Work‐related stress and coping methods of internists and primary care physicians during the COVID‐19 pandemic in Japan: A mixed‐method study

Abstract Background The COVID‐19 pandemic has affected the mental health of health care workers. This study aimed to investigate the stress factors that cause burnout in Japanese physicians and their coping methods during the COVID‐19 pandemic. Methods We conducted a sequential explanatory mixed‐method study to investigate the psychological responses of physicians in the early stages of the pandemic. A cross‐sectional, web‐based, anonymous survey was conducted among members of the American College of Physicians Japan Chapter to quantitatively investigate the stress factors and prevalence of burnout. An open‐ended questionnaire with questions about stress factors and coping methods was additionally administered. The qualitative data were analyzed using qualitative content analysis. Results Among the 1173 physicians surveyed, 214 (18.2%) responded. Among the participants, 107 (50.0%) responded “yes” to the question “I feel or have felt very stressed at work during the COVID‐19 pandemic,” and 68 (31.8%) reported burnout symptoms. Those who reported feeling stress (117 respondents) were asked to select 12 items of the stress factors related to COVID‐19. The most significant stress factor related to COVID‐19 was “Perceived risk of spreading COVID‐19 to family members” (n = 47). Content analysis identified 12 categories for the stress factors and 7 for stress‐coping methods corresponding to COVID‐19 (Cohen's kappa = 0.84 and 0.95, respectively). Conclusion Several distinct stressors existed during the COVID‐19 pandemic, which might be related to burnout among physicians. Practicing stress‐coping strategies, as identified in the present study, may help reduce work‐related stress and prevent burnout.


| INTRODUC TI ON
The novel coronavirus disease (COVID- 19)  Overall disease severity in the fourth wave was higher than that in the first through third waves. Internists and primary care physicians have played a central role as frontline healthcare workers in the diagnosis and treatment of COVID-19 with continued uncertainty. 3 The COVID-19 pandemic has had detrimental effects on the mental health of healthcare workers, including burnout, anxiety, and depression. [3][4][5][6][7][8][9][10] Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and a diminished sense of personal achievement. 11 Burnout occurs in response to prolonged exposure to specific job demands when a person can no longer endure the stress they have been experiencing. 12 Additionally, both quantity and quality of healthcare providers' care could be negatively affected by stress and burnout. Burnout is also known to lead to adverse outcomes in quality of patient care and increased health care costs. 13,14 Despite the significance of burnout as a public health issue, the stress factors and coping methods related to COVID- 19 have not been well investigated in the wake of COVID- 19. 15 To reduce physician burnout, we need to know the stress factors that cause physician burnout and coping methods during the COVID-19 pandemic. Naturally, burnout also exists in the non-COVID-19 period, but it is more apparent during the COVID-19 pandemic. We also investigated the stress-coping mechanisms physicians use to minimize these stress factors.

| Study design overview
Using a pragmatic approach, we used a mixed-method design that incorporated quantitative (questionnaires) and qualitative (open-ended questionnaire) techniques. 16 We conducted a cross-sectional, webbased, anonymous survey of physician members of the American College of Physicians Japan Chapter (ACP-JC) to quantitatively investigate the stress factors and prevalence of burnout. The ACP-JC is mainly composed of internists and primary care physicians, including fellows, residents, and medical students. For this study, we asked only physicians working in Japan to respond to the survey. We sent an invitation to physician members on March 2, 2021, via email listservs of the ACP-JC, which included a link to the survey on Google Forms. This period was the fourth wave of the surge with approximately 12,000 COVID-19 hospitalizations patients in Japan. 17 The fourth wave caused a medical crisis because beds for severe cases were at maximum capacity, restricting the transfer of some patients to advanced hospitals. 18 Additionally, we sent three reminder emails, the last of which was sent on March 16, when we closed the survey.
The survey was conducted between the end of the third wave of the COVID-19 pandemic in Japan and another surge leading to the fourth wave. During this period, the number of newly diagnosed patients daily in Japan ranged from 922 to 1977, and the participants did not receive any incentives.
Qualitative data consisting of stress factors and stress-coping methods based on internist and primary care physicians' perceptions were also collected. We aimed to conduct an exploratory study of stressors and stress-coping during the COVID-19 pandemic using quantitative and qualitative data.

| Questionnaire design
The questionnaire variables were selected based on a literature review and discussion within the study group, which included internists, primary care physicians, psychiatrists, critical care physicians, and residents. The variables included were (1) personal information (age, sex, career duration, practice location, workplace, and marital status),  19,20 The Mini Z 2.0 Survey is a simple tool that can measure burnout and workplace conditions among physicians validated in Japanese. 20,21 We used the single-item Mini Z Burnout Assessment (range 1-5) as follows 19 : COVID-19 was "Perceived risk of spreading COVID-19 to family members" (n = 47). Content analysis identified 12 categories for the stress factors and 7 for stress-coping methods corresponding to COVID-19 (Cohen's kappa = 0.84 and 0.95, respectively).

