Abstract
Background:
The coronavirus disease 2019 (COVID-19) pandemic has resulted in inducting trainee resident doctors (RDs) in the care of COVID-19 patients. Limited research has been conducted to understand the impact of domains other than physical and emotional health on their lives. The focus has been to understand the negative consequences of COVID-19 duties, disregarding the possibility of any positive impact that could have emerged.
Aim:
This mixed-methods study (qualitative and quantitative) aims to explore the holistic and comprehensive impacts of COVID-19 duties on RD's lives.
Materials and Methods:
This is a mixed-methods convergent design study conducted in a 1400-bed multispecialty teaching hospital in a metropolitan city in India. A phenomenological approach was used for the qualitative part of the study, and the data were collected using focus group discussions (FGDs). For quantitative purposes, the World Health Organization Quality of Life Brief Version (WHOQOL-BREF) questionnaire was administered.
Results:
Qualitative findings show themes of negative impact covering domains of physical, emotional, social, and professional life. Themes that reveal a positive impact have emerged in the social, professional, and personal domains of the RDs' lives. Quantitative and qualitative results were in agreement with all the questions covered in the WHOQOL-BREF scale; however, the qualitative data findings extend far beyond.
Conclusion:
In the course of the COVID-19 duties, the RD has suffered in multiple domains, yet it has allowed them to self-reflect and change. As a consequence, they have grown as individuals in many areas of their lives. Working in COVID-19 wards has had a holistic impact on the RDs and has transformed them into better doctors.
Keywords: COVID-19, mixed-methods study, positive impact, post-traumatic growth, resident doctors
The coronavirus disease 2019 (COVID-19) pandemic has overwhelmed the healthcare system of many countries requiring governments to take drastic measures. One key action was to convert multispecialty training hospitals into COVID-19 care centers.[1] This subsequently resulted in roping trainee resident doctors (RDs) of different specialties into the care of COVID-19 patients. Doctors working in COVID-19 wards suffer from physical and mental health consequences, such as fever, headache, myalgia, weakness, anxiety, depression, insomnia, and burnout, as highlighted in studies.[2,3,4] Limited research has been conducted to understand the impact of other domains on the RD's lives, such as professional, social, and personal. The focus has been to understand the negative consequences of COVID-19 duties, disregarding the possibility of any positive impact that could have emerged from these hard times. This mixed-methods study (qualitative and quantitative) aims to explore the holistic and comprehensive impacts of COVID-19 duties on RD's life.
MATERIAL AND METHOD
This is a mixed-methods convergent design study that was granted ethics clearance for its conduct in a 1400-bed multispecialty teaching hospital, training around 200 residents per year, located in a metropolitan city in India. The hospital had admitted around 3500 COVID-19-positive patients till December 2021. Ethical clearance was obtained from the Institutional Ethical Committee of BYL Nair Charitable Hospital. All participants gave written informed consent.
The RDs who consented and worked in COVID-19 wards for at least 12 whole weeks were included in the study. The recruitment of participants was conducted via invites on social media platforms and word-of-mouth publicity. The sample was collected until data saturation (no additional information was obtained) was achieved.
A phenomenological approach was used for the qualitative part of the study, and the data were collected using focus group discussions (FGDs). These online FGDs were held every two weeks between May and August 2021 as per the time convenience of the participants. Each FGD had five to seven randomly assigned participants. Two moderators and one notetaker were trained, and mental health professionals conducted the FGDs.
For quantitative purposes, the World Health Organization Quality of Life Brief Version (WHOQOL-BREF) questionnaire was administered at the end of FGD by every participant, and scores across 4 domains (physical, psychological, social, and environmental) were obtained. The following table briefly outlines a broad structure that was followed during each session.
The FGDs were transcribed verbatim, and the codes, categories, subcategories, and themes were formulated by the team. The themes were discussed and were concurred upon in case of differences. Information obtained through the Case Report Form and WHOQOL-BREF scores was coded in Excel, and frequencies were computed using Statistical Package for the Social Sciences (SPSS) version 21.
RESULTS
Demographics
A total of 35 doctors responded to the invites, of whom 30 met the inclusion criteria. The final number of participants who took part in the study was 26.
The demographic data are tabulated in Table 1, and the study sample consists of eight (31%) males and 18 (69%) females. The mean duration of COVID-19 duty was 26.5 weeks (max—34 and min—18) of 6-hour shifts per day.
Table 1.
