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COVID-19

COVID-19’s Impact on the Mental Health of Non-Frontline Physicians and Physician Assistants

The article examines the mental health of physicians and physician assistants at an Orange County Urgent Care clinic during the COVID-19 pandemic. Through a correlation and statistical analysis, it was determined that the psychological well-being of physician assistants was impacted by the pandemic at greater levels than physicians.

By Alex Sunday

Published 5:41 EST, Sat November 13, 2021

Research Question

How has the COVID-19 pandemic affected the mental health of non-frontline physicians and physician assistants at an Orange County clinic?

Abstract

The COVID-19 virus originated in the Hubei Province of Wuhan, China in December of 2019. The virus inflicted a multitude of mental health detriments onto healthcare workers who were tasked with the treatment of COVID-19 patients. Moreover, a delineation between non-frontline and frontline healthcare workers was soon created as media networks and governments became interested in frontline healthcare at large-capacity hospitals. Unfortunately, in current pandemic research, several generalizations of the mental health of non-frontline healthcare workers (categorizing the group into one variation of healthcare worker) have been made and have led to a heightened focus and justification of this focus on frontline healthcare workers who are often in close proximity to COVID-19 patients. As a result, this research study examines non-frontline physicians and physician assistants to fill in the research concerning the mental health of a variation of non-frontline healthcare workers during the COVID-19 pandemic. Through a case study at a small clinic (comprising five tested variables: risk, physical changes, anxiety, work environment, and technology’s impact on mental health) and a survey research approach, it was determined that physician assistants face higher levels of risk, work environment stress, and adverse implications of technology on their mental health than physicians. This discovery was primarily attributed to closer physician assistant contact with patients and thus more healthcare responsibilities (filing case reports and creating treatment plans) than physicians. Ultimately, from this study’s findings, it is evident that employer action is immediately required as both physician and physician assistants reported high levels of the five variables tested. 

Introduction

The COVID-19 disease originated in Wuhan, China, and was a contagious disease that spread to nations in early January of 2020. COVID-19 altered human interaction, educational institutions, and the mental health of individuals. Eventually, hospitals and healthcare systems in regions with large populations such as New York, Los Angeles, and Beijing became overwhelmed because of the large numbers of patients admitted, coupled with an absence of personal protective equipment (PPE) for healthcare professionals. As a result, global coverage of the COVID-19 pandemic was relayed in major news networks such as FOX News or CNN. This media attention directed focus to frontline healthcare workers (HCWs) in high-risk areas. Importantly, frontline physicians and physician assistants were physically, emotionally, and psychologically strained because of detrimental effects from COVID-19: an influx of disease-carrying patients, lack of employer support, potential risk of contracting and spreading the virus to family, friends, and associates, and years of ensuing psychological trauma. 

As a result of the increased media concentration on frontline HCWs, governmental and corporate networks have neglected the psychological well-being of non-frontline HCWs during the COVID-19 pandemic. Researchers have conducted limited research on the mental health of non-frontline HCWs because of the perceived importance of frontline medical staff who are in closer proximity to COVID-19 patients. Moreover, the research on non-frontline HCWs is concentrated on physicians, indicating that researchers have generalized non-frontline HCWs to be individuals with medical and doctorate degrees rather than acknowledging the subgroups of clinical workers – physician assistants, nurse practitioners, and physical therapists. To reverse these generalizations, this research study uncovers and analyzes the extent to which the mental health of a non-front line clinic’s physicians and physician assistants has been affected by COVID-19. 

Literature Review

Although COVID-19 was discovered recently in December 2019, there has been a copious amount of global research on the virus’s impact on medical employees. Apart from physical health detriments of COVID-19, including chronic respiratory issues and neurovascular effects, HCWs face lasting mental health consequences – anxiety, stress, fatigue, changes in mood, and depressive symptoms – which ultimately hinder their performance in the workplace. These indicators of a decline in mental health are referred to as occupational stressors – psychological determinants that arise from career-related activities. Furthermore, as COVID-19 spread to multiple regions of the world, the delineation between non-frontline and frontline HCWs was exacerbated by researchers and the global population primarily concerned with emergency medicine and large-capacity hospitals. For instance, investigators Kristen Santarone, Mark McKenney, and Adel Elkbuli of the Department of Surgery at the Kendall Regional Medical Center constructed a summative paper describing how physicians face emotional fatigue and burnout attributed to occupational stress in the COVID-19 pandemic. In addition, Santarone and her colleagues documented how frontline physicians are increasingly accustomed to social isolation and are vulnerable to depression and anxiety. Ultimately, the researchers’ descriptive analysis concluded with how medical journals should direct most of their informative solutions when discussing the mental health of HCWs, to solely focus on the betterment of frontline medical workers due to their closer proximity to COVID-19 patients. 

