key: cord-1040138-30wr8nim
authors: Amin, Dina; Austin, Thomas M.; Roser, Steven M.; Abramowicz, Shelly
title: A Cross-Sectional Survey of Anxiety Levels of Oral and Maxillofacial Surgery Residents during early COVID-19 Pandemic
date: 2021-02-08
journal: Oral Surg Oral Med Oral Pathol Oral Radiol
DOI: 10.1016/j.oooo.2021.01.024
sha: 75c220abd25059510c908ec0ad785711d68477af
doc_id: 1040138
cord_uid: 30wr8nim

PURPOSE: The coronavirus disease (COVID-19) pandemic increased anxiety among general population. The purpose of this project was to investigate attitudes and anxiety among Oral and Maxillofacial Surgery (OMS) residents during the early COVID-19 pandemic. MATERIALS AND METHODS: This was a cross-sectional study. OMS residents were invited electronically to answer a survey. The survey was sent in April and May 2020. Residents enrolled in OMS residency programs accredited by the Commission of Dental Accreditation (CODA) were included. Predictor variable was attitudes of OMS residents toward pandemic. The outcome variable was anxiety levels of OMS residents due to pandemic according to Hospital Anxiety and Depression Scale-A (HADS-A). Other variables were: demographics, general knowledge regarding pandemic, and attitudes of OMS residents toward pandemic. Statistical analysis consisted of Fisher's exact test, Wilcoxon rank sum test, and univariate and multivariable logistic regression (P < 0.05 significance). RESULTS: We received 275 responses. Majority were males (74.5%) in 26-30 age group (52.7%). Residents reported different levels of anxiety (i.e. mild 58.2%, severe 41.8%). Based on multivariable analysis, moderate or severe anxiety was associated with being a female (p= 0.048) and a senior resident (p=0.049). Factors such as potential deployment to other services, availability of personal protective equipment (PPE), and unclear disease status of patients contributed to anxiety. CONCLUSION: Our study found that during early COVID-19 pandemic, all residents experienced some anxiety. Senior OMS residents, and female OMS residents experience higher anxiety levels than other residents.

In December 2019, city officials in Wuhan, China, recognized a cluster of patients with pneumonia caused by an unknown etiology and linked to Huanan Seafood Wholesale Market. 1, 2 In February 2020, the world health organization (WHO) officially named the disease as coronavirus disease 2019 . 1 The rapid virus transmission caused an international emergency associated with substantial morbidity and mortality worldwide. 1,3,4 COVID-19 is now considered a pandemic. 3 COVID-19 is unique because asymptomatic patients can act as carriers for weeks before they develop symptoms. 5 COVID-19 is transmitted mainly by the respiratory route or via contact with infected secretions, 6 but other methods of transmission have been reported (e.g., fomite, 7 fecal-oral route, 6 ). COVID-19 concentrates in the upper airway mucosa; 5 procedures involving this location (i.e., majority of procedures in oral and maxillofacial surgery, OMS) are considered high risk. When viral particles become aerosolized, they can stay in the air for at least 3 hours. 5, 8 COVID-19 infection can progress rapidly, has unknown definitive treatment, and may require intensive resuscitation and rehabilitation.

During this pandemic, emotional distress and anxiety are increasing in the general population. There is fear of becoming ill, financial losses, shelter-in-place orders, inability to spend time with family and friends, and conflicting messages from authorities. 9, 10 Healthcare workers (HCW) are not immune to the psychological effect of COVID-19 pandemic. 11 HCW face unique circumstances with long working hours, an increase in risk of infection, an increase in loss and suffering, and a shortage of personal protective equipment (PPE). 11, 12 The asymptomatic COVID-19 carriers increase disease transmission. 13 HCW can be asymptomatic carriers of the virus, causing virus transmission to their family and friends.

Previous to the COVID-19 pandemic, more than half of OMS residents reported moderate to severe anxiety during their residency. 14 The COVID-19 pandemic is hypothesized to further to increase the level of anxiety among OMS residents. 14, 15 The purpose of this study was to investigate attitudes and presence of anxiety among OMS residents during the early COVID-19 pandemic. The investigators hypothesize that anxiety levels are high due to the COVID-19 pandemic. The specific aims were: 1) to investigate the attitudes of OMS residents toward the early COVID-19 pandemic, and 2) to investigate OMS residents" anxiety levels during early COVID-19 pandemic.

