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Changing self-concept in the time of COVID-19: a close look at physician reflections on social media

Changing self-concept in the time of COVID-19: a close look at physician reflections on social media Background: The COVID-19 pandemic has changed the healthcare landscape drastically. Stricken by sharp surges in morbidity and mortality with resource and manpower shortages confounding their efforts, the medical community has witnessed high rates of burnout and post-traumatic stress amongst themselves. Whilst the prevailing literature has offered glimpses into their professional war, no review thus far has collated the deeply personal reflections of physicians and ascertained how their self-concept, self-esteem and perceived self-worth has altered during this crisis. Without adequate intervention, this may have profound effects on their mental and physical health, personal relation- ships and professional efficacy. Methods: With mentions of the coronavirus pervading social media by the millions, this paper set out to collate and thematically analyse social media posts containing first-person physician reflections on how COVID-19 affected their lives and their coping mechanisms. A consistent search strategy was employed and a PRISMA flowchart was used to map out the inclusion/exclusion criteria. Results: A total of 590 social media posts were screened, 511 evaluated, and 108 included for analysis. Salient themes identified include Disruptions to Personal Psycho-Emotional State, Disruptions to Professional Care Delivery, Concern for Family, Response from Institution, Response from Society and Coping Mechanisms. Conclusion: It is evident that the distress experienced by physicians during this time has been manifold, multi- faceted and dominantly negative. Self-concepts were distorted with weakened self-esteem and perceived self-worth observed. The Ring Theory of Personhood (RToP) was adopted to explain COVID-19’s impact on physician personhood as it considers existential, individual, relational and social concepts of the self. These entwined self-concepts serve as ‘compensatory’ to one another, with coping mechanisms buffering and fortifying the physician’s overall personhood. With healthcare institutions playing a vital role in providing timely and targeted support, it was further proposed that a comprehensive assessment tool based on the RToP could be developed to detect at-risk physicians and evaluate the presence and effectiveness of established support structures. *Correspondence: lalit.radha-krishna@liverpool.ac.uk Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool L3 9TA, UK Full list of author information is available at the end of the article © The Author(s) 2022. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Chiam et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 2 of 11 Keywords: COVID-19, Physicians, Reflections, Personal experiences, Social media, Self-concept, Personhood, Ring Theory of Personhood Introduction Reddit, KevinMD and Medium. Physicians were lim- The COVID-19 global pandemic has raged devastations ited to those involved in the care of COVID-19 and/or on economies, social practices and have overwhelmed non-COVID-19 patients both  in-person and/or through healthcare systems like never before in modern times [1– telemedicine during the pandemic. Only first-person 4]. Unprecedented waves of morbidity and mortality have reflections contained within social media posts including seen a whirlwind of attempts to contain the infection those from personal interviews and published between 1 amidst shortages in manpower and personal protective January 2020 and 26 May 2020 were selected in line with equipment [5, 6]. With their professional responsibilities increasing global awareness of the virus. To accommo- pushed to the fore, it is perhaps easy to take for granted date time constraints faced by the research team, only the profound humanity of these healthcare workers and social media posts in the form of written text or audio- the acute distress they are called to shoulder. Rates of visual video, and in English or translated into English, burnout and post-traumatic stress have been astronomi- were included. No restrictions were placed on geographi- cal [7–10]. Although  BBC interviews [11, 12] and various cal location and searches were carried out between 21 podcasts [13, 14] have provided glimpses into their har- May 2020 and 26 May 2020. The search strategy may be rowing professional lives, no review conducted thus far found in Additional file 1: Appendix A. has given sufficient voice to their deeply personal stories - in particular, how the crisis has affected their perceptions Extracting and charting results of themselves. This notion of self-concept is significant as Sandelowski and Barroso’s (2006) [27] approach to it is tied closely to self-image, self-esteem, and perceived ‘negotiated consensual validation’ was used to achieve self-worth [15–19]. Without adequate intervention, this consensus on the final list of social media posts through may have longitudinal ramifications on their mental and reiterative and collaborative discussions between team physical health, personal relationships and professional members.  