To fully understand the division of non-frontline and frontline HCWs in the coronavirus-2019 pandemic, examining the similar circumstances in the Severe Acute Respiratory Syndrome (SARS) outbreak of 2002 to 2004 is required. Within this context – especially at the epicenters of China, Vietnam, and Hong Kong – many hospitals were overwhelmed by the amount of SARS patients admitted. As a result, the risk of transmission of the virus to frontline HCWs significantly increased and promoted the insurgence of mental health issues. Ping Wu and her colleagues, associate professors for the Department of Psychiatry at Columbia University, researched the psychological implications of SARS on Beijing HCWs at a sizable hospital. Wu and her associates used a mixed-methods cross-sectional study that presented hospital employees with an opportunity to detail their encounters with SARS, including increased work exposure or fear of contracting the virus. The researchers’ study found that ten percent of 549 HCWs at the hospital suffered from post-traumatic stress symptoms up to three years after contact with the SARS virus. Additionally, through descriptive and bivariate analysis, the researchers manufactured a regression equation that illustrated the prevalence of ongoing burnout even after the SARS outbreak. To further strengthen the proposal of severe burnout among hospital employees, the regression equation integrated associations between the prevalence of post-traumatic stress symptoms and two dependent variables – work exposure and quarantining. Although the study provided valuable insight into the mental health of HCWs during the SARS outbreak, a chief delimitation of the research was the deficiency of information on the mental health of HCWs at local hospitals. 

The presence of SARS in the early 2000s coerced world attention and network headlines to focus on medical employees at substantial hospitals instead of non-frontline HCWs that faced a similar degradation of mental health. Additionally, governments and private businesses disproportionately developed solutions in favor of frontline HCWs. Similar to Ping Wu and her associates, Robert Maunder and his colleagues, members of the Department of Psychiatry at the University of Toronto, conducted an observational study at the Mount Sinai hospital and neighboring clinics where HCW descriptions of their ordeals with SARS patients were analyzed. With direct commentary from medical employees, the researchers uncovered an underwhelming amount of hospital protection for HCWs. As a result, Maunder and his associates presented the information to private entities, finding the corporate response to the SARS outbreak – intensive screening and distribution of personal protective equipment (PPE) – to be almost immediate. However, this corporate initiative was only administered for the Mount Sinai hospital as the neighboring clinics were deemed non-essential. Thus, governmental and corporate attitudes toward favoring frontline medical employees are not newly discovered but were highly emphasized during past outbreaks. 

The global public, researchers, and world governments have categorized healthcare workers into non-frontline and frontline HCWs during the COVID-19 pandemic while demonstrating favoritism to individuals with a higher risk of contracting the virus. In a contemporary context, many research publications have attempted to include studies of COVID-19’s impact on the mental health of non-frontline HCWs, unlike in previous global or regional outbreak research. However, these research studies have rarely produced solutions that address the relevant circumstances of non-frontline HCWs. Instead, the research primarily promotes solutions for frontline and non-frontline HCW groups by assuming both worker variations face identical work environments and administrative personnel. For instance, Xie Zhang and his colleagues, members of the Ningbo Medical Centre Li Hulli Hospital in China, conducted a cross-sectional study in Wenzhou, China, on 524 medical staff – 150 of which were frontline HCWs. The study utilized the Patient Health Questionnaire (PHQ), Insomnia Severity Index (ISI), and Occupational Stress Questionnaire (OSQ) to ascertain that frontline HCWs were more susceptible to insomnia, anxiety, and occupational stress as opposed to non-frontline HCWs. As a result, the researchers concluded that the psychological burden of COVID-19 was more intense among frontline medical workers. The cross-sectional study provided crucial information for policymakers to engineer solutions that primarily assisted those with frequent exposure to the virus. Although Zhang and his associates knew the different occupational circumstances between non-frontline and frontline medical workers, they fabricated solutions that were interchangeable for both variations of medical employees resulting in counterproductive research for non-frontline medical workers. Moreover, the researchers generalized non-frontline HCWs as one subgroup of HCW. Ultimately, although comparisons to frontline HCWs address the mental health of non-frontline HCWs during the COVID-19 pandemic, solutions seldom mitigate the decline in the mental health of non-frontline employees who provide healthcare for many individuals. 

