Has the COVID-19 Pandemic Changed the Daily Practices and Psychological State of Orthopaedic Residents?
Authors: Castioni Davide , Galasso Olimpio , Rava Alessandro , Massè Alessandro , Gasparini Giorgio , Mercurio Michele 
Published: March 2021

Abstract

Background
The coronavirus-19 (COVID-19) pandemic has been an unprecedented time for healthcare and has substantially changed resource availability in surgeons’ work practices and routines. Many orthopaedic departments suspended elective surgery, and some re-deployed orthopaedic residents to stressful nonorthopaedic tasks; long hours were commonplace. Stress-reaction symptoms such as anxiety and depression have been reported in about 10% of healthcare workers during previous infectious-diseases outbreaks (including the Ebola virus), but little is known about the psychological needs of residents faced with this global disaster.

Questions/purposes
(1) Have anxiety and depression symptoms among orthopaedic residents worsened from the period before to the period after the lockdown in Italy? (2) Are there differences in anxiety and depression symptoms between residents who worked in a COVID-19 department and those who did not?

Methods
The Italian Association of Orthopaedic and Traumatology Residents is comprised of 365 members who were recruited through the organization’s mailing list; they were asked to respond to a survey about their health and well-being at the beginning and end of the first COVID-19 Italian lockdown (March 9, 2020 to May 3, 2020). For the survey’s development, 10 orthopaedic surgery residents at the Magna Graecia University of Catanzaro were preliminarily asked to answer the surveys, and both face validity and content validity were tested. The test-retest reliability was 0.9. Impact on and future concerns about family life and daily work practice, as well as sleep disorders, were investigated. Anxiety and depression were assessed with the Hospital Anxiety and Depression Scale (HADS), which includes 14 questions (seven for anxiety, HADS-A; and seven for depression, HADS-D) on a Likert scale (0-3); thus, a patient can have a score between 0 and 21 for either the HADS-A or HADS-D, with higher scores indicating a greater likelihood of anxiety or depression. Previously reported minimum clinically important differences ranged from 1.5 to 1.7. For each scale, total scores of ≤ 7 , 8 to 10, and ≥ 11 were taken to represent normal, borderline, or abnormal level of anxiety or depression, respectively. Overall, 75% (272 of 365) of residents completed the survey at both the beginning and end of the lockdown; 72% (196 of 272) were men, the mean ± SD age was 30 ± 3 years, 72% (197 of 272) worked in a hospital setting with patients who were COVID-19-positive, 20% (55 of 272) served in a COVID-19 department, and 5% (7 of 139) tested positive for COVID-19 by nasal-pharyngeal swab. Overall, 9% (24 of 272) of residents had family members who contracted COVID-19, and 3% (8 of 272) had a relative who died. Because of the risk of possible COVID-19 exposure, 18% (48 of 272) of residents needed to temporarily change their household given that social distancing was considered the best way to slow the spread of COVID-19.

Results
At the end of the lockdown, orthopaedic residents exhibited signs of worsening anxiety and depression as measured by the overall HADS score (median 9 [IQR 5 to 14] versus median 11 [IQR 6 to 17.8], respectively; median difference -1 [95% CI -1.5 to -0.5]; effect size [r] = -0.24; p < 0.001) as well as in the depression subscale (median 4 [IQR 2 to 7] versus median 5.5 [IQR 3 to 8], respectively; median difference -1 [95% CI -1.5 to -0.5]; r = -0.36; p < 0.001). We found no difference in the development of anxiety or depression between residents who worked in a COVID-19 department and those who did not, as demonstrated by comparing the change in HADS scores between these groups (median 1 [IQR -3 to 4] versus median 1 [IQR -2 to 4] in HADS change score over time; median difference 0 [95% CI -1 to 2]; r = -0.03; p = 0.61).

Conclusion
The COVID-19 pandemic has affected the daily practice of orthopaedic residents and has had important, far-reaching consequences on their health and well-being, including social implications. Residents showed higher anxiety and depression symptoms at the end of the lockdown. No differences were found in changes of anxiety and depression, over time, for residents who worked in a COVID-19 department compared with those who did not. The evaluation of anxiety and depression through standardized questionnaires could help to identify residents at risk of higher psychological distress who could be referred to regular psychological counseling as a possible prevention strategy during stressful times. Future studies should confirm the long-term effects of these findings.

Level of Evidence
Level II, prognostic study.