The impacts of the COVID-19 pandemic on the mental health and residency training of family medicine residents: findings from a nationwide cross-sectional survey in Turkey

The World Health Organization (WHO) defined COVID-19 as a pandemic on March 11, 2020 consequent to the spread and severity of the virus [1]. Many hospitals, emergency rooms, almost all in-patient departments, and intensive care units were suddenly overwhelmed with suspected and confirmed COVID-19 patients, and functioned at full capacity [2]. As of 17 June 2021, more than 5 million people in Turkey have been infected with COVID-19 and the number of deaths has exceeded 49 thousand including a considerable number of healthcare professionals [3]. Since the beginning of the COVID-19 pandemic, measures have been taken to reduce the spread of the virus such as stopping reciprocal flights to countries with a high number of cases, closing kindergartens and schools, and implementation of legal arrangements and incentives to provide opportunities to work from home. Curfew for people aged above 65 and for young people aged under 20, temporary curfews, and a full lock-down on April 2021 due to the extreme increase in COVID-19 cases in Turkey have been implemented by the government. Pandemic hospitals were established in anticipation of increasing case numbers. By April 2020, contact tracing (filiation studies) teams were established for the purpose of finding cases and contact tracing in the field of pandemic control [2, 4, 5] More than 38 million doses of COVID-19 vaccines have been administered to date [3].

The pandemic related unpredictable circumstances forced healthcare systems to rapidly reorganize their network to optimize resources and reduce the spread of COVID-19 and within this framework, the COVID-19 pandemic resulted in the switch from person-centered care to community-centered care. Increased incidents of the COVID-19 infection forced healthcare professionals to put other preventive health services and management of non-communicable diseases (NCD) on the back burner, and has resulted in a decrease of person-centered care [6]. Supplies, medical devices, and drugs were produced, purchased, and procured at short notice within Turkey and all healthcare system employees were redeployed to manage COVID-19 patients. Overall, this trajectory has rapidly led to a substantial decrease in medical practice other than COVID-19, like NCD management, in Turkey [7] and consequently, may result in ongoing disruption threatening the continuum of residency training [8].

WHO has stated that countries should strengthen their primary care systems in the fight against the COVID-19 pandemic. In addition to pandemic action plans, such as determining potential cases as soon as possible, it is also expected that primary healthcare services should continue to be responsible for the well-being of the individual and society, by ensuring the provision of primary healthcare and preventive medicine practices, including vaccination and infant-child monitoring [9]. Family doctors, as a primary healthcare provider, have an important role during the pandemic, with comprehensive healthcare services independent of age and gender provided by accessible primary care clinics (PCC) [10]. FM residency training increases the quality of primary care services in line with WHO recommendations. Clinical training of residents to adopt FM core competencies and rotation training are required for a comprehensive and holistic approach. Studies conducted in FM clinics during the pandemic have shown that one of the main problems in resident training is the uncertainty about how their rotations will be affected by the pandemic in the long term [11].

It has been stated in literature that healthcare professionals require mental health support during the pandemic and that the implementation of relevant policies and interventions by managers is a vital need [12‐14]. Mental health disorders including post-traumatic stress disorder, anxiety disorder, depression and burnout syndrome occur in physicians due to working conditions, increased stress, resource limitations, and uncertainty of physical safety [12]. It has been reported that the uncertainty resulting from the interruption of training programs and rotations, as well as the constant change of planned workplace rotations, due to the pandemic has also negatively affect the mental health of physicians. As such, an education programme should be intentionally prioritized [15]. Worldwide, face-to-face training programmes were translated to online formats and thus the continuation of the training programmes was ensured [16].

Residents have the most prolonged direct contact with suspected or confirmed cases of COVID-19, resulting in enhanced mental and physical stressors [17] and it is impossible to ignore the adverse impact the COVID-19 pandemic has had on residents, residency training and primary health care services. The aim of this nationwide survey was to investigate the effects of the COVID-19 pandemic on FM residents in Turkey, including the levels of depression and burnout in this period.

The results of the present study show that, FM residents have spent less time in their departments, and instead, have taken on frontline duties in the fight against the COVID-19 pandemic. Both the duration of participation in educational activities and of working in their own departments decreased, resulting in less opportunity to engage with and learn FM core competencies and concepts.

