Physician preparedness for resource allocation decisions under pandemic conditions: A cross-sectional survey of Canadian physicians, April 2020

Psychological Impact of the COVID-19 Pandemic on Canadian Surgical Residents: A Province-Wide Study

OBJECTIVES

The objective of this study was to evaluate the psychological impact of the COVID-19 pandemic on surgical residents.

DESIGN

An online survey was distributed evaluating multiple domains: demographics, health and socioeconomic factors, clinical experience, educational experience, and psychological outcomes. The Mayo Clinic Resident Well-Being Index (RWBI) was used as a validated measure of resident mental health.

SETTING AND PARTICIPANTS

Surgical residents from University of British Columbia's surgical residency programs.

RESULTS

A total of 31/86 surgical residents responded to the survey. Of which, 57% and 46% reported feeling burned out or depressed, respectively. Residents who were concerned about personal protective equipment supply and who lived with family members with comorbidities had a higher risk of depression (p = 0.03, p = 0.04). The median Mayo Clinic Resident Well-Being Index was 2.5, higher than the median of 2 observed in the United States national survey of residents.

CONCLUSIONS

The pandemic had a considerable negative impact on the psychological well-being of surgical residents.

Evaluating the impact of COVID-19 pandemic on the physicians' psychological health: A systematic scoping review

Background

COVID-19 has endangered healthcare systems at multiple levels worldwide. Published data suggests that moral dilemmas faced during these unprecedented times have placed physicians at the intersections of ethical and unethical considerations. This phenomenon has questioned the physicians' morality and how that has affected their conduct. The purpose of our review is to tap into the spectrum of the transforming optics of patient care during the pandemic and its impact on psychological wellbeing of physicians.

Methods

We adopted the Arksey and O'Malley's framework, defining research questions, identifying relevant studies, selecting the studies using agreed inclusion and exclusion criteria, charting the data, and summarizing and reporting results. Databases of PubMed/Medline, Web of Science, Scopus, Science Direct, CINAHL, and PsycInfo were searched using a predefined search string. The retrieved titles and abstracts were reviewed. Later, a detailed full-text analysis of the studies which matched our inclusion criteria was performed.

Results

Our first search identified 875 titles and abstracts. After excluding duplicates, irrelevant, and incomplete titles, we selected 28 studies for further analysis. The sample size in 28 studies was 15,509 with an average size of 637 per study. Both quantitative and qualitative approaches were used, with cross-sectional surveys being utilized in all 16 quantitative studies. Using the data from semi-structured interviews, several discrete codes were generated, which led to the identification of five main themes; mental health, individual challenges, decision-making, change in patient care, and support services.

Conclusion

This scoping review reports an alarming rise in psychological distress, moral injury, cynicism, uncertainty, burnout, and grief among physicians during the pandemic. Decision-making and patient care were mostly regulated by rationing, triaging, age, gender, and life expectancy. Poor professional controls and institutional services potentially led to physicians' crumbling wellbeing. This research calls for the remediation of the deteriorating mental health and a restoration of medical profession's advocacy and equity.

Physician questions and concerns related to COVID-19: a content analysis of advice calls to a medico-legal helpline

BACKGROUND

With the onset of the COVID-19 pandemic, physicians have had concerns related to the impact of the pandemic on their practice of medicine. Our objective was to evaluate physician questions and concerns related to the COVID-19 pandemic by studying physician calls made to a medico-legal telephone helpline, and explore associations between the pattern of these calls and the temporal progression of the pandemic.

METHODS

We conducted a descriptive study of calls related to the COVID-19 pandemic to the Canadian Medical Protective Association (CMPA) from Jan. 1, 2020, to June 30, 2021. Using content analysis, we classified calls into themes. Using a Poisson regression model, we tested for associations between the weekly numbers of physician calls related to COVID-19 and national rates of COVID-19 cases and deaths.

RESULTS

We analyzed 3810 COVID-19-related calls. The highest call volume was observed during the pandemic's early months and was widely distributed across the country. Call volume correlated with rates of SARS-CoV-2 infection during the pandemic's first wave (p = 0.002) but not across the entire study period. Call themes included virtual care (826 calls), the pandemic's effect on health care (1160 calls) and challenging patient interactions (1091 calls).

INTERPRETATION

We observed high volumes of physician calls to a medico-legal helpline during the first 18 months of the COVID-19 pandemic in Canada. Our data provide insight into the questions and concerns of Canadian physicians, and serve as a contemporaneous account of the adaptability and resilience of physicians during this challenging time.

“Everything has been tried and his heart can’t recover…”: A Descriptive Review of “Do Everything!” in the Archive of Ontario Consent and Capacity Board

Background

In end-of-life situations, the phrase “do everything” is sometimes invoked by physicians, patients, or substitute decision-makers (SDM), though its meaning is ambiguous. We examined instances of the phrase “do everything” in the archive of the Ontario Consent and Capacity Board (CCB) in Canada, a tribunal with judicial authority to adjudicate physician–patient conflicts in order to explore its potential meanings.

Methods

We systematically searched the CCB’s online public archive from its inception to 2018 for any references to “do everything” in the context of critical care medicine and end-of-life care. Two independent assessors reviewed decisions, collected characteristics, and identified key themes.

