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Abstract

Introduction:

During catastrophes, physicians face significant stress and emotional challenges. This review explored existing evidence about the challenges family physicians face during infectious catastrophes, and their perceived well-being needs.

Materials and Methods:

We conducted a mixed studies literature review using 2 databases, Ovid MEDLINE ALL (1946 to February 2023) and PsycInfo on Ovid (1806 to February 2023). To assess methodological quality, we used Mixed Methods Appraisal Tool. The extracted data were analyzed employing a data-based convergent mixed methods design.

Results:

Thirty-four (34) studies met the criteria for data extraction. Line-by-line coding for thematic analysis was applied to Result and Discussion sections of included articles. Findings were categorized into 4 levels: Societal, Institutional, Organizational, and Individual. Seven themes were identified in total.

Discussion:

Public health authorities should focus on systemic changes, including organizational development to improve coordination within and across organizations. Clinician involvement in decision-making, clear communication, mental health support, and adequate resources are crucial. Policy implications underscore the necessity for healthcare policies prioritizing physician well-being, and organizational support during infectious catastrophes. Improving work conditions extends beyond personal protective equipment (PPE) access, requiring swift betterment of service innovations, with ongoing reassessment for sustainable care planning, financing, and delivery beyond emergencies.

Keywords

family physician mental health infectious catastrophe wellbeing family doctor

Introduction

A catastrophe is a powerful event disrupting most or all community structures and processes,^1
-3 and hindering local personnel from performing their roles due to illness, injury, or death.^4,5 While traditionally associated with sudden physical disasters, recent scholarship suggests that prolonged and widespread crises can also be understood as catastrophes due to their systemic and transformative impacts on society.² Examples includes Hurricane Katrina in New Orleans (USA), and Coronavirus Disease (COVID-19) pandemic,² declared by the World Health Organization on March 11, 2020, and ended on May 5, 2023.⁶ While catastrophes have immediate impacts, they are also characterized by their prolonged duration and far-reaching consequences and several factors may influence their severity and consequences.^5,7 Beyond environmental aspects, social roles and responsibilities significantly shape their aftermath.⁸ The COVID-19, highlighted the crucial roles of primary healthcare workers, whose efforts mitigated the catastrophe’s impact, often at high personal costs.⁹

Family physicians, as one of the main providers of primary healthcare, are the first point of contact for patients,^10,11 offering ongoing medical care to patients, making diagnosis, establishing a treatment, and referring patients to other specialized providers.¹² During infectious catastrophes, they face higher demands, infection risks, equipment shortages, heavy workloads, and moral injuries.¹³ They also deal with patient and colleague deaths, treatment delays, and adapting to different treatment modalities such as virtual care.^14,15 These operational, ethical, and emotional challenges place significant mental health burdens on them.^16,17 Even before recent catastrophes, evidence indicated that family physicians were prone to higher mental health issues (eg, depression and suicide) compared to other specialties.^18
-23 Infectious catastrophes exacerbate this crisis, leading to increased mental distress.²⁴ To better prepare these providers to face critical situations, it is important to acknowledge the challenges and mental health needs that physicians face in dealing with such demanding circumstances with timely preparation and appropriate actions to ensure they receive the necessary support. The most recent pandemic (ie, COVID-19) exposed the limited and often low-quality research on this critical topic.²⁵ While the topic is abundant, no review has synthesized current knowledge on family physicians’ perceived mental health needs during catastrophic situations. In response, this study aims to rigorously synthesize current knowledge about the perceived needs of physicians regarding their mental health during health infectious catastrophic situations.

Methodology

We conducted a mixed studies literature review, integrating findings from qualitative, quantitative, and mixed method original studies, following Pluye et al^26,27 framework:

Step #1: Formulate the Review Question

This review is part of a broader empirical investigation by Continuing Professional Development Office, whose goal is to develop initiatives fostering resilience among primary care providers during emergencies. We formulated the review question as follows²⁸: “What is currently known about the perceived needs of family physicians regarding their mental health and well-being during an infectious catastrophic situation?”