We thought that all residents took an active role in the fight against COVID-19, regardless of seniority due to the insignificant difference between the time spent in residency and the average weekly contact time with COVID-19 positive patients.

The residents’ acquisition of clinical competencies outside the department was limited due to the reduction of both departmental training activities and rotations. 86.4% of residents stated that external rotations were negatively or very negatively affected (Table 4). The negative impact of the COVID-19 pandemic did not only affect FM residents, but also residents from other specialties. During the pandemic, residents were reported to work in most branches of the healthcare services and were assigned to departments outside their area of expertise, with consequent delay in specialty education [11, 25]. Suspended rotations, postponed face-to-face training and elective operations, due to the spread of COVID-19, were amongst the main problems that significantly affected resident training [25]. Residents, who may not be able to fulfill their clinical rotations, complete the minimum required surgeries and clinical competencies, may be subject to the greatest negative impact of this experience deficits [26]. In the United States (US), where the pandemic is intense, changes have been made in surgical residency programmes. 70% of the residents reported working in shifts, 31% reported suspension of some services, 33% reported limitation of annual leave, and 35% reported work re-assignment from non-surgical units to pandemic units [21].

On the basis of our study, CFMRs reported that no change was made to their residency training with a statistically significant higher frequency compared to other residents. It is thought that the probable cause for this situation is that CFMRs only work in the hospital during their rotation and go on such rotation for an average of only 3 months a year. The effect of the COVID-19 pandemic on their residencies could thus have been less than for full-time FM residents, as they continued to work in the PCC in the time period outside their rotation.

The present study shows that resident training hours decreased during the pandemic, with 90.2% of the residents stating that their training programmes were negatively or very negatively affected. In studies conducted with surgical residents in various places, most of the participants reported that COVID-19 had a negative effect on their clinical experience and training programmes [21, 27]. It has been recommended in various literature that resident training should be a priority even under pandemic conditions, and continuous education conferences could help residents to maintain a sense of ‘normalcy’ [15, 28]. The effects of preventive measures to minimize personal interactions during the COVID-19 pandemic is also reflected in training programmes. The effects of cancellations of face-to-face medical meetings were mitigated through recorded lectures, live broadcasts, and online seminars. There are even faculties that see the current pandemic conditions as an opportunity to begin mastering virtual learning [28]. Although webcasts have been increasingly adopted, face-to-face instructional lectures and experience transfer remain the cornerstone of medical education, and failure to sustain such traditional education methods negatively affected residents emotionally and spiritually [16, 29].

Almost 80% of the residents stated that their physical health was negatively or very negatively affected. Among surgical residents in the US, this rate has been reported as approximately 50% [21]. Less than one third of the institutions where residents trained provided all the necessary PPE, and this was associated with lower scores in the depression and burnout scales. In the literature, it has been observed that the lack of sufficient PPE can exacerbate burnout feelings amongst residents [30, 31]. PPE access is reported as protective not only in maintaining physical well-being, but also emotional and mental well-being [32, 33]. In a cross-sectional survey study conducted with general practitioners in Italy, it was reported that contact with COVID-19 positive patients with insufficient PPE was associated with increased depressive symptoms [32]. Mortagniti et al. conducted a study of 2707 health professionals from 60 countries, and reported that 51% of healthcare professionals suffered burnout during the pandemic [33]. Exposure to COVID-19 positive patients together with the consequent making of vital decisions increased burnout, whereas adequate and appropriate PPE was reported to be protective against burnout [33].

It should not be forgotten that working in healthcare is a source of stress in itself, even when there is no pandemic crisis [34, 35]. The fact that there are suicide attempts as well as exhaustion and physical stress in healthcare workers that result in death indicates mental stress [36]. The results of our survey showed that 90.6% of the residents stated that their mental health was negatively or very negatively affected during the COVID-19 pandemic. Previously, in healthcare workers taking care of COVID-19 patients, the prevalence of depression has been reported as 22.8–28% [37, 38]. According to the results of the PHQ-9 and BMS instruments, it was determined that while 30.6% of the residents suffered from moderately severe or severe depression, almost half had a very severe burnout problem or should seek professional help immediately. Depression and burnout levels amongst female residents were found to be higher in this study, similar to recent studies in the literature [21, 31]. In this study, it was noteworthy that married residents or those having children had lower levels of depression and burnout compared to single residents. This may be due to the improved social support for such doctors during the COVID-19 pandemic. According to published data from the US and Japan, depressive symptoms were also observed at higher rates in singles and women [39]. Difficult working conditions with increased stress, resource limitations, uncertain personal security, and increased patient morbidity and mortality during the COVID-19 pandemic have been compared to battlefield conditions. Healthcare providers caring for COVID-19 patients are known to have higher levels of burnout than those in other healthcare settings [40]. Such uncertainty and anxiety predispose residents to stress exposure syndromes such as post-traumatic stress disorder and burnout, as well as increased malpractice and inadequate patient care [12].

