Covid-19 pandemic induced traumatizing medical job contents and mental health distortions of physicians working in private practices and in hospitals

doi:10.21203/rs.3.rs-1977765/v1

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Covid-19 pandemic induced traumatizing medical job contents and mental health distortions of physicians working in private practices and in hospitals

https://doi.org/10.21203/rs.3.rs-1977765/v1

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published 31 Mar, 2023

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Background:

The traumatic burden of the Covid-19 pandemic during its early phases posed significant psychological threats particularly for medical frontline personal. It is unclear whether the medical workforce with the passage of time has adapted to these threats or whether emotional perturbations have generalized to wider medical settings.

Participants and Methods:

An online survey was conducted among 1,476 physicians. Valid data were achieved from 1,327 participants. A pandemic induced job context score was built by nine items. Depression and anxiety were screened with the PHQ-2 and the GAD-2.

Results:

Among a subtotal of 1,139 (86.6%) physicians with personal treatment experiences with Covid-19 patients, 553 (84.8%) worked in a private practice (PP) and 586 (88.3%) in a hospital (HP). Covid-19 provoked profound conflicts between professional and ethical values: more physicians in PPs than HPs reported external constraints on their medical care being in conflict with the code of medical ethics (39.1% vs. 34.4%, p<0.002). However, significantly more HPs failed to maintain the dignity of their patients during the pandemic (48% vs. 27%, p< 0.0001). Prevalence of depression was 23.0% and 24.16% for anxiety. Comparison with mean PHQ-2 and GAD-2 data from reference groups among physicians with comparable size and settings during the first wave of Covid-19 revealed a significant increase in mental health distortions. A total of 63.3% HPs and 53.4% PPs reported feelings of helplessness associated with female sex, minor years of medical experience, being weakened by sleeping problems (OR= 2.5) and being encountered to unsettling events (OR=3.4). The association between exposure to unsettling events and helplessness was significantly mediated by sleep disturbances (Indirect path: ß= 0.29, S E= 0.03, p<0.0001).

Conclusions:

Major Covid-19 induced stress job content issues have broadened to more medical disciplines beyond frontline workers. Mental health deteriorations and feelings of helplessness among physicians have become frequent. (248)

Covid-19 pandemic

physicians in private practice

in hospital settings

medical ethics

depression

anxiety

helplessness

sleeping problems

Shortly after the World Health Organization (WHO) qualified the newly identified SARS-CoV-2 virus spread as a “pandemic”, the majority of countries around the world initiated social distancing measures of a size never seen before. The rapidly evolving situation led to substantial economic setbacks and drastically disrupted the social and working life across the globe. Nevertheless, lockdown measures were only insufficiently able to slow down the spread of the SARS-CoV-2 virus subsequently leading to excess mortality and physical morbidity. Furthermore, it became rapidly clear that the Covid-19 pandemic also unfolded detrimental effects on mental health. Mainly based on large scale population based observational studies from countries around the globe conducted in the acceleration phase of the pandemic ¹, solid evidence accumulated elevated psychological distress, impaired wellbeing and Covid-19 induced increases in affective disorders (mainly depression, anxiety and posttraumatic stress disorders) ²

Among potential risk populations, particularly health care workers (HCW) with frontline personnel received attention in the public echoed by extended research activities. A systematic umbrella review, summarising the prevalence of anxiety and depression among HCWs during the Covid-19 pandemic, identified 10 systematic reviews based on evidence from 169,157 HCWs in 35 countries ³. Mental health disruptions were pronounced: the prevalence of anxiety among physicians (n = 5,820) ranged between 17% and 19.8% and for nurses (n = 14,938) between 22.8% and 27%. Of note, the prevalence of depression with 40.4% among physicians was significantly higher than among nurses with 28%. A closer look into pandemic induced disruptions of medical work organisations and its job contents was provided by a scoping review ⁴ evidencing that for instance the shift from patient-centred ethics in health care to public health-centred ethics - imposed by the current circumstances - triggered moral dilemmas and represented a major challenge in hospital settings.