Step #2: Define Inclusion and Exclusion Criteria

English and Persian studies were included. The scope included studies on infectious catastrophes affecting the mental health of general medical practitioners or family physicians working on the frontline during catastrophes, report their perceived needs. The detailed inclusion and exclusion criteria are outlined in Table 1.

Table 1.

Inclusion and Exclusion Criteria.

Type of Criteria	Criteria
Inclusion criteria	1. Articles and sources written in English and Persian (ie, the first author’s language proficiency)
	2. Studies referring to infectious catastrophic situations that can influence family physicians’ mental health and well-being during and prior to the catastrophes (ie, from 1806 onwards).
	3. Investigations whose study population includes family physicians or general medical practitioners working on the frontline of catastrophic conditions
	4. Any study reporting practicing family physicians’ perceived needs pertain to working during catastrophic conditions
Exclusion criteria	1. Studies that concern other healthcare professionals or family medicine residents rather than autonomous practicing family physicians.
	2. Studies that focus on other disorders rather than mental health issues
	3. Studies that do not examine family physicians’ mental health and well-being needs.
	4. Studies that do not relate to catastrophes.
	5. Studies in languages other than English and Persian.
	6. Studies conducted in any other than community-based primary care centers, primary care clinics and polyclinics, hospital inpatient units, emergency departments, and long-term and nursing homes.
	7. Articles for which full text cannot be obtained.

Step #3: Source of Information

We chose OVID MEDLINE and PsycINFO (Ovid) for their balanced collection of literature on catastrophic events and physician mental health.

Step #4: Search Strategy to Identify Relevant Studies

To ensure thoroughness and precision, a professional health sciences librarian refined the search strategy.²⁹ With adherence to the broader study and a focused on needs, physicians, and well-being, the strategy combined key themes to identify relevant studies comprehensively. To maximize study retention, the keyword “catastrophe” was excluded from the search as it significantly reduced results, we instead screened for it manually. The reviewer tracked references from selected literature to enhance inclusivity. The initial search occurred in January 2022, with an update in February 2023. For more details, please refer to Supplemental Appendices B and C.

Step #5: Screen and Select Relevant Studies

We used Systematic Review Accelerator website to remove duplicate references.³⁰ We then screened titles, abstracts, and full text and extracted data from the final included articles, tracking the process in an Excel spreadsheet with co-authors oversight. While using a single reviewer in this strategy avoids discrepancies, it may introduce biases affecting the reliability and reproducibility of findings.³¹ To mitigate this, the senior co-author input, during several meetings, was incorporated to enhance credibility, transparency, and accountability.

Step #6: Appraise the Quality of Studies

We used Mixed Methods Appraisal Tool to assess the scientific rigor of the final included studies.³²

Based on Mixed Method Appraisal Tool, the appraisal process for research studies that employ qualitative and quantitative methodologies is based on a set of 5 questions.³² For mixed-method studies, a more extensive examination is required, involving a set of 15 questions divided into 3 segments, each corresponding to the qualitative, quantitative, and mixed-method components of the study.³³ Interestingly, 28 of the included studies were rated at 80% or higher and 5 studies rated at 60%, and only 1 study rated at 40%. This quality appraisal enhances the credibility and transferability of the findings, demonstrating that the included studies were of moderate to high quality.

Step #7: Extract Data

A structured data extraction template was developed in alignment with the overarching study objectives. The template was tested on a subset of studies and refined accordingly. The extracted data for this review included title, author(s), publication year, research design, study country, research objective, participants number, clinical settings, summary of findings about needs, challenges, and catastrophe type.