Breakup of the focus group discussions (FGD) guide
| Duration | Discussion guide |
|---|---|
| 3–5 mins | Introducing the study team and research topic and setting ground rules |
| 5–10 mins | Rapport building and collecting information for the case report form |
| 10–15 mins | Broad introductory questions |
| 20–30 mins | Specific questions on key emerging topics |
| 5–10 mins | Closing questions |
| 5–10 mins | Filling the WHOQOL-BREF |
Qualitative analysis
Thematic redundancy was achieved in the fourth FGD, and the fifth FGD was conducted to confirm the same.
The themes were broadly categorized into those having a negative and positive impact, which was further divided into subcategories as shown in Tables 2 and Figure 1, respectively.
Table 2.
Demographic details of the participants
| Gender | Role inward | |
|---|---|---|
| Males—8 (31%) | Primary (in charge of patient management)—8 (30%) | |
| Females—18 (69%) | Secondary (supportive role)—12 (46%) | |
| Both—6 (24%) | ||
|
| ||
| Age | Department | |
|
| ||
| 24 years—5 (19%) | Medicine—3 (12%) | Psychiatry—5 (19%) |
| 25 years—4 (15%) | Anesthesia—4 (16%) | Pharmacology—1 (4%) |
| 26 years—9 (35%) | Dermatology—2 (7%) | Radiology—1 (4%) |
| 27 years—5 (19%) | Ophthalmology—2 (7%) | Pathology—1 (4%) |
| 28 years—3 (12%) | Obstetrics and gynecology—3 (12%) | Plastic surgery—1 (4%) |
| Pulmonary medicine—3 (21%) | ||
|
| ||
| Year | Ward stability | |
|
| ||
| First year—9 (34%) | Stable (asymptomatic and symptomatic but not requiring mechanical ventilation)—8 (30%) | |
| Second year—11 (43%) | ||
| Third year—4 (15%) | Unstable wards (patients needing mechanical ventilation)—11 (43%) | |
| Senior resident—1 (4%) | ||
| Super-speciality resident—1 (4%) | Both—7 (27%) | |
Figure 1.
Negative impact of COVID-19 duties on resident doctors
Negative
Physical health
All the groups reported being exhausted and fatigued lasting during the duty and the ensuing week. Dehydration secondary to sweating, restricted fluid intake, and no access to the washroom in personal protective equipment (PPE) were also prominent subtheme. A5 said, “Dehydration is a major issue, For a 10 p.m. shift I have to stop taking fluids by 6 p.m. because we cannot change PPE during shifts.”
Continuous COVID-19 duties led to lasting physical complications; for example, D3 said, “I had continuous 21-night shifts, and because of these sleepless nights and stress I had severe hair loss.”
Disturbed sleep was reported by the majority of the participants; some said it was due to the constant change in the shift schedule, others said that it was due to anticipation of duty the next morning, and some reported it was due to the stress of uncertainty about their academics.
Emotional health
Anxiety, irritability, low mood, helplessness, and hopelessness have been mentioned by participants in all the FGDs. The reasons for the same are detailed in Figure 2.
Figure 2.
Post-traumatic growth in resident doctors
Some report anxiety about contracting the virus, and A2 says, “COVID is airborne so the viral load keeps accumulating, we live with constant fear.”
Some are worried about their careers, and B1 said, “We have no exposure to patients of our speciality, even after we become seniors, we will know nothing more than junior most.” Other doctors reported being anxious to handle wards alone, make life-saving decisions, and break bad news. E2 mentioned, “I have palpitations when I wake up and am expected to go to duties, I know bad patents are waiting for me.”
The RDs who were posted mainly in intensive care units (ICUs) felt depressed having to see only critical patients. E3 states, “I have either declared death or transferred a stable patient to the ward, I have never given a good prognosis for 2 years.”
All groups discussed suffering psychological distress after the death of their patients. B4 said, “there used to be 2-3 deaths per shift, I used to come back and cry, I just could not take it.”
The doctors reported feeling guilty about being unable to provide optimum patient care. A2 said, “There is insufficient equipment and manpower we want to help patients but we can't, support is lacking.”
Professional life
The participants reported academic loss, citing a marked drop in patient exposure, bedside clinics, and didactic lectures.
C2 says, “The basis of my specialty is seeing OPD patients, the more unique patients we see the more we learn, so with low non-covid cases we did not learn anything.”
Self-doubt crept in regarding their ability to be successful in their careers. C1 says, “You have to absorb whatever your training period offers but that has now gone, how will our future be.”
