key: cord-0828454-1tnat0ee
authors: Baumann, Brigitte M.; Cooper, Richelle J.; Medak, Anthony J.; Lim, Stephen; Chinnock, Brian; Frazier, Remi; Roberts, Brian W.; Epel, Elissa S.; Rodriguez, Robert M.
title: Emergency physician stressors, concerns, and behavioral changes during COVID‐19: A longitudinal study
date: 2021-02-16
journal: Acad Emerg Med
DOI: 10.1111/acem.14219
sha: 022624608a1309277a81c59589ed6aab4ac8f6ca
doc_id: 828454
cord_uid: 1tnat0ee

OBJECTIVES: The objective was to provide a longitudinal assessment of anxiety levels and work and home concerns of U.S. emergency physicians during the COVID‐19 pandemic. METHODS: We performed a longitudinal, cross‐sectional email survey of clinically active emergency physicians (attending, fellow, and resident) at seven academic emergency departments. Follow‐up surveys were sent 4 to 6 weeks after the initial survey and assessed the following: COVID‐19 patient exposure, availability of COVID‐19 testing, levels of home and workplace anxiety/stress, changes in behaviors, and performance on a primary care posttraumatic stress disorder screen (PC‐PTSD‐5). Logistic regression explored factors associated with a high PC‐PTSD‐5 scale score (≥3), indicating increased risk for PTSD. RESULTS: Of the 426 surveyed initial respondents, 262 (61.5%) completed the follow‐up survey. While 97.3% (255/262) reported treating suspected COVID‐19 patients, most physicians (162/262, 61.8%) had not received testing themselves. In follow‐up, respondents were most concerned about the relaxing of social distancing leading to a second wave (median score = 6, IQR = 4–7). Physicians reported a consistently high ability to order COVID‐19 tests for patients (median score = 6, IQR = 5–7) and access to personal protective equipment (median score = 6, IQR = 5–6). Women physicians were more likely to score ≥ 3 than men on the PC‐PTSD‐5 screener on the initial survey (43.3% vs. 22.5%; Δ 20.8%, 95% confidence interval [CI] = 9.3% to 31.5%), and despite decreases in overall proportions, this discrepancy remained in follow‐up (34.7% vs. 16.8%; Δ 17.9%, 95% CI = 7.1% to 28.1%). In examining the relationship between demographics, living situations, and institution location on having a PC‐PTSD‐5 score ≥ 3, only female sex was associated with a PC‐PTSD‐5 score ≥ 3 (adjusted odds ratio = 2.48, 95% CI = 1.28 to 4.79). CONCLUSIONS: While exposure to suspected COVID‐19 patients was nearly universal, stress levels in emergency physicians decreased with time. At both initial and follow‐up assessments, women were more likely to test positive on the PC‐PTSD‐5 screener compared to men.

High levels of psychiatric morbidity have been reported by health care workers treating coronavirus disease 2019 (COVID-19) patients. In Asia and Europe, increased rates of anxiety, stress, insomnia, and depressive symptoms have been noted in frontline health care providers. [1] [2] [3] [4] [5] [6] In the first and only report on U.S. emergency physicians, we similarly found negative effects of the COVID-19 pandemic on provider mental health. 7 Given the evolving nature of the pandemic, we anticipated that stressors related to the COVID-19 outbreak would change as health care systems and providers dealt with the initial phases of the pandemic. 8 To further examine this evolution, we undertook a longitudinal investigation of stressors, mitigating factors, and stress and anxiety levels in U.S. emergency physicians.