Step #8: Data Analysis and Synthesize Included Studies

We analyzed both quantitative and qualitative information.^27,31 For quantitative analysis, a descriptive analysis was conducted which characterized the number of studies, study design, continent, type of catastrophe, and methodology. For the qualitative synthesis, we followed the thematic synthesis approach described by Thomas and Harden,³⁴ aimed at identifying and describing patterns (themes) inside and across the data. This involved line-by-line coding of result and discussion parts of each study, grouping them into descriptive themes, and developing analytic themes to interpret broader patterns related to the review question.^34,35

Evidence Synthesis

We employed data-based convergent synthesis design to integrate qualitative and quantitative data.^31,36 This approach used where qualitative and quantitative evidence are integrated during analysis using a single synthesis method, typically qualitative thematic synthesis.³⁶ Therefore, beside extraction of meaningful qualitative data, quantitative data also were subjected to qualitative interpretation through open coding, enabling the identification of patterns and their categorization into themes, as described by Thomas and Harden.³⁴

Findings

The identified articles (n = 4191) underwent eligibility screening. Title and abstract reviews excluded 2905 records, leaving 1276 for full-text review. Any doubts were discussed with coauthors. Further exclusions based on inclusion criteria resulted in final 34 articles. The PRISMA flowchart outline the study selection process (Figure 1). For a detailed overview, see Supplemental S1. Characteristics of the included studies are detailed in Supplemental Appendix A and summarized in Table 2.

Figure 1.

Prisma flow chart.

Table 2.

Bibliometric Details of Included Publications.

Characteristic	No. of publications (%)
Continent of publication
Europe	14 (41.2)
North America	7 (20.5)
Asia	11 (32.4)
Oceania	2 (5.9)
Type of study
Quantitative	15 (44.1)
Qualitative	17 (50)
Mixed methods	2 (5.9)
Type of catastrophe
COVID-19	28 (82.4)
SARS	4 (11.8)
EBOLA	1 (2.9)
MERS	1 (2.9)

We categorized the findings of this review into 7 descriptive themes which grouped into 4 different conceptual levels of analysis, namely: 1. Societal, 2. Institutional, 3. Organizational, and 4. Individual. Refer to Figure 2 for a visual summary of the levels and themes.

Figure 2.

Concept map of challenges and perceived needs of family physicians regarding their mental health during infectious catastrophes.

Level #1—Societal Level: Challenges and Needs of Physicians Rooted in Society

Physicians face unique challenges intertwined with societal factors, which can be encapsulated under the first umbrella theme:

Theme #1: Social Challenges amid Infectious Catastrophes: The Need for Social Support and Inclusion

Physicians often feel isolated and unsupported by the communities they serve, particularly during crises.^37,38 The violations of lockdown rules and changing public attitudes during the COVID-19 pandemic only made these feelings worse, leading to frustration and a sense of distance from the public.³⁹ They also experienced guilt and stigmatization due to fears of spreading the virus,^40
-45 resulting in discrimination, professional disengagement, and social withdrawal,³⁸ all contributing to loneliness and isolation.⁴⁰

In response to these societal challenges, they expressed a need for social inclusion and support, highlighting the importance of maintaining relationships with colleagues, family, and friends.^46,47 Media could help alleviate their stress by providing social and psychological support.⁴⁸

Level #2—Institutional Level: Challenges and Needs of Physicians Within the Institutional Level

At the institutional level, the broader organizational and systemic aspects of the healthcare system play roles, encompassing structures, policies, and practices for managing and delivering healthcare services. This led us to the second theme:

Theme #2: Diverse Institutional Challenges in Infectious Catastrophes: From Policy Failures to Systemic Innovations

Family physicians faced inadequate support from governmental organizations.⁴⁰ unsuccessful health policy and lack of clear protocols and timely information have led physicians feeling unsupported.^{15,39,40,44,45,47,49
-54} Additionally, bureaucratic processes prevented retired healthcare personnel from returning to practice, depriving the system of valuable experience.⁴⁵

