The Mental Health Toll: Medical Trainees Living with Disabilities during the COVID-19 Pandemic

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Introduction
Recent studies have shown that the coronavirus-19 (COVID-19) pandemic placed healthcare professionals (HCPs) in unprecedented medical and moral situations, involving difcult decision making and working under extreme pressures [1].Subsequently, emotional distress and adverse psychological outcomes including stress, anxiety, depression, and sleep disturbances were found to be prevalent among HCPs worldwide [2].Among HCPs, medical trainees are uniquely vulnerable, functioning simultaneously as both learners and frontline service providers.

Medical Training during the COVID-19 Pandemic.
Since medical trainees are continuously evaluated and need to develop their sense of professional identity, they are one of the more vulnerable groups within the medical feld [3].It has been shown that some of the main concerns of medical trainees during the COVID-19 pandemic are similar to concerns that HCPs experience in general, such as fears regarding their own safety, the safety of their patients and their loved ones, fear of potential shortages of protective personal equipment (PPE), moral distress and ethical dilemmas, and feeling distant from patients while wearing PPE [4].
Nevertheless, medical interns and residents have been expressing additional concerns regarding their medical training, which has been altered during COVID-19.For instance, in many institutions, clinical clerkships have been considerably modifed.Many clerks were removed from clinical rotations, and fnal year clerks were asked to graduate early and begin residency immediately so that they would be able to provide patient care [5].Residents were reassigned and rotations revised or suspended [6].Procedural specialties postponed many elective surgeries and many hospitals and clinics have transitioned to a virtual model [7].In some countries, residents experienced an unprecedented stressful workload of COVID-19 patient care [8].At the same time, outpatient volume and non-COVID patients' volume declined, leading to a decrease in exposure to diverse patients [9].Decision making has become more difcult during the current pandemic, as residents are at the frontline of care and need to maximize every moment spent with patients in order to make appropriate medical decisions while limiting unnecessary exposure [10].Moreover, a shortage of trainees due to illness or quarantine has put a strain on hospital wards, and some residents and fellows were redeployed to internal medicine wards and intensive care units [11].
In addition, since many educational activities such as lectures, conferences, and in-person meetings were cancelled, trainees had fewer opportunities for learning and receiving the emotional and social support that comes with being part of a community of learners [10,11].In a study conducted in Saudi Arabia, 46.7% of the residents reported being instructed to work in COVID-19 wards, not by choice [12].For some fnal year residents, the postponement of their licensing examinations infuenced their employment trajectories [5].
Te changes in training processes as well as in workload may have an emotional toll on medical trainees.For example, among urology residents, cancellation of elective cases was associated with higher rates of concern about their training, while this concern was found to correlate with a higher severity of depression [13].A qualitative study of medical residents working at the frontline in Pakistan found that psychological distress was related to the shortage of PPE, direct exposure to COVID-19, concern for personal safety, fear of being infected and infecting loved ones, physical distancing from loved ones, and working long hours [14].Moreover, two-thirds of otolaryngology residents perceived that residents were at a higher risk for being infected with COVID-19 compared to attendings [15].Te fear of rationing PPE and ventilators was shown to cause moral distress among residents who may feel that they are not qualifed to make these difcult moral decisions [16].Despite having more days of per month during the pandemic, one-third of medical residents reported more burnout than usual [4], while attendings have been shown to experience decreased burnout in comparison to residents [17].Tese initial fndings are important, but since these studies did not compare medical learners and trainees to experienced HCPs, it is not clear if the distress impacts all medical teams in the same manner, or if there is variability associated with role and level of training.

