Our survey reveals that the level of stress was very high in GPs during the first wave of the COVID-19 pandemic within lockdown phase in France, as half of the GPs were stressed (PSS ≥ 27), and a third very stressed (PSS ≥ 30).
A Danish study conducted on 3,350 GPs in a non-pandemic period, also using PSS-10, showed that the baseline level of stress can be as high as 21% of GPs, which is much lower than the 49% observed in our study (12). Though French and Danish GPs are likely to be not comparable, it is estimated that in Europe, 25% of workers are presenting a stress related to work, which is also much lower than the rate we observed (13, 14).
This significantly different rate of stress is likely to be due to the context of the pandemic and the lockdown, though no baseline evaluation of stress in GPs was performed prior to these events. It was reported that the pandemic was a source of stress in the general population and among hospital medical staff, and there is no reason to consider that GPs were spared (15, 16, 17).
Besides this stressful context, we identified independent determinants of stress. Contrary to popular belief, one of these determinants was not the workload, but rather the change in practice which corroborates results from a flash survey conducted by the French government in April 2020 (18). Previous studies showed that GPs aren’t sufficiently trained and prepared for health crises (19, 20). Although there were pre-defined plans to respond to a pandemic, we believe it is important to highlight that there was a lack of collaboration between GPs and the health care authorities (21). It was not limited to the French context, and this appears to be a root-cause of professional stress (21). In addition, in a context of shortage of protective equipment, GPs had to quickly modify their practices and constantly adapt their local organization as they received multiple conflicting and late information from the health authorities.
To summarize, GPs suffered from a health policy considered as too hospital-based. This pre-existing lack of communication and collaboration between GPs and hospitals was revealed by the pandemic (22). To assist GPs and minimize their likelihood of stress in a health crisis, it might be beneficial to improve their level of information. Health authorities and the media are playing a crucial role in crisis situations and effective communication strategies have shown to improve dissemination of accurate and appropriate information (23, 24). As highlighted by Desborough J et al., our results urge that in time of crisis a single source of reliable information from health authorities is needed, both for clinicians and the public (25).
As we conducted our study in real-time, GPs were questioned at the heart of the first pandemic wave and during the lockdown in France. This means that GPs answers might have been more spontaneous and closer to their feelings about the health crisis. This also biased the analysis of the determinant of stress, as no baseline evaluation was available. In France, women are more representative of the young generation of GPs (26). As the census was held online, the young generation were likely to be prompt for answer (27). This could explain the biased selection of women in our study. Women appeared more stressed, which could increase the mean PSS score. But this trend is well known and described for the PSS score (28). We used the PSS score, as it has the advantage of being short and quick to fill, while it provides a quantitative measurement of the subjective dimension of stress. Some studies prefer other tools, often associated, to explore different dimensions of well-being, of which we inspired to construct our agreement items (29, 30). In this singular context, some stress scale have been created to better understand and specifically assess COVID-19-related distress (31). But this stress scale were validated after the beginning of our study (31). As we used a mixed method for data analysis, we were able to discuss the associations founded.
In conclusion, the COVID-19 pandemic was very stressful for GPs at time of first wave, during the lockdown. A structured and non-controversial chain of communication from the health authorities is important to ensure GP’s confidence. The pandemic underlines the importance of GPs and the liberal network in a health crisis, to provide an ambulatory follow-up of patients with continuity of care. It is therefore crucial to fully integrate GPs in the management and decision process of a health crisis. Links with local hospitals should be developed. A prospective follow-up of GP’s stress during the different phases of the epidemic is needed to strengthen the identification of stress determinants and their evolution.