Therefore, physicians highlighted needs for effective protocols, clear guidelines, and regular, trustworthy information on various aspects of the pandemic to maintain a safe healthcare environment.^{15,37,47,48,50,55
-60} They also called for robust primary care delivery modes for vulnerable populations and ensure continuity of care.^37,56 These models required adequate funding and technical support to address issues (eg, lost connections) and help balance professional and personal responsibilities.^37,50 Additionally, they perceived basic needs, including financial security and risk communication to support them effectively.^37,46,48

Level #3—Organizational Level: Physicians’ Challenges and Needs at the Organizational Level

During infectious catastrophes, physicians faced significant challenges within their organizational frameworks, leading to specific needs. These challenges categorized into 4 overarching themes:

Theme #3: Enhancing the Capacity of Family Physicians to Navigate Work Environment Challenges

During early COVID-19, family physicians faced significant challenges as makeshift outpatient zones were rapidly created to provide care. This adaptation, coupled with logistical obstacles, hindered continuity and quality care, particularly in outpatient settings.^{42,47,54,55,61} Family physicians handled increased responsibilities and workloads.^{15,38,39,41,44,45,49,50,53,55,58,62} The surge in patient queries (eg, vaccinations) intensified this pressure.^49,50,62 Additionally, new roles including administrative tasks⁴⁵ and stringent cleaning and PPE led to overwhelm and exhaustion.⁴¹ Staff shortages, limited space, and a lack of effective decision-making structures further strained physicians,^{15,39,49,54,61} making it difficult to disengage from work and maintain work-life balance.⁴⁹

Furthermore, fragmented emergency responses and working independently in each institution caused uncertainties in different aspects including obtaining PPE and using telehealth.^38,39,59 In some waves of the pandemic, reduced patient counts, e-consultations, and fewer routine care visits were associated with financial concerns for these health professionals as well.^44,59,61 This strain coupled with inadequate organizational support left these professionals feeling undervalued.

Thus, physicians called for adequate staff, sufficient physical space, essential equipment, and clear planning.^37,48,55 They emphasized the need for mental health resources, psychological support, tailored training programs, organizational support,^{15,37,38,45,48,57,60,63} sufficient fundings and protected time.^40,60 Moreover, physicians sought intra and inter-organizational collaboration, through clearer communication with other health authorities.^50,56,59

Theme #4: Empowering Family Physicians to Overcome Managerial Issues

Lack of efficient management and leadership often left physicians feeling excluded from decision-making processes, amplifying feelings of being unheard or uninvolved.^37,49,52,60 This sentiment was compounded by a perceived lack of empathy from senior managers, which intensified disconnection feelings.^40,49 Moreover, many junior physicians experienced a hierarchical management system, feeling that senior managers were notably absent from the frontline during the pandemic.⁴⁰ Subsequently, these challenges highlighted the need for improved leadership, with senior health professionals acting as role models and supporting well-being.⁴⁰ The department head—a crucial role in problem-solving and workflow management⁴⁸—or leaders should be visibly present during crises, improving communication and staff support.^40,60,61 Effective communication was mentioned as crucial to fostering a supportive work environment,^15,44,49,52 offering professionals opportunities to voice their concerns⁵¹ and to be involved in decision-making to enhance motivation and job satisfaction.^{37,40,46,60,61}

Theme #5: Enhancing Team Dynamics for Family Physicians

During infectious crises, many staff identified redeployment to unfamiliar teams as disrupting team relationship building and trust.^38,49,60 Emotional strains within teams exacerbated by PPE use, social distancing, and observing colleagues’ stress.^39,53 Conflicts and insufficient collaboration between senior and junior staff further complicated team dynamics.^38,40,45,55 These challenges, coupled with increased absenteeism from peers and reduced tolerance to work-related stress, caused psychological distress³⁸ and negatively affected team morale, leading to issues like bullying, aggression, and infection control noncompliance.³⁹

