Abstract and Introduction
Abstract
Introduction: Emergency medicine is characterized by high volume decision-making while under multiple stressors. With the arrival of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus in early 2020, physicians across the world were met with a surge of critically ill patients. Emergency physicians (EP) are prone to developing burnout and post-traumatic stress disorder (PTSD), due to experiencing emotional trauma as well as the cumulative stress of practice. Thus, calls have been made for attempts to prevent physician PTSD during this current pandemic.
Methods: From July 2019–January 2020, emergency medicine (EM) resident physicians at a large, academic healthcare system were surveyed for symptoms of burnout using the Maslach Burnout Inventory (MBI). In late April and early May 2020, during the outbreak surge of coronavirus disease 2019 (COVID-19) in the Northeast USA, these same residents and the whole EM residency at the institution were again surveyed for symptoms of burnout as well as post-traumatic stress using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (PCL-5). A final survey was administered to the EM residents after the COVID-19 surge had largely subsided in June 2020.
Results: Twenty-two residents participated in the pre-pandemic study and completed the MBI. Twelve (55%) completed the two follow-up MBI surveys. In the larger EM residency cohort, 31/60 residents completed the MBI and PCL-5 survey during the pandemic peak and 30/60 (50%) completed the follow-up surveys. There were no significant differences in the three MBI burnout category measures of emotional exhaustion (P = 0.49), depersonalization (P = 0.13), and personal accomplishment (P = 0.70) pre-, during, and post-COVID. Of 31 participants, 11 (35%) scored greater than 31 on the PCL-5. Two residents had scores between 21–30, interpreted as "at risk." At greater than one month follow-up, 2/30 continued to meet criteria for a preliminary PTSD diagnosis, and five were "at risk."
Conclusion: A significant proportion of residents (35%) experienced post-traumatic symptoms acutely during the COVID-19 pandemic crisis, potentially indicating a high prevalence of acute stress disorder in this population and increased risk of developing PTSD. However, there was no significant difference in burnout levels in this cohort before, during, or after the initial COVID-19 surge. Early screening for physicians at risk and referral for assessment and treatment may be important to mitigate pandemic-related PTSD.
Introduction
Emergency medicine (EM) is characterized by a high volume of decision-making under high stress. Emergency physicians (EP) are particularly prone to developing burnout, with 35–77.8% of physicians reporting significant risks.[1,2] Burnout, characterized by emotional exhaustion, depersonalization, and feelings of decreased personal accomplishment, affects the physicians and their patients.[3–6] Workload, violence, traumatic events, uncontrolled stress, work-family conflict, and poor staffing have been identified as factors in EM that contribute to burnout.[1,7,8] Burnout has been associated with lower reported quality of life and of education among residents, as well as increased early retirement and turnover among EPs in practice.[6,9]
Emergency physicians are also at increased risk of developing post-traumatic stress disorder (PTSD), both due to experiencing emotional trauma as well as the cumulative stress of practice.[10,11] One study identified 15.8% of EP respondents as meeting preliminary criteria for PTSD, with prior trauma or abuse as the primary predictor.[12] Post-traumatic stress disorder is characterized by exposure to an extreme stressor or traumatic event followed by at least one month of three distinct types of symptoms: re-experiencing the event; avoidance of reminders of the event; and hyperarousal.[13] In addition to prior trauma, female gender, genetics, family and personal psychiatric history, impaired executive function, trauma intensity and type, and physiological arousal have been identified as risk factors for development of PTSD after trauma. Social support has been identified as a protective factor.[14] For EM resident physicians, one institution found that 11.9% met criteria to diagnose PTSD, and that the proportion of residents meeting criteria increased with level of training.[15] A recent survey of surgical residents found 22% screened positive for PTSD, with an additional 35% considered "at risk."[16]
With the arrival of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus in early 2020, physicians across the world were met with a surge of critically ill patients. From experience in prior pandemics such as SARS in 2003, we know that healthcare workers who treated SARS patients had significantly higher levels of burnout and PTSD, a condition that portends a high risk of suicidal ideations, attempts, and completions.[17–20] Physicians may be particularly at risk, and thus calls have been made for attention to helping to prevent PTSD during this current pandemic.[17,21] Data from China, the first country to experience the pandemic surge, confirms this prediction, with 27% of their medical staff who treated coronavirus disease 2019 (COVID-19) patients reporting post-traumatic stress symptoms.[22]
After the arrival of Sars-CoV-2 to the United States, the Northeast experienced an influx of cases during the months of March, April, and May 2020. (CDC). By May 31, 2020, as the initial surge waned, 42,743 people had been infected with SARS-CoV-2 and 3970 had died. There was an average daily hospital census of 1174 persons statewide.[23] As the majority of hospital admissions are first managed and stabilized in the emergency department (ED), the volume of COVID-19 patients and its strain on resources was acutely felt by the ED staff. In this study, we examine the association between the peak and wane of COVID-19 cases on physicians at a large, academic healthcare system and symptoms of burnout and post-traumatic stress among our EM resident population. We were able to compare the burnout across a same matched cohort across three time periods: before, during, and after the peak COVID surge in the Northeast US to better elucidate the effectiveness of current methods to reduce physician burnout.
Western J Emerg Med. 2022;23(2):251-257. © 2022 Western Journal of Emergency Medicine
