key: cord-0702962-rywoxhdt authors: Dionisi, Tommaso; Sestito, Luisa; Tarli, Claudia; Antonelli, Mariangela; Tosoni, Alberto; D’Addio, Stefano; Mirijello, Antonio; Vassallo, Gabriele Angelo; Leggio, Lorenzo; Gasbarrini, Antonio; Addolorato, Giovanni title: Risk of burnout and stress in physicians working in a COVID team: A longitudinal survey date: 2021-09-08 journal: Int J Clin Pract DOI: 10.1111/ijcp.14755 sha: 7024a29a7360a6f8243158ad3fbb43200f2372a3 doc_id: 702962 cord_uid: rywoxhdt BACKGROUND AND AIMS: The COVID‐19 pandemic represents a source of stress and potential burnout for many physicians. This single‐site survey aimed at assessing perceived stress and risk to develop burnout syndrome among physicians operating in COVID wards. METHODS: This longitudinal survey evaluated stress and burnout in 51 physicians operating in the COVID team of Gemelli Hospital, Italy. Participants were asked to complete the Maslach Burnout Inventory (MBI) and the Perceived Stress Questionnaire on a short run (PSQs) (referring to the past 7 days) at baseline (T0) and then for four weeks (T1‐T4). Perceived Stress Questionnaire on a long run (PSQl) (referring to the past 2 years) was completed only at T0. RESULTS: Compared with physicians board‐certified in internal medicine, those board‐certified in other disciplines showed higher scores for the Emotional Exhaustion (EE) score of the MBI scale (P < .001). Depersonalisation (DP) score showed a reduction over time (P = .002). Attending physicians scored lower than the resident physicians on the DP scale (P = .048) and higher than resident physicians on the Personal Accomplishment (PA) scale (P = .04). PSQl predicted higher scores on the EE scale (P = .003), DP scale (P = .003) and lower scores on the PA scale (P < .001). PSQs showed a reduction over time (P = .03). Attending physicians had a lower PSQs score compared with the resident physicians (P = .04). CONCLUSIONS: Medical specialty and clinical position could represent risk factors for the development of burnout in a COVID team. In these preliminary results, physicians board‐certified in internal medicine showed lower risk of developing EE during the entire course of the study. The novel coronavirus (SARS-CoV-2), originating from Wuhan, China in December 2019, is in the same family as the causative agents for previous Middle East Respiratory Syndrome (MERS) and severe acute respiratory syndrome (SARS) outbreaks. The high rates of transmissibility, in particular from asymptomatic carriers, as well as the high severity of illness in individuals with very common preexisting chronic conditions (eg, diabetes, obesity, heart disease, lung disease) 1 Physician burnout has always been a universal dilemma that is seen in healthcare professionals, resulting from chronic work-related stress, with symptoms characterised by feelings of energy depletion or exhaustion, increased mental distance from one's job, or feelings of negativism or cynicism related to one's job, and reduced professional efficacy. 4 Factors such as working hours, workload expectations, insufficient rewards, interpersonal communication, negative leadership, and quality of night sleep have always been considered influential. 4 Many physicians had to change departments quickly, often on a short notice and found themselves working in an unfamiliar environment. They found themselves caring for patients who were not their usual ones and having to manage new and unexpected clinical challenges. It was considered appropriate to investigate which specialists were best suited to manage this unprecedented situation. As shown in the literature, work experience and age are protective factors against Burnout. 4 In addition, the type of work performed may also have an impact on stress and the risk of developing Burnout. Age, career years, and the type of activity performed are related to a job position. More experienced physicians have older age and have more managerial roles, and have less contact with the patient. Moreover, the development of burnout syndrome affects patients' quality of care, and it has a direct, negative impact on the physicians' quality of life, in particular on mood disorders, anxiety, alcohol and substance use disorders, and suicides. 4 During the COVID-19 pandemic, it is more important than ever to address the physical and psychological health of physicians, who are already at risk of experiencing stress and developing burnout syndrome. This pilot study aimed to conduct a survey in a group of physicians, working in a COVID team, during the March-April 2020 outbreak in Italy. The goal of the survey was to evaluate their perceived stress and burnout before, during and after the experience in a COVID team, and identify subgroups of physicians at higher risk of developing burnout and stress. This longitudinal survey was conducted among physicians involved in the COVID team of the Gemelli Hospital, Rome, Italy during the Conclusions: Medical specialty and clinical position could represent risk factors for the development of burnout in a COVID team. In these preliminary results, physicians board-certified in internal medicine showed lower risk of developing EE during the entire course of the study. Physician burnout has always been a universal dilemma that is seen in healthcare professionals. COVID-19 pandemic has had an important impact on the health care system all over the world, and the response