A total of 590 posts were screened, 511 full efficacy [20–23]. posts evaluated, and 108 full posts included for analy- As George Agich observed, reflections serve as sis. The PRISMA flowchart which maps out the inclu - the intellectual concomitant of adaptive and coping sion/exclusion criteria  may be found in Additional behaviours in the face of internal and external disrup- file 1 : Appendix B. tions to habitual routines [24]. On 28 February 2020 Whilst dominantly from the United States, social alone, Forbes reported that 6.7 million people mentioned media posts from physicians based in the United King- coronavirus on social media [25] and analytics company dom, Australia, Philippines, Singapore, China and India Sprinklr reported over 19 million mentions of corona- were also included. The data extracted and charted were virus-related terms just weeks later [26]. Some  of these garnered from physicians from Emergency Medicine, were from personal reflections written by physicians. Critical Care, Anaesthesiology, Internal Medicine, Family This paper thus  set out to collate social media posts Medicine, Obstetrics and Gynaecology, Paediatrics and containing first-person physician reflections on how the Psychiatry. precarious climate has affected their personal and pro - fessional lives. In tandem, it looked at the coping mecha- Ethics nisms that have fortified them. In the process, the paper This study was granted exemption by the SingHealth identified a key conceptual framework that may elucidate Centralised Institutional Review Board (CIRB Ref ways in which healthcare institutions could better proffer 2020/3055: Changing Self-concept in the Time of timely and targeted support. COVID-19: A Close Look at Physician Reflections on Social Media). Whilst data was gathered from pub- Methodology licly available domains, concerted efforts were made to Searching remove personal identifiers through searches on Google The research team searched for the keywords, ‘physi - and the social media platform that the data was derived cians’, ‘COVID-19’, ‘experience’, ‘reflection’, ‘lives’ and from. Identifiable direct quotations were  presented only their permutations and focused on the following social where cited in news articles or interviews. media platforms: YouTube, Twitter, Instagram, Facebook, Chiam  et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 3 of 11 prolonged periods on-call, with some shifting into auto- Results pilot and experiencing a sense of depersonalisation. With Physicians’ experiences all aspects of life, social media and medicine focused on Salient themes from these reflections have been grouped the COVID-19 pandemic, one physician acknowledged into the following: Personal Psycho-Emotional State, Pro- that her struggles were rooted in her inability to discon- fessional Care Delivery, Concern for Family, Response nect due to the pandemic’s  intrusive presence. Lack of from Institution, Response from Society and Coping time for self-care for another saw rashes burgeoning all Mechanisms. over his chest, neck and arms. Whilst this lack of reprieve was recognised as unsustainable, one acknowledged that Disruptions to personal psycho‑emotional state her sleep deprivation and lack of time off were products Confrontation with own susceptibility and mortality of her own choosing, a necessary trade-off. With hospital wards saturated with the critically ill and dying, physicians observed a heightened confrontation Disruptions to professional care delivery with their own mortality, their patients’ cadaverous bod- Sense of unpreparedness, helplessness and inadequacy ies presaging their own human fallibility. ‘You walk in and This tumultuous climate also saw helplessness per - you can smell fear, you can smell death,’ one described. vade the wards with physicians grappling with their Whilst many likened the raging COVID-19 devastations own appraisals of their professional adequacy. One physi- to a war zone, persistent risk of their own infection dur- cian described his inability to stop COVID-19’s devastat- ing patient care delivery saw them ruefully reflect that ing disease progression in his patients as akin to watching they did not enter medicine to risk their lives. With one a train crash played out in slow motion. Even critical care resigning himself to the fact that it was only a matter of specialists armoured with the experience of witnessing time before he fell victim to the disease, others formu- the sickest of the sick in their day to day were left feel- lated their contingency plans. ‘We’ve talked about who ing  ‘out of their wheelhouse’, untrained and unprepared. gets our pets…which is somewhat of an easier discussion With contradicting recommendations leaving them than who gets your children,’ one bitterly noted. disoriented, piecemeal knowledge on the virus led to poignant statements on their feelings of ‘impotence’ and Pervasive guilt ‘futility’ as well as questions as to whether they had made Guilt was also commonplace amongst healthcare work- a difference at all. ers. In particular, those who were not shoulder to shoulder on the frontlines agonised over their own inef- Adaptations and disruptions fectuality, guilt-ridden for voicing their hardships in their The speed at which adaptations to clinical practice was better off positions.  