Comparable to Zhang and his colleagues, Muna Alshekaili and her research organization, members of the Centre of Studies and Research at the Oman Ministry of Health conducted a cross-sectional study on healthcare settings and mental health of non-frontline and frontline HCWs during the COVID-19 pandemic. The study surveyed 1139 Oman HCWs through a Depression, Anxiety, and Stress Scale (DASS-21) – a screening report aimed at measuring depressive symptoms, anxiety, and stress. Al Shekaili and her associates found that higher frequencies on the DASS-21 were reported in frontline HCWs, indicating a decline in mental health attributed to COVID-19. The cross-sectional study compared demographic and psychological effects in frontline and non-frontline HCWs, illustrating that frontline HCWs were more susceptible to a drastic decline in mental health. Importantly, unlike Zhang and his associates, the Oman cross-sectional study focused on insomnia and sleep deprivation as predictors of COVID-19’s impact on the mental wellbeing of HCWs. However, a similar conclusion was made by the Oman researchers that claimed frontline HCWs should be allotted more governmental and corporate funding because of their closer proximity to the virus. Additionally, Alshekali and her colleagues offered solutions for frontline HCWs, including psychological intervention to ensure the development of coping mechanisms and the promotion of resilience tactics. 

Although there is extensive research published on the mental health of HCWs, governmental agencies and private entities have neglected non-frontline medical workers, opting to direct their resources into frontline medical employees during the coronavirus-2019 pandemic. Additionally, comparative studies on non-frontline and frontline HCWs serve to justify the sole focus on frontline HCWs by engineering solutions for the totality of medical workers using statistics from both worker variations and generalizing non-frontline HCWs as one specific sub-group of HCW. This research malpractice, assuming the impact on the mental health of non-frontline and frontline HCWs is indistinguishable, is detrimental and counterproductive. Furthermore, throughout contemporary research, no efforts have been made to reconcile governmental interests with the wellbeing of employees residing in local hospitals, clinics, and urgent care centers. Regarding bureaucratic unwillingness to assure equal representation of medical workers that face a similar degradation of livelihood, this research study attempts to fill in the gap on the mental health of different variations of non-frontline HCWs by conducting a case study at a local clinic that examines the mental health of non-frontline physicians and physician assistants.

Methodology

This research study utilizes a mixed-methods approach consisting of a case study and survey methodology to measure participants’ mental health and allow for a more focused interpretation of data. Additionally, risk, anxiety, physical changes, work environment, and technology’s impact on mental health were variables that were measured through questionnaires in this research study. Ultimately, it was predicted that physicians would face a more significant decline in mental health due to their perceived, heightened responsibilities in the clinic as opposed to physician assistants. 

Table A. Variable Description

VariablesDescription
RiskThe participant’s psychological response to the possibility of contracting COVID-19. This variable evaluates participant perception of their personal risk compared to other individuals whose employment does not reside in the medical field. Moreover, this variable measures participant perceived safety. 
AnxietyThis variable measures levels of anguish or worry over self-contraction of the virus, family, associate or acquaintance contraction of the virus, and the possibility of future, lasting detriments attributed to COVID-19.
Physical changesDefined as any disruption in normal sleep routine correlated to the emergence of COVID-19. This may take the form of newly-discovered insomnia or any reports of change in sleep. Moreover, participant unproductiveness, mood changes, and affinity to taking on new tasks are measured. 
Work EnvironmentThis variable measures participant opinion on their work environment, psychological support from colleagues, working hours, workload (influx of patients), and employer support.  
Technology’s Impact on Mental HealthDefined as participant opinion on TeleMed (an online medical platform where medical professionals may virtually administer medicine).

