Sources of Distress and Coping Strategies Among Emergency Physicians During COVID-19

Erin Dehon, PhD; Kori S. Zachrison, MD, MSc; Jennifer Peltzer-Jones, PsyD, RN; Ramin R. Tabatabai, MD; Elizabeth Clair, DO; Michael A. Puskarich, MD; Amy Ondeyka, MD; Katherine Dixon-Gordon, PhD; Lauren A. Walter, MD; Elaine H. Situ-LaCasse, MD; Megan L. Fix, MD


Western J Emerg Med. 2021;22(6):1240-1252. 

In This Article

Abstract and Introduction


Introduction: The coronavirus disease 2019 (COVID-19) pandemic has been shown to increase levels of psychological distress among healthcare workers. Little is known, however, about specific positive and negative individual and organizational factors that affect the mental health of emergency physicians (EP) during COVID-19. Our objective was to assess these factors in a broad geographic sample of EPs in the United States.

Methods: We conducted an electronic, prospective, cross-sectional national survey of EPs from October 6–December 29, 2020. Measures assessed negative mental health outcomes (depression, anxiety, post-traumatic stress, and insomnia), positive work-related outcomes, and strategies used to cope with COVID-19. After preliminary analyses and internal reliability testing, we performed four separate three-stage hierarchical multiple regression analyses to examine individual and organizational predictive factors for psychological distress.

Results: Response rate was 50%, with 517 EPs completing the survey from 11 different sites. Overall, 85% of respondents reported negative psychological effects due to COVID-19. Participants reported feeling more stressed (31%), lonelier (26%), more anxious (25%), more irritable (24%) and sadder (17.5%). Prevalence of mental health conditions was 17% for depression, 13% for anxiety, 7.5% for post-traumatic stress disorder (PTSD), and 18% for insomnia. Regular exercise decreased from 69% to 56%, while daily alcohol use increased from 8% to 15%. Coping strategies of behavioral disengagement, self-blame, and venting were significant predictors of psychological distress, while humor and positive reframing were negatively associated with psychological distress.

Conclusion: Emergency physicians have experienced high levels of psychological distress during the COVID-19 pandemic. Those using avoidant coping strategies were most likely to experience depression, anxiety, insomnia, and PTSD, while humor and positive reframing were effective coping strategies.


Prior to the coronavirus 2019 (COVID-19) pandemic, physicians struggled with heightened levels of burnout, job dissatisfaction, depression, post-traumatic stress symptoms (PTSS), and suicidal ideation.[1,2] Over the past year, emergency physicians (EP) were positioned as frontline caregivers for COVID-19, which further escalated challenges and pressure on the healthcare system and its workers.

Studies have shown that pandemics such as severe acute respiratory syndrome (SARS) 2003 and COVID-19 are associated with increased levels of healthcare worker psychological distress, including burnout, anxiety, depression, insomnia, and post-traumatic stress.[3–10] During the early stages of COVID-19, distress was particularly high in healthcare workers without consistent access to personal protective equipment (PPE)[11] and those exposed to COVID-19 patients.[12] A systematic review of 59 internationally diverse studies revealed that psychological distress associated with COVID-19 is a global problem.[13] Studies of EPs, in particular, show increased levels of psychological distress in response to COVID-19.[10,14,15] One survey of over 400 EPs revealed increases in work stress, home anxiety, emotional exhaustion, and burnout.[14]

Given that physicians are experiencing negative effects from the COVID-19 pandemic, it is critical to identify factors influencing physician stress for appropriate interventions to be designed. To date, there is limited data on which interventions have yielded the most success. Of the few published qualitative studies that have investigated potential contributors to physician anxiety, organizational factors such as access to PPE, exposure to COVID-19 at work, uncertainty of organizational support and lack of access to testing, childcare access and up-to-date information and communication were noted as main drivers.[16]

Current EP-specific literature is limited. Most studies were performed outside the US or in limited geographical areas such as New York City. Additionally, many do not include measures of psychological distress with strong validity evidence. Furthermore, there is not, to our knowledge, any current data focusing on possible positive psychological reactions to COVID-19 or effective coping strategies. Finally, although some studies have looked at factors contributing to clinician stress, none have performed a comprehensive stepwise approach using an assessment of multiple contributory factors. Our aim in this study was to extend prior research by identifying both individual and organizational factors that place EPs at risk for psychological distress during COVID-19. Additionally, we sought to identify any positive effects related to COVID-19 and examine coping strategies used by EPs.