Covid-19 pandemic induced traumatizing medical job contents and mental health distortions of physicians working in private practices and in hospitals

Healthcare workers, especially frontline staff, experienced pronounced psychological burdens at the start of Covid-19. The study investigates whether, by late 2021 (fourth wave in Europe), these stressors had diminished through adaptation or expanded to broader medical settings, including private practices. Prior literature reports high prevalence of anxiety and depression among HCWs, moral dilemmas due to shifts from patient-centered to public health-centered ethics, and risk factors such as junior status, female sex, and family responsibilities. Evidence specific to physicians in private practices is limited, and comparisons with hospital physicians are scarce. The study aims to: (1) systematically assess traumatogenic job content among physicians during the fourth Covid-19 wave; (2) compare the differential impact on mental distress between hospital physicians (HPs) and private practice physicians (PPs); and (3) identify personal, job-related, organizational, and Covid-19-related factors, including ethical dilemmas, associated with mental health outcomes and feelings of helplessness.

The paper summarizes evidence showing high mental health burden among HCWs early in the pandemic, with anxiety among physicians around 17–19.8% and depression up to 40.4% in some reviews. Scoping reviews highlight moral dilemmas from shifting ethics during crises as major challenges in hospitals. Risk factors for distress include direct patient contact, being younger/junior, parenting, and having infected family members. Some studies indicated that, after adjusting for work conditions, caring for Covid-19 patients might be associated with lower risk of adverse mental health among nurses, suggesting complex dynamics. For general practitioners, studies from Italy, France, and a multi-country survey reported substantial distress, with higher risk among females, rural settings, less experience, and increased substance use linked to work stress. A French study among radiologists suggested public hospital work could be protective for insomnia, anxiety, and depression. Overall, evidence points to high psychological burden, ethical conflicts, and potential differences across settings, but direct comparisons between hospital and private practice physicians remain limited, motivating the current study.

Design and setting: Cross-sectional anonymous online survey distributed by the Medical Council of Westfalen-Lippe (Germany) and supported by AFNET (Münster, NRW), covering ~8.2 million inhabitants. Ethics approval: September 16, 2021. Data collection period: November 4 to December 31, 2021. Informed consent obtained; confidentiality assured. Participants: 1476 physicians reached; valid data from 1327; analyses focused on 1139 (86.6%) who reported personal treatment experiences with Covid-19 patients. Among these, 553 PPs and 586 HPs. Majority vaccinated (98%); prior infection reported by ~9% PPs and 15% HPs. Sex distribution: 54.7% women overall, with more female physicians working in HPs (53.2%). About 16% had <5 years medical employment. Measures: - Pandemic-induced traumatizing medical job content: Nine items derived via modified Delphi process (led by A.G.) capturing adverse working conditions: confrontation with dying patients (0–3), number of Covid-19 patients treated (0–3), professional restrictions (0–1), forced to limit treatment of non-Covid-19 patients (0–1), external constraints conflicting with medical ethics (0–3), inability to maintain patient dignity (0–3), forced prioritization of treatment (0–3), etc. Items combined into a general score (0–17); 176 missing values. - Future outlook: Beliefs about lasting effects on medical care, telemedicine’s role, personal offering of telemedicine; personal future expectation on VAS 1–10 (catastrophic to excellent). - Behavioral/psychological variables: Feeling helpless measured by a dichotomized one-item question; Self-rated health (WHO standard item; aggregated to 3 levels: good, fair, poor); Sleep disturbances from Uppsala Sleep Inventory items (difficulties initiating sleep, maintaining sleep, premature awakening; each 0–1; total 0–3); Depression (PHQ-2, cut-off ≥3); Generalized anxiety (GAD-2, cut-off ≥3); Psycho-traumatogenic impact of encounters with Covid-19 patients (0–5 Likert-like). Statistical analysis: Descriptive statistics; multivariate linear and logistic regression to examine factors associated with helplessness (N=1315); mediation analysis to test whether sleep disturbances mediate the association between exposure to unsettling events and helplessness using Baron and Kenny framework and nonparametric bootstrap (1000 resamples) to estimate indirect effects and proportion mediated. Analyses in SAS 9.4 and R ‘mediation’ package; significance level p<0.05; STROBE guidelines followed for reporting cross-sectional data.