Case Study Research

As this research study identifies COVID-19’s effect on the mental health of non-frontline physicians and physician assistants at a clinic, a case study emphasis is required. MeanThat™, an academic research platform, rationalizes that case studies are most effective when concentrating on a selective participant population. Moreover, MeanThat™ claims that holistic case studies, a deviation from a case study that analyzes the totality of situations, are useful for mental health research because of their ability to isolate and identify variables in participants. Following their findings, this research study acquires data from a select number of individuals at a sole clinic. In previous pandemics, a similar case study methodology was used to research HCW mental health. For example, Grainne M. McAlonan and her colleagues, members of the Translational Neuroscience department at King’s College London, researched HCWs during the peak period of the SARS outbreak at two general care hospitals in Hong Kong using a case study methodology. In these hospitals, the researchers instituted questionnaires containing the Perceived Stress Scale-10 item (PSS-10) index in addition to routine observational analysis that was kept constant within both hospitals. The use of a case study allowed McAlonan and her associates to identify the frequencies of mental health detriments in a small number of individuals because of their localized research. Ultimately, their interpretation of data concluded that indicators of stress and burnout persisted in HCWs for approximately one year after the outbreak had concluded. Moreover, McAlonan and her research staff asserted, when selecting their method, that a case study methodology was more beneficial to pandemic mental health research than other approaches such as an experimental method due to a case study’s effectiveness of examining variables within a specific participant population. 

Although case studies are generally effective in pandemic research, they may become one-dimensional if they do not incorporate other sub-groups of research methodology, unlike experimental research, which only requires the identification of variables and control to be effective. As a result, to ensure effectiveness, this research study will utilize survey methods incorporated into a case study approach to provide extensive results, interpretations, and conclusions. 

Survey Research

The final methodology of this research study’s mixed-methods approach entails quantitative survey research. Specifically, this research study utilizes two distinct quantitative surveys: the COVID-19 Questionnaire-8 (Scale) and COVID-19 Questionnaire-9 (MHCQ). The COVID-19 Questionnaire-8 (Scale) is an 8 item scale survey that asks participants structured questions to quantify variables such as workload, risk, and sleep habits. Furthermore, each question has the phrases strongly disagree, disagree, neutral, agree, and strongly agree as possible answer choices. Questions are scored on a 1-5 scale with a potential of a total of 40 points – the higher a respondent’s scores, the more likely their mental health has regressed during the COVID-19 pandemic. The COVID-19 Questionnaire-9 (MHCQ) is a 9 item survey containing questions ranging from anxiety levels to implications of co-workers on participant mental health. Moreover, answer choices consist of a 0-5 index and a “prefer not to respond” choice selection to mitigate any discomfort that may arise from questions. The “0-5” index translates into “never, rarely, once in a while, sometimes, almost always, and always” respectively. The survey is scored on a tally system of 0-5 and each “prefer not to answer” response is omitted from the data. This MHCQ and Scale questionnaire correlates to the Beck Anxiety Inventory (BAI) and Patient Health Questionnaire (PHQ) – questionnaires found in research dissertations concerning COVID-19’s impact on HCW mental health and have also been utilized by the National Institute of Health.

Mental health researchers used survey methodologies in previous pandemics as well as the current coronavirus-2019 outbreak. For instance, Mariela Mosheva and her colleagues, researchers at the Sheba Medical Center in Tel Hashomer, Israel, utilized a survey methodology consisting of the BAI and Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires to conduct their research. The researchers used the BAI and PROMIS systems to measure socio-demographic characteristics, anxiety, and resilience traits. As a result of the quantifiable statistics generated from the BAI and PROMIS, Mosheva and her associates were able to construct a multivariable linear regression model that found that mental exhaustion, fear of contracting the virus, spreading the virus to family members, and disruptions in standard sleep patterns were vital contributors to an HCW decline in mental health. Without statistical data, the researchers would not have drawn accurate and detailed conclusions resulting in counterintuitive research.