Disabled Trainees during the Pandemic.
Te COVID-19 pandemic presented notable challenges for people living with disabilities (we alternate between identity-frst language and Person-frst language to allow representation of the diferent preferences within the disabilities communities).Studies documenting these challenges have shown that disabled patients experience lower rates of access to care [18], increased emotional distress [19], and the need for more psychological support [20].Te current pandemic may also pose additional barriers to daily living-for example, the requirement to wear masks may be extremely challenging for people who are assisted by lip-reading [21].Furthermore, according to the Centers for Disease Control and Prevention [22], people living with disabilities are three times more likely than adults living without disabilities to have underlying medical conditions (e.g., heart disease, stroke, or diabetes) that may lead to a higher risk of COVID-19 infection or severe illness [22].
As for the work environment, the World Health Organization (WHO) recommended that fexible work arrangements and infection control measures be supported by employers through working remotely or allowing immunocompromised individuals to take leave until the risk of infection is reduced [23].Tese changes in the work environment, such as normalizing the option of working from home and enabling fexible schedules, actually enabled the COVID-19 pandemic to accommodate individuals with disabilities and chronic health conditions [24].Unfortunately, these changes in the work environment are more difcult to apply for HCPs, and especially for medical trainees, who are engaged in clinical "hands-on" learning.
All studies conducted among disabled people were conducted from the perspective of patients and service receivers.However, HCPs and trainees could be both service providers and service receivers [25].Being a medical trainee and living with a disability during the pandemic could be stressful and burdensome, but not much is known about the mental health toll of being a medical trainee living with a disability during the pandemic.Tis study aimed to explore the impact of the pandemic on the mental health of medical trainees who live with a disability.Te main research question was: in what ways do the level of medical training and living with disability impact the mental health of medical interns and residents, in comparison to attending physicians during the COVID-19 pandemic?

Methods
2.1.Participants and Procedures.Tis was a cross-sectional study, with online recruitment including advertisements, email campaigns, blogs, social media, and snowball text message campaigns.Te Israeli Medical Association endorsed recruitment among doctors (internal medicine, family medicine, intensive care, and psychiatry).Te Internal Review Board of the Shalvata Mental Health Center approved the study (approval number: 0012-20-SHA).Informed consent was obtained electronically before data were collected from the participants.Te survey was administered during the frst lockdown in Israel, between April 15 and April 25, 2020.

Measures
2.2.1.Demographic Questionnaires.Demographic questionnaires included age, gender, marital status, socioeconomic status, and feld of specialization, as well as questions regarding disability.Disability was defned as a condition of the body or mind that makes it more difcult for the person with the condition to perform certain activities (activity limitations) and interact with the world around them, whether formally or informally diagnosed [26].[27,28].Te FCV-19s is a self-report scale for the assessment of fear of COVID-19.Te scale is comprised of seven items referring to fear responses to the pandemic.For example: "I am afraid of losing my life because of the coronavirus."Participants are asked to respond on a fve-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree).Te total score ranges from 7 to 35, with a higher total score indicating higher fear of COVID-19.Te measure showed good internal validity (Cronbach alpha 0.82).In the current study, the scale showed good internal consistency, with an alpha Cronbach of 0.84.[29].Te Dass-21 is a selfreport measure for the assessment of three dimensions of mental health: depression, anxiety, and stress.Te subscales include seven items each, for example, "I found it difcult to relax."Participants are asked to respond using a four-point Likert scale ranging from 1 (did not apply to me at all) to 4 (applied to me very much).In the current study, the DASS-21 scale showed good internal consistency, with an alpha Cronbach of 0.86 for the depression scale, alpha Cronbach 0.78 for the anxiety scale, and alpha Cronbach of 0.90 for the stress scale.[30].Te 14-item Mental Health Continuum-Short Form (MHC-SF) [30] was developed to assess the three components of wellbeing: emotional, social, and psychological.Te emotional wellbeing subscale (EWB) includes the measurement of positive afect or satisfaction with life.Social wellbeing (SWB) is assessed with fve items representing diferent aspects of belonging: social contribution, social integration, social actualization, social acceptance, and social coherence.Te other six items correspond to the dimensions of psychological wellbeing (PWB) mainly the sense of psychological meaning.Participants are asked to respond to items on a 6-point Likert-type scale based on their experiences over the last month (never, once or twice, about once a week, 2 or 3 times a week, almost every day, or every day).Te measure had good internal consistency, Alpha Cronbach for the total score of the emotional wellbeing subscale was 0.86, Alpha Cronbach for the belonging subscale was 0.80, and Alpha Cronbach for the psychological meaning subscale was 0.87.

