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Canadian emergency physician psychological distress and burnout during the first 10 weeks of COVID‐19: A mixed‐methods study

Abstract Objectives The aim of this study was to report burnout time trends and describe the psychological effects of working as a Canadian emergency physician during the first weeks of the coronavirus disease 2019 (COVID‐19) pandemic. Methods This was a mixed‐methods study. Emergency physicians completed a weekly online survey. The primary outcome was physician burnout as measured by the emotional exhaustion and depersonalization items, from the Maslach Burnout Inventory. We captured data on work patterns, aerosolizing procedures, testing and diagnosis of COVID‐19. Each week participants entered free text explaining their experiences and well‐being. Results There were 468 participants who worked in 143 Canadian hospitals. Burnout levels did not significantly change over time (emotional exhaustion P = 0.632, depersonalization P = 0.155). Three participants were diagnosed with COVID‐19. Being tested for COVID‐19 (odds ratio [OR] 11.5, 95% confidence interval [CI] 3.1–42.5) and the number of shifts worked (OR 1.3, 95% CI 1.1–1.5 per additional shift) were associated with high emotional exhaustion. Having been tested for COVID‐19 (OR 4.3, 95% CI 1.1–17.8) was also associated with high depersonalization. Personal safety, academic and educational work, personal protective equipment, the workforce, patient volumes, work patterns, and work environment had an impact on physician well‐being. A new financial reality and contrasting negative and positive experiences affected participants’ psychological health. Conclusion Emergency physician burnout levels remained stable during the initial 10 weeks of this pandemic. The impact of COVID‐19 on the work environment and personal perceptions and fears about the impact on lifestyle have affected physician well‐being.

Being tested for COVID-19 (odds ratio [OR] 11.5, 95% confidence interval [CI] 3.1-42.5) and the number of shifts worked (OR 1.3, 95% CI 1.1-1.5 per additional shift) were associated with high emotional exhaustion. Having been tested for COVID-19 (OR 4.3, 95% CI 1. 1-17.8) was also associated with high depersonalization. Personal safety, academic and educational work, personal protective equipment, the workforce, patient volumes, work patterns, and work environment had an impact on physician well-being. A new financial reality and contrasting negative and positive experiences affected participants' psychological health.

Background
Healthcare providers are at risk of negative psychological reactions after being exposed to stressful situations, ranging from symptoms such as fear and stress to posttraumatic stress disorder. 1 During the coronavirus disease 2019 (COVID-19) pandemic, it is expected that some healthcare workers will experience moral injury, burnout, and mood disorders. Moral injury is the distress (shame or guilt) experienced after violating one's own moral code, 2 for example when rationing access to levels of health care. Burnout is a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment. 3 Burnout can lead to frustration, a sense of loss of control, and diminishing morale. 4 Burnout affects workforce retention and can lead to important mental health consequences including depression and suicide. 5

Importance
There are many reasons why the COVID-19 pandemic has the potential to cause burnout among the emergency physician community.
The job demands-resources theory suggests that burnout results from increased physical or psychological work demands and reduced resources. 6

Goals of this investigation
The aim of this study was to report burnout time trends and describe the psychological effects of working as an emergency physician in Canada during the first 10 weeks of the COVID-19 pandemic.

Study design and setting
This was a mixed-methods study that follows the Good Reporting of A Mixed Methods Study guidance. 12 We followed a cohort of Canadian emergency physicians through the first 10 weeks of the COVID-19 pandemic. The mixed-methods approach allowed us to monitor burnout levels while simultaneously collecting both quantifiable risks for burnout and rich information on sources of psychological distress and participant experience.

Quantitative measurements
The study used a weekly online survey that was designed to be completed quickly, on a phone, tablet, or computer. Physicians were asked to complete the survey once a week for 10 weeks. The survey was designed to be as simple as possible to minimize loss to follow-up as time progressed. Also, we were mindful that the burden of our sur-

Outcomes
Burnout, the most commonly used measure of physician mental health, 13 was our primary outcome. We measured physician burnout using the single item measures of emotional exhaustion and depersonalization from the Maslach Burnout Inventory, "I feel burned out from my work" and "I have become more callous toward people since I took this job," with a 7-point Likert scale response (never/a few times a year or less/once a month or less/a few times a month/once a week/a few times a week/every day). These items have been shown to correlate to the emotional exhaustion and depersonalization domains from the Maslach Burnout Inventory 14 and exhibit consistent association with key outcomes such as perceived major medical errors, unprofessional attitudes, and serious thoughts of dropping out in cohorts of medical students and physicians. 15 High levels of emotional exhaustion and depersonalization were defined as responses indicating occurrence at least weekly. 15 To minimize prior response recall, the Maslach Burnout Inventory items were included every 2 weeks (weeks 4, 6, 8, and 10). Our survey's secondary outcomes were shifts missed at short notice (with reasons for missing the shift) and participant COVID-19 infection.

