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.