Carolinas Research Day 2021

The Impact Of COVID-19 On The Work-Life Balance And Mental Health Of Resident Physicians In Southeastern US Mya Lor, OMS-IV 1 ; Cecilia Paez, OMS-IV 1 ; Kelly Ward, OMS-IV 1 ; Lindsay Tjiattas-Saleski, DO, MBA, FACOEP 1 ; Ning Cheng, MS, PhD 2 Edward Via College of Osteopathic Medicine - Carolinas Campus, Spartanburg, South Carolina 1 Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, Alabama 2 Abstract Results

#CLIN-7

Discussion

Medical residents experience extreme levels of stress due to high job demands, intense patient care, and prolonged working hours. In addition to experiencing work-related stressors, it can be difficult, yet imperative, to maintain a work-life balance. The objective of this cross-sectional study was to investigate whether medical residents are more likely to experience dissatisfaction in work-life balance and have increased mental health symptoms due to the COVID pandemic. A survey containing a Depression Anxiety Stress Scale (DASS-21) and questions pertaining to factors that may affect work-life balance (WLB) and mental health (MH) were emailed to residents. Factors considered were hours worked per week, physical health, family interactions, and financial responsibilities. Resident physicians in Family Medicine, Internal Medicine and Emergency Medicine programs in the Southeastern states of Alabama (AL), Florida (FL), Georgia (GA), North Carolina (NC), South Carolina (SC) and Virginia (VA) were surveyed. A total of 167 participants completed the online survey. ANOVA, chi-square, and t-tests were utilized to analyze the data. Results showed there were no significant correlations to the specialty of residency program, state, gender, PGY status, marital status, and age of dependent(s) with the results of the DASS-21 Score. However, data showed that residents who slept less hours per night scored higher on the DASS-21. It also revealed that there was a significant association between number of hours worked per week, number of hours slept per night, and hours of exercise per week on residents’ WLB. This study identified different factors that influence the MH and WLB of medical residents such as sleeping less hours per night, working more hours per week, and exercising less per week. This information can help residency programs make realistic adjustments throughout their programs in emergency situations similar to COVID-19 and provide residency directors with more insight to create a program that can appropriately consider the needs of the future medical workforce. According to Geobert et al., in 2009, an estimated 12% of medical students and residents suffered from major depression. This is twice as high as the national average for adults in the United States. Studies show that both male and female residents experience anxiety and depressive symptoms, with female residents reporting a significantly higher proportion (41% compared to 27%) and experiencing symptoms for a longer duration. In a study done by Shanafelt et. al in 2016, satisfaction with WLB in physicians between the years of 2011 and 2014 decreased from 48.5% to 40.9%. When compared to a sample of working US adults, physicians were more likely to “burn out” (37.9% vs 27.8%) and be dissatisfied with WLB (40.2% vs 23.2%) (Tait, 2012). A recent study conducted in 2017 by the American Medical Association found that 92% of millennial physicians rated WLB as a priority, but only 65% felt they had achieved it (Miller, 2017). In recent years there has also been a preference towards residencies that offer shift work, such as emergency medicine and hospitalist, as millennial physicians try to achieve a better WLB (Miller, 2017). Currently, there is scarce data concerning medical residents, WLB, and MH. This study looks further into the WLB of medical residents and specific factors influencing anxiety, depression and stress during the COVID-19 pandemic. A validated, self-administered questionnaire and the Depression Anxiety Stress Scale (DASS-21) was developed and distributed to Family Medicine, Internal Medicine, and Emergency Medicine residents in the Southeastern (SE) region, including the states of FL, GA, AL, SC, NC and VA. Participants voluntarily completed the survey online which included questions about demographics, depression, anxiety, stress, and physical, social, and financial factors. Data was analyzed using IBM SPSS Statics. The research focused overall on two main categories: 1. Identifying anxiety, depression and stress of medical residents by various demographics (i.e residency specialty, location, gender, marital status, and dependents) 2. Identifying factors affecting WLB of medical residents displaying anxiety, depression and/or stress via the DASS-21 survey through category type WLB stressors. I. Physical (number of hours worked per week, number of hours of sleep per night, hours of exercise per week, etc.) II. Outside work and social (family time, meals eaten together with family, entertainment and traveling) III. Financial burden (addition of bills, new expenses, loss or addition of income) Introduction

