**3. What is physician burnout?**

Burnout was a term originally defined by psychologist Herbert Freudenberger in a 1974 article titled, "Staff Burnout", essentially discussing job dissatisfaction precipitated by work-related stress [9]. Physician burnout is defined as a syndrome related to the healthcare profession involving emotional exhaustion, depersonalization or decrease in personal satisfaction [9]. In May 2019, the 11th revision of the International Classification of Diseases (ICD-11) included a more detailed definition

**Figure 1.** *The 3 domains of physician burnout as adapted from west et al. [10].*

of burnout, characterizing it as a chronic work-related syndrome that can be assimilated into the healthcare profession. This definition of burnout incorporates three different domains including: feelings of energy depletion or emotional exhaustion, increased mental distance from one's job or feelings of cynicism or negativism about one's job and reduced professional efficacy [10]. Additionally, the WHO designated burnout not as disorder, rather a phenomenon. Physician burnout correlates to lower patient satisfaction, higher rates of medical errors and malpractice, higher physician turnover and predisposition to substance abuse, addiction and suicide [11]. Presently, the epidemic of physician burnout in the United States is being appreciably addressed in the setting of post-doctoral education to deter the adverse consequences that contribute to the conveyance of substandard healthcare that quite often originates as a resident/fellow and propagates into one's practice as an attending physician (**Figure 1**).

#### **4. Physician burnout in physician trainees before COVID-19**

Prior to the COVID-19 pandemic, physician burnout among post-doctoral trainees was becoming immensely problematic with an alarming increase in the prevalence and pervasiveness of this phenomenon. A 2018 excerpt in the Journal of the American Medical Association (JAMA) illustrated this alarming increase in physician burnout through two studies. One of the studies surveyed about 3,600 second-year residents and illustrated that approximately 45% of the residents encountered burnout whereas approximately 15% of said surveyed residents regretted practicing medicine [12]. Also, this study indicated a higher prevalence of burnout among physician trainees versus non-healthcare personnel (28.4%). Per the second study included in the 2018 JAMA excerpt, 182 articles spanning 1991–2018 surveyed approximately 100,000 trainees in 45 countries in regard to burnout. The prevalence of burnout varied from 0%–81% including emotional exhaustion, depersonalization or negativism, reduced professional efficacy or a combination of all three domains [12]. In contrast, Monsalve-Reyes et al. (2018) demonstrated that a lower prevalence of burnout existed among about 1110 primary care nurses versus their resident trainee counterparts [13]. These examinations exemplify that although burnout is a phenomenon that is able to be encountered by any laboring individual, it is evident that the physician trainees suffer from a higher prevalence of burnout, even in comparison to other individuals involved in healthcare.

Analogous to the COVID-19 pandemic, previous pandemics including the 2009 Influenza A (H1N1) pandemic and the 2014 Ebola Virus Disease (EVD) pandemic, exemplify that an emotional burden exists pertaining to not merely alterations in an individual's behavior, rather predilection to mood disorders. This is consequential of medically managing symptomatic patients infected by a deadly disease and encountering deceased individuals of said deadly disease including the bereavement of deceased individuals in your support system. A 2017 excerpt that examined observers of the Ebola pandemic illustrated that 39% experienced difficulty concentrating on errands, 33% experienced difficulty sleeping subsequent to worry and 5–10% experienced feelings of worthlessness, diminished decisiveness or loss of confidence in one's self [14].

Conversely, this excerpt emphasized the significance of a sensation coined "posttraumatic growth", commonly referred to as PTG. This is defined as a positive change in one's behavior as a result of struggle regarding a major life crisis or trauma [14]. PTG is described as an augmentation in different domains including an increase in appreciation for one's existence and others in addition to an improved sense of closeness and cohesion in interpersonal relationships that is conducive to an individual's ability to contest adversity [15]. This is in opposition to remaining in a disparaging

*The Impact of Coronavirus Disease 2019 (COVID-19) on Graduate Medical Education (GME)… DOI: http://dx.doi.org/10.5772/intechopen.96764*


#### **Figure 2.**

*The 4 precipitating factors of post-traumatic growth (PTG) as adapted from Godbold et al. [16].*

#### **Figure 3.**

*The 5 domains of post-traumatic growth (PTG) as adapted from CT et al. [17].*

rotation of maladaptive behavior that is common in mood disorders including posttraumatic stress disorder (PTSD). Also, encountering trauma or substantial distress promotes reprioritization of an individual's commitments through incorporating a revision in their spirituality or sense of self [15]. Therefore, additional studies are merited to examine physician burnout and post-traumatic growth pertaining to

adaptive behaviors as opposed to maladaptive behaviors that are routinely recognized in traumatic experiences, particularly amidst a pandemic (**Figures 2** and **3**).