Survey research is a generic methodology that is universally applicable to many studies. Thus, pandemic researchers such as Mariela Mosheva and her associates do not solely use surveys to conduct their research. Alternatively, researchers use a combination of survey, interview, experimental, observational, or case study methods to examine the mental health of HCW participants in outbreaks of disease. Specifically, Mosheva and her researchers claimed that a case study approach per survey research was more appropriate for mental health research than observational or experimental methods because of its ability to collect data for a small number of individuals. Importantly, in the modern context of the COVID-19 pandemic, solely quantifiable statistics are not adequate to reach conclusive findings. As a result, this research study uses survey research in addition to case study methodologies to accurately identify and interpret the effects of COVID-19 on the mental health of non-frontline physicians and physicians’ assistants. 

Results

Procedures

During the data collection process, the COVID-19 MHCQ and COVID-19 Scale surveys were instrumental to conducting research. In this case study, 38 non-frontline healthcare workers – 19 physicians and 19 physician assistants – responded to both questionnaires over an allotted seven days. Each participant completed each survey independently without the influence of loved ones, associates, and familiar individuals. In addition to responding to the questionnaires, each participant stated their profession and designation – but for security purposes – their identities became nominal (participant A, participant B, etc.). The questionnaires, COVID-19 MHCQ (9-item) and COVID-19 Scale (8-item), accounted for five variables – work environment, physical changes, anxiety, risk, and technological impact on mental health. 

Work Environment

The Work Environment Variable (WEV) was measured as a combination of scores from the COVID-19 MHCQ and Scale questionnaires. Across the questionnaires, eight questions were presented to the participants, requesting information on their physical work environment, coworkers (their physical and emotional support), workload management (influx of patients and longer shifts), and employer support (monetary, physical, or emotional). Each response had a point value ranging from 0 to 5 points, and the scores were additive, leading to the end range of the WEV: 0-40. Additionally, the scores were divided into six categories (0-7, 8-15, 16-23, 24-30, 31-35, 36+) to delineate among the responses; the subgroupings translated into 0-7: stress-free WE, 8-15: slightly stressful WE, 16-23: stressful WE, 24-30: exacting WE (hinders productivity), 31-35: almost unmanageable WE, 36+: unmanageable WE. The score range 16-30 was prioritized because the intermediate-range indicated a stress-inducing environment, and most responses resided in this range. 

Table A. WEV Questions

Question #QuestionQuestionnaire
2Has your work environment been helpful in managing stress (issuance of beneficial work-related policies, supportive staff, perceived employer empathy/consideration for employees, etc.)?MHCQ
3Do you feel as if your working hours are negatively impacting your mental health (increased presence of stress, more commitments, etc.)?MHCQ
6Have your co-workers positively impacted your mental health (supported you with compassion, understanding, and any other positive emotional qualities)?MHCQ
10How often have you had to trust your co-workers to accomplish something (tasks, support, etc.) for you? MHCQ
2My workload has not been manageable during the last two months (more patients, longer workdays, less physical support concerning the absence of some staff members, etc.)Scale
6My work environment before the COVID-19 pandemic was more tolerable (fewer distractions, absence of fear concerning contraction of disease, etc.).Scale
7During the past two months, I have not received psychological support from my co-workers and friends (daily check-ins, counseling, etc.) Scale
8During the past two months, I have not received support from my employer (monetary, new policies, etc.). Scale

Graph Set A. WEV

Physical Changes

The Physical Changes Variable (PCV) was measured as a combination of scores from the COVID-19 MHCQ and Scale questionnaires. The PCV accounted for unproductiveness, mood changes, affinity to facing new tasks, and change in sleep patterns. Five questions from the COVID-19 MHCQ and Scale questionnaires were needed to test for the PCV. Each response had a point value ranging from 0 to 5 points, and the scores were additive, leading to the end range of the PCV: 0-25. Moreover, the 0-25 point range was categorized into five subgroupings that translated into 0-5: unnoticeable PC, 6-10: irritating PC but nondestructive to medical practice, 11-15: PC conduces slightly intolerable medical practice, 16-20: almost unmanageable medical practice attributed to PC, 21-25: unmanageable medical practice attributed to PC. No score range was prioritized for the PCV data collection process. 

