key: cord-0722709-gl1ijahd authors: Misery, L; Fluhr, J W; Beylot-Barry, M; Jouan, N; Hamann, P; Consoli, S G; Schollhammer, M; Charleux, D; Bewley, A; Rathod, D title: Psychological and professional impact of COVID-19 lockdown on French dermatologists: Data from a large survey date: 2021-01-28 journal: Ann Dermatol Venereol DOI: 10.1016/j.annder.2021.01.004 sha: 1289b67c74642ebe0989fa58ccdee212b6b7fd28 doc_id: 722709 cord_uid: gl1ijahd Aim: To evaluate the extent to which COVID-19-related lockdown affected dermatologists. Methods: An anonymous online survey was proposed to all French dermatologists and dermatology residents to assess the impact of COVID-19 lockdown on their professional activity, their level of stress and their psychological state, as well as their coping strategies. Results: Exactly 800 dermatologists completed the survey. The respondents noted changes in behavior in their professional and personal environment. The number of cancelled or rescheduled appointments was very high, with a huge financial impact for private practitioners. Stigmatization was also reported. Anxiety and a feeling of increased stress were very frequent. Increased substance use was also reported. Conclusion: The impact of the COVID-19 pandemic and lockdown was significant for French dermatologists, with risks to their own health, profound changes in their practice, and financial and psychological impact, but also the development of new consultation and evaluation strategies to improve their work-life balance. implemented from March 17 to May 11, with banning of all public gatherings and obliging citizens to remain in their homes except for grocery shopping, work in key sectors (health, food industry, transportation) and other essential areas. In France, people were also required to fill out a standardized form stating their reason for leaving the house. Outdoor exercise was only permitted once a day, alone and for a maximum period of one hour. Families were permitted to take walks but only within a 1-kilometer radius of their homes. Walking dogs was allowed, although owners had to write down what time they left home to make sure they remained within the one-hour limit. Those breaching lockdown rules faced fines of between €135 and €3,700, as well as up to six months' prison in the event of multiple violations. Discontinuation of face-to-face work, possibly replaced by teleworking, was clearly recommended for all. As a result, physicians were required to strictly limit face-to-face consultations to emergency situations or telemedicine work. Patients were also obliged to limit medical consultations to urgent situations [1] [2] [3] . Hospital admission to dermatology departments was only permitted for patients with a very severe (life-threatening) skin disease not responding to outpatient treatment. COVID-19, especially in times of lockdown, had many apparent consequences on dermatology practice, and there was a need to evaluate these [4] [5] [6] . An anonymous online survey was sent to all French dermatologists and dermatology residents to assess the impact of COVID-19 lockdown on their professional activity, their level of stress and their psychological state, as well as their coping strategies. All categorical variables were presented as percentages and data was entered into Microsoft Excel 2007 and Prism 6.0 for statistical analysis. Quantitative variables were expressed as mean and standard deviation. Qualitative variables were expressed as absolute numbers or percentages. ANOVA (Kruskal-Wallis Test) was used where there were more than 2 groups, with post-hoc analysis for pair-wise comparison (Dunnett's Test). Most of the data sets showed non-Gaussian distribution and non-parametric tests were thus selected. The significance level was set at 5%. Notably, 715 respondents answered within the first 3 days of the survey. Exactly 800 dermatologists completed the survey (response rate: 18.6%): 80.2% were women and 19.85% were men, 94.6% were fully accredited dermatologists and 5.4% were dermatology residents; 82.5% had a private practice and 17.5% were employees (16% in hospitals) ( Table S1 , see additional material in the online version of this article). Most dermatologists were in a high-risk group for severe COVID-19. Indeed, 58.7% were aged between 50 and 70 years, 4% were aged over 70 years, 7.4% had hypertension and 6.1% were overweight or obese. Other risk factors were reported by under 5% of respondents. SARS-CoV-2-positive nasopharyngeal PCR was reported by 3.7% of respondents, while 19.4% thought they had been infected because they presented the classic symptoms of COVID-19 but without confirmatory positive testing; 36.2% thought they had not been infected, and 40.7% did not know. Regarding COVID-19 in patients, 53.7% of respondents felt they had encountered patients with cutaneous symptoms of COVID-19 and 27.5% felt