the number of medical professionals, the duty

hours would get decreased, and this would have a positive influence on the patient care and

also on the well-being of the doctors.

Long working hours are damaging to doctors’ well-being and have a significant effect on

patient care. Doctors can develop illnesses like insomnia as they don't have sufficient time to

take naps and to socialize outside of work. Their working hours must be reduced (16).

Accidents also happen due to these long working hours, which endanger human lives. When

doctors are exhausted, they also cannot treat patients to their fullest, which is a cause of

mistrust between patients and doctors, and this could imply that the doctors are being wilfully

negligent.

In modern times, the well-being of medical professionals stands as the foundation of the

medical system. The focus of our research is on the physical well-being and social aspect of

doctors. As the demands of the medical profession multiply, understanding the relationship

between long duty hours, physical well-being, and social life of doctors becomes important.

This research not only identifies the challenges faced by doctors but also illuminates potential

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solutions. We aim to contribute in making of such a healthcare system where professionals

who dedicate their lives treating the sick also enjoy amenities of life themselves.

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 CHAPTER: 3

LITERATURE REVIEW

Literature review:

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Imagine living in the 21st st century and being unable to successfully eliminate the burden of

extended work hours. Long duty hours can be defined as working an increased number of

work hours than one is supposed to work. According to the International Labour Organization

(17), a maximum cutoff limit for the weekly work hours is 40h/week and still the standard of

living of the people shouldn’t decrease. According to the National labour law of the Islamic

Republic of Pakistan, Section 8 of the West Pakistan Shops and Establishments Ordinance

1969, maximum work hours are 48h per week(18). The first

First ILO convention was adopted in 1919, where regulations regarding the work hours and

safety of the industrial workers were established (19). The work hours were restricted at

48/week. Since then, many conventions have been adopted by the member states, including

40h/week schedule, paid leaves, rest days, reduction of hours, night work convention, and

part-time work convention. According to a report by ILO dated June 2007 (20), Pakistan was

4th worst among developing countries regarding the incidence of long working hours (more

than 48/week) standing at 44.4% between the period of 2004-2005.

As per international standards, work hours should be kept below 40 hours per week, but still

this feat is dream for young doctors and residents working as trainees in different teaching

hospitals around the world. According to a survey in US(21), 51% of clinicians were working

more than 71h/week. The hallmark of the 20th century was absurdly long working hours for

the trainee doctors in the name of learning. Situation isn’t very good even today with work

hours still very high. ACGME in US capped resident working hours at no more than

80h/week(22) which is still very high as compared to 40h work week for many other

workplace environments. Despite of this, interns still work more than 80h/ week as they have

to finish their outstanding work. So real working hours highly exceed the capped limit(23).

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If we generally outline the effects of long working hours on humans, the list would be very

diverse. Starting from the most obvious ones including burnout, sleep loss, and fatigue (24),

decline of cognitive function (25), low problem-solving capability, decreased quality of the

output(26) and decreased job satisfaction(27) (28). Including all these general effects, there

are more specific outcomes affecting only the field of medicine, including increased non-

medical errors, BBF exposures, and increased number of NSIs. There are other factors that

affect the quality of life of the medical professional, including his/her own work-life balance

(28), mental health (29), leisure time, and his personal relationships.

Effects of long working hours:

Overall effects of long working hours have been described previously. In this part we tend to

explain these effects in a detailed manner

(i) Sleep loss and fatigue: An obvious result of long working hours and especially

continuous working hours, exactly what happens in the call, when a resident has

to do an extra continuous shift in the hospital. The medical industry is unlike

others; patient care is a round-the-clock duty. It is especially true for the

emergencies or in case of accidents. Sleep deprivation (30) affects numerous

aspects of the of our lives, including overall quality of work, emotional well-

being, cognitive function. Sleep deprived doctors make mistakes resulting

negative impact on both patient outcome and doctor’s integrity. With sleep

loss(31) a person exhibits progressive delayed reflexes and a tendency to sleep

(few milli seconds of sleep is called microsleep). They also fail to set task priority

or appropriately allocate attention. Acute shortness of sleep(32) can cause lapses

in concentration and fatigue, which can increase the risk of occupational injuries

and self-reported errors. Chronic sleep deprivation(33) can cause obesity, diabetes,

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 decreased glucose tolerance, CVD and hypertension, alcohol use disorder, and

Anxiety symptoms.