The wear and tear of the pandemic course resulted in several waves. In the second half of the year 2021, Europe faced a fourth infection wave, thus accumulating adverse traumatic burden of face-to-face experiences and sustained threat for subjects working in medical settings. On the other hand, psychological adaptation may have taken place – a phenome often observed among emergency medicine personal ⁵. Furthermore, the focus on frontline workers may have obstructed the view on other medical settings, particularly on personnel in ambulances. To the best of our knowledge, a comprehensive analysis of the differential impact of the Covid-19 pandemic on these different settings has not been established so far.

Therefore, the purpose of the present investigation was 1) to assess systematically the traumatogenic job content in the professional life of physicians during the fourth wave of the Covid-19 pandemic course and 2) to elucidate the differential impact of the pandemic on the mental distress of physicians working in hospitals (HPs) and in private practices (PPs).

2.1. Setting

The present study was conducted as online survey distributed by the local Medical Council of a western district of Germany (Westfalen-Lippe) and operationally supported by the academic research organisation Atrial Fibrillation NETwork (AFNET) in Münster (NRW) covering a catchment area of 8.2 Mio inhabitants.

The study was approved by the Ethics Committee of this Medical Council together with the University of Muenster on September 16th 2021. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects and/or their legal guardian(s). The campaign was launched in a period of two months between November 4th and December 31st 2021.

2.2. Participants

Participants from the following disciplines were invited: general, internal and paediatric medicine, general surgery, gynaecology. Originally based on 1,316 valid cases, a total of 1.139 participants reported treatment experiences with Covid-19 patients, thus qualifying as the index group for this study (Fig. 1).

2.3. Survey measures

2.3.1. Basic data:

The survey documented the participant’s sex; working in PP or in HP; years of professional experience (coded 3 fold) and whether the participant had experience in treatment of Covid-19 patients. The participants’ vaccination status was documented and whether he/she had been already affected by Covid-19.

2.3.2.: Pandemic induced traumatogenic impact of the medical job content

We assessed the job content items through a modified Delphi process (under the lead management of A.G.) utilising the experience of professionals working in the field to identify quality indicators for evaluating Covid-19 induced job stress items first by gathering items, and in a second round shortening the list through prioritisation leading to nine items reflecting adverse working conditions during the pandemic covering the following content: confrontation with dying patients (0–3); number of Covid-19 patients treated (0–3); professional restrictions (0–1); forced to limit treatment of non-Covid − 19 patients (0–1); external constraints on medical care in conflict with the code of med. ethics (0–3); inability to maintain the dignity of patients (0–3); forced to prioritize treatment options (0–3). In order to capture the pandemic induced traumatizing impact of the medical job content, we combined these nine items to a general score ranging from 0–17. For the score variable, there were 176 missing data.

2.3.3. Future outlook of the pandemic.

To seize the impact of the Covid-19 Pandemic on future medical treatment, participants were asked whether the pandemic will have a lasting effect on medical care, whether telemedicine will receive an increasing meaning in medical treatment and whether he/she will offer telemedicine-applications him/herself? The psychological aspect of future outlook was assessed by rating the personal future on a VAS scale 1–10, ranging from catastrophic to excellent.