Thus, family physicians required a sense of belonging and positive peer relationships.⁴⁷ Redefining roles,⁵⁶ peer support and team-building exercises were required for a stable team environment.^47,55,56,61 Improved intra-team communication and interdisciplinary collaboration could further address team-related challenges.^37,38,44

Theme #6: Improving Physician Safety by Addressing Protection Challenges

Physicians voiced concerns about their personal health, feeling vulnerable and unsupported especially during the initial stages of outbreaks.^39,44,47,62 Key concerns included potential infection and transmission to loved ones and colleagues.^{15,37,38,41,45, 52,53,55,64
-66} Inadequate PPE and training, amplified safety concerns,^{15,38
-41,44,45,52,54,55,61,62,64} while prolonged PPE use caused physical exhaustion and hindered their communication.^52,67

Therefore, physicians underscored the need for adequate PPE, supplementary equipment, testing, vaccine,^{37,40,44,47,48,50,58} and basic necessities (eg, clean restrooms and healthy food choices).^40,51

Level #4—Individual Level: Physicians’ Challenges at the Individual Level

Theme #7: Moral Challenges in Healthcare Decision-Making and Delivery

Physicians faced mental health issues from the potential impact of their decisions. Challenges included fear of mistakes due to fatigue,⁴⁵ feelings of incompetence, and clinical doubts.⁶⁵ Decision-making complexity increased with younger patients, causing moral distress in resource allocation.^38,39 Moreover, family physicians experienced guilt when doffing PPE during breaks, driven by resource scarcity awareness.⁵² New care models also caused distress when delivering bad news remotely, hindering empathy and risking misdiagnoses due to limited clinical information.⁴⁵ These challenges included concerns over inequalities in access to telehealth.⁴⁵ It is interesting to note that physicians’ capacity to cope with stress varied by sociodemographic factors, with female and early-practice physicians often facing lower mental health levels during crises.^53,59,67

Discussion

Principal Findings

This literature review assesses existing knowledge about family physicians’ needs regarding their mental health during infectious catastrophes. Particularly, it first allowed us to document the numerous challenges that family physicians must face when confronting such events. Then, it has unveiled that these challenges are present across different contextual levels, from societal to institutional, organizational, and individual.

However, most reviewed studies focus on the organizational level, highlighting exhaustion, physical and emotional strain, and fear of virus contraction. In accordance with Algunmeeyn et al’s⁶⁸ viewpoint, this review shows that enhancing the working environment markedly influences physicians’ psychological well-being. Efficient physical facilities and adequate staffing along with allocating rest periods could prevent burnout and mental disorders.⁶⁹ Moreover, continuing professional development (CPD) educators could prioritize mental health in their programming, partnering with medical societies and associations.⁷⁰

Our review, consistent with Moura et al,⁷¹ underscores strong leadership among General Practitioners to foster good relationship within the team and promote open discussions about mental health.⁶⁰ Leaders should be actively present and engaged, providing support for vulnerable staff to ensure their well-being, facilitating service delivery, and clear communication. Moreover, conflicts and emotional strain among colleagues contribute to psychological distress and lower team morale. Hoernke et al⁷² assert that redeployment led to challenges due to lack of team cohesion and training. Addressing these issues requires enhancing team dynamics through clear role definitions, interdisciplinary collaboration, and communication.⁷²

Family physicians need to feel ‘safe’ in a comprehensive way, including emotional, mental, and physical well-being. Insufficient PPE access and training contribute to mental distress during crises. Galanis et al,⁷³ study highlights physical ailments from improper PPE. Therefore, CPD activities can provide essential PPE training, support mental health, and enable risk assessments for COVID-19 transmission sources.

While often overlooked, the individual level bears great significance, as physicians confront internal and moral challenges that directly impact their psychological well-being. Issues such as decision-making anxiety, resource allocation dilemmas, and feelings of guilt regarding PPE utilization, worsened mental health concerns. Some research highlights the significant impact of age on physicians’ mental health, particularly among young ones,⁷⁴ but research on individual characteristics, such as gender, remains limited. Further exploration is needed to understand how sociodemographic characteristics may influence one’s ability to face individual-level challenges.

