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\begin{document}

\title{Impact~ of COVID-19 on the mental health of surgeons and coping
strategies~}



\author[1]{Anusha Balasubramanian, MRCS, MMED (ORL-HNS)}%
\affil[1]{The Royal Marsden NHS Foundation Trust}%


\vspace{-1em}



  
  \date{March 14, 2025}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Unprecedented times call for extraordinary measures. While surgeons
across the globe try to comprehend the evolving fa\selectlanguage{ngerman}çade of the COVID 19
pandemic and improvise surgical practice to the best of their ability,
the psychological impact of the stress on their own mental health and
wellbeing has been underestimated. This paper aims to review the
indirect and overt factors that may affect the mental health of a
surgeon in the present circumstances. Furthermore, it will aim to
highlight key coping mechanisms at individual and institutional level,
so as to mitigate the negative psychological impact on surgeons.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


Anusha Balasubramanian, MRCS, MMED (ORL-HNS)\textsuperscript{1}

Vigneshwar Paleri, MSc\textsuperscript{2}

Robin Bennett, PhD\textsuperscript{2}

Vinidh Paleri, MS, FRCS (ORL-HNS)\textsuperscript{1}

~\textbf{AFFLIATIONS OF AUTHORS :}

1 Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK

2 Lewisham CAMHS, South London and Maudsley NHS Foundation Trust,
London, UK

\textbf{CORRESPONDING AUTHOR :}

Anusha Balasubramanian

Head and Neck Unit,

The Royal Marsden NHS Foundation Trust,

London, UK

Email : \textbf{} {htchd766@gmail.com}

Tel : +44 7783442155

\textbf{~}

\textbf{BRIEF RUNNING TITLE :}

COVID-19 mental health impact on surgeons

~\textbf{KEYWORDS :}

covid-19 impact, mental health, surgeons, otolaryngology, head neck

~\textbf{CONFLICT OF INTEREST AND FUNDING :}

Nil

~\textbf{DISCLOSURE :}

None

\textbf{ABSTRACT}

Unprecedented times call for extraordinary measures. While surgeons
across the globe try to comprehend the evolving fa\selectlanguage{ngerman}çade of the COVID 19
pandemic and improvise surgical practice to the best of their ability,
the psychological impact of the stress on their own mental health and
wellbeing has been underestimated. This paper aims to review the
indirect and overt factors that may affect the mental health of a
surgeon in the present circumstances. Furthermore, it will aim to
highlight key coping mechanisms at individual and institutional level,
so as to mitigate the negative psychological impact on surgeons.

\par\null

\textbf{INTRODUCTION}

Surgical training hones one to be tough, yet calm especially during
stressful periods. During these unprecedented times, all clinicians are
susceptible to mental stress. Measures should be taken, both at an
organisational and at a personal level to provide service while
minimising risks to all healthcare professionals.

Irrespective of specialty, healthcare workers fear the reality of the
present and uncertainty of the future. It is evident that ORL, oral,
maxillo-facial and head and neck surgeons are at significant risk of
exposure. While all protective measures must be taken and guidance
adhered to consciously at all times, maintaining a well-balanced
physical and mental health is of paramount importance to function with
optimal clarity.

This paper will focus on consolidating the pre-existing self-care tips
and mental health resources, summarise webinars and teleconference
proceedings from hard hit areas, and discussions with experts in the
field, which will serve as a resource to mitigate the short and
long-term psychological effects of the current pandemic.

\textbf{The Risks of COVID-19 to Surgeons}

As of May 6\textsuperscript{th}, 2020, the Johns Hopkins coronavirus
resource center had reported 3,689,887 confirmed cases involving 187
countries worldwide, with 258,160 deaths. Data from Italy revealed that
up to 20\% of healthcare workers were potentially
infected\textsuperscript{1}, and as of 29\textsuperscript{th} April
2020, a total of 154 Italian doctors had
succumbed.\textsuperscript{2}Surgeons dealing with the upper
aerodigestive tract were found to be equally at risk as their
counterparts in the emergency room, general ward and intensive care
units.\textsuperscript{3} It is notable that the first healthcare
workers to succumb of COVID-19 complications in Wuhan, China and UK were
both ORL surgeons.\textsuperscript{4,5}