The Bottom Line
There are several threats to emergency physician psychological well-being during this current pandemic, ranging from safety in the work environment to personal perceptions and fears about the impact on home life. The paper uses a mixed-methods approach to explore psychological stressors and their association with physician burnout during the early stages of the coronavirus disease 2019 (COVID- 19) pandemic.

Explanatory variables
We hypothesized that working a higher number of shifts, additional shifts at short notice, and in unfamiliar settings could have detrimental effects on physician mental health, leading to burnout. We recorded the number of scheduled shifts participants worked every week, the number of shifts participants worked at short notice, and shifts worked in unfamiliar hospitals or areas other than the ED. We also tracked the number of aerosolizing procedures performed weekly because these procedures are thought to pose a high risk for hospital-acquired COVID infection. We collected data on family circumstances including children, partners who worked in health care and other caregiver roles, as well as self-identified immunosuppression.
The survey was anonymous; however, we collected age, genderhospital, province, and city of work, and prior experience of severe acute respiratory syndrome coronavirus or Middle East respiratory syndrome coronavirus.

Qualitative data collection
We asked participants to explain how they were feeling or else explain their survey answers in a free-text box each week. There was no limit on text length. These qualitative comments were used adjunctively to augment our quantitative findings and to explore sources of psychological stress.

Analysis
The primary analysis was the time trend in emotional exhaustion and depersonalization burnout scores over the 10-week study duration.

Ethics
The study was approved by Hamilton Integrated Research Board on April 3, 2020.

RESULTS
In total, 583 physicians consented to participate in the survey of whom,   Table 2 shows the results of the multivariable hierarchical logistic regression models.
We analyzed a total of 516 qualitative comments over the 10-

LIMITATIONS
Our study had several limitations. Not all participants responded to the survey every week, meaning those who felt burned out may not have respond to the survey reminders. If this was the case, we would have underreported burnout rates. We did not directly measure burnout pre-pandemic and are unable to report our findings in the context of "usual" burnout levels among this cohort. Our qualitative analysis was based on free text from the survey responses rather than interviews.
We are still conducting in-depth interviews with the same cohort and will report these results later, in relation to the findings from this survey.

DISCUSSION
In this Canadian emergency physician cohort, we did not detect a trend toward increasing physician burnout over time during the initial 10 weeks of the COVID-19 pandemic. Our qualitative data suggest Our findings suggest that emergency physician experiences are much broader and wide ranging than a simple burnout metric -their comments on the pandemic ranged from childrearing woes to finance to workplace safety issues. Although many participants commented on the burnout they were feeling, some found that the pandemic offered a new take on their professional lives, providing them with F I G U R E 2 Continued newfound purpose and resilience. This phenomenon has been previously described: after experiencing adversity, some people may develop mental health difficulties 21 whereas others develop selfesteem and resilience. 22 Our study found that COVID-19 testing and working more shifts in the prior week were associated with burnout.
To our knowledge, the association with COVID-19 testing has not previously been evaluated. Our qualitative data suggested COVID-19 testing could be particularly stressful for an emergency physician because of stigma; having potentially exposed patients, coworkers, or family to the virus; and loss of income during illness or quarantine.
However, it is also possible that those who felt burned out were more likely to be tested. Burnout and compassion fatigue are known to be associated with working longer hours. 23 There may be several reasons why we did not identify association between burnout and the progression of time during the first weeks of the pandemic. First, psychological distress is associated with high levels of exposure to traumatic events, 8 which may explain our lack of worsening burnout levels over time during the pandemic. It is possible that our cohort did not experience the concentrated numbers of sick patients seen in other parts of the world. Second, the mental health effects of a disaster or mass casualty are known to trail behind the initial trauma or event. 24,25 We may simply have measured burnout too soon after the start of this pandemic to detect changing burnout levels.
Our study has a number of strengths. Our reported burnout levels are comparable to those reported by an Italian cohort of nurses and physicians during the COVID-19 pandemic 26 and those reported by