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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Perceived impact of the COVID-19 pandemic on postgraduate residents
Ajay Solanki1, Hrishikesh Solunke2, TS Sathyanarayana Rao1, M Kishor1
1 Department of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
2 Department of Psychiatry, SMT. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
| Date of Submission | 18-Mar-2022 |
| Date of Decision | 24-Apr-2022 |
| Date of Acceptance | 29-Apr-2022 |
| Date of Web Publication | 10-Nov-2022 |
Correspondence Address:
M Kishor,
Department of Psychiatry, JSS Hospital, MG Road, Mysuru - 570 004, Karnataka
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/aip.aip_47_22
Introduction: COVID-19 has led to an increase in burden on health-care workers. Postgraduate residents are at the forefront of the pandemic. Understanding its impact and the perspectives of postgraduate residents could provide better solutions to their problems. Objectives: 1. To assess the psychological impact of the COVID-19 pandemic on postgraduate doctors. 2. To assess the perception of postgraduate doctors regarding the medical profession and its association to the psychological impact of the COVID-19 pandemic. Methodology: This cross-sectional study recruited 65 postgraduate medical resident doctors working in teaching hospitals involved in the care of COVID-19 patients. They were requested to complete the questionnaire consisting of qualitative as well as quantitative questions. For an objective assessment of anxiety, the Generalized Anxiety Disorder-7 (GAD-7) scale was used. Relevant statistical methods were employed and statistical analysis was done using IBM SPSS software version 20.0. Results: The qualitative data showed themes of concern regarding social awareness about COVID-19 (hygiene, masks, and social distancing), working conditions of doctors, and increased stress and burnout. 47.54% (n = 29) of respondents said that they would reconsider their profession/specialty, out of which 21 said that they would switch to another profession. The resident doctors who would reconsider their choice of profession/specialty had significantly higher (P < 0.05) scores for anxiety (GAD-7). Conclusion: Owing to the significant association between anxiety and desire to change their profession altogether, greater psychological support for doctors appears to be a pressing need. It is important that the concerns of the postgraduate residents are addressed promptly and holistically.
Keywords: Anxiety, burnout, COVID-19, psychological impact, resident doctors, stress
How to cite this URL:
Solanki A, Solunke H, Sathyanarayana Rao T S, Kishor M. Perceived impact of the COVID-19 pandemic on postgraduate residents. Ann Indian Psychiatry [Epub ahead of print] [cited 2023 Mar 30]. Available from: https://www.anip.co.in/preprintarticle.asp?id=360834 |
| Introduction | |  |
COVID-19, a severe acute respiratory syndrome, caused by the novel coronavirus (SARS-CoV-2), since its outbreak, has affected all aspects of human life across the world. Within months of being recognized as a public health emergency of international concern, the WHO declared it as a pandemic in March 2020. As of May 2021, there have been close to 172 million cases and 3.7 million deaths worldwide attributed to COVID-19.[1] This has led to an unprecedented increase in burden on health-care systems across the world as well as in India which has been highlighted in various studies conducted across the world since the advent of the pandemic. The pandemic has also led to increase in suicide and self-harm attempts. Even though systematic studies are yet to confirm this, various reports published globally including India point toward this worrying trend emerging.[2]
In Indian health-care services, postgraduate residents play a vital role. There are over 500 medical colleges and teaching hospitals in India and in the academic year of 2020–2201, above 40,000 doctors enrolled in postgraduate residency programs. These doctors are at the forefront of the current pandemic situation. Understanding the impact of the pandemic and the respective perspectives of postgraduate residents regarding issues and problems that affect them as frontline workers could provide a direction to solutions to the same.[3]
Throughout history, infectious disease outbreaks have caused adverse psychological impacts not only on the general population but also on health-care workers (HCWs). Studies on the severe acute respiratory syndrome (SARS) outbreak of 2003 revealed symptoms of acute stress disorder in up to 5% of HCWs along with the presence of insomnia, exhaustion, and uncertainty about the frequent changes to infection control protocols.[4] Another study on SARS carried out in Canada showed up to 18.1% of physicians having perceived stress related to working during the pandemic.[5]
Symptoms of burnout,[6],[7],[8] posttraumatic stress (PTS),[9],[10],[11] depression,[10],[12] anxiety,[10],[13] insomnia,[10],[12] and general psychological distress[14],[15],[16] in HCWs during various pandemics have been well documented.