High viral loads have been detected in the nose and throat especially
after symptom onset.\textsuperscript{6} Thus, both office-based and
operating theatre-based procedures such as nasal endoscopy,
laryngoscopy, tracheostomy and all transoral interventions are
considered to be aerosol generating procedures, and deemed to put the
clinician at higher risk of viral infection. In their recent
recommendations for the COVID-19 pandemic, the International Head and
Neck Scientific Group (IHNSG) have advised to avoid all forms of aerosol
generating procedures and that they should be employed only when it is
absolutely necessary.\textsuperscript{3}

Issues with personal protective equipment (PPE) have been reported
worldwide.\textsuperscript{7} While the IHNSG have strongly recommended
the use of full PPE for healthcare personnel involved with procedures of
the upper aerodigestive tract,\textsuperscript{3} reports of surgical
teams having to resort to creating their own PPE using garbage bags,
glue, rubber bands and plastic cover of folders bought from stationary
shops have emerged.\textsuperscript{8} Health care workers have
expressed concerns over acute supply shortages, insufficient time for
adequate training and unavailability of mask fitting test. A survey of
258 ENT surgeons was conducted across the UK during the peak of the
pandemic in March 2020, seeking their opinion around PPE-related
issues.\textsuperscript{9} Among the respondents, 40\% stated that they
had not attended a PPE training course or that one was unavailable. More
worrying was the fact that N95 masks were only available to 27\% of ENT
surgeons with 95\% predicting that PPE stocks would deplete in due
course. More than half were aware that there was a COVID-19 protocol in
place implemented by their Trust.\textsuperscript{9}

\textbf{The Impact of COVID-19 on Mental Health}

Surgeons and trainee doctors from various surgical disciplines have been
redeployed to cover on COVID wards and work in the frontline in hotspot
areas to help cope with rising demands attributed to the surge in
patients. The stress of having to step out of the comfort zone of usual
practice into a high-risk unfamiliar environment at a short notice can
be overwhelming, as demonstrated by Lai et al where 70\% and 50\% of
1257 healthcare workers (40\% frontline professionals) in China reported
symptoms of distress and depression respectively.\textsuperscript{10}

Similarly, Liang et al assessed the mental health status of 59 staff
associated with COVID departments and other related departments at the
Fifth Affiliated Hospital of Sun Yat-sen University~using Zung's
self-rating depression scale (SDS) and self-rating anxiety scale
(SAS).\textsuperscript{11} Although statistically insignificant, younger
staff members (\selectlanguage{english}[?] 30 years of age) were found to have higher SDS scores.
Huang et al conducted a similar assessment of the mental health of
frontline clinicians in China.\textsuperscript{12} Across 230 responses,
the prevalence of anxiety and stress disorders were 23\% and 27\%
respectively; with higher incidence of SAS scores and stress disorders
among female clinicians.\textsuperscript{12} On a larger scale, Lv et al
found an incidence rate of 34.7\% overall anxiety and 24.8\% of mild
anxiety across 8028 surveyed doctors and nurses on the
frontline.\textsuperscript{13}

Further to this, Kang et al. explored the impact of mental health and
coping strategies of Wuhan medical personnel between January 29th and
February 4th 2020.\textsuperscript{14} Employing mental health measures
for depression (Patient Health Questionnaire-9; PHQ-9), anxiety
(Generalised Anxiety Disorder-7; GAD-7) and distress symptoms (Impact of
Events Scale-Revised; IES-R) - a cohort of 994 staff responded to the
study. Statistically significant results revealed mental health
disturbances were prevalent across all participants for the three
outcome measures. Individuals reported to be symptomatic across the
sub-threshold (36\%), mild (34.4\%), moderate (22.4\%) and severe
(6.2\%) levels. Pivotally, coping strategies were varied across all
participants ranging from perusing psychological resources (36.3\%),
50.4\% accessing digital psychological recommendations (36.3\%) and
participating in therapeutic support (17.5\%). Individuals who
experienced severe disturbances were less likely to access psychological
materials or online mental health guidance. These aforementioned studies
not only highlight the necessity for greater and earlier support, but
also the versatility of resources that should be provided and promoted
to frontline clinicians.

Finally, importance should be given to the social and practical factors
associated with living through the social-isolation response to the
pandemic. Several facets are adversely impacted inclusive of
socialisation with friends and family, regular engagement in leisure
activities and procurement of sustenance and other essential items.
Fundamentally, there is a detrimental impact on the freedom of movement
and a risk of increased anxiety about the health and safety of friends
and family. These factors consolidated, may affect the surgeon's ability
to manage stress on a daily basis. As normal service resumes in clinics,
there is a potential that there could be a surge in referrals of the
``worried well'' group, leading to increased demand on services and
further work stress.