(ii) Decline of cognitive functions: Cognitive functions mean multiple mental

abilities, including learning, thinking, reasoning, remembering, problem-solving,

decision making, and attention. Although a decline in cognitive function (34) can

be attributed to age, genetics, learning, health, deteriorating disease, and

environmental factors. Apart from that, there is also a risk associated with

extended working hours. According to Lee et al (35), there is an overall HR of

1.13 for both sexes for extended duty hours and loss of cognitive function but it is

1.5 for women. There is a higher risk of dementia among the permanent night shift

workers, those who work extended shifts(36). Although no data available is

conclusive for a strong association between longer shifts, there is an insignificant

positive relationship among them (which can be attributed to chance).

(iii) Medical errors: It can be defined as a diverse group of events that vary in their

magnitude and their potential harm to the patients(37). They can be a preventable

error, significant error, or an error leading to an adverse event. Long work hours

have been associated with an increased number of all three types of errors. Barger

et al(38) found an odds ratio of 3.5 (during the month with 1 long shift) and 7.5

(when there were 4 long shifts) between long hours and significant medical errors

due to fatigue. Similar odds ratios of 8.7 and 7.0 were found with preventable

medical errors. There is also literature that supports the idea that there is

essentially no difference among the patient outcomes among those residents who

had ACGME(22) work schedule and those who chose to work with a more

flexible schedule. These trials were conducted on the residents of Surgery and

Internal medicine where they found that there was no difference among the two

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 groups supporting the idea that long shift hours don’t lead to an adverse

outcome(39) (40). However, regarding the learning opportunities, the group with

flexible work hours performed worse than those who were working standard

working hours(41).

(iv) Personal Relationships: As previously discussed, long work hours lead to

increased risk of anxiety and fatigue. This can indirectly lead to their personal

relationship strains. A study among the American surgeons stated that only 36% of

participants had enough time left for their family and personal life(42). For the

couples where both partners work, the scenario is a bit tricky for genders. The

amount of stress felt by the women, coupled with men working long hours is

increased, while men having wives working long sifts don’t have increased stress,

the reason being that their female counterparts have more home responsibility

than male counterparts(43). Similarly, another study(44) conducted on working

women in D.G Khan area of Pakistan concluded that 45% of women strongly

agreed that relationships were negatively impacted due to females working long

hours.

(v) Occupational exposures: Occupational exposure to blood and body fluids is

accidental contact with blood and body fluids during a medical intervention. It can

result from percutaneous and mucocutaneous injury or blood contact with the

eyes, mouth, nose, or non-intact skin. The most common means of exposure to

blood and body fluids happen to be NSIs. These exposures occur while the doctor

is performing activities like taking blood samples, giving injections, surgery,

giving emergency care and recapping already used needles. While performing

these activities doctors are at risk of acquiring infections via blood and body fluid

exposure. The main concern is the transmission of blood borne infections such as

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 HIV, hepatitis B virus and hepatitis C virus. Other pathogens like bacteria and

parasites can also be transmitted. According to WHO data(45), 35.7 million

HCWs in the world are exposed to the risks of NSIs. There is a study(46) which

shows that 136 doctors reported OBBFES out of 175. This is quite a large

proportion of doctors that had contact. These exposures occurred when doctors

were working >12 h shifts. This shows that working long duty hours can lead to

fatigue and burnout that then lead to these drastic effects. Another study(47)

shows that, of the total 241 (87%) study participants had been exposed to blood

and other body fluids in their lifetime. While describing NSIs one study(48)

showed that there was a total of 32 reported episodes of NSIs out of 153 HCWs.

(vi) Work life balance: Burnout is a state of physical and emotional exhaustion that

leads to decreased effectiveness and loss of interest at work. A study(49)

conducted in the US showed the percentage of burnout and dissatisfaction of

physicians with their work life balance. About 37.9% of physicians were likely to

have symptoms of burnout and 40.2% dissatisfied with their work life balance.

