Perceived implications of COVID-19 on physical,mental and social aspects of resident doctors in a tertiary care hospital

2.1 Research team

The first author is the principal investigator of the study, whereas the second, third and fourth authors are co-investigators. All authors were aware about qualitative research methods. All in-depth interviews were conducted by the first three authors. The first author is an Assistant Professor in the Community Medicine Department. Second and third authors are in the final year of MBBS. The fourth author is an Assistant Professor in the General Medicine Department. Before conducting this research, all authors discussed the purpose of conducting the research and the potential benefits of its findings in the future for residents. The discussion gave a clue to the potential study participants who were likely to be more vocal.

2.2 Study design and participants

Our qualitative study consisted of in-depth, face to face, interviews exclusively of resident doctors from general medicine department who have worked maximum (average duration of 16 months) during the COVID-19 pandemic among all residents from various departments. We used thematic analysis [9] for our research work. The significance of thematic analysis was on identifying, analyzing and interpreting patterns of meaning within qualitative data. The inclusion criteria were: (1) Resident doctors from general medicine department who have worked in COVID-19 wards and (2) resident doctors who gave written informed consent to participate in the study. The sample size was determined by data saturation, i.e. at a point where no novel opinions or perceptions from participants’ experience aroused. We achieved a saturation point after 10 interviews. Interviewers already knew the participants. Residents from each year (first year resident, second year resident, third year resident) and both males and female residents were interviewed to obtain diversity of answers. The study objectives and voluntary nature of study were explained to all participants. They were told that they had the right to answer in any comfortable language or not to answer any given question or stop the interview at any time. Prior permission was taken for audio recording of information and to use that data in research. Written informed consent was taken from study participants after explaining the nature and purpose of study in vernacular (Gujarati) language. They were also informed about the potential benefit and expected duration of the study. Anonymity and confidentiality was assured by numbering the participants instead of using names.

2.3 Procedure

The list of total number of residents enrolled in general medicine department was obtained from administrative department of college. There were a total of 21 potential participants. Each resident was first approached via mobile call explaining them the nature and details of study and was subsequently asked to participate into it. Upon each resident’s approval as a study participant, we conducted semi-structured in-depth face to face interviews on a convenient time to participants between 20–27 December. All interviews were audio-recorded by taking permission from participants. Prior pilot testing had been conducted by the interviewer team to check the appropriateness of questions. One-on-one interviews were conducted in a separate well-lighted room without any disturbances. There were no repeat interviews. The average duration of interviews was 15 minutes (ranging from 8–30 minutes). Methods such as active listening, noting facial expressions of participants and clarifying the spoken statements were used to develop authenticity of data. The researchers sustained an unbiased stance while conducting interviews and kept cordial relations with the participants. Participants were initially asked questions like their age, marital status and number of months of COVID-19 duty. Further broad questions were asked like “Can you differentiate your experience between those days of COVID-19 duties to current days?”, “What difficulties you faced during your duties, how did you manage it?”, “How did you manage to be healthy and what extra precautions or prophylaxis did you take while on duty or off duty?”, “What was the impact on your mental health and how deeply it affected you?”, “How did you cope up or managed those situations, did you receive any support or motivation to face these challenges?”, “Did you have any positive experience during your duties, can you describe it?”. Open ended follow up questions were asked like “What you consider when you say duties are frustrating?”, “What difficulties you faced in treatment part of patient?”, “What change did you feel inside you while taking care of patients”. Leading questions were asked to get deep understanding of the perceived experience. Data analysis was done after data collection. Interview questions were in English, but the answers were in mix Gujarati, Hindi and English language. Audio recordings were then transcribed by the authors in English.

2.4 Ethical considerations

Institutional Review Board approval was obtained from the Ethics Committee our institute to conduct this study (approval no. 1144/22). The authors assure that there was no academic misconduct such as plagiarism, data fabrication, falsification and repeated publications.

