Resource Library

[This is an excerpt.] We read with great interest the educational perspective of Barrett et al. As physicians and more specifically radiology residents in a developing country, your article seems utopian to us. In Colombia, there were 869 radiology specialists nationwide in 2017. Since our population in 2017 was 48 million inhabitants, there is a very low ratio of specialists per capita as compared with developed countries such as the United States. Moreover, since the COVID-19 pandemic began, the workload has increased exponentially due to the number and complexity of the cases). We agree that taking a break from this busy profession is essential to avoid burnout. However, in a developing country, it is not easy. With our 11 hour workday, manda- tory study hours, and time spent commuting there is little time left to engage in leisure activities, much less outdoor activities. [To read more, click View Resource.]

Academic medicine as a practice model provides unique benefits to society. Clinical care remains an important part of the academic mission; however, equally important are the educational and research missions. More specifically, the sustainability of health care in the United States relies on an educated and expertly trained physician workforce directly provided by academic medicine models. Similarly, the research charge to deliver innovation and discovery to improve health care and to cure disease is key to academic missions. Therefore, to support and promote the growth and sustainability of academic medicine, attracting and engaging top talent from fellows in training and early career faculty is of vital importance. However, as the health care needs of the nation have risen, clinicians have experienced unprecedented demand, and individual wellness and burnout have been examined more closely. Here, we provide a close look at the unique drivers of burnout in academic cardiovascular medicine and propose system-level and personal interventions to support individual wellness in this model.

Physician and clinician well-being is an increasingly recognized problem. There is mounting evidence that more caregivers are experiencing the signs and symptoms of burnout, and many individuals are finding the profession of caring for people less rewarding. Multiple factors are conspiring to exacerbate the loss of meaning and purpose. Career dissatisfaction significantly impacts the larger healthcare system in the form of increased physician turnover, increased medical error rate, and decreased patient satisfaction. Early retirement, substance abuse, depression, and in the worst cases, suicide are all real problems in healthcare today. Optimal care cannot be provided by healers who have exhausted their reservoirs of resilience. The global coronavirus pandemic has further frayed the bonds of community that have served to tie doctors, nurses, and other healthcare team members together. Individual and organizational strategies have been described to restore a sense of personal and professional satisfaction. Thoughtful and inclusive institutional leadership has been shown to be valuable and effective in establishing a culture that is compassionate to all participants. Intentional application of these strategies and investment of resources at multiple levels is the challenge before the medical community.

IMPORTANCE: Burnout is common among physicians and is associated with suboptimal patient outcomes. Little is known about how experiences with patients, families, and visitors differ by physician characteristics or contribute to the risk of burnout. OBJECTIVE: To examine the occurrence of mistreatment and discrimination by patients, families, and visitors by physician characteristics and the association between such interactions and experiencing burnout. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional survey was conducted from November 20, 2020, to March 23, 2021, among US physicians. EXPOSURES: Mistreatment and discrimination were measured using items adapted from the Association of American Medical College's Graduation Questionnaire with an additional item querying respondents about refusal of care because of the physicians' personal attributes; higher score indicated greater exposure to mistreatment and discrimination. MAIN OUTCOMES AND MEASURES: Burnout as measured by the Maslach Burnout Inventory. RESULTS: Of 6512 responding physicians, 2450 (39.4%) were female, and 369 (7.2%) were Hispanic; 681 (13.3%) were non-Hispanic Asian, Native Hawaiian, or Pacific Islander; and 3633 (70.5%) were non-Hispanic White individuals. Being subjected to racially or ethnically offensive remarks (1849 [29.4%]), offensive sexist remarks (1810 [28.7%]), or unwanted sexual advances (1291 [20.5%]) by patients, families, or visitors at least once in the previous year were common experiences. Approximately 1 in 5 physicians (1359 [21.6%]) had experienced a patient or their family refusing to allow them to provide care because of the physician's personal attributes at least once in the previous year. On multivariable analyses, female physicians (OR, 2.33; 95% CI, 2.02-2.69) and ethnic and racial minority physicians (e.g., Black or African American: OR, 1.59; 95% CI, 1.13-2.23) were more likely to report mistreatment or discrimination in the previous year. Experience of mistreatment or discrimination was independently associated with higher odds of burnout (vs score of 0 [no mistreatment], score of 1: OR, 1.27; 95% CI, 1.04-1.55; score of 2: OR, 1.70; 95% CI, 1.38-2.08; score of 3: OR, 2.20; 95% CI, 1.89-2.57). There was no difference in the odds of burnout by gender after controlling for experiencing mistreatment and discrimination score and other demographic factors, specialty, practice setting, work hours, and frequency of overnight call. CONCLUSIONS AND RELEVANCE: In this study, mistreatment and discrimination by patients, families, and visitors were common, especially for female and racial and ethnic minority physicians, and associated with burnout. Efforts to mitigate physician burnout should include attention to patient and visitor conduct.

