Psychological distress among infectious disease physicians during the response to the COVID-19 outbreak in the Republic of Korea

An infectious diseases (ID) physician has an important role when dealing with emerging diseases such as coronavirus disease 2019 (COVID-19). ID physicians have a combined role in participating in patient care and providing advice based on scientific evidence for prevention strategies to each medical institution and government [1]. Since the 2000s, the Republic of Korea (ROK) has experienced several ID outbreaks, including the H1N1 influenza pandemic in 2009 and the Middle East respiratory syndrome (MERS) outbreak in 2015 [1, 2].

The first case of COVID-19 in the ROK was diagnosed in a person who entered from Wuhan, China, in January 2020 and, since then, the ROK has been combatting the COVID-19 pandemic. A large-scale outbreak occurred in Daegu and surrounding areas that was linked to a religious event held in mid-February, followed by several smaller outbreaks throughout the ROK and, by the end of April 2020, a total of 10,752 patients with COVID-19 had been confirmed, along with 244 COVID-19-related deaths [3].

In response to the COVID-19 outbreak that has continued for more than three months, the psychological effects of this outbreak on medical staff has been analyzed in several countries [4, 5]. However, there has been no analysis of the psychological effects on ID physicians, specifically, specialists who have played a pivotal role in responding to the COVID-19 outbreak in many countries, including the ROK. This study aimed to analyze the extent of psychological distress among ID physicians in the ROK during the COVID-19 outbreak. Moreover, we aimed to investigate factors protecting against psychological distress and the difficulties facing ID physicians when dealing with the COVID-19 outbreak to determine their specific work-related requirements.

During the COVID-19 outbreak, the prevalence rate of burnout among the ID physicians in the ROK responding to our survey was 90.4%. There have been inconsistencies in defining burnout and in the assessment methods used to identify burnout across studies; however, our results showed higher burnout than those of a previous meta-analysis involving physicians, which reported a burnout range from 0 to 80.5% [9]. Compared to studies conducted in 1992 and in 2008 in the United States involving ID physicians that reported burnout levels of 40–50%, the prevalence of burnout in our study was considerably higher [7, 10]. Our results showed that ID physicians experienced burnout more during the COVID-19 outbreak. One study, undertaken during the COVID-19 pandemic at an oncology ward in Wuhan, China, reported the prevalence of burnout among oncology physicians and nurses was 26%. Unexpectedly, the prevalence was significantly lower for frontline medical personnel than for those working in the oncology ward [5]. In our study, direct COVID-19 patient care resulted in long working hours and night duty; however, the frequency of burnout and the levels of depression, anxiety, and stress did not differ significantly between ID physicians who cared for patients with COVID-19 and those who did not. Moreover, female ID physicians were found to report a significantly higher frequency of psychological issues in depression, anxiety, stress, and emotional exhaustion compared to males. It is possible that they may be at risk because of undertaking greater responsibilities for childcare and household duties due to social changes occurring at the start of the pandemic, such as the closure of schools and delays in their re-opening.

In November 2019, there were 255 ID physicians working in the ROK, who comprised only 3.2% of subspecialized internal medicine doctors. The number of ID physicians was 0.5 per 100,000 people, which is a lower ratio than the number of ID physicians working in the United States (2.8 per 100,000 people) [11]. ID physicians play an important role not only in the outbreak response to COVID-19 but also in direct patient care, infection control, antibiotic stewardship, education, disease surveillance, and outpatient antibiotic therapy [12, 13]. Concerning patient care, intervention by ID physicians has been reported to be significantly associated with lower mortality rates, shorter hospital stays, and reduced healthcare costs [14, 15]. Many studies have shown that consultation with ID physicians can optimize antibiotic prescription [16, 17]. In a study conducted in a large Korean hospital, one ID specialist-led antimicrobial stewardship program concerning antibiotic use resulted in a meaningful reduction in antibiotic use and a decrease in the antibiotic resistance rate without changing the mortality rate [17]. However, despite the proven efficacy of ID physician intervention, much of their work has been reported to be undercompensated [18].

During the COVID-19 outbreak, most respondents felt valued in their work and had been recognized by others. However, > 90% of respondents considered that there was a shortage of adequate staff and inadequate financial compensation. Supporting medical staff and infection control practitioners who directly care for patients with COVID-19 was found to be a more urgent requirement than dealing with issues arising due to a lack of PPE or AIIRs. All respondents were working in hospitals, and more than two-thirds worked in university-affiliated hospitals. Furthermore, > 40% of the ID physicians were ID Department Directors or Directors of an Infection Control team. Our results showed that most ID physicians in the ROK played various roles, not only in terms of patient care but also in infection control, administration, education, and research.

The ROK experienced a MERS outbreak in 2015; however, only approximately 50 ID physicians had been subsequently trained by 2020, with only 10 applicants for the ID specialty annually (data not shown). During an infectious disease crisis, ID physicians have acted as coordinators and have been at the forefront of the response to the outbreak and in providing patient care, but they have been reported to be inadequately compensated by relevant institutions or governments [1]. This latter factor may have led to fewer applicants for the role of ID physician or as ICP. A shortage of ID physicians is likely to require greater participation in various duties related to caring for confirmed patients with COVID-19 and in infection control with a more demanding workload, resulting in a higher likelihood of psychological distress such as burnout, depression, anxiety, and stress.

In the survey, only 40% of the ID physicians responded that they were satisfied with their work and that they would select to be an ID physician again if they had another chance to choose their specialty. However, 76% of the respondents indicated they felt a sense of responsibility and pride in their work in combatting COVID-19. In particular, female ID physicians were found to have significantly lower satisfaction than males. This may also be related to the psychological distress reported as experienced by female ID physicians, which was worse than that reported for their male colleagues. One Korean study of gastrointestinal physicians highlighted a work-life imbalance, and burnout was found to be most severe among young female gastrointestinal physicians due to additional pressure to address domestic requirements [19]. In our study, this factor could also be a possible explanation for differences between male and female ID physicians, as female ID physicians reported feeling considerably more pressure than male ID physicians in terms of childcare commitments. Further research is needed to confirm whether this factor is important in relation to ID physicians. In addition, this apparent sex difference needs to be re-evaluated outside of the COVID-19 outbreak.

This study had some limitations. As only ID physicians were surveyed, it would be difficult to draw conclusions in terms of other specialties. Further, the response rate was only 43.3%, and the responses obtained may not be accurately representative of the ID physician population. Because of the relatively short response time, it is possible that busy respondents could not answer. However, it would have been challenging to attain a higher response rate, despite the survey time having been extended for > 5 days, because of the reality of time constraints and high workload volumes due to the COVID-19 outbreak during this survey period.

The findings of our study showed that the COVID-19 outbreak imposed considerable psychological distress on ID physicians and that greater numbers of ID physicians and support staff were needed for patient care and infection control. Strategies to secure human resources are crucial to prepare effectively for future epidemics and pandemics.