2.5 Data analysis

We used the method of thematic analysis which was introduced by Braun and Clarke in 2006 [9]. The analysis includes listening to those audios many times, converting that information into written form in English and thus transcripts were made in Microsoft word. Three authors independently canvassed all available information by reading the transcripts several times to gain deep understanding of meanings conveyed. The discrepancies between authors were settled through mutual discussion among research team and consensus was reached. Utmost care was taken that the original meaning of answers remains retained by peer debriefing among research team. The transcripts were sent to all respective interviewees to check the correctness of transcription. Analysis also included noting of non-verbal facial expression of participants. After a judicious reading of transcript, important statements were extracted from the available information. Main keywords (codes) were labelled to those statements such that those codes could convey entire meaning of that statement. Codes were then compiled under categories, themes and sufficient quotations were mentioned. Finally, findings were then compared and discussed among all authors. Microsoft Excel was used to construct codes and categories.

The unprecedented COVID-19 outbreak has led to an increased number of patients requiring health care opinion. With rising COVID-19 cases, the doctor patient ratio declined steadily. In between many doctors were deputed to severely affected areas contributing more to further decline in doctor patient ratio. Due to this, duty hours at hospital increased with improperly arranged timetable. This resulted in increased work burden on resident doctors with higher workload than usual and disturbed sleeping patterns. With decreased paramedical staff to patient ratio and haphazardly distributed work, doctors had to do activities that were not a routine part of their duty. As the pandemic worsened patients’ endurance to treatment decreased. With critically ill patients it became difficult to determine the prognosis of patients. Such patients required aggressive treatment and constant monitoring. Doctors opined that unlike other clinical scenario which required brainstorming, treating COVID-19 patients was straightforward as they have to follow clear cut guidelines. Healthcare workers were at a risk of contracting COVID-19 from infected patients. Despite taking all precautionary and preventive measures there was still a risk of exposure especially in a high risk setting. Contracting an infection can lead to physical symptoms and may require hospitalization. There was a complete sense of uncertainty of their safety. Wearing personal protection equipment (PPE) such as mask, face shield, gown and gloves for long hours of hot Indian summers was in fact the major contributor to physical distress as it caused significant discomfort, dyspnea and physical exhaustion. The above mentioned factors are just a few factors that directly or indirectly contributed to physician burnout.

Excessive workload, Require constant monitoring, Straightforward Treatment –

“In those days of duties were frustrating with excessive workload and no satisfaction at all, also due to high mortality rate we could not get cure results.” (Second Year Resident) (Third Year Resident)

“Our COVID-19 duties were limited to 8 hours a day, but it required continuous monitoring of patients every half hour and a constant stay near patients. Treating COVID-19 patients was much irksome. All you need to do is to follow clear cut guidelines. There was no much differential diagnosis and brainstorming.” (First Year Resident) (Third Year Resident)

Patient overflow, Decrease doctor patient ratio –

“The number of patients in those days were beyond the capacity of hospital accommodation. I was frightened to work in triage area because I have seen relatives of patients begging, crying and even bowing my feet to admit patients to hospital and we have to explain each of them that there were no vacant beds left.” (Second Year Resident)

“With less doctors and threefold increase in patients it became difficult to manage them. Like ground floor and first floor of hospital was under the responsibility of one intern doctor and one resident doctor as a team.” (First Year Resident)

“We were given deputation to other district hospitals, especially medicine and anaesthesia residents due to which here doctor population decreased even much more.” (First Year Resident)

Improper work distribution –

“Everything right from paperwork, treating patients, communicating with patients’ relatives and counselling them, arranging for ventilators and beds, managing dead bodies and much more was expected to be done by residents alone, and in between if something went wrong residents have to bear the consequences and be answerable. I usually felt that I had to do work that in actual is the work of paramedical and other hospital staff.” (First Year Resident) (Second Year Resident)

Disturbed circadian rhythm –

“During both waves our duty hours were not flexible. For example; eight hours in evening and eight hours in next morning, with few hours break in between. And the next duty might be scheduled one day after. This significantly affected our sleeping pattern.” (First Year Resident) (Third Year Resident)

Uncertainty of safety –

“COVID-19 posed risks to everyone and everywhere. I used to live with my old grandmother during COVID-19 duties, I always worried about her health and my other family members as I might transmit infection to them. I couldn’t guarantee their safety. Due to this I think I passed 2–3 months alone in one single room at my home to ensure health safety of my family members. Also, I might be a source of infection to all other people near me; be it patients, their relatives, neighbours and colleagues. There were significant risks to my health also as there were increased chances of transmission at hospital. This was fuelled by decreased immunity via wearing PPE kit in hot summers, lack of adequate sleep and much more.” (First Year Resident)