The study was approved by Emory University Institutional Review Board (approval # 00000418). We designed and implemented a cross-sectional analytical study. A 27-question, close-ended, anonymous survey ( Figure 1 ) was sent electronically to OMS residents in the US.

The study population consisted of all US OMS residents enrolled in an OMS residency program which is approved by the Commission of Dental Accreditation (CODA) in US. The study sample consisted of residents who responded and submitted survey. Exclusion criteria were: 1) OMS residents in non-CODA accredited programs, 2) incomplete surveys, 3) surveys returned after the closure of the study, 4) residents with invalid emails. The study team contacted representatives of all OMS programs to obtain email addresses of residents. The survey was sent to OMS residents in April and May 2020.

The primary predictor variables were attitudes regarding effects of pandemic on residents" own health, graduation requirements, and self -perceived competency. The primary outcome variable was anxiety level measured using HADS-A. The survey consisted of 3 sections. The first section included demographic data [age, gender, marital status, parental status, 16, 17 HADS-A has 88% sensitivity and 81% specificity for diagnosis of an anxiety disorder. 14, 18 Further discussion regarding utility of HADS is beyond scope of this manuscript. The survey reliability and validity were previously tested to measure anxiety and depression on various patient populations. [19] [20] [21] [22] In our study, we used the anxiety scores (HADS-A) with subcategories of feelings (tension, fear, worry, relaxed, nervous, panic, and restlessness). 14,18 Each item has a Likert response scale ("0" indicates most of the time to "3" which indicates from time to time or occasionally). 23 Scores are summarized (0 to 21); higher scores indicate an increase in anxiety.

Total score places a participant into a category: none/mild (0-7), moderate (8-10), or severe (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) anxiety. Previous studies demonstrated that these scores are reliable. 16 

The Study data was collected and managed using Research Electronic Data Capture platform (REDCap, Fort Lauderdale, Florida) hosted at Emory University School of Medicine. 24

All analyses were performed using R statistical software (Version 3.6.3). For the purposes of this analysis, residents were dichotomized into two cohorts based on anxiety scores of < 8 (no/mild anxiety) and ≥ 8 (moderate/severe anxiety). For univariate analyses, Fisher"s exact test was used to examine categorical variables. Wilcoxon rank sum test was used to examine differences in ordinal variables between cohorts. For multivariable analysis of predictors of moderate/severe anxiety, multivariable logistic regression was performed on predictors with P < 0.1 on univariate analysis. In order to limit model overfitting, backwards elimination variable selection was then performed based on minimizing the corrected Akaike information criteria (AICc). Statistical significance was defined as P < 0.05.

All 101 OMS residency programs were contacted to request email addresses of OMS residents. Of them, 82 programs shared a complete list of resident emails, 8 programs provided an institutional email listserve, and 2 programs shared individual emails of residents who were interested in participating. Nine programs did not participate: 8 did not reply and one refused to participate. The survey was sent to 1142 residents. There were 14 invalid email addresses from various programs. Overall, 275 (24.3%) residents completed the survey.

Of the 275 residents who responded, there were 205 males (74.5%) and 70 females (25.5%).

Ages consisted of 26-30 years (n=145, 52.7%), 31-35 years (n=110, 40%), 36-40 years (n=16, 5.8%), younger than 25 (n=2, 0.7%), or older than 40 (n=2, 0.7%). The majority of respondents were married (n=147, 53.5%). Respondents had no children (n=193, 70.2%), had children (n=72, 26.2%) or were expecting (n=10, 3.6%). Most of the residents surveyed were located in northeastern states (n=104, 37.8 %). Residents were also located in southeast (n=71, 25.8%), midwest (n=60, 21.8%), southwest (n=35, 2.7%), northwest states (n=1, 0.04%), or other (4, 1.5%). Most residents were enrolled in a 4-year (n=148, 53.8%) or a 6-year (n=120, 43.6%) OMS program. Respondents were in PGY 1 (n=66, 23.7%), PGY 2 (n=62, 22.3%), PGY 3 (n=50, 18%), PGY 4 (n=42, 15.1%), PGY 5 (n=20, 7.2%), PGY 6 (n=22, 7.9%), or were noncategorical (n=13, 4.7%) ( Table 1) . Table 2 presents the primary predictor variable, attitudes of OMS residents toward the COVID-19 pandemic. The majority of respondents reported that they believed that if they became infected with COVID-19, they would recover (n=270, 98.2%). Almost all respondents reported that in their opinion, an infected patient will survive from COVID-19 (n=274, 99.6%).

