Stress and psychological resilience among general surgery residents during COVID-19 pandemic

Discussion

In general, the field of healthcare can be mentally, physically, and emotionally demanding. During times of crisis such as this pandemic, surgeons and those in training, find their workload markedly altered and inflated. It can be inordinately stressful to care for patients while simultaneously fearing for their own health and that of their families. For surgical residents, their training and educational process is an added concern.

In this study, surgical trainees who participated in our questionnaire were mostly young (mean age 28), single (53.8%) males (65.8%) as shown in Table 2. Approximately half of the responders (50.4%) have been deployed to cover staffing shortages in either intensive care units (ICUs) or emergency departments (EDs), with 175 (74.8%) coming in contact with COVID-19 positive patients, and 14 (8%) testing positive themselves.

There was a significant association between experiencing excessive anxiety and being a male, resident’s level of training, deployment to cover ICU, tested positive for COVID-19 and having a family member with a positive COVID-19 test (p-values of 0.055, 0.002, 0.050, 0.054 and 0.004 respectively). Likewise, Lai et al5 found that 50.4% of 1257 Chinese health care workers suffered from depressive symptoms, while 44.6% had anxiety symptoms. Nurses, female health care workers, and front liners are of higher incidence of experiencing anxiety were more severely affected by the pandemic as reported by Huang et al5,6 Contradicting our results in which male surgeons were found to experience excessive anxiety than female participants. On the other hand, Song et al7 have demonstrated the corresponding result in the form of that male emergency medical staff have suffered from depression and post-traumatic stress disorder (PTSD) more than female staff who were included in their study.

While 105 pediatricians enrolled in the study of Chen et al,8 there was no significant difference in the prevalence of anxiety when comparing physicians who had exposure to COVID-19 patients and physicians who did not.

Additionally, we found that alterations in the nature of work such as covering ICUs and caring for COVID-19 patients has negatively impacted the improvement of surgical skills (median Likert scale 1, p=0.047). On the other hand, this did not impact communication skills with colleagues and superiors (median Likert scale 3, p=0.008), or with nurses (median Likert scale 3, p=0.019). It also did not affect the ability to make clinical decisions (median Likert scale 3, p=0.017) (Table 3). Meanwhile, Wen Lu et al9 observed that medical staff who were working in the departments of respiratory, emergency and infectious disease medicine or covering ICU are more susceptible to develop psychological disorders.

Regarding residents’ psychological health and their ability to cope during this demanding time, we investigated for generalized anxiety disorder (GAD) using a short screening tool comprised of 4 questions; formulated by the Anxiety and depression association of America. Having 2 or more ‘yes’ responses to these questions implies that the respondent warrants further psychiatric evaluation, but does not necessarily diagnose GAD. We observed that half of our trainees (n=117) scored positive using this screening tool.

One hundred and thirty two (56.4%) residents described themselves as experiencing excessive anxiety, with 92.4% of them identifying a worsening in episodic frequency and intensity levels. Also, 23.5% of the participants use some form of stress relief; with exercise the most frequently used by 13.7%, and psychotherapy as the least utilized option used by 1.7% of the residents. Only 2.1% of the residents reported the use of anxiolytic medication.

In terms of practice and the delivery of patient care, we concluded that clinical encounters during this pandemic have significantly contributed to the anxiety and distress general surgery trainees have suffered (Table 4). Ninety-two percent of 275 urology residents enrolled in the French association of urologists report having experienced stress during this pandemic; with 60% further documenting that this crisis has negatively impacted their quality of life and 83.3% stating their urological training has been negatively affected. Additionally, researchers have found that being stressed is significantly associated with working in a high epidemic region, caring for COVID-19 positive patients, and having a personal medical history of respiratory illness.10

Both medical and non-medical personnel caring for COVID-19 patients in tertiary institutions in Singapore have been investigated for psychological morbidities, with a total of 470 participants. Approximately 14% screened positive for anxiety, 8.9% for depression, 6.6% for stress, and 7.7% experienced post-traumatic stress disorder.11

Turkish emergency physicians have also shown to be affected by the pandemic with 62% of 290 physicians reporting depressive symptoms and 35.5% reporting symptoms of anxiety.12

Surgical residents of a tertiary care hospital recorded a considerable decrease in burnout prevalence inconsistent with the forced reduction of working hours due to pandemic crisis mode. Among 122 residents, 61% were concerned about the health of their families and 38.4% feared dying as a result of direct exposure to the virus.13

Finally, in a similar study conducted by Al Sulais et al,14 in KSA, including 529 physicians from various specialties across the Kingdom; worry (67.5%), isolation (56.9%) and fear (49.7%) were the most identified emotions. Female physicians were more likely to experience fear.

In line with the literature, the psychological burden of this global pandemic have been well described throughout the world and it has been of interest to researchers to explore its effect on healthcare workers regardless of their levels and specialties. To cope and overcome the drastic change brought by the pandemic, institutions have implemented restructuring organizational strategies in order to maintain provision of care for emergency and oncology patients as well as handling the influx of COVID-19 patients. A given example is the Italian experience in restructuring their colorectal services, Saverio et al,15 described their modification to practice, starting from suspending all elective non-cancer procedures, employ telemedicine to follow outpatients, adhere to conservative approach whenever amenable, mandatory screening of all patients requiring emergency interventions, postponing chemo and immune modulation therapies if possible. While concerning hospital staff; they reduced number of staff attending patients, handled all patient as COVID-19 positive by taking proper precautions and use of personal protective equipments (PPE), assigned negative pressure rooms, and specific routes for transferring COVID-19 patients, intubated and recovered patients inside theaters.15 However, in order to achieve minimum aerosolization and spread of infection; surgeons were practicing number of measures; use of sealed trocars, perform small incisions, deflate pneumoperitoneum via negative pressure suction connected to water seal, avoid laparoscopy lavage, minimize use of electrocautery during open procedures, perform one stage definitive procedures, minimize anesthesia time, and utilize local anesthesia when suitable. They also defined a classification system to prioritize colorectal cancer patients to prevent substantial delay in their treatment plans.15

Benitez et al,16 have published a number of recommendations concerning proper use of PPE when handling suspected or confirmed cases, limit the use of laparoscopy and gas leak during procedures. While most of these measures were formulated to help alleviate the stress of health working forces and providing safer work environment, many surgeons have reported that the use of PPE during procedures hindered their surgical performance.17 On the other hand, educational institutions have an extra responsibility in maintaining their training programs at excellency. As seen in McGill university health center, surgical residents were given special attention by providing them access to webinars and simulation facilities, regulating their re-allocation according to their level of training to acquire appropriate competencies, ensuring their active participation in available practice such as telemedicine and guaranteeing their return to regular surgical workflow as soon as restrictions are lifted.18