Unmasking Resident Physician Burnout During the COVID-19 Era

High infection and transmission rates imposed strict visitor policies in hospitals in the setting of elevated mortality and morbidity. End-of-life discussions with family/loved ones were transitioned to phone calls, and the overall pain, suffering, and death witnessed led to a level of dehumanization of the situation.⁵ All aspects of the pandemic played a role in the increased stress/duress, including repeated surges of COVID-19 cases, changing clinical roles, and escalated workload and hours.⁵ The pandemic disproportionately affected Black, Hispanic, and other racial and ethnic minority communities, traditionally underrepresented in medicine, and may have contributed to increased burnout in residents from these racial and ethnic minority groups.⁵

Residents play a hands-on role in the health care field and were direct observers and participants in the effects of the pandemic on the health care system, including limited resources, mandatory masking, and worry regarding contracting and spreading the virus.^3,5,10 However, despite their role, residents have no decision-making authority on topics such as ventilator distribution, PPE supply, or experimental therapies but are responsible for how they are used in clinical care, which can increase the stress of making ethical decisions without control.³ Although residents did not have control over the supply of resources, they were responsible for the allocation of resources, including which patients to escalate to the ICU for a limited bed, whether to reuse N95 masks, and weighing time at bedside with personal health concerns.³

Related to having less experience, residents have little control over their work life/scheduling, and their clinical decisions must be looked over by more experienced practitioners, leading to feelings of depersonalization and emotional exhaustion.^1,5 These feelings are present across all specialties.⁶ Vijay et al conducted a study of residents near the beginning of the pandemic and found that greater than 50% of residents had symptoms of emotional exhaustion, and only 42.9% felt valued by their institution.¹ Outside of work, Natsuhara et al described that the need to wear a mask leads to depersonalization because it hides emotions and the identities of practitioners, changing human interaction.⁵

Hospital systems were pushed past their limits during the first couple of years of the pandemic. Hospital and ICU beds were filled with patients, and many residents were reallocated from their scheduled rotations and ambulatory rotations to work in the emergency department, ward units, and ICUs given the increased need for medical personnel.^4,8,9,11 These reallocations may have been mandatory versus voluntary, but residents may have felt pressure to volunteer.³ At one institution, half of the residents were reassigned with an additional quarter of residents on standby with the potential for reassignment.¹¹ However, 76% of those residents were “somewhat uncomfortable” or “very uncomfortable” with their program director or institution making decisions about reassignment.¹¹ Of the reassigned residents, 67.5% reported that reassignment was not voluntary.¹¹ Depending on the institution, either attendings or attending/resident teams were directly treating patients with COVID-19.^4,12 A proportion of residents had increased work hours, had greater odds of experiencing burnout, and may have been redeployed to patients outside their intended specialty.⁹

The increase in need for medical personnel during the pandemic resulted in residents transitioning from their normal routine to inpatient care.¹⁰ Residency programs are set up to further a resident’s training, but the pandemic affected the general learning culture. Programs changed their structure and delivery of teaching/learning resources.⁴ Trainees were concerned about their careers, developing clinical competency, and fulfilling requirements of their training program.^1,3,7,9 Approximately 75% of residents at a single institution stated that their educational activities had decreased due to the pandemic, and they were concerned about the need to catch up in the coming years.¹¹ Some institutions had attendings as the ones who primarily cared for patients with COVID-19 infection, limiting clinical care opportunities to residents and leading to an internal battle between personal health and clinical competency.^3,12

The death toll from COVID-19 globally is in the millions. In the setting of increased morbidity and mortality, personal health concerns were noted among residents. Prior to the availability of vaccinations, there were fears regarding the health of residents and their loved ones. Throughout the pandemic, there were concerns from residents regarding shortages of PPE, exposure to COVID-19 at work/becoming ill, not having access to testing, and the fear of spreading the infection both at work and at home.^2,3,8–11 Although the concern for PPE shortage was not related to residents’ concerns about their ability to take care of patients, it resulted in significant concern regarding the ability to protect themselves.^8,10 The concerns regarding shortages correlated with adverse effects on mental and physical wellness.^8,10 There was overwhelming anxiety about the safety of loved ones, including concern about loved ones acquiring the infection, transmitting the infection to family, and not being able to visit loved ones if anyone were to become sick.^2,7–11 Increased stress regarding childcare arose in the occurrence of school and daycare closures, because it was necessary for residents with children to find additional support systems.^2,5 When vaccinations became available in limited supply, the health concerns resurfaced, perhaps more so for racial and ethnic minority residents and their families due to inequitable vaccine availability.

