The COVID Pandemic - Potential Collateral Damage in a Less
Focused Dimension
Hans-Joachim Schäfers, MD1, Carolin
Kunz1, Volker Köllner, MD2
1 Department of Thoracic and Cardiovascular Surgery,
Saarland University Medical Center, Homburg/Saar, Germany
2 Department of Psychosomatic Medicine, Rehabilitation
Center Seehof, Research Group Psychosomatic Rehabilitation, Charité
University, Berlin, Germany
Address for correspondence
Prof. Dr. H.-J. Schäfers
Department of Thoracic and Cardiovascular Surgery,
Saarland University Medical Center,
66421 Homburg Saar, Germany
Fax: +49-6841-1632005
Email: h-j.schaefers@uks.eu
In the past 60 years cardiac surgery has become such a routine part of
the portfolio of treatment options offered to the patient that we rarely
think about medical and psychological basic aspects.
The Covid pandemic has interfered with many aspects of daily life that
have been taken for granted. Travelling or going to a restaurant seems
to be more affected than cardiac surgery. The concern of many cardiac
surgeons has been that - due to a “medical lockdown” – they could not
continue their regular activities but had to wait for the initial
onslaught of the pandemic to pass by. In some institutions cardiac
participated in the ICU management of Covid patients, in others they
ended up idling because units were closed or patients too afraid to have
their acute cardiovascular diseases treated in-hospital. With the first
wave having passed in most European countries, life seemingly continues
as normal. Protective measures, however, are still part of our routine,
such as wearing masks, distancing, or variable travel restrictions.
Since we cardiac surgeons are used to working with masks, we may believe
that at least our professional lives have returned to normal.
A careful look at some details regarding our patients will give us a
different view, and this is primarily related to the psychologic aspects
of having a cardiac disease and requiring surgical treatment. Most
operations in cardiac surgery are performed for vital, i.e.
life-threatening reasons. It is well known that patients will develop a
high anxiety level once they are understand their diagnosis. The anxiety
increases even further when they hear they have to undergo cardiac
surgery (1). The moment the surgeon first sees the patient, he is
therefore faced with a patient who has a high level of anxiety. Among
other things it is the responsibility of the surgeon to overcome this
anxiety and to generate trust in order to bring the patient to the point
where he or she agrees to undergo the necessary treatment.
Anxiety has different facets. It does have a rational part, related to
the objective risks of an intervention. In addition, there is the
subconscious part which is more difficult to deal with. The patient
experiences loss of control over his situation; there may be cognitive
incongruence in that the patient wants the positive aspects of his
therapy but wants to avoid risks or consequences of the intervention.
This psychological internal conflict may lead to irrational decisions,
such as preferring PCI over coronary surgery irrespective of the facts,
or believing that a TAVI is the best solution despite young age and
objective facts speaking a different language.
During the first encounter with the patient the cardiac surgeon has to
inform him in a rational and understandable way, in addition he also has
to build up trust. This is done through adequate communication, both
verbal and nonverbal. Both protective masks and distancing may present
as difficulties in verbal communication, both to the patient and the
surgeon. Through a mask the voice loses in clarity, it sounds muffled.
Even more important, a variable part of understanding speech comes
through watching lip motion (2, 3), which is lost when wearing a mask.
Such problems are aggravated by hearing deficits and communication in a
non-native language. It can be expected that a variable degree of
information is lost by communication under these circumstances.
Also the nonverbal communication is limited by masks and distance. This
nonverbal communication is an essential part of dealing with emotions,
such as the anxiety that the patient presents with. Trust develops on
the basis of verbal and nonverbal communication. Wearing a mask may
limit the “first impression”. First impression formation has been
shown in general and occupational psychology to have an important and
lasting influence on judgment and further reception (4, 5). This is
formed by the initial reception, in which facial mimics play an
important role. (6). It has not been studied yet but appears conceivable
that first impression formation is influenced by not being able to see
the other person’s face fully. More importantly, unconscious reading of
the facial movements contributes to nonverbal communication by sensing
the emotional components of the sender of a message, and also the
recipient (7). It is thus more difficult for the surgeon to sense fears,
excitement, hope, or other emotional states. More importantly, the
surgeon will have difficulty to transmit confidence and empathy to the
patient.
Thus, wearing the mask will limit communication for the patient and the
cardiac surgeon. Having said this, it is clear that certain protective
measures have to be taken, and masks are an apparently effective means
of limiting Covid spread. On the other hand, we have to focus on dealing
with communication under these circumstances. Regarding verbal
communication, the hurdle can theoretically be overcome by speaking more
slowly and louder. We will have to investigate how we can best minimize
the limiting effect on nonverbal communication. It is unclear whether,
for instance, transparent masks facilitate reception of facial movements
while still providing protection against the current viral challenge.
Thus, Covid has been and still is a challenge to human interaction. It
affects the patient-physician interaction, it also limits the
traditional ways of information transfer, such as travelling to a
meeting in order to hear someone speak rather than follow her or his
message from a distance, i.e. through a publication or a blog. We should
focus on these hurdles to communication, and incorporation of
psychological research results into our daily practice appears as a
promising way to maintain interaction while allowing epidemiological
safety.