Telehealth, which expanded during COVID-19, brought challenges, including technology limitations and potential devaluation of physician skills, patient assessments adequacy,⁷⁵ and potential negative effects on interprofessional collaboration.^76,77 Hence, there is a need for enhancement of family physicians’ mental well-being due to telehealth use.^78-82 Although individual needs related to telehealth warrant further research, this review suggests the need for refining policies to support physicians’ mental health.

Strengths and Limitations

Mixed Studies Reviews demonstrate diversity in findings, methodologies, geographic scope, and sources from reputable academic journals. The use of a single reviewer may introduce bias and affect the reliability of findings. To address this, senior co-authors’ input was documented throughout the process to enhance transparency and accountability. The diversity of study methodologies complicates synthesis and increases the risk of inconsistency and bias. While citation tracking ensured comprehensive coverage, excluding grey literature may omit some relevant sources.

Recommendations for Future Research

Future studies should evaluate the impact of organizational interventions on family physicians’ mental well-being during infectious catastrophes through CPD activities including conferences, workshops, and self-assessments. These should focus on leadership, teamwork, staffing, and working hours. Outcome based evaluations provide feedback for improving CPD initiatives and ensure that they fulfil the needs of physicians.⁷⁰ Further research should explore support enhance healthcare workers’ well-being and mutual learning.⁸¹ While this review reveals the perceived needs of family physicians, a comprehensive needs assessment is required to uncover their unperceived needs as well.⁸²

Supplemental Material

sj-docx-1-jpc-10.1177_21501319251356557 – Supplemental material for Family Physicians’ Perceived Needs Regarding Their Mental Health and Wellbeing in Infectious Catastrophic Events: A Mixed Studies Literature Review

Supplemental material, sj-docx-1-jpc-10.1177_21501319251356557 for Family Physicians’ Perceived Needs Regarding Their Mental Health and Wellbeing in Infectious Catastrophic Events: A Mixed Studies Literature Review by Sima Zahedi, Pierre-Paul Tellier, Francesca Luconi, Genevieve Gore and Charo Rodríguez in Journal of Primary Care & Community Health

Supplemental Material

sj-docx-2-jpc-10.1177_21501319251356557 – Supplemental material for Family Physicians’ Perceived Needs Regarding Their Mental Health and Wellbeing in Infectious Catastrophic Events: A Mixed Studies Literature Review

Supplemental material, sj-docx-2-jpc-10.1177_21501319251356557 for Family Physicians’ Perceived Needs Regarding Their Mental Health and Wellbeing in Infectious Catastrophic Events: A Mixed Studies Literature Review by Sima Zahedi, Pierre-Paul Tellier, Francesca Luconi, Genevieve Gore and Charo Rodríguez in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

We would like to express our sincere gratitude to Dr. Pierre Pluye, who is no longer among us, for their invaluable guidance and constructive feedback.

ORCID iD

Sima Zahedi

Ethical Considerations

There are no human participants in this article and informed consent is not required.

Consent for Publication

Not applicable.

Author Contributions

SZ: Conceptualization, methods, original material development, screening and data extraction, analysis, and writing (original draft and editing). PPT, FL, and GG: Supervision, conceptualization, methods, and writing (review and editing). ChR: Supervision, conceptualization, methods, original material development, analysis, and writing (original draft, review, and editing). All authors read and approved the final draft.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We would also acknowledge that the first author was granted a McGill Family Medicine Education Research (FMER) Group complementary bursary in 2021 to 2022 and 2022 to 2023 (CDN $5000/year). Further, the Phil Manning Research Award granted the first author 2021 to 2022 and 2022 to 2023 (CDN $10 000 in total).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Supplemental Material

Supplemental material for this article is available online.

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