Pediatric Radiology

https://doi.org/10.1007/s00247-020-04727-9

COMMENTARY

Stresses and anxieties in the time of the COVID-19 pandemic — what

we can learn
Rama S. Ayyala 1 & George A. Taylor 2,3 & Michael J. Callahan 2

Received: 17 April 2020 / Revised: 17 April 2020 / Accepted: 18 May 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

"Adversity is the mother of progress." and cruelty that disturb their core beliefs about humanity.
– Mahatma Gandhi These events may result in lasting emotional, psychological,
social, behavioral and spiritual injury [3]. Before this pandem-
ic, a strong case had been made that a more appropriate char-
The COVID-19 pandemic has created unprecedented com- acterization of physician burnout is moral injury among phy-
plex challenges for society and has heightened our awareness sicians, previously thought to be due to the “increasingly com-
of preexisting deficiencies in our health care system. plex web of providers’ highly conflicted allegiances — to
Long-standing discrepancies in access to health care and patients, to self, and to employers” [4]. However, in the cur-
health insurance, particularly racial and income-based in- rent situation, moral injury has taken on new meaning among
equalities, have become more apparent than ever during the health care workers who are fighting a war against COVID-
pandemic. Within the medical community, the arrival of 19. Clinicians and other health care workers are facing situa-
COVID-19 has added yet another acute level of stress and tions that were never fathomed before, such as difficult triage
potential cause for burnout, in addition to the previously rec- decisions for critically ill patients due to limitations in re-
ognized drivers of burnout and job-related stress, such as bur- sources, including ventilators and other vital therapies.
densome administrative requirements and electronic medical These issues are affecting health care workers in all medicine
record systems as well as increasing demands for higher pro- subspecialties in different ways, with radiologists not immune
ductivity [1, 2]. The added stress on healthcare workers due to to this phenomenon. Radiologists may be experiencing moral
COVID-19 is in at least three different forms: moral injury, distress due to limiting access to imaging in patients present-
grief and concerns for personal safety. ing with urgent or emergent conditions, effectively depriving
children of nonurgent, yet needed, imaging studies. At the
same time, radiologists may experience moral distress associ-
Moral injury ated with not being on the front line like other clinical col-
leagues, such as emergency medicine and intensive care unit
This term was first used among combat veterans to character- physicians. As health care workers, radiologists enter the field
ize post-traumatic stress. During wartime, service members with the intention of providing the best patient care. The cur-
may act in ways that offend deeply held moral and ethical rent times are severely testing those assumptions.
beliefs. They may be exposed to intense human suffering

* Rama S. Ayyala Grief

[email protected]
The world changed drastically in the first few months of 2020.
1
Department of Diagnostic Imaging, Rhode Island Hospital – Hasbro
We lost a sense of normalcy, and now are left with a great deal
Children’s Hospital, Warren Alpert Medical School of Brown of uncertainty about how long this crisis will last and what the
University, 593 Eddy St., Providence, RI 02903, USA world will look like when we emerge from the pandemic.
2
Department of Radiology, Boston Children’s Hospital, Experts have termed this coping mechanism as anticipatory
Boston, MA, USA grief [5]. Many of us associate grief with a response to devas-
3
Department of Radiology, Children’s Hospital of Philadelphia, tating outcomes, such as the death of a loved one. We are all
Philadelphia, PA, USA witnessing and experiencing unexpected hardships and the
 Pediatr Radiol

loss of the sense of safety that comes with feeling in control other members of the department (technologists, office staff,
and being able to predict expectations, both personally and research personnel, trainees, etc.).
professionally. There are several contributing drivers, includ- “Protect me”: In radiology, our primary frontline health care
ing lower overall imaging volumes resulting in decreased rev- workers typically consist of technologists and nurses, followed
enues to many departments and institutions. The repercus- by radiologists and other mid-level providers. It is critically im-
sions to individuals are as yet unclear, although some have portant to assure everyone’s safety is being addressed in these
already experienced pay decreases and furloughs. In addition, uncertain times, particularly those on the front line. This assur-
guidelines for social and physical distancing have decreased the ance ranges from regular and frequent messaging and communi-
number of radiologists physically present in the department, tak- cation from hospital and departmental leadership, adequate PPE
ing away the sense of purpose associated with being able to and updated PPE guidelines, consistent safety protocols to min-
perform examinations and interact with patients. Similarly, work- imize staff viral exposure, and support for department members
ing from remote locations leaves us unable to interact with col- from financial repercussions when they are unable to carry out
leagues, a large source of regular social interactions. their duties. One potential resource for radiology departments is
the Coronavirus Aid, Relief and Economic Security (CARES)
loan program (https://www.acr.org/Advocacy-and-Economics/
Personal safety Advocacy-News/Advocacy-News-Issues/In-the-April-4-2020-
Issue/CARES-Act-Offers-Loans-and-Tax-Relief-to-Radiology-
Many health care workers are being asked to assume greater Practices). Most radiology departments and medical institutions
risks to their personal safety and that of their families, exacer- are already undergoing economic hardships and are attempting to
bated by a lack of personal protective equipment (PPE). Our protect their members from the effects. This is an unfortunate
technologists, nurses and radiologists are our frontline staff consequence of the pandemic and will require a coordinated
and are faced with a higher risk of exposure to the virus, effort at national, institutional and departmental levels.
especially when performing invasive procedures on high- “Prepare me”: Some radiology staff are being repurposed
risk patients. Outside the hospital, physical and social distanc- to work in other areas of the hospital with more significant
ing measures have heightened awareness of personal health needs. Providing adequate training for these roles is key.
vulnerabilities, especially for those who are older or have un- Within departments, it is important to clearly communicate
derlying health issues that can increase the risk of infection. the challenges and decisions being made. Inconsistent mes-
Lastly, we are all grappling with the uncertainty of the finan- saging by leadership should be avoided whenever possible. It
cial implications of this pandemic: How long and how severe is also important to make clear that people should not be afraid
will they be, both for departments/institutions and individ- to ask for help. Everyone is navigating new challenges and it
uals? Will I lose my job? Will I lose my health insurance? is important for people to know they are not alone.
Will I lose my housing? These questions raise concerns that “Support me”: Radiologists are being asked to read remotely
few of us had considered until recently. (either in their offices or at home), which can be very isolating. In
addition, the complex balancing act of dealing with other life
stressors may be more apparent than ever. These include working
What can we do? from home with a family and tending to children, potentially
overseeing homeschooling, caring for other loved ones who
A recent article detailed sources of anxieties in health care may be in high-risk populations (the elderly or those with under-
professionals and suggested lessons to be learned and applied lying medical conditions), and being forced to face one’s own
in moving forward after the pandemic. The authors engaged in vulnerabilities that put them at risk. It is important to support one
eight listening sessions with a total of 69 physicians, nurses, another and acknowledge that everyone has their own unique
advanced practice clinicians, residents and fellows during the struggles, stresses and anxieties during these times.
first week of the COVID-19 pandemic. They explored three Compassion, tolerance, understanding and support for our co-
key concerns: what health care professionals were most con- workers is more important than ever [7]. With technology and
cerned about, what messaging and behaviors they needed virtual portals of communication, a simple text or email check-in
from their leaders, and what other tangible sources of support can make a huge difference.
they believed would be most helpful to them [6]. “Care for me”: Pediatric radiology departments vary in
“Hear me”: More so than ever, it is especially important to size and organization, therefore initiatives that work at one
listen to the concerns of those in the department and for lead- place may not be implemented effectively at another. For in-
ership to be present and available. Different avenues for input stance, small pediatric radiology departments may have chal-
and feedback can be created, such as email suggestion boxes lenges in staffing, especially if a radiologist or a family mem-
and virtual town hall meetings. Radiology leaders must ensure ber is affected personally by the virus. In a larger free-standing
these discussions happen not only for radiologists, but also for pediatric radiology department, low examination volumes can
Pediatr Radiol