This resource is found in our Actionable Strategies for Health Organizations: Promoting Diversity, Equity, & Inclusion.

PURPOSE: Clinical pharmacists are recognized as valuable team members in primary care clinics due to the variety of patient care services they provide. This study examined nonpharmacist healthcare providers' perceptions of how embedded clinical pharmacists impact the work environment in ambulatory care clinics. SUMMARY: This was an exploratory mixed methods study consisting of semistructured interviews and a subsequent survey. Participants included attending and resident physicians and advanced practice providers (APPs) practicing in clinics with an embedded clinical pharmacist. Coded interview transcripts were analyzed to identify themes that were used to develop a survey. Interview participants were not asked to complete the survey. Survey responses were analyzed utilizing descriptive statistics. Subgroup analysis assessed for differences in responses based on provider type, gender, clinical practice area, years of practice, and pharmacy services utilization. Fourteen physicians and APPs participated in the semistructured interviews, and 43 other providers completed the survey. In the interviews, participants stated the clinical pharmacist contributed positively in terms of work environment, workload, work-related stress, and burnout. The major themes identified were sharing patient care responsibilities, saving provider time, and being a knowledgeable resource. Survey responses were consistent with interview statements; however, the positive impact differed between nonusers and moderate to high utilizers of clinical pharmacy services. The main barrier to collaborating with clinical pharmacists was their limited availability. CONCLUSION: Embedded clinical pharmacists positively impact the work environment in ambulatory care clinics by reducing provider workload, work-related stress, and burnout. Participants also noted clinical pharmacists are a trusted resource for patient care and drug information questions.

[This is an excerpt.] In July 2016, The American Medical Association conducted a comprehensive study of physician’s motivations and requirements for the adoption of digital clinical tools. The AMA repeated the study to determine the degree to which adoption has occurred in the past 3 years and identify attitudinal shifts among physicians towards their use and adoption. The goals for this research were to update the 2016 and 2019 studies to determine: 1. Any change in overall interest in digital health tools and the degree to which physicians believe they will help or hinder their patient care 2. Current familiarity with 7 specific digital health tools and physician enthusiasm, belief in the relevance to their practice, timeline for incorporating or current use 3. For each tool, the motivators and level of disruption caused or foreseen 4. The ideal level of involvement physicians would like to have in adoption decisions 5. An understanding of enthusiasm, current usage and requirements for emerging technologies. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Using Technology to Improve Workflows) 

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OBJECTIVES: This prospective cohort study assessed the impact of a 12-hour mindfulness-based wellness curriculum on OB-GYN residents’ burnout, mindfulness, and self-compassion. METHODS: Fourteen 1st year OB-GYN residents at the University of California, Irvine (n = 7 in two separate cohorts) were eligible and participated in a 12-hour, in-person wellness curriculum between January 2017 and May 2018 emphasizing meditation training, present moment emotional awareness, and self-compassion. The curriculum included didactic and experiential components and home-based exercises. Participants were assessed before starting the curriculum (T1), after finishing the curriculum (T2), and 6-9-months later (T3) using the Maslach Burnout Inventory (MBI), the Five Facet Mindfulness Questionnaire (FFMQ), and the Self-Compassion Scale (SCS). RESULTS: Fourteen residents (100%) completed the survey at T1, 13 residents (93%) completed the survey at T2, and 12 residents (86%) completed the survey at T3. Levels of burnout did not change significantly. Overall mindfulness increased from T1 to T3 (p < .05), as did non-judging inner experiences (p < .01). Overall levels of self-compassion increased from T1 to T3 (p < .05), with self-kindness and self-judgment improving from T1 to T3 (both p < .05). The vast majority of improvements were evident at the 6-9-month follow-up. CONCLUSIONS: This study provides preliminary support that a mindfulness-based wellness curriculum may improve overall levels of mindfulness and self-compassion in 1st year OB-GYN residents.