For one ER physician, feelings of required of physicians proved to be physically and psy- remorse persisted even though her late term pregnancy chologically demanding. With the persistent need to don necessitated her stepping away from her overwhelmed their personal protective equipment, some experienced team. One observed the double bind of the profession – dehydration, headaches, painful abrasions and feelings that absence from family and dying patients alike evoked of claustrophobia. A move towards telemedicine also led feelings of culpability. to back-to-back schedules which heavily fatigued some. One psychiatrist who conducted consultations from Overwhelming sorrow home saw the blurring of her home and work life. Yet, Amidst mounting uncertainties, staggering caseloads and multiple physicians notably reported greater disconnect having to watch patients die alone, permutations of the from their patients, either due to the lack of human touch word ‘heartbreaking’ surfaced repeatedly. Some physi- afforded by these online interactions or their diminished cians expressed their grief through moments of tears personability when suited up in protective gear. One with one ER physician crying for the ones who had died, described a dementia patient cowering in fear and wail- for the families who could not see them die and for the ing upon seeing her – ‘I wasn’t human,’ she observed. ones waiting in the lobby yet to know of their demise. The distortion of their faces, muffling of their voices and Many described their sorrow and weeping as unprec- inability to maintain eye contact intervened with their edented with some left deeply distraught and unable to duty and desire to care and comfort. Fear for their own contain their emotions in front of their patients. lives also saw physicians taking pause – ‘it is harder to save your patients’ lives when you are trying to save your Sacrificing self‑care own,’ one explained. Conversely, some deeply worried Finding avenues for stress relief proved difficult as inces - that they would infect and compromise the safety of the sant exposure to patients on the verge of crashing led to vulnerable. Chiam et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 4 of 11 Fraught ethical decision‑making through an iPad – ‘I desperately...wanted to be the person Most pertinently, scarcity in manpower, ventilators, he was walking toward’. beds in the intensive care unit and key medications such as  sedatives and opioids saw the need for wartime tri- Disruptions to family arrangements and rituals age and fraught ethical decision-making. The question With mass closure of stores and services, one single as to whether to abide by the rhetoric of first come first mother bemoaned that her inability to find childcare served or ‘apply a cruel and horrible utilitarian calcu- arrangements interfered with her professional commit- lus’ in the discerning of who to treat or let die saw some ments. Social distancing measures and travel restrictions physicians reiterating their moral distress – ‘I definitely also saw funeral rituals, meant to be a ‘ceremony of a cel- did not go into the practice of medicine to play God ebration of life’, severely modified, shortened or carried and nor do I want to’. In addition, with more healthcare out in their absence. One mourned the knowledge that workers required to be in the thick of things, team lead- her mother, diagnosed with COVID-19, had died at an ers were faced with the difficult dilemma of sending their assisted living facility out of state, her burial attended by colleagues into close contact with COVID-19 patients just ten people, without her. without sufficient protection. A heavy weight that led to  feelings of both terror and guilt, one senior  physi- cian  voiced her desire to make contact with  COVID-19 Response from institution cases volunteer-only, that she would otherwise see to Failure in duty to protect these patients herself in order to protect her people. Expected to toil in hazardous settings for long hours without adequate protective equipment, many believed that  the duty of care they were owed was severely lack- Concern for family ing under the current for-profit medical system. Won - Worry for close relations dering if their Hippocratic oaths equated to a moral duty With the tenacious spread of COVID-19, many physi- that would not see them treated in kind, one perceived cians expressed deep worry for their close relations – himself as a commodity, an  expendable cog within the close colleagues, friends and family. Whilst some were machinery of the larger economy. Instructed to wear terrified at the eventuality of receiving news that their trash bags and bandanas in place of proper medical