\textbf{The Role of the Surgeon}

As a team leader, manager or senior clinician, the surgeon is expected
to be at his/her best at all times. Personnel who are emotionally
distressed may express fear, panic, anger, absenteeism, carelessness in
protecting themselves and inadvertently expose others to avoidable risk.
In this context, The British Psychological Society's practical guidance
outlines the role that is expected of a leader or manager in supporting
staffs who are apprehensive or emotionally affected during the COVID-19
pandemic, the various response phases and the principles on responding
well to the needs of the staff (Table 1).

In addition to the above, the surgeon is expected to provide holistic
person-centred care for outpatients. In the theatre environment, they
undertake several responsibilities inclusive of allocating resources
optimally, mobilising staffs, managing daily issues while attempting to
remain calm and composed, push their own thoughts aside, and continually
make rational, crucial and critical judgments when required to do so.

This pressure is further mounted by the fear of transmitting infection
to family members when they return home. Reports have emerged that many
doctors have resorted to isolating themselves from their family so as to
protect their loved ones.\textsuperscript{15} The pre-existing emotional
stress is further aggravated by self-isolation.

Continual efforts have been made to create pathways, modify working
practices especially where resources are severely constrained, as well
as create guidance for the clinical management of COVID positive
patients and, to adapt the current management protocols in the pandemic
setting, as evidenced by the constant updates on the ENT UK
website.\textsuperscript{16} However, there still remains the underlying
fear, worry, panic, confusion, uncertainty, depression, grief and
anxiety in many members of the surgical fraternity which have been
overlooked and require equal and immediate attention.

.

\textbf{The Dangers of Burnout}

Prior to COVID-19 concerns, reviews have highlighted that up to 54\% of
medical professionals in the UK are emotionally
exhausted.\textsuperscript{17} Alongside fatigue and frustration,
emotional exhaustion is a core symptom of burnout in clinicians.
Vijendren et al, found that within a cohort of 108 ENT Surgeons in the
UK, 56.5\% of respondents were classified at high risk of developing
psychological morbidity, with 28.9\% of reported scores suggesting
burnout.\textsuperscript{18} As such, given the additional stresses and
disruption caused by COVID-19, clinicians have a greater likelihood of
developing burnout in the long-term.\textsuperscript{19}

Burnout has several harmful ramifications including substance misuse,
absenteeism and medical errors,\textsuperscript{20-22} which can
escalate to mental health difficulties such as increased suicidal
ideation and depression.\textsuperscript{23,24} Surprisingly, the sole
study investigating burnout prevalence in clinicians during COVID-19
epidemic found a lower frequency of burnout in healthcare professionals
working on the frontline comparatively to those who were working on
wards for uninfected patients.\textsuperscript{25} Several limitations
were revealed inclusive of small sample size and selection bias of
responses (i.e. distressed medical professionals may have not responded
to the survey). Critically, the authors point out that the timing of
their study (March 2020) was not a peak period for COVID-19 in Wuhan,
China.

Furthermore, a cross-sectional study by Cai et al explored the
psychological burden and coping strategies over 500 frontline medical
staff in Hunan. Specifically, researchers found the core facets
associated with stress were concerns for their families, personal and
patient safety. Comparatively to other healthcare workers, doctors felt
a higher degree of social and moral responsibility in their vocation and
greater scores of anxiety associated with working
overtime.\textsuperscript{26}

The aforementioned factors (summarised in Table 2), highlights the
detrimental impact of burnout on mental health. A surgeon should ideally
be in a strong and stable frame of mind to focus on the work at hand,
once the various coping mechanisms have been adopted to deal with
possible emotional effects of the current pandemic. Irrespective of
specialty, Cai et al discovered that knowledge of COVID-19 prevention
and transmission, social isolation measures, exhibiting positive
self-attitude and seeking family and peer support were all essential
facets that significantly reduced stress and burnout in
clinicians.\textsuperscript{26} Hereinafter, key coping strategies as
recommended by health services are discussed in greater depth.