BACKGROUND: Burnout and medical resident well-being has become an increasingly studied topic in medical degree (MD) and doctor of osteopathic medicine (DO) fields and specialties, which has led to systemic changes in postgraduate education and training. Although an important topic to address for physicians of all experience levels and fields of practice, there is little research on this topic as it pertains specifically to the podiatric medical community. METHODS: A wellness needs assessment was developed and distributed to podiatric medical residents via electronic survey to assess overall wellness levels of residents and to highlight several subdomains of well-being in the training programs of the podiatric medical profession. RESULTS: A total of 121 residents completed the wellness needs assessment. Survey respondents indicated that they experienced high levels of professional burnout, with large numbers of them experiencing depression and anxiety. When analyzing the different subdomains of wellness, levels of intellectual and environmental wellness were high, and levels of financial and physical wellness were reported as low. In addition, free response answers were recorded in the survey regarding well-being initiatives that have been implemented in residency programs, and in many cases no such programs are reported to exist. CONCLUSIONS: Podiatric medical residents experience compromised well-being similar to their MD/DO counterparts. These exploratory survey group results are concerning and warrant further investigation as well as organizational introspection. Analyzing well-being and implementing changes that can support podiatric physicians at all levels of training could decrease the deleterious effects of burnout in all its forms.

Although the police have been identified as a key service provider when responding to domestic violence and abuse (DVA), very few studies have investigated their response in relation to children. This review aims to examine children’s experiences of police response in the context of DVA and to explore how the police understand and respond to children living with DVA. A rapid review of the empirical literature on the police response to DVA involving children was undertaken. PsycINFO, Web of Science and ProQuest were searched. Studies with a qualitative element, concerning children under 18 with experience of police involvement, or police experiences of children, in the context of DVA were included. The final sample comprised of six studies. Using reflexive thematic analysis, four key themes emerged in relation to children: children’s experiences of DVA; fear, uncertainty, and mistrust of police; confronting “childism”: a matter of children’s rights; and going beyond empathy: equality and justice. Regarding the police, three key themes emerged: variability in police response; limited view of police role; lack of professional competence. The findings underscore the need for awareness raising and an urgent review of the training officers receive regarding the impact of DVA on children. They also highlight the pivotal role of police when responding to DVA where children are present, as well as to advance the frontiers of research by including not only adults and professionals but also the most vulnerable DVA victim: the child.

[This is an excerpt.] Prior research, practical experience, and clinical practice in the field of law enforcement support the fact that police work is challenging, stressful, and that exposure to potentially traumatic events is endemic to police work. Over the last couple of decades, research, policy, and clinical practice have also focused on police resilience and wellness. Exploring the impact, for instance, of gruesome crime scenes (e.g., decomposed dead bodies) on officers' health from a psychopathological perspective is one aspect of the phenomenon. On the other hand, many researchers and professionals have also placed emphasis on studying what makes police officers resilient and what strategies can help police officers maintain resilience and promote wellness. This is an intriguing topic allowing us to explore what helps officers thrive despite exposure to hundreds or even thousands of potentially traumatic events over the course of their career. In contrast, the average civilian would probably be exposed to a small number, if any, of potentially traumatic incidents over the course of their lives. [To read more, click View Resource.]