gear, good friends on the frontlines had died, for others, the many physicians felt undervalued, ill-protected and let lonely deaths of their patients culminated in a transfer- down. Likening the pandemic to an incoming tsunami, ence of fear. One new mother reportedly suffered from one physician expressed dismay that a life buoy was all ‘crippling anxiety’ whenever anyone came into close that their federal government had  offered. The prospect proximity to her immunocompromised newborn child. of being detained for whistleblowing also underscored Another recalled deliriously pleading with her husband the skewed priorities of government bodies in placing not to die. Due to the high-risk nature of their job, some national image over safety. worried about contagion risk to older family members who were  more susceptible to infection, morbidity and mortality. Some physicians resorted to stripping off their Response from society scrubs and changing in the hospital parking lot before Ignorance and flippancy returning home. Due to a  pervasive fear of the hospital environment, late presentations of non-COVID-19 conditions  in patients Enforced self‑isolation resulted in a sharp increase in complex emergency cases, To reduce compromising their loved ones, many placed further overwhelming physicians. The questionable veracity themselves under enforced isolation, ‘trading one touch of travel declarations made by patients also resulted in much for another’ as patients became their primary source of distress as these implicated safety and triaging procedures. human contact. Whilst one psychiatrist made the diffi - The casual ignorance and lack of adherence to social distanc - cult  decision to stop breastfeeding, another critical care ing measures by members of the wider society also caused physician voluntarily left home  to safeguard his family physicians much grief as they threatened to nullify progress – sleeping in his car, the hospital call room, and finally made with containing the spread of infection. In turn, the a tent in his garage, uncertain as to  how long it would spread of misinformation, labelling of COVID-19 as a polit- be his homestay. Such self-quarantine measures also led ically-driven hoax and aggressive protests for freedom not to important family milestones being missed with one only undermined their concerted healthcare efforts but trivi - internist lamenting having only caught his son’s first steps alised their pain and the innocent deaths they were forced to bear witness to. Chiam  et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 5 of 11 Overt hostility and racism useful in alleviating their anguish (Table  1). Communal Some healthcare workers were reportedly viewed as a support offered by friends and family, fellow healthcare health threat and thus shunned by the public, verbally professionals and the wider society were also seen from and physically abused with their children told not to these reflections as having bolstered them in their time of return to school. The wave of anti-Chinese sentiment duress (Table 2). that reverberated across the globe also saw a plethora of ethnically Asian physicians reflecting upon the rampant Discussion racism they experienced and witnessed in their commu- All‑consuming effects on personhood nity. These ranged from microaggressions to threatened From these reflections, it is clear that the distress expe - or explicit harm. Slanderous accusations of being ‘a dis- rienced by physicians during the COVID-19 pandemic gusting, filthy bat-eater’ and ‘a selfish disease carrier’ saw has been manifold, multi-faceted and dominantly nega- further disparaging remarks that they had no right to tive. Indeed they resonate with findings from prevail - be in their country. One physician described his ordeal ing literature [7–10, 28–31] and that of the 2015 Middle as having made him hyperaware of himself – ‘the racism East Respiratory Syndrome (MERS) [32] and 2003 Severe conjured by COVID-19 has made it impossible to forget Acute Respiratory Syndrome (SARS) outbreaks [33–36]. my Asian self when with my patients. I am now highly Implicit is the struggle they face with their perceived self- conscious of who I am’. worth and their prevailing sense of having fallen short – as a physician, colleague, mother, daughter, person Coping mechanisms [37, 38]. This is perplexing as burnout, post-traumatic In response, physicians described various coping strate- stress, depression and anxiety disorders are already com- gies that they either personally adopted or recognised as monplace in their ordinary line of work [39–43]. When Table 1 Personal coping strategies discerned from physicians’ social media reflections Personal Coping Strategies Taking Action Speaking out ▪ Expressing personal emotions and grievances ▪ Honouring and mourning deaths of colleagues and patients ▪ Emphasising shared humanity and taking a stand against discrimination ▪ Spreading awareness of COVID-19’s severity ▪ Sharing COVID-19 information and dispelling myths ▪ Illuminating ways in which healthcare workers could be directly supported Practising