More Evidence of COVID's Crushing Mental-Health Toll on Healthcare Workers

By Megan Brooks

August 16, 2021

NEW YORK (Reuters Health) - The COVID-19 pandemic has taken a huge psychological toll on healthcare workers, particularly those working in emergency departments, new surveys confirm.

"Regardless of training level, physicians and mid-level practitioners report symptoms suggestive of post-traumatic stress disorder (PTSD) and sub-PTSD," Dr. Morgan Bowling reported in a presentation to the American College of Emergency Physicians (ACEP) Research Forum on COVID-19.

Dr. Bowling is with the Department of Pediatric Emergency Medicine at The Children's Hospital of New Jersey at Newark Beth Israel Medical Center.

She and her colleagues had 176 physicians (attendings, fellows, and residents) and mid-level practitioners (MLPs) working in emergency departments across New Jersey complete a survey between December 2020 and March 2021. MLPs include nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists and physician assistants.

The survey used the PCL-5, a self-report measure that assesses 20 symptoms of PTSD, answered on a four-point Likert scale, with a cutoff score of 31 for probable PTSD.

Overall, 25% of MLPs met criteria for PTSD and 30% to 50% met subthreshold criteria for PTSD, depending on the specific criteria.

About 14% of attending physicians and 4% of resident or fellow physicians met PTSD criteria, again with significantly more meeting subthreshold PTSD criteria.

What's particularly noteworthy, said Dr. Bowling, is that post-graduate year two (PGY2) resident physicians had the highest average continuous total severity score on the PCL-5.

"Current second year emergency medicine residents will have started their training in July 2019 - just eight months before the novel coronavirus hit the United States. "These physicians-in-training would have had their intern year completely taken over by the pandemic and would be largely unprepared in both medical expertise and emotional resilience to face this unprecedented crisis," Dr. Bowling said.

"Physician burnout is well documented in the U.S. and there has been a movement within the medical education community in recent years to focus more on resident wellness," Dr. Bowling said. This includes reforming duty hours and a dedicated emphasis on work-life balance.

"The pandemic put a dent in the movement for physician wellness," said Dr. Bowling.

"Attending physicians in teaching hospitals are responsible for, in addition to patient care, the training of residents. The burden of navigating a mentorship role while managing the high volume of critical ill patients suffering from a novel disease can't be ignored," she added.

A related study reported at the ACEP forum finds that perfectionistic characteristics, which are common among physicians, may be contributing to COVID-19 burnout among pediatric emergency physicians.

Burnout, which may develop after ongoing exposure to stressful work experiences, typically includes emotional exhaustion, low sense of personal accomplishment, and depersonalization (feelings of alienation or apathy concerning work or patient care).

Dr. Sarah Martin and colleagues of the University of California, Irvine, surveyed 20 attending pediatric emergency medicine physicians (10 female) working in a children's hospital during the COVID-19 pandemic. Their median age was 44 years.

More than one third of them (35%) reported high levels of depersonalization, and a similar percentage reported moderate levels of emotional exhaustion.

Perfectionism was the only characteristic associated with burnout. With each unit increase in "socially prescribed" perfectionism, the odds of experiencing high depersonalization burnout were 1.64 times higher, Dr. Martin reported (P=0.03).

This suggests that "stronger beliefs or perception that others expect perfect performance may have contributed to interpersonal detachment while navigating stressors during the pandemic," she noted in her presentation.

A large-scale survey conducted by the U.S. Centers for Disease Control and Prevention released last month found that more than half of public-health workers reported symptoms of at least one mental-health condition including symptoms of depression, anxiety, PTSD and suicidal ideation.

The ACEP is working to protect the mental health and wellbeing of emergency physicians, knock down barriers for those who seek mental-health treatment and reduce the stigma of physicians' mental illness.

Last week, the Senate passed the Dr. Lorna Breen Health Care Provider Protection Act, which ACEP lobbied hard for. The bill was named for the emergency physician who took her own life in April 2020 after struggling with mental-health issues stemming from the pandemic.

The bill will help in developing policies to prevent burnout and improve mental health among health care clinicians, removing barriers to accessing care and treatment, including consideration of stigma and licensing concerns.

The ACEP now turns its focus to pushing for the House version of the bill.

In email to Reuters Health, ACEP President Dr. Mark Rosenberg said: "Emergency physicians continue to absorb extraordinary levels of grief and other stressors after battling this pandemic for more than a year."

"Despite the prevalence of mental health challenges, many on the front lines do not feel they can address their mental health out of fear they could lose their medical license or other hurdles that prevent access to care, including the persistent stigma against seeking treatment. This bill takes very important steps to create a healthier work environment for emergency physicians and other health care workers who have risked their lives throughout this pandemic," said Dr. Rosenberg.

"The pandemic makes it all too clear that we must do more to protect physician mental health and address the contributing factors to burnout and stress that have been pushed under the rug for too long," he added.

SOURCE: ACEP Research Forum: Special Edition: COVID, held online August 4, 2021.