Prolonged exposure to stressful environments is associated with adverse psychological outcomes, including sleep disturbance and burnout. Burnout rates have increased substantially during the unprecedented challenges faced by healthcare workers (HCWs) during the COVID-19 pandemic. Since burnout has been associated with significant health risk and adverse organizational outcomes, it is important to identify factors that inform preventive or therapeutic approaches to mitigate adverse outcomes in HCWs.Participants were HCWs (physicians, nurses, advanced practice providers, technicians etc.) from 4 emergency departments in New York City who completed a cross-sectional electronic survey (completed at study enrollment between November 2020-October 2021). The Pittsburgh Sleep Quality Index (PSQI) assessed global sleep quality. The Maslach Burnout Inventory (MBI) assessed 3 burnout dimensions: emotional exhaustion (EE; feelings of being emotionally overextended and exhausted by one's work); Feelings of depersonalization (DP; unfeeling and impersonal response towards patients); and reduced personal accomplishment (PA; feelings of competence and successful achievement in one's work). Descriptive statistics were calculated and separate binary logistic regressions were used to predict poor global sleep quality (PSQI >5) from individual MBI subscales (dimensions of burnout), while controlling for age, race, ethnicity, and gender.Ninety-one participants, studied to date, were included in the analysis (51% non-Hispanic/Latino White, 63% female, mean age: 40 [SD: 9.6] y). Poor global sleep quality was reported by 68%. High EE (score >9), DP (score >6) and reduced PA (score <9) were reported by 44%, 27%, and 18% of participants, respectively. Poor global sleep quality was significantly associated with presence of elevated EE (OR: 3.04, 95% CI: 1.07-8.63, p=0.037), but not with elevated DP (OR: 1.35, 95% CI: 0.44-4.10, p=0.603) or reduced PA (OR: 3.29, 95% CI: 0.65-16.44, p=0.146).During the COVID-19 pandemic, poor sleep quality was reported by the majority of participants and associated with increased burnout in HCWs. Poor global sleep appears to have the most influence on the burnout dimension EE, thus suggesting new evidence about associations between sleep and emotional regulation in HCW during the pandemic. Future trials should test whether existing (or novel) interventions can improve sleep and thereby support HCWs in high stress periods.R01HL146911

There is a need for increased access to confidential mental health services in the law enforcement community to abate the impact post-traumatic stress disorder (PTSD) causes the officer, agency, and community. Officers repeatedly expose themselves to traumatic experiences often without an opportunity to formally process the psychophysiological fallout experienced throughout the day as the officer continues policing the community. Depression rates in law enforcement are generally double that of the general United States (U.S.) population. Tragically, death by suicide in the law enforcement community remains double the U.S. rate. Building and expanding access to robust health and wellness agency programs tailored specifically to law enforcement professionals has proven instrumental throughout the lifespan of an officer’s career.

Healthcare workers (HCWs) and public safety personnel (PSP) across the globe have continued to face ethically and morally challenging situations during the COVID-19 pandemic that increase their risk for the development of moral distress (MD) and moral injury (MI). To date, however, the global circumstances that confer risk for MD and MI in these cohorts have not been systematically explored, nor have the unique circumstances that may exist across countries been explored. Here, we sought to identify and compare, across the globe, potentially morally injurious or distressful events (PMIDEs) in HCWs and PSP during the COVID-19 pandemic. A scoping review was conducted to identify and synthesize global knowledge on PMIDEs in HCWs and select PSP. Six databases were searched, including MEDLINE, EMBASE, Web of Science, PsychInfo, CINAHL, and Global Health. A total of 1,412 articles were retrieved, of which 57 articles were included in this review. These articles collectively described the experiences of samples from 19 different countries, which were comprised almost exclusively of HCWs. Given the lack of PSP data, the following results should not be generalized to PSP populations without further research. Using qualitative content analysis, six themes describing circumstances associated with PMIDEs were identified: (1) Risk of contracting or transmitting COVID-19; (2) Inability to work on the frontlines; (3) Provision of suboptimal care; (4) Care prioritization and resource allocation; (5) Perceived lack of support and unfair treatment by their organization; and (6) Stigma, discrimination, and abuse. HCWs described a range of emotions related to these PMIDEs, including anxiety, fear, guilt, shame, burnout, anger, and helplessness. Most PMIDE themes appeared to be shared globally, particularly the ‘Risk of contracting or transmitting COVID-19’ and the ‘Perceived lack of support and unfair treatment by their organization.’ Articles included within the theme of ‘Stigma, discrimination, and abuse’ represented the smallest global distribution of all PMIDE themes. Overall, the present review provides insight into PMIDEs encountered by HCWs across the globe during COVID-19. Further research is required to differentiate the experience of PSP from HCWs, and to explore the impact of social and cultural factors on the experience of MD and MI.