Results

Of 598 cases in the archive, 41 referred to “do everything” in end-of-life situations. The phrase was overwhelmingly invoked by SDMs (38/41, 93%), typically to advocate for life-prolonging measures that contradicted physician advice. Physicians generally related “doing everything” to describe the interventions they had already performed (3/41, 7%), using it to recommend focusing on patients’ quality of life. SDMs were generally reluctant to accept death, whereas physicians found prolonging life at all costs to be morally distressing. The CCB did not interpret appeals to “do everything” legally but followed existing laws by deferring to patients’ prior wishes whenever known, or to concepts of “best interests” when not. The CCB generally recommended against life-prolonging measures in these cases (26/41, 63%), focusing on patients’ “well-being” and “best interests.”

Conclusions

In this unique sample of cases involving conflict surrounding resuscitation and end-of-life care, references to “do everything” highlighted conflicts over quantity versus quality of life. These appeals were associated with signs of cognitive distress on the behalf of SDMs who were facing the prospect of a patient’s death, whereas physicians identified moral distress related to the prolongation of patients’ suffering through their use of life-sustaining interventions. This divergence in perspectives on death versus suffering was consistently the locus of conflict. These findings support the importance of tools such as the Serious Illness Conversation Guide that can be used by physicians to direct conversations on the patients’ goals, wishes, trade-offs, and to recommend a treatment plan that may include palliative care.

Trial Registration

Not applicable.

Potential Circumstances Associated With Moral Injury and Moral Distress in Healthcare Workers and Public Safety Personnel Across the Globe During COVID-19: A Scoping Review

Healthcare workers (HCWs) and public safety personnel (PSP) across the globe have continued to face ethically and morally challenging situations during the COVID-19 pandemic that increase their risk for the development of moral distress (MD) and moral injury (MI). To date, however, the global circumstances that confer risk for MD and MI in these cohorts have not been systematically explored, nor have the unique circumstances that may exist across countries been explored. Here, we sought to identify and compare, across the globe, potentially morally injurious or distressful events (PMIDEs) in HCWs and PSP during the COVID-19 pandemic. A scoping review was conducted to identify and synthesize global knowledge on PMIDEs in HCWs and select PSP. Six databases were searched, including MEDLINE, EMBASE, Web of Science, PsychInfo, CINAHL, and Global Health. A total of 1,412 articles were retrieved, of which 57 articles were included in this review. These articles collectively described the experiences of samples from 19 different countries, which were comprised almost exclusively of HCWs. Given the lack of PSP data, the following results should not be generalized to PSP populations without further research. Using qualitative content analysis, six themes describing circumstances associated with PMIDEs were identified: (1) Risk of contracting or transmitting COVID-19; (2) Inability to work on the frontlines; (3) Provision of suboptimal care; (4) Care prioritization and resource allocation; (5) Perceived lack of support and unfair treatment by their organization; and (6) Stigma, discrimination, and abuse. HCWs described a range of emotions related to these PMIDEs, including anxiety, fear, guilt, shame, burnout, anger, and helplessness. Most PMIDE themes appeared to be shared globally, particularly the 'Risk of contracting or transmitting COVID-19' and the 'Perceived lack of support and unfair treatment by their organization.' Articles included within the theme of 'Stigma, discrimination, and abuse' represented the smallest global distribution of all PMIDE themes. Overall, the present review provides insight into PMIDEs encountered by HCWs across the globe during COVID-19. Further research is required to differentiate the experience of PSP from HCWs, and to explore the impact of social and cultural factors on the experience of MD and MI.

Pandemic Preparedness

Pandemic preparedness is a key function of any health care facility. Activities pertaining to pandemic preparedness should be developed and maintained within a broader emergency management plan. The use of a Hospital Incident Command System can centralize coordination of the response and facilitate internal and external communication. This review addresses several components of pandemic preparedness, including incident management, health care personnel safety, strategies to support ongoing clinical activities, and organizational communication during a pandemic. Preparations addressing potential ethical challenges and the psychological impact associated with pandemic response are also reviewed.

Perceptions, Experiences, and Challenges of Physicians Involved in Dementia Care During the COVID-19 Lockdown in India: A Qualitative Study

Introduction: With 5.3 million people living with dementia in India and the pandemic wreaking havoc, dementia care has faced unique challenges during the outbreak, with reduced healthcare access, travel restriction, long-term lockdown and fear of hospitalization. We explored the experiences and barriers faced by the physicians involved in dementia care during the lockdown period. Methods: A qualitative approach was used with purposive sampling. After an initial pilot, 148 physicians were included in the study. They were virtually interviewed in-depth based on a pre-designed semi-structured questionnaire, in areas related to tele-consultations, attributes related to dementia care, challenges faced and way forward. Interviews were recorded, transcribed and thematically analyzed using Nvivo-10 software. Triangulation, peer debriefing and respondent validation were used to ensure rigor. Results: The overarching categories that emerged were "Tele-medicine as the future of dementia care in India," "people living with dementia being uniquely susceptible to the pandemic with a triple burden of: age, ageism and lack of autonomy" and "markedly reduced healthcare access in this population with significant mental health burden of caregivers." The experiences of the physicians were categorized into their challenges during the lockdown period and perceptions related to specific facets of dementia care during the crisis. The general physicians expressed special "unmet needs" of dementia-specific training and specialist collaboration. Most of the participants perceived ambiguity related to the newly released telepsychiatry guidelines. Conclusion: Resource constraints and pandemic burden are currently high. This study looks at the "voices" of those actively providing dementia care during the ongoing crisis and to the best of our knowledge, is the first one from India to do so. Concurring with their experiences, PwD and their families are exposed to multiple vulnerabilities during COVID-19, need tailored care, especially at the primary healthcare level which includes general physicians. These relevant "voices" are discussed in light of the new tele-psychiatry guidelines and further optimization of dementia care in an aging India.