Table B. PCV Questions

Question #QuestionQuestionnaire
9My sleep schedule has suffered as a result of the COVID-19 pandemic. Scale
4During the past two months, have you felt unmotivated?MHCQ
5During the past two months, have you felt unproductive?MHCQ
8Have you noticed any changes in mood?MHCQ
9How often have you been willing, more than usual, to take on new tasks (clinical responsibilities, family responsibilities, etc.)?MHCQ

Graph Set B. PCV

Anxiety

The COVID-19 MHCQ survey measured the Anxiety Variable (AV). Moreover, the AV defined anxiety as a response consisting of fear, dread, and uneasiness; the AV was present in one question of the COVID-19 MHCQ survey. The 0-5 point range translated into 0: no symptoms of worry or fear, 1: slight symptoms of anxiety, 2: symptoms of anxiety are noticeable but do not hinder the quality of medical practice, 3: the slight decline of quality of medical practice attributed to anxiety, 4: noticeable decline in quality of medical practice attributed to anxiety, 5: medical practice is unmanageable/implausible due to anxiety symptoms. A score range was not prioritized for the AV data collection process as the 0-5 point range was categorized into single-digit subgroups.

Table C. AV Questions

Question #QuestionQuestionnaire
5During the last two months, my anxiety levels have increased (increased presence of uncontrollable worry/anguish).Scale

Graph Set C. AV

Risk 

The COVID-19 MHCQ and Scale questionnaires measured the Risk Variable (RV). The RV measured respondents’ perception of risk compared to their acquaintances, families, and colleagues whose careers did not reside in the medical field. Additionally, the RV accounted for the respondent’s perception of safety, or lack thereof, at the non-frontline clinic concerning personal protective equipment (PPE), variations of patients that received healthcare, and an evaluation of colleague precaution to the COVID-19 pandemic. Moreover, the RV was prevalent in three questions in the COVID-19 MHCQ and COVID-19 Scale questionnaires, and a 0-15 point range measured the RV. Specifically, this 0-15 point range was divided into four subsections/categories that translated into 0-3: no fear of participant safety, 4-7: slight fear of participant safety, 8-11: visible symptoms and reservations of administering healthcare during COVID-19 but does not hinder the quality of medical practice, 12-15, the participant was deeply concerned of their safety, thus leading to a decline in their medical practice. A score range was not prioritized for the RV data collection process. 

Table D. RV Questions

Question #QuestionQuestionnaire
3I feel as if I am at more risk than many of my friends/family members whose employment does not reside in the medical field.Scale
4I have worried/been concerned more about my safety during the COVID-19 pandemic than I have ever before.Scale
7Does the risk of contracting COVID-19 have a negative impact on your medical practice (less likely to see new patients, fear of direct contact with patients, a decline in administrative healthcare quality, etc.)? MHCQ

Graph Set D. RV

Technology’s Impact on Mental Health 

The Technological Impact on Mental Health Variable (TIMHV) was measured in the COVID-19 Scale questionnaire. The TIMHV accounted for the TeleMed – a virtual medicine platform for medical practitioners during COVID-19 manufactured for the administration of healthcare – and its impact (ex. difficult for the participant to ensure quality healthcare for their patients) on the mental health of physicians and physician assistants. Additionally, in this context, mental health was defined as a state of personal well-being. The TIMHV was presented to respondents in one question of the COVID-19 Scale questionnaire; the variable had a point range of 0-5 that translated into 0: TeleMed is beneficial for the participant’s mental health, 1: TeleMed’s few drawbacks do not hinder the quality of the participant’s administrative healthcare, 2: software issues are prevalent but do not interfere with participant medical practice, 3: TeleMed is slightly confusing to utilize but manageable for participants, 4: TeleMed’s numerous problems significantly hinder participant mental health, 5: TeleMed is unusable for a participant. There was not a score range prioritized for TIMHV data collection. 