Numerous studies have also explored the psychological effects that remain in HCWs even beyond the pandemics. A study conducted 1 month after the end of the SARS outbreak showed the persistence of PTS symptoms in 19.3% of HCWs[17] while another study that included 549 hospital employees found a high level of depressive symptoms (Center for Epidemiologic Studies Depression Scale > 24) in 8.8% of the participants, even 3 years after the end of the SARS outbreak.[18]
Studies conducted after the Middle East respiratory syndrome outbreak on its psychological sequelae yielded findings of increased anxiety in HCWs regarding contracting the virus and potentially transmitting to their family members.[19],[20]
The psychological impact of the current COVID-19 pandemic on HCWs is proving to be similar to that of previous pandemics. In a recent multinational, multicenter study, among the 906 HCWs who participated in it, 5.3% screened positive for moderate-to-very severe depression, 8.7% for moderate-to-very severe anxiety, and 3.8% for moderate-to-severe levels of psychological distress.[21]
Similar findings have also been noted in HCWs in India. A nationwide observational, Internet-based study with 433 participants showed the prevalence of high level stress to be 3.7% while the prevalence rates of depressive and anxiety symptoms were 11.4% and 17.7%, respectively. These effects were twice as likely to be present in female HCWs.[22]
Another factor to be highlighted is the stigma associated with the pandemic which has affected nurses, medical practitioners, and other frontline workers, and not just patients or their families.[23] A systematic review of 13 studies in South Asian countries showed increased reporting of guilt, stigma, anxiety, and poor sleep quality among frontline workers.[24]
The training of residents has also been compromised in the wake of the pandemic. It is also possibly changing the ways of learning for the medical students and residents and has led to an opportunity to innovate.[25]
Based on the research evidence available, it is clear that the psychological condition of HCWs and resident doctors in particular may be affected during the COVID-19 outbreak. However, it may be important to also explore aspects such as: What was learned by postgraduates during this crisis? What are the concerns postgraduates have about their profession and specialty in the current situation of the pandemic? And is there an association between psychological state and their specific concerns? Hence, there is a need to understand the above issues, and this study makes an effort in that direction.
Considering the unprecedented circumstances that require social distancing and wearing personal protective equipment (PPE), online surveys are better tools for such studies.
| Methodology | | |
This cross-sectional study recruited medical postgraduate students from tertiary health-care institutions via an online survey that was circulated over social media. Postgraduate medical resident doctors presently working in teaching hospitals actively involved in the care of COVID-19 patients, who agreed to voluntarily participate in the study, were requested to complete the questionnaire. The study was approved by the institutional ethical committee.
The semi-structured questionnaire consisted of qualitative as well as quantitative questions, and was divided into two parts. The first part consisted of demographic variables which included age, gender (male or female), specialty and year of residency, and city and state of residence. Along with the demographic characteristics, qualitative data were collected using the following five questions:
- Please mention three or more important things, that you have learned or realized during the COVID-19 crisis
- Please mention three or more important things, that you would like to change in relation to residents' duties, work, or management, during the COVID-19 crisis
- If you had an opportunity to reconsider your profession and specialty, would you still choose the same profession and specialty? If yes, please describe why?
- If you would choose the same profession but a different specialty, please mention which one, and why?
- If you would change your profession entirely, please mention what profession you would choose, and why?
The responses to Questions 3, 4, and 5 were divided into three groups:
- Group A: Resident doctors who would choose to continue in the medical profession in the same specialty
- Group B: Resident doctors who would leave the medical profession entirely
- Group C: Resident doctors who would remain in the medical field but would opt for a different specialty.
The second part of the questionnaire consisted of an objective assessment for anxiety symptoms, for which the Generalized Anxiety Disorder-7 (GAD-7) scale was used.
The study used the Shapiro–Wilk test to check for normality which found a nonnormal distribution, so instead of the mean scores, severity levels of anxiety were used for comparison. The total anxiety scores obtained were categorized on the basis of severity, as per the GAD-7, into minimal, mild, moderate, and severe. These categories of severity were then cross-tabulated against the three aforementioned groups using the Cramer's V test. For statistical analysis, the IBM SPSS software (version 20.0) was employed.
| Results | | |
A total of 65 participants responded, out of which 4 were not considered in the analysis due to being incomplete. Sixty-one (93.85%) responses were considered for the analysis.
[Table 1] shows the sociodemographic characteristics of the participants. [Table 2] shows the distribution of the respondents according to their specialties.
The responses to questions in the first part of the questionnaire displayed prominent themes of concern regarding inadequate social awareness about COVID-19 that included: maintenance of basic hygiene, use of proper masks, and social distancing (n = 35, 57.38%). Opinions regarding workplace conditions, especially availability of adequate PPE and optimal working hours, were also noted (n = 18, 29.51%). Other replies highlighted the attitudes toward HCWs, which included the stigma, and on occasion violence encountered by HCWs working in COVID hospitals (n = 17, 27.87%). A large number of residents were also apprehensive about contracting and spreading the illness to their colleagues, friends, and family (n = 42, 68.85%).
