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Impacts and challenges of the COVID-19 pandemic on emergency medicine physicians in the United States

Journal logoUnlabelled imageAmerican Journal of Emergency Medicine 48 (2021) 38-47

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American Journal of Emergency Medicine

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Impacts and challenges of the COVID-19 pandemic on emergency medicine physicians in the United States

Jackie Nguyen a, Amy Liu a, Mark McKenney, MD, MBA a,b, Huazhi Liu, MS c,

Darwin Ang, MD, PhD, MPH c,d, Adel Elkbuli, MD, MPH a,?

a Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA

b Department of Surgery, University of South Florida, Tampa, FL, USA

c Department of Surgery, Ocala Regional Medical Center, Ocala, FL, USA

d Department of Surgery, University of Central Florida, Ocala, FL, USA

a r t i c l e i n f o

Article history:

Received 20 January 2021

Received in revised form 9 March 2021 Accepted 29 March 2021

Keywords:

COVID-19 pandemic Emergency physicians, burnout Institutional support

Job satisfaction

American College of Emergency Physicians

a b s t r a c t

Background: Emergency medicine (EM) physicians have been on the front line of the COVID-19 pandemic. This study aims to determine the impact of COVID-19 pandemic and other related factors such as resource availability and institutional support on well-being, burnout and job-satisfaction of EM physicians in the United States.

Methods: A cross-sectional survey study of EM physicians was conducted through the Emergency Medicine Prac- tice Research Network of the ACEP. The survey focused on resource adequacy, institutional support, well-being, and burnout. A total of 890 EM physicians were invited to participate. Both descriptive and risk adjusted, and multivariate regressions were performed with a statistical significance defined as p < 0.05.

Results: EM physicians’ response rate was 18.7% (166) from 39 states. Burnout was reported by 74.7% (124) since

the start of the pandemic. Factors contributing included work-related emotional strain and anxiety, isolation from family and friends, and increased workload. Those reporting inadequate resources felt ignored by their in- stitutions (p < 0.0001). Physicians who felt there was inadequate institutional support, were also dissatisfied with patient care resources (p = 0.001). Physicians expressing job dissatisfaction were more likely to report feel- ings of burnout (p = 0.001).

Conclusion: EM physicians face greater burnout in the COVID-19 pandemic. This may be compounded by resource scarcity, psychological stress, isolation, and job dissatisfaction. Many of the survey respondents reported inade- quate mental health services and resources. The findings of this study may help identify solutions to mitigate these issues.

(C) 2021 Published by Elsevier Inc.

  1. Introduction

The novel severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2), which causes coronavirus disease 2019 (COVID-19), has rapidly spread worldwide. The clinical course ranges from asymptomatic to se- vere [1-3]. The task of management and infection containment has largely fallen on emergency medicine (EM) physicians, who have be- come first-line of defense in the pandemic. They must isolate, diagnose, and treat patients with a highly infectious disease, while still managing other emergent cases.

Resources and staffing have become a growing concern nationwide [4-6]. The shortage of vital resources has resulted in greater risk of infec- tion and increased work-relatED strain among EM physicians [7,8,5,9,10]. High-stakes rapid decision-making is routine in EM.

* Corresponding author at: Department of Surgery, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL 33175, USA.

E-mail address: [email protected] (A. Elkbuli).

However, this can come with a significant psychological burden and in- creased mental, emotional, and physical exhaustion caused by job stress, resulting in burnout and affecting both health and well-being [11]. EM physicians consistently rank among the specialties with the highest burnout rates [12]. The higher risk of litigation, chronic fatigue from circadian rhythm disruption, and workload intensity have been identified as key reasons [13]. Although, 42% of physicians reported feel- ings of burnout in 2020, only a small portion of these individuals have sought professional help [12].

A longitudinal prospective cohort survey of 213 EM physicians found that feelings of isolation were also prevalent during the initial surge of the pandemic [14]. More than 50% of respondents reported relationship strain and isolation, which remained unchanged over the four-week study period. Furthermore, 66% of EM providers reported negative im- pacts on basic self-care [14]. Another recent survey study of 1300 EM physicians found that post-traumatic stress disorder (PTSD) was signif- icant and a major source of stress was disinformation about COVID-19, PPE and workload [15]. This is concerning as higher levels of burnout

https://doi.org/10.1016/j.ajem.2021.03.088 0735-6757/(C) 2021 Published by Elsevier Inc.

have been associated with increased Medical errors, lower patient satis- faction, unprofessional behavior, and prolonged ED wait times [16-18]. The COVID-19 pandemic has had a significant impact on EM physicians [19-21]. This study aims to survey EM physicians in the United States to ascertain changes in perspectives of burnout as a result of changes to re- source levels, institutional support, well-being, and job satisfaction dur- ing the COVID-19 pandemic.

  1. Methods
    1. Study design and setting

In this cross-sectional study, an online 18-item survey was adminis- tered to US EM physicians between November 12th, 2020 to December 22nd, 2020 to determine the psychological and emotional impact of the COVID-19 pandemic on EM physicians, and the factors which may influ- ence burnout.

    1. Selection of participants

The Emergency Medicine Practice Research Network (EMPRN) was utilized to recruit participants. The EMPRN is a practice-based network created by the American College of Emergency Physicians (ACEP) consisting of approximately 890 EM physicians nationwide utilized for research in the advancement of EM [22]. EM physicians currently prac- ticing in the US during the COVID-19 pandemic were eligible for enroll- ment. International physicians and resident physicians were not eligible.

