Discussion

This cross-sectional survey enrolled 127 respondents and revealed a high prevalence of mental health symptoms among the residents during the COVID-19 pandemic in Qatar. Overall, 42.5%, 41.7% and 30.7% all participants reported symptoms of depression, anxiety and stress, respectively. In contrast, the residents demonstrated high compassion satisfaction, moderate-to-low burnout and secondary traumatic stress, all of which translate into high professional quality of life. Multivariate analysis showed significant effects of seniority in residency, with junior residents having poorer outcomes. In addition, there was a statistically significant interaction effect on mental health outcomes, with moderate effect sizes between gender and working on the front line, as well as gender, working on the front line and seniority. Univariate analysis showed that the effect of gender on the depression score depended on working on the front line versus second line, and vice versa. Moreover, the effect of gender on all scores depended on working on the front line and seniority, with junior female front-line residents and male junior second-line residents exhibiting the poorest outcomes. Together, our findings present concerns about the psychological well-being of the junior residents during the COVID-19 pandemic.

In this study, a significant proportion of participants experienced symptoms of depression, anxiety and psychological symptoms. In a previous study during the acute SARS outbreak, 89% of healthcare workers who were in high-risk situations reported more negative psychological effects (using the Perceived Stress Scale) than the control group.^{Reference Chua, Cheung, Cheung, McAlonan, Wong and Cheung20} During the COVID-19 pandemic in Wuhan, China, a survey among healthcare workers showed a high prevalence of depression (50.4%), anxiety (44.6%) and distress (71.5%).^{Reference Lai, Ma, Wang, Cai, Hu and Wei6} Similarly, 90% of the neurosurgery residents across different programmes believed that this pandemic had influenced their mental health and social life.^{Reference Alhaj, Al-Saadi, Mohammad and Alabri9} In a national study among otolaryngology residents and attending physicians in the USA, the prevalence of depression, anxiety, distress and burnout among the medical residents were 10.6%, 47.9%, 60.2% and 21.8%, respectively. The authors also found that the residents had increased burnout relative to attending physicians.^{Reference Civantos, Byrnes, Chang, Prasad, Chorath and Poonia12} In terms of association with gender, previous studies have found a higher level of depression, anxiety, distress and burnout in women, which are probably explained by a combination of biological and social factors.^{Reference Lai, Ma, Wang, Cai, Hu and Wei6,Reference Civantos, Byrnes, Chang, Prasad, Chorath and Poonia12} In our study, female gender was not independently associated with any of the mental health outcomes. Nonetheless, our study demonstrated an interaction effect between gender and working on the front line, as well as an interaction between gender, working on the front line and seniority, which showed a moderate but significant effect on mental health outcomes. This probably means that female medical residents might be at a higher risk of detrimental psychological effects when they are junior residents and/or working on the front line, but are probably less affected as they gain experience (become senior residents) or as long as they are not deployed to COVID-19 sites. Possible explanations might include increased experiences of fear related to COVID-19 among women, but these fear experiences are probably attenuated by their medical experience.^{Reference Schimmenti, Starcevic, Giardina, Khazaal and Billieux21}

In contrast with previous findings, our study showed that residents did not report high levels of burnout, whereas the prevalence of burnout among the Romanian residents was as high as 76% during the COVID-19 pandemic.^{Reference Dimitriu, Pantea-Stoian, Smaranda, Nica, Carap and Constantin13} Internal medicine and psychiatry residents in Michigan, USA, have stated a lack of adequate personal protective equipment, physical and emotional exhaustion and overwhelming fear of catching the virus and infecting their loved ones, as potential grounds for burnout in front-line medical residents.^{Reference Gautam, Kaur and Mahr22} They also suggested that the psychiatry residents, for example, who are not working on the front line may develop higher vicarious traumatisation, as suggested by a study in Wuhan illustrating that second-line nurses had significantly higher level of vicarious traumatisation than front-line nurses.^{Reference Li, Ge, Yang, Feng, Qiao and Jiang23} Possible explanations for the lower propensity of developing burnout and vicarious traumatisation among the medical residents in Qatar are high levels of personal accomplishment and satisfaction with medicine, and a low level of depersonalisation, as illustrated in a cross-sectional study in 2017 among medical residents in the HMC.^{Reference Afana, Ghannam, Ho, Al-Khal, Al-Arab and Bylund24} On the other hand, we do not have a direct comparison using scales used in this study. As part of ACGME-I accreditation, the well-being of the residents is monitored and HMC did not receive any citations regarding this in their 2018 site visit. Nonetheless, in general, medical residents experience exceptional stress during their training programmes because of long working hours, heavy workload, poor work environment, lack of social support, problems of relocation and difficult patients and families.^{Reference Afana, Ghannam, Ho, Al-Khal, Al-Arab and Bylund24}

