key: cord-0757174-v40usppd
authors: Welsh, Margaux; Chimowitz, Hannah; Nanavati, Janvi D.; Huff, Nathan R.; Isbell, Linda M.
title: A qualitative investigation of the impact of coronavirus disease 2019 (COVID‐19) on emergency physicians’ emotional experiences and coping strategies
date: 2021-10-27
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12578
sha: 91547720526fb15d0cabdf2312df1b3b1b340eaa
doc_id: 757174
cord_uid: v40usppd

STUDY OBJECTIVE: Throughout the coronavirus disease 2019 (COVID‐19) pandemic, emergency physicians in the United States have faced unprecedented challenges, risks, and uncertainty while caring for patients in an already vulnerable healthcare system. As such, the pandemic has exacerbated high levels of negative emotions and burnout among emergency physicians, but little systematic qualitative work has documented these phenomena. The purpose of this qualitative investigation was to study emergency physicians’ emotional experiences in response to COVID‐19 and the coping strategies that they employed to navigate the pandemic. METHODS: From September 2020 to February 2021, we conducted semistructured interviews with 26 emergency physicians recruited from 2 early COVID‐19 epicenters: New York City and the Metro Boston region. Interviews, coding, and analyses were conducted using a grounded theory approach. RESULTS: Emergency physicians reported heightened anxiety, empathy, sadness, frustration, and anger during the pandemic. Physicians frequently attributed feelings of anxiety to medical uncertainty around the COVID‐19 virus, personal risk of contracting the virus and transmitting it to family members, the emergency environment, and resource availability. Emergency physicians also discussed the emotional effects of policies prohibiting patients’ family members from entering the emergency department (ED), both on themselves and patients. Sources of physician anger and frustration included changing policies and rules, hospital leadership and administration, and pay cuts. Some physicians described an evolving, ongoing coping process in response to the pandemic, and most identified collective discussion and processing within the emergency medicine community as an effective coping strategy. CONCLUSIONS: Our findings underscore the need to investigate the effects of physicians’ pandemic‐related emotional stress and burnout on patient care. Evidence‐based interventions to support emergency physicians in coping with pandemic‐related trauma are needed.

interventions to support emergency physicians in coping with pandemic-related trauma are needed.

coping behavior, COVID-19 pandemic, emergency departments, emergency medicine, emotions, qualitative research INTRODUCTION

Research conducted before the coronavirus disease 2019 (COVID- 19) pandemic demonstrates that emergency physicians experience negative emotions related to patient factors (eg, unpredictability, abusive behaviors, entitlement), hospital-level concerns (eg, overcrowding, understaffing, and limited resources), and system-level issues (eg, time constraints, lack of community resources). 1 Emergency physicians have recognized that these negative emotions may result in adverse effects on patient care and compromise patient safety. 2 Negative emotions can also impact provider well-being, leading to increased anxiety, depression, and burnout-which likewise can impact patient care. 3 Burnout-characterized by chronic exhaustion, cynicism, and inefficacy 4 -is prevalent among physicians, 5 with emergency physicians exhibiting the highest rates of burnout (ranging between 24.4% and 71.4%) among all medical specialties. 5, 6 The COVID-19 pandemic has amplified preexisting stressors, introduced unforeseen challenges to the emergency department (ED) environment, and triggered difficult emotional experiences for all healthcare workers. For example, a large study conducted in China during the early months of the COVID-19 outbreak found that healthcare workers caring for patients with COVID-19 reported experiencing symptoms of depression, anxiety, insomnia, and distress. 7 Studies of healthcare workers in the United States demonstrate similar trends, with a large majority experiencing higher than usual levels of stress attributed to COVID-19. 8 Among ED workers, pandemic-related anxiety and burnout have been prevalent. 9 Unfortunately, longitudinal work on the effects of previous outbreaks suggests that these negative effects persist long after the pandemic ends. 10,11