    1. Survey content and administration

The 18-item survey consists of original items and a number of mod- ified questions from a previously validated instrument (Supplementary File). Basic demographic information such as gender, age, and geo- graphic location were provided by the EMPRN. Questions regarding in- stitution type and years in practice were included in this survey. Additional questions elicited information regarding opinions on re- source levels, institutional support, well-being, and feelings of burnout. The well-being and burnout questions, specifically, were adapted from the Maslach Burnout Inventory-Human Services Survey for Medical Per- sonnel (MBI-HSS (MP)). The MBI-HSS (MP) is a validated tool widely used to evaluate burnout [23,24]. The survey was comprised of multiple-choice, five-point agreement Likert scale, and five-point fre- quency Likert questions. An “Other” option for free responses was avail- able where applicable.

Prior to dissemination, the survey was internally validated through a small pilot study conducted internally within our institution. The inter- nal pilot study was utilized to refine language, test for face validity and assess survey questions clarity, and improve content and quality. Revi- sions were completed to ensure ease of understanding and consistency of the questions. The survey was then submitted to the ACEP Practice Management Manager and Research Surveys Committee for review and approval before distribution to the ACEP members through the EMPRN. Revisions were made to standardize survey questions based on the recommendations provided by the ACEP Practice Management Manager and Research Surveys Committee, and the ACEP survey guide- lines [22]. Once approved by the ACEP Practice Management and Re- search Surveys Committee, the survey was directly distributed through ACEP to its members via the EMPRN webmail system.

The survey remained open for six weeks. Two reminder emails were sent on November 24th and December 17th. No identifying information was recorded. No incentives were offered to complete the survey. The human subjects review board at Nova Southeastern University deemed this study to be exempt. This study was performed in compliance with the standards outlined by the board.

    1. Data analysis

All data were analyzed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Nonparametric data were evaluated by Fisher’s exact test for proportions and the Wilcoxon rank-sum test for continuous data. Mul- tivariable logistic regression was used for calculating the adjusted odds ratio for binary outcomes. Confounders were identified if there was either literature or a logical reason to support a variable having an inde- pendent effect on the exposure or outcome. The final regression model included age, gender, institution type, number of years in practice, re- source availability, institutional support, and job satisfaction. P-values

<0.05 were considered significant.

    1. Study outcomes

The primary outcome was burnout. Burnout was defined by answer- ing either “sometimes”, “often”, or “always” to question 14 of the sur- vey. Not being burned out was defined by answering either “never” or “rarely”. Question 14 reads: I feel more burned out because of the COVID-19 pandemic as compared to before it. Secondary outcomes exam- ined were resource availability, institutional support, and job satisfac- tion. Resource availability was defined by answering either “strongly agree” or “somewhat agree” to question one. Lack of resource availabil- ity was defined by either answering “neither agree nor disagree”, “somewhat disagree”, or “strongly disagree”. Question one reads: Since the start of the COVID-19 pandemic (Jan 20th) to currently, I have felt sup- ported by my institution through implementation of extra precautionary techniques and/or maintenance of adequate resource level (PPE, sanitation items, etc.). Institutional support was defined by answering question four as either “strongly agree” or somewhat agree”. Lack of institutional support was defined as either answering “neither agree nor disagree”, “somewhat disagree”, or “strongly disagree”. Question four reads: I feel that my institution was prepared for the COVID-19 pandemic and has the proper guidelines/protocols in place needed for the identification, treat- ment, and isolation of COVID-19 patients. Job satisfaction was defined as answering question 15 as either “strongly agree” or somewhat agree”. Lack of job satisfaction was defined as either answering “neither agree nor disagree”, “somewhat disagree”, or “strongly disagree”. Question 15 reads: I feel satisfied with my work since the start of the COVID-19 pandemic.

    1. Cohort groups and risk factors

To identify variables associated with each outcome, a stratified anal- ysis was carried out by the presence or lack of certain risk factors. For the primary outcome burnout, it was stratified by either having re- source availability, institutional support, job satisfaction, having mental health support, satisfaction with level of resources, attitudes towards patients and staff, and risk factors leading to being burned out. For the secondary outcome resource availability, it was further stratified by whether the physician felt that there was adequate level of SARS-CoV- 2 testing for patients, whether they felt that the turnaround time for testing was adequate, whether they felt that their institution listened to their concerns, having mental health support, and whether or not they felt that they had adequate level of resources. For the secondary outcome of institutional support, it was further stratified by whether or not they felt that their institution listened to their concerns, if their institution had furloughed or laid off staff, if their institution offered mental health support, whether or not they felt that they had adequate level of resources, whether or not there was appropriate precautions to prevent colleague to colleague spread of COVID-19, and specific risk fac- tors related to burnout. For the secondary outcome of job satisfaction, stratified analysis was carried out by whether or not the physicians felt that the institutions listened to their concerns, whether or not they had access to mental health counseling, whether or not there was appropriate precautions to prevent colleague to colleague spread

of COVID-19, whether or not they felt more callous towards patient and staff, whether or not they felt that their academic obligations were com- promised, and if they felt more burned out.

Table 2

Reported feelings of burnout, resource availability, institutional support, and job satisfac- tion by surveyed emergency medicine physicians stratified by demographics. P-values were determined using Fisher’s exact test.

  1. Results

Burnout Yes: Sometimes/often/always feel burned out (n = 124)

No: Never/rarely feel burned out (n = 42)

p-value

    1. Characteristics of study subjects

Age 0.04

0.01

32-40

13.7% (17)

11.9% (5)

A total of 166 participants completed the survey; the response rate

41-50

37.9% (47)

19.1% (8)

was 18.7% (166/890). There were respondents from 39 different states.