Less resources –

“Poor infrastructure, poor supply of drugs and medications, less manpower led to decreased efficiency in treating patients.” (First Year Resident) (Second Year Resident) (Third Year Resident)

Precautions –

“I used universal precautions like wearing PPE kit, maintaining hand hygiene and avoiding contact with face and mouth after interacting with a possibly contaminated environment at hospital. Immediately after duty I used to take bath regularly. I avoided fasting and took balanced diet. I always ensured that my stomach is not empty before going for duty. Apart from this I took two timely dosages of the COVID-19 vaccine.” (First Year Resident) (Second Year Resident) (Third Year Resident)

Separate COVID-19 wards –

“During the second wave, residents were given COVID-19 duties and general wards separately for a certain period of time. This lessened the chances of transmission of infection from COVID-19 patients to non-COVID-19 ones and residents.” (First Year Resident)

While COVID-19 duties were physically exhausting it has led to significant mental distress. Doctors were getting constantly churned due to constant burnout, their mental health has been significantly neglected. The pandemic has brought high levels of stress and anxiety among doctors. They felt sudden increase in their responsibilities of managing serious patients without much guidance and a rapidly changing working atmosphere. Being unfamiliar with disease, its course of progression and recovery from it, doctors suffered through a great deal of emotional needs, worries and questions of patients and their relatives. They sensed their inability to provide quality care to the patients. During the pandemic there was meagre supply of resources to hospitals and resident doctors often had to take tough decisions of prioritising patients and letting other patients suffer from deadly infection without adequate treatment. This always gave them a sense of dis-satisfaction and internal conflicts. They often felt that they could not gave their 100% efforts despite having adequate knowledge and skills. Witnessing seriously ill patients and their deteriorating health, concerns of transmitting virus to loved ones and fears of losing them led to emotional drain and brought intrusive thoughts regarding of painful experiences. With chaos around and the number of faculties being less in number to cope up with the demand of treating increased number of patients and meeting their expectations, there was less time spared for resident doctors by faculties which led to inadequate assistance from consultants which further contributed more to mental distress of resident doctors. They often felt moral-less and helpless. As residency is a crucial time for learning various topics in detail, doctors were quite worried about their less knowledge of internal medicine subfields because during pandemic they felt they could only learn treating COVID-19 patients without much broader differential diagnosis.

Mental distress, Tedious counselling –

“I was stressed because I was not knowing the outcomes of treating a patient, whether he/she will have good prognosis or not. I really could not answer all questions of grieving patients’ near and dear ones.” (First Year Resident)

Expectation beyond capacity –

“I felt that with insufficient guidance from seniors and consultants arising out of decreased number of seniors and consultants as compared to the number of patients, I was given responsibility on forefront to fight alone and manage not only OPD and ward patients but also critical care ICU patients. I was obliged to manage patients anyhow by hook or crook. I think there should be graded learning among residents and professors, with each professor or senior as a guide to junior.” (First Year Resident)

Traumatised with death, Decrease confidence –

“I think I was trapped in vicious cycle. Even though I wanted to do best but with limited resources I was unable to do much. With that I used to encounter minimum 14-15 deaths in my 8 hour of duty which decreased my confidence more. Often at times I felt moral-less and irritated and ended up in fight with patients’ relatives. This worsened my relation with patients also. With less resources and less training, I couldn’t be able to deliver my 100% knowledge.” (First Year Resident) (Third Year Resident)

“The whole ground and first floors of the hospital used to be the responsibility of one intern doctor and resident doctor as team at night. With more critical patients and less manpower I couldn’t be able to give adequate time to each patient. This always deep inside hurts me that with my good knowledge and skills I am failing to save patients.” (First Year Resident)

“My mental health especially during second wave more deteriorated. Even after giving whole treatment of standard protocol, the chance of patient survival was very less. I can remember that I saw 11-12 deaths in my 8 hours of duty. This used to step down in my confidence. Also giving same treatment to all patients with no variation that too with no guarantee of survival led to diffidence.” (First Year Resident)