Differences in satisfaction with work life balance were observed by specialty and

the specialties with low burnout (dermatology, general paediatrics) had the highest

rated satisfaction with work life balance, whereas physicians practicing general

surgery, general surgery subspecialties and obstetrics/gynaecology had the lowest

rate of job satisfaction. Another study(50) shows the work life and satisfaction of

general internists. Specialty satisfaction was to be significantly lower for these

doctors. This was also found that the internists spent more of their work week in

the hospital than family physicians. Higher satisfaction for general internists was

associated with older physician age, fewer work hours and less time pressure. A

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 study(51) conducted in Pakistan stated that 73% (1045 out of 1406) were satisfied

with their work life balance.

(vii) Motor vehicle crashes: Long duty hours can affect sleep, productivity, and safety

of the doctors. Medical doctors are often subjected to long duty hours with

minimal rest in between the shifts. This has led to many fatal and non-fatal motor

vehicle crashes. A safety group at Harvard University(52) when looked into the

behavior of those in training in hospitals found that interns' odds of crashing more

than double as work hours increase. Interns also experienced more than five times

as many near misses as non-sleep deprived drivers. In a study(53) among house

staff (HS) revealed that HS slept 2.7±0.9 when on call. 44% of HS fell asleep

when stopped at a red light, 23% fell asleep while driving. A total of 49% of HS

had fallen asleep at the wheel, and 90% of these events occurred post-call. HS

were involved in a total of 20 motor vehicle accidents. Another study (3) showed

that 76 residents (8%) reported having 96 crashes, and 553 (58%) residents

reported being involved in 1446 crashes. Nearly three-fourths of the motor vehicle

crashes and 80% of the near crashes followed the night shift. In another study

(54), the odds ratio for reporting a motor vehicle crash and for reporting a near

miss incident after an extended work shift as compared with a shift that was not

extended, were 2.3 and 5.9 respectively. Moreover, every extended work shift in a

month increased the monthly risk of motor vehicle crashes by 9.1% and increased

the monthly risk of a crash during a commute from work by 16.2%.

The hours worked by doctors are of grave concern worldwide. Specifically, in hospitals, these

long hours are often worked in a demanding, stressful environment in which there is a

necessity to make critical decisions within a limited timeframe. It is unsurprising in such an

environment that mistakes occur. After working these many hours, anyone would be at risk of

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having impaired cognitive functioning with little sleep in a stressful and mentally challenging

environment. Through surveys of residents in the US before (2002-2007) and after (2014-

2017) the limit was enacted, they found that resident-physician-reported medical errors and

adverse events dropped by more than a third, and medical errors resulting in patient death

declined by more than two-thirds when there was a 16-hour limit in place. After analyzing the

data, they found that there was a 32 percent reduction in reports of significant medical errors,

a 34 percent reduction in reported preventable adverse events, and a 63 percent reduction in

reported medical errors resulting in patient death.

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 CHAPTER: 4

STUDY OBJECTIVES

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Study Objectives:

The study aims at:

1. To investigate the relationship between long duty hours and physical health of doctors

2. To investigate the relationship between long duty hours and social aspects of doctors.

Operational Definitions:

Young Doctors: All the doctors posted below the designation of Assistant Professor, including

HOs, MOs, PGRs and SRs.

Long Duty Hours: More than 48 hours per week are characterized as long duty hours.

Extended Shifts: Shifts that are comprised of more than 8 hours per day.

Outpatient\ambulatory rotation: Providing medical services to patients that does not require

hospitalization.

Intensive Care Unit: Department of a hospital in which patients who are constantly ill are

kept under constant observation.

Elective: Non-compulsory duty undertaken by the doctor.

Rotating shift: The shifts in which one day the doctors are in the day team and the other day

they are in the night team.

Irregular shift: The shifts in which there is no rhythm of shifts; they could be at any time, day

or night.

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Near miss crashes: Narrowly avoided property damage or bodily harm.

Continuous hours without sleep: A continuous amount of time dedicated to performing

physical tasks without extended pauses or rest intervals or sleep.

Physical work hours: Amount of time an individual spends actively engaged in tasks as part

of their duty.

Outside work hours: Amount of time spent working at a job other than the main duty.

OFE: Situations in which individuals encounter bodily fluids.

Relationship strain: Tension, stress, or difficulties that arise within a relationship, causing a

sense of discomfort within individuals.

