COVID-19 pandemic in São Paulo: a quantitative study on clinical practice and mental health among medical residency specialties

ABSTRACT BACKGROUND: 2020 was a challenging year for all healthcare professionals worldwide. In São Paulo, Brazil, the virus SARS-CoV-2 took 47,222 lives up to December 29, 2020. The front line of medical professionals in São Paulo was composed of many residents, who were transferred from their rotations to cover the needs of the pandemic. OBJECTIVE: To identify medical residents’ mental health and clinical issues, regarding symptoms of burnout, depression and anxiety during the pandemic, and to compare them among specialties. DESIGN AND SETTING: Quantitative study using a convenience sample of medical resident volunteers who responded to an anonymous online survey that was available during April 2020. METHODS: This investigation collected sociodemographic information and used the Oldenburg Burnout Inventory (OLBI) to measure burnout, the Patient Health Questionnaire (PHQ-9) to measure depression and the General Anxiety Disorder (GAD-7) scale to measure anxiety symptoms. This study also developed a COVID-19 Impact Questionnaire (CIQ-19) to assess the residents’ beliefs and clinical practices relating to COVID-19 patients. RESULTS: The sample comprised 1,392 medical residents in São Paulo, Brazil. Clinical specialty physicians showed the highest rates of anxiety symptoms (52.6%) and burnout (51.2%), among the specialties. CONCLUSION: Clinical specialty residents are at higher risk of anxiety, depression and burnout. The symptoms of anxiety and depression have worsened during the COVID-19 pandemic. There is a general need for mental health support interventions for medical resident physicians, which requires reinforcement during this worldwide crisis.

exhibited increased levels of acute or posttraumatic stress and psychological distress. 13 The risk factors included younger age and less experience: two aspects that may be related to medical residents, a group that clearly needs guidance from more experienced staff to help them achieve the required knowledge and ethical maturity to deal with the difficulties and feelings inherent to this period, which can be an extremely rich learning experience. 14

OBJECTIVE
The purpose of this study was to identify the mental health and clinical issues of medical residents in São Paulo, Brazil, regarding collective symptoms of burnout, depression and anxiety during the COVID-19 pandemic and compare them among medical specialties.

Study design and procedures
A quantitative study was conducted in accordance with the This study used a convenience sample from an anonymous online survey that was advertised through social media and distributed by means of e-mails from the residency committees of hospitals that are linked to universities and medical associations in São Paulo.
Given that a convenience sample was used, no calculation of sample size was performed. Advertisement of the research was performed in line with the good practice guidelines. 15 There was no financial support for the volunteers who responded to the survey. The survey was available during the month of April 2020 in São Paulo.