#### **5. Physician burnout in physician trainees after COVID-19**

Presumably, the COVID-19 pandemic has presented inimitable challenges to the delivery of healthcare, particularly by post-doctoral trainees in residency and fellowship programs. Post-doctoral trainees are predominantly on the forefront of healthcare to acquire an unmediated, practical proficiency in the practice of medicine in addition to addressing the increasing demand for appropriate healthcare. The COVID-19 pandemic has certainly stimulated an increase in the demand of healthcare as substantiated by the cumulative COVID-19-associated hospitalization rate of 364 hospitalization per 100,000 population through January 2021 in contrast to the hospitalization rate of 4.6 per 100,000 population at the beginning of March 2020, prior to the pandemic [18]. The COVID-19 pandemic has undoubtedly exacerbated the preexisting problem of physician burnout, particularly pertaining to post-doctoral trainees. Several studies have examined the presence of behavioral health ailments like mood disorders including depression, anxiety or stress and diminished satisfaction in their corresponding specialties, corresponding to their particular exposure to COVID-19 versus non-COVID-19 patients. Physician trainees exposed to COVID-19 patients encountered higher prevalence rates of mood disorders like depression (28%), anxiety (22%) and overall stress (29%) compared to their non-COVID-19 exposed peers (26%, 15% and 19% correspondingly) and the ordinary populace (12%, 11% and 11% correspondingly), as illustrated by comparable scoring using the Beck Depression Inventory, Beck Anxiety Inventory and the State–Trait Anxiety Inventory [18]. Exposure to COVID-19 patients increased the prevalence of burnout in physician trainees (46%) compared to 33% in non-COVID-19 patient exposure, as illustrated by examination of physical/emotional exhaustion, interpersonal disengagement (depersonalization) and professional satisfaction, using the Stanford Professional Fulfillment Index (PFI) [19]. Exposure to COVID-19 patients did not contribute to the low professional satisfaction scores pertaining to clinical concerns (25.2% vs. 25.9%) [19].

Aside from an increased prevalence of behavioral health ailments like depression, anxiety or stress and diminished satisfaction in their corresponding specialties, the COVID-19 pandemic has impaired the trainee's ability to achieve a balance between professional and personal responsibilities. Physician trainees were queried about common psychosocial stressors, if applicable, including monetary concerns, childcare and eldercare. Additional queries included ability to take time off and interference regarding a trainee's personal responsibilities. Exposure to COVID-19 patients increased the prevalence of stress related to childcare (62%) versus trainees not exposed to COVID-19 patients (39%), an increased prevalence of inability to take time off (74%) versus trainees not exposed to COVID-19 patients (48%) and interference in personal responsibilities (68%) versus 55% in non-exposed trainees [20]. In comparison, exposure to COVID-19 patients did not contribute to an increase in prevalence of monetary concerns (67% for each cohort) or eldercare (82% for each cohort) [20].

#### **6. Negative impact of COVID-19 pertaining to GME training**

Considerable reformation of ACGME/GME policies and procedures pertaining the adverse clinical settings created by the COVID-19 pandemic and physician burnout

#### *The Impact of Coronavirus Disease 2019 (COVID-19) on Graduate Medical Education (GME)… DOI: http://dx.doi.org/10.5772/intechopen.96764*

have been implemented to mitigate the disadvantages and detriments of physician burnout. The ACGME assigned six core competencies to assure competency-based assessment and specialty-specified milestones include: patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice and medical knowledge [21]. Historically, these competencies were created to assist not merely in ACGME accreditation of 12,500 corresponding residency and fellowship programs to assure appropriate training of approximately 140,000 trainees, rather to assure that trainees are prepared to address the increasing demands imposed on the healthcare system [21]. This has become increasingly imperative as a result of the COVID-19 pandemic.

Consequential of the increase in demand of healthcare propagated by the COVID-19 pandemic, the ACGME has reiterated the importance of prioritizing the response to the COVID-19 pandemic versus previous GME protocols except appropriate work-hour restraints and resident oversight by attending physicians [22]. This has adversely affected the compulsory volume of patients evaluated by trainees in the inpatient and outpatient settings, including the cancelation of elective procedures. Unfortunately, this has adversely affected proficiency in the practice of medicine derived from pragmatic experience, particularly in specialties that are constructed around procedures. Additionally, trainees have encountered instances of reassignment to assist in the delivery of COVID-19 related medical management, often outside the realm of one's specialty of study and concurrently in the pervasive presence of a shortage of personal protective equipment (PPE) [22]. Although this allows for diverseness in experiential education, the uncertainty of resident rotations including electives and reassignment to the forefront of the pandemic lessens experiences in a trainee's respective specialties. The archetypical medical lectures and symposiums have undeniably been susceptible to the COVID-19 pandemic because of the present CDC's suggestions to abandon in-person instruction. Therefore, transitioning post-doctoral training to adhere to the requirements for distance learning has required innovative implementation to diminish the disruption to medical education delivery and sense of comradery that comes from socialization.