Leisure time: Period when individuals are free from work and can engage in activities of their

choice for relaxation and enjoyment.

Work-life balance: The equilibrium between the time and energy individuals dedicate to their

professional responsibilities and their personal life activities.

Page | 32
 CHAPTER: 5

METHODOLOGY

Methods:

Page | 33
 1. Study Design:

The study employs a cross-sectional study design.

2. Study Settings:

The investigation took place in the medical, surgical, eye, ENT, pulmonology,

dermatology, urology, gynecology, psychiatry, orthopaedic, nephrology, anesthesia,

oncology, and neurosurgery wards of Khyber Teaching Hospital, Lady Reading

Hospital Peshawar, and Hayatabad Medical Complex Peshawar.

3. Study Duration:

The study spanned a duration of 3 months from January 19 to April 19, 2025 during

which data collection, and analysis would be done.

4. Study Population:

Our study population comprises of doctors.

5. Selection Criteria:

Inclusion criteria:

The study includes doctors below the designation of Assistant Professor (HO, PGR,

MO, SR). This criterion is chosen because the doctors falling in this domain have

similar duty hours.

Exclusion Criteria:

Doctors at or above the designation of assistant professor would be excluded as they

have fewer duty hours as compared to others.

6. Sample size:

The sample size as calculated via OpenEpi in a population of 1,000,000 Young

doctors is 384 with a 5% margin of error and a 95% confidence limit with an

anticipated frequency of 50%.

7. Sampling Technique:

Page | 34
 The non-random convenience sampling technique was adopted to collect data of the

desired sample size.

8. Data Collection and Management:

Participants were approached by the researchers in the hospital settings. Written

consent of participants was taken, and they were and were completely briefed about

the study. Interview-based filling of the questionnaire was done. The data was

checked by another researcher before leaving the participant. The data was entered in

SPSS version 27. Three researchers independently did the data cleaning and checking.

9. Data Analysis Procedure:

The data was analyzed via SPSS version 27. Qualitative data was summarized as

frequency and percentages. Quantitative data was summarized as mean and standard

deviation. The data is reported in this report in the form of frequencies, tables, charts,

and graphs. Chi-square was used as a test of significance in this report.

Ethical consideration:

Some following ethical considerations will be emphasized while doing this research.

 Formal permission was sought from the concerned authority.

 Participants were made clear about the nature of the research before conducting the

survey research.

 Informed consent was taken from participants, and it is declared that they can

withdraw from the research whenever they want.

 There were no trials, no tests, and no financial burden on participants.

Page | 35
  Participants were confirmed that the required information was held confidential and

will not be shared with anyone who was irrelevant from research.

Page | 36
 CHAPTER: 6

RESULTS

Page | 37
Results:

A total of 384 young doctors posted below the designation of Assistant professors from

Khyber Teaching Hospital, Lady Reading Hospital and Hayatabad Medical Complex

participated in this study, out of which females were 104 (27.1%) and males were 280

(72.9%). Among those 384 participants, 130 (33.9%) were married, while the other 254

(66.1%) were not married.

Most of the participants were young doctors and residents, and mean age in this sample

population was 27.8 ± 4.14 Y. Mean experience for each participant was 16.2 ± 21.54

months. HOs made up almost half the participants with the staggering 195 (50.8%), followed

by PGRs 138 (35.9%), followed by MOs 32 (8.3%) and SRs being 13 (5%).

This study was conducted in different Wards of the setting hospitals with frequency of

number of participants from every ward as follows; there were 24 (6.3%) in Anesthesia, 10

(2.6%) in Cardiology, 27 (7.0%) in Dermatology, 26 (6.8%) in ENT, 20 (5.2%) in Eye, 34

(8.9%) in Gynecology, 66 (17.2%) in Medicine, 12 (3.1%) in Neurology, 11 (2.9%) in

Nephrology, 2 (0.5%) in Oncology, 20 (5.2%) in Orthopedics, 27 (7.0%) in Paeds, 11 (2.9%)

in Pulmonology, 1 (0.3%) Radiology and 93 (24.1%) in Surgery.

The average number of weekly work done by the participants including patient care,

administrative duties, teaching and/or attending any seminars was at 56.3 ± 12.47 h per week.