Several studies have compared front-line and second-line healthcare workers, with the majority showing poorer mental health outcomes for those in high-risk environments.^{Reference Brooks, Dunn, Amlot, Rubin and Greenberg25} A recent study in Wuhan showed that working on the front line was an independent risk factor for worse mental health outcomes such as depression, anxiety, distress and insomnia.^{Reference Lai, Ma, Wang, Cai, Hu and Wei6} In our study, the male junior second-line residents and female junior front-line residents had the highest levels of psychological symptoms. A possible explanation could be that the junior residents have less clinical and infection control knowledge and experience, and consequently, are less prepared to face the current pandemic crisis.^{Reference Brooks, Dunn, Amlot, Rubin and Greenberg25} In Singapore, front-line medical residents had lower stress levels than second-line residents, because of the higher degree of psychological preparedness among front-line residents and anticipatory anxiety among second-line residents, despite the fact that second-line residents seem further away from the crisis.^{Reference Chew, Chia, Ng, Lee, Tan and Wong11} Furthermore, following the deployment of the residents to high-risk areas, second-line residents may have faced longer working hours, extra responsibilities and less supervision.

Our findings indicate worse mental health outcomes among junior residents. This is in accordance with the findings from a study in Wuhan, which indicated that healthcare workers with junior titles may be at higher risk of more severe mental health outcomes in terms of depression, anxiety, insomnia and distress.^{Reference Lai, Ma, Wang, Cai, Hu and Wei6} Nonetheless, a study in Singapore found no difference between the junior and senior residents in terms of psychological responses to the pandemic.^{Reference Chew, Chia, Ng, Lee, Tan and Wong11} On the other hand, the junior residents and second-line residents in Qatar were at increased risk for symptoms of depression, anxiety and stress. Consequently, their mental health may require special attention, bearing in mind that they are particularly vulnerable. In a recent paper, the leaders of the American Heart Association wrote that ‘residents and fellows — whether due to lack of experience, poor preparation or lack of training — are particularly vulnerable’. Therefore, they are the ones most in need of protection and mental health support during moments like this. They went on to state ‘Protect medical trainees on the COVID-19 front lines or do not send them in’.^{Reference Harrington, Elkind and Benjamin26} In France, a collaborative and helping crisis department has been set up for every medical resident in need. This department connects the residents in training with the psychiatry residents 24 hours a day, to address their mental health needs.^{Reference Abdessater, Roupret, Misrai, Matillon, Gondran-Tellier and Freton8} It is also important for healthcare leaders to develop and implement support measures based on the needs and desires of the healthcare workers. For instance, in a survey among New York medical residents and other healthcare workers on potential wellness resources, self-guided counselling with access to a therapist, individual counselling and therapy, and an online clinician support group gathered the most interest.^{Reference Shechter, Diaz, Moise, Anstey, Ye and Agarwal16}

This study has several strengths, chief among them that the survey was sent to all medical residents in Qatar, and used validated, widely used questionnaires in the field. However, a few limitations need to be acknowledged. Indeed, we had a low response rate of 20% and the possibility of non-response bias cannot be ruled out. Indeed, it is possible that the nonrespondents were either too stressed to respond or were in good health and therefore not interested in this survey.^{Reference Sax, Gilmartin and Bryant27} Besides, our response rate is comparable with rates of 20% and 27.4% from national studies in USA and South Korea, respectively.^{Reference Chang, Park, Baek, Kim, Bosco and Hey10,Reference Khusid, Weinstein, Becerra, Kashani, Robins and Fink14} This means that extrapolating our findings to the entire population of medical residents might be difficult. The observed power of 60.4% was also rather low, thus indicating the possibility of a type 2 error. Moreover, we did not include a control group and therefore are unable to definitely conclude that these symptoms in the medical residents differ from those of the general population. Last, but not least, we have not investigated secondary stressors, such as familial and social stressors, between the front-line and second-line residents, which may affect the residents’ longer-term mental health.^{Reference Lock, Rubin, Murray, Rogers, Amlot and Williams28}

In conclusion, our findings indicate that medical residents, and in particular the junior residents, display high levels of depressive, anxiety and stress symptoms during the COVID-19 pandemic. Contrary to preconceived ideas, these symptoms are not limited to frontline healthcare workers. Medical residents may require particular attention during a pandemic. This includes wellness resources such as individual counselling with a therapist, or a support group with the other residents. The reassuring professional quality-of-life scores in our study may indicate that the residents may benefit from engagement, opportunities for continuous education and other opportunities to grow in their position. Nonetheless, further studies are needed to capture the longitudinal picture during the ongoing COVID-19 pandemic, for it is important that institutions continue their efforts regarding the mental wellness of their medical residents.