Compassion fatigue encompasses both the emotional and physical exhaustion that physicians can experience throughout their careers. It is characterized by anger and irritability, negative coping behaviors, a diminished sense of enjoyment and satisfaction from work, and a reduced ability to feel sympathy and empathy. Compassion fatigue ultimately leads to higher rates of depression and anxiety among caregivers, increased clinical errors, degradation of the workplace climate, and suboptimal patient care [[1], [2], [3]]. Typically, compassion fatigue is composed of two elements: burnout and secondary traumatic stress (STS). In contrast, compassion satisfaction is deriving pleasure from being able to do one's work [4]. Working in the emergency department (ED) presents a set of unique stressors due to the fast-paced environment, patient acuity, trauma, crowding, and pressure to manage cases quickly and efficiently [5]. Consequently, two years into the COVID-19 pandemic, with two different variants of COVID-19, Delta (B.1.617.2) and Omicron (B.1.1.529), and an effective FDA-approved vaccination against COVID-19, additional stressors are arising in the ED in regards to exposure to unvaccinated patients [6,7].
To investigate compassion fatigue (including burnout & secondary traumatic stress) and compassion satisfaction in emergency medicine (EM) physicians during COVID-19 surges, we designed a survey that encompassed the Professional Quality of Life Scale (ProQOL), a 30-question questionnaire that objectively measures these concepts [8]. At the end of the survey, three COVID-19-related questions were included in addition to a free-text box for additional comments.
A total of 608 EM physicians completed the survey. All regions of the United States were represented with the majority from the Southern (n = 207, 34.05%) and Midwest (n = 177, 29.11%) regions. The ProQOL survey uses total scores to evaluate these parameters. A score ≤ 23 indicates positive feelings about effectiveness in one's work, 23–41 indicates neutral feelings, and ≥ 42 suggests burnout. A score ≥ 43 indicates the participant may be experiencing secondary traumatic stress. A score ≤ 23 suggests reduced compassion satisfaction. ProQOL scores varied significantly across age, gender, and years in practice (Table 1 ). The mean participant scores for compassion satisfaction, burnout, and secondary traumatic stress scores were 33 (SD 7.26), 29.27 (SD 6.45), and 25.14 (SD 7), respectively. The compassion satisfaction score suggested satisfaction in one's work, the burnout score suggested neutral feelings, and the secondary traumatic stress score suggested that secondary traumatic stress is not being experienced. At face value this is reassuring, however, when compared to prior pre-COVID investigations [9], there are statistically significant lower scores of compassion satisfaction and higher scores of secondary traumatic stress validating the subjective feelings of EM physicians as reported in the COVID-19 questions. Burnout means show no difference pre vs. post-COVID, albeit, they are in the “neutral” category (Table 2 ). Furthermore, with questions investigating COVID-19, the majority of respondents felt that their answers would have been different before the COVID-19 pandemic (n = 478, 79.01%), a patient's vaccination status contributed to their overall emotional exhaustion (n = 465, 76.86%), and that they have experienced increased burnout during the COVID-19 Delta (B.1.617.2) and Omicron (B.1.1.529) surges (n = 515, 85.98%).
Table 1.
Comparisons of ProQOL raw scores across demographic categories, (n = 608).
| Demographics | n (%) | Compassion satisfaction |
Burnout |
Secondary traumatic stress |
|||
|---|---|---|---|---|---|---|---|
| Mean (SD) | P-value | Mean (SD) | P-value | Mean (SD) | P-value | ||
| Region | |||||||
| Frontier | 35 (5.76) | 32.03 (7.18) | 0.234 | 30.23 (6.01) | 0.164 | 26.89 (6.24) | 0.130 |
| Midwest | 177 (29.11) | 33.31 (6.79) | 28.74 (6.37) | 25.19 (6.70) | |||
| Northeast | 109 (17.93) | 34.11 (6.84) | 28.50 (6.23) | 24.19 (6.40) | |||
| Pacific | 80 (13.16) | 32.00 (7.50) | 30.45 (6.50) | 26.38 (7.48) | |||
| South | 207 (34.05) | 32.71 (7.74) | 29.52 (6.66) | 24.82 (7.42) | |||
| Age | |||||||
| 25–35 | 133 (21.88) | 31.66 (7.29) | <0.001 | 29.60 (6.66) | <0.001 | 26.16 (7.38) | 0.217 |
| 36–45 | 242 (39.80) | 31.77 (6.76) | 30.24 (6.00) | 25.02 (6.82) | |||
| 46–55 | 129 (21.22) | 32.84 (6.86) | 29.81 (6.42) | 24.98 (7.07) | |||
| 56 and above | 104 (17.11) | 37.76 (6.93) | 25.93 (6.26) | 24.30 (6.78) | |||
| Provider level | |||||||
| Attending | 572 (94.08) | 33.02 (7.28) | 0.813 | 29.32 (6.49) | 0.429 | 25.10 (7.02) | 0.623 |
| Resident | 36 (5.92) | 32.72 (6.98) | 28.44 (5.95) | 25.69 (6.67) | |||
| Children | |||||||
| No | 170 (27.96) | 32.35 (7.19) | 0.167 | 29.97 (6.35) | 0.096 | 25.59 (7.08) | 0.324 |
| Yes | 438 (72.04) | 33.25 (7.28) | 29.00 (6.48) | 24.96 (6.97) | |||
| Years of practice | |||||||
| ≤4 | 144 (23.68) | 32.06 (7.34) | 0.555 | 29.65 (6.48) | <0.001 | 25.88 (7.10) | 0.660 |
| 5–9 | 123 (20.23) | 31.70 (6.79) | 29.76 (6.31) | 25.11 (6.78) | |||
| 10–14 | 117 (19.24) | 31.51 (6.48) | 30.59 (5.67) | 24.89 (6.70) | |||
| 15 to 19 | 69 (11.35) | 31.83 (6.83) | 31.16 (5.96) | 26.64 (7.70) | |||
| ≥20 | 155 (25.49) | 36.55 (7.17) | 26.69 (6.63) | 24.00 (6.85) | |||
| Gender | |||||||
| Female | 297 (49.34) | 32.25 (6.60) | 0.003 | 30.21 (5.64) | <0.001 | 26.63 (6.90) | <0.001 |
| Male | 305 (50.66) | 33.84 (7.74) | 28.31 (7.04) | 23.69 (6.85) | |||
CS: ≤23 less job satisfaction. Burnout: ≤23 indicates positive feelings about effectiveness in one's work, 23–41, neutral feelings, and ≥42 suggests burnout. STS, ≤41 does not indicate the participant is experiencing STS, ≥43 indicates the participant may be experiencing STS [8].