The participants reported concern over having gaps in their careers due to the delay in admissions and final examinations due to the pandemic.
Social life
All groups discussed having to isolate from family members. B4 said, “Was not able to see my parents for 6 months and even after the train started, I did not go home as I did not want to infect them.” Also, C3 mentioned, “I stay half an hour away, staying so close and not being able to meet my parents was the most difficult part.”
Two groups discussed feeling stigmatized by society, and they reported incidents where people treated them differently because they were doing COVID-19 duties. One of the participants hid her COVID-19-positive status from society due to the fear of being ostracized.
Positive impact
Professional life
Some doctors felt that their knowledge, skill, and confidence in dealing with emergency medical situations had improved. B5 says, “Our decision-making skills have improved, we can individually treat patients, and I became better at handling things.”
RD reports to have grown more sensitive toward the emotional needs of their patients.
Some stated they being forced into a managerial role has made them more assertive and enhanced their professional networks.
Social life
The most common positive impact reported was developing a closer relationship with family, friends, and colleagues. C2 mentioned, “I have got very close to my family I speak to them more often; we lighten up each other's moods, and we now understand each other better.”
C3 says, “I never interacted with other department residents. I made friends in other clinical branches that I wouldn't have known otherwise.”
Personal life
Improved life skills were a subtheme that emerged, and these included punctuality, communication skills, planning, multitasking, proactiveness, and emotional regulation.
A2 said, “I learned to start preparing 1-2 hrs before the duty from having food to taking a bath or wearing scrubs and keeping everything ready for when I come back.”
Residents reported having inculcated many life values and principles.
A5 said, “I think looking at all this pain has made us more compassionate and braver.”
D2 said, “Seeing so many unpredictable deaths, I just realized that life is short, so I just feel like we should try and live every moment to the fullest.”
C3 added, “We will lose out a lot if we only keep working throughout our lives.”
The participants discussed that they have become more grateful individuals, D1 said, “I feel blessed to be alive right now,” and B4 said, “After seeing so much loss, I feel thankful to have my loved ones with me.”
Quantitative analysis
The WHOQOL-BREF score was calculated for each domain, and the score was transformed on a scale of 1 to 100, where the higher the number the better the quality of life. The mean and standard deviation for each domain are shown in Figure 3. The mean score for the physical domain is the least, followed by the psychological and environmental domains. The mean score for the social domain was found to be the highest as compared to the other domains.
Figure 3.
Positive impact of COVID-19 duties on resident doctors
Integration of qualitative and quantitative analysis
The most common response for individual questions on the WHOQOL-BREF scale was calculated. These responses were compared to codes emerging from the qualitative analysis, and the results are tabulated in Figure 4.
Figure 4.
Mean and Standard deviation of WHO BREF QOL score in each domain
The analysis revealed that quantitative and qualitative results were in agreement with all the questions covered in the WHOQOL-BREF scale. The qualitative data findings extend beyond the topics covered in the questionnaire for psychological and social domains. The FGDs also provide information in the professional and personal domains, which were not covered in the quantitative analysis.
DISCUSSION
Working in COVID-19 wards for nearly 2 years through a stressful, traumatic experience has been laced with positive dividends too. In this mixed-methods convergent study, we used FGDs and the WHOQOL-BREF questionnaire to understand the comprehensive impact of COVID-19 duties on RD.
Most available research conducted during COVID-19 focuses on the psychological and physical impacts on healthcare workers.[2,3,4] It is well known that a prolonged stressor can affect multiple areas of one's life; also, the effect in one domain can cascade into other domains. This study corroborated that COVID-19 duties had impacted the lives of the RD in multiple domains both positively and negatively.
The physical problems suffered by the study participants were similar to those found in other studies.[5] The WHOQOL-BREF scale findings show that compared to all the other domains the physical health domain (mean = 35.69) showed the most adversely affected QOL. This could be because of stand-alone and/or combination of many factors, including the impact of prolonged PPE use, post-COVID sequelae, and physical manifestations of psychological and emotional distress.