self‑ care by disconnecting from medicine ▪ Distancing from social media ▪ Engaging in religious activities and prayer ▪ Immersing in hobbies such as exercise, reading and other home projects ▪ Indulging in humour by creating light-hearted videos and viral challenges Adapting with an open mind ▪ Using e-platforms to broach physical distance with loved ones ▪ Developing novel ways to comfort and communicate with patients ▪ Upskilling and learning to refashion medical equipment ▪ Supporting intensive care units as a volunteer ▪ Serving as an informal mentor to junior members of the healthcare team Reframing Thoughts Validating one’s own: ▪ Actions as morally necessary ▪ Personal strengths such as resourcefulness and resilience ▪ Past experiences as a source of knowledge and preparedness ▪ Professional commitment to caring for patients ▪ Professional duty as offering life purpose and satisfaction Focusing on gratitude for: ▪ Accessibility to personal protective equipment ▪ Job security ▪ Family’s health and safety ▪ Opportunities to witness patients recover ▪ Opportunities to work in a dynamic and skillful team ▪ Colleagues working on the frontlines Chiam et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 6 of 11 Table 2 Communal support discerned from physicians’ social media reflections Communal Support Family and friends ▪ Oer ff ing emotional outlets and confidential avenues for sharing of experiences Fellow healthcare professionals ▪ Providing intercollegial solidarity ▪ Role modelling through acts of selflessness and fearlessness ▪ Reigniting and encouraging hope ▪ Infusing work environment with humour and positivity ▪ Daily check-ins by wellness teams drawing attention to importance of mental health Wider society ▪ Online support groups offering advice and validating personal anxieties ▪ Essential workers in the service industry helping to keep public spaces safe ▪ Community members showing appreciation for healthcare efforts ▪ Community members donating food and medical resources unaddressed, these issues reportedly lead to higher rates the face of extended suffering or if they serve as sources of professional medical errors and malpractice, personal of duress themselves. substance abuse, divorce, early retirement, self-harm and suicide [44–50]. Intruding on their usual thoughts and functioning, this crisis has potentially all-consuming Innate ring effects on their personhood and may exacerbate these The Innate Ring comprises the inalienable aspects of poor outcomes. human beings – their being alive, their genetic makeup Personhood here broadly refers to one’s state of being endowing them with human features and their connec- human – an entity conferred full moral status, dignity tions with the Divine. Lost only upon death, these serve and the right to life [51–53]. Well beyond the scope of as the Core of their personhood. this paper, comprehensive overviews and diverse per- As death often inspires fear, particularly when one’s spectives have been offered by Carrithers et  al. (1985) own is intimated, confrontation with one’s own mortality [54], Sarah Bishop Merrill (1998) [55] and Huyssteen threatens the integrity of this fundamental self-concept. et  al. (2011) [56]. However only one framework to date The human features the physicians share with the griev - offers rigorous accounts of personhood with a compre - ously ill reinforces their common fallibility, foreshadow- hensive approach towards existential, individual, rela- ing not only an end, but a potential trajectory that sees tional and social concepts of the self – one that accounts them wasting away. Death anxiety has high correlations for flux and change, influenced by internal and external to burnout, depersonalisation and absenteeism [66–69] sources of duress. and may lead to wavering of religious faith previously serving as a coping mechanism [70, 71]. The Ring Theory of Personhood: a relevant, responsive Individual ring framework The Individual Ring relates to the person’s conscious Krishna and Alsuwaigh’s (2015) Ring Theory of Per - function. This includes their emotions, cognitive sonhood (RToP), originally designed for the palliative thoughts, values, beliefs, hopes and their ability for care setting, is adopted to explain COVID-19’s impact cogitation, communication and action. As such, emo- on personhood as it serves as a dynamic, clinically-evi- tional, cognitive and behavioural responses to disrup- denced and  holistic framework [57–59]. Personhood is tions within the other rings are often made manifest here broadly defined here as ‘what makes you, you’. Although where consciousness, self-awareness and human capaci- particularly pertinent to issues surrounding euthana- ties for self-expression reside. sia, abortion and dementia care [60–65], for the sen- Emotional, psychological and physical ramifications tient person, it also calls into question one’s personal such as personal guilt, sorrow, fatigue and feelings of belief in their right to life and willingness or ability to helplessness and unpreparedness in the professional live. The RToP captures evolving