to the pandemic has represented additional stress for all health care providers, including physicians. Some peculiarities could represent potential risk factors for the development of burnout in a COVID team of physicians. Medical specialty and clinical position could represent potential risk factors for the development of burnout in a COVID team of physicians. In our sample, physicians board-certified in internal medicine showed lower risk of developing emotional exhaustion, during the entire course of the study, compared with physicians board-certified in other disciplines. The latter had an increase in the perceived stress over time, compared with physicians boardcertified in internal medicine. March-April 2020 outbreak, specifically from March 19, 2020 to April 21, 2020. All of the physicians to whom the survey was submitted worked in departments with a similar intensity of care. No other exclusion criteria were used. A sample size was not calculated a priori for this study, which in fact represents a pilot investigation that may guide power calculation and other aspects of future larger studies. A total of 136 physicians were invited by email, face-to-face or direct phone call to participate, at their entry into the COVID team. The invitation to participate explained the voluntary and confidential nature of the study. Among them, 53 consented to participate in the study. None of the physicians who filled out the questionnaires had a psychiatric history. Participants were asked to indicate their gender and age. Also, information was collected on their clinical position (ie, whether they were attending physicians or resident physicians), and on their medical specialty (board-certified in internal medicine or in other disciplines). Once they left the COVID team, they were asked to specify whether they had been in contact with patients who had died because of COVID-19. Given the small sample and the high percentage of physicians board-certified in internal medicine in our study, the specialty variable divided the sample into physicians board-certified in internal medicine vs physicians board-certified in other disciplines. The latter subgroup included physicians board-certified in endocrinology, rheumatology, gastroenterology, emergency medicine, geriatrics and allergology. Sociodemographic and professional characteristics of the sample are reported in Table 1 . Physicians were asked to complete the PSQ on a long term (PSQl) at enrolment and Maslach Burnout Inventory (MBI) and PSQ on a short term (PSQs) at enrolment and weekly. Reminders to complete the questionnaires were periodically sent to the participants by email. Two participants, who only answered one questionnaire, were excluded from the data analysis, therefore the final analysed sample included 51 participants. The questionnaires were administered at baseline and at each follow-up timepoint. The exact timeline was slightly flexible, based on the shifts during which the participants were working in the COVID team. T0 refers to questionnaires completed during a time window ranging from 3 days before to 3 days after joining the COVID team. Burnout was measured using MBI-HSS (Italian validated version). 5 The questionnaire consists of 22 items, divided into 3 scales: 9 items for Emotional Exhaustion (EE), 5 items for Depersonalisation (DP) and 8 for Personal Accomplishment (PA). Each item was scored according to a Likert scale ranging from "never" (0) to "every day" (6) . Each subscale was scored individually and assessed on a continuous scale. The dimensions were categorised into low, moderate and high levels, considering the cut-off points previously validated. In particular, EE scores were categorised as low: 0-18, medium: 19-26, high: ≥27. DP scores were categorised as: low: 0-5, moderate: 6-9, high: ≥10. PA scores were categorised as: low: 0-33, moderate: 34-39, high: ≥40. Low scores for EE and DP and high ones for PA indicate the absence of burnout. Exceeding the cut-off in all scales corresponds to a higher risk of burnout syndrome. A reduced PA is inversely associated with burnout. 6,7 The perceived stress was measured using the Italian version of the PSQ. 8 Worries, Tension and Joy measure the individual's internal stress reactions and Demands represents the individual's general perception of external stressors. Each item was rated on a 4-point Likert scale from 1: "almost never" to 4: "usually." A linear transformation changes the subscale scores to values from 0 to 1. 9 Participants were asked to fill out the questionnaire on a long run form (Perceived Stress Questionnaire on Long term, PSQl), marking the answers that best described their emotional state over the last 2 years. In addition, they were asked to mark the answers that best described their TA B L E 1 Sociodemographic and professional characteristics. All values are reported as frequency and percentage or mean and standard deviation All analyses were conducted using Stata 14, according to the modi- On MBI, median (IQR) values were analysed for each scale. EE showed a value of 19 (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) at T0, and of 13 (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) CI: −2.36 to −0.06; P = .04) ( Figure 1 ). The data analysis showed a significant reduction in the DP scores P < .001). Attending physicians score significantly higher than resident physicians on the PA scale (β, 3.8; 95% CI: 0.14 to 7.45; P = .04) ( Figure 3 ). On PSQl, the effect of the medical specialty on the Worries score was statistically significant, and physicians board-certified in inter- Table 4 . The data analysis showed a significant reduction of the Overall None of the parameters analysed in the study were able to predict the Worries scale score. The data analysis did not show a significant reduction in the The present study investigated the perceived stress and burnout, assessed by the PSQ and MBI questionnaires, respectively, in The concern of being infected, the increase in working hours, the critical conditions of patients are some of the main causes leading to stress and burnout, which in turn may increase medical error. 