2.3.4. Behavioural and psychological variables.

Feeling helpless: Helplessness is defined as a profound belief that control over the situation or its outcomes is impossible. Following a suggestion by Shea and Barney ⁶, this factor was measured by a dichotomized one-item question (“How helpless did you feel during the pandemic?”). Self-rated health (SRH): was assessed by a one standardized question recommended by the WHO asking participants to rate their current health on a 5-point scale in response to the question “Do you consider your health at the moment to be very poor, fair (average), good, or excellent?” For the analyses, we used a 3-point scale (good, fair, poor SRH) by aggregating excellent and good SRH, and very poor and poor SRH ⁷. Sleeping problems were assessed based on three items adopted from the Uppsala Sleep Inventory ⁸ concerning difficulties initiating sleep (DIS), difficulties maintaining sleep (DMS) and premature awakening each scoring 0 to 1, leading to score range of 0–3. Depression and anxiety: Depressive and general anxiety symptoms were measured with the short form of the Patient Health Questionnaire (PHQ–D) which is divided into a depression (PHQ-2) and a generalized anxiety module (GAD-2) (both with two items ranging from 1 to 3). We considered a cut-off-value of ≥ 3 as indicative for probable cases of clinically significant levels of depressive and anxiety symptoms. Psycho-traumatogenic impact: was assessed employing a one-item question with a Likert-like scoring ranging from 0–5 (“Have encounters with Covid-19 patients unsettled you?”).

2.3.5. Statistical analysis

Participant’s characteristics were stratified by PP and HP settings and presented as proportions or means ± standard deviation (± SD), accordingly. Bivariate associations between groups were tested using the χ2 test for categorical variables and Wilcoxon–Mann–Whitney test for continuous variables. Comparisons with reference values were performed with the one sample t-test for continuous variables. Means (± SD) and p-values for pairwise comparison were reported as were effect sizes (Cohen’s d) (d ≥ 0.2 = small, d ≥ 0.5 = medium, d ≥ 0.8 = large effect size) ⁹. Multivariate linear regression analyses were performed to examine factors associated with helplessness among participants (N = 1,315).

We evaluated the mediation effect of sleeping problems on the association between unsettling events and helplessness within a four-step framework described by Baron and Kenny ¹⁰ Step 1 examined the relationship between unsettling events and sleep problems (path a). Step 2 examined the relationship between sleep problems and helplessness while controlling for unsettling events (path b). Step 3 examined the relationship between unsettling events and helplessness (path a). Step 4 examined the relationship between unsettling events and helplessness while controlling for sleep problems (path a’). Path a is the total effect, path a’ is the direct effect, and path b x c is the indirect effect (i.e., an exposure to unsettling events is associated with sleep problems, leading to feeling of helplessness). We then calculated the mediation analyses with nonparametric bootstrap, with 1,000 resamples to obtain the proportion mediated, the magnitude of the average total effect, and the significance of the indirect effects ¹¹. Descriptive and regression analyses were run in SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Mediation analyses were performed by using ‘Mediation’ package in R. The significance level was set at p < 0.05. We followed the STROBE criteria for presenting cross-sectional data.

The present investigation is based on a sample of 1,139 (86.6%) participants who reported personal treatment experiences with Covid-19 patients. Among these, n= 553 (84.8%) worked in PPs and n= 586 (88.3%) in HPs. A total of 720 (54.7%) women and 596 (45.3) men were included with more female physicians (53.2%; n=353) working in HPs. Professional experience in patient care was high: only about 16% of participates reported < 5 years of medical employment. The majority of 98 % of all physicians were vaccinated against SARS Cov2. Approximately 9 % of the physicians in PPs and 15% of HP physicians had already been infected with Cov2.

3.1. Work organisation and ethical values

Table 1 displays the impact of Covid-19 cases on the professional life of physicians, stratified for physicians working either in PPs or HPs. A high proportion of physicians in PPs (60.8%) had been confronted with dying patients. Still, confrontation with death was substantially more intense among physicians in HPs.

Job content and work organisation: Approximately 80% of all physicians experienced professional restrictions through the pandemic and about 87 % reported limitations in the treatment of non-Covid-19 patients irrespective of working in PPs or HPs. Regulatory hygiene measures to ensure a personal protective environment were implemented in the majority of workplaces. More physicians in PPs than in HPs faced economic disadvantages by the pandemic (49% vs. 42,4%, p<0.0001) while a fourfold higher number of staff members in HPs compared to PPs had resigned because of the pandemic (23.8% vs. 7.4%, p<0.0001).