One hundred twenty-one respondents (72.9%) were male. The largest age demographic represented respondents between 41 and 50 years

51-60

61-70

71-75

Gender

23.4% (29)

21.8% (27)

3.2% (4)

31.0% (13)

23.8% (10)

14.3% (6)

old (33.1%). The largest institution demographic represented respon-

Male

67.7% (84)

88.1% (37)

dents practicing at community teaching hospitals (31.3%). The largest

Female

32.3% (40)

11.9% (5)

regional demographic represented respondents located in the Southern

Race

0.66

US (34.9%). The majority of respondents have practiced for >20 years White

70.2% (87)

81.0% (34)

Black

0.8% (1)

0.0% (0)

(51.2%). Complete participant demographics are shown in Table 1. Hispanic

1.6% (2)

0.0% (0)

Asian

4.0% (5)

4.8% (2)

3.2. Well-being and burnout Other

23.4% (29)

14.3% (6)

Institution Type

University

25.0% (31)

26.2% (11)

A majority of participating EM physicians disclosed increased feel- Teaching

ings of burnout since the start of the pandemic. There were three Hospital

times as many physicians reporting burnout than those that did not Community

23.4% (29)

38.1% (16)

non-teaching

(74.7% vs 25.3%) (Table 2). There was a statistically significant associa- hospital

tion between reported feelings of burnout and age (p = 0.04) as well Community

34.7% (43)

21.4% (9)

as gender (p = 0.01). The age group with the highest proportion of re- teaching

ported burnout were those between 41 and 50 years; those in the oldest hospital

age group, 71-75, reported burnout in the lowest proportions. Of the Combined

11.3% (14)

4.8% (2)

Others

physicians reporting burnout, 70.2% were white, 67.7% were male, Practicing Years

5.7% (7)

9.5% (4)

34.7% were employed at a community teaching hospital, 46.8% have

<=5

3.3% (4)

0.0% (0)

been in practice for >20 years, and 37.1% are located in the Southern US.

6-10

14.6% (18)

16.7% (7)

0.17

0.14

Respondents reporting burnout also reported higher proportions of feeling callous towards patients and other staff compared to those

Table 1

Characteristics of survey respondents.

Demographics (Total = 166) n %

Age

32-40

22

13.3%

41-50

55

33.1%

51-60

42

25.3%

61-70

37

22.3%

71-75

10

6.0%

Gender

11-20 35.0% (43) 19.1% (8)

>20 47.2% (58) 64.3% (27)

Region 0.32

Midwest 22.6% (28) 14.3% (6)

Northeast 16.1% (20) 19.1% (8)

South 37.1% (46) 28.6% (12)

West 20.2% (25) 28.6% (12)

Unknown 4.0% (5) 9.5% (4)

Resource Yes: Strongly availability agree/somewhat agree

(n = 121)

No: Neither agree or disagree/Somewhat disagree/Strongly

disagree (n = 45)

p-value

Age

32-40 17.4% (21)

2.2% (1)

0.05

41-50 30.6% (37)

40.0% (18)

Male

121

72.9%

51-60

26.5% (32)

22.2% (10)

Female

45

27.1%

61-70

19.8% (24)

28.9% (13)

Race

White 121 72.9%

71-75 5.8% (7) 6.7% (3)

Gender 0.84

Black

1

0.6%

Male

73.6% (89)

71.1% (32)

Hispanic

2

1.2%

Female

26.4% (32)

28.9% (13)

Asian 7

4.2%

Race 0.73

Other 35

21.1%

White

70.3% (85)

80.0% (36)

Institution Type

Black

0.8% (1)

0.0% (0)

University Teaching Hospital

42

25.3%

Hispanic

1.7% (2)

0.0% (0)

Community non-teaching hospital

45

27.1%

Asian

4.1% (5)

4.4% (2)

Community teaching hospital

52

31.3%

Other

23.1% (28)

15.6% (7)

Combined

16

9.6%

Institution Type

0.77

Others

11

6.6%

University

24.0% (29)

28.9% (13)

Practicing Years

Teaching

<=5

4

2.4%

Hospital

6-10

25

15.1%

Community

26.5% (32)

28.9% (13)

11-20

51

30.7%

non-teaching

>20

85

51.2%

hospital

Region

Community

33.1% (40)

26.7% (12)

Midwest

34

20.5%

teaching

Northeast

28

16.9%

hospital

South

58

34.9%

Combined

10.7% (13)

6.7% (3)

West

37

22.3%

Others

5.8% (7)

8.9% (4)

Unknown

9

5.4%

Table 2 (continued)

Burnout Yes: Sometimes/often/always

No: Never/rarely feel burned out (n = 42)

p-value

Table 2 (continued)

Burnout Yes: Sometimes/often/always

No: Never/rarely feel burned out (n = 42)

p-value

feel burned out (n = 124) feel burned out (n = 124)

Practicing Years

0.60

Asian

4.3% (4)

4.2% (3)

<=5

1.7% (2)

4.4% (2)

Other

21.3% (20)

20.8% (15)

6-10

15.8% (19)

13.3% (6)

Institution Type

0.75

11-20

32.5% (39)

26.7% (12)

University

28.7% (27)

20.8% (15)

>20

50.0% (60)

55.6% (25)

Teaching

Region

0.66

Hospital

Midwest

18.2% (22)

26.7% (12)

Community

24.5% (23)

30.6% (22)

Northeast

19.0% (23)

11.1% (5)

non-teaching

South

34.7% (42)

35.6% (16)

hospital

West

22.3% (27)

22.2% (10)

Community

31.9% (30)

30.6% (22)

Unknown

5.8% (7)

4.4% (2)

teaching

hospital

Institutional

Yes: Strongly

No: Neither agree or

p-value

Combined

8.5% (8)

11.1% (8)

support

agree/somewhat agree

disagree/somewhat

Others

6.4% (6)

6.9% (5)

(n = 84)

disagree/strongly

Practicing Years

0.74

disagree (n = 82)

Age 0.67

32-40

13.1% (11)

13.4% (11)

>20

54.3% (51)

47.9% (34)

41-50

34.5% (29)

31.7% (26)

Region

0.71

51-60

25.0% (21)

25.6% (21)

Midwest

21.3% (20)

19.4% (14)

61-70

19.1% (16)

25.6% (21)

Northeast

17.0% (16)

16.7% (12)

11-20 30.9% (29) 31.0% (22)

71-75 8.3% (7) 3.7% (3)

<=5

2.1% (2)

2.8% (2)

6-10

12.7% (12)

18.3% (13)

Gender 0.60

South 30.9% (29) 40.3% (29)

West 25.5% (24) 18.1% (13)

Male

75.0% (63)

70.7% (58)

Unknown

5.3% (5)

5.6% (4)

Female

Race

25.0% (21)

29.3% (24)

0.6

7

who reported no burnout (36.1% vs 4.8%, p = 0.0001). The most com- mon feelings contributing to burnout were increased work-related emotional strain and anxiety, followed by isolation from family and friends, and then by increased workload (Table 3).