Among these average hours of the work per week, continuous hours without sleep were 20.1

± 5.66 h per week.

As for the time unrelated to their basic duty in the parent institution, some doctors also had

jobs at some other place and mean working hours for that turned out to be 8.3 ± 7.46. The

mean sleep hours per week for these young doctors came out to be 37.8 ± 19.77 h. The

Page | 38
weekly average for sleep at the workplace is 3.5 ± 3.41 h. The mean sleep hours per week for

these young doctors came out to be 37.8 ± 19.77 h per week.

Out of 384, 291 (75.8%) participants reported at least one nod during work or study-related

activity, while the average number of nods per week for the participants was 2.6 ± 3.07. Out

of 384, 53 (13.8%) faced crashes while they were diving, 131 (34.1%) had an OFEs while 88

(22.9%) caused OFE to patients, 111 (28.9%) participants think that the safety measures in

place were inadequate with 205 (53.4%) facing health issues. Out of 384, 175 (45.6%) faced

strains in their relationships, 218 (56.8%) think they don’t have time for leisure activities, 154

(40.1%) had a hard time attending social gatherings, and 131 (34.1%) think they don’t have a

positive work-life balance.

For the sake of describing the results in a more elaborate way, we divided the doctors into

two groups based on the amount of work. 167 doctors worked less than 56h per week, while

217 worked more than that. Out of 167 working less than 56h only 16 reported motor vehicle

crashes, while the number was more than double for those 217 working more than 56h. Of

those 167, 52 reported occupational fluid exposure while out of 217, 77 doctors reported this.

The number of participants from different wards is represented in the fig 2. Of all the wards,

Surgery and Medicine had the greatest number of participants, respectively, and on the lower

end of the distribution were Oncology and Radiology. For the speciality with the highest

number of outcomes, Surgery was at the top with 15 crashes and 37 OFEs. The individual

outcomes against the specific ward are given below in the table (2)

Page | 39
 Figure 1
Number of participants from each ward.

Page | 40
 Table 1
DEMOGRAPHICS
VARIABLE VALUE
AGE 27.8 ± 4.14 Y
GENDER
FEMALES 27.1%
MALES 72.9%
MARITAL STATUS
MARRIED 120 (33.9%)
SINGLE 254 (66.1%)
RESIDENCE
PESHAWAR 149 (38.8%)
OUTSIDE PESHAWAR 235 (61.2%)
DESIGNATION
HO 195 (50.8%)
MO 32 (8.3%)
PGR 138 (35.9%)
SR 13 (4.9%)
EXPERIENCE (MONTHS) 16.2 ± 21.54 months
PHYSICAL WORK HOURS* 56.3 ± 12.47h
CONTINUOUS HOURS WITHOUT 20.1 ± 5.66h
SLEEP*
OUTSIDE WORK HOURS* 8.3 ± 7.46h
SLEEP AT WORK PLACE* 3.5 ± 3.41h
SLEEP OUTSIDE WORKPLACE* 37.8 ± 19.77h
REST DAYS* 0.8 ± 0.40 days
*All values are for one-week period.

Page | 41
 Table 2

Outcomes with respect to each ward

Wards Number of Number of Number Number Number of
occupational crashes of fluid of health relationship
fluid while exposures issues to strains*
exposures participant Caused the
caused to was by doctors*
the doctor* driving* doctors*

Anesthesia 7 7 6 17 17
Cardiology 2 0 2 4 2
Dermatology 11 5 6 19 14
ENT 8 1 9 6 11
Eye 6 1 7 12 8
Gynecology 8 8 12 18 8
Medicine 21 9 11 30 29
Neurology 4 1 2 7 9
Nephrology 4 2 2 7 8
Oncology 1 0 1 0 2
Orthopedics 5 3 3 9 4
Paediatrics 13 1 2 11 9
Pulmonology 3 0 2 6 2
Radiology 1 0 0 0 1
Surgery 37 15 23 59 51

