Prevalence and Determinants of Distress Among Residents During COVID Crisis

1. Abstract Background and Objectives Residents are predisposed to develop distress, burnout, and depression. With COVID-19, new stressful working conditions were imposed. This study aims to assess the impact of COVID-19 on residents’ wellbeing in France.

Methods Residents completed an online survey assessing the sociodemographic characteristics, the workload, the work environment, the burden, and the psychological impact of the pandemic. Wellbeing, burnout, and depression were assessed using respectively the Residents and fellows’ wellbeing index (RSWBI), the abbreviated Maslach Burnout Inventory (aMBI) and the PHQ-9 questionnaire. Analysis was done on SPSS 25. Variables were significantly associated with the outcomes if p value ≤ 0.05.

Results Thirty-four residents completed the survey. Their mean age was 28.4 years. Out of the respondents, 20.6% were at high risk for distress, 56% were at moderate to severe risk for burnout and 27% had moderate to severe depressive symptoms. Being single and work overload increased the risk of distress and burnout. Although, COVID-19 did not affect the prevalence of distress and burnout, it increased the intensity of the stress. Residents were concerned about the repercussions that the pandemic might have on their training and on their future. Higher wellbeing index was significantly associated with poorer quality of life (p=0.001), higher regrets (p=0.004) and lower satisfaction (p=0.043) on the professional level.

Conclusion COVID-19 had an indirect impact on residents ’wellbeing. The interruption of courses, the compromised training and the social isolation contributed to residents’ burnout and distress. The remedy would be to create a wellness program that promotes self-care and resilience.

2. Introduction Physician wellness is a topic of much concern. It is emerging as an important indicator of the quality of medical programs [1]. Wellness as defined by EcKleberry-Hunt and colleagues is “a dynamic and ongoing process involving self-awareness and health choices resulting in a successful balanced lifestyle” [2]. Becoming a physician comes with sacrifices and challenges but it doesn’t mean that one needs to suffer during the process. Despite rising the awareness and recognizing the importance of physician wellness, the prevalence of burn out, depression and suicidal ideation is higher among resident physician than the general population3. In fact, residents spend [3-7] years of their lives specializing in a medical field of interest. They are exposed to stressful and traumatic situations that comes with limited control and high responsibilities. They experience pain and death; they have long duty hours, and they are preoccupied by their training and their future while facing their personal insecurities. With these overwhelming stressors and always feeling the need to compete and to be the best, maintaining residents’ wellbeing and avoiding burn-out become hard and challenging. The prevalence of burnout among residents in the US varies between 27 and 75% depending on their specialty4. The prevalence of burnout in the European countries is around 27.72% (95% CI: 17.4–41.11)5. In the US, 28.8% of residents have depressive symptoms6. In France, 10% of the residents have suicidal ideation. Furthermore, the incidence of suicides among residents is 3 times higher than the general population with an incidence of 33 per 1000007. The harmful impact of distress is not limited to residents. It may also affect patient care, and health care systems. The effects include lower physician productivity, increased medical errors, longer recovery time, and lower patient satisfaction. As if all these stressors were not enough, in 2020, Health care professionals (HCP) were facing a new challenge. SARS COV-2 virus (COVID-19) spread, and the world was facing a global pandemic with more than 4 million deaths. Residents were on the frontlines providing care to infected patients. In the light of the uprising crisis, they had to work overtime and stay away from their families. Some were redeployed to other services, while others had their courses cancelled. Studies showed that Covid-19 had an impact on HCP burnout, but few studies checked the effect of the crisis on residents’ wellbeing [8,9]. This survey focuses on the prevalence of distress, burnout, and depression among residents in France during the pandemic. It also investigates the impact of COVID-19 related factors on residents’mental health, and it assesses its repercussion on residents’ personal, social and professional lives. These data will allow the conception of new strategies in the residency programs to promote wellness and prevent burnout.

3. Materials and Methods Study Design A cross sectional study was conducted among residents in hospitals in France between May and September 2021. An online survey designed in google forms was diffused via email, WhatsApp, and social media to reach as many residents as possible. An abstract on the study and its purpose were provided on the first page of the survey. Residents who filled the questionnaire were assumed to have given their consent to take part in this study. Data was collected anonymously without any potential identifier to protect confidentiality.

Study Population Residents were defined as those who are doing a specialty after graduating from medical school. The inclusion criteria were a resident working in a hospital in France during the past year and willing to participate in this study. Any participant who did not fulfill the latter criteria was excluded.