White

70.2% (59)

75.6% (62)

Black

1.2% (1)

0.0% (0)

Hispanic

2.4% (2)

0.0% (0)

Asian

4.8% (4)

3.7% (3)

Other

21.4% (18)

20.7% (17)

Institution Type

0.94

University

22.6% (19)

28.1% (23)

Teaching

Hospital

Community

27.4% (23)

26.8% (22)

non-teaching

hospital

Community

33.3% (28)

29.3% (24)

teaching

hospital

Combined

9.5% (8)

9.8% (8)

Others

7.1% (6)

6.1% (5)

Practicing Years

0.93

<=5

2.4% (2)

2.5% (2)

6-10

14.3% (12)

16.1% (13)

11-20

33.3% (28)

28.4% (23)

>20

50.0% (42)

53.1% (43)

Region

0.61

Midwest

21.4% (18)

19.5% (16)

Northeast

19.1% (16)

14.6% (12)

South

29.8% (25)

40.2% (33)

West

22.6% (19)

22.0% (18)

Unknown

7.1% (6)

3.7% (3)

    1. Resource availability

Job satisfaction Yes: Strongly

agree/somewhat agree (n = 94)

No: Neither agree or disagree/somewhat disagree/strongly disagree (n = 72)

p-value

Most participants (72.9%) reported adequate availability of re- sources such as PPE and sanitation items since the start of the pandemic (Table 2). There was a statistically significant association between re- ported feelings of resource adequacy and age (p = 0.05). Physicians age 32-40 reported feelings of resource adequacy in the highest propor- tions compared to all other age groups. Physicians who practice in the Southern US (34.7%) reported the most resource adequacy. Those employed at community teaching hospitals and those located in the Southern US reported the highest rate of feeling adequately supplied with necessary resources (33.1% and 34.7%, respectively). Participants employed at community non-teaching and those employed at univer- sity teaching hospitals each accounted for 28.9% of those who disagreed their institution maintained adequate resource levels. The highest pro- portion of physicians who did not feel there were adequate resource levels were those who had been practicing for >20 years (55.6%).

Respondents reporting burnout noted resource and supply inade- quacy (sanitation items, Hospital beds, and ventilators) for treating COVID-19 positive patients at higher proportions compared to those who did not report burnout (21.8% vs 2.4%, p = 0.004) (Table 3). How-

Age 0.84

32-40

14.9% (14)

11.1% (8)

41-50

31.9% (30)

34.7% (25)

51-60

23.4% (22)

27.8% (20)

61-70

22.3% (21)

22.2% (16)

71-75

7.5% (7)

4.2% (3)

Gender 0.03

Male 79.8% (75) 63.9% (46)

Female 20.2% (19) 36.1% (26)

Race 0.85

White

71.3% (67)

75.0% (54)

Black

1.1% (1)

0.0% (0)

Hispanic

2.1% (2)

0.0% (0)

ever, after adjusting for confounding factors (age, gender, institution type, number of years in practice, institutional Support, job Satisfaction), the odds of burnout were not significantly increased with feelings of re- source inadequacy (Table 4a). Furthermore, a greater proportion of re- spondents reporting feelings of inadequate resource availability also expressed that SARS-CoV-2 testing for their patients was inadequate compared to those who reported sufficient resources (44.4% vs 26.5%, p = 0.03) (Table 5). None of the respondents reporting feelings of inad- equate resources felt there was sufficient testing compared to 11.6% of those who felt adequately supplied (p = 0.02). A greater proportion of those who reported feelings of resource inadequacy also strongly disagreed that there was adequate turnaround time for SARS-CoV-2

Table 3

Reported feelings of burnout (yes/no) stratified by various survey questions.

reported feeling inadequate institutional support, the largest propor- tions were between ages 41-50 (31.7%), white (70.7%), employed at a

Burnout Yes:

Sometimes/often/always feel burned

out (n = 124)

No: never/rarely feel burned out (n = 42)

p-value

community teaching hospital (29.3%) or university teaching hospital (28.1%), have been in practice for >20 years (53.1%), and located in the Southern US (40.2%).

There was no significantly increased odds of burnout associated with

Professional counseling and/or mental health support was offered by my institution as a result of the impact on workload and stress from the COVID-19 pandemic

Strongly disagree

14.5% (18)

9.5% (4)

0.41

Disagree

13.7% (17)

14.3% (6)

0.93

Neutral

12.1% (15)

19.1% (8)

0.26

Agree

29.8% (37)

26.2% (11)

0.65

Strongly Agree

29.8% (37)

31.0% (13)

0.89

I am satisfied with the level of resources (sanitation items, hospital beds capacity, ventilators, medications, administration support etc.) provided by my institution to treat COVID-19 patients

Strongly disagree

21.8% (27)

2.4% (1)

0.004

Disagree

23.4% (29)

11.9% (5)

0.11

Neutral

12.1% (15)

16.7% (7)

0.45

Agree

29.8% (37)

38.1% (16)

0.32

Strongly Agree

12.9% (16)

31.0% (13)

0.01

I feel more callous towards patients, staff, family, and/or people around me as a result of my work during the COVID-19 pandemic

Never

23.0% (28)

59.5% (25)

<0.0001

Rarely

32.0% (39)

33.3% (14)

0.82

Sometimes

36.1% (44)

4.8% (2)

0.0001

Often

7.4% (9)

2.4% (1)

0.25

Always

1.6% (2)

0.0% (0)

0.41

What, if anything, is/are contributing your feeling of burnout? Select all that apply

Increased emotional

29.6% (102)

29.8% (17)

0.97

strain/anxiety from work

Increased workload

19.7% (68)

14.0% (8)

0.31

Isolation from

26.4% (91)

22.8% (13)

0.57

family/friends

Lack of institutional

12.8% (44)

12.3% (7)

0.92

support

Need for a safe place to

6.7% (23)

8.8% (5)

0.56

go after work

Other

4.9% (17)

12.3% (7)

0.03

test results compared to those who reported adequate resources (55.6% vs. 35.5%, p = 0.02).