Support comes in a variety of flavors, whether that be at peer, family, friend, or institutional levels. It is known that residents prefer to talk with family or friends for support, which was difficult during the COVID-19 pandemic due to lockdowns and health concerns.⁸ Mendonca et al found that residents felt that talking with peers and immediate supervisors was protective to residents’ mental health.⁸ This is reflected in other studies that demonstrated residents had lower burnout scores when they felt valued by immediate supervisors.^8,9 Many studies found that a common coping mechanism of residents is spending time with family and loved ones.¹¹

In a study of multiple specialties, therapy was the most preferred intervention for managing burnout, with greater than 50% of all residents considering psychotherapy and professional coaching.¹² Multiple studies recommend making mental health resources accessible to help provide support.^5,9 Detterline et al described an escalation of an in-place wellness and psychological support system during the pandemic by ensuring residents could participate at least every other week,⁴ keeping in mind that the needs of residents differ, and mental health support may not be desirable to some.⁹

At the beginning of the pandemic, new knowledge and recommendations were coming out seemingly every hour, emphasizing the importance of communication to ensure that residents were staying updated. Overall, residents did not need the answers but needed to know that leadership would be willing to listen, acknowledge and address requests, provide up-to-date information, and adjust plans as the latest information arose.^2,4 Proactive programs that addressed the pandemic challenges had positive responses.¹⁰ Methods of communication varied and included town halls, direct messaging, weekly conference calls, check-ins with other residents, staff meetings with residents and leadership, and instructional sessions about COVID-19 preparedness, all with the goal of transparency and providing support.^4,9 Discussions were not focused solely on pandemic response, they also included changes in scheduling, provision of food, and instructional topics.⁴ Interventions to continue past the acute state of the pandemic include maintaining transparency and seeking input from residents without repercussions.⁴

Residents spend a considerable amount of time with their peers and unsurprisingly find support among their co-residents.^6,9,10 Peer-support groups can help with the psychological impacts of training programs.⁸ Natsuhara et al recommends building a longitudinal peer-support curriculum to help teach peer-support skills, instead of developing them by trial and error, and to help relay concerns about those who may need more support.⁵

The pandemic era led to a transition to online instruction. Certain programs saw an increase in engagement in virtual versus in-person conferences, and most residents stated either no change or a positive impact on education.^4,11 Education included typical medicine-related topics and those relevant to the pandemic and end-of-life/palliative care discussions.⁴

Residents have limited free time to start with, and scheduling time to address mental health and burnout during that time may lead to more burnout and stress. Institutions should be aware of the culture of the institution and the specific factors that contribute to their residents’ burnout.⁵ Making sure that residents have stable duty hours and meetings that highlight and address the challenges that residents face all help to reduce burnout scores.^5,9 Ideally meetings would start at the beginning of training and continue throughout the year to demonstrate the institution’s prioritization of their residents’ well-being.^1,5

The pandemic placed financial strain on resident physicians, who are already income stretched. Detterline et al suggested providing food, hotel rooms, transportation assistance, and childcare resources to help reduce resource-related stressors of residents.⁴ Others have backed up the idea of crisis pay to help provide financial support in addition to food, PPE, and childcare.^5,9

Telemedicine became a main source of outpatient care when face-to-face visits became limited due to concern of virus spread. Mills et al found that most (91%) of their internal medicine and family medicine residents thought that telemedicine was a secure alternative to in-person clinic visits.¹³ Also, they found that telemedicine decreased burnout, emotional exhaustion, and depersonalization scores.