Data Analysis.
Descriptive statistics were used to explore demographic data.Two-way ANOVA with "training level" and "disability" as independent variables, and "Fear of COVID 19" as the dependent variable was conducted.To test the relation between fear of COVID-19 and mental health outcomes, a series of Pearson correlation tests was conducted.Additionally, two MANOVAS were conducted.Te frst MANOVA tested training level and disability as independent factors and the three DASS scales as dependent variables.Te second MANOVA tested training level and disability as independent factors and the three wellbeing subscales as dependent variables.Statistical analysis was performed with an SPSS Version 26 package.

Results
Te fnal sample included 347 HCPs participants: 68 (19.59%) medical interns, 132 (38.04%) medical residents, and 147 (42.36%) attendings.Of the 347 HCPs, 91 participants (26.2%) presented with self-reported disability.Of the 91, 16 (17.49%)reported of the existence of physical disabilities such as cancer, arthritis, or quadriplegia and 36 (39.56%) reported a neurological or mental health chronic condition such as Tourette syndrome, PTSD, or depression.Forty-two (46.15%) participants did not agree to disclose their specifc disabilities.Table 1 presents the demographic characteristics of the sample and Table 2 presents the means and standard deviations of the mental health outcome measures by groups

Fear of COVID-19.
Two main efects and an interaction efect were found to be signifcant (Table 3).Post hoc tests of the main efects revealed that residents (M � 16.75, SD � 0.52) reported higher levels of fear of COVID-19 than attendings (M � 14.64, SD � 0.424, p < 0.05).Additionally, disabled participants (M � 16.17, SD � 5.46) were more afraid of COVID-19 than those who had no disabilities (M � 14.81, SD � 4.60, p < 0.05).However, the signifcant interaction efect supersedes those main efect results.Simple efects analysis revealed that the sources of interaction were that residents living with disabilities reported higher levels of fear of COVID-19 than residents with no disabilities (p < 0.05).No other signifcant simple efects were found, all p's > 0.05.

Depression, Anxiety, and Stress (DASS-21).
Te results of the MANOVA indicate that there were three disability main efects on all three DASS subscales: participants with a disability reported higher levels of depression, levels of anxiety, and levels of stress (M � 4.58, SD � 4.36; M � 1.88, SD � 2.72; M � 6.98, SD � 5.14 respectively) than those with  Finally, the signifcant interaction efects found for all three DASS subscales (see Table 4) supersede those reported for the main efects.Post hoc tests revealed that the sources of interactions found between living with a disability and the level of training on the depression, anxiety and stress subscales were the diferences between participants with disability and participants with no disability for both interns (p's < 0.05), and residents (p < 0.005), while no such differences were revealed for the attendings (p's > 0.05) (see Figure 1 and Table 3).

Emotional Wellbeing, Belonging, and Psychological
Meaning.Te results of the MANOVA indicated that there was a disability main efect on all three subscales (see Table 4).
Post hoc tests revealed that the main efects presented in Table 4 stemmed from lower levels of wellbeing reported by disabled participants compared to those with no disability: on the emotional subscale, disabled participants reported lower emotional wellbeing than participants with no disability (M � 13.67, SD � 3.91; M � 14.81, SD � 4.60, respectively), p < 0.05; on the belonging subscale, participants with a disability reported lower belonging than participants with no disabilities (M � 18.87, SD � 6.87; M � 20.59, SD � 6.81, respectively), p < 0.05; on the psychological meaning subscale, disabled participants reported lower psychological meaning than participants with no disabilities (M � 27.81, SD � 7.46; M � 30.45,SD � 7.79, p < 0.005).More main efects emerged for the belonging and meaning scales, such that residents reported lower sense of meaning than attendings (M � 25.40, SD � 7.87; M � 29.56, SD � 6.38, p � 0.008).On the belonging scale, residents had lower sense of belonging compared to attendings (M � 16.68, SD � 6.49; M � 20.46, SD � 6.28), p � 0.004.No other signifcant diferences were found, all p's > 0.05.

