Abdul Hannan  ( Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, USA. )

Madam, doctors\\\' burnout and stress is an important area where a lot of research and studies are needed especially in 3rd world countries. I read this paper \\\'Do doctors have hidden distress; a study conducted at tertiary care hospital at Lahore\\\' published in your esteemed journal, in recent issue of Jan 2016.
Though it was a nice effort but I would like to highlight a couple of important points, which seriously jeopardize this study results:

• It was strange that level of distress was quite low as compared to international figures, as it has been mentioned from 30-65% in US data.¹
• Other conflicting results from this data set were being married (p=0.006), as international data suggest that marriage or in relation is associated with less burn outs and distress.²
• The data set would be more reliable if authors mentioned the nature of job and specialty as ER physicians, critical care doctors, surgeons and oncologists have more stress as compared to other less demanding specialties. In fact, authors failed to identify the relation of nature of job to distress (nature of job - p value 0.531).^3,4
• Secondly, less than 50% of the intended population responded to the questionnaire.
• Last but not the least, additional working hours did not show any relation to stress (p=0.623).⁵

It would have been nice if authors included the General health Questionnaire-12 used in this study for interested readers ease.
To my understanding distress and burn out must have been more common due to socio-economic conditions and number of patient every physician needs to see in 3rd world countries. These need to be addressed in a developing country like Pakistan.


References

1. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population.Arch Intern Med. 2012; 172:1377-85.
2. Caplan RP. Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers. BMJ. 1994; 309:1261-3.
3. Frank E, Carrera J, DharamsiS. Political self-characterization of U.S. medical students.J Gen Intern Med. 2007; 22:514-7.
4. Keeton K, Fenner DE, Johnson TR, Hayward RA. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol. 2007; 109:949-55.
5. Tucker P, Bejerot E, Kecklund G, Aronsson G, Åkerstedt T. The impact of work time control on physicians\\\' sleep and well-being. Appl Ergon. 2015; 47:109-16.