Total 131 53 88 205 175

*All values are for one week period

Page | 42
 Table 3

Outcomes:
OUTCOME WORKING WORKING P-VALUE

<56H PER >56H PER

WEEK = 167 WEEK =217

Yes No Yes No

MOTOR 16 151 37 180 4.426

VEHICLE

CRASHES

OCCUPATIONA 52 115 77 140 1.165

L FLUID

EXPOSURE

HEALTH ISSUES 68 99 106 111 4.128

RELATIONSHIP 79 88 95 121 0.358

STRAIN

LEISURE TIME 80 87 86 131 2.632

MISSED 123 44 107 110 23.283

PERSONAL

GATHERINGS

WORK-LIFE 133 34 120 97 24.877

BALANCE

Page | 43
Out of 384 participants 53 (13.8%) reported road side crashes, 131 (34.1%) reported

occupational fluid exposures, 205 (53.4%) reported health issues, 175 (45.6%) reported

relationship strain with any of their family members, only 166 (43.2%) reported to have

leisure for their hobbies or other activities, 230 (59.9%) have reported to miss family

gathering while on duty, and only 131 (34.1%) doctors are able to maintain a positive work-

life balance.

Page | 44
 CHAPTER:7

DISCUSSION

Discussion:

Page | 45
There were 384 participants in this study, out of which females were 104 (27.1%) and males

were 280 (72.9%). Out of 384, 130 (33.9%) were married and 254 (66.1%) were single, while

149 (38.8%) were day-scholars and 235 (61.2%) were Hostilities. There were 24 (6.3%) in

Anesthesia, 10 (2.6%) in Cardiology, 27 (7.0%) in Dermatology, 26 (6.8%) in ENT, 20

(5.2%) in Eye, 34 (8.9%) in Gynecology, 66 (17.2%) in Medicine, 12 (3.1%) in Neurology,

11 (2.9%) in Nephrology, 2 (0.5%) in Oncology, 20 (5.2%) in Orthopedics, 27 (7.0%) in

Paeds, 11 (2.9%) in Pulmonology, 1 (0.3%) Radiology and 93 (24.1%) in Surgery. There

were 195 (50.8%) HOs, 32 (8.3%) MOs, 138 (35.9%) PGRs, 13 (5%). Mean experience of

every participant was 16.2 ± 21.54 months. Total weekly physical work hours were 56.3 ±

12.47 h, while continuous work hours without sleep were 20.1 ± 5.66 h, outside work hours

were 8.3 ± 7.46 h. The participants, on average, slept 3.5 ± 3.41 h at the workplace while they

slept 37.8 ± 19.77h outside the workplace in a whole week. Average weekly rest days were

0.8 ± 0.4 days per week. 291 (75.8%) participants reported at least one nod during work or

study related activity while the average nods per week for the participants were 2.6 ± 3.07.

Out of 384, 53 (13.8%) faced crashes while they were diving, 131 (34.1%) had an OFEs

while 88 (22.9%) caused OFE to patients, 111 (28.9%) participants think that the safety

measures in place were inadequate with 205 (53.4%) facing health issues. Out of 384, 175

(45.6%) faced strains in their relationships, 218 (56.8%) think they don’t have time for

leisure activities, 154 (40.1%) had a hard time attending social gatherings and 131 (34.1%)

think they don’t have a positive work-life balance.

While these results show a very hard everyday life for young doctors, we were unable to form

any associations between long duty hours and any of the aforementioned outcomes with p-

values that were insignificant for every relationship between the outcome and the duty hours

groups. There was no clear trend for an increase in the outcome for the two groups, possibly

Page | 46
showing a mere no effect on the outcome, or the 56 hour per week schedule is way too much

that the outcomes were very high for the group working less than 56 h per week.

Out of 384 participants, 88 (22.9%) acknowledged having caused a fluid exposure to their

patients, while 306 doctors had a rest day during the week, as Sunday is off in the week for

most doctors if they have no call.

Prevalence of roadside incidents among medical doctors turns out to be somewhere between

7.9 – 24.6%(2) which is consistent with our findings of 13.8%. Meanwhile, the incidence of

occupational fluid exposure among the subjects stands out to be at 34.1% compared to

21.01%(56) incidence among the residents worldwide. A possible explanation for that could

be due to lack(6) (57) of workforce in Pakistan including nurses and doctors. The prevalence

of Health issues among doctors was 53.4% which was close to another reported value for

burnout stood at 58.2%(58) for the resident doctors in Canada. 65.9% doctors in Pakistan

were unable to maintain a positive work-life balance which is also consistent with a study

carried out in Jordon where the incidence was reported to be 62.9%(59).

