The COVID-19 pandemic presented significant psychological challenges, particularly for frontline healthcare workers (HCWs). Early research revealed a high risk of unfavorable mental health outcomes among HCWs exposed to COVID-19, including elevated rates of anxiety and depression. While initial studies focused on frontline personnel, the pandemic's impact extended to a wider range of medical disciplines and settings, including private practices. A scoping review highlighted the ethical dilemmas created by shifting from patient-centered to public health-centered ethics. Helplessness, a key driver of mental health deterioration, had not been thoroughly investigated among medical professionals. Risk factors for increased psychological distress in HCWs during viral outbreaks often include patient contact, junior positions, parenting, and infected family members. However, recent studies have shown mixed results, with some suggesting that caring for COVID-19 patients might be associated with a lower risk of adverse mental health after adjusting for other work conditions. The pandemic’s effects unfolded in waves, creating cumulative traumatic burden. Research on the impact of the pandemic on physicians in private practices, compared to hospital staff, remains limited. Existing studies show significant psychological distress among general practitioners (GPs) in various countries, with factors such as female gender, rural practice setting, and less professional experience contributing to higher anxiety and depression. This study aimed to systematically assess traumatogenic job content among physicians during the fourth pandemic wave in Germany and to elucidate the differential impact on the mental distress of physicians in hospitals and private practices.

Existing literature demonstrates the significant psychological toll of the COVID-19 pandemic on healthcare workers (HCWs), particularly frontline personnel. Studies consistently reported increased prevalence of anxiety and depression among physicians and nurses. An umbrella review encompassing data from 169,157 HCWs across 35 countries confirmed these findings. The shift in ethical priorities from patient-centered care to public health-focused measures during the pandemic created moral dilemmas, especially in hospital settings. Helplessness emerged as a strong predictor of mental health decline in general populations, although its significance among medical professionals remained understudied. Several studies identified risk factors for increased psychological distress in HCWs, including exposure to infected patients, junior work status, family responsibilities, and having infected family members. However, the impact of caring for COVID-19 patients on mental health appeared to be nuanced and potentially less detrimental when considering other workplace factors. Studies focusing on general practitioners (GPs) also revealed significant psychological distress, with female gender, rural practice settings, and less experience as contributing factors. In contrast, the ability to diagnose COVID-19 sometimes correlated with reduced burnout. The impact on physicians in private practices remains relatively under-researched compared to hospital-based physicians. A French study examining radiologists showed that working in a public hospital, unexpectedly, had a protective effect.

This study employed an online survey distributed through the local Medical Council of a western German district and supported by the Atrial Fibrillation NETwork (AFNET). The study was approved by the Ethics Committee. Data were collected anonymously over two months (November 4th to December 31st, 2021). The survey included 1327 physicians with valid data; 1139 (86.6%) reported treating COVID-19 patients. Job content was assessed using a modified Delphi process, yielding nine items reflecting adverse working conditions, including confrontation with dying patients, limitations on treatment, and ethical conflicts. These items were combined into a sum score (0–17). The survey also assessed future outlook regarding the pandemic's impact on medical care and telemedicine, as well as personal future outlook. Psychological variables measured included helplessness (dichotomous), self-rated health (3-point scale), sleep disturbances (0–3 score), depression (PHQ-2), and anxiety (GAD-2). Psycho-traumatogenic impact was assessed using a Likert-like scale. Multivariate linear regression analyses examined factors associated with helplessness, and mediation analyses explored the role of sleep disturbances in the relationship between unsettling events and helplessness. Data were analyzed using SAS and R.

Of 1139 physicians reporting personal treatment experiences with COVID-19 patients, 553 (84.8%) worked in private practices (PPs) and 586 (88.3%) in hospitals (HPs). A total of 720 (54.7%) were women. Most physicians (98%) were vaccinated against SARS-CoV-2. Physicians in both PPs and HPs faced numerous work-related challenges. Confrontation with dying patients was higher among HP physicians. About 80% experienced professional restrictions, and 87% reported limitations in treating non-COVID-19 patients. PP physicians faced more economic disadvantages, while HP physicians had a fourfold higher resignation rate. More PP physicians reported external constraints conflicting with medical ethics, whereas significantly more HP physicians struggled to maintain patient dignity. The overall score for adverse structural impact of COVID-19 on work environment was significantly higher for HP physicians. Most physicians (80%) believed the pandemic would lastingly affect medical care, and 43% planned to offer telemedicine. Prevalence of sleep disturbances was high (52%), with no difference between PPs and HPs. Clinically significant depression affected 179 (13.6%) physicians, more in HPs (27.2%) than in PPs (18.7%). Anxiety prevalence was 24.2% overall, with similar patterns between PPs and HPs. Helplessness was reported by 768 (58.4%) physicians, significantly more in HPs (63.3%) than in PPs (53.4%). Factors associated with helplessness included exposure to unsettling events, lower medical experience, female sex, and sleep disturbances. Mediation analysis confirmed that sleep disturbances significantly mediated the association between unsettling events and helplessness.

The study findings confirm the significant and ongoing mental health burden on physicians during and after the peak of the COVID-19 pandemic, extending beyond frontline workers to include those in both hospital and private practice settings. The high prevalence of depression and anxiety, exceeding pre-pandemic levels, contradicts the notion of adaptation or a downward trend in mental health distress over time. The widespread feelings of helplessness underscore the overwhelming challenges faced by physicians, highlighting the need for tailored interventions and support systems. The mediating role of sleep disturbances suggests the importance of addressing this factor in mitigating the impact of traumatic experiences. The disproportionate effect on female physicians and junior doctors requires further investigation and targeted support. The differences in experiences between private practice and hospital settings warrant the development of context-specific interventions to address the unique challenges in each setting.

This study reveals a considerable mental health burden among physicians in Germany during the fourth COVID-19 wave, with significant increases in depression and anxiety. The persistent mental health challenges highlight the need for ongoing support and interventions tailored to the unique needs of physicians in both hospital and private practice settings. Future research should explore the long-term effects of the pandemic on physician mental health and examine the effectiveness of various interventions to mitigate the observed challenges.

The study's major limitation is the relatively low response rate, potentially introducing sampling bias. Self-report bias inherent in using questionnaires is another limitation. The cross-sectional design prevents establishing causal relationships between variables. However, the comparison with other studies using similar methodologies helps to mitigate some limitations.