Respondents who felt that they had inadequate resource availability either disagreed or strongly disagreed that their institutions listened to them (p < 0.0001). Additionally, more disagreed that they had adequate professional counseling and support compared to those who felt that adequately supplied (24.4% vs 9.9%, p = 0.02).

    1. Institutional support

Participants were ambivalent regarding the adequacy of institu- tional support during the COVID-19 pandemic. There was no significant difference in feelings of institutional support; 50.6% of the respondents agreed and 49.4% disagreed that their institutions were prepared with proper guidelines and protocols (Table 2). Of the physicians who

feeling a lack of institutional support (Table 4b). A larger proportion of respondents who felt a lack of institutional support strongly disagreed that they were satisfied with the resources available to their patients compared to those who felt supported (26.8% vs. 7.1%, p = 0.001) (Table 6). However, even among those who felt that they had adequate institutional support, the majority felt increased emotional strain and anxiety from work (p = 0.03).

    1. Job satisfaction

A majority of respondents (56.6.%) reported feelings of job satisfac- tion since the start of the COVID-19 pandemic (Table 2). There was a statistically significant association between reported job satisfaction and gender (p = 0.03). Women reported job dissatisfaction in higher proportions than men (57.8% vs. 38.0%). Physicians located in the Southern US reported the highest proportion of job dissatisfaction (40.3%) compared to those in other regions. Job satisfaction was higher among those who felt their institution listened to them, compared to those who did not (44.7% vs. 27.8%, p = 0.03) (Table 7). Those who re- ported job satisfaction also reported greater availability of professional counseling (p = 0.003). A greater proportion of those who were satis- fied with their jobs reported that they rarely saw their clinical responsi- bilities as hurting their academic obligations, compared to those who were dissatisfied (20.9% vs. 4.4%, p = 0.003).

Physicians reporting burnout were also more likely to report job dis-

satisfaction (aOR 6.94; 95% CI 2.47, 19.54) (Table 4c). This remained even when adjusting for age, gender, institution, number of years in practice, and sense of resource adequacy. There was also a positive cor- relation between feelings of burnout and a sense of lack of resources or institutional support. However, these relationships were not statisti- cally significant. Additionally, among respondents reporting burnout, those who also reported job dissatisfaction were more likely to feel burnout due to COVID-19, compared to those who were satisfied with their jobs (p = 0.001) (Table 7).

  1. Discussion

The COVID-19 pandemic has placed tremendous strain on the US health care system. As the number of cases increases, there is a related increase in admission rates from the ED. [25] Previous surveys have broadly evaluated the mental health of EM physicians, although none have looked at which specific pandemic-related factors contribute to their burnout.

The findings of our survey are consistent with previous literature that EM physicians face greater psychological burdens since the pan- demic onset [26].A recent nationwide poll conducted by ACEP found

Table 4a

Feelings of burnout as reported by surveyed emergency medicine physicians in relation to resource availability.

Resource availability

Yes: Strongly agree/Somewhat agree (N = 121)

No: Neither agree or disagree/somewhat disagree/strongly disagree (N = 45)

Burnout Yes: Sometimes/often/always feel burned out 71.1% (86) 84.4% (38)

2.24 (0.91, 5.48)

2.16 (0.63, 7.39)a

No: Never/rarely feel burned out 28.9% (35) 15.6% (7)

0.45 (0.18, 1.10)

0.46 (0.14, 1.59)a

a Adjusted Odds Ratio by: Age, Gender, Institution Type, # of Years in Practice, Institutional Support, Job Satisfaction.

Table 4b

Feelings of burnout as reported by surveyed emergency medicine physicians in relation to institutional support.

Institutional support

Yes: Strongly agree/somewhat agree (N = 84)

No: Neither agree or disagree/somewhat disagree/strongly disagree (N = 82)

Burnout Yes: Sometimes/Often/Always Feel Burned Out 69.1% (58) 80.5% (66)

1.82 (0.89, 3.73)

1.26 (0.49, 3.20)a

No: Never/Rarely Feel Burned Out 30.9% (26) 19.5% (16)

0.55 (0.27, 1.12)

0.80 (0.31, 2.03)a

a Adjusted Odds Ratio by: Age, Gender, Institution Type, # of Years in Practice, Resource Availability, Job Satisfaction.

Table 4c

Feelings of burnout as reported by surveyed emergency medicine physicians in relation to job satisfaction.

Job satisfaction

Yes: Strongly agree/somewhat agree (N = 94)

No: Neither agree or disagree/somewhat disagree/strongly disagree (N = 72)

Burnout Yes: Sometimes/Often/Always Feel Burned Out 61.7% (58) 91.7% (66)

6.72 (2.64, 17.11)

6.94 (2.47, 19.54)a

No: Never/Rarely Feel Burned Out 38.3% (36) 8.3% (6)

0.15 (0.06, 0.38)

0.14 (0.05, 0.41)a

a Adjusted Odds Ratio by: Age, Gender, Institution Type, # of Years in Practice, Resource Availability, Institutional Support.