In late March 2020, we initiated a three-part longitudinal study (acceleration phase, pandemic phase, and postpandemic phase) to assess work-and home-related factors affecting emergency physicians in the United States during the COVID-19 pandemic. 7 In our first survey, we found high rates of stress, concerns about inadequate access to personal protective equipment (PPE), and changes in behaviors, of both providers and their family and friends. In this follow-up survey, we reassessed home and workplace anxiety, workrelated stressors, changes to home life, and perceptions as to what measures might ease provider anxiety. We additionally explored stressors that we did not originally anticipate in the initial survey including loss of income, second wave/surge of COVID-19 cases, and stress due to dependent care. Those responding to the first survey were invited to participate in the second phase follow-up survey conducted May 7 to 14, 2020. Our goals in this follow-up study are:

(1) to assess changes in stressors and anxiety over time, (2) to determine which stress mitigators were available to respondents at follow-up, (3) to examine how respondents' behaviors with family and friends changed over time, and (4) to determine which variables are associated with a higher primary care posttraumatic stress disorder (PC-PTSD-5) screener score (≥3). 9

Our follow-up cross-sectional survey was administered via email May 7 to 14, 2020, to all emergency physicians (attending, fellow, and resident) who responded to the first survey (March 23, 2020-April 10, 2020; N = 426) at seven emergency medicine residencies and affiliated institutions in California, New Jersey, and Louisiana. Sites were primarily recruited through their involvement in the National Emergency X-radiography Utilization Study (NEXUS) network. To broaden the sampling to sites that were experiencing heavy surges of COVID-19 patients during the acceleration phase (first phase of this study), we contacted two residencies in New York City and one in New Orleans. The investigators in New York declined to participate, because their staff was too overwhelmed at study initiation to meaningfully participate. We excluded nonclinically active physicians for the initial survey. Our study followed the Strengthening the Reporting of Observational Studies in Epidemiology reporting guideline and was deemed exempt by the respective institutional review boards. 10

Collaborating with the University of California Stress Network, we developed a follow-up survey instrument to reassess perceptions and key elements about the following domains: personal experience with COVID-19 testing, home and workplace anxiety, identification of work-related stressors, changes in behavior at home arising from their work during the pandemic, and perceptions as to what measures might decrease provider anxiety. This is described in greater detail in our original publication. 7 On the follow-up survey, we additionally assessed anxiety related to new stressors that physicians were facing. We generated these items based on prior literature and our teams' own experiences. [1] [2] [3] [4] 8 These new items included potential income reductions, anxiety related to decreased staffing due to quarantines or staff furloughs, ability for respondents to adequately care for dependents, and concerns regarding patient surges and anticipated "second wave" of COVID-19 cases. We reassessed emotional exhaustion and burnout by asking participants to rate on a 1 to 7 scale (1 = not at all, 4 = somewhat, and 7= very much) "to what extent were you experiencing severe, ongoing job stress where you felt emotionally exhausted, burned out, cynical about your work and fatigued, even when you wake up?" We also included the five items from the validated PC-PTSD-5 scale and used the recommended cutoff of three of five positive responses as a highly sensitive indicator of probable PTSD (Box 1). 9 After pilot testing our follow-up instrument on five physicians to ensure understanding and a completion time of <5 minutes, our final survey consisted of 18 items. Initial respondents were contacted using the email addresses they supplied when they completed the first survey. Respondent emails were placed into a blinded listserv that was never accessed by the authors, to maintain anonymity of respondents. Only one follow-up survey submission was allowed per each original respondent. We collected data anonymously via email (with repeat email requests sent two additional times to increase response rate) to each group of providers (Data Supplement S1, Box S1, available as supporting 

We captured survey responses using REDCap and used IBM SPSS Statistics version 27.0 (IBM Corp., Armonk, NY) for analyses, summarizing patient characteristics and key responses as raw counts, frequency percent, medians, and interquartile ranges (IQRs).

Differences in percentages are presented as Δ with 95% confidence intervals (CIs). Respondents' ratings of ongoing concerns (initial and follow-up survey) were compared using Wilcoxon signed-rank tests, with p < 0.05 as significant. We a priori identified variables that we believed would be associated with a self-reported PC-PTSD-5 scale score ≥ 3 at follow-up based on our initial results as well as findings from the literature with respect to increased stress levels experi- 

Of the 426 respondents to the initial survey, 262 (61.5%) completed the follow-up survey. 7 Table 1 displays the demographics of the survey respondents and Table S1 displays the demographics and item responses to the initial survey among respondents who did and did not complete the follow-up survey. With the exception of one item, "Personal protective equipment (PPE) is inadequate," the median scores in the original survey items did not differ between those who participated in the follow-up survey and those who did not (Table S1) Note: Data are reported as median (IQR), n/N (%), or n (%).