The questions also garnered feedback about improvement in working conditions for doctors. Ideas about altering schedules to mitigate burnout and provision of better PPE were expressed by a significant number of resident doctors (n = 48, 78.69%). Other recommendations included undertaking awareness programs for the general public to relay information about the cause and transmission of COVID-19 and the dispelling of myths around it, about social distancing, use of masks, and other basic personal hygiene measures (n = 30, 49.18%). Suggestions for increment in pay for the resident doctors were also made (n = 45, 73.77%).
The responses to subsequent questions about reconsideration of profession (Questions 3, 4, and 5) were divided into three groups:
- Group A: Resident doctors who would choose to continue in the medical profession in the same specialty
- Group B: Resident doctors who would leave the medical profession entirely
- Group C: Resident doctors who would remain in the medical field but would opt for a different specialty.
[Table 3] shows the categorization of the participants into Groups A, B, and C based on their responses.
Out of the 61 participants in the study, 21 had minimal anxiety, 19 had mild anxiety, 14 had moderate, while 7 had severe anxiety on the GAD-7. The Cramer's V test yielded a statistically significant association between GAD-7 severity of the three groups. As [Table 4] shows, Groups B and C had significantly more number of respondents with a higher level of severity than Group A on the GAD-7 (P < 0.05).
| Discussion | | |
A total of 65 postgraduates responded, out of which 61 were considered for analysis. Out of the 61 respondents, majority were aged between 26 and 30 years (63.93%), were males (57.38%), and were unmarried (75.41%).
Almost half the number of participants were in their 3rd year of residency (49.18%). More than half of the total respondents belonged to the branches of general medicine, general surgery, and anesthesiology (n = 35, 57.38%). Resident doctors in these branches of medicine, especially in their final year of residency, are generally involved in critical care management and are more likely to be on the frontline of managing the COVID-19 crisis.
With the advent of the COVID-19 pandemic, an already burdened health-care system in India is likely to be stretched to limits for the foreseeable future. As evidenced by studies on previous pandemics, HCWs are more likely to be impacted psychologically than non-HCWs.[3] A qualitative study involving 172 physicians working in COVID-designated centers across India pointed to fear of infection, uncertainty, stigma, guilt, and social isolation as the main challenges faced by HCWs.[26] The poor state of mental health in health-care professionals likely reflects their unmet mental health-care needs.[27] Hence, their perspectives would provide not just a unique view of the problems faced by HCWs but also probable ways to address them.
Question 1
Please mention three or more important things, that you have learned or realized during the COVID-19 crisis:
This study found that social distancing and other protective measures were prominent on the list of things that the participants mentioned. Concerns regarding social awareness of the pandemic and regarding the inadequacies in the health sector were pervasive (57.38%). For example, “.maintaining social distancing is important,” “.frequent hand washing,” “.proper usage of masks,” and “.contact tracing” were some of the issues brought up in the responses to the first question. This suggests that the postgraduates were trained in the domain of infection transmission. Other things mentioned also included “judicious use of resources,” “.importance of family and social support,” and “.learning to work with what is available.”
The resident doctors in this study also talk about health infrastructure and lack of preparedness for the pandemic with phrases such as “.shortage of PPE,” “.lack of investment in the health sector,” and “.myths and misconceptions.” Since this study was conducted in the month of August 2020, these concerns would be more prominent then, as the country at the time was still in the preparatory phase of mitigation of the pandemic. Further periodic studies should be conducted to assess the ground realities of the ongoing situation. Apprehension with regard to societal stigma and unease with the working conditions were also visible with phrases such as “.ignorance of the government,” “.bias against doctors,” “…scared of violence,” and “…will I be evicted” appearing in the descriptions. These themes seem to suggest an underlying dissatisfaction of HCWs, possibly highlighting an often overlooked aspect of the health-care sector that might need to be addressed at all levels of the care delivery system in the country. These findings are also similar to ones in earlier studies conducted during previous pandemics.[4],[28],[29],[30],[31]
With the contagious nature of the illness, there was also present, a fear regarding the same (68.85%), with the participants using phrases such as “…high mortality rate,” “.what if I pass it on to my family?,” and “.I fear for my parents.” These concerns need addressing as they might hamper the ability of the HCWs to function optimally. They also suggest that HCWs need continued help and guidance to dispense quality care.