Discussion
Tis cross-sectional study aimed to explore the mental health of medical trainees during the COVID-19 pandemic as related to their level of training and living with a disability.In terms of fear of COVID-19, disabled residents had the highest scores for fear of COVID-19, which were greater than the scores of all other participants.Tere was no difference in fear of COVID-19 levels between interns and attendings living with or without disabilities, meaning that the most vulnerable group is the disabled residents.
Medical training is a challenging phase for residents who are engaged in frontline work and challenging decision making while still learning and practicing how to become HCPs [3].COVID-19 intensifed challenges for medical residents; some trainees had to work with an overload of COVID-19 patients and make difcult moral decisions, while receiving less support [31].Our results indicate that the combination of being a resident and living with a disability probably compounded fear during the pandemic.It is known that disabilities could increase feelings of stress [32], and the COVID-19 pandemic added another source of psychological distress to residents with disabilities.Tis new fnding could be attributed to the fact that some disabilities increase the risk for COVID-19 complications, thereby increasing the fear of people with disabilities of becoming infected [22].Another possible explanation of this heightened fear could also be the limited options for accommodations and support available for medical trainees at their various stages of clinical training.Some barriers to support are lack of clear procedures, fear of disclosure due to stigma, and fear that asking for accommodations would negatively impact the evaluation [33].
Another important fnding of the study is that disabled interns and residents exhibited more depression, stress, and anxiety than the rest of the participants.Interns and residents without disabilities had levels of depression, stress, and anxiety similar to the attendings.Terefore, interns and residents with disabilities are the groups most vulnerable to experience psychological distress.Some of this distress could be related to fear of COVID-19, which was positively and signifcantly correlated with the DASS measures.Finally, participants with disabilities (in general, from all three groups) had lower wellbeing in all three measures.Residents with disabilities had the lowest wellbeing levels.Te fndings regarding the vulnerability of residents could be explained by the concerns experienced during the pandemic, such as being removed from clinical rotation [5], reassignment and rotations revised or suspended [6], and unprecedented stressful workload of COVID-19 patient care [8].Te changes and extra stress could explain the results found in this study and emphasize the mental health toll paid by medical trainees during the pandemic, including lowered sense of meaning and belonging.Te results also highlight the mental health toll paid by medical trainees or attendings living with disabilities.Te pandemic presented challenges for people living with disabilities, including increased psychological stress and increased isolation and loneliness [19].Medical trainees and attendings had to continue their education and work facing these challenges, and this study highlights the transparent mental toll of fear of COVID-19 and psychological stress.
Te mental health of medical trainees living with disabilities has been highlighted before as an area of concern that is understudied [34].Medical trainees living with disabilities are in a unique position as both service users and service providers, and need to merge these identities.Tey sometimes hide their disabilities for fear of being conceived as incompetent [35] and to avoid experiences of delegitimization, which increases isolation [36].Te disclosure processes of disability could be an ongoing stressful journey for people with disabilities in healthcare professions [37].Some of the mental distress that people with disabilities experience in medical education may be related to their perceived need to hide their disability, which in itself is very stressful.Tis extra stress is "transparent" and represents a hidden mental health toll paid by healthcare professionals  4) residents with no disabilities (n � 106), (5) attendings living with disabilities (n � 46), and (6) interns with no disabilities (n � 141).
Table 5: Te implications of the study and recommendations for medical education stakeholders.
(1) Medical educators should provide the necessary accommodations, at the university, and in clinical education settings for disabled trainees to safely continue their educational journey.During pandemic time, it is important to reconsider these accommodations and adapt them to the new reality and needs (2) Mental health and self-care should be part of the curriculum and should be discussed in medical education settings for all trainees, especially during a pandemic (3) Te wellbeing of medical trainees during the pandemic could be enhanced by increasing their sense of belonging, sense of mastery, and sense of meaning in their social roles as healthcare providers (4) Medical education settings and supervision relationships should provide empathy, encouragement, and emotional support, especially during massive crises such as a pandemic.Terefore, (5) It is important that supervisors, preceptors, and feld educators will also receive training on how to best support their trainees and especially trainees with disabilities (6) In general, but especially during a pandemic, it is important to promote a culture of legitimacy to express emotional hardships without facing stigma or negative attributions 6 Health & Social Care in the Community with disabilities [36].Clearly, the accumulative stress of being a medical trainee and living with a disability during the pandemic resulted in increased stress and isolation, which lowered the sense of belonging and meaning for these trainees.Te current results emphasize the need for educators, preceptors, and supervisors to support medical trainees with disabilities, especially during stressful times such as the pandemic.
4.1.Study Limitations.Since the study was conducted among medical trainees from one country, replication in diferent countries would allow a better generalization.In addition, the study used self-report measures, and therefore, the generalization of the results should be interpreted with caution.Te study evaluated mental health only at one point in time, making it hard to diferentiate the causes for the mental health toll on trainees and especially trainees with disabilities.Future longitudinal studies are warranted to determine how changes in their workload and education during the pandemic may impact the mental health of medical trainees.