Table E. TIMHV Questions

Question #QuestionQuestionnaire
10TeleMed is helpful in mitigating stress and anxiety (do not have to see patients physically, easy to use and navigate, etc.).Scale

Graph Set E. TIMHV 

Discussion

Correlational/Statistical Analysis

On average, 84.4% of physicians and 94.7% of physician assistants consider their clinical work environment to be slight to moderately stress-inducing. External factors such as an influx of patients or clinical responsibilities (filing more case reports, managing schedules, and creating virtual or in-person appointments for patients) contributed towards negative respondent opinions. Specifically, participants believed that their parent company could exert more effort in mitigating declines in HCW mental health. The 10.3% difference between physician assistants and physicians regarding their outlook on work environment issues may be ascribed to administrative focus on physicians with medical degrees. Although non-frontline physicians and physician assistants are not considered to be as essential as frontline medical professionals, within the employee construct at California clinics, physicians are deemed to be more integral to patient healthcare than physician assistants due to a certain level of expertise and training achieved during medical school and residency programs. In the context of the COVID-19 pandemic, when California healthcare administrative officers consider the employees required in healthcare service, a medical director (MD) is legally obligated to occupy the clinic while physician assistants are deemed optional per the state legislature.

Negative physical changes – unproductiveness, mood changes, changes in sleep pattern, and affinity to facing new tasks – were rampant among both physician and physician assistant respondents. In particular, physicians who scored between 6-20 (89.5%) were 9% higher than physician assistants (79%). However, physician assistant respondents incurred more outliers – 21.1% scored 16+, indicating that COVID-19 incited unmanageable conditions for more physician assistants than physicians. This phenomenon can be attributed to job insecurity among physician assistants because of California’s requirement for clinics to contain more physicians with medical degrees than physician assistants. Moreover, physician assistants were not accustomed to longer working hours and potential burnout because of their nine-to-five workday schedule. Alternatively, before the COVID-19 pandemic, physicians were expected to participate in demanding shifts (12 or more hours per day). For both physician and physician assistant respondent groups, 10.5% agreed that the COVID-19 pandemic did not perpetuate any negative physical changes. This outlier is rooted in situational factors that are common occurrences in the medical field (ex. physicians incurring a relaxed schedule during COVID-19). Similarly, the anxiety variable results determined that 52.6% of physicians and 42.1% of physician assistants experienced anxiety-related symptoms that do not harm their healthcare administration. 65.8% of total respondents experienced little to no symptoms of worry or fear-related anxiety concerning their medical practice during the last two months of the COVID-19 pandemic. Slight to moderate anxiety in respondents is most attributed to personal and immediate family health concerns because of subsequent responses to increased risk. Specifically, for physician assistants, salary uncertainty is a plausible factor for moderate anxiety because of a decline in career availability. 

For the risk variable (RV), 47.4% of physicians and 57.9% of physician assistants scored between 8-11, suggesting that reservations of administering healthcare due to increased perceived risk existed among both non-frontline HCW variations. Moreover, physician assistants (26.3%) who scored between 12-15 were 10.5% more likely to incur personal safety concerns leading to a decline in medical practice quality than physicians who scored between 12-15 (15.8%). This phenomenon is correlated to the proximity of physician assistants to patients. While physicians usually examine a patient once or twice then deliberate in forming a diagnosis, physician assistants are constantly performing numerous tests (eyesight, heartbeats, hearing, and reflex). As a result, the risk of contracting COVID-19 or similar diseases is disproportionate to physician assistants. Moreover, as deduced from the WEV results, the employer may not have sufficient physical or mental health policies. 

According to TIMHV results, physician assistants considered the TeleMed application to be less beneficial for their profession than physicians. For instance, the percentage between physician assistants (89.5%) and physicians (68.4%) scored between 2-4 was 21.1%. Physician assistants are more likely to conceive online medical platforms as inefficient because diagnosing illness, developing treatment plans, and prescribing medications are difficult tasks to accomplish without conducting in-person examinations. However, physicians discuss treatment plans with their patients and schedule in-person appointments using the TeleMed online application. Moreover, TeleMed automates much of the medical process, suggesting that physician assistants may not be as crucial to patient healthcare as previously conceived due to the flexibility of online medical platforms during COVID-19.