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This resource is found in our Actionable Strategies for Public Safety Organizations: Drivers (Relational Breakdown) AND Drivers (Operational Breakdown)

OBJECTIVE: This study aimed to examine the impact of COVID-19 on hospice Interdisciplinary team (IDT) members’ self-reported stress and identify possible sources of moral distress. METHODS: A cross-sectional survey was conducted using Qualtrics to understand the impact of COVID-19 on quality improvement initiative implementation and hospice IDT members’ general and dementia-specific care provision. Directed qualitative content analysis was used to analyze hospice IDT members’ responses from five open-ended survey questions that were indicative of stress and possible moral distress. RESULTS: The final sample consisted of 101 unique respondents and 175 comments analyzed. Three categories related to sources of moral distress based on hospice IDT member survey responses were identified: (1) impact of telehealth, personal protective equipment (PPE), and visit restrictions on relationships; (2) lack of COVID-19-specific skills; and (3) organizational climate. Sources of moral distress were categorized in 40% of all responses analyzed. SIGNIFIGANCE OF RESULTS: This study is one of the first to document and confirm evidence of potential stress and moral distress amongst hospice IDT members during COVID-19. It is imperative given the possible negative impact on patient care and clinician well-being, that future research and interventions incorporate mechanisms to support clinicians’ emotional and ethical attunement and support organizations to actively engage in practices that address clinician moral distress resulting from restrictive environments, such as the one necessitated by COVID-19.

OBJECTIVE: Potentially morally injurious events (PMIEs) are events that contradict one's own personal ethics and may promote a deep sense of violation, leading to psychological distress. Individuals with greater trait gratitude and mindfulness may be less likely to perceive events as being morally injurious and may, in turn, be less likely to experience subsequent distress. The current study seeks to examine (a) PMIE rates in a multioccupational first responder sample and (b) the indirect effect of trait gratitude and mindfulness on psychological distress via fewer perceived PMIEs. METHOD: 293 first responders from agencies/departments within southeastern Texas (in-person) and nationwide (online) completed a survey assessing PMIEs, PTSD symptoms (PCL-C), anxiety (GAD-7), depression (PHQ-8), gratitude (GRAT-S), and mindfulness (MAAS). RESULTS: PMIEs were common (61% witnessed a transgression; 21% committed a transgression; 40% felt betrayed by others). Gratitude was indirectly associated with fewer PTSD [-.09, 95% CI (-.13, -.05)], anxiety [-.03, 95% CI (-.04, -.01)], and depression [-.03, 95% CI (-.05, -.01)] symptoms via lower PMIEs. Similarly, mindfulness was indirectly associated with fewer PTSD [-.92, 95% CI (-1.55, -.38)], anxiety [-.20, 95% CI (-.42, .02)], and depression [-.26, 95% CI (-.48, -.06)] symptoms via lower PMIEs. CONCLUSIONS: PMIEs were common in this first responder sample and associated with increased distress. Trait gratitude and mindfulness may protect first responders from perceiving events as morally injurious, which may lead to improved mental health. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The nurse practitioner (NP) workforce in community health centers (CHCs) increases access to primary care for underserved populations. Working with medically complex patients, high workloads, and low resources in the CHC setting, CHC NPs may be susceptible to poor workforce outcomes. This study uses NP survey data collected from 6 US states to describe and assess the relationship between CHC NP practice environment and burnout, job satisfaction, and turnover intention. CHC NPs rated their practice environments favorably, and more than 89% of CHC NPs reported satisfaction with their job. Better rating of NPs' relationship with CHC administration was associated with improved job satisfaction and decreased turnover intention.

Burnout is an occupational syndrome resulting from chronic workplace stress not appropriately managed. In nursing, burnout has been associated with adverse job characteristics (e.g., high responsibility for others, heavy workload, lack of infrastructure), with negative outcomes for the individual, the organization, and the recipients of care. The objective of this review is to describe the approaches used to predict burnout of practicing nurses to allow health care organizations to proactively address nursing burnout. We searched Scopus and PubMed for publications containing either in their title or abstract the terms “nurs*”, “burnout”, and “predict*” from 1970 to 2021. Our multi-phase screening process resulted in 312 papers. A gap in existing research relates to the primary method all studies but one used to capture data—questionnaires. Burnout is essentially a cumulative condition, and questionnaires identify the damage reactively, after burnout is experienced, by placing an additional demand on the individual, i.e., they further increase workload. Methods, ideally requiring minimal effort, to predict, not detect, burnout are needed so that individuals and organizations can take measures to prevent, reduce, and ultimately eliminate burnout among nurses and other clinicians. © 2022 “IISE”.