Ethical values: Covid-19 created profound conflicts between professional and ethical values for a significant proportion of participants: more physicians in PPs than HPs reported external constraints on their medical care being in conflict with the code of medical ethics (39.1% vs. 34.4%, p<0.002). However, significantly more HP physicians were unable to maintain the dignity of their patients during the pandemic (48% vs. 27%, p< 0.0001).

Adverse structural impact of the medical job content: The comprehensive sum score of all adverse structural impact of Covid-19 on the work environment revealed an overall higher mean score level (mean, ±SD) for physicians in HPs compared to PPs, with no sex differences: 7.1 (3.0) in PPs and 8.4 (3.7) in HPs (p<0.0001).)

Future outlook: The majority of all participating physicians (80%) believed that the Covid-19 Pandemic will have a lasting effect on medical care and about 43% will actively offer telemedicine-applications.

3.2. Mental health of physicians during the pandemic

3.2.1. Prevalence of mental health disruptions among physicians

Only among an evanescent minority of participates of about 16%, encounters with Covid-19 patients had not unsettled participants disclosing the traumatizing impact of Covid-19 on the physicians’ mental state. As further displayed in Table 2, the prevalence of sleeping disturbances with 52% was high and disclosed no differences between PPs and HPs. Mean values of future expectancy ranging from a possible catastrophic to an excellent outlook of the physician’s personal future (VAS scale 1-10) revealed a minor right sided (favourable) distribution with a mean of 6.79 (±1.88) for PPs and 6.84 (±1.68) for HPs (n.s.). A total of 179 (13.6%) physicians suffered from clinically significant levels of depressive symptoms (Table 2) - substantially more among physicians in HPs (27.2%) than in PPs (18.7%). Findings for anxiety were similar: 317 (24.2%) in the total sample and 21.9% in PPs and 26.3% in HPs. Differences for female physicians in both settings did not reach significance.

Applying mean PHQ-2 and GAD-2 data from reference groups and population based studies before and in the early stages of the Covid-19 pandemic, Table 3 reveals significant higher values compared to earlier studies among physicians (A and B) but lower values compared to a population based study in the early phase of the pandemic (C). However, mean values compared to a pre-pandemic population based screening study (D) were substantially higher.

3.2.1. Covariates of helplessness

A total of n=768 (58.4%) of participants reported feelings of helplessness with significantly more physicians in HPs (420, 63.3%) than in PPs (348, 53.4%). Covariates significantly associated with feeling helpless are displayed in Figure 2: male sex (OR=0.58, 95% CI=0.44-0.76) was associated with lower odds of helplessness, while having <5 years of experience (2.39, 1.57-3.65), sleeping problems (2.50, 1.94-3.30), traumatogenic score (per 5-unit increase) (1.60, 1.30-2.00) and being encountered to an unsettling event (3.44, 2.62-4.51) were associated with higher odds of helplessness.

3.2.2. Mediation Analysis

In a sensitivity analysis as depicted in Figure 3, the association between exposure to unsettling events and helplessness was significantly mediated by sleep disturbances (Indirect path: ß= 0.29, S E= 0.03, p<0.0001).

The Covid-19 pandemic has burdened an unprecedented psychological stress on members of the medical workforce - in the initial phase especially on frontline medical staff in close contact with infected patients. With the passage of time, professional involvement with Covid-19 patients generalized to a much wider array of medical disciplines without being sufficiently addressed in research attempts. Focussing on physicians with treatment experiences of Covid-19 patients either working in PPs or in HPs, we were able to show that the pandemic is a sustained crisis situation with major structural impact and psychological challenges for physicians in both settings which remained still being present during the culmination point of the fourth Covid-19 pandemic in late 2021.