Almost 20% of the residents had been infected with COVID-19, and 4.2% of them stated that they continued to work without treatment. A previous study reported that 14.9% of COVID-19 positive residents working in New York City were not quarantined [41]. Given the expected future waves of the COVID-19 pandemic, it is thus suggested that appropriate strategies should be implemented to improve the safety of residents and the sustainability of clinical training [42, 43].

Almost 60% of the residents stated that their greatest concern relating to the pandemic was the fear of transmitting the virus to their families. In a study conducted in Saudi Arabia, 76.3% of residents and fellows were working in pandemic departments, and more than half of the doctors stated that they were mostly concerned about the safety of their families [16]. As with healthcare workers previously, residents were trying to manage their physical and mental health integrity, while having to balance the needs of patients with their own needs and those of their families [44].

The exposure of residents to COVID-19 positive patients is associated with increased burnout [45]. In the present study, it was observed that the duration of contact with COVID-19 positive patients affected residents’ depression and burnout scale scores. Likewise, it was observed that residents working in TRH and University Hospitals, who were frequently assigned to pandemic outpatient clinics and wards, were more likely to have had COVID-19 infection when compared to residents working in PCC. This study determined that COVID-19 infection in residents correlated with serious burnout problems. It has been reported in the literature that doctors who come into direct contact with suspected or confirmed cases of COVID-19 in hospitals are the healthcare professionals most susceptible to this disease, and this situation has multiple negative effects on mental health [46, 47].

Although the sequelae of this pandemic crisis on residents cannot be determined until pandemic eradication, the results of this study reveal what residents have been experiencing throughout the COVID-19 pandemic. It has been put forward that organizational and social psychological counselling and support will reduce mental health problems in healthcare workers during the pandemic [48, 49]. In addition, the support needed by frontline health workers should include basic needs, PPE availability, and childcare support. Counselling sessions and the availability of anonymous psychological support resources (e.g. crisis hotlines), and ensuring the continuation of existing support are considered crucial for health of healthcare workers [50, 51]. We want to emphasize that as healthcare professionals, we need to think about what we can do not only for our patients, but also for our colleagues, juniors, residents and ourselves, for our physical and mental well-being.

Although this is the first study of the effect of the COVID-19 pandemic on FM residents in Turkey, it has the usual limitations of self-administered surveys, especially considering the low response rate. The questionnaire aims to determine FM residents’ perceptions of the impact of the COVID-19 pandemic on their mental health and residency training. Since the participation was based on a voluntary basis, it is possible that residents who have more interest in the subject and have more heightened negative experiences may participate more, resulting in a possible volunteer bias. In addition, the seniority of the residents and their place of work at the time of answering the questionnaire may have influenced their perceptions. The exclusion of incomplete questionnaires from the analysis was another limitation of the present study. It is possible that incomplete questionnaires and omission of answers may have led to insights not previously considered. Another possible limitation, as this study was conducted during the pandemic period, is that it may not reflect the chronic consequences of stress associated with the pandemic. Long-term prospective studies may better reflect the cause-and-effect relationship between the pandemic conditions and residents’ physical and mental health. However, the detection of important findings including the depression and burnout states of residents, lack of training opportunities, and the requirement of necessary precautions reveal the importance of the study.

As in other worldwide disciplines [16, 48, 52], the COVID-19 pandemic has had an adverse impact on FM training programmes for residents working in the frontline during the COVID-19 pandemic in Turkey. This creates the need for educational institutions to create a consensus to develop and implement innovative education techniques to compensate for such deficiencies. Heavy workload and disruption in residency training caused by the pandemic is closely related to increased depression and burnout. Due to the unpredictability of the pandemic, evidence-based decisions, and long-term action plans should be implemented to better address the educational needs of residents, as learners and frontline care providers, and to protect their physical and mental health.