concepts of person - domain are expressed here. Closely associated are dis- hood through porous circles that correspond with one’s tressing thoughts, decision-making and forced adap- Innate, Individual, Relational and Societal Ring. The tations, out of the physician’s locus of control. Whilst RToP draws attention to whether the elements that professional roles and obligations are established in the presently ‘make you, you’ will suffice to bolster you in Chiam  et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 7 of 11 Fig. 1 Compensatory Nature of Rings wider Societal Ring in accordance with institutional This ring notably confers to physicians their basic and enculturated expectations, it is difficult for one to rights and social value. It is clear that care owed to them fully  separate  their personal values, beliefs and hopes by local governments and host institutions have been  from their professional selves. With entwined self-con- lacking severely, with evidence rooted in poor national cepts affected, heightened despair may result in mala - responses to the viral outbreak and injustice entrenched daptive coping strategies such as indulging in alcohol, in prevailing healthcare systems. The ignorance and hos - gambling or avoidance behaviours such as emotional tility of the wider community also threatens to under- withdrawal if appropriate avenues are not made known mine them as persons deserving dignity and respect. [72–75]. As social creatures, membership and approval deeply influence one’s self-concept and sense of worth. Societal Relational ring indifference or malevolence may  heighten feelings of The Relational Ring comprises close relationships, a priv - insignificance and inadequacy [18, 78–81]. ilege conferred to others by virtue of their being family, or established through personal and positive interactions. Adaptive and ‘compensatory’ nature of rings This extends to good friends or even close colleagues and The greatest strength of the RToP framework is that it their importance is determined by the person themselves. encaptures personhood as an individualised, situation- One’s concept of personhood is also keenly associated specific and evolving concept. Here, sizes of the rings to the joys and afflictions experienced with  these close correspond to the number of elements contained within relations. These enduring ties forged by mutual affec - them, the most important positioned closest to the cen- tion, dependence and the  desire for mutual beneficence tre. If long-standing spiritual beliefs once ingrained no are upheld through the fulfilment of explicit or implicit longer have significant bearings on the physician’s per - duties. With the intent of minimising harm and the sonhood, this element may be removed from their Innate spread of infection, however, drastic modifications have Ring, thus shrinking its size. If colleagues once distant been made to family and home living arrangements, grow closer due to shared harrowing experiences in the interfering with the physician’s ability to provide comfort COVID-19 pandemic, these colleagues may shift from and support to their loved ones. Reduced accessibility to the Societal Ring to the Relational Ring. usual support systems may further intensify their grief In addition, the presence of coping strategies account and sense of isolation beyond the physical [76, 77]. for the rings’ ‘compensatory’ nature. Whilst various forms of suffering serve as tensions that threaten the Societal ring integrity of specific rings, coping strategies may serve as The Societal Ring comprises of less intimate relation - ‘buffers’ which continue to fortify the physician’s overall ships such as more distant family, friends, colleagues concept of personhood. An example is visualised in Fig. 1 and members of the wider community. In addition, it where the overall size of the rings are maintained despite also contains enculturated roles and expectations that internal changes. As death anxiety threatens their spir- the person is bound to by virtue of their presence within itual faith, the Innate Ring shrinks in size and influence. society. It obliges the person to comply with legal, ethical As fraught ethical triaging disintegrates the cogency of and sociocultural standards. their moral values and as racial attacks threaten their Chiam et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 8 of 11 societal membership, the Individual and Societal Ring modelling and the mutual trading of life experiences, also shrink. However, the presence of strong intercol- advice and lighthearted camaraderie. The institution of legial support from close co-workers may imbue them such support structures will affirm these physicians that with a sense of personal value through validation of their their needs are valid and their lives valued. efforts. The Relational Ring thus successfully buffers against loss of integrity in the other rings. This encapsu - Conclusion lates the paramount importance of providing physicians Framed through The Ring Theory of Personhood, it is with timely and targeted support. clear that