A Cross-Sectional Study to Evaluate Work-Life Balance Among Indian Medical Students

Introduction The concept of work-life balance is a complex, multidimensional intertwinement of the roles an individual plays in their professional and personal life. Work-life balance is crucial for every profession, and doctors have no exemption not exempted from it. Medical students and young graduates face numerous challenges that potentially impact their work (study)-life balance. Objectives of the study The aim is to assess the hours spent in study and the hours spent in non-study activities by medical students and graduates in India and to assess the study-life balance among them. Methodology A cross-sectional observational study employing a predefined web-based survey to investigate the study-life balance among medical students and graduates across India. A predesigned questionnaire was designed and made accessible through Google Forms, which was distributed among doctors across India via popular social media platforms. Data management was conducted using Microsoft Excel and Data analysis was done using SPSS (IBM Corp., Armonk, NY). Results A total of 416 responses were included in the study. The study participants were predominantly female (64.2%). Most of the study participants were from the State of Telangana (63.9%). The time spent studying was < 10 hours/week for 43.8% students and 10-25 hours/week for 27.2% students. Around 24% students reported spending 10-25 hours/week in hospital. While 47.4% reported spending less than one to two hours per day with their family, 26% of the participants answered “yes” to the question “Do you feel that your study-life is stressful?.” Conclusions Self-care and study-life balance is a multi-factorial focal area that is based on balancing stress and happiness, with completing the tasks of the medical school. Medical students need to receive proper guidelines to transition into medical school for better study-life balance.


Introduction
Work-life balance functions as a key contributor to a person's well-being personally and professionally and also plays a significant role in their career decisions.Defining work-life balance is a complex task and has multiple definitions.Work-life balance can be described by categorizing into two key dimensions, namely (A) role engagement in multiple roles in work and nonwork life and (B) minimal conflict between work and nonwork roles.Each of the two key dimensions has multiple definitions.The first key dimension has four well-known definitions while the second has three [1].
The first definition (A) of work-life balance for the first dimension involves attentive engagement in multiple roles [2].The second definition is based on equal time and involvement across multiple roles.The third talks about balanced satisfaction across all life domains, and the final (fourth) involves balanced involvement across life domains [3].The second dimension (B) "minimal conflict between work and nonwork roles" has three definitions.The first states minimizing the role conflict between work and family [4], the second involves role enrichment with no role conflict [5], and the third reflects the best possible resource management to minimize role conflict [6].All these definitions have generated much complexity in defining, understanding, and measuring the work-life balance and identifying the consequences of poor work-life balance.Work-life balance cannot be explained with an isolated definition from the abovementioned but is usually a combination of multiple definitions based on the circumstances of the individuals under study.
Similar to all professions, work-life balance is an essential factor for doctors.Self-care should begin at an undergraduate level.Medical students and young graduates need to balance their time between multiple circumstances including studying, exams, extra-curricular activities, teaching, clinics, and extracurricular activities.The combination of academic overload, stressful and tough exams, and clinical environment can threaten the work-life balance and well-being of medical students and young graduates [7].
Studies have shown the effect of poor work-life balance on the mental and physical health of nurses, doctors, and other front-line workers during the time of the pandemic.Mental and physical health is equally important for all.Similar to long hours of work, mental fatigue by long hours of study can lead to significant problems and should not be ignored.This is to assess the hours spent in study and the hours spent in nonstudy activities by medical students and graduates in India and to assess the study-life balance among them.

Materials And Methods
The present research employs a cross-sectional observational study design, employing a web-based survey to investigate the study-life balance among medical students and graduates across India.The study was conducted entirely in the virtual realm, with data collection taking place over a period of one month.Ethical clearance was obtained from the Genebandhu Independent Ethics Committee with protocol number ECG001/2023 dated January 17, 2023.
A predesigned questionnaire was designed and made accessible through Google Forms, which was distributed among doctors across India via popular social media platforms.Informed consent was obtained from all participants, providing them with a clear understanding of the research's purpose and reassuring them about the confidentiality of their responses.Furthermore, the questionnaire was also pretested to ensure clarity and relevance, enhancing the validity of the data collected.
The study solely included voluntary participants who meet the inclusion criteria, which are medical students pursuing their MBBS degree and graduates employed by medical institutions in India.Postgraduate students, medical students and graduates who declined participation were excluded from the study.Data management was conducted using Microsoft Excel and data analysis was done using IBM SPSS Statistics Software for Windows, Version 21.0 (IBM Corp., Armonk, NY; Released 2012).

Results
A total of 416 responses were included in the study.A total of 267 (64.2%) females and 149 (35.8%) males participated in the study.The study participants represent different states of India with Telangana state being the most represented state with 266 participants (63.9%).The participants belong to various academic levels of medical career, with major representation being from the first-year students (140 participants, 33.7%), followed by those in internship (83 participants, 20%).Table 2 focuses on the study-life, exploring the place of study, method of studying, hours spent in studying, and also the hours spent in clinical activities which affect their study routine.The use of medical videos in preparation for entrance exams has been widely used in India, this is a key point that was evaluated in this section together with the cumulative stress that comes with studying.Values are expressed in N (%).Furthermore, 183 (44%) of the respondents have an entrance exam within a year, 171 (41.1%) after two years, and 62 (14.9%) within two years.In terms of the stress levels related to studies, 108 (26%) responded as highly agreeing to feeling stressed and eight (1.9%) highly disagreed to feeling stressed.This difference was statistically significant (p < 0.001), using the Kruskal-Wallis test.