- Sample: 1139 physicians with direct Covid-19 patient care (553 PPs; 586 HPs). 54.7% women; 16% with <5 years’ experience; 98% vaccinated. - Work organization and ethics: ~80% experienced professional restrictions; ~87% reported limitations in treatment of non-Covid patients. Economic disadvantages more frequent in PPs vs HPs (49.0% vs 42.4%, p<0.0001). Staff resignations higher in HPs vs PPs (23.8% vs 7.4%, p<0.0001). - Ethical conflicts: External constraints conflicting with medical ethics more often in PPs vs HPs (39.1% vs 34.4%, p<0.002). Inability to maintain patient dignity more often in HPs vs PPs (48% vs 27%, p<0.0001). - Adverse job content score: Higher in HPs than PPs (mean 8.4±3.7 vs 7.1±3.0; p<0.0001). No sex differences reported in score levels. - Affective impact: ~84% reported being unsettled/afflicted by encounters with Covid-19 patients. - Sleep disturbances: 51.8% overall (no significant difference between PPs and HPs; component patterns varied slightly). - Depression (PHQ-2 ≥3): 23.0% overall; higher in HPs than PPs (27.2% vs 18.7%; p=0.0002). - Anxiety (GAD-2 ≥3): 24.16% overall; higher in HPs than PPs (26.3% vs 21.9%; p=0.07 overall; significant in some subgroup comparisons). - Helplessness: 58.4% overall; higher in HPs vs PPs (63.3% vs 53.4%; p=0.0002). - Future outlook (VAS 1–10): Mean ~6.8 in both settings (PPs 6.79±1.88; HPs 6.84±1.68; n.s.). 80% believed the pandemic will have lasting effects on medical care; ~43% planned to offer telemedicine. - Mediation: Sleep disturbances significantly mediated the association between exposure to unsettling events and helplessness (indirect effect β=0.29, SE=0.03, p<0.0001).

Findings indicate that by the fourth wave of Covid-19, adverse work conditions and ethical dilemmas extended beyond frontline roles to both hospital and private practice settings. Hospital physicians experienced higher traumatogenic job content scores and more difficulty maintaining patient dignity, whereas private practice physicians more often reported economic disadvantages and external constraints conflicting with medical ethics. Mental health burden remained high, with approximately one quarter screening positive for depression and anxiety, exceeding early-pandemic physician benchmarks and pre-pandemic general population values, suggesting no adaptation or decline in affective burden over time. Feelings of helplessness affected over half of physicians and were more common in hospitals. Female sex, fewer years of medical experience, sleep problems, and exposure to unsettling events were associated with helplessness. Sleep disturbances mediated the impact of unsettling events on helplessness, highlighting sleep as a key pathway for stress translation into affective outcomes. These results underscore that Covid-19-related stressors are pervasive across medical settings and continue to impair physicians’ mental health and perceived ability to uphold ethical standards and function optimally.

During the fourth pandemic wave in Germany, physicians in both hospitals and private practices showed high rates of depressive (23%) and anxiety (24%) symptoms, substantial sleep disturbances, and prevalent feelings of helplessness (58%). Adverse job content and ethical conflicts were common, with hospital physicians bearing higher traumatogenic workload and dignity-related constraints and private practice physicians experiencing more economic and external ethical constraints. Compared with early-pandemic physician data, mental health impairment appears to have increased, arguing against a broad adaptive decline in distress. Interventions should prioritize organizational support (adequate rest, staffing, training, clear communication), ethical guidance, and accessible, tailored psychological support, including strategies that improve sleep. Future research should use longitudinal designs to assess causal pathways, monitor trajectories over time, and evaluate the effectiveness of targeted interventions across settings.

Low response rate raises potential nonresponse/sampling bias due to self-selection. Cross-sectional design limits causal inference. Reliance on self-report measures may introduce reporting bias. Some measures used single-item assessments. The job content score had missing data for 176 participants. Generalizability beyond the surveyed region and time window may be limited.