The impact of COVID‐19 on the resident well‐being in a single US healthcare system

The coronavirus disease 2019 (COVID-19) pandemic has impacted the entire society, but arguably, the healthcare system the most. Challenges to providers include rapidly evolving treatment paradigms, the risk of personal infection or spread to loved ones, shortages of personal protective equipment (PPE), extreme workloads, and added childcare responsibilities with school closures.. Resident physicians form the bulk of the frontline physician healthcare workforce. They are the most junior and most vulnerable group of physicians. Therefore, policies and procedures exist to provide a safe and abuse-free culture for residents. In an article titled “Legacy of Abuse in a Sacred Profession: Another Call for Change,” Janet Rose Osuch discusses the high workload and the prevalent verbal and psychological abuse of residents globally. This abuse is also described in several opinion pieces like the “COVID-19 Crisis Exposes Resident Abuse.” A pandemic can have stressors compounded. Direct exposure to sick patients has also been associated with higher reported stress and burnout levels. A physician's well-being directly impacts their competence, professionalism, career satisfaction, and the quality of care delivered to their patients. We sought to understand better the pandemic's impact on the well-being of residents. We hypothesized that wellbeing would likely worsen during the pandemic and may be affected by PPE availability, training on its use, and direct exposure to COVID19 patients. 2 | RESEARCH DESIGN AND METHODS


| INTRODUCTION
The coronavirus disease 2019 (COVID-19) pandemic has impacted the entire society, but arguably, the healthcare system the most. 1 Challenges to providers include rapidly evolving treatment paradigms, the risk of personal infection or spread to loved ones, shortages of personal protective equipment (PPE), extreme workloads, and added childcare responsibilities with school closures.. 1 Resident physicians form the bulk of the frontline physician healthcare workforce. They are the most junior and most vulnerable group of physicians. 2 Therefore, policies and procedures exist to provide a safe and abuse-free culture for residents. 3 In an article titled "Legacy of Abuse in a Sacred Profession: Another Call for Change," Janet Rose Osuch discusses the high workload and the prevalent verbal and psychological abuse of residents globally. 4 This abuse is also described in several opinion pieces like the "COVID-19 Crisis Exposes Resident Abuse." 5 A pandemic can have stressors compounded. 6 Direct exposure to sick patients has also been associated with higher reported stress and burnout levels. 7 A physician's well-being directly impacts their competence, professionalism, career satisfaction, and the quality of care delivered to their patients. 8,9 We sought to understand better the pandemic's impact on the well-being of residents. We hypothesized that wellbeing would likely worsen during the pandemic and may be affected by PPE availability, training on its use, and direct exposure to COVID-19 patients.

| Study design
A cross-sectional survey of US residents was performed between July and August 2020 at a six-hospital south-eastern Pennsylvania health system.

| Inclusion criteria
Participants surveyed included 257 residents from 20 different residencies across the system's six hospitals. Convenience sampling was used, and the survey was conducted using email. A statement describing the purpose of the survey was included in the email. All results were de-identified before analysis.

| Exclusion criteria
Residency programs with less than five respondents were excluded.

| Study parameters
The Mayo Well-Being Index (WBI) is a 7-point scoring tool that correlates well with the mental quality of life (QOL), fatigue, and suicidal ideation. 10 The seven questions are dichotomously scored as "yes" or "no," describing a specific facet of low well-being, with higher scores indicating poor well-being. A score of ≥5 is considered a high score indicating the low mental QOL, high fatigue, or recent suicidal ideation. 11 WBI is validated for the residents working in the United States of America. 10 Additional questions included demographics, training level, exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients, training for doffing/donning of PPE, adequate PPE availability, and involvement in care for patients with COVID-19 patients. After completion of the survey, participants were offered self-help resources, and the resources accessed were analyzed.

