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It Wasn't All COVID-19: Resident Distress and Reasons for It Among Different Specialties During the Pandemic


Traditional stresses of residency training were subjected to the demands of the pandemic.

Despite its critical role in developing competent physicians, residency training has been recognized as a stressful experience for over thirty years.1 The contemporary literature, and no doubt, personal experience tells us that stress, especially as encapsulated in the polar terms of burnout and wellness, remains a challenge in resident education. 2,3 Another layer to the stressors of clinical care and training was created by the impact of COVID-19 on residents, staff physicians, and all health care workers. 4,5 Thus, traditional stresses of residency training were subjected to the demands of the pandemic.

In an earlier study 6 we sought to disentangle the relative contributions of the pandemic, residency training itself and ongoing socio-political influences to the emotional status and/or distress in residents. The impacts on emotional status were found to be both positive (less stress) and negative (more stress). Related to the source of change in these stress levels, 13 factors were seen as predominantly influenced by residency training and 5 factors predominantly influenced by the pandemic. One factor was equally influenced by both and one factors were primarily influenced by the socio-political climate. Such clarification of relative contributions is important for continuing efforts to develop prevention and intervention strategies for the deleterious effects of these stressors on resident burnout and wellness, performance and patient care.

A subsequent and current question is if there are differences in the impact and response to these stressors based on medical specialty. We were especially interested in the impact on internal medicine residents compared to other residency specialties. This comparison was seen as being of importance given that it is typically internal medicine trainees and staff that have (had) the greatest ongoing and most intimate responsibility for Covid-19 patients (while still engaging in usual residency requirements).

We developed a 20-item questionnaire comprised of recognized resident stressors and administered it to 90 residents across four specialties at a university-affiliated health system, obtaining a response rate of 70%: internal medicine (57.1%), emergency medicine (12.5%), general surgery (22.2%), and orthopedic surgery (7.5%).

The survey was administered from October to November of 2020 instructing residents to reference a time period from the start of the academic year July 2020 through September 2020.Residents were asked to indicate for each stress factor if: 1) there was any change to how it affected them; (2) whether that change was in a positive (less stress) or a negative (more stress) direction; (3) the intensity of that change, on 0 to 10 scale; and (4) to what did they attribute the change: residency training, the covid-19 pandemic, the socio-political climate of the country, or other.

We found the mean change in status during this period was 2.66 points on an eleven-point scale. Changes in status were in both a positive and negative direction.

Three factors demonstrated a significant (p< .05) difference between internal medicine and all other specialties. These were ”your trust in societal institutions,” “ your contact with family/friends,” and “your ability to maintain work/life balance.”

In looking at the etiology of these changes in status, in these comparisons, the item, your trust in societal institutions, was most influenced by socio-political factors with 28.57% of residents indicating this as a primary influence. For your contact with family/friends, 36.50% of the residents ranked the pandemic, and for your ability to maintain work/life balance, 49.20% of the residents ranked the residency training as the greatest influence.

The Covid-19 pandemic, with its devastating mortality rate throughout the world, was a unique strain on resident wellness. In the last decade or so, graduate medical education (GME) programs and medical literature have been increasingly and highly focused on resident wellness in the light of high burnout rates among medical professionals. This burnout concern was heightened due to the pandemic.7

This data told us that there were changes in residents’ stress status over the three months coinciding with the start of the residency year and an increase in the severity of the pandemic. Of note, however, not all change was in a negative or more stressful direction. Further, not all specialties were impacted in the same manner, nor was all change seen as the result of the pandemic.

We believe an important lesson here is the differential impacts betweeninternal medicine residents and residents from other specialties. Despite the more direct and prolonged encounter of the IM residents with the COVID-19 patients compared to other specialties,IM residents were found to report instances of relatively more positive change.

The reasons for this are not simple to discern. Pro-active efforts such as modifying work schedules during the pandemic may well have had an effect.8,9 In this specific setting of the survey, the development of support and solution-focused meetings named Frontline Meetings may also have had a positive impact. IM residents providing care to patients in the Intensive Care Unit and clinical floors attended these meetings bi-weekly in protected time to express their concerns and share their experiences.