4.1. Workplace aspects

Of note, physicians were exposed to a multitude of challenging or even traumatogenic aspects of their work environment regardless of working in PPs or HPs. Often confronted with dying Covid-19 patients; with professional restrictions including limitations in the treatment of non-Covid-19 patients; with facing pandemic induced economic disadvantages and being subjected to limiting hygiene measures in their practice/institutions. Most importantly, however, Covid-19 had created profound conflicts between professional and ethical values for a significant proportion of all participating physicians. Although more physicians in PPs than HPs reported external constraints on their medical care being in conflict with the code of medical ethics, substantially significantly more HP physicians were unable to maintain the dignity of their patients during the pandemic.

Taken together, these adverse structural features of Covid-19 on the work environment constitute a universal hazard for the medical work force irrespective of the particular setting ¹². The high impact of disturbing features on physicians has not been shown before and not been addressed particularly comparing physicians working in PP and HP settings. It becomes evident that the level of distressing effects has reached a substantial impact on the professional life of all physicians involved in Covid-19 treatment (although still more intense for physicians working in HPs).

4.2. Mental health of physicians treating Covid-19 patients

Depression and anxiety: Umbrella review data derived from early stages of the pandemic ³ point to an excess prevalence of approximately 40% for depression and 17% for anxiety among physicians. A more recent meta-analysis among doctors during the first twelve months of the Covid-19 pandemic, calculated from 26 studies and 31,447 participants, found a significantly lower and more realistic pooled prevalence of depression of 20.5% (95% CI 16.0–25.3%) and a higher overall pooled prevalence of anxiety in 25.8% (95% CI 20.4–31.5%) of physicians, calculated from 30 studies including 33,281 participants ¹³. In our study with data assessed during the culminating point of the fourth wave of the pandemic, 23.0% of all physicians under investigation suffered from clinical meaningful depressive symptoms and were in the upper range of prevalence estimates from the later meta-analysis. However, stratification between physicians in PPs and HPs disclosed a marked difference: 18.7 % in PPs but a much higher total of 27.2% in HPs experienced depression. A comparable picture appeared for anxiety: 24.16% of all participants stratified for 21.9% in PPs and 26.3% in HPs reported significant anxiety.

In the early phases of the pandemic, a steep incline in depression and anxiety had been observed compared to the pre-pandemic time. Repeated cross sectional findings from representative surveys in the US (e.g. ¹⁴ ¹⁵ and elsewhere ¹⁶, or longitudinal data from the UK ¹⁷ point to an approximately 3-fold increase in the number of people with meaningful severity of depressed symptoms (see ¹ for more details) during the initial phase of the pandemic. Comparing mean values of depression and anxiety with pre- Covid-19 data from the general population in Germany (N=6,509) (with the identical screening instrument) revealed that the means had doubled ¹⁸.

The question arises whether over the passage of time, a downward trend from these early peaks may have occurred particularly among health specialists. After experiencing an initial shockwave, so the idea, people may have adapted to the stressful global situation ¹⁹. The German web-based VOICE survey including data from 1.006 HPs performed during the early phase of the pandemic allows an adequate comparison ²⁰: at that time point, a significantly lower prevalence of 17.4% for clinically significant levels of depressive and 17.8% for anxiety symptoms (assessed with the identical screening instrument as in our study) were documented (see also ²¹). Taken together, our data do not support the assumption that over the passage of time, a downward trend from the early peaks has occurred. On the contrary: our data indicate a further increase in affective suffering among physicians, particularly in HPs.

Helplessness: Helplessness is a cognitive state often in close combination with desperate affective sentiments in the face of losing control over a given situation or its outcomes. The exponent is increasingly convinced that there is nothing that can be done to improve the hopeless situation. It is of particular concern that more than half of all physicians (58.4%) confirmed feeling helplessness – a psychological condition which may (at least gradually) hamper the exponent’s ability to function properly and may in part inhibit engagement in new, potentially effective, behaviours – qualifications, which is intuitively expected being a core feature of the medical profession. Thus, the high level of helplessness among physicians is likely to reflect the enormous threat the pandemic unfolds on professionals as well. Our study disclosed features which contribute to helplessness among physicians. It confirms that being encountered to an unsettling event (3.4-fold increase in odds of feeling helpless) had the strongest impact. Physicians in the lowest stratum of medical experience, female sex and sustained sleeping problems were less likely to resist to the toxic impact of the sustained traumatising work environment. Sleeping problems in particular not only reflect a cumulative number of worries and experience of adversities ²² but may also weaken the capacity to withstand stressful hardship. Based on these findings, it is not surprising that significantly more physicians in HPs (63.3%) than in PPs (53.4%) experienced these feelings.

