In March 2020, the World Health Organization (WHO) announced COVID-19 outbreak as a global pandemic. This pandemic was associated with the emergence of new cases of depression and anxiety and/or an exacerbation of existing mental disorders, with distinguished psychological and physical impacts on health care providers . The perceived extensive fear of COVID-19 (FCV) is a novel term that describes the anxiety and apprehensive thoughts of getting COVID-19 infection. This FCV would likely be attributed to the uncertainties about potential sequelae of the current outbreak .
The main finding of this study is that there was a robust correlation between the FCV and BOS symptoms (higher depersonalization and emotional exhaustion, and lower personal accomplishment) and poor QoL (physical, psychological, social, and environmental domains). Physicians often had conflictual thoughts and feelings about making a balance between their roles as healthcare providers with professional responsibility and the anxiety of being infected, with self-reproach about potentially infecting their families [21, 22]. A study investigating the possible etiologies of excessive fears among medical staff found that the FCV was attributed to the fears of COVID-19 complications reported by their patients (60.36%), infecting their family members (80%), misdiagnosing their COVID-19 patients (28%), or becoming asymptomatic carriers (29%). These disturbed perceptions regarding the pandemic were a stressful state that would eventually increase the risk of developing BOS symptoms . Moreover, several studies reported that FCV had a negative impact on the psychological and physical well-being of the individuals particularly during the periods of lockdown by intensifying the levels of depression, anxiety, and perceived stress, and reducing sleep quality [24, 25]. During the current crisis, thousands of healthcare providers including physicians were infected or even lost their lives worldwide , with an immense toll on the health care system during the current pandemic, and most physicians experienced higher levels of extreme workloads, associated with a state of uncertainty, health anxiety, and emotional distress as most physicians had insufficient time to take care of their families during the epidemic .
In Egypt, during the time of data collection, the official report of the Egyptian Ministry of Health and Population referred that the confirmed COVID-19 infected cases reached about 48,000 cases and around 1800 deaths (mortality rate 2–3%). The numbers of physicians and other health care workers who were infected and deceased, however, were extremely high when compared to the general population. The official number of infected doctors was about 430 with 68 deaths (mortality rate 16%) . A recent study found that the most frequent concerns regarding the COVID-19-related fears among medical staff in Egypt were the high transmissibility of the disease, the fears of getting infected and transmitting the infection to their families, and the COVID-19-related stigma. Furthermore, the workplace-related factors would add further loads to the physicians. It was claimed that the limited numbers of well-trained physicians and other health care workers, insufficient personal protective equipment (PPE), dealing with the public who were not committed to protective or social distance measures together with ill-ventilated and overcrowded workplaces were potential causes of increased levels of anxiety among Egyptian physicians .
Previous research reported that BOS might be complicated by depression, social isolation, and suicide among physicians [29, 30]. The current study found that associated anxiety and depression, ideas about death, and insufficient COVID-19 training were associated with all items of BOS among physicians. It was unclear whether such variables were etiologies or consequences of BOS. Yet, it was likely that both scenarios might occur [31, 32]. Based on the research of previous outbreaks of Middle East respiratory syndrome (MERS), severe acute respiratory syndrome (SARS), influenza, and H1N1, it was well established that young physicians experienced a varying degree of BOS. Anxiety and stress developed during the outbreaks were found to be associated with higher Maslach burnout inventory scores [33, 34]. Also, the lack of effective training and inadequate personal protective equipment (PPE) were reported as major contributing factors .
Interestingly, this study stated that being fresh graduates and residents was associated with higher scores of emotional exhaustion and depersonalization subscales of BOS. Our findings were in line with previous studies conducted in nearby Arabic  and non-Arabic countries during previous pandemics [36, 37]. The younger physicians would be more vulnerable to BOS owing to the heavier workloads, unpredicted changes in duty schedules to accommodate the new needs, cancelation of vacations, and prolonged contact with COVID-19 patients .
Frontline physicians were the ones who had direct contact with isolated patients diagnosed with COVID-19 virus infection. The current study revealed that the frontline physicians were more likely to be younger and develop depersonalization symptoms than second-line physicians. To ensure gaining clinical skills and accommodate to work under a higher level of stress, residents and young physicians were expected to spend a substantial part of their residency programs at the emergency departments, which would increase the probability of contact with COVID-19 patients. Moreover, frontline physicians were more likely to use their PPE for a long time resulting in excessive heat and lack of hydration and alimentation which would affect their physical health status. Therefore, all together with sleep deprivation and accentuated fatigue would eventually lead to the development of BOS symptoms . Unlikely, another Chinese study, however, found that the frontline health professionals reported a milder degree of BOS symptoms than their second-line counterparts during COVID-19 pandemic. This apparent difference was explained as frontline physicians might perceive a greater sense of control of their situation, which would act as the main driver of engagement and essential for overcoming BOS .
The study was a cross-sectional study; therefore, it was difficult to investigate the cause-effect relationship. Besides, the physicians’ subspecialty as a potential variable was not assessed. However, our study had several strengths; to our knowledge, this study would be one of the earliest studies, if any, in Egypt which investigated the impact of FCV during the peak of the pandemic. This would lead this study to serve as one of the few sources of information about the mental health impacts of the COVID-19 pandemic in Egypt.