\textbf{COPING STRATEGIES}

\textbf{Positive Lifestyle Behaviours}

Capitalising on coping strategies akin to positive lifestyle behaviours
can vastly improve mental health wellbeing. These activities which
include eating healthy food, engaging in regular physical activity,
practicing good sleep hygiene where possible and guaranteeing sufficient
rest between shifts have been recommended by the World Health
Organisation (WHO).\textsuperscript{27} Furthermore, avoidance of
harmful coping strategies such as alcohol and drug misuse, consistent
rumination about COVID-19 or engaging in high-risk behaviours (i.e.
gambling / excessive spending) is pivotal due to these activities being
more damaging in the long-term. Alternatively, social media use for the
purpose of maintaining social contact can be considered as a positive
lifestyle behaviour. However, consuming excessive media coverage
pertinent to COVID-19 may impact negatively on mental health, comparably
to the relationship found between viewing disaster media coverage and
adverse psychological outcomes.\textsuperscript{28}

\textbf{Mindfulness}

In addition to positive lifestyle changes, compliance with
mindfulness-based programmes have been shown to reduce symptoms of
burnout in doctors.\textsuperscript{29} Lebares et al's cross-sectional
study indicated dispositional mindfulness was associated with a
decreased risk of symptoms associated with burnout, distress and severe
stress in surgeons.\textsuperscript{30} Similarly, research has shown
that specific relaxation techniques (i.e. progressive muscle relaxation)
based on elements in mindfulness has been shown to reduce symptoms of
anxiety and promote sleep quality in patients with
COVID-19.\textsuperscript{31}

In this age of exponential technological progress, mobile-health apps
are being increasingly used as a source to enhance personal wellbeing.
Mindfulness apps have been shown to significantly strengthen resilience
and reduce burnout in medical trainees.\textsuperscript{32} The American
Psychiatric Association's ``app evaluation model'' is a framework that
rates the efficacy and dangers of mobile and online
apps.\textsuperscript{33} This is in line with ORCHA (Organisation for
the Review of Care and Health Apps), a health app evaluation and advisor
organisation for NHS Digital and NHS England, who have recently launched
a COVID-19 specific health-app formulary supporting healthcare
professionals and patients. (Table 1) Pospos et al, reviewed data on the
effectiveness of these key apps used by clinicians and the general
public, recommending the following for specific circumstances:
meditation (Headspace, guided meditation audios), suicide prevention
(Stay Alive, Virtual Hope box), breathing (Breath2Relax) and Web-based
Cognitive Behavioural Therapy (MoodGYM, Stress
Gym).\textsuperscript{34}Specifically, the MoodGYM app has been shown to
decrease suicidal ideation amongst medical interns.\textsuperscript{35}
Given the ease and accessibility of the aforementioned apps, these
mindfulness-based platforms act as a virtual space to disconnect,
de-stress and strengthen resilience.\textsuperscript{36,37}

\textbf{EXTERNAL RESOURCES}

The following sections will seek to provide helpful resources for
clinicians and highlight novel approaches for institutions to consider
during this current climate. It should be noted that whilst extensive,
the list of materials is not exhaustive. Consistent modifications to
resources are being provided by several websites and services, and the
most up-to-date advice should be prioritised.

\textbf{Supporting the Individual}

The Academy of Medical Royal Colleges have dedicated a page on self-care
tips and resources to utilize during the pandemic, some of which have
been summarised in Table 3 below. ( Table 1 )

Several validated scales can be employed to assess one's own mental
health state. The most prevalent outcome measure in the UK for
depression and anxiety would be the PHQ-9 \& GAD-7 respectively. Further
notice should be given to IES-R as well; a short assessment for
traumatic stress symptoms. Alternative measures also include Zung's
self-rating depression scale (SDS) and self-rating anxiety scale (SAS).
All questionnaires are highlighted below (Table 1 ).

If clinicians struggle with regular compliance for mindfulness apps -
practical steps have been created that can be followed, specifically
during this period. FACE COVID is a 9-step programme that healthcare
professionals can hold in mind, based on key principles of Acceptance
and Commitment Therapy.\textsuperscript{38} Among the steps outlined
involve acknowledging one's thoughts, identifying available resources
and instituting the appropriate measures. (Table 1 )

\textbf{Support from the Institution}

Healthcare provider organisations and institutions have a crucial role
to play in terms of supporting healthcare staffs of all backgrounds in
dealing with the emotional effects of the pandemic. Financial, digital
platform, logistics and psychological services support may be required
according to the needs of every individual. Key mechanisms will be
discussed that could be implemented across hospital sites that may prove
useful to individuals on managing their mental health wellbeing during
the COVID-19 pandemic.