they had encountered patients with extra-cutaneous symptoms. Concerning use of personal protection, dermatologists used masks (97.9%), hydro-alcoholic gel (95.4%), soap (87.0%), gloves (83.5%), white coats (64.4%), and, less frequently, glasses (44.1%), mobcaps (14.1%) or overshoes (5.4%). Among the respondents, 10.7% indicated that they had created their own personal protective kit. Since the beginning of the epidemic, 41.9% used gloves but wished to stop after the end of the epidemic, while 29.5% wanted to Page 7 of 19 J o u r n a l P r e -p r o o f 7 retain this approach permanently. Conversely, 19.5% did not wish to use gloves due to negative effects on the patient-doctor relationship, 9.9% because they did not physically touch patients, and 2.5% due to problems of materials supply. In their professional environment, respondents noted changes in their behavior since the start of lockdown: closer relationships for 35.8%, social distancing for 16.5%, increased tension for 12.5%, and impaired team spirit for 4.5%. Increased use of phones (48.7%), e-mails (44.1%) and videoconferences (29.0%) were also noted. Very high numbers of cancelled or rescheduled appointments were reported (Fig. S1 , see additional material in the online version of this article). As a result, loss of income was huge for dermatologists in private practice, while there was no impact for other dermatologists (Fig. 1 ). Consequently, 16.2% of respondents decided to take out a loan while 66.2% decided not to, and 17.6% did not know what they would do. Two thirds of colleagues practiced telemedicine and two thirds maintained some face-to-face consultations. Among the respondents, 15.2% had non-dermatological but medical activities, and 14.1% had ceased all activities. During teleconsultations, 45.3% of dermatologists felt the patient-physician relationship was worse, 31.9% felt it was much worse, 19.5% felt it was unchanged, 4.1% felt it was better, and 0.8% thought it was much better. Respondents considered that their partner (66.3%), their friends (56.6%), their children (51.7%), their parents (32.7%), or other persons (12.2%) were supportive during the acute COVID crisis. However, 11.0% thought that nobody was helpful to them. Regarding COVID-19 and the feeling of being worried about themselves, 2.4% of dermatologists were enormously worried about themselves, while 12.4% were very worried, 59.6% a little, and 25.7% not at all (Fig. S2 , see additional material in the online version of this article). Social distancing affected the emotional status of 50.1% of the participants slightly, 25% considerably, 5.4% greatly, and 19.1% not at all. Dermatologists working in hospitals were more affected (Fig. S3 , see additional material in the online version of this article). When we asked which were the 3 most predominant personal feelings since the beginning of the pandemic, a wide variety of answers was given, but most dermatologists reported anxiety and feelings of greater stress (Table 1) . The most frequent concerns were fear of loved ones being affected by COVID-19 (87.0%), a high post-lockdown workload (62.5%), personal economic consequences (59.4%), consequences on patient's health (32.3%), and fear of being infected by the virus (29.3%). Positive feelings were also reported: pride in being an HCP (28.2%) and a heightened sense of purpose (16.1%). Between 3 and 4% (6% in the redeployment group) of respondents were seeking professional psychological support. The groups did not differ statistically. A large majority were satisfied that they were being adequately supported. Among respondents, 52.2 % were confined with their family and 31.8% with their partner, while 13.7% were alone (other situations: 2.3%). One or more household member(s) in lockdown were HCPs in 41.1% of cases. Respondents noted changes in behavior within their own households since the start of lockdown: closer relationships (54.1%), more frequent disputes (12.1%), relationship spacing (5.1%) or physical abuse (1 person). Increased use of Internet (56.6%), phone (56.1%) and e-mails (33.7%) were also noted. Several activities were increased: cooking (59.3%), sport (34.3%), listening to music (25.5%), walking (23.5%), yoga (13.2%), meditation (12.0%), and actively playing music (6.4%). Dermatologists generally felt these activities to be beneficial (59.1%) while 13.4% felt that they were not, and 27.5% did not know. Respondents declared that they never drank alcohol (50.7%) while 86.6% never smoked tobacco. Psychotropic drugs were never used by 88.9% while benzodiazepines were used by 5.5%, serotonin reuptake inhibitors by 4.5%, hypnotics by 2.6% and other psychotropic drugs Page 10 of 19 J o u r n a l P r e -p r o o f 10 by 1.9%. However, some respondents admitted that lockdown was followed by increased consumption of alcohol (20.5%), tobacco (5.5%), psychotropic drugs (3.6%), or cannabis (0.2%). The increase in substance use was higher among hospital dermatologists (Fig. 2) . During lockdown, 37% of respondents indicated a wish for more teleconsultations after the crisis, while 35.8% wished to reduce their activity, 29.8% wished to take more time for their personal life, 22.3% wished to have more consultations than before the epidemic to make up for lost time, and 21.3% wanted more consultations for financial reasons. However, 15% thought that their professional practice would be unchanged after the epidemic. To the best of our knowledge, this study was the first to evaluate so completely the impact on dermatologists of the COVID-19-induced lockdown, which is an important moment in the history of dermatology. Dermatologists were frequently, and legitimately, concerned about themselves. They commonly used the recommended means of protection, despite the known capacity of personal protective equipment to induce facial dermatoses or hand dermatitis [7, 8] . Dermatologists reported numerous modifications of their social relationships. Fortunately, most colleagues observed closer relationships in their workplace and even more often in their household. This could be partly related to the presence of one or more HCPs in households, with the possibility of discussing common concerns. Dermatological activities were severely affected by the lockdown. In private practice, a huge financial impact was reported despite government financial assistance. Hospital dermatologists were in some cases recruited for non-dermatological activities in emergency departments, mainly (but not only) screening/triage, or in newly created departments and wards specifically for COVID-19. The consequences were greater in the most severely affected regions of France, namely Eastern France, Ile-de-France (Paris metropolitan area), Northern France and Burgundy-Franche-Comté. The pandemic was accompanied by large-scale development of telemedicine in France, as shown by our study and others [9] . In many cases, dermatologists not completely satisfied with this approach. Chinese and Macedonian studies also showed changes in reasons for dermatological consultations [10, 11] . Dermatologists frequently felt stigmatized, which should be studied further. Stigmatization of HCPs and the fears of contaminating others are known risk factors for mental health disorders among HCPs [12] . Feelings of stress and anxiety were common among dermatologists. For those in private practice, the personal economic consequences were the main cause. For those in hospitals, fears were related more to the disease itself. For both, a heavy post-lockdown workload was feared. Depression, anxiety, insomnia and psychological distress are known to be increasingly frequent as HCPs are confronted with this disease [13] . Among the French population, higher risk of anxiety during lockdown was seen to be associated with numerous characteristics [14] : -Socio-demographic characteristics: being a woman, being a parent of children aged 16 years or younger, experiencing a difficult financial situation; -Living conditions related to the epidemic situation: working from home and having a friend or relative who has been ill or has had symptoms of Covid-19; Appendix S1: Questionnaire to assess the impact of COVID-19 lockdown (only available in French) Figure S1 : Cancelled and rescheduled appointments. All four dermatology practice groups had to cancel or extensively reschedule their appointments. The group most affected was that of locum dermatologists, who had a significantly higher cancellation/reschedule rate than the hospital group (ANOVA: p= 0.0384; direct comparison p<0.05 hospital vs. locum). Figure S2 : Feeling of concern for themselves. Dermatologists working in private practice were experienced slightly more concern for themselves than doctors working in hospital settings; a statistical trend (p=0.0520) was noted but was below the level of statistical significance. Figure S3 : Emotional effects of social distancing. Social distancing had a significantly higher impact on physicians working in hospitals compared to those working in private practice (ANOVA: p=0.0099; followed by Dunn's Test, with significant differences between the hospital group and both private practice groups; p<0.05) What dermatologists could do to cope with the novel coronavirus (SARS-CoV-2): a dermatologist's perspective from China COVID-19 and dermatology: A comprehensive guide for dermatologists Dermatology practices as vectors for COVID-19 transmission: A call for immediate cessation of nonemergent dermatology visits Dermatologists and SARS-CoV-2: the impact of pandemic on daily practice Impact of COVID-19 pandemic on dermatologists and dermatology practice The aftermath of COVID-19 in dermatology practice: What's next? 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