4.3. Limitations

One strength of the present investigation is the focus on physicians in HPs and in PPs with an in-depth assessment of traumatizing medical job contents which were related to mental health impairments of the physicians involved. The major limitation is the low response rate increasing a sampling bias due to respondents’ self-selection to participate. However, following a decision framework for assessing nonresponse bias ²³, we found other investigations with involvement of physicians from the early phase of the pandemic undertaken with identical methods and comparable features (e.g. participation rates, sex distribution, amount of medical experience of participating physicians). These study features also helped to overcome the limitations of a cross sectional design by allowing estimates of repeated cross sectional findings.

During the culminating point of the fourth wave of the pandemic, a total of 23 % of all physicians under investigation suffered from clinical meaningful depressive symptoms and 24% from anxiety. Comparing these data with cross sectional studies with physicians during the early phase of the pandemic, the findings suggest a further raise in affective burden and do not support a healing adaptation to the adverse environment. The results provide new insights in Covid-19 consequences by. evidencing that for physicians working in HP but also in PP settings most likely to play a crucial role in exacerbating mental health impairments and declines in quality of life. For a substantial proportion of physicians under investigation the pandemic cause feelings of helplessness which may compromise in part the ability of the exponents to function properly in the sustained traumatizing content.

Funding:

The study was in part funded by Josef Freitag Stiftung, Paderborn.

Data Availability:

Data sharing for collaborative work is highly welcomed. Individual participant data and a data dictionary defining each field in the set will be made available to others after approval of a proposal with a signed data access agreement sent to the Academic research organisation Atrial Fibrillation NETwork (AFNET), Münster, Germany. [email protected]

Acknowledgements:

The researchers are grateful for the contribution of 1,316 highly active physicians who agreed to participate in this survey. We also thank the AFNET organisation for undertaking the web based survey, to contribute with the data management and to interact with the local Medical Council for which the study also opened new avenues.

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Table 1: Impact of COVID-19 cases on treatment and professional life of physicians, stratified for physicians in private practice (PPs) (n= 652) and hospital (HPs) settings (n= 664) in N (%) (Total, N=1316)