The results obtained replicate findings of a few other studies.[19],[20],[32],[33]
Question 2
Please mention three or more important things, that you would like to change in relation to residents' duties, work, or management, during the COVID-19 crisis:
The replies to the second question were in line with the concerns expressed. The postgraduates suggested and expected changes in hospital management and the handling of the crisis (78.69%). This included a revision to the allocation of duty rosters in order to have more uniformity and balance, so as to mitigate stress and burnout which have been noted to occur during previous pandemics[8],[9],[15],[34] as well as the current one.[10] The respondents were also specific regarding improvements they would like to see in the quality and quantity of PPE, masks, and other hospital equipment. Themes that were frequently touched upon were: “.change the duty schedules,” “.increase staff numbers and reduce number of continuous duty days,” “.should be given better quality masks and PPE kits,” and “.increase in stipend needed for the extra hours of work.” This suggests that duty rosters need constant revision and the need for hospitals to utilize all available resources including departments not earlier involved in the management of the crisis. The resident doctors also spoke of a need for more positive coverage of HCWs by the news media, which could result in improved public perception and attitudes toward doctors.
Questions 3-5
If you had an opportunity to reconsider your profession and specialty, would you still choose the same profession and specialty? If yes, please describe why?
If you would choose the same profession but a different specialty, please mention which one, and why?
If you would change your profession entirely, please mention what profession you would choose, and why?
In these unprecedented times, the increase in the burden on HCWs could lead to them reconsidering their choice of profession. The lack of desire to continue as HCWs has been studied previously.[35] In this study, 29 (47.54%) of the resident doctors said that they would reconsider their choice of profession/specialty. Out of these, 21 (34.43%) said that they would switch to another profession completely. The reasons stated for this included “.too much risk,” “.I don't want to infect my family,” “.I am not paid enough for this,” “.the lack of recognition and respect is too much to take,” “.I have no time for myself,” “.there is more comfort in other professions,” and “.I feel there is no point in continuing as a doctor.” The remaining 8 respondents (13.11%) said that they would prefer to switch to a different specialty within the medical profession with some citing reasons such as “.I want a branch with low risk,” “.more pay than there is in my speciality,” “.fixed duty hours, no emergencies,” and “.no worries about patient deaths and violence against doctors from patient relatives.” These are matters of urgent concern and require a reappraisal of postgraduate residency programs. A change in training methods of postgraduates should possibly be considered, so as to better equip them to handle the stress that comes with such scenarios. Aspirant HCWs should also be provided better information about the demands and risks involved in the field before enrolling in it.
Association of anxiety and change of specialty or profession
This study found that the resident doctors who said that they would reconsider their profession/specialty had statistically significantly higher mean scores for anxiety on the GAD-7 than the 32 residents who said that they would still continue to work in the same profession and specialty. It is interesting to note that the residents who were keen to continue in the same branch and specialty, held strong values, which was conveyed by statements such as “medicine is the noble profession,” “medicine has the highest job satisfaction,” “if doctors back out, who will do this job?” “serving the society is a doctor's duty.” An increased level of anxiety among resident doctors who were reconsidering their choice of profession or specialty, Such findings were also noted in other studies. A cross-sectional study involving 1563 HCWs found significantly high anxiety scores in 44.7% of the participants.[17] Similarly, studies have found significantly higher levels of exhaustion,[6],[7],[8] stress,[5],[34],[35] insomnia[10],[12],[36] as well as PTS symptoms.[9],[10],[11],[12] This study sheds light on some of the prevailing sentiments held by HCWs regarding the challenges faced during the COVID-19 pandemic. Despite the many concerns expressed, it should be noted that almost two-third of the respondents in the study wanted to continue working in the medical profession. A recent cross-sectional survey in the United States of America comprising 17,903 doctors across more than 29 specialties found that 78% of the respondents would still choose medicine as their profession.[37] It is important that along with relevant infrastructural changes, a consideration should be made by the concerned authorities to increase the renumeration for doctors during times like these.
This study has limitations. Owing to stringent social distancing protocols, only an online questionnaire could be used. The cross-sectional nature of the study meant that any causality for the findings could not be established. The study was conducted over a relatively short period of time, and the sample size of the study was small, which meant that possible correlation between the subspecialties and degree of anxiety could not be assessed.
Moreover, having involved only resident doctors, the findings cannot be generalized to other categories of HCWs. The study also did not consider the presence of preexisting psychiatric comorbid conditions.
| Conclusion | | |
In contrast to most previous studies which focused on psychological issues of HCWs in a pandemic, this study also looks at lessons learned and possible solutions to the challenges faced from the perspective of the resident doctors themselves. This study describes a broad spectrum of views and opinions held by the participating resident doctors that range from fear, frustration, apprehension, and anxiety to a sense of duty toward the profession. Owing to the significant association between anxiety and the desire to change their profession altogether, greater psychological support for HCWs appears to be the need of the hour. It is important to address the concerns of the postgraduate residents at all stages of the pandemic and across all areas such as psychological issues such as delivery of health services, comprehensive integration and management, as well as the psychological issues.
More studies are required to focus on these pertinent issues faced by postgraduate residents who have been frontline workers since the beginning of the first wave of the pandemic.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 37. | |
[Table 1], [Table 2], [Table 3], [Table 4]
|