Study Instruments An online survey addressed to residents was developed using previously validated instruments. The self-administered questionnaire covered four areas: the socio-demographic characteristics, the work conditions, the impact of COVID-19 and the residents’ mental health. Primary Outcome The prevalence of distress, burnout and depression among residents were calculated based the Resident/Fellow Well-Being Index (RSWBI), the abbreviated Maslach Burnout Inventory (aMBI) and the Patient Health Questionnaire (PHQ-9) respectively. A- Wellbeing: The survey utilized the RSWBI, a Mayo clinic validated 7 yes/ no questions tool to assess residents’ wellbeing [10]. The scores range from 0 to 7. Based on a national survey, the mean score is 2.53 and the median is 2. Residents with a score of 5 or more are in distress and are at higher risk for depression, burnout, and suicide. B- Burnout: Burnout was assessed with the use of the modified a MBI [11,12]. It uses a three‐item screening questions for each of the three dimensions: emotional exhaustion (EE), depersonalization (DP), and personal achievement (PA). Each question uses a 7 item Likert scale, and scores go from 0 (never) to 6 (always). Each component of burnout scores from 0 to 18. A score above 9 on EE or DP means that residents have moderate to severe emotional exhaustion and depersonalization. Whereas if they score 0-9 on PA, they have a low sense of personal achievement. Residents are considered to have burnout when they have one abnormal score in these subscales. C- Depression: The severity of depression was assessed using the validated PHQ-913. The score can go from 0 to 27 with each item being attributed a number from 0 to 3 depending on the frequency of occurrence of the described symptom. A cutoff of ≥5 identify the presence of any depression related symptom and a cut-off of ≥10 identify a moderate to severe depression. Secondary Outcome The association between the study variables and wellbeing, burnout and depression scores were tested to identify possible risk factors. The repercussion of the residents’ wellness status on the different aspects in life were assessed. A- Sociodemographic characteristics: data on the age, the gender, the nationality, the household status, and the marital status were collected. B- Workload: Residents were asked about their weekly schedule and about having extracurricular activities. Sleep deprivation was defined as residents sleeping less than 7 hours per day. The Workload score was based on working hours (overtime, working more than 60 hours/week, duty hours/ week), on work intensity score, on sleeping hours and on the interactions with patients. One point was attributed to each item except for the work intensity score in which 1 point was attributed for the values [6-7], and 2 points were attributed to the values [8] and above. C- Work environment: To assess the work environment, 5-point Likert scale questions on teamwork, level of communication and the amount of contribution to decision making were used. Also, mistreatment was assessed by reporting the frequency of exposure to any type of discrimination during this year of residency. Residents were classified by the maximum reported frequency of any of the mistreatment exposure into no exposure, exposure a few times/year and exposure few times/ month14. The validated mayo clinic leadership behavior score was also used. Each item in this score has a 5 point-Likert scale to assess the behavior of the residents’super-

4. Results Baseline Characteristics and General Working Conditions Despite reaching out to many hospitals, only 34 residents completed the survey. The response rate couldn’t be estimated since we don’t know the exact number of residents that got the link of the questionnaire. Most respondents were females and were originally from France. Their mean age was 28.4 years. Of the respondents, 59% were in a relationship, 61.8% were sharing their apartments with a family member, a partner, or a roommate and 14.7% had kids (Table1). Participants were mainly working in hospitals located in Paris and its suburbs with only 15.1% working in Lyon or Bordeaux (supp Figure 1). The majority were in post-graduate year 3 (84.8%) (supp Figure 2). 69.7% were specializing in non-surgical specialties (supp Figure 3). In their last rotation, residents were equally assigned to a surgical or a medical service within which 65% admitted critical patients. On average, they were taking care of 28 patients/week. Around 38% of residents claimed to have a limited interaction with their patients. Among the participants, 44% were working more than 60 hours per week, 50% were sleeping less than 7 hours/ day, 70% had to take courses and 35% had to participate in lab research in addition to their usual tasks. When asked about the frequency of working overtime, almost 41% of residents answered frequently or every day. When asked about work intensity on a scale from 0 to 10, 41% attributed a score of 8 or more (supp Figure 5). When it comes to the work environment 80% of the residents reported having a good dynamic within the team and 70% reported a possibility to assist in decision making (supp Figure 6). 30% were subject to discriminations based on gender, on race, on pregnancy status and/or on origin. The nature of the abuse was either verbal (60%) and/or emotional (40%) and/or sexual (30%) (Table1). The residents were also asked to assess the leadership skills of their supervisor. Around 50% agreed that their supervisor held career development conversations with them, recognized them for a job well done and took the time to inform them about the changes occurring in the division. Around 65% agreed that their supervisor encouraged them to do their job and gain experience and provide them with helpful feedback. 82% agreed that the supervisor respected them and treated them with dignity (Supp Figure 7). Prevalence of distress, burnout, and depression during COVID-19 crisis. The average wellness index score in all participants was 3 (SD=1.7) with 20.6% being at greater risk to have a distress related personal or professional consequence.