Conclusion:
Several distinct stressors existed during the COVID-19 pandemic, which might be related to burnout among physicians. Practicing stress-coping strategies, as identified in the present study, may help reduce work-related stress and prevent burnout.

K E Y W O R D S
burnout, COVID-19, mixed method, stress coping, stress factor Please circle the option that best describes your situation based on your definition of "burnout", and select one of the following response options: An open-ended questionnaire was additionally administered with two questions: "Please tell us more about your stress and reallife problems (stress factors)" and "Please tell us how you get help or handle the stress on your own (coping methods)." A qualitative inquiry was conducted following the quantitative study to better explain the quantitative results. Identifiers such as names were removed from the descriptions. 22 The transcripts were analyzed using deductive content analysis, drawing upon the stress factors and stress-coping methods as the coding frame with the cognitive process dimensions as the theme categories and subcategories. 23 The categories and subcategories derived by two authors (KN and YN) emerged from the data for triangulation in qualitative research. 26 The categories and subcategories were regularly discussed and reviewed for content by an author (KS) with extensive experience in qualitative research to ensure the credibility of the findings. 26 The concepts for each of the stress factors and stress-coping methods were analyzed, and the number of units of analysis for each concept was counted.
Some research has focused on stress-coping methods in physicians during non-pandemic situations: problem-focused strategies (active coping, instrumental support, and planning), emotion-focused strategies (acceptance, emotional support, humor, positive reframing, and religion), and dysfunctional coping strategies (behavioral disengagement, denial, self-distraction, self-blame, substance use, and venting). [27][28][29] The correspondence between these strategies and the subcategories created from the content analysis was examined.

| Ethics approval and consent to participate
This study was approved by the Institutional Review Board of Kurashiki Central Hospital. We adhered to the consensus-based checklist for reporting survey studies. 30

| Outcome measures
The primary outcome of the study was the prevalence of burnout and the percentage of COVID-19-related stress factors.

| Statistical analysis
There were no missing data for any item. All statistical analyses were performed using SPSS version 26.0 (IBM Corp.).

| RE SULTS
Among the 1173 ACP-JC physicians, 214 (18.2%) completed the survey. Table 1  In total, 107 respondents who reported feeling stress related to COVID-19 were asked to select 12 items of the stress factors related to COVID-19 ( Figure 1). The most common responses were "Perceived risk of spreading COVID-19 to family members" (n = 47). The absolute frequencies of the codes for stress factors and stress-coping methods in the data of the present study are presented in Tables 2 and 3. In the COVID-19-related stress factor, a total of 12 categories and 39 subcategories were identified: "Material workload," "Workplace relationship," "Organization," "Achievement," "Emotional workload," "Human resource," "Family," "Infection control and prevention," "Self-care," "Income," "Infodemic," and "Patient care" ( Table 2). A total of 7 categories and 49 subcategories were identified in the stress-coping methods: "Self-care activity," "Mindset," "Spending time with family," "Physical activity," "Sharing emotions," "Communication," and "Teaming" ( Table 3). The most frequent subcategory by the number of codes was "Excessive workload" in the COVID-19-related stress factors and "Conversation with the family" in the stress-coping method. The interrater reliability was substantial (Cohen's kappa = 0.84 and 0.95, respectively).