The data from
Various activities that are commonly used by the participants as part of recreation are explored in Table 3.
The time spent sleeping, doing household chores and time spent with family is evaluated.Also, time spent by participants in indoor activities like watching entertainment platforms and listening to music is studied.Furthermore, time spent in physical fitness like sports, yoga, and trekking was evaluated alongside leisure activities like arts, hobbies, and long drives.The participants have also quantified the non-educational time spent with friends.The study also tries to explore the relationship between studies and personal life.Figure 1 shows the responses of the participants using the Likert scale to rate the impact of studies on personal life and vice versa.

Discussion
A well-rounded lifestyle that cohesively balances both work and personal life is of utmost importance for the proper functioning of individuals across all sectors, including healthcare.A cross-sectional study by Langade et al. on burnout in medical practitioners reported an alarming level of emotional exhaustion (45% of individuals) and depersonalization (87%) among registered medical practitioners in India [8].Shanafelt et al.
reported that approximately 45% of oncologists in the study sample (n= 1,490), felt emotionally exhausted and depersonalized [9].To evaluate whether these effects start very early in their healthcare career, our study was designed to evaluate the study-life balance in Indian medical students and graduates.A total of 416 subjects across the various states of India participated in the study, with around 74.1% of the student population finding study-life to be stressful.
Throughout the existing literature, we can find compelling evidence corroborating the findings of our study.Iqbal et al. documented that a majority of medical undergraduate students are affected by depression (51%), stress (53%), and anxiety (67%).Furthermore, morbidity due to stress and anxiety-related causes were greater in fifth-semester students when compared to second-semester students [10].With regard to sleep quality, Shad et al., by observing and analyzing the Global Pittsburgh Sleep Quality Index (PSQI) have found that the majority of students (62.6%) in general, are poor sleepers, but medical students have poorer quality of sleep (73%) when compared to their non-medical peers (52%) [11].
To battle these dire circumstances and effects of poor work-life or study-life balance, most developed countries, have adapted to a transformation in the medical education system, with a noticeable shift in the direction of prioritizing self-care of students.This implies a departure from the preceding ethos that emphasized majorly on altruism and self-sacrifice [12].But in many developing countries or less developed countries like India, self-care is yet to be prioritized, which is justified by our study.Our study outlines a clear difference in the time spent on hobbies and studies, indicating burnout.To prevent grave complications, and to restore balance between study and life, Border theory can be implemented for the students in India.
Border theory is a conceptual paradigm that focuses on the "boundaries" an individual establishes between their work and personal life.The theory emphasizes on effective establishment and management of these boundaries by utilizing strategies like segmentation, integration, and boundary management to achieve proper work-life harmony [13].Medical councils and governing bodies in developing countries such as India, should emphasize the importance of self-care to support students in safeguarding their health and overall well-being amidst the challenges of pursuing a medical degree.This can be done by improving working conditions, giving support for physical and mental health issues, and finally promoting a stable working and studying environment [14].Organizational support can have a positive influence on maintaining a study-life balance or work-life balance [15].This support can be given by medical councils and governing bodies of the respective countries.

Strengths and limitations
High response rates, the inclusion of students from diverse institutions across various states, and various academic years are a few of the strengths of our study.However, a few certain limitations are present which include, the impact of institution-specific factors on study-life balance Furthermore, data collection during the exam season might have been influenced by stress, altered study and working patterns, and test-related anxiety.It is possible that few of the responses were an outlet of the above-mentioned stress than facts.

Conclusions
Our study notes that time spent by medical students was largely for studying and working in hospital.The time spent for recreational activities was less.Self-care and study-life balance is a multi-factorial focal area based on balancing monitoring stress and happiness while completing the tasks of medical school.Extrinsic factors like peer pressure and culture play an important role in this.There was a significant imbalance between the study and life of medical students due to the heavy academic workload with less time spent on leisure activities.Medical students need to receive guidelines for a better transition into medical school.
The medical councils and governing bodies also need to regulate self-care guidelines for the better mental health of students.

Figure 2
Figure 2 explains the relationship between study-life balance and other variables using the Spearman correlation coefficient.Factors like years of MBBS studies, and time spent in clinical duties showed a weak negative relationship with study-life balance with Spearman correlation coefficient (denoted as ρ) values of -0.119 and -0.121, respectively.

FIGURE 2 :
FIGURE 2: Correlation of study-life balance to appropriate factors

Table 1
explores the detailed demographic characteristics of the study group including the gender, and the state of India they belong to.Furthermore, it explores the participant's year of study.

Table 2
reveal that the majority of the participants study at home, 321( 72.2%) while 95 (22.8%) prefer studying in the library.Most respondents, 319 (76.7%) prefer studying on their own, while 91 (21.9%) prefer discussion and only four (1.4%) prefer studying in a group.The number of hours spent in studying and other activities varied among the group.Study shows 182 (43.8%) study < 10 hours a week while three (0.7%) study more than 10 hours a day for studies.