Schwartz rounds are an evidence-based forum that allows a group of
staffs of all backgrounds to reflect and discuss their emotions related
to work matters.\textsuperscript{39} The positive impact of the Schwartz
rounds has been demonstrated, with feedback indicating that emotions
were acknowledged, validated and staff members took pride in being a
member of a strong supportive team.\textsuperscript{40.41} In light of
the present pandemic, this forum can be held on a virtual platform.

Greenberg and colleagues have described measures that may be implemented
by healthcare managers and individuals in supervisory roles to promote
and protect mental health among staffs. This includes utilisation and
enrolling staffs into pre-existing institution-based peer support
programmes.\textsuperscript{41}

Considerations regarding a shift rota system in place of the regular
daily routine may be beneficial for healthcare
professionals.\textsuperscript{42} Breaks from the hospital environment
for surgeons can be implemented in addition to assembling a secondary
workforce from home, should a colleague need to be replaced.
Furthermore, psychology consultation and counselling services that are
presently being converted into telemedicine services via digital
platforms in many institutions should be easily accessible to staffs and
surgeons alike.\textsuperscript{43} Reiteration on maintenance of
confidentiality should be emphasised as advocated by The Royal College
of Psychiatrists. (table 1)

Chen et al found that mental health can be strengthened creatively by
setting up specific teams designed to provide psychologic support (i.e.
an assistance hotline team, an interventions team for stress-relief
activities and a medical team providing online
courses).\textsuperscript{44} However, the authors stress on the
importance of key resources that should be provided by hospitals (i.e.
comfortable place for rest, necessary PPE training and access to
COVID-19 guidance and recommendations). These measures were implemented
at the Second Xiangya Hospital of Central South University, the largest
tertiary hospital in the epicentre of the Hunan province to support
their staffs during the peak of the pandemic.\textsuperscript{44} The
relevant measures described above have been summarized in Table 4.

\textbf{CONCLUSION}

Healthcare professionals and provider institutions have a self and
corporate responsibility to ensure that the mental health aspect of all
staff is adequately monitored and addressed especially during times of
global crisis. Long term mental health issues among healthcare
professionals as a result of the pandemic should be minimized. The
stigma associated with mental health may result in internalising
unhelpful thoughts and emotions. Early recognition of symptoms of low
mood and anxiety allows for interventions from friends, family and the
organisation. This cycle of support can continue to allow for safer and
productive outcomes for surgeons in the workplace. It is imperative that
the importance of mental health is championed during the COVID-19
pandemic.

\textbf{REFERENCES}

1. Remuzzi A, Remuzzi G. COVID-19 and Italy: what next?. \emph{The
Lancet.} 2020;395(10231):1225-1228.

2.\emph{https://portale.fnomceo.it/elenco-dei-medici-caduti-nel-corso-dellepidemia-di-covid-19/},
accessed April 20, 2020.

3. Kowalski, LP,~Sanabria, A,~Ridge, JA, et al.~COVID\selectlanguage{english}-19 pandemic:
Effects and evidence\selectlanguage{english}-based recommendations for otolaryngology and head
and neck surgery practice.~\emph{Head \& Neck} .~2020;~1--~9.

4. Chan JYK, Wong EWY, Lam W. Practical Aspects of Otolaryngologic
clinical services during the 2019 novel coronavirus epidemic:~an
experience in Hong Kong.~\emph{JAMA Otolaryngol Head Neck Surg.}
~Published online March 20, 2020. doi:10.1001/jamaoto.2020.0488.

5.\emph{https://www.theguardian.com/world/2020/mar/29/worrying-event-deaths-of-nhs-doctors-from-covid-19-stark-reminder-of-pandemic,}accessed
April 7, 2020.

6. Zou L, Ruan F, Huang M, et al. SARS-CoV-2 viral load in upper
respiratory specimens of infected patients. \emph{N Engl J Med}
.2020;382:1177-1179.

7.\emph{https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide},
accessed April 19, 2020.

