The COVID-19 pandemic in 2020 challenged the global healthcare landscape and greatly impacted the physician workforce.(1) New York City became an early epicenter in spring 2020, as a staggering rise in cases led to rapid restructuring of the regional healthcare delivery system and new challenges for physicians.(2,3)
Physicians on the frontlines faced a multitude of stressors spanning the professional and personal spectrum, including shifting clinical responsibilities, increased workload, lack of specific treatment for COVID-19, fluctuating personal protective equipment requirements and availability, and fear of infection of oneself and family.(4)
Since the onset of the pandemic, reports show increased psychological burden among healthcare workers, with many reporting symptoms of depression, anxiety, and distress.(4-9)
Emergency medicine (EM) physicians are particularly vulnerable to psychological distress given their position on the frontlines of the COVID-19 pandemic. At baseline, EM physicians generally report higher rates of burnout and stress compared to physicians in other specialties, with factors associated with burnout including difficult work conditions, work-family conflict, lack of support, and poor resources.(10-12) Recent reports indicate that the pandemic has amplified these stressors and that EM physicians experienced increased rates of burnout, stress, and anxiety due to factors related to COVID-19.(13,14)
Healthcare systems implemented interventions aimed to support physician wellness and reduce burnout through the pandemic, with interventions generally focused on individual, team, and organizational strategies.(15-19) Hospitals and health systems strengthened existing wellness programs and offered new resources, including but not limited to designated relaxation areas, peer support, psychological counseling and psychiatric support, food provisions, and regular updates from leadership.(15,17,19)
A comprehensive wellness platform that encompasses efforts on all levels is critical to support physician wellness during and beyond the COVID-19 pandemic.(17,19) Despite these efforts, many EM physicians report inadequate wellness resources.(20)
There is a paucity of data on the usage and perceived effectiveness of wellness resources, particularly in regard to how they align with the specific needs of EM physicians. This study addresses this gap and informs future wellness programs by surveying emergency medicine physicians at an academic medical center in New York City about their stressors, needs, and usage and perception of the wellness resources provided during the pandemic.
Research Methods
Data were collected using a cross-sectional survey of EM physicians at a single academic medical center in New York City. Participants were eligible if they were adult or pediatric EM attending physicians or fellows (n = 96); residents were ineligible for this study.
Participants were invited using a standardized recruitment email containing an anonymous link to a web-based survey. Only participants who completed the survey in full were included in the analysis. All participants provided electronic informed consent at the start of the survey. This study was submitted to the IRB at Weill Cornell Medicine and considered exempt.
The survey consisted of four sections: (1) demographics, (2) stressors and needs, (3) usage, and (4) perceived effectiveness of resources. The survey assessed the utilization of wellness resources on three levels: (1) institutional, (2) departmental, and (3) personal. Descriptions of the institutional and departmental resources evaluated can be found in Table 1a and Table 1b.
We also aimed to specifically examine the perceived effectiveness of department-offered wellness resources. Survey response options included the following: multiple choice, rank order, binary (“yes”/“no”), 5-point Likert scale ranging from “strongly disagree” (1) to “strongly agree” (5), and Net Promoter Score (NPS) scale. We used NPS, a popular customer experience metric, to assess participants’ satisfaction with specific departmental wellness resources.(21) Participants were given the opportunity to provide any additional feedback via free response questions.
Statistical analysis was performed using descriptive statistics, with calculations of proportions and medians as appropriate. No significance testing was conducted due to small sample size. Qualitative data were analyzed using thematic analysis.
Research Results
Of the 96 individuals to whom the survey was sent, 64 participants completed the survey (67%). Thirty-one (48%) respondents were male, 31 (48%) were female, and two (3%) were non-binary or other. Fifty (78%) respondents worked in the adult emergency department (ED), 11 (17%) in the pediatric ED, and three (5%) in both. Demographic information is summarized in Table 2.
Stressors. Stressors in descending order of importance were reported as (mean Likert score ± standard deviation): risk of infection to others (4.1 ± 1.1), risk of infection to oneself (4.0 ± 1.1), the novel nature of COVID-19 (3.9 ± 1.2), resource allocation and patient-care decisions (3.7 ± 1.2), changing personal responsibilities (3.1 ± 1.4), and changing professional responsibilities (3.1 ± 1.3). Summary statistics can be found in Table 3.
Needs. Free response revealed the following needs: greater emphasis for consistent messaging and protocol regarding PPE, clean and safe space for breaks and meals, continued support for daily living needs, continued wellness resources provided through the department, and additional scheduling options for the departmental peer support group.
Resource Utilization and Perceived Effectiveness. The most-used personal resources were time with family and friends (72%), exercise (70%), and sleep (56%). A detailed breakdown of additional personal resource utilization is shown in Figure 1a. The most-utilized institutional resources were food delivery (58%), parking (33%), and child care (23%). A detailed breakdown of additional institutional resource utilization is shown in Figure 1b.