OBJECTIVE: One potential barrier to optimal healthcare may be provider burnout or occupational-related stress in the workplace. The objective of this study is to conduct a systematic review to identify the predictors of burnout among US. healthcare providers. DESIGN: Systematic review using in-depth critical appraisal to assess risk of bias and present the quality of evidence in synthesised results from the prognostic studies. DATA SOURCES: We searched 11 databases, registries, existing reviews and contacted experts through 4 October 2021. Eligibility criteria for selecting studies We included all studies evaluating potential predictors and documenting the presence and absence of associations with burnout assessed as a multidimensional construct. We excluded studies that relied solely on a single continuous subscale of burnout. Data were abstracted from eligible studies and checked for accuracy by a content expert and a methodologist. Data extraction and synthesis Two reviewers independently screened citations and full-text publications using predetermined eligibility criteria. RESULTS: The 141 identified studies evaluated a range of burnout predictors. Findings for demographic characteristics were conflicting or show no association. Workplace factors, such as workload, work/life balance, job autonomy and perceived support from leadership, had stronger associations with risk for burnout. Mental health factors, such as anxiety, and physical health risks may increase the risk, although the direction of these associations is unclear as few prospective studies exist to address this question. Factors such as social support appear to have a protective effect. CONLCUSION: We found the most evidence for workplace, mental health and psychosocial factors in predicting burnout but limited evidence for other potential predictors. However, more prospective studies are needed to improve our understanding about how to prevent provider burnout. PROSPERO registration number CRD4202014836.

Although burnout has been increasingly well studied among medical (nurses, physicians, residents) and mental health providers (psychologists, psychiatrists, social workers), there continues to be a lack of attention on the well-being of community-based providers, such as Community Health Workers (CHWs), within the United States. Using cross-sectional data from 75 CHWs employed in 14 agencies funded through the Maternal and Infant Community Health Collaboratives Initiative (MICHC) in New York, our study examined predictors (anxiety, physical health, adverse childhood experiences, job satisfaction, role certainty, demographic and work characteristics) of burnout, compassion fatigue (CF) and compassion satisfaction (CS). Descriptive statistics were used to characterize our sample and linear regression was employed to investigate the correlates of burnout, CF and CS. Results indicated that CHWs with higher levels of anxiety and lower job satisfaction were more likely to have higher burnout scores. CHWs with higher levels of anxiety, lower job satisfaction and fewer days of poorer health were more likely to report higher CF. Those who worked more than 35 h per week were less likely to report higher CS. The study provides recommendations for organizational-level interventions to address risk factors of burnout and CF and promote CS among CHWs, such as bolstering supervision, encouraging greater communication, offering recognition/appreciation of CHWs and creating opportunities for self-care. Findings should be considered when designing organizational-level preventive measures that mitigate burnout and CF and promote CS.

Physicians are particularly vulnerable to mental health symptoms during global stressors such as the COVID-19 pandemic. Such stressors can increase death anxiety, which is a vulnerability factor for psychological dysfunction. Thus, exposure to COVID-related death may play a unique role in physicians’ mental health during the pandemic. This cross-sectional study collected self-reported data from 485 resident physicians and fellows. Participants reported mental health symptoms, including posttraumatic stress symptoms (PTSS), burnout, and functional impairment due to the pandemic. Participants also reported death anxiety, COVID-19 anxiety, cognitive accessibility of death-related thoughts (DTA), and workplace exposure to COVID-19. Death anxiety, COVID-19 anxiety, DTA, and workplace COVID-19 exposure all independently predicted PTSS. Furthermore, COVID-19 anxiety and DTA interacted to predict PTSS, such that high levels of COVID-19 anxiety predicted higher PTSS, regardless of DTA level. Death anxiety and COVID-19 workplace exposure interacted to predict PTSS as well, such that death anxiety predicted PTSS only when COVID-19 exposure was high. Burnout was predicted by COVID-19 anxiety and workplace exposure, and COVID-related functional impairment was predicted by death anxiety and COVID anxiety. These findings demonstrate that death-related and COVID-related concerns, independently and in interaction with each other, play an important role in psychological distress among physicians.