	Total	PPs (49.5%, n=652)	HPs (50.5%, n=664)	p	*p (male)*	*p (female)*
Experience with COVID-19 patient treatment? (yes)	1139 (86.6)	553 (84.8)	586 (88.3)	0.07	0.89	0.02
How many of your COVID-19 patients died? No one 1-9 10-19 ≥ 20	414 (36.3) 520 (45.6) 117 (10.3) 90 (7.9)	217 (39.2) 278 (50.2) 43 (7.8) 16 (2.9)	197 (33.6) 242 (41.2) 74 (12.6) 74 (12.6)	<.0001	<.0001	<.0001
Cardiac co-morbidity of COVID-19 patients (yes)	617 (54.1)	271 (48.9)	346 (59.1)	0.001	0.05	0.004
Did the pandemic result in professional restrictions? (yes)	1059 (80.5)	521(79.9)	538 (81.0)	0.61	0.65	0.30
Did Covid-19 limit treatment of non-Covid-19 patients? No restrictions Somewhat restricted Severely restricted	168 (12.8) 733 (55.7) 415 (31.5)	87 (13.3) 378 (58.0) 187 (28.7))	81 (12.2) 355 (53.5) 228 (34.3)	0.09	0.32	0.19
Did you face economic disadvantages by the COVID-19 Pandemic? No Yes, moderate Yes, severe	780 (59.4) 409 (31.2) 124 (9.4)	331 (51.0) 257 (39.6) 61 (9.4)	449 (67.6) 152 (22.9) 63 (9.5)	<.0001	0.0002	<.0001
Were yourself affected by COVID-19? (yes)	156 (11.9)	59 (9.1)	97 (14.6)	0.002	0.06	0.01
Staff members resigned because of COVID-19? (yes)	206 (15.7)	48 (7.4)	158 (23.8)	<.0001	<.0001	<.0001
Do you consider regulatory restrictions for your institution/ practice as meaningful? No Yes, in part Yes, completely	77 (5.9)583 (44.3) 656 (49.9)	303 (46.7) 301 (46.2) 48 (7.4)	353 (53.2) 282 (42.5) 29 (4.4)	0.01	0.72	0.001
External constraints on your medical care which are in conflict with the code of medical ethics? No constraints One time Several times On a regular basis	826 (62.8) 107 (8.1) 306 (23.3) 76 (5.8)	395 (60.7) 44 (6.8) 161 (24.7) 51 (7.8)	435 (64.6) 63 (9.5) 145 (21.8) 25 (3.8)	0.002	0.01	0.02
Could you maintain the dignity of your patients during the pandemic? (yes)	821 (62.4)	476 (73.0)	345 (52.0)	<.0001	<.0001	<.0001
Are you vaccinated against SARS Cov2? (yes)	1286 (97.7)	637 (97.7)	649 (97.7)	0.96	0.26	0.22
Will COVID19 Pandemic have a lasting effect on medical care? (yes)	1065 (80.9)	535 (82.1)	530 (79.8)	0.30	0.64	0.36
Will telemedicine receive an increasing meaning in medical treatment? (yes)	982 (74.6)	442(67.8)	540 (81.3)	<.0001	<.0001	<.0001
Will you offer telemedicine-applications yourself? (yes)	573 (43.5)	286 (43.9)	287 (43.2)	0.81	0.003	0.002
Priorities in treatment decisions (yes)	342 (26.0)	76 (11.7)	266 (40.1)	<.0001	<.0001	<.0001

*p-value for differences between PPs and HPs; p-values obtained from chi-square-test for categorical variables and Wilcoxon-Mann-Whitney test for continuous variables.

Table 2: Impact of COVID-19 cases on mental distress in physicians, stratified for physicians in private practice (PPs) (n = 652) and hospital (HPs) settings (n = 664) in N (%).

	Total	PPs (49.5%, n=652)	HPs (50.5%, n=664)	p	*P (male)*	*P (female)*
Have encounters with COVID-19 Patients unsettled yourself? this was not the case somewhat moderate fairly very much	210 (16.0) 352 (26.8) 307 (23.3) 299 (22.7) 148 (11.3)	107 (16.4) 203 (31.1) 142 (21.8) 133 (20.4) 67 (10.3)	103 (15.5) 149 (22.4) 165 (24.9) 166 (25.0) 81 (12.2)	0.005	0.02	0.14
Have encounters with COVID-19 Patients unsettled yourself? A little / No Moderate/Fairly/Very	562 (57.3) 754 (42.7)	310 (47.6) 342 (52.5)	252 (38.0) 412 (62.1)	0.0004	0.01	0.01
Feeling helpless	768 (58.4)	348 (53.4)	420 (63.3)	0.0002	0.0001	0.10
Self-rated health poor moderate good very good excellent	31 (2.4) 201 (15.3) 570 (43.3) 398 (30.2) 116 (8.8)	17 (2.6) 106 (16.3) 289 (44.3) 188 (28.8) 52 (7.9)	14 (2.1) 95 (14.3) 281 (42.3) 210 (31.6) 64 (9.6)	0.50	0.45	0.97
Self-rated health Poor Good	232 (17.6) 1084 (82.4)	123 (18.9) 529 (81.1)	109 (16.4) 555 (83.6)	0.24	0.21	0.65
How would you rate your future? 1 catastrophal 10 excellent (Mean, ±SD)	6.82 (±1.79)	6.79 (±1.88)	6.84 (±1.68)	0.004	0.70	0.61
Sleep Disturbances No Difficulties initiating sleep Difficulties maintaining sleep Waking up too early	635 (48.3) 130 (9.9) 362 (27.5) 189 (14.4)	312 (47.9) 48 (7.4) 184 (28.2) 108 (16.6)	323 (48.6) 82 (12.4) 178 (26.8) 81 (12.2)	0.005	0.01	0.04
Sleep Disturbances No Yes	635 (48.2) 681 (51.8)	340 (52.2) 312 (47.9)	341 (51.4) 323 (48.6)	0.77	0.08	0.06
Depression (Yes)	302 (23.0)	122 (18.7)	180 (27.2)	0.0002	0.0006	0.08
Anxiety (Yes)	317 (24.16)	143 (21.9)	174 (26.3)	0.07	0.004	0.99
How difficult have problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very Difficult Extremely Difficult	581 (44.2) 543 (41.3) 139 (10.6) 51 (3.9)	290 (44.5) 284 (43.6) 57 (8.7) 21 (3.2)	291 (44.0) 259 (39.1) 82 (12.4) 30 (4.5)	0.07	0.18	0.05