| Statistical analyses
A descriptive and summary analysis was performed. The analysis compared mean WBI between residents surveyed 1 year before the COVID-19 pandemic and residents working during the first wave of COVID-19. The means were compared with the national average.
Answers to PPE, training on that equipment, exposure to patients with COVID-19, and accessed resources were reported as percentages.

| RESULTS
Surveys were sent to 257 participants, out of which 140 recipients (54.4%) signed up to participate in the WBI survey. The total number of completed responses was 35% (90/257), of whom 55% (45/90) were female. The mean 7-point WBI score for all participants was 2.42 (standard deviation [SD] 1.83), an 18.2% raw difference, with lower scores indicating better well-being than scores performed in the same system during the same months in 2019. Male residents had a higher mean WBI score of 2.59 (SD 1.96) than females (Table 1).
Third-year residents in our survey had the highest mean score of 2.95 (SD 1.77). The percentage of residents with a mean well-being index score > 5 was 15.8% ( Figure 1). However, 20% of postgraduate year-3 residents (n = 18) had scores >5 (20%). Ninety-two percent of surveyed participants reported adequate training in donning and doffing PPE, and 81% reported PPE availability. The most commonly accessed resources following the survey completion were on career development (n = 13) and stress and anxiety (n = 8) (Figure 2) ( Table S1).

| DISCUSSION
Contrary to our hypothesis, our survey results showed improved overall trainees' mean WBI scores compared to the prepandemic survey and lower rates than the national US average. Male residents had a higher score as compared to the national comparators and last year's scores. Female respondents' average WBI was lower than national comparators. Last year's third-year residents had an 8% higher score than the prepandemic survey and 3% higher than the national average ( Our study also found that 16% of the participants had a mean well-being index score above 5, which correlates to high stress levels. However, this was comparatively less than the previous local survey, mean national average in the 2020 (19.4%), staff physicians (35.1%), nurses (57.1%), students (22.0%), and other healthcare employees (46.3%). 11 Stress levels in PGY-3 residents were 8% higher than the prepandemic survey and 3% higher than the national average (Table 2). Career development was the most accessed module ( Figure 2). We speculate that a higher level of critical decision-making, searching for work, and fellowship placement may have contributed to this subset's higher scores.
Most of our participants (73%) had direct exposure to COVID-19 patients. As the survey was anonymous, we could not extract data based on COVID-19 responses and tabulate them against the mean WBI scores.
Strengths of this work include using the same well-being index as a validated tool for self-assessment screening purposes. The previous surveys provided a fair comparison to the residents' pre-COVID-19 mental well-being in our health system. However, our study has some limitations. Our sample was female predominant (55%). In a typical 3-year residency, 33% of the residents graduate each year, so our comparison populations differ. This study was carried out just after the first peak of the COVID-19, so the real impact of the pandemic on well-being may be unmasked after a prolonged period of pandemics with repeated weaves of COVID-19. Interpretation of subgroups in our study (men, PGY-3s) must be made with caution, as a few results can skew means in small sample sizes. Although our response rates (35%) were higher than the nationally reported rates for the WBI (22.5%), there could be very significant low well-being rates among those who did not participate that were missed by our sampling.

| CONCLUSION
Our survey showed lower than expected levels of poor well-being in the resident physicians during the pandemic's first wave.

CONFLICT OF INTEREST
None of the authors has any conflict of interest to disclose.

F I G U R E 2 Number of accessed resources
Haseeb Chaudhary (lead author) had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis. The lead author Haseeb Chaudhary affirms that this manuscript is an honest, accurate, and transparent account of the study being reported, that no important aspects of the study have been omitted, and that any discrepancies from the study as planned have been explained.

CONSENT
Informed consent was not required, as this is an anonymous survey conducted after approval from the institutional review board.

ROLE OF STUDY SPONSOR OR FUNDER
The study sponsor/funder was not involved in the study's design, the collection, analysis, and interpretation of data writing the report and did not impose any restrictions regarding the report's publication.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.