87% of surveyed EM physicians had experienced more stress due to the pandemic; 72% reported feelings of burnout; 73% felt uncomfortable seeking mental health treatment due to the perceived stigma [27]. Rodriquez et al. found that greater than 90% of surveyed EM physicians during the pandemic reported changes in their behavior which included decreased affection towards friends and family [28]. Our results further

support these findings as among surveyed participants, three times the number of EM physicians noted increased feelings of burnout and cal- lousness towards loved ones since the start of the pandemic.

The significant number of EM physicians reporting burnout may be attributable to the immense emotional and mental burden of frontline work during the pandemic. However, our study found no statistically

Table 5

Feelings of resource availability (yes/no) stratified by various survey questions.

Resource availability

Yes: Sometimes/often/always (n = 121)

No: Neither agree or disagree/somewhat disagree/strongly disagree (n = 45)

p-value

During the COVID-19 pandemic, I felt the needed level of testing for COVID-19 for patients was adequate

Strongly disagree

26.5% (32)

44.4% (20)

0.03

Disagree

32.2% (39)

33.3% (15)

0.89

Neutral

5.0% (6)

8.9% (4)

0.35

Agree

24.8% (30)

13.3% (6)

0.11

Strongly agree

11.6% (14)

0.0% (0)

0.02

During the COVID-19 pandemic, I felt the turnaround time for COVID-19 test results was adequate for patients

Strongly disagree

35.5% (43)

55.6% (25)

0.02

Disagree

36.4% (44)

31.1% (14)

0.53

Neutral

5.0% (6)

6.7% (3)

0.67

Agree

15.7% (19)

4.4% (2)

0.05

Strongly agree

7.4% (9)

2.2% (1)

0.21

I feel that my institution listens when I voice concerns related to the COVID-19 pandemic

Strongly disagree

2.5% (3)

28.9% (13)

<0.0001

Disagree

7.4% (9)

33.3% (15)

<0.0001

Neutral

24.0% (29)

20.0% (9)

0.59

Agree

45.5% (55)

15.6% (7)

0.0004

Strongly agree

20.7% (25)

2.2% (1)

0.004

Professional counseling and/or mental health support was offered by my institution as a result of the impact on workload and stress from the COVID-19 pandemic

Strongly disagree

11.6% (14)

17.8% (8)

0.30

Disagree

9.9% (12)

24.4% (11)

0.02

Neutral

11.6% (14)

20.0% (9)

0.16

Agree

28.9% (35)

28.9% (13)

1

Strongly agree

38.0% (46)

8.9% (4)

0.0003

I am satisfied with the level of resources (sanitation items, hospital beds capacity, ventilators, medications, administration support etc.) provided by my institution to treat COVID-19 patients

Strongly disagree

6.6% (8)

44.4% (20)

<0.0001

Disagree

17.4% (21)

28.9% (13)

0.10

Neutral

10.7% (13)

20.0% (9)

0.12

Agree

42.2% (51)

4.4% (2)

<0.0001

Strongly agree

23.1% (28)

2.2% (1)

0.002

Table 6

Feelings of institutional support (yes/no) stratified by various survey question.

Institutional support Yes: Strongly agree/somewhat agree

No: Neither agree or disagree/somewhat disagree/strongly disagree

p-value

(n = 84)

(n = 82)

I feel that my institution listens when I voice concerns related to the COVID-19 pandemic

Strongly disagree

1.2% (1)

18.3% (15)

0.0002

Disagree

7.1% (6)

22.0% (18)

0.01

Neutral

25.0% (21)

20.7% (17)

0.51

Agree

45.2% (38)

29.3% (24)

0.03

Strongly agree

21.4% (18)

9.8% (8)

0.04

My institution has furloughed/laid off significant numbers of Healthcare workers during the COVID-19 pandemic

Strongly disagree

32.1% (27)

19.5% (16)

0.06

Disagree

16.7% (14)

13.4% (11)

0.56

Neutral

11.9% (10)

20.7% (17)

0.12

Agree

23.8% (20)

28.1% (23)

0.53

Strongly agree

15.5% (13)

18.3% (15)

0.63

Professional counseling and/or mental health support was offered by my institution as a result of the impact on workload and stress from the COVID-19 pandemic

Strongly disagree

9.5% (8)

17.1% (14)

0.15

Disagree

13.1% (11)

14.6% (12)

0.77

Neutral

9.5% (8)

18.3% (15)

0.10

Agree

33.3% (28)

24.4% (20)

0.21

Strongly agree

34.5% (29)

25.6% (21)

0.21

I am satisfied with the level of resources (sanitation items, hospital beds capacity, ventilators, medications, administration support etc.) provided by my institution to treat COVID-19 patients

Strongly disagree

7.1% (6)

26.8% (22)

0.001

Disagree

14.3% (12)

26.8% (22)

0.05

Neutral

7.1% (6)

19.5% (16)

0.02

Agree

46.4% (39)

17.1% (14)

<0.0001

Strongly agree

25.0% (21)

9.8% (8)

0.01

If you were infected with COVID-19, who is/are the most likely source(s) of the infection?

Colleagues

1.2% (1)

3.7% (3)

0.30

Family

6.0% (5)

7.3% (6)

0.72

Friends

1.2% (1)

4.9% (4)

0.17

Neighbors

2.4% (2)

0.0% (0)

0.16

Patient

17.9% (15)

14.6% (12)

0.57

Unknown

8.3% (7)

7.3% (6)

0.81

Not applicable

63.1% (53)

62.2% (51)

0.90

If you were infected with COVID-19 do you suspect or worry you may have infected others including but not limited to family, friends, patients, or colleagues? Select one

Yes

32.1% (27)

30.0% (24)

0.69

No

4.8% (4)

7.5% (6)

0.49

Not applicable

63.1% (53)

62.5% (50)

0.78

Yes: Strongly agree/Somewhat agree (n =

No: Neither agree or disagree/Somewhat disagree/Strongly disagree (n

p-value

180)

= 222)