Implications for Medical
Education.Tis study contributes to the existing limited knowledge about the mental health of medical trainees with disabilities during the pandemic.Since medical trainees hold important positions as HCPs battling the pandemic, society depends on their coping and wellbeing.Te study results focus on the extra mental health toll and isolation that medical trainees with disabilities experienced during the COVID-19 pandemic.Tese usually "invisible mental tolls" are not always disclosed by people with disabilities, because medical settings are usually competitive and high paced, and therefore asking for support could entail stigma and negative judgments [38,39].One of the implications of this study is that medical educators should be aware of the "transparent toll" on disabled trainees and create a more supportive climate that will provide the necessary accommodations for trainees to safely continue their educational journey with their peers, and increase their sense of belonging and psychological meaning.Tis is needed in regular times, but even more so during stressful times such as the pandemic.Disregarding this emotional toll generates inequities and an extra burden that medical trainees living with disabilities often experience when entering healthcare professions [38,39].Additionally, this extra burden could be considered a form of "minority tax," a price paid by individuals from minority groups when they embark on medical education, including disparities in mentorship, advocacy eforts, feelings of isolation and the need to represent their group in various forums with no reimbursement of their time or eforts [40].
Another implication for medical educators is that mental health and self-care should be part of the curriculum and should be discussed in medical education settings for all trainees.Educational programs must provide residents the support they need to cope with the psychological burden they may experience during a pandemic, while promoting a culture of legitimacy to express emotional hardships without facing stigma or negative attributions.Support for medical trainees should be provided in a way that will allow all trainees to maintain their psychological safety [38,39].Terefore, it is important that supervisors, preceptors, and educators will also receive training on how to support their trainees, in particular those who live with a disability [38].Te fndings of this study also suggest possible directions for support indicated by the wellbeing outcomes.Wellbeing of medical trainees could be enhanced by increasing the sense of belonging and psychological meaning.Tese could be addressed within the training settings and within supervision relationships that should provide empathy, encouragement, and emotional support.Tis suggests the importance of providing supportive work and learning environments for medical trainees, especially during the pandemic.Tese specifc implications for key stakeholders such as educators, healthcare institutions, and policymakers are summarized in Table 5.

Conclusion
Medical trainees living with disabilities were more prone to experience high levels of psychological distress during the COVID-19 pandemic compared to their peers without disabilities.Terefore, there is a need to address this emotional toll.Based on the fndings of this study, future studies should focus on exploring the specifc challenges for medical trainees during the pandemic and the best ways to provide accommodations and support.Future studies could also explore the unique contributions of disabled trainees to patient care during the pandemic, as they hold valuable experiential knowledge and ofer dual perspectives as both service providers and service users.Other studies could explore the opportunities and new ways that the pandemic brought to medical training that could beneft disabled medical trainees (i.e., online learning or shorter shifts).Te COVID-19 pandemic created substantial changes in educational settings; some could promote the creation of more inclusive medical education.

Data Availability
Te data used to support the fndings of this study will be available on request.For requests, please contact Dr. Yael Mayer (yaelmayer10@gmail.com).

Additional Points
Highlights. (i) Medical trainees experienced psychological distress during the COVID-19 pandemic.(ii) When medical trainees are living with disabilities, psychological distress may be exacerbated.(iii) Participants in the study were 201 medical trainees and 147 medical attendings.(iv) Participants completed an online survey regarding psychological distress and wellbeing.(v) Disabled trainees experienced greater psychological distress and lower wellbeing, belonging, and meaning than all other groups.Tweet.Participants in the study (201 medical trainees and 147 medical attendings) completed an online survey regarding distress, fear and wellbeing during the COVID-19 pandemic.Disabled trainees had greater psychological distress than all other groups.

Table 1 :
Demographic characteristics of the sample.

Table 2 :
Means and standard deviations of the mental health outcome measures by groups.