*p-value for differences between PPs and HPs; p-values obtained from chi-square-test for categorical variables and Wilcoxon-Mann-Whitney test for continuous variables.

Table 3: Severity of depressive symptoms (PHQ-2) and generalized anxiety symptoms (GAD-2) for physicians in private practice and hospital settings, in comparison with general population and reference groups before and during the COVID-19 pandemic.

Comparison with physicians during the COVID-19 pandemic in Germany (N=1061)^a

Comparison with physicians during the early phase of pandemic in Germany (N=492)^b

Comparison with general population during early phase of pandemic in Germany (N=6509)^c

Comparison with general population in Germany (N=5010)^d

Study population

Mean (±SD)

Mean (±SD)

P; effect size

Mean (±SD)

P; effect size

Mean (±SD)

P; effect size

Mean (±SD)

P; effect size

Depressive symptoms (PHQ-2)

Total

1.76 (±1.50)

1313

1.48 (±1.35)

<.0001; 0.20

0.60 (±1.13)

<.0001; 0.82

2.11 (±1.70)

<.0001; 0.56

0.94 (±1.20)

<.0001; 0.65

Private physicians

1.61 (±1.42)

652

0.02; 0.10

<.0001; 0.78

<.0001; 0.30

<0.0001; 0.55

Hospital

1.91 (±1.56)

661

<0.0001; 0.30

<.0001; 0.94

0.01; 0.12

<0.0001; 0.78

Generalized anxiety symptoms (GAD-2)

Total

1.66 (±1.52)

1314

1.45 (±1.41)

<.0001; 0.14

2.03 (±1.76)

<.0001; 0.22

0.82 (±1.10)

<.0001; 0.70

Private physicians

1.60 (±1.45)

652

0.01; 0.01

<0.0001; 0.25

<0.0001; 0.68

Hospital

1.72 (±1.58)

662

<0.0001; 0.18

<0.0001; 0.77

^aMarowa et al. (2021)

^bSkoda et al. (2020)

^cPetzold et al. (2020)

^dLöwe et al. (2010)

*Mean (±SD) and pairwise comparison, P-values; effect size Cohen’s d; d ≥ 0.2 = small, d ≥ 0.5 = medium and d ≥ 0.8 = large effect size

No competing interests reported.

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Covid-19 pandemic induced traumatizing medical job contents and mental health distortions of physicians working in private practices and in hospitals

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1. Introduction

2. Methods And Participants

2.1. Setting

2.2. Participants

2.3. Survey measures

2.3.1. Basic data:

2.3.3. Future outlook of the pandemic.

2.3.4. Behavioural and psychological variables.

2.3.5. Statistical analysis

3. Results

4. Discussion

5. Conclusions

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