The COVID-19 pandemic has been immensely disruptive to health care, escalating safety risks to patients, physicians, and other healthcare workers. 12 Fear of infection, need for personal protection, increased workload, and shifts in clinical understanding have changed the landscape of emergency medicine and intensified the emotional burdens faced by healthcare workers. In work conducted before the pandemic, emergency physicians reported employing various coping and emotion regulation strategies to reduce risks to patient safety, including suppression, distraction, cognitive reappraisal, humor, sup-port seeking, and taking breaks. 1 However, the coping strategies emergency physicians have available and employ to manage the unprecedented and prolonged emotional distress and anxiety experienced during the COVID-19 pandemic remain poorly understood. To address and mitigate the potentially chronic, negative impacts of the pandemic on emergency physicians, it is critical to gain a thorough understanding of physicians' experiences, emotional challenges, and coping mechanisms during the pandemic. We use an in-depth qualitative research approach to gain greater insight into the complex effects of COVID-19 on emergency physicians' emotional experiences and the coping strategies they have employed during the pandemic. Ultimately, through qualitative methods, this understanding can inform interventions geared at supporting emergency physicians in coping with pandemic-related trauma.

The purpose of the current study is to use qualitative methods to investigate the impact of COVID-19 on emergency physicians' emotional experiences and the specific coping strategies that physicians employed throughout the pandemic.

We conducted semistructured interviews with 26 attending emer- 

The research team developed a semistructured interview guide based 

All interviews were video-and audio-recorded and transcribed using the Zoom videoconferencing service. 17 Transcriptions were deidentified, reviewed, and corrected as needed by at least 2 research assistants working independently to ensure accuracy. After this process, for independent coding using the agreed-upon codebook. Each coded interview was then reviewed by the other coder, who reviewed the initial coding for consistency and made note of any disagreements.

Researchers corresponded via email and conducted biweekly meetings to discuss and reconcile any coding or to add new codes as needed. Codes were then carefully analyzed and collectively discussed to inform our results. Open and axial codes were continually identified and/or refined as data collection and analyses progressed and were compared across all transcripts. This repetitive, holistic process of constant comparison in qualitative analysis increases accuracy and rigor. 13, 14 After open and axial coding, we generated selective codes that integrated axial codes to construct an overarching description of the data. Continuing with the same example, 1 selective code from our data was "Effects of COVID-19 on physician experiences and emotions." The selective codes are described in the Results, which are organized by the 2 primary topics guiding our investigation.

We interviewed a total of 26 physicians ( Table 1 .

Physicians reported a broad range of negative emotions in response to the pandemic. Within the overarching theme of the impact of COVID-19 on physicians' emotional experiences, physicians described experiencing anxiety and uncertainty, feeling overwhelmed, a sense of disconnect and sadness, increased empathy, and feelings of frustration and anger. The causes and features of these emotional experiences are described in this section, and additional representative quotations for each along with respective subthemes are displayed in Table 2 .

Emergency physicians in our sample reported a great deal of anxiety, oftentimes related to the unprecedented, uncertain circumstances in which the pandemic began. Physicians described an initial confusion about COVID-19 symptoms and appropriate precautions. Furthermore, with no clear treatment available at the onset of the pandemic, physicians described feeling anxious about not knowing how to identify or treat COVID-19. Fortunately, physicians widely agreed that as their understanding of COVID-19 increased, their anxiety about diagnosing decreased. Many physicians noted that after a certain point in the pandemic, they assumed everyone had COVID-19, so identifying and diagnosing the disease no longer induced as much anxiety.

In addition to anxiety associated with diagnosis, some physicians reported feeling anxious about contracting the virus themselves. A few providers described feeling anxious about rapidly changing personal protective equipment (PPE) protocols: "there was a lot of anxiety about PPE, one day we were wearing regular masks. The next day we were wearing surgical masks. The next day, wearing N95s and then you're kind of just, like, well, yesterday I wore a regular mask, am I gonna get sick because I wasn't wearing that then?" (participant 15).