For this study, potential associations of WLB and MH with physical and social factors were investigated in order to understand how these factors play a role in medical residents’ daily lives. One hypothesis analyzed was if participants’ demographic information had an association with their scoring of the DASS-21 questionnaire. The outcome of the DASS-21 had three separate but interrelated components: depression, anxiety, and stress; results ranging from normal (1), mild (2), moderate (3), severe (4), to moderately severe (5). Data shows that there were no statistical significance in any of the demographic areas of residency program, state, gender, PGY year, marital status and number of dependent(s) in association to the DASS-21 score. In regards to physical factors for our survey, there were no statistical significance between post-COVID number of hours worked per week, post-COVID hours of exercise per week, and post-COVID PTO days off in association to how participants scored on the DASS-21. However, there was a significant difference among post-COVID sleep hours categorized into four levels, (<4 hours/night, 4-6 hours/night, 7-8 hours/night, and >8 hours/night) associated to scores of depression (p = 0.001), anxiety (p = 0.003) and stress (p = 0.008). Table 1 shows each category of sleep hours/night and the mean and standard deviation (SD) for post-COVID sleep hours in relation to DASS-21 scoring. For example, participants who slept 4-6 hours/night, scored a mean of 2.06 with a standard deviation of 1.268. While those who slept for 7-8 hours scored a lower mean of 1.52, SD of 0.933. Figure 1 demonstrates the drastic change in sleep hours of pre- and post-COVID.