The majority believed that they have a higher occupational risk of becoming infected (n=271, 98.5%). More than half of the respondents reported some hesitancy toward treating COVID-19 positive patients (n=165, 60%). Approximately half of respondents (n=119, 43.3%) reported concern about deployment to other services (e.g. critical care, medicine, anesthesia, etc.). OMS residents thought that an N95 mask would not provide sufficient personal protection during treatment of positive patient (n=168, 61.1 %) but N95 mask is appropriate when treating COVID-19 negative patient (n=254, 92.4%). Approximately half felt that N95 mask would provide sufficient protection when treating a PUI (n=147, 53.5%).

The majority of residents believed that their institutions should test COVID-19 status for every patient (n=161, 58.5%). The majority believed that pandemic was getting appropriate media attention (n=221, 80.4%), but felt that government is not taking enough steps to control the pandemic, (n= 183, 64.8%). Most felt that they would be able to meet graduation requirements from their program (n=200, 72.7%), and reported being comfortable with their own surgical competency despite a significant decrease in surgical volume due to COVID-19 pandemic (n=175, 63.6%).

Of 275 responses, 160 (58.2%) residents reported normal/mild anxiety and 115 (41.8%) residents expressed moderate or severe anxiety levels ( Figure 2 ). Based on univariate testing, eleven variables met criteria to be introduced into the multivariable logistic regression model: gender, residency year, and COVID questions 4-6 and 8-13 (Tables 1 and 2 ). After multivariable model fitting, only gender, residency year and COVID questions 6, 9, and 12 were statistically significant (Table 3 ). Based on this analysis, moderate or severe anxiety was associated with being a female (p=0.048) and a senior (p=0.049) resident. Residents reported an increase in anxiety levels when they (1) believed that N95 mask did not offer protection from a patient with COVID-19 (p<0.001), (2) thought that their institution should test all patients for COVID (p<0.001) but institution was not testing, and (3) when resident felt that a decrease in surgical volume because of pandemic may result in not meeting graduation requirements (p=0.001) ( Table 3) .

The purpose of this study was to investigate attitudes and anxiety among OMS residents during the early COVID-19 pandemic. The investigators hypothesized that residents feel anxiety due to the COVID-19 pandemic. The specific aims were: 1) to investigate the attitudes of OMS residents toward the early COVID-19 pandemic, and 2) to investigate the residents" anxiety level during the early COVID-19 pandemic.

The majority of the respondents were males in 26-30 years age group, without children, and living in northeastern region of US. These demographics of OMS residents as a group are similar to previous reports. 25-29 Therefore, we felt comfortable comparing our findings to previous reports of anxiety in residents. The majority of residents who completed the survey were in PGY 1 or 2. This is likely due to a reduction in clinical patient care 4 patients. This led to earlier aggressive responses implemented by the states and institutions than in states that experienced a later surge. 32

Regarding residents" own attitudes toward COVID-19 pandemic, it is possible that ongoing uncertainty regarding the pandemic introduced anxiety. Conflicting recommendations from the World Health Organization (WHO) 33 

Prevention (CDC) 34 caused confusion during early stage of pandemic. At the time of the survey, WHO stated that surgical masks were adequate to care for patients with COVID-19, 33 but CDC indicated that the exact role of the airborne route in the transmission of COVID-19 was unknown. 35, 34 Since then, institutional daily operations and recommendations continued to evolve. The ongoing tension between maintenance of health and safety of HCW and patient care 36, 37, 38 has the potential to increase anxiety. 39 Therefore, it is not surprising that answers from our survey were mixed. Approximately half of the responders in our survey believed that their institution should test every patient. However, this was not the protocol in many institutions.

received priority tests. It is possible that as tests become more available with a faster result, that all patients will be required to undergo pre-operative COVID test. Additional and faster testing would likely decrease uncertainty and thus decrease anxiety in HCW including OMS residents.