Many physicians also expressed anxiety about spreading the virus to friends and family members, especially those who were not in positions where they could physically separate from family. Physicians described developing rigorous sanitation routines to keep COVID-19-exposed clothing or other materials away from their homes as much as possible. Lastly, physicians reported feeling anxious about their work environment, expressing worries over whether their hospital would have adequate resources. One physician described the mind-set of going to work as a "wartime mentality" (participant 20).

According to many physicians, this initial sense of uncertainty affected patients and physicians alike, with 1 physician stating, "The anxiety was palpable. . . through everyone" (participant 20). Although many discussed feeling and showing more empathy toward patients, providers felt that having their faces covered by PPE prevented them from being able to physically express empathy. Emergency physicians noted how the extensive coverage of colleagues' , patients' , and their own bodies and faces exacerbated the stress of the ED environment.

Often, wearing PPE resulted in an inability to recognize coworkers, eliminating 1 of the few constants of the ED. Furthermore, physicians described how PPE could impair communication and connection among care team members and patients. One physician noted, "I can't even tell which colleague is which with all the gear that people have to wear, much less communicate and demonstrate empathy with a patient" (participant 12). Physicians also described challenges understanding patients' nonverbal cues, describing how reading masked individuals' facial expressions was nearly impossible. To combat some of these difficulties in communication, physicians described shouting through their masks or getting an interpreter more often. Two physicians even mentioned at times removing their masks because they could not bear to talk to the patient through it, especially when delivering grim or difficult news. Medical uncertainty "We chose a profession because we have the ability to heal people. . . we can do that really well because we have lots of science, lots of technology, lots of resources. . . and so I think we basically kind of got exposed because this was something brand new. And we had not figured out how to do that well yet. And I think that's where a lot of anxiety came from is getting to a place where people could die just because you weren't exactly sure what the right management was" (participant 5).

Resource availability "I don't think I felt anxious about getting COVID. I felt anxious about not knowing how many patients were going to be in the emergency room, if this was the night. . . we ran out of ventilators, or if. . . we found somebody dead in a corner because there's just not enough providers" (participant 21).

Overwhelmed Patient volume and acuity "We were literally busting. Busting our seams so to speak from an intensive care perspective, from the amount of acute very sick patient perspective, and from the perspective of, at that time, just being completely overwhelmed by how many people were dying, close to death all at the same time, and how quickly people would go from walking and talking to being completely, you know, nearing death" (participant 18).

"And it kind of felt like we were working so hard and so overwhelmed, and everybody was dying. . . a lot of times like we work hard and, and people get better and that that's the nice part of medicine. . . with COVID. . . there were pure weeks like where everybody just died. . . and that was very hard" (participant 22).

Personal protective equipment "I couldn't connect with my patients and I could not breathe through my equipment. I think I was mostly like angry, like. . . I was not happy at my work. It just was miserable, and it seemed like everything we were doing to help patients was not working. And you lose that connection and you're exhausted" (participant 11).

Managing patient expectations "They had COVID, they felt awful, but they didn't need supplemental oxygen, or they needed two liters and we were able to coordinate for them to get that at home. Those people were not admitted and there was a frustration on both ends because patients, when they feel horrible, want to be in the hospital taken care of, and on my end, I want to do. . . what's best for patients, but also you have to account for the volume and the capacity to care for patients" (participant 12).

Sadness "I think one of the hardest things for me was that family members of patients who were dying or near death and who could not be with their loved ones, because of restrictions in terms of visitation rights. That was really difficult because you were sometimes the last one that they spoke to and you were stretched to the limits of your mental and physical capacity" (participant 25).