impose restrictions on needed personnel, potentially putting cope differently. The future is yet to be determined, but we are
people in financial limbo. Trainees are also experiencing learning from this journey. These lessons will ultimately
unique stresses, such as fewer cases to read and learn from, strengthen the pediatric radiology community, with one
as well as decreased opportunities for learning at the worksta- of the most important lessons being simply to be there
tion from attending radiologists. A myriad of stresses will for each other.
arise from this pandemic, and it will be different for every
department and individual — unprecedented work-related Compliance with ethical standards
stresses never previously accounted for in our assess-
ment of work-related stress and burnout. Ultimately, Conflicts of interest None
the key is for all levels of the organization to support
the individuals in the department.
References
1. Ayyala RS, Ahmed F, Ruzal-Shapiro CB, Taylor G (2019) Stressors
What can we take away from this time? contributing to burnout amongst pediatric radiologists: results from a
survey of the Society for Pediatric Radiology. Pediatr Radiol 49:
None of us chose to be in our current situation. All of the 714–722
concerns and stresses we are facing related to COVID-19 are 2. Ayyala RS, Baird GL, Sze R et al (2020) The growing issue of
undoubtedly real and justified; however, the manner by which burnout in radiology- a survey-based evaluation of driving factors
and potential impacts in pediatric radiologists. Pediatr Radiol. https://
we cope with these newfound pressures is of utmost impor- doi.org/10.1007/s00247-020-04693-2
tance so that the grief is not all-consuming. We are all sharing 3. Litz BT, Stein N, Delaney E et al (2009) Moral injury and moral
in the uncertainty of what will happen to us, to our families repair in war veterans: a preliminary model and intervention strategy.
and to our communities. With it comes the important task of Clin Psychol Rev 29:695–706
managing our anticipatory grief. David Kessler, grief expert, 4. Talbot SG, Dean W (2018) Physicians aren’t “burning out”: They are
suffering moral injury. https://www.statnews.com/2018/07/26/
and the coauthor of On Grief and Grieving with Elizabeth physicians-not-burning-out-they-are-suffering-moral-injury/.
Kübler-Ross, has added a sixth stage to the traditional five Accessed 18 January 2019
stages of grief (denial, anger, bargaining, depression and ac- 5. Berinato S (2020) That discomfort you’re feeling is grief. Harv Bus
ceptance): meaning [5]. After accepting that we have to deal Rev. https://hbr.org/2020/03/that-discomfort-youre-feeling-is-grief.
Accessed 17 April 2020
with this new reality, it is important to find lessons, positive or
6. Shanafelt T, Ripp J, Trockel M (2020) Understanding and addressing
negative, from these difficult times. We also have an oppor- sources of anxiety among health care professionals during the
tunity to rediscover and appreciate things we may have taken COVID-19 pandemic. JAMA. https://doi.org/10.1001/jama.2020.
for granted. The simple act of connecting with others has 5893
allowed us to acknowledge individual vulnerability and has 7. Gallo A (2020) What your coworkers need right now is compassion.
Harv Bus Rev. https://hbr.org/2020/03/what-your-coworkers-need-
become heightened as one of the most powerful coping mech- right-now-is-compassion. Accessed 17 April 2020
anisms. Focusing on these acts can help one be in the present,
rather than agonizing over the uncertainty of the future. We Publisher’s note Springer Nature remains neutral with regard to jurisdic-
are all dealing with different stresses and anxieties, and we all tional claims in published maps and institutional affiliations.