Implications

From the five variables tested – work environment, physical changes, anxiety, risk, and technology’s impact on mental health, it is evident that non-frontline HCWs face degradation in personal well-being stemming from the COVID-19 pandemic. Moreover, regardless of designation (physicians and physician assistants), non-frontline medical professionals that participated in this case study reported high levels of work environment stress and fear of contracting the coronavirus-2019 disease. Although this case study generated results from 38 participants, the correlational and statistical analysis provided from the research should be applied to other non-frontline healthcare establishments (urgent cares, small hospitals, and dentistries) for the intent of collecting data and subsequently developing beneficial solutions for this underrepresented group. The delineation between physician and physician assistants was integral to the foundations of this case study due to popular misconceptions which generalize all non-frontline healthcare workers as incurring identical mental health detriments. In actuality, HCWs at local clinics are primarily physicians and physician assistants. As a result, from this case study, employer policies will more likely pertain to a specific employee rather than a generalized majority, and regional awareness will follow as non-frontline HCWs are essential in treating patients in their local communities.

Limitations

In the data collection process, a plausible limitation was participant weariness or fear of responding truthfully to the COVID-19 MHCQ and Scale questionnaires. Although the questionnaires contained an informed consent form and a presurvey statement detailing how participant identity would not be revealed, per the Institutional Review Board (IRB), at the final publication of the research paper, there may have been some fraudulent responses in the dataset. The possibility of untruthful answers could have skewed the dataset and fabricated minor inaccuracies in the statistical and correlational analysis. Another limitation resides in the structure of the questions presented to the HCW respondents; questions may have been perceived as invasive or incessantly personal. As such, participants may have not responded to the entirety of the COVID-19 MHCQ and Scale questionnaires, leading to a skew in the dataset. Additionally, an integral limitation exists in consonance with the sample size and case study nature of the research. For instance, 50 physicians and physician assistants are employed at the non-frontline clinic, but only 76% ultimately were evaluated in the case study. The remaining 24% of non-frontline HCWs may have altered the dataset.

Conclusion

The mental health of non-frontline physicians and physician assistants at a medical clinic is in jeopardy, as the results, analysis, and implications of this case study suggest: both physicians and physician assistants expressed external psychological and physical factors such as anxiety, fear of COVID-19 contraction, unproductiveness, the negative impact of technology, unsatisfactory employer and associate support, and mood changes. Although the case study contrasted physicians and physician assistants, their mental health has experienced a similar degradation. However, the initial hypothesis was ultimately disproved, as on average, physician assistants faced a larger degradation in mental health than physicians regarding the findings on the five tested variables. Comparable to the SARS outbreak, the COVID-19 pandemic has altered how non-frontline medical establishments operate. Moreover, physicians and physician assistants alike are at risk of losing their employment status and contracting the uncontrolled virus while incurring severe mental health detriments. 

The results of the case study illustrate why domestic and global powers should concentrate resources in non-frontline medical practices because of their importance to a local and frequently underrepresented community. For instance, the clinic evaluated in this case study provides resources to underserved individuals – people of color, low-income individuals, workers compensation patients, and disabled individuals. As a result, the importance of immediate action from local and international governments is evident. If the mental health of these non-frontline physicians and physician assistants continues to regress, the quality of healthcare for the individuals they serve will likewise begin to decline. Moreover, the basis of this case study should be applied to other local hospitals in regions of the United States and abroad due to the absence of research on non-frontline healthcare professionals during the COVID-19 pandemic. 

Future researchers should implement the COVID-19 MHCQ and Scale surveys in their respective research endeavors because of the expansive variables covered in all facets of the questionnaires – work environment, physical changes, anxiety, perception of risk, and technology’s impact on mental health. Furthermore, researchers should use this case study’s findings and interpretations to develop relevant solutions that address the problems faced by physicians and physician assistants. Importantly, these two subsets of HCWs in future studies should not be generalized as their experiences and acquired trauma during the COVID-19 pandemic slightly differs. Ultimately, the mental health of non-frontline healthcare professionals should be prioritized when discussing pandemic-related healthcare issues because of their illustrious impact on society coupled with underwhelming provisions for their humanitarian efforts.  

Alex Sunday, Youth Medical Journal 2021

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By Alex Sunday

Alex Sunday is a student at Corona del Mar High School in Newport Beach, California. He is interested in the fields of psychology, biotechnology, and public health.

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