“Actually, the second wave was threatening for all of the residents. The mortality was very high I have seen death of a pregnant female patient who had triplets in her womb, this was more grievous than anything else. The thoughts of patient death were constantly hitting our mind which became a hurdle to treat other patients too. I was really anxious and stressful while working in a casualty ward.” (Second Year Resident)

Insufficient training, Inadequate support –

“Training in form of computer and power point presentation in room is useless until you don’t give once or twice hands on experience under guidance of experienced faculties.” (Second Year Resident)

“I faced much problems in managing Intensive Care Unit patients. Deciding when to keep any patient on ventilator, with that what parameters to set on ventilators, doing continuous monitoring, taking care whether the patient was worsening or improving was a great challenge. This trouble was overwhelmed by less than expected guidance from consultants or seniors.” (First Year Resident)

Serious patients, Mediocre outcomes, Sudden demise –

“The first wave (slow rise–plateau phase–slow decline) of COVID-19 had stable patients. We could easily manage them on a non-rebreather mask, nasal O2 and bilevel positive airway pressure (BiPap). While during the second wave (sudden rise—peak–sudden drop) there were more GCS 4 patients. In that even after intubation and with ventilator, chance of patient survival was low and they were difficult to treat. I have seen that patients used to be conscious, cooperative and healthy at one point of time and after half an hour or so, those same patients were deteriorating or have died. Sudden death of patients significantly affected my mental health and there was a constant fear of it.” (First Year Resident)

Less resources –

“In spite of knowing that certain patients are in need of ventilators or BiPap but due to scarce supply of instruments we placed those patients just on simple Bain circuit. Often at times the condition was so worse that we let old moribund patients with questionable benefit deprived of ventilators and instead paid much attention to young and to those whose prognosis can be good. The scenario was so worst that one ventilator was shared by 4-5 patients with each critical patient getting oxygen supply for few hours only. From this I always felt guilty that I was not giving equal treatment to all patients and was biased.” (First Year Resident) (Second Year Resident) (Third Year Resident)

Less diverse learning, Less knowledge –

“During the first wave I was a First Year Resident, so first six months went just treating the COVID-19 patients, giving them same treatment as per guidelines was quiet boring, that too sometimes death was inevitable despite of good treatment. This I considered it to be more as backlash because I felt that I knew nothing apart from treating COVID-19 patients, as in regular wards we have patients with many different diseases with more differential diagnosis and more diverse learning. I feared of my inadequate knowledge about internal medicine subfields.” (First Year Resident)

Self-belief –

“I tried to be mentally healthy because I personally believed that if we will lose our confidence then it will worsen the situation and may decrease quality of patient care more by ourselves. Therefore, I tried hard not to get disheartened by self-motivation, talking with colleagues and family members. We even counselled patients and their family members to stay strong and keep giving efforts in these difficult times and together we will fight and everything else is in hands of God.” (First Year Resident)

Many resident doctors used to live away from home during their duties. With increased burden of work, insufficient support from seniors, fear of scolding from consultants etc. resident doctors began feeling lonely. To overcome their loneliness, they talked with their colleagues and family members to relieve their stress. To acknowledge the well-being of resident doctors, hospitals were organizing counselling sessions, some doctors felt the initiative very helpful for themselves, while many felt it as a formality session and not so beneficial to them. They also considered rumours from community as a hurdle in combating the virus.

Ray of hope –

“I was really unhappy, me and my colleagues were constantly under depressive thoughts. We stayed confident and altogether thinking that this tough situation might end soon.” (Second Year Resident)

Talk with family members –

”I used to make a phone call to my mom whenever I felt low in confidence or after a bad day at hospital. Often my parents used to sympathise me and provided emotional support”. (First Year Resident)

Formality sympathy session –

“Our department frequently conducted various seminars related to the pandemic and tough situations sympathizing us by telling that you are not alone in this. Moreover, government also felicitated doctors by showering flowers and giving us a tag of COVID-19 warriors, society also endorsed our work. I feel that this was only a formality because in actual the working environment was very poor (scarce ventilators, inflexible duty hours, inadequate senior support, frequent quarrels between doctors and patient relatives, summer and PPE kit) and didn’t change at all even after complains. There was constant physician burnout.” (First Year Resident)

“Counselling sessions conducted by department weren’t fruitful.” (Third Year Resident)

