Though physicians are critical to our effective responses to public health crises, they are not impervious to either the infectious nature of the diseases they treat nor the mental burden of protracted exposure to unexpected suffering and death. We have known for centuries that facing infectious disease has significant psychological effects on doctors. In the 14th century, for instance, towns across Europe lost doctors during the Black Death not only because doctors succumbed to the bubonic plague but also because doctors were too afraid to expose themselves to infected patients.1
While there is extensive research on the psychological impact of the spread of viruses like COVID-19, much of the data relate to public responses and do not focus on the unique experience of the physicians who care for the patients.2-9 As the weeks of treating COVID-19 patients accumulate, it is important to consider what the short- and long-term consequences will be for relevant physicians, as well as the implications of these consequences.
Data collected on this issue from previous pandemics and other public health crises may provide a small lens through which we can gather information on the realities of the psychological impact of COVID-19 and arm ourselves with the necessary tools to mitigate the burden on physicians and, ultimately, on the entire healthcare system.
Outbreaks increase symptoms of anxiety and depression in physicians.
While several psychological phenomena have been observed in physicians dealing with pandemics, most of the psychological data point to the emergence of symptoms related to anxiety and depression. For example, COVID-19 workers are experiencing guilt associated with watching patients dying alone and their need to break news to loved ones via technology rather than in person.10,11 This guilt may translate immediately or eventually into clinical anxiety or depression, which would be consistent with findings from previous outbreaks.
Anxiety. Several studies of healthcare workers’ responses to outbreaks have pointed to the increased risk for anxiety. Healthcare workers on the frontlines of the severe acute respiratory syndrome (SARS) outbreak have suffered from symptoms of anxiety and have reported feelings of extreme vulnerability.12 Their symptoms have even included cognitive changes. Similarly, a study in Greece during the 2009 swine flu (H1N1) demonstrated that more than half of healthcare workers at a tertiary hospital reported moderately high anxiety.13 The flu has also been associated with fear-specific anxiety in physicians. One study found that 30% of physicians and 42% of nurses were afraid of the avian flu (H5N1).14
Data collected this year on the effects of COVID-19 on Chinese medical workers found that they are more likely to be suffering from mental health issues like anxiety than their nonmedical worker counterparts also working in the healthcare system.15
Depression. Depressive symptoms have also been observed in healthcare workers caring for patients infected during an outbreak. While the SARS outbreak was associated with anxiety in the short-term, much of the anxiety felt by healthcare workers eventually translated to depression.12 Workers caring for patients during the Ebola outbreak also experienced both anxiety and depression, and they were specifically described as displaying loneliness, fear, and sadness, as well as feelings of being ostracized, disrespected, and unloved.16 These healthcare workers felt a loss of social connectedness and were adversely impacted by a perceived erosion of trust within and across their communities.
Research thus far on the psychological impact of COVID-19 has already revealed signs of depression in Chinese medical workers.15 These depressive symptoms are accompanied by insomnia and several signs of anxiety.
Outbreaks increase the likelihood that healthcare workers will abandon their work.
Though it is unclear if it is due to illness, an attempt at protection, or some other reason, healthcare workers are less likely to show up for work during public health crises. A study on healthcare workers’ willingness to work during an avian flu outbreak showed that nearly 1 of every 4 workers was absent.17
Not only are there data showing that physicians and other healthcare workers are less likely to work during outbreaks, but also there are data showing that the workers can actually anticipate this behavior. Studies into intentions to work in the context of future pandemics have been carried out in several countries, and, regardless of location or culture, between 20% and 30% of healthcare workers display hesitation about working during a pandemic.18
Following the SARS outbreak, research on the attitudes of physicians, nurses, medical students, and hospital officials in Germany revealed that 28% of them believed it was acceptable for healthcare workers to abandon their jobs in the event of a future pandemic to protect themselves and their loved ones.19 Around the same time, nearly 50% of public health workers in a Maryland study said that they would be unlikely to report to work in the case of another influenza pandemic.20
What could reduce psychological risk for physicians?
Researchers have suggested that healthcare workers whose jobs are in public health, emergency medicine, primary care, and intensive or critical care are at a particularly high risk for developing psychological symptoms related to the COVID-19 pandemic.21 However, pandemic data have also pointed to specific factors that increase the likelihood of mental health destruction on these workers. According to this research, physicians’ mental health can be protected by helping them feel both physically and psychologically safe during these pandemics.
Preparedness. A study on the attitudes of healthcare workers regarding an H1N1 outbreak in Egypt showed that more than one-third of the physicians surveyed reported that they felt unprepared to deal with an H1N1 pandemic. Resident physicians were even more hesitant to face H1N1, citing less personal protective equipment (PPE) training compared with other healthcare professionals.22
Research on the mental health effects of COVID-19 on healthcare workers has shown that these workers feel a sense of helplessness around accessing enough PPE to protect themselves. Given that their own safety depends on how well hospitals are developing and deploying safety measures, healthcare administrators can help physicians feel not only physically safe through access to equipment and updated protocols but also cared for and supported by their colleagues.14
Psychological Support. Although physicians are trained extensively in the clinical aspects of their jobs, they have much less support learning how to cope with the emotional strain that many of them will feel. In the case of pandemics like COVID-19, physicians often struggle with seemingly irreconcilable motivations and are forced to make unanticipated choices.23,24 One study found that, in the face of public health crises, willingness to work on the frontlines was enhanced when conflicting emotions about the disease were resolved.18
Although we all suffer the psychological consequences of social isolation during a pandemic, this psychological stress on physicians is furthered by work-related trauma.25 With social support stripped away, physicians are likely to benefit from psychological support provided through their work or through the support of professionally trained psychologists or psychiatrists.
The details of the mental health of those caring for COVID-19 patients have not yet been reported,26 and critical data points are likely to show up in the future. However, protecting the mental health of healthcare workers is important not only to reduce the psychological suffering that these workers face but also because psychological distress threatens to reduce these workers’ willingness or ability to continue their essential roles on the frontlines. Researchers suggest that, in addition to enhancing preparedness among physicians and other healthcare workers, we also need psychological tools and perhaps healthcare professionals focused on the psychological impact of biologic threats to help healthcare workers cope with the stress and anxiety of facing pandemics.14 By minimizing the adverse psychological effects on physicians, we protect these critical workers and the integrity of the healthcare system.