Discussion
In this national survey-based study, we found large proportions of participants to be experiencing symptoms of burnout, anxiety, and distress. Furthermore, we identified demographic risk factors for presence of symptoms, including type of physician, sex, geographic region, and incidence of COVID-19. Turning attention to physician mental health is of great importance, as these problems have high prevalence in the physician population even prior to this pandemic. Studies conducted prior to the COVID-19 pandemic have reported prevalence of burnout in all physicians as greater than 50%,34 and prevalence of depressive symptoms in surgeons as around 30%.35Though studies conflict regarding the exact prevalence of suicide in the US physician population,36 the suicide rate is widely cited as being higher than the general population.37The increased pressures during the current pandemic have raised concerns for worsening mental health from this baseline.38,39Given the route of transmission of Sars-CoV-2, there is increased concern for otolaryngologists due to the multidisciplinary nature of the field and risk of aerosolization during procedures.4,6To our knowledge, this is the only study that has specifically surveyed academic otolaryngologists during a pandemic using standardized metrics of burnout, anxiety, distress, and depression.
Our findings show that 47.9% of participants had symptoms of anxiety, 60.2% had symptoms of distress, 21.8% reported burnout, and 10.6% screened positive for depression symptoms. Out of the four, distress was the most prevalent positive result among our participants. Increased IES scores have correlated with a risk of PTSD, with Coffey et al. suggesting a cut-off of 27.31,40 27.5% of our participants fall into the moderate and severe ranges, which start at a score of 26. A score of 10 or greater on the GAD-7 is thought to be a reasonable cut-off point for identifying cases of generalized anxiety disorder,26 and 18.9% of our participants scored above that. The PHQ-2 assesses the degree to which an individual has experienced depressed mood and anhedonia over the past two weeks, serving as a screener for depression. It should be emphasized that a positive screening on PHQ-2 requires further evaluation with the PHQ-9 to make any conclusions, with 10.6% of our participants warranting additional screening. Overall, the reported symptoms in our study are concerning for the future mental wellbeing of our physicians, particularly regarding distress and anxiety, though further study is needed.
Residents reported increased burnout compared to attendings. This is unsurprising given the nature of their role in the hospital and the increased work hours. Prior studies have revealed significantly elevated levels of burnout in US otolaryngology residents compared to attendings at baseline.41 Importantly, these studies have used the Maslach Burnout Inventory (MBI) as their measure of burnout, which our Mini-Z burnout assessment has been validated against with particularly good correlation for the MBI’s emotional exhaustion subscale.28 A study by Golub et al. reported high emotional exhaustion in 33% of residents, moderate in 29%, and low in 38%, which was strongly associated with increased work hours.42 In our study, 29.7% of residents reported at least “I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion,” and 70.3% of residents reported “I enjoy my work. I have no symptoms of burnout” or “I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.” Taken together, it is possible that we are in fact seeing a decrease in burnout from baseline in our study. Though residents anecdotally report increased anxiety and stress in response to COVID-19, they also acknowledge that their work hours are much improved due to the cancellation of elective procedures and limitations on the number of in-hospital personnel. Thus, in the specific case of burnout, increased time off may have mitigated increased stressors in the workplace for our population.
Given the uneven spread of COVID-19 throughout the United States, we sought to identify an association between severity of COVID-19 and our mental health outcome measures. Our findings identified differences in distress based on these variables. Physicians working in states with greater than 20,000 positive cases or 1,000 deaths reported increased symptoms of distress compared to those in states with less than 20,00 positive cases or 1,000 deaths. When looking specifically at intrusive distress symptoms, separated out from the avoidant symptoms, there was a significant difference by region, with the Northeast having the highest median intrusive distress scores. As the Northeast had a substantially greater number of cases during our study period,25these participants are more likely to be treating positive patients or potentially being re-deployed to other roles, and their stress may be compounded by diminishing PPE. Given the relationship between positive case numbers, death numbers, and region, only the positive case number variable was included in the multivariable analysis, and remained significant for distress.
Female respondents reported significantly higher amounts of burnout, anxiety, and distress. These findings are consistent with those identified in other studies during the current pandemic in China.21,22 This is also supported by an abundance of literature on a higher prevalence of “internalizing” psychiatric disorders such as anxiety and depression in females compared to males, who have higher prevalence of substance abuse and “externalizing” disorders, including attention-deficit/hyperactivity disorder, conduct disorder, intermittent explosive disorder, and oppositional defiant disorder.43,44 However, it is also important to consider the risks of response and measurement bias in these screening tools. These tools rely on symptom-based reporting, where males may be less likely to report symptoms.45-47 Furthermore, their symptoms may not fit these standard measurement tools, and their “externalizing” disorders may be masking depression and anxiety.46 For these reasons, it is possible that males may be underdiagnosed by these tools and clinically. Thus, our study may not be fully capturing the state of mental health among males, and therefore it is important to focus efforts on improving mental wellness in all physicians regardless of their gender.
This study has several limitations that are important to consider. Depending on the trajectory of the pandemic, the mental health symptoms of health care workers could intensify or diminish over time. Thus, long-term psychological implications of this population are worth future investigation. In addition, we did not include a control group and therefore are unable to definitely conclude that these symptoms in healthcare workers differ from those of the general population or of any other specialty. However, Zhang et al. found healthcare workers mental health scores to be significantly increased compared to nonmedical health care workers during COVID-19 in China.22 We are also unable to distinguish whether these symptoms are in the setting of preexisting mental health symptoms rather than new symptoms, though free responses to an optional question at the end of the survey suggest that many are experiencing a mental change that they attribute to COVID-19. Additionally, because our survey was emailed to each program director to distribute to their department, we are unable to confirm whether they received this email and/or forwarded it to their department. Given our response rates, we cannot exclude the possibility of a non-response bias. Providers who received but did not respond to the survey may not have been experiencing any distress, anxiety, burnout, or depression and therefore were not interested in responding. Alternatively, those who received the survey but did not fill it out could have been too overwhelmed to respond.