8. Bowden E, Campanile C, Golding B. Worker at NYC hospital where nurses
wear trash bags as protection dies from coronavirus. New York Post. 25
March,
2020.\emph{https://nypost.com/2020/03/25/worker-at-nyc-hospital-where-nurses-wear-trash-bags-as-protection-dies-from-coronavirus/},
accessed April 15, 2020.

9. Davis A, O'Donoghue G. Protect our healthcare workers. \emph{BMJ} .
2020;369:m1324.

10. Lai J, Ma S, Wang Y et al. Factors associated with mental health
outcomes among health careworkers exposed to coronavirus disease
2019.\emph{JAMA Network Open} . 2020;3(3):e203976.

11. Liang Y, Chen M, Zheng X, Liu J. Screening for Chinese medical staff
mental health by SDS and SAS during the outbreak of COVID-19. \emph{J
Psychosom Res} . 2020;133:110102.

12. Huang JZ, Han MF, Luo TD, Ren AK, Zhou XP. Mental health survey of
230 medical staff in a tertiary infectious disease hospital for
COVID-19. Chinese journal of industrial hygiene and occupational
diseases. 2020 Mar 4;38:E001-.

13. Lv Y, Zhang Z, Zeng W, Li J, Wang X, Luo GQ. Anxiety and Depression
Survey of Chinese Medical Staff Before and During COVID-19 Defense.
Available at SSRN 3551350. 2020 Mar
7.\emph{https://ssrn.com/abstract=3551350}, accessed April 14, 2020.

14. Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, Yao L, Bai H, Cai Z,
Yang B.X. and Hu S, 2020. Impact on mental health and perceptions of
psychological care among medical and nursing staff in Wuhan during the
2019 novel coronavirus disease outbreak: A cross-sectional
study.\emph{Brain, behavior, and immunity} . 2020 Mar 30.

15.\emph{https://www.dailymail.co.uk/femail/article-8136037/Doctors-isolating-FAMILIES-prevent-spread-COVID-19.html},
accessed April 19, 2020.

16. ENT UK Covid 19 page.\emph{https://www.entuk.org/covid-19}, accessed
April 21, 2020.

17. Imo UO. Burnout and psychiatric morbidity among doctors in the UK: a
systematic literature review of prevalence and associated factors.
BJPsych bulletin. 2017 Aug;41(4):197-204. Accessed April 16, 2020.

18. Vijendren A, Yung M, Shiralkar U. Are ENT surgeons in the UK at risk
of stress, psychological morbidities and burnout? A national
questionnaire survey. \emph{The Ssurgeon} . 2018 Feb 1;16(1): 12-9.

19. Dewey C, Hingle S, Goelz E, Linzer M. Supporting clinicians during
the COVID-19 pandemic {[}published online ahead of print, 2020 Mar
20{]}.~\emph{Ann Intern Med} . 2020;M20-1033.

20. Dyrbye LN, Shanafelt TD, Balch CM et al. Relationship between
work-home conflicts and burnout among American surgeons: a comparison by
sex.~\emph{Arch Surg} . 2011;146(2):211--217.

21. Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use
disorders among American surgeons.~\emph{Arch Surg} .
2012;147(2):168--174.

22. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical
errors among American surgeons.~\emph{Ann Surg} . 2010;251(6):995--1000.

23. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal
ideation among American surgeons.~\emph{Arch Surg} . 2011;146(1):54--62.

24. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: A systematic
review.~\emph{J Am Coll Surg} . 2016;222(6):1230--1239.

25. Wu Y, Wang J, Luo C, et al. A comparison of burnout frequency among
oncology physicians and nurses working on the front lines and usual
wards during the COVID-19 epidemic in Wuhan, China {[}published online
ahead of print, 2020 Apr 10{]}.~\emph{J Pain Symptom Manage} .
2020;S0885-3924(20)30205-0.

26. Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, Zhuang Q. Psychological
Impact and Coping Strategies of Frontline Medical Staff in Hunan Between
January and March 2020 During the Outbreak of Coronavirus Disease 2019
(COVID\selectlanguage{english}-19) in Hubei, China. \emph{Med Sci Monit} . 2020 Apr 15;26.

27. World Health Organization. Mental health and psychosocial
considerations during the COVID-19 outbreak, 18 March 2020. World Health
Organization; 2020.

28. Pfefferbaum B, Newman E, Nelson SD, Nitiema P, Pfefferbaum RL,
Rahman A. Disaster media coverage and psychological outcomes:
descriptive findings in the extant research. Current psychiatry reports.
2014 Sep 1;16(9):464.

29. Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ,
Quill TE. Association of an educational program in mindful communication
with burnout, empathy, and attitudes among primary care
physicians.\emph{JAMA} . 2009 Sep 23;302(12):1284-1293.

30. Lebares CC, Guvva EV, Ascher NL et al. Burnout and stress among us
surgery residents: Psychological distress and resilience.~\emph{J Am
Coll Surg} . 2018;226(1):80--90.

\subsection*{\texorpdfstring{31. Liu K, Chen Y, Wu D, Lin R, Wang Z, Pan
L. Effects of progressive muscle relaxation on anxiety and sleep quality
in patients with COVID-19. \emph{Complementary Therapies in Clinical
Practice} . 2020 Mar
6:101132.}{31. Liu K, Chen Y, Wu D, Lin R, Wang Z, Pan L. Effects of progressive muscle relaxation on anxiety and sleep quality in patients with COVID-19. Complementary Therapies in Clinical Practice . 2020 Mar 6:101132.}}

{\label{liu-k-chen-y-wu-d-lin-r-wang-z-pan-l.-effects-of-progressive-muscle-relaxation-on-anxiety-and-sleep-quality-in-patients-with-covid-19.-complementary-therapies-in-clinical-practice.-2020-mar-6101132.}}

32. Yeo CJ, Barbieri A, Roman G et al. Using smartphone mindfulness apps
to increase trainee resilience and reduce burnout. \emph{Neurology} .
2019;92~(15 Supplement)~P2.9-005.

33. American Psychiatric Association. App Evaluation Model. 2017. URL:
https://www.\emph{psychiatry.org/psychiatrists/practice/mental-health-apps/app-evaluation-model}.
Accessed April 17, 2020

34. Pospos S, Young IT, Downs N, et al. Web-based tools and mobile
applications to mitigate burnout, depression, and suicidality among
healthcare students and professionals: A systematic review.~\emph{Acad
Psychiatry} . 2018;42(1):109--120.

35. Guille C, Zhao Z, Krystal J et al. Web-based cognitive behavioral
therapy intervention for the prevention of suicidal ideation in medical
interns: A randomized clinical trial.~\emph{JAMA Psychiatry} .
2015;72(12):1192--1198.

36. Ho CS, Chee CY, Ho RC. mental health strategies to combat the
psychological impact of COVID-19 beyond paranoia and panic.~\emph{Ann
Acad Med Singapore} . 2020;49(3):155--160.

37. Bansal P, Bingemann TA, Greenhawt M, Mosnaim G, Nanda A, Oppenheimer
J, Sharma H, Stukus D, Shaker M. Clinician Wellness During the COVID-19
Pandemic: Extraordinary Times and Unusual Challenges for the
Allergist/Immunologist. \emph{J Allergy Clin Immunol: In Practice} .
2020 Apr 4.

38. FACE COVID' How to respond effectively to the Corona crisis by Dr
Russ Harris, author of The Happiness
Trap.\emph{https://www.baps.org.uk/content/uploads/2020/03/FACE-COVID-by-Russ-Harris-pdf-pdf.pdf.}Accessed
April 16, 2020.

39. Lown BA, Manning CF. The Schwartz Center Rounds: evaluation of an
interdisciplinary approach to enhancing patient-centered communication,
teamwork, and provider support.~\emph{Acad Med} . 2010;85(6):1073--1081.

40. Sanghavi DM. What makes for a compassionate patient-caregiver
relationship?.~\emph{Jt Comm J Qual Patient Saf} . 2006;32(5):283--292.

41. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental
health challenges faced by healthcare workers during covid-19
pandemic.~\emph{BMJ} . 2020;368:m1211.

42.\emph{https://www.rcpch.ac.uk/resources/covid-19-guidance-planning-paediatric-staffing-rotas\#rotas},
accessed April 20, 2020.

43. Ayanian JZ. Mental health needs of health care workers providing
frontline COVID-19 care. JAMA Health Forum
2020.\emph{https://jamanetwork.com/channels/health-forum/fullarticle/2764228},
accessed April 9,2020.

44. Chen Q, Liang M, Li Y, et al. Mental health care for medical staff
in China during the COVID-19 outbreak.~\emph{Lancet Psychiatry} .
2020;7(4):e15--e16.

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