Inadequate senior support, No shared responsibility, Fear of scolding –

“We had a timetable of equally divided duty hours among first, second and third year residents on paper. But in real only first year residents had to bear majority of workload, we got very little support from seniors and consultants. Our senior helped us only during the second wave when the number of cases increased. I think there should be a graded learning among residents and professors, with each professor or senior as a guide to junior.” (First Year Resident)

“We received less than expected support from seniors or consultants. I always feared of them because if anything went wrong they might admonish us.” (Second Year Resident)

Spoiled personal relations –

“COVID-19 duties were frustrating. I think it was a test to check our patience level. Often I lost my temper after a quarrel with patients’ relatives and I vented my anger on near and dear ones.” (Second Year Resident)

Rumours from the community –

“Community people are responsible for false rumours and myths related to COVID-19 which deteriorates the situation more. At first when the COVID-19 vaccine was introduced into the market people started gossiping about its adverse effect of developing paralysis, possible impotence and much more. This was a hurdle to develop herd immunity. Many old people just reluctant to get admit to the hospital even after getting diagnosed positive because of inherent fear and the talks they have heard from people that doctors just charge hefty money by keeping you admitted to hospital for over a month and treating by giving just multi-vitamins and one antibiotic.” (First Year Resident) (Third Year Resident)

Doctors are foundations of any strong health care system. Often when doctors are happy they treat patients well with their full potential. Few factors have played a pivotal role during COVID-19 that gave doctors a sense of self-esteem and confidence. During their duties doctors pondered deep within themselves and realised their improved efficiency at work and potential of working tirelessly. They felt unstoppable. Appreciation from patients and their relatives motivated them to work even more harder. There was increased bonding between doctors and patients and their relatives. They could also feel a sense of brotherhood between colleagues and residents from other department where they joined hands together in combating covid. Moreover, when patients recovered from severe disease or after intensive care resident doctors felt that their perseverance of treating patients brought fruitful results and sense of self-satisfaction.

Cooperation –

“Patients’ cooperation with treatment. I remember one patient who was discharged after 56 days of hospital stay, he aroused a ray of hope and confidence in me.” (First Year Resident)

Improved efficiency –

“With increased patient load I learned to be perseverant. I learned to manage comorbid patients, how to deal with colleagues in cases of misunderstandings, handle a difficult situation like tackling bereaved patients’ relatives and most importantly not to lose temper easily.” (First Year Resident) (Second Year Resident)

Cooperation between departments –

“During the peak time of COVID-19 cases all residents from preclinical, para-clinical and clinical departments helped us in treating patients. The Department of General medicine, Pathology, Microbiology and all others significantly contributed to patient treatment.” (First Year Resident)

Spiritual environment, Increase bonding, Improved communication skills –

“With increasing COVID-19 cases and high number of deaths even the healthy patients’ mental health began deteriorating. Seeing death of 3-4 patients one by one within a one-hour span, other patients in same ward feared of their health. At that time, we doctors not only treated them with medicines, but also provided them with full emotional support by singing devotional songs for them, playing musical instruments, make a phone call to patients’ near and dear ones, listening to their complains and responding wisely etc. Infact it felt like we were the next family members of those lonely patients.” (First Year Resident)

Felt unstoppable and appreciated –

“I think blessings in life contribute to our success. Many patients here in government run hospitals are from low socio-economic class. I always felt unstoppable especially when those poor helpless patients and their relatives blessed me from their bottom of the heart upon improvement in their health status or discharge from hospital. Often they appreciated me for my work and wished me good luck and future.” (Second Year Resident)

Recovery as hope for others –

“As patients after a long stay at hospital were discharged after their recovery, our team of residents always felt a sense of confidence within us and gave us enthusiasm to treat other patients too with same vigour. Patients’ discharge and recovery often set example for other critically ill patients that they too can get well.” (First Year Resident)

Increased Compliance, Wean from BiPap –

“I feel that timely intervention with appropriate dosages of medicines and proper nursing care increased patient compliance.” (First Year Resident)

“I felt rewarded when I discharged patient upon their recovery or when they used to get wean from BiPap/ventilator to simple nasal O2”. (First Year Resident) (Second Year Resident) (Third Year Resident)