In this study, the results differed significantly from the initial expectations. The data obtained

line up with the hypothesized outcomes, challenging the anticipated conclusions. Despite

strict data protocols, the observed findings differ from the initial predictions. Several factors

contribute to these unexpected results, including recall bias and unaccounted variables. This

significant difference between the actual results and expected ones implies that it needs a lot

of further investigation and evaluation. Although our results differed from our hypotheses,

these provide an opportunity to re-evaluate the existing assumptions and to highlight the

previous unconsidered factors that could influence the study. Thus, it is mandatory to analyze

these unexpected findings for more comprehensive future research.

Page | 47
Although authors were unable to estimate any association of long duty hours to any of the

aforementioned outcomes yet it is clear by the above discussions that prevalence of these

outcomes is high not only among the junior doctors and residents of Pakistan but also among

the doctors around the globe. This is causing a lot of negative physical as well as social

impact on the lives of physicians, risking the quality of healthcare provided. As of now the

prevalence of stress and burnout is very high in the medical community impacting both

physicians and paramedics(60). This effect is more prominent on the empathy of the

physicians and paramedics(61) showing a very adverse outcome. This affects the doctor

patient relationship and reduces the confidence of patient in his/her attending and reduces the

drug adherence.

In Pakistan there is a clear literature gap in this field regarding these outcomes for the young

doctors and resident physicians. Authors attempted to fill this literature gap and compare the

data with the previously available data from literature. Our research provides valuable

insights on potential health risks with long duty hours. It also signifies the importance of

work-life balance, which essential for their well-being. It also highlights a lack of time for

their gatherings and leisure activities and the bulk of relationship strains that, in turn, have a

negative impact on their professional duties. It is also helpful in raising awareness among

future doctors about the importance of self-care and maintaining a healthy work environment.

It also contributes to the development of policies that promote better working conditions and

ensure their health and social well-being while also enhancing the quality of patient care in

Pakistan.

Page | 48
 CHAPTER: 8

ACKNOWLEDGEMENT AND

LIMITATION

Page | 49
Acknowledgement of Limitation:

Authors acknowledge following limitations or biases in the study;

(i) Selection Bias: The collection of data was only from 3 tertiary care hospitals, s

although there are a few other tertiary care hospitals in our locality.

(ii) Sampling: Non-random convenience sampling was used by the researchers.

(iii) Recall bias: We have asked questions regarding previous week which, although

cause very little bias, but still there might be some.

(iv) Observer Bias: The data was collected by interviewing the participants by

different interviewers, which can potentially cause an observer bias

(v) Confounding Bias: Although there was an effort to reduce potential confounders,

there are still some confounders which could not be controlled like emotional

status of participant at the time of interview, Ward of the resident, number of calls

in a single week, experience of young doctors due to difference in year of

graduation, or their own academic performance.

After all these limitation, our research can still serve as a stepping stone for future studies.

Science is always evolving; thus, the limitations that we are unable to remove could be

removed in the future, and the findings could be more impactful. Our result can still be valid

in the above-mentioned settings. Even after these limitations, this study highlights important

findings that can be impactful for future decision-making.

Page | 50
 CHAPTER: 9

RECOMMENDATIONS

Page | 51
Recommendations:

Hospitals should reduce the long duty hours and ensure regular breaks in between long shifts.

There should be a separate unit for the mental health services of the medical professional

addressing the psychological aspects of the doctors. There must be training programs to

emphasize the importance of self-care and healthy lifestyles. A regular health checkup policy

should be implemented to screen and monitor the health of the young doctors. There should

be leadership training for the senior medical staff and administrators to enhance supportive

and empathetic leadership.

By implementing these recommendations, we can create a healthy environment that not only

supports the physical and social well-being of young doctors but also will improve the quality

of patient care.

This study can be a source for further research ideas like comparative analysis of healthcare

systems of different countries to mitigate the adverse effects on doctors. Interventional

studies should be conducted to assess different management techniques. Investigation of

various adaptation techniques used by doctors to manage the challenges. By exploring these

research ideas, researchers can contribute substantial knowledge to improve the overall well-

being of doctors.