Table 2.
Average ProQOL CF and CS means pre-COVID and post-COVID in EM physicians.
| Pre-COVID [9] (n = 226) | Post-COVID (n = 608) | Difference | P-Value | |
|---|---|---|---|---|
| Compassion Satisfaction | 39.0 | 33.00 | −6 | <0.001 |
| Burnout | 29.7 | 29.27 | −0.4 | 0.102 |
| Secondary Traumatic Stress | 20.6 | 25.14 | 4.5 | <0.001 |
CS: ≤23 less job satisfaction. Burnout: ≤23 indicates positive feelings about effectiveness in one's work, 23–41, neutral feelings, and ≥ 42 suggests burnout. STS, ≤41 does not indicate the participant is experiencing STS, ≥43 indicates the participant may be experiencing STS [8].
The COVID-19 Delta (B.1.617.2) and Omicron (B.1.1.529) surges had a negative impact on the wellness of EM physicians in regards to feelings of compassion satisfaction and compassion fatigue, specifically secondary traumatic stress. The healthcare system was overwhelmed during the pandemic and while many individuals had the option of staying at home, healthcare workers placed themselves at risk every day, especially with a patient's unknown COVID-19 status [10]. We hypothesize that these increased stressors during the pandemic may have contributed to secondary traumatic stress and decreased compassion satisfaction. The majority of EM physicians subjectively reported burnout and emotional exhaustion in regards to a patient's vaccination status and felt that their answers to questions investigating compassion satisfaction and compassion fatigue were impacted by the COVID-19 Delta (B.1.617.2) and Omicron (B.1.1.529) surges. Furthermore, free-text responses at the end of the survey presented a variety of stressors that EM physicians attribute to their perceived compassion fatigue (Table 3 ). Some responses cited fear of dying after repeated COVID-19 exposure stating “I am worried about dying at work.” Others attribute the polarizing politics of the COVID-19 pandemic and misinformation to being the source of their perceived compassion fatigue with statements like “I don't feel as though the virus depressed me as much as seeing the medical complex and society's responses to it.” In contrast, others had a positive outlook on their career during the pandemic stating things like “I actually feel more of a sense of purpose working through the surges than I ever have in my career.”
Table 3.
Examples of anonymous responses from the survey.
| “The last 2 years of my career have been quite awful. I always wanted to be an emergency physician and now I fantasize about doing something or anything else. I am not as available as a parent to my children as I want to be.” |
| “I have been assaulted and verbally abused when I have diagnosed COVID in unvaccinated patients.” |
| “In emergency medicine, we signed on to treat the wise and the unwise. People make unfortunate choices daily and we must treat them despite their choices. Compassion for all is built into the DNA of emergency physicians.” |
| “I think about killing myself every day.” |
| “I love being an emergency physician. I've worked in war torn nations, I've worked with Ebola and TB. Nothing was worse than COVID and I think a large part of that was that I had no emotional support structure left. No drinks after work, no family I could see, no hugs. I saw a therapist and they said I was fine and I just needed to talk about it. I am tired and I've lost 2 years of my life.” |
| “As emergency physicians, we battle all shift, every shift, regardless of what is waiting in the lobby. No matter what the challenges are, we will overcome them. That is what emergency medicine is all about. Our job has always been, and will continue to be, compassionately doing our best for our patients with limited resources, limited time, etc. But this is emergency medicine, and we should all be proud to be tough enough to be in it during these challenging times.” |
| “I feel hopeless often. We were initially lauded as heroes, but now we are the villains for championing the vaccine and being cautious. A matter of science and health has become politicized to the point you can't reason with people anymore. I'm a new attending, and I am already planning my exit strategy because this pandemic has crushed me.” |
The COVID-19 pandemic has shown the resilience of EM physicians. Our hope in this investigation is to bring awareness for EM physicians nationwide as to the emotional challenges of the COVID-19 pandemic. We often inadvertently take on our patients' trauma and it manifests as depression, anger, and anxiety which in turn lead to erosion of our empathy [1]. This may translate to more medical errors and even increased suicide risk [11]. Please advocate for yourself and your colleagues. Recognize compassion fatigue exists and explore ways to combat it.
Credit authorship contribution statement
John M. Bowling: Writing – review & editing, Writing – original draft, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Christina Campana: Writing – review & editing, Supervision, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization. Jessica Krizo: Writing – review & editing, Resources, Methodology, Investigation, Data curation, Conceptualization. Caroline Mangira: Software, Methodology, Data curation. Erin L. Simon: Writing – review & editing, Supervision, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization.
Declaration of Competing Interest
We have no conflicts of interest to disclose.
Acknowledgments
American College of Emergency Physicians - Ohio Chapter.
EM Docs.
The Center for Victims of Torture - https://www.proqol.org/
Nicholas Belleza, BS.
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