The majority of residents believed that they have an occupational risk for COVID -19 infection but that they would recover if infected. Regarding PPE, residents indicated they did not feel protected with an N95 mask when treating a positive patient but felt protected with an N95 mask when treating a negative patient. Half of respondents felt protected by an N95 mask when patient was PUI. It is likely that the US benefited from information from countries that experienced the pandemic first 40, 41 and initiated early protocols to protect Head and Neck Surgeons (including OMS). 40, 41 This knowledge combined with guidance by OMS programs 17 likely provided assurance to OMS residents. Therefore, it is not surprising that in our survey, all residents reported anxiety as a result of pandemic, albeit at different severity levels.

Residents" stress, anxiety, and depression have been discussed in the literature. 14, 42, 43 Stress has a negative impact on mental and emotional health. 43, 44, 45 Studies conducted prior to the pandemic reported that OMS residents exhibit moderate to severe levels of anxiety, 14 low personal achievement, episodic cognitive disturbances, chronic anger, family disharmony, depression, drug abuse, suicidal ideations and suicide. 14, 42, 43 In our project, all residents reported anxiety, albeit at different severities. We found that certain variables were associated with severe anxiety: female gender, late residency year, and having specific beliefs regarding COVID-19 pandemic (i.e., feeling protected with N95 mask during treatment of a positive patient, belief that institution should test patients, and graduation requirements). Numerous factors might lead to an increase in anxiety among chief residents such as the potential pandemic effect on their graduation requirements, inadequate time to obtain surgical competency and skills, and/or availability of jobs after graduation. We believe that female residents experienced more anxiety because of additional responsibilities/concerns such as kids being more at home (due to day care or school shut closure), or the possibility of being pregnant during the pandemic.

Regarding surgical competency, our study found that most residents were not concerned about completing graduation requirements because of COVID-19 pandemic. This finding is surprising since determining surgical competency is challenging. The specific number of OMS procedures that need to be completed before a resident achieves competency is unclear. 46 Traditional methods of evaluating competency of OMS residents (e.g. number of cases, volume, duration of training, etc.) 46 may have to be modified because pandemic decreased patient interactions. In comparison to OMS surgeons, general surgery residents expressed a significant difficulty in achieving minimum case requirements. 39 It is possible that residents did not report concern regarding completion of requirements because residents trusted that residency programs would develop guidelines and modify graduation requirements during pandemic. This project has some limitations. First, only approximately a quarter of all OMS residents in US participated. However, we believe that the respondents adequately represent the group since overall demographics were similar to previous studies. [25] [26] [27] [28] [29] Second, as the COVID-19 pandemic evolved, our knowledge and understanding of transmission and treatment progressed. This undoubtedly influenced anxiety levels of respondents from initial to last days of survey. Our study is a cross-sectional analytical study; thus, we did not examine test-retest reliability or whether an increase in COVID-related knowledge decreased levels of anxiety over time. In addition, the survey was administered prior to discovery that various races/ethnic groups have different outcomes. 47 Therefore, we did not obtain ethnic/race information.

In conclusion, the early COVID-19 pandemic introduced overall anxiety and uncertainly to OMS residents in US. Our study showed that females and senior residents experience higher anxiety levels than other residents. Institutions should encourage female support groups, promote work life balance, and promote diverse mentorship programs. Inconsistent PPE, ever changing institutional policy regarding patient testing, and COVID-19"s effects on the case volume required for graduation all increased anxiety amongst OMS residents. Education and policies directed at these specific COVID-related matters may help to decrease anxiety levels in OMS residents. 

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Figure 1: Survey Questions Section 1: Demographics 1. What is your age group? 2. What is your gender? 3. What is your marital status?

Do all infected patients with COVID-19 die? 10. Are you at occupational risk of getting COVID-19? 11. Are you hesitant about treating patients with COVID-19? 12. Are you worried about being deployed to critical care, medicine or anesthesia services? 13. Do you feel N95 mask provides enough personal protection during treatment of a COVID-19 POSITIVE patient?

Do you feel N95 mask provides enough personal protection during treatment of a COVID-19 NEGATIVE patient?

Do you feel N95 mask provides enough personal protection during treatment of a PERSON UNDER INVESTIGATION (PUI)?

Do you believe that your institution should test every patient for COVID-19 virus?

COVID-19 pandemic?

Data presented as count (percentage)

* P-value based on Fisher"s Exact Test