What, if anything, is/are contributing your feeling of burnout? Select all that apply

Increased emotional strain/anxiety from

35.0% (63)

25.2% (56)

0.03

work

Increased workload

18.9% (34)

18.9% (42)

1

Isolation from family/friends

29.4% (53)

23.0% (51)

0.14

Lack of institutional support

7.8% (14)

16.7% (37)

0.01

Need for a safe place to go after work

5.0% (9)

8.6% (19)

0.17

Other (please specify)

3.9% (7)

7.7% (17)

0.11

significant difference in the number of respondents endorsing versus denying burnout. A previous study investigating the mental health ef- fects of the COVID-19 pandemic on healthcare workers found that healthcare workers felt that they and their loved ones were more sus- ceptible to infection due to the shortage of supplies and resources [29]. IncreasED patient volume and work intensity were also named as contributing factors to this group’s decline in overall mental health [29]. Additionally, the highly infectious nature of the virus and lack of definitive management guidelines or viable treatment options were found to be at least partly responsible for the mental health decline as well [30]. Lai et al. noted a significant proportion of surveyed healthcare workers reported insomnia, anxiety, depression, and distress symptoms due to treating patients with COVID-19 [31]. Our survey also found the most cited factors contributing to EM physician burnout to be increased work-related emotional strain and anxiety, isolation from family and friends, and increased workload. However, no significant difference was found for citing these contributors between respondents reporting feelings of burnout and those who did not.

Not only did our survey demonstrate EM physicians face greater burnout from the pandemic, but it also shows that a greater proportion of EM physicians reported inadequate professional counseling and

support as a component of inadequate resource availability. We also found that physicians reporting job satisfaction noted greater availabil- ity of such services. These findings highlight the importance of mental health services [26]. Physicians with access to readily available psycho- logical support services have shown reduced burnout rates [32]. More- over, distressed physicians were found to benefit from confidential, secure mental health services as well exhibiting again decreased burn- out rates and increased professional fulfillment [33]. Unfortunately, the limited access to mental health support and services during pan- demic closures has further worsened issues of anxiety, psychological distress, and depression [29]. This is especially concerning as a few ED physicians have died by suicide as a result of the strain of the COVID- 19 pandemic [34,35].

The results of this survey also indicate a relationship between job dissatisfaction and burnout; EM physicians reporting feelings of burn- out were more likely to express job dissatisfaction. This finding is con- sistent with existing literature on physicians in other specialties [36,37]. Interestingly, our survey found that physicians age 41-60 re- ported the highest proportion of job dissatisfaction and burnout. This seems to suggest that those most at risk of burnout are mid-career phy- sicians. The Medscape National Physician Burnout & Suicide Report

Table 7

Feelings of job satisfaction (yes/no) stratified by various survey questions.

experienced physicians are more aware of burnout, they have delin- eated personal boundaries from their professional responsibilities to

Job satisfaction

Yes: Strongly agree/somewhat agree (n = 94)

No: Neither agree or disagree/somewhat disagree/strongly disagree (n = 72)

p-value

protect themselves. Furthermore, the accumulated clinical experience of late-career physicians has fostered confidence in their abilities and in so liberated them from the stressors of providing quality healthcare [41].

I feel that my institution listens when I voice concerns related to the COVID-19 pandemic

Strongly

5.3% (5)

15.3% (11)

0.03

disagree

Disagree

12.8% (12)

16.7% (12)

0.48

Neutral

19.2% (18)

27.8% (20)

0.19

Agree

44.7% (42)

27.8% (20)

0.03

Strongly agree

18.1% (17)

12.5% (9)

0.33

Professional counseling and/or mental health support was offered by my institution as a result of the impact on workload and stress from the COVID-19 pandemic

Strongly

10.6% (10)

16.7% (12)

0.26

disagree

Disagree

10.6% (10)

18.1% (13)

0.17

Neutral

9.6% (9)

19.4% (14)

0.07

Agree

29.8% (28)

27.8% (20)

0.78

Strongly agree

39.4% (37)

18.1% (13)

0.003

If you were infected with COVID-19 do you suspect or worry you may have infected others including but not limited to family, friends, patients, or colleagues? Select one

Yes

31.2% (29)

31.0% (22)

0.97

No

7.5% (7)

4.2% (3)

0.38

Not applicable

61.3% (57)

64.8% (46)

0.67

I feel more callous towards patients, staff, family, and/or people around me as a result of my work during the COVID-19 pandemic

Never

37.6% (35)

25.4% (18)

0.09

Rarely

36.6% (34)

26.8% (19)

0.18

Sometimes

22.6% (21)

35.2% (25)

0.08

Often

3.2% (3)

9.9% (7)

0.08

Always

0.0% (0)

2.8% (2)

0.11

I feel my academic obligations (research, teaching, etc.) have been negatively

We also found that EM physicians who were satisfied with their ca- reer, more likely to feel listened to by their institutions. They were also more likely to feel that they were able to carry on with obligations out- side their clinical duties such as research or education. It is important to recognize this phenomenon. A sense of control over practice environ- ment and autonomy can aid in not only increasing job satisfaction and reducing burnout but also can improve the quality of healthcare pro- vided and physician adherence to guidelines [42].

Our survey found that the highest proportion of physicians reporting burnout were in the South, followed by the Midwest, and the Western US. However, there was no statistically significant difference in the pro- portion reporting burnout versus no burnout in any region. This may be due to the greater number of survey respondents were from these re- gions. The geographic distribution of respondents may not be completely representative. The analysis of differences in survey re- sponses between regions may limit the overall generalizability due to the variations in COVID-19 exposure surges, severity of cases and fatal- ities, and resource utilization. Also, it is possible that regional differences in responses can be linked to dissimilarities in provincial politics how- ever, it is not possible to make definitive conclusions on the effect of pol- itics in survey responses. Of note, the lowest number of respondents were from the Northeast, one of the regions initially most impacted by COVID-19 [43,44].