Study measurements and analysis
This investigation collected sociodemographic information and used the Oldenburg Burnout Inventory (OLBI) to measure burnout, the Patient Health Questionnaire (PHQ-9) to measure depression and the General Anxiety Disorders (GAD-7) to measure anxiety symptoms. [16][17][18] All three scales had previously been adapted and validated for use in Brazilian contexts and populations. This study also developed a COVID-19 Impact Questionnaire  to assess the residents' beliefs and clinical practices relating to COVID-19 patients, their behaviors concerning disease prevention and their substance use after the beginning of the pandemic.
All fields were marked as mandatory, so a participant could move forward only after answering all questions. Therefore, all the participants included completed the entire questionnaire, and no data were missing. The protocol was reviewed and approved by the defined as positive if the total score on GAD-7 was 10 or greater.
For the variable "depression". three categories were used: no depression or mild depression (PHQ-9 score of nine or less), moderate (PHQ-9 score between 10 and 14) and severe depression (PHQ-9 score of 15 or higher).
The analyses were performed using SPSS Statistics for Windows,  Table 1).
Our findings were significant with regard to mental health scales, COVID-19 aspects of clinical practice and mental healthcare among medical residents training in São Paulo.
In terms of aspects of COVID-19, residents in surgical specialties were less likely to feel that they themselves and their hospital were sufficiently prepared to treat patients with this disease (46.4% and 33.6%, respectively). The residents in these specialties also revealed that there was a lack of supervisor support for treating COVID-19 patients (55.6%).
Residents said that their personal protection equipment   Medical residents' mental health was already a topic that worried medical educators worldwide, even before the pandemic scenario emerged. In the light of this worldwide scenario, we observed  In 2014, the prevalence rates for anxiety, depression and burnout were 41.3%, 21.6% and 58.4% respectively, among Brazilian residents. Thus, although the prevalence of burnout that was identified was similar to that of the pre-pandemic scenario, symptoms of anxiety were increased twofold and symptoms of depression exhibited an approximately threefold increase in the scenario of the COVID-19 pandemic. 19 These findings are similar to those of a survey of 1,257 healthcare workers who were in contact with COVID-19 patients in China, in which high rates of depression (50.4%), anxiety (44.6%) and distress (71.5%) were reported using the same instruments as those used in our study. 20 Mental distress was also reported in Italy, where only 20% to 25% of healthcare workers declared that they felt psychologically safe and only 48% reported having access to mental healthcare. 21 Another study observed that the prevalence of burnout among surgical residents was 69%. This rate was associated with high levels of stress, depression and suicidal ideation. Surgical trainees have purposefully chosen a field with high baseline stress by definition, presumably due in part to the widely held belief among surgeons that not all stress is bad. Although burnout among them is known to be high, it is not clear whether stress and distress have the same strong associations with burnout, depression and anxiety symptoms, as seen in other medical specialties. 22 Unfortunately, we did not find any Brazilian studies that compared medical specialties. To our knowledge, our study is the first to show a relevant difference among residents in medical specialties regarding the collective symptoms of burnout, depression and anxiety. Similar results have been found recently in studies among medical residents without comparing areas of specialties. 11,19 Two of these studies included Brazilian residents as participants. Given our findings relating to different behaviors among medical residents exposed to patients infected with or suspected of being infected with COVID-19, and the factors correlated with the development of mental disorder symptoms, it is necessary to develop interventional programs to prevent mental illness.
This investigation found that residents did not feel prepared to treat patients with COVID-19 and were afraid of getting it.
Since these individuals believed that talking to colleagues and immediate line managers protected their mental health, it can be suggested that supervisors and peers should pay attention to residents with signs of at-risk behavior. 23  The results from the present study suggested that there had not been any significant increase in substance use among these residents. However, another study found that residents in surgical specialties were more likely to present alcohol dependence than were residents in clinical specialties. Another study among practicing surgeons in the United States showed that alcohol abuse and dependence are a significant problem in that population. It is necessary to assess the relationship between substance dependence and personality among medical residents, since these are risk factors for this population. 25,26 The cross-sectional design chosen for the present study was suitable for investigating associations and for providing wide-ranging data for discussion, but it does not allow inferences of causality. In addition, since our sample was restricted to one state in Brazil, further studies should investigate whether the trend cited above is replicable in other countries. Therefore, caution is needed with regard to generalizations of these results to distinct populations.

CONCLUSION
This study was conducted during the worldwide crisis of the COVID-19 pandemic. It is understandable that most of our sample of physicians undergoing training felt unprepared to deal with COVID-19 patients. This was one of the variables related to increased mental illness, such as depression, anxiety and burnout.
Residents in clinical specialties seem to be at higher risk of depression, anxiety and burnout during the pandemic, but previous studies that have been conducted outside of this scenario have shown the same results. Our findings from comparisons between specialties among Brazilian resident physicians highlights the need to better explore mental health in this population, since surgical specialties did not follow a trend towards higher rates, which was restricted to the clinical group.
This study demonstrates that there is a general need for better access to mental health professionals for resident physicians, which has been reinforced during the COVID-19 pandemic. Moreover, the feeling that support from staff is available appears to have a protective function in relation to mental health. Therefore, we suggest that support groups might give rise to the possibility of assessing mental health. We also emphasize that there is a need for more comparative studies between medical specialties.