Abbreviations: COVID-19, coronavirus disease 2019; RT-PCR, reverse transcription polymerase chain reaction.

In the past month, have you… New concerns surveyed I worry that the relaxing of social distancing will lead to a second wave of cases -6 (4-7)

I worry that changes in prehospital protocols for other acute patients in the era of COVID-19 are not best practices given efforts to mitigate exposures and risks to health care providers -

I worry that colleagues and staff at my medical center will be furloughed or let go to mitigate medical center income loss -

I worry that my income over the next several months will be impacted by changes in hospital or ED volumes and shortcomings in income at the medical center I can easily take leave from work to care for myself and my family members

Since the pandemic started, to what extent are you experiencing severe, ongoing job stress where you feel emotionally exhausted, burned out, cynical about your work, and fatigued even when you wake up?

Over the past week, to what extent are you experiencing severe, ongoing job stress where you feel emotionally exhausted, burned out, cynical about your work, and fatigued even when you wake up? Median (IQR) work and home stress levels decreased over time from the initial survey 5 (4-6) versus 4 (4-5) at follow-up.

In fact, almost all concerns that were reassessed were less highly rated at follow-up ( Table 2 ). There were no differences in median stress levels between faculty versus residents/fellows, site, race, or ethnicity. When respondents were asked, "Over the past week,

to what extent are you experiencing severe, ongoing job stress where you feel emotionally exhausted, burned out, cynical about your work, and fatigued even when you wake up?" the median burnout score was 4 (2-5), which did not differ from a similar item in the first assessment (Table 2) . 7 We further explored potential differences in self-reported stress levels, burnout, and PC-PTSD-5 scores between men and women. For the stress items, women scored higher than men in both the initial and the current surveys (Table 3) .

Differences in burnout levels over time between men and women are presented in Figure 1 . For all three time periods, there were no differences in responses between male and female physicians, with the exception of the middle item, captured on the initial survey; at the beginning of the pandemic, the median stress level reported by men was 4 (3-5.5) and women was 5 (4-6; p = 0.013). Likewise, the PC-PTSD-5 scores also differed between men and women, both on the initial survey and in follow-up, with women scoring higher than men in both time periods (Figure 2 Table S2 ).

In follow-up, respondents reported being most concerned about the relaxing of social distancing leading to a second wave of cases (median score = 6, IQR = 4-7), increased exposure risk to family members due to work (median score = 5, IQR = 4-6), and risk to the community by patients with unclear diagnoses (median score = 5, IQR = 4-6; Table 2 ). In spite of these concerns, physicians reported a high level of agreement with being able to order tests for patients (Table 4) . (Table 5 ).

In this first longitudinal survey of emergency physicians during the COVID-19 pandemic, we found that overall, stress and anxiety de- At follow-up, physicians were predominantly worried about a potential second wave due to relaxation of social distancing, which, in retrospect, was prescient for the impending rise in COVID-19 caseloads the United States was about to experience during the summer of 2020 ( Figure 3 ).

The reduction in stress levels, we believe, was in part due to im- increased levels of social support show lower levels of depression, anxiety, stress, and burnout. 13 Adequate social support has also been linked with resilience-an individual's capacity to deal with significant adversity and respond with quick recovery. In a study of Chinese health care workers during the COVID-19 pandemic,