While our study focused on the effect of COVID-19 on feelings of

impacted by my clinical responsibil

Never 29.7% (27)

Rarely 20.9% (19)

ities due to the COVID-19 pandemic

23.2% (16)

4.4% (3)

0.34

0.003

burnout among EM physicians, it may be appropriate to examine effects in other medical specialties and non-medical fields as well. EM physi-

Sometimes

23.1% (21)

33.3% (23)

0.17

cians may not be alone in feeling increased burnout due to recent

Often

17.6% (16)

30.4% (21)

0.06

events. Jha et al. evaluated the COVID-19-related burnout among inter-

Always

8.8% (8)

8.7% (6)

0.97

ventional pain specialists and found that 98% of responding practices

I feel more burned out because of the COVID-19 pandemic as compared to before it were negatively affected by the pandemic, and 52% of responding phy-

Never 10.6% (10) 5.6% (4) 0.24

2020: The Generational Divide reported similar findings [12]. In their evaluation of suicide among surgeons, Elkbuli et al. found that middle aged physicians comprised the majority of completed suicides [38]. Dryby et al. evaluated differences in Physician satisfaction and burnout by career stage [39]. They found mid-career physicians, defined as hav- ing 11-20 years of work experience, were more likely to have burnout and high emotional exhaustion compared to physicians at other career stages, and were more likely to consider leaving the medical field. These findings persisted even after controlling for factors such as gen- der, specialty, and institution type. The mid-career peak burnout may be attributable to dissatisfaction with career progress, home or personal conflicts, and long work hours and call days; dissonance between mid-career expectations and reality may impact burnout and warrants further investigation [39].

Conversely, physicians with >20 Years of practice were less likely to report burnout. Del Carmen et al. assessed burnout of physicians in a large academic center. They noted that when compared to mid-career physicians, those in their late-career were less vulnerable to burnout [40]. Dryby et also found late-career physicians demonstrate lower levels of burnout and higher job satisfaction when compared to early and mid-career physicians [39]. Peisah et al. investigated this trend and identified two key factors that allow for the lower burnout levels seen in late-career physicians [41]. The authors found that as

sicians reported burnout. However, they also found that 76% of those

surveyed previously felt this way earlier in their careers [45].

Rarely

27.7% (26)

2.8% (2)

<0.0001

Sometimes

42.6% (40)

38.9% (28)

0.64

Often

14.9% (14)

31.9% (23)

0.01

Always

4.3% (4)

20.8% (15)

0.001

The following limitations should be considered when interpreting the results of this study. The response rate of 18.7% was relatively low and may represent some level of nonresponse bias. It is possible that in- creased workload or burnout itself may present a barrier to survey com- pletion. Because of the low response rate and small sample size, this survey may not reflect the sentiment and attitudes of all EM physicians. Instead, it offers useful insights from EM colleagues who are actively participating in the care of COVID-19 patients and who are members of the ACEP and EMPRN. Their experiences across the country are likely similar to many of their colleagues. Several attempts were made to max- imize the response rate; reminder emails were sent two and four weeks after the initial dispersal of the survey through the EMPRN online mail system. Additionally, the cross-sectional nature of this study only allows for momentary insight into the perspective of the respondents. This sur- vey was distributed after a peak in US COVID-19 incidence, which may have some effect on responses regarding institutional resources and support. It may be of value to reexamine the effects of vaccine availabil- ity on EM physician responses to burnout. Geographic differences in COVID-19 burden may also account for any regional differences in sen- timent; there were notable differences in response rate and peak case incidence between states. The majority of respondents of this survey were male and white; therefore, the generalizability of these findings may be limited; the perspective of female and minority EM physicians may be under-reported. This is interesting to note as the literature has demonstrated high levels of burnout and lower perceived control over work environment among female EM physicians [46-48]. Those who are mid-career are seven-fold more likely to seriously contemplate leaving the field when compared to their male counterparts [47].

Additionally, prior studies have found minority physicians report race- related struggles such as discrimination, microaggressions, and feelings of marginalization contributing to higher Levels of career dissatisfaction and contemplation of switching careers [49-51]. Therefore, more inves- tigation of these two under-reported groups is needed.

There are no studies that we are aware of that evaluate burnout as a result of COVID-19 between different medical specialties. In the future, this survey may be distributed to other specialty professional societies to examine potential differences between groups. Interestingly, in the study conducted by Wu and colleagues in Wuhan, China, evaluating burnout among physicians in frontline COVID-19 work areas and non- COVID-19 wards, there was significantly lower burnout in the frontline group [52]. Further investigation on whether burnout is related to front- line work versus COVID-19-related stress, in general, may be needed.

  1. Conclusion

EM physicians face many stressors from the inherent high-stakes na- ture of the field, which may be further heightened in the COVID-19 pan- demic. EM physician burnout may be compounded by perceived resource scarcity, psychological stress, isolation, and job dissatisfaction. The importance of mental health support for EM physicians is highlighted by the report of inadequate mental health services and re- sources by many of the survey respondents. It may be valuable to reex- amine shifting attitudes and the evolution of contributing factors through the progression of this pandemic. The findings of this study may help identify solutions to mitigate these issues.

Author contribution

Study design and conception: Adel Elkbuli, Jackie Nguyen.

Data collection, interpretation and analysis: Adel Elkbuli, Jackie Nguyen, Amy Liu, Huazhi Liu, Darwin Ang, Mark McKenney.

Manuscript preparation: Adel Elkbuli, Jackie Nguyen, Amy Liu, Mark McKenney, Darwin Ang.

Critical revision of manuscript: Adel Elkbuli, Jackie Nguyen, Amy Liu, Huazhi Liu, Mark McKenney, Darwin Ang.

All authors read and approved the final manuscript.

Funding

None.

Declaration of Competing Interest

Authors disclose no competing interest.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2021.03.088.

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