"Sometimes it would just make me, you know, so sad that this was happening to so many people and there was so little that we could do to help them. And then. . . when I saw there are other doctors who are similar to me on the ventilator then, you know, that always hits you more because you're like, 'Oh, well, that could just be me'" (participant 14). a Empathy "They're probably going to die. . . in someplace that they did not want to be, in a foreign place. difficult when patients came in with an altered mental status or dementia. Physicians reported needing to call family members much more often, which was time-consuming and frequently unsuccessful. However, some physicians also spoke about nurses taking on this task: "I'll be honest with you, the nurses do a lot of that heavy lifting to get those family members on board" (participant 5). Physicians also described emotional burdens that resulted from policies keeping family members out of the ED. Without family members, who often provide muchneeded company and emotional support to patients, physicians felt they frequently had to step into these roles. Physicians also recognized that nurses and staff regularly took on this responsibility as well. As 1 physician noted, "The absence of the family members. . . had consequences for the nurses, who then had to take up some of that emotional labor" (participant 13).

In addition to feeling that they had to carry the emotional burden that family members would normally absorb, physicians perceived that patients themselves felt much more anxious and isolated because of the combination of wearing increased PPE and the absence of their family members. One physician commented, "In the period before visitors were allowed, I think it was really hard on the staff and the nurses because they were having to really do a lot more emotional support for these patients who are essentially there alone" (participant being well prepared for the pandemic. One physician described how physicians and residents at their hospital had to buy their own PPE, and how as a result, they felt the administration did not care about the safety of its frontline workers. Physicians reported feeling particularly angry in response to pay cuts. One physician described the dip in morale that came with these cuts: ". . . it kind of further contributes to burnout when you're going to work, and you're getting your butt kicked and you're working so hard and you're exposing your family to COVID and you're like, I'm not making the money that I used to make" (participant 15). Other uncontrollable factors described as sources of frustration were an inability to provide certain treatments such as bilevel positive airway pressure and the increased amount of phone calls to families to retrieve necessary information.

A number of physicians also mentioned frustration directly related to patient care during the pandemic. When taking care of patients, physicians reported feeling frustrated that-because of the high patient volume and no clear treatment plan for COVID-19-they were not able to effectively do the job for which they had been trained. Physicians also identified non-emergent and demanding patients as a source of frustration, even while recognizing that these patients are likely to be experiencing frustration themselves. Lastly, physicians described feeling frustrated about the lack of time they had to cope with all of the emotional stressors in the ED, with one provider remarking, "You have a patient that dies and you want to reflect on that, but you cannot because you have 30 other patients that you're taking care of" (participant 12).

When asked about how they had been coping with stressors during the pandemic, a handful of physicians immediately responded that they were coping poorly. However, most emergency physicians referred to at least 1 coping strategy that they had employed. These included seeking social support from ED colleagues, talking with a therapist or close others, using humor, and exercising. Representative quotations can be found in Table 3 .

Nearly all of the participants mentioned that talking with coworkers, friends, and/or family helped them get through the struggles they faced during the pandemic. Collective discussion and processing among the emergency medicine community of physicians was highly valuable for many participants. Some described the pandemic bringing their teams However, other physicians described a transformation in their needs and approaches to coping. One participant mentioned receiving therapy specifically for COVID-related trauma, undergoing a therapeutic modality targeted at posttraumatic stress disorder that was made freely available to healthcare workers. Another stated, "We have witnessed more patients suffering, and therefore it has affected us more.

With COVID, I have been more open to explore expressing my feelings. . . before I used to leave everything at work, but now, since COVID I even come talk to my wife" (participant 23).

Other coping strategies physicians discussed included detaching from emotional events, using humor, writing, speaking to a therapist, and exercising. Physicians described coping mechanisms evolving over time, such that the initial stage of the pandemic was a matter of TA B L E 3 Provider coping strategies: key quotes

Social support from colleagues "Mostly trying to, to commiserate with, with others that are in the same situation as I am. But that's also difficult because we like doing fewer things with other people than we were doing before outside of the hospital, right. And so, I would say that like trying to maintain relationships. . . that allow you to relieve that stress and anxiety has been important" (participant 3).