Page | 52
 CHAPTER: 10

CONCLUSION

Page | 53
Conclusion:

In summary, this study focused on the possible physical and social relationship of working

extended shifts, primarily focusing on young interns and resident trainees. The study pointed

out various effects but was unable to form any association between working long hours and

any of the aforementioned impacts. Yet it sheds light on the immense number of hours a

doctor has to work in Pakistan. In essence, this study provides important data regarding the

work schedule of Pakistani doctors and suggests more thorough research should be done to

effectively understand this very complex yet important issue.

Page | 54
 CHAPTER: 11
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Effect of Long Duty Hours on Physical and Social Dimensions of Young Doctors
Demographics
 Age _________
 Gender ☐ Male ☐Female
 Marital Status
☐single ☐Married
 Are you a ☐ Hostellite ☐ Day Scholar
 Ward _____________.
 Your experience in specified ward_______________ years.
 Designation
HO
MO
PGR
Consultant
Registrar
SR

Activity that best ☐ Outpatient

describes the week ☐ Intensive care unit
rotation
☐ In-hospital ward
rotation
☐ Night team
☐ Emergency
Department
☐ Research
☐ Elective
☐ Vacation
Timing of work that best ☐ Day team
describes the week ☐ Night team
☐ Rotating
☐ Irregular
Hours spent working or
studying outside of the
hospital or workplace
(e.g., at home or at the
library) related to your
program.

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 Hours spent working at
any other job outside of
your program (including
moonlighting)
Hours of sleep at the
workplace or hospital
Hours of sleep outside of
the workplace or
hospital
Number of days off (i.e.,
a full 24-hour period)
In Last week, what was the longest ________________ hours that you were actually
physically at work?

Include protected time for sleep provided during an extended shift and round to the nearest
hour____________

In Last week, what was the longest number of continuous hours that you went without
sleep?
Please round to the nearest hour ____________

In Last week, on average per week, how many hours were spent:

The following questions ask about your extended shifts during the week (>24 hours)

Participating in direct patient care (examining patients, writing Hours

notes,
interpreting diagnostic tests/radiographic studies/pathology
specimens, consulting with other physicians, etc.)
In the workplace in duties not directly related to patient care Hours
(other paperwork, scheduling tests, etc.)
In formal structured learning including classes/ Hours
laboratories/grand rounds
In self-directed learning outside of the workplace Hours
Teaching students or house staff Hours
In leisure activities outside of the hospital or workplace Hours
Page | 62
 Outcomes
(i) Physical
In the last week, how many times did you nod off or fall asleep:
Number of times you nodded Check if not applicable
off or fell asleep *
During lectures, seminars, or _____ ☐ I didn't attend any that
grand rounds week
During rounds with the _____ ☐ I didn’t do rounds with
attending an
attending that week
While talking to or examining _____ ☐ I didn’t examine/talk
patients with
patients that week
During surgery _____ ☐ I didn’t do surgeries that
week
While driving _____ ☐ I didn't drive that week
While stopped in traffic _____ ☐ I didn't drive that week

* Enter 0 for zero or none, unless the option does not apply (then leave blank).

For the following question, please answer only in terms of when you personally were
responsible.

In the last week, did you have any motor vehicle ☐ Yes ☐ No
accidents
In or crashes
the last week, (actual
did you collisions)
personally haveinan
which you ☐ Yes ☐ No
were driving?
occupational exposure to potentially contaminated
blood or other body fluid?
In the last week, did you cause an occupational ☐ Yes ☐ No
exposure to potentially contaminated blood or other
body fluid to others?
Do you think there are sufficient measures in your ☐ Yes ☐ No
workplace to prevent the risk of contamination when
dealing with body fluids?

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 Have you experienced any physical health issues as a ☐ Yes ☐ No
result of extended duty hours?

(ii) Social

Have you noticed any strain in your relationships with ☐ Yes ☐ No

family members or friends due to your work schedule?
Do you find enough time for leisure activities? ☐ Yes ☐ No

Do you often find it challenging to attend social ☐ Yes ☐ No

gatherings or community events due to your work
commitments?
Do you often find it challenging to balance your work ☐ Yes ☐ No
responsibilities with your personal life?

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