11 Occupational risk factors were considered in this study. reported in the pre-COVID era. 23 This could be because of a rearrangement of work as working hours are reduced and remote work is employed. 23, 24 This observation may be related to a higher professional experience of attending physicians in patients' management, and the greater perception of own responsibility could be related to higher personal accomplishment. In particular, resident physicians seem to be at higher risk of burnout syndrome among doctors, and the risk of burnout is progressively reduced with career progression. 25 Also, the age of the physicians (older than resident physicians) could play a role in this risk reduction: previous investigations already documented an inverse relationship between the prevalence of burnout syndrome and the age of physicians. 26 The different job roles of residents, with more demanding call schedules, could also impact this difference, affecting work and family life, sleep, and possibly being associated with an increased risk of depression and burnout. 20, 27, 28 Some protective factors in addition to mentorship and support, having control over one's time and taking mental breaks. 29 As reported in the literature, 21 Attending physicians showed lower score on the DP scale over time than resident physicians (β, −3.05; 95% CI, −6.07 to −0.02; P = .048). The latter showed decreasing score on the DP scale over time than attending physicians (β, 0.505; 95% CI, 0.01 to 1.00; P = .047). B, scatter plot and regression line indicating the correlation between DP score and PSQ on a long run score (β, 14.91; 95% CI, 5.11 to 24.72; P = .003) Although during a public health emergency like this unprecedented pandemic it is not easy to select the staff to be involved, it would be useful to enlist mainly those with a lower risk of developing burnout syndrome. Moreover, based on our data, it would be appropriate to start involving the most experienced physicians. Besides, monitoring physicians through MBI administration every two weeks could help establish a shift system to reduce the perception of environmental stress through even short periods of rest at home. This study has some limitations: because of the different organisation of the teams of other health professionals (eg, nurses and social workers) involved in the COVID emergency in our hospital, it was not feasible to enrol them. The small sample and the fact that the survey was conducted in one hospital prevent generalisability of the findings. Moreover, missing data and failure to adhere to the timing of the follow up could contribute to a bias in the results, although this was a limitation impossible to control for, given the emergency conditions under which the study was conducted. Another limitation of this study is that no patient information was called, therefore we were not able to investigate whether patient's severity of the disease could have an impact on the outcomes assessed in the COVID team. Also, the short follow up may have overestimated the predictive ability of the PSQl on the risk of burnout. In conclusion, assessing risk factors for stress and burnout syndrome in physicians involved in an emergency response such as COVID-19 could be useful in order to: (a) provide adequate psychological support to those who need it, (b) help physicians find a balance recognising what they can and cannot control 35 and (c) help them address their concerns, improve the individuals' stress response and, consequently, their professional performance. Such a supportive work environment can be critical in maintaining the resilience of clinicians, especially during a crisis such as COVID-19. 25 Institutions should also provide support to healthcare teams to help with their work organisation and internal dynamics, as well as provide individual support to healthcare professionals to improve the working environment and mental health of their employees. 36 It would also be desirable that health care organisations first provide information on reducing burnout and propose a screening of the physicians involved in the emergency teams, to identify those at higher risk of burnout early and set appropriate shift rotations. D'Angelo, Francesca D'Aversa, Alessandro D'Errico, Fernando Comorbidity and its impact on patients with COVID-19 COVID-19) Situation Summary How essential is to focus on physician's health and burnout in coronavirus (COVID-19) pandemic? 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The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Data available on request from the authors. https://orcid.org/0000-0003-3932-3803Giovanni Addolorato https://orcid.org/0000-0002-1522-9946