| DISCUSS ION
We extracted stress factors and stress-coping methods among physicians during the COVID-19 pandemic through a survey. Primarily, we investigate the psychological responses of physicians in the early stages of the pandemic using a mixed-method approach. Previously investigated factors, such as the fear of getting infected or infecting family and friends, excessive workload, the intermittent shortage of personal protective equipment, and the need to take stressful precautions in the clinical setting and operative fields, can add enormous psychological burdens among frontline health care providers. 31 In this study, the most common stress factor related to COVID-19 was the "Perceived risk of contamination of COVID-19 to family members" (47/107 responses). In addition, content analysis extracted the same theme categories, such as "Material workload," "Family," and "Infection control and prevention," and the relatively new themes categories such as "Income," "Organization," "Workplace relationship," "Achievement," "Human resource," "Self-care," "Infodemic," and "Patient care." Among these, one of the distinctive categories is "Infodemic." The disease, combined with forced quarantine to combat COVID-19 applied by nationwide lockdowns, can produce mental health problems. 32 These have been fueled by an "Infodemic" spread via different social media platforms. Information about COVID-19 is disseminated through media and social networking sites; however, there is also misleading and inaccurate information being disseminated, and such information overload can be significantly stressful.
The difficulty in using traditional methods of communication during the COVID-19 pandemic is related to stress factors. One of the other categories is "Organization," which includes the subcategory of "Insufficient leadership." Emotional distress was associated with the experience of poor communication from supervisors, 33 probably due to the scarcity of traditional communication. It may suggest that poor communication with the supervisor was one of the stress factors for physicians because they did not feel sufficient leadership from the supervisor.
For these stress factors, the content analysis extracted the following stress-coping methods: "Self-care activity," "Mindset," "Spending time with family," "Physical activity," "Sharing emotions," "Communication," and "Teaming." One of the strengths of this survey is that it revealed stress-coping methods during the COVID-19 pandemic. The characteristics of these stress-coping methods include rejuvenating through exercise, self-care by getting enough sleep, and spending relaxing time with family and pets. In addition, sharing one's feelings with others and good communication with team members can be effective in coping with stress. In the survey by the stress-coping strategies subscale including 17 items for stress by COVID-19, the following 7 items were used by all participants 34 : "Taking preventive measures," "Actively learning about COVID-19," "Actively learning professional knowledge," "Adjusting the attitude and facing the COVID-19 epidemic positively," "Chatting with families and friends," "Recreational activities," and "Engaging in health-promoting activities." The significant difference between these items was that the items listed defense and active learning against COVID-19, which was not extracted in the current study. This was a different result from the data in the current study, in which Japanese internists and primary care physicians primarily used their leisure time, such as time with family, vacation, and mindset, as coping strategies. The differences may be due to some aspects of culture, the social system of medicine, and psychological reactions of those that have not yet accepted the pandemic.
When the results of the content analysis were compared for the three categories of problem-focused, emotion-focused, and dysfunctional coping strategies, dysfunctional coping strategies were the most common (n = 19). Dysfunctional coping strategies are not the preferred stress-coping methods; however, during the COVID-19 epidemic, people rely on stress-coping that can be implemented to avoid infection, which may be why dysfunctional coping strategies were the most common. Another explanation was that participant physicians used self-care and physical activities categorized in behavioral disengagement, distancing and avoiding the problem or work during the COVID-19 pandemic.
Even before the COVID-19 pandemic, one mixed-method study identified that physicians' coping strategies after leaving work were the use of exercise, having quiet time such as watching television, reading or mindless activities, and spending time with family. 35 The next most common were problem-focused strategies with a frequency of 14. Nevertheless, it is novel to find that positive stress-coping methods, such as trying to improve the current situation and thinking about what should be done, are also actively used in the COVID-19 pandemic.
The measures that can be taken at the organizational level to reduce stress factors in this way will be an issue for the future. It is essential to reduce these stressors and avoid burnout among Japanese internists and primary care physicians by using coping methods during the COVID-19 epidemic. This study may be looking at psychological responses in the early stages of the COVID-19 pandemic and may be generalizable to other pandemics and disasters.

| Limitations
This study has several limitations. First, the response rates of our survey were low (18.2%). Previous web-based unincentivized F I G U R E 1 Respondents who reported feeling stress related to COVID-19 were asked to select 12 related stress factors with the most common response being "Perceived risk of spreading COVID-19 to family members" (n = 47)

TA B L E 2 Content analysis of COVID-19-related stress factors
Category Subcategory

Number of codes Quotes
Material workload Excessive workload 10 "Due to the small number of physicians, even the head of the department is in charge of more than 10 patients as an attending physician, and this has resulted in a vicious cycle of inadequate education system and consequently no increase in the number of physicians."

Lack of time 2
Administrative tasks 1  [36][37][38] However, some evidence shows that response rates might be poorly associated with non-responder bias. 39 Considering that burnout is a sensitive topic and, further, the COVID-19 pandemic, the low response rate may not have a sig-

| CON CLUS ION
Several distinct stressors existed during the COVID-19 pandemic that might be related to burnout among physicians. Practicing stress-coping strategies, as identified in the present study, may help in reducing work-related stress and preventing burnout.

ACK N OWLED G M ENTS
The authors would like to sincerely thank the participants who responded to the web-based surveys used in this study.