References 1. A study of anxiety/depressive symptoms of medical students, house staff, and their spouses/partners. H. C. Hendrie, D. K. Clair, H. M. Brittain, P. E. Fadul. J Nerv Ment Dis. 1990 Mar; 178(3): 204– 207.Gander, P., Briar, C., Garden, A., Purnell, H., & Woodward, A. (2010). A Gender-Based Analysis of Work Patterns, Fatigue, and Work/Life Balance Among Physicians in Postgraduate Training. Academic Medicine, 85(9), 1526–1536. https://doi.org/10.1097/acm.0b013e3181eabd06 2. Goebert, D., Thompson, D., Takeshita, J., Beach, C., Bryson, P., Ephgrave, K.S., Kent, A., Kunkel, M., Schechter, J.E., & Tate, J. (2009). Depressive symptoms in medical students and residents: a multischool study. Academic medicine : journal of the Association of American Medical Colleges, 84 2 , 236-41. 3. Jeung DY, Kim C, Chang SJ. Emotional Labor and Burnout: A Review of Literature. Yonsei Med J . 2018;59(2):187 ‐ 193. doi:10.3349/ymj.2018.59.2.187 4. Lockwood, N. R. (2003). Work/Life Balance-Challenges and Solutions. Alexandria, USA: Society for Human Resource Management (SHRM). 5. Miller, Robert (2017). Millennial physicians sound off on state of medicine today. Academic medicine: journal of the Association of American Medical Colleges. 6. Shanafelt TD, Boone S, Tan L, et al. (2012). Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 2012;172(18):1377– 1385. doi:10.1001/archinternmed.2012.3199 7. Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, C., Satele, D., Sloan, J., & West, C. P. (2015). Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings, 90(12), 1600–1613. https://doi.org/10.1016/j.mayocp.2015.08.023 8. Steele, C. M., Spencer, S. J., & Aronson, J. (2002). Contending with group image: The psychology of stereotype and social identity threat. In M. P. Zanna (Ed.), Advances in experimental social psychology, Vol. 34 (p. 379–440). Academic Press. https://doi.org/10.1016/S0065-2601(02)80009-0 9. Young, Aaron, et al. “A Census of Actively Licensed Physicians in the United States, 2016.” Journal of Medical Regulations , vol. 103, no. 2, 2017, www.fsmb.org/siteassets/advocacy/publications/2016census.pdf. 10. Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour research and therapy , 33 (3), 335-343. Conclusions and Future Considerations The objective of this cross-sectional study was to investigate whether medical residents are more likely to experience dissatisfaction in WLB and have increased MH symptoms due to the COVID pandemic. Based on the current analyzed data, it can be concluded that many factors are associated with medical residents’ MH, specifically depression, anxiety, and stress. These factors that impact MH include the number of hours slept per night, the number of hours worked per week, and the hours of exercise per week. It can also be concluded that although medical residents may experience MH symptoms, it is not always associated with dissatisfaction in WLB. Future investigations can further analyze this study’s data to look into other factors such as whether certain additional roles like virtual schooling and childcare could play a role in affecting WLB and MH in residents. With the displayed results, this research could ultimately provide beginning insight for residency program directors to better understand how these various factors play a role in the overall WLB and MH well-being of a resident, in order to better provide them support during emergent situations such as the COVID-19 pandemic. ● ff An interesting observation we saw was how one physical factor, number of hours slept per night post-COVID, had contradicting outcomes between MH and WLB. Results showed that residents who slept less hours per night post-COVID scored significantly higher on the DASS-21, demonstrating increased depressive, anxious and stress-like symptoms. However, when number of hours slept post-COVID were compared to WLB, the majority of residents reported that the lack of sleep had no effect on their WLB. These differing results could be attributed to many things. One, the DASS-21 was a more objective measure of MH symptoms, whereas the WLB questionnaire was more subjective. Two, each medical residents’ perception of quality of sleep vs. quantity of sleep can be very different. And third, the lack of sleep may be normalized during residency. Due to the nature of the DASS-21 survey, using it to give a person diagnosis of depression, anxiety and stress would not be acceptable, but it is used to measure the symptoms of depression, anxiety, and stress. As used in this study, the DASS-21 was able to give us further insight into whether medical residents, at the time of survey, were experiencing features of depression, anxiety and stress enabling us to better understand how these physical, social, and financial factors could be playing a role in their overall MH. Lastly, this research project’s final objective was to bring surface as to how to better equip residency programs to support their resident’s WLB and MH. With the factors: number of hours slept, hours worked, hours of exercise, and financial burden being noted to have significance in playing a role in WLB and MH of residents in our data, we can direct residency program directors to consider providing additional consideration, resources or support for these specific factors in order to potentially improve the WLB and MH of residents in the future. Limitations For this study, limitations in the distribution and participation levels with the survey were taken into consideration. It was noted that some residents did not complete all parts of DASS-21 or left a significant amount of questions unanswered; not all residents who completed the survey completed it to 100%. Knowing this, it should be understood that our results could be under- or over- estimating the general assessment of DASS features. It also brings into consideration if our sample population had a higher or lower assessment of WLB when compared to physical, social and financial factors. Future replications of this study can consider making sure residents must complete all parts of survey before submission in order to get a greater level of survey power. Another limitation could be recall bias, as participants were asked to retrieve events and experiences that occurred before February 1st, 2020. Lastly, due to the timeframe in which residents had to compare changes happening pre- and post-COVID, some factors could not be accounted for. Examples of factors not having an applicable pre- and post-COVID comparison include: not having a pre-COVID work income due to being a new resident or getting married or having children in the time span of survey documentation. The study demonstrated a significant association between the WLB and MH of a medical resident working in the Southeastern states during the COVID pandemic. The physical and social factors that were found to have a significant association were: amount of hours slept per night, amount of hours worked per week, and amount of hours exercised per week. Data analysis reveals that although the financial factor of changes of financial burden was statistically significant when compared to WLB, it was significant in regards to having no effect on WLB. A result that was unexpected was the relationship between demographic factors and MH. Previously conducted studies showed that some demographics, especially gender, played a role in residents’ MH. Geobert et al. notes that female medical residents significantly experience anxiety and depressive symptoms compared to their male counterparts. Using ANOVA to analyze whether there is a relationship between demographic factors and MH, it was found that there was no significant association. These findings could be a result of our small sample size, data collection error, or an analytical error. In analyzing the data, the sample size observed for those who reported less than four hours of sleep per night was small (Depression N = 7). When taking this into consideration, it was noted to show them having a lower mean score on the DASS-21 compared to those in the sample size who slept between 4-6 (Depression N = 86) and 7-8 hours (Depression N = 82). Due to the nature of the smaller sample size for those who reported <4 hours of sleep, there exists a possibility of the data underestimating the association between number of hours slept and MH in those who slept <4 hrs post-COVID.

Sleep Hours & DASS-21

The next objective is whether residents are more likely to experience dissatisfaction in WLB along with having increased MH symptoms during the COVID pandemic. Even though residents who slept less hours/night appeared to have scored higher on the DASS-21, over half of the participants, 51.18% reported that less sleep did not affect their WLB. 45.29% reported that their post- COVID sleep hours affected their WLB negatively, and 3.53% reported it affected their WLB positively.

Hours/ Night

Depression N

Depression Mean

Depression SD

Anxiety N

Anxiety Mean

Anxiety SD

Stress N

Stress Mean

Stress SD

4

7

1

0

7 1.43 0.787

7

1

0

4-6

86

2.06 1.268 87 1.87 1.265

87 1.84 1.119

7-8

82

1.52 0.933 82 1.3 0.781

81 1.4 0.904

Another objective was to investigate whether participants felt working more hours post-COVID impacted their WLB negatively. The results confirmed that 49% of individuals felt working more hours impacted their WLB negatively compared to the 6% of individuals who felt that working more hours post-COVID impacted their WLB positively. It was noted that the results did show that 45% of residents felt working more hours had no effect on their WLB. In order to draw further associations on the difference between post-COVID hours affecting WLB, a Fisher's Exact test was conducted to see whether there was significant difference between the proportion of those who felt working more hours post-COVID impacted their WLB negatively, positively, or had no effect. The Fisher's Exact Test showed that there was a significant difference between the groups (p <0.01). 0 6 1.17 0.408 Table 1 Statistically Significant Association Between Medical Residents Hours Slept and DASS-21 Post-COVID . 8 6 1 0 6 1

It was very well observed that the amount of hours worked post-COVID had an impact on social factors affecting WLB. Figure 4 demonstrates the differences of work hours pre- and post-COVID. Seventy-three and a fourth percent of participants reported that post-COVID work hours negatively affected their social gatherings with friends and family, and 67.77% of participants said it negatively affected their family time, including family meals, family game nights, and other family-like entertainment. Finally, we anticipated that financial burden changes such as increased bills, increased family financial responsibility and loss of income would negatively impact residents’ WLB. However, results showed that 58.39% of medical residents reported that changes in financial burden had no effect on their WLB (Figure 5).

Methods

A three-part survey was created that consisted of identifying demographics, the DASS-21 questionnaire, and factors affecting WLB (physical, social and financial). The survey was sent to family medicine, internal medicine and emergency medicine residents in the SE region. Results were collected from December 23rd, 2020 to February 12th, 2021. The first 200 participants received a $10.00 Starbucks gift card. After careful literature review from previous studies on WLB such as factors in relation to resident burnout and MH, the survey was created to assess physical, social and financial factors that affect residents’ WLB and MH. Furthermore, to make it applicable to the current COVID-19 pandemic, residents were asked to compare how their responses changed from before February 1st, 2020 to after February 1st, 2020 at the beginning of the COVID-19 pandemic. The format of our Qualtrics survey included: 1. Demographics a. Residency specialty, state, gender, marital status and child dependents, ages 0-18. 2. The Depression Anxiety and Stress scale (DASS-21) a. This scale is a modified version of the DASS-42 questionnaire developed by The University of New South Wales, AU, in order to assess depression, anxiety and stress. The DASS-21 consist of 21 questions assessing symptoms of depression, anxiety or stress. The total values of each factor are then multiplied by two in order to give a final result comparable to the original DASS questionnaire. Lastly, these values are scored on a scale of 1-5, ranging from normal findings of depression, anxiety and stress to moderately severe findings of depression, anxiety and stress. 3. Factors That Relate To Work Life Balance and Mental Health a. In this section, the survey was split into three parts: physical factors, outside work and social factors and financial factors.

31

2 0 2 1 R e s e a r c h R e c o g n i t i o n D a y