"And that WhatsApp group I think probably literally saved people's lives. Saved people from losing it. We were able to cry together there, we were able to commiserate, we were able to laugh, we were able to live. . . just knowing that you're not the only one going through it. . . that you're not the only one who is clueless on how to manage this person who literally is dying right in front of you. Finding out what are people doing? How are we to cope with this, teaching each other? It was. . . that was our wellness group right there" (participant 18).

"This was like one tragedy after another, you'd hear relatives are dying, you'd hear your colleagues are dying. You're like, scared about yourself, you're scared about your family. So those are things you had to. . . discuss with your colleagues and you know we were kind of, everyone was each other's crutch, in other words, so they would kind of support each other. . . we had to have a good social system" (participant 17).

Social support from others "I talked a lot with, with folks. . . commiserate with, with people at work, commiserate with my friends back home, and then sharing my story, certainly helps. . . I think just talking about it helps" (participant 6).

"I think I'm closer to my family now than I ever have been, you know, since the beginning of my medical training, just because I realized that's where I need to draw strength from. So that's where I've gone" (participant 5).

Humor "I think humor. Sometimes like making light of the chaos that was around us. It's not the patients, not the severity that was going on, but just the chaos of how protocols are changing every day and you know how ridiculous it was but how necessary it was, was also an important coping mechanism" (participant 11).

Exercise and sleep "I go running and try to stay healthy, mentally, and physically" (participant 25).

"I've tried to be very mindful of. . . things that are just important to my own health and wellness and for me that's making sure every night I'm sleeping at least six hours. . . and you know having some time to exercise every day, and those are the two things that I feel like if I'm able to maintain those, then I'm usually able to maintain at least a good portion of my own wellness" (participant 14). 

The broad themes that emerged from our data come from interviews with a diverse sample of physicians who varied in leadership and ED An additional limitation of our work is the possibility that our recruitment method may have resulted in selection bias, as physicians interested in discussing their experiences during the pandemic may have been more likely to participate. Finally, as with most qualitative research methods, the interviews reflect self-reported behavior and attitudes, which may be limited by incomplete recollection, hindsight bias, or social desirability bias. To combat some of these concerns (eg, social desirability), participants were assured that interviews were confidential and would not be associated with their names or the institutions where they worked. Physicians' emotions were heightened because of various institutional and patient level factors, and physicians reported having limited time to process these feelings. Feeling physically and emotionally exhausted, unable to connect with patients, and helpless in treating patients are all qualities exemplifying burnout, which is known to disproportionately affect emergency physicians. 6 Our data demonstrate that emergency physicians, who are already at an increased risk of burnout, feel that COVID-19-related stressors exacerbate their risks.

In many respects, the results of our qualitative study converge with previous findings obtained using largely survey-based meth- There were numerous emergency physicians in our sample who expressed frustration and anger because their hospital systems were unprepared for the pandemic, a finding that is also consistent with prior research. Insufficient institutional preparedness has been associated with psychological harm to healthcare workers during previous pandemics, 31 and a recent study conducted in Ghana found that low perceived preparedness to respond to COVID-19 among healthcare workers was associated with increased stress and burnout. 32 Anger among emergency physicians in response to pay cuts during the COVID-19 pandemic is less documented in the literature; although health professionals in Pakistan reported distress over their financial instability that occurred as a result of COVID-19, 27 another study conducted in Pennsylvania found no increase in emergency physicians' financial concerns. 33 Even so, an international survey found that >60%

of US physicians experienced a decline in income since the start of the pandemic, 34 and our findings suggest some physicians found pay cuts to be a source of anger.