Hou et al. 14 demonstrated that the relationship between resilience and mental health is stronger among young adults compared to older adults. In younger adults, mental health is more influenced by social interactions and relationships with others, whereas the mental health of older adults is thought to be more dependent on generativity, i.e., contributions to society and the next generation via work and child-rearing. 14, 15 These findings should raise concerns for the mental health of our trainees and younger physicians, because they may be more likely to suffer negative effects from social isolation than more senior practitioners. Practical solutions to address these concerns may include practitioner bereavement rounds, strict protection of "off time" where providers remain free from patient care and administrative duties, and encouragement for practitioners to provide honest feedback about the stressors they face. 16 The latter could be achieved through an anonymous in March (the time of the initial survey) but these continued to increase throughout May, with a rapid rise in June. Thus, it is possible that our follow-up survey assessed health care workers at three different pandemic periods: post peak (NJ), interim peak (LA), and pre-second peak of COVID-19 cases (CA; Figure 3 ). Finally, 18 respondents did not provide a viable follow-up email address. If these 18 respondents are excluded, our response rate was 262/408 (64.2%). In spite of these limitations, we believe that our real-time assessments remain superior to postpandemic stress assessments due to the high potential for recall bias.

A lack of baseline stress, burnout and PTSD measures from before the pandemic is also problematic. There are little data about prepandemic stress levels of health care providers-even with other, prior pandemics, where increased stress levels of men and women are reported. 18, 19 We attempted to overcome this limitation by asking respondents what they believe their stress and burnout levels

were prior to the COVID-19 pandemic in our initial survey, but fully acknowledge that these responses may have been affected by recall bias. Finally, we noted a discrepancy between our median burnout stress scores and PC-PTSD-5 screener ≥ 3 scores. At follow-up, female physicians had higher stress/anxiety scores and median PC-PTSD-5 scores than men, but there was no difference in median burnout scores. We are unsure why this discrepancy exists. It is possible that our burnout question was too limited in scope, focusing only on "severe, ongoing job stress" as opposed to all stressors, including those at home. We believe that there were factors that may have affected women to a greater degree than men that we were unable to capture in our follow-up survey. To address this, we a priori made our follow-up stress question more open-ended by not specifying work-versus home-related stress. The higher self-reported stress level for women at follow-up was subtle as demonstrated in Table 3 .

The PC-PTSD-5 screener appeared to be more sensitive in assessing distress symptoms in our cohort, with higher median scores and a greater proportion of high scores (≥3) in women when compared to men. The reason for this difference may be an actual increase in trauma symptoms, due to COVID-19, in women, or possible limitations in the PC-PTSD-5 screener scale. The screener may be too sensitive in women, overestimating PTSD levels, possibly due to measurement error induced by a scale validated on a mostly male veteran sample. 9 Alternatively, the screener may be performing appropriately, because sex differences in PTSD are well established, with a 2:1 sex ratio favoring women. 29 The original, four-item PC-PTSD screener was noted as one of the bestperforming screeners in a systemic review of 15 PTSD screening instruments and has been used in diverse populations. 30, 31 Because of its brevity and ease in administration, the revised PC-PTSD-5 was used in our investigation and has been used by others during the COVID-19 pandemic. [32] [33] [34] In a recently published study conducted on the general public from 20 countries 16.4% of women and 17.7% of men screened positive on the PC-PTSD-5. 32

Currently, a cohort study of stressors, coping, and symptoms of adjustment disorder in the course of the COVID-19 pandemic is being undertaken in 10 European countries utilizing the PC-PTSD-5. 34 We anticipate that these findings will contribute to ours in the assessment of stressors during the COVID-19 pandemic.

We demonstrated an improvement in stress and PC-PTSD-5 scores over time in the first longitudinal study of emergency physicians during the COVID-19 pandemic. A greater proportion of female emergency medicine physicians had PC-PTSD-5 screener scores ≥ 3 compared to men; however, our findings did not clearly delineate the cause. Given the ongoing pandemic, further attention should be given to elucidate why and how some physicians are more impacted by the pandemic stressors than others, particularly women and residents. Additional study may play an increasing role in maintaining physician mental health, particularly if the COVID-19 pandemic fails to abate in the United States.

We thank Ashley Mason, PhD, and the UCSF Stress Network for their assistance with development of the survey instrument.

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