The meetings provided a forum residents, gave residents a voice and lead to inclusiveness and "being heard." They may have also combatted feelings of isolation by "not being alone" and promoting a sense that "everyone being in the same boat rowing together." 10, 11 The positive reception to these group meetings was such that they have been continued despite the waning intensity of the pandemic.

A final observation comes from the fact that the pandemic coincided with a volatile and polarized socio-political environment. Our limited study tells us that although residents are aware of the socio-political climate, and it does affect their status, it does not do so to the degree of the pandemic or residency training itself.12

While this data is limited, the lessons suggested are instructive. It appears that positive change and experiences can occur even in acutely stressful conditions and may be promoted by innovative and supportive efforts. Related to this, the most important conclusion is that, despite the enormous impact of the Covid-19 pandemic (or other negative influences), traditional residency stressors remain present and problematic (i.e., quantity and quality of sleep). As all our items were impacted by both the pandemic and residency training, the critical efforts to mitigate the potential adverse effects of both (and not just an acute crisis) need to continue.

About the authors

Tabinda Saleem, MD

Internal Medicine Residency Program

UPMC Pinnacle Hospitals

Brady 3, 205 South Front Street, Harrisburg, Pa 17104

Michael J. Asken, PhD

Director, Provider Well-Being

UPMC Pinnacle Hospitals

Brady 9, 205 South Front Street, Harrisburg, PA 17104

Hafiz Qurashi, MBBS, MD

Chief Resident

Internal Medicine Residency Program

UPMC Pinnacle Hospitals

Brady 3, 205 South Front Street, Harrisburg, PA 17104

Yi-Ju Chen, MD

Internal Medicine Residency Program

UPMC Pinnacle Hospitals

Brady 3, 205 South Front Street, Harrisburg, Pa 17104

Anas Atrash, MD, FACP


Internal Medicine Residency Program

UPMC Pinnacle Hospitals

Brady 3, 205 South Front Street, Harrisburg, PA 17104

Special appreciation is expressed to Yijin Wert, M.S. for her statistical help in the preparation of this paper.


1) Butterfield P. The stress of residency: A review of the literature. Arch Intern Med. 1988; 148(6): 1428-35.

2) PilarskiA & Simonson J. Resident well-being: A guide for residency programs. 2017. HcPro, Middleton, MA.

3) Orlovich D. Solving resident burnout. 2020. Horowitz Publishing. Middleton, De.

4) Raudenska J, Steinerova V, Javurkova A, Urits I, Kaye A, Viswanath O, and Varrassi G. Occupational burnout syndrome and post-traumatic stress among healthcare professional during the novel coronavirus disease 2019 (Covid-19) pandemic. Best Practices in Research and Clinical Anesthesiology. 2020; 34(3): 553-560.

5) Shanafelt T, Ripp J, & Trockel M. Understanding and addressing sources of anxiety among health care professionals during the Covid-19 pandemic. JAMA. 2020; 323(21):2133-2134. doi:10.1001/jama.2020.5893.

6) Qurashi H, Atrash A, Asken M. Is it all COVID? Resident Distress and Reasons for It in 2020. Southern Medical Journal, In Press, 2022

7) Taylor W, Blackford J. Mental health treatment for front-line clinicians during and after the coronavirus disease 2019 (COVID-19) pandemic: A plea to the medical community. Ann Intern Med. 2020; Published online May 26: doi:10.7326/M20-2440.

8) Shanafelt T, Noseworthy J. Executive leadership and physician well-being; Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017:92 (1) 129-146.

9) Anton M, Wright J, Braithwaite M, Sturgeon G, Locke B, Milne C, Crosby A. Creating a COVID-19 action plan for GME programs. Journal of Graduate Medical Education. 2020: 12 (4): 399-402.

10) Myers B. Professional support groups inspired by COVID-19: Antidote to physician loneliness and burnout? Academic Medicine. 2021:96 (8): 1082.

11) Rogers E, Polonijo A, Carpiano R. Getting by with a little help from friends and colleagues: Testing how residents’ social support networks affect loneliness and burnout. Canadian Family Physician. 2016: 62: e677-83.

12) Frank E, Nallamothu B, Zhao Z, & Sen S.Political events and mood among you physicians: A prospective cohort study. BMJ. 2019;367:16322.

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