Our findings documenting the coping strategies that physicians employed to manage pandemic-related emotions and stress are consistent with some research conducted near the onset (April 2020) of the COVID-19 pandemic. 29, 30, 35 Among Japanese healthcare workers, lower levels of communication with friends and higher levels of anxiety were related to poorer mental health, suggesting that coping with the pandemic by communicating with close others may buffer healthcare worker mental health and well-being. 35 In a sample of healthcare workers in New York, 86% reported engaging in at least 1 coping behavior to manage stress during the pandemic, with physical activity/exercise being the most commonly endorsed behavior (59%). 30 Physicians in our study also reported engaging in physical exercise, and a small minority did not identify any specific coping strategies or changes in coping. Although our results echo previous evidence that family support is a common coping strategy for healthcare workers during the COVID-19 pandemic, 36 our findings also shed light on the important role that social support within the emergency medicine community plays for emergency physicians coping with pandemic-related stress.

None of the physicians in our study reported using maladaptive coping strategies (eg, excessive alcohol or substance use) to manage pandemic-related stressors. This finding may accurately reflect our physicians' experiences, or it may reflect a social desirability bias in reporting such behaviors during a face-to-face interview-particularly given that a recent report revealed increased alcohol consumption among emergency physicians since the COVID-19 began; more than a third (34%) of those surveyed reported drinking alcohol to cope with burnout. 37 Using alternative methods to assess maladaptive coping behaviors is important for future research given the adverse effects that these strategies can have on physician burnout and well-being.

There is an urgent need for future investigations of burnout among emergency physicians, as well as multipronged interventions that can help to relieve and heal these feelings, and specific attention to how the pandemic has amplified preexisting stressors and created new stressors. Fortunately, scholarship and research conducted during and after previous epidemics and pandemics highlight potential approaches to preventing, reducing, and managing pandemic-related stress and burnout among healthcare workers. For example, simply raising awareness of potential pandemic-related trauma, stress, and burnout may serve to reduce stigma associated with these conditions, increase support seeking, and increase resilience among healthcare workers. 38, 39 Healthcare institutions can take measures to reduce burnout by including regular facilitated group discussions and reducing workload through scheduling changes. 40 Scholars have also recommended that healthcare workers practice breathing exercises and other mindfulness "micropractices" to reduce anxiety, and that employers make telehealth services available to facilitate peer support and occupational counseling. 41, 42 Insights from emergency physicians in our sample identify several promising strategies available to healthcare workers and institutions.

Talking with other people undergoing similar experiences provided release and comfort to physicians, reminding them that they are not alone. Going forward, creating safe spaces for emergency physicians to freely share their experiences and feelings about the COVID-19 pandemic could help physicians cope with negative emotions and stressors, potentially attenuating burnout. Although much of the acute anxiety during the early stages of the pandemic has dissipated for healthcare workers, consistent and clear communication between hospital administration, ED staff, physicians, and nurses has the potential to alleviate lingering worries and accommodate the emotional and physical needs of healthcare workers. Lastly, empirically assessing the efficacy of new, COVID-19-specific interventions is essential. A recent review of organizational interventions implemented to help healthcare workers cope with psychosocial challenges related to COVID-19 suggests that the limited number of documented protocols and the heterogeneity of existing protocols results in an inability to determine if some programs offer distinct benefits. 43 In sum, before the emergence of COVID-19, the ED was known to be an emotionally evocative setting for physicians and other healthcare workers. 1,2 Through qualitative interviews with emergency physicians, we found that the pandemic has exacerbated many of these emotions, making experiences of sadness, empathy, anger, frustration, and anxiety more intense and frequent. The prolonged experience of negative emotions gives rise to burnout, and our data illuminate how the pandemic has amplified these malignant processes for emergency physicians. In summarizing physicians' own insights, it is clear there is an urgent need to provide all ED staff with adequate tools and support to cope with their experiences. Doing so has the potential to better prepare EDs to care for its physicians and other staff, and by extension its patients, both during normal ED operations and any future global health crises.

This project was funded by the Agency for Healthcare Research and 

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The authors declare no conflict of interest.

Margaux Welsh designed the project in close collaboration with Linda