Figure 1a. Percentage of Survey Respondents Who Utilized Each Personal Wellness Resource
Figure 1b. Percentage of Survey Respondents Who Utilized Each Institutional Wellness Resource
The most-utilized departmental resources were the weekly arts email (73%), peer support group (58%), and informal group chats (58%). The most highly rated departmental resources were the peer support group (NPS + 41), WhatsApp fitness group (NPS + 29), and informal group chats (NPS + 22). A detailed breakdown of frequency and ratings of departmental resources is illustrated in Figure 2. For those who did not attend the departmental peer support group, 53% cited scheduling conflict.
Figure 2. Number of Survey Respondents Who Utilized Each Departmental Wellness Resource and NPS for Each Departmental Resource
Participants were also asked to indicate interest in personal check-ins with members of the department as a potential future resource. Forty-eight percent of respondents reported they would be interested in regular personal check-ins within the department. Of those who were interested, 74% were interested in meeting with a member of the EM wellness committee; 55% were interested in meeting with EM departmental leadership. The EM wellness committee consisted of two attending EM physicians who spearheaded wellness initiatives within the department. Of those who were interested, 39% were interested in meeting monthly, 26% were interested in meeting quarterly, while 23% were interested in meeting bi-weekly.
Discussion
Our study identified major stressors affecting physicians during the pandemic, including the risk of infection to oneself and others, the novel nature of COVID-19, and changing clinical responsibilities. Survey respondents expressed specific needs, including clear communication from leadership, a safe break space, and continued resources provided by both the institution and the department. When crafting a physician wellness strategy and determining which resources to invest in, institutions must keep these specific needs in mind.
Our study corroborates the findings of previous studies regarding the specific stressors and needs of physicians during the pandemic.(3) Discussions have focused on several key sources of stress, including the risk of infection with COVID-19, PPE availability, lacking support for daily living needs, and unclear communication from leadership (e.g., regarding PPE protocols, case numbers), all of which are similar to our findings.(13,14)
Experts have largely suggested a broad approach to creating wellness support platforms aimed at targeting the areas of need,(4) for which our findings provide evidence. The majority of related literature focuses primarily on stressors and needs to make strategic recommendations, but little has previously been described regarding specific resources.
This study characterized the most used and effective institutional, departmental, and personal resources at an academic medical center, with findings providing support for multilevel resources as part of a comprehensive wellness strategy.
On an institutional level, the resources that were most highly utilized were those that facilitated respondents’ ability to focus on their role as frontline providers. These resources included food delivery, parking, child care, and transportation. Specific spaces were provided for employees to recharge and relax. It is vital that these break rooms allow for appropriate social distancing to alleviate the anxiety surrounding the risk of transmission. Institutions that are able to achieve economies of scale should consider dedicating funds to these job-enabling resources.
On a departmental level, the resources that were both highly utilized and highly rated were those that incorporated aspects of peer support. These resources included a peer support group and informal group chats. Additionally, respondents expressed interest in one-on-one peer support check-ins from members of the faculty wellness committee.
While institutions may be able to provide logistical resources for physicians across specialties, EM physicians may be more readily able to support their colleagues. As such, peer support may be better found within this smaller community in the ED than within the larger hospital environment, which is a topic for further exploration.
Our results further show that physicians rely on many of their own personal resources to protect their personal well-being. The most popular resources were quality time with loved ones, exercise, and sleep. These resources must not be discounted, and it is important that institutions and departments respect and aim to enable these personal resources. All other initiatives must prioritize this balance, as well.
Respecting time may increase utilization of provided resources. For example, many of the physicians who otherwise were interested in attending the peer support group were not able to due to personal time constraints, as the sessions were scheduled during the evening.
While this study adds to the conversation about how to best support EM physician well-being, especially during times of increased stress, it comes with several limitations. First, this study is limited to a small population of attending physicians and fellows at a single academic center in New York City. Specific needs and the utility of interventions may be different in other geographic regions and among residents.
In the analysis itself, we also recognize that NPS is a measure of personal satisfaction with departmental resources, but does not directly measure the efficacy of these resources. Additionally, only utilization was measured for institutional and personal resources. An interesting avenue for future research would be to compare the perceived and actual efficacy of resources across the three levels: institutional, departmental, and personal. Future studies could also provide additional qualitative context surrounding wellness resources, which was limited by our survey approach.
The findings of this study further affirm the need for wellness policies and programs to support EM physicians and suggest that these interventions should align with the needs reported by physicians themselves to be most effective and useful. Resources implemented through institutional, departmental, and personal strategies all have utility within a comprehensive wellness plan.
Conclusion
Given the multitude of resources perceived as important, our study suggests prioritizing resources available at each level in a multipronged wellness strategy. Taking this into account, we hope these findings help inform future initiatives to support physician well-being during public health crises.
These findings are worthy of further study and may be generalizable and important to physician well-being, both day-to-day and in crisis circumstances.
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