5. COVID Direct Effect on Residents Among participants, 88.2% took care of COVID-19 patients mainly inpatients on regular floors and in the ICU, for an average period of 6 months. 43.3% were involved in treating these patients during the 3 waves. 73.3% worked with infected patients during the third wave. They were seeing on average 6 patients/day. Table 2 describes in detail the personal, emotional, and professional situation of residents during COVID-19. These COVID related variables had no significant effect on residents’ wellbeing, burnout, or depression (supp Figure 15). However, the RSWBI was the highest in those who did not manage COVID patients and those who treated COVID positive patients for at least 2 waves including the third wave. The lowest score was seen in those who only worked during the last wave (Figure 3A). Reversed variations were seen with burnout (Figure 3B). During the crisis, residents were more stressed. (r=0.43 p< 0.001). The mean stress intensity increased from 52.2(SD=23.9) before COVID-19 to 70.7 (SD=22.1) during COVID-19 (Figure 2A). The fear from acquiring the disease and the change in workload were significantly associated with the increase in stress (Mean increase (fear/no fear) 27.3 v/s 5.3 p=0.029 and Median 15 v/s 5 p=0.037) (Figure 2B-C). In residents’ opinion, the most important stressors during the past year were taking care of patients (23.5%) and planning the future (23.5%). Only 14.7% chose COVID-19 as a major source of stress (Figure 4A). It was a common stressor among residents at risk for burnout, whereas the other two stressors were common among residents at risk for depression or distress (supp Figure 9). Most residents (76.9%) felt that their education and training were compromised by the crisis in many aspects (Table 2). Explicitly, residents were concerned about missing training, losing educational opportunities, and lacking professional development which might affect their future. Some were also frustrated about not having the time to grief (supp Figure 10). Talking to family and colleagues was the most common strategy adapted by residents to deal with the stressors (Figure 4B)

6. Discussion This survey of 34 residents revealed that during COVID-19, the respondents are at a higher risk of distress regardless of the exposure to COVID positive patients. The workload and the family status affected the residents’ wellbeing. From the COVID-19 related factors, none was significantly associated to the wellbeing, burnout, and depression scores. However, fear from getting the disease and the increased workload were associated with an increased stress. During the crisis, residents were mainly concerned about the interruption of the educational activities and the repercussion of the whole situation on their future career. The distress put them at risk for substance abuse, it compromised their quality of life and the level of satisfaction of the work-life balance. Impact of COVID on the prevalence of Wellbeing, Burnout, and depression. During the crisis, residents scored higher on the wellbeing index. It is difficult to compare the values observed in this study to the ones from other studies due to the heterogeneity of the used indexes. However, similar mean RSWBI values and higher at-risk percentages were observed in a study conducted during COVID-19 among US residents when using the same index (mean=2.84+- 2.04, at-risk=24%)18. The report of 2020-2021 from Mayo clinic showed that out of the 9,164 assessed residents and fellows from the world, 16.4% were at high risk for distress. The differences in at risk percentages can be explained by the regional variation of medical programs and COVID-19 burden. Burnout is one of the dimensions in wellbeing; it correlates with wellbeing without being similar. Despite the previous study showing increased residents’ burnout during the pandemic19, the prevalence of burnout in this study was unchanged. The calculated frequency is in the range of values obtained from other studies before and during COVID-193, 19, 20. Nevertheless, COVID-19 did influence the burnout dimensions. During the pandemic, residents mostly experienced high emotional exhaustion. This was not the case before COVID-19. Results from the national Bourbon study showed that junior residents report high prevalence of depersonalization (30- 38%) and of low personal accomplishment (29-42%) and lower prevalence of emotional exhaustion (12-29%)21. This is consistent with a study on medical and surgical residents showing that 50% have severe loss of empathy22.

7. Conclusion Even before the pandemic, residents faced distress, burnout, and depression. COVID-19 did not influence the prevalence of distress or burnout among residents, but it has increased the depressive symptoms and the intensity of stress. Residents were deprived from the family support and from the ability to acquire skills in their field. The consequences were a decrease in the quality of life, a regret of choosing medicine and a dissatisfaction of the worklife balance. During these difficult times, the best way to support residents and prevent psychological, social, and personal repercussions is to create a wellness program that promote residents’ wellbeing.

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Pamela Houeiss. Prevalence and Determinants of Distress Among Residents During COVID Crisis. Annals of Clinical and Medical Case Reports 2022