Numerous studies have reported that doctors working in COVID-19 wards suffer from various emotional problems including stress and anxiety.[6,7,8] This study found that the factors causing anxiety for RD were either related to contracting COVID-19, working in COVID-19 wards, or uncertainty about the future. Another cause of emotional distress for the RD was being unable to provide care to the patients due to constraints, beyond their control. The lack of knowledge and resources because of the sudden and unprecedented nature of this pandemic has resulted in moral injury among doctors as found in studies conducted in the early stages of the pandemic.[9,10]
It is well known that the death of a patient can be similar to a grief reaction for the treating doctor.[11] Witnessing a large number (3–4 per day) of sudden and unpredictable deaths and working with only critically ill patients could have led to an increase in the sense of loss felt by this RD. This study also found that among the doctors who felt intense emotional distress at the death of a patient, five reported having lost their loved ones in this pandemic. It is likely that when faced with the death of patients whom they could relate to in some form (physical characteristics, similar birth order, age group, culture, etc.), they reexperienced the trauma of their loss.
The healthcare workers were seen as “superspreaders” due to continuous exposure to the virus while on COVID-19 duties, resulting in them having to face stigma from society.[12] As also seen in other studies, the RD voluntarily physically distanced themselves from their loved ones due to fear of infecting them.[13]
Academics have been largely impacted by this pandemic.[14,15] The need to divert all resources for service resulted in ignoring academic training. This sense of loss was a major finding of this study. The RD reported self-doubt, which may be due to curtailed training.
RD felt that the duties have also positively impacted their lives. An article published on the effects of COVID-19 proposes a hypothesis based on positive psychology models, which state that the pandemic can have a positive impact on the well-being of a person.[16] Fioretti et al.[17] analyzed the narratives of experiences of adolescents living in the pandemic, and they found positive experiences, such as “Discovering oneself,” “Re-discovering family,” and “Sharing life at a distance.”
This study found that despite physical distance, emotional bonds with family members improved. This could be secondary to the uncertainty of life and the unpredictability of death.
This uncertainty along with increased cohesion at the workplace resulted in a closer bond with their colleagues. A qualitative study conducted during this pandemic on adults in the community found that spending more time together strengthens emotional bonds between people.[18] Bastian et al.[19] reported that stressful times bring doctors together, calling it “pain as glue.” These could be the possible reasons that the quality of life in the social domain on the WHOQOL-BREF scale was better than the other domains.
RD reported having gained the skills needed to treat critical patients. For around half of the study participants, specialty work (such as pharmacology, pathology, and psychiatry) did not involve routinely working in ICUs. COVID-19 duties for these doctors meant getting exposed and trained in managing emergencies, a skill they would not have developed otherwise.
Having to make the best of the limited resources (both human and others) while doing COVID-19 duties could have led to the development of skills, such as effective communication, teamwork, networking, planning and multitasking, assertiveness, and punctuality as reported by the RD.
The difficult working conditions made them reflect on their life values and made them more grateful and accepting individuals. Self-care also improved, and this is in resonance with models of positive psychology, which state that uncertainties and transitions demand greater focus on self-care.[16]
These positive changes that occur in a person during traumatic periods like this pandemic have been termed and studied as post-traumatic growth (PTG). This model as described by R. Tedeschi and L. Calhoun[20] states that stressful situations bring about emotional distress because they challenge preexisting beliefs and schemas. Self-reflection and self-analysis, along with social support and role modeling, can lead to a reassessment of goals and change in belief systems.
The RD of this study has grown in all domains of PTG as described in the literature. These include better relationships (deeper social bond), new possibilities (rekindled and found new hobbies), personal strength (skills such as multitasking and communication), and a greater appreciation of their life.
Figure 1 illustrates the use of this model to explain the growth that has occurred in different domains in this study.
The PTG does not undermine the negative impact of COVID-19 duties. Post-traumatic stress disorder (PTSD), anxiety, and depression can occur along with PTG.[21] Some studies have reported a positive correlation between PTSD and PTG, proving that traumatic events can have an impact on an individual in multiple ways.[22] By understanding both the negative and positive effects of COVID-19 duties, this study explores the impact on the lives of RD comprehensively.
The scope is limited by its small sample size and short study duration, and further research into the more long-term sequelae of the impact of COVID-19 duties on doctors is essential.
CONCLUSIONS
In the course of the COVID-19 duties, the RD has suffered academic loss, social isolation, physical hardships, and emotional turmoil. These hardships, although severe enough to affect their quality of life, allowed the RD to self-reflect and change their preexisting values and beliefs. As a consequence, they have grown as individuals in many domains, and they have found new opportunities, deepened their social bonds, honed their personal skills, and developed a greater appreciation of life. Working in COVID-19 wards has had a holistic impact on the RD and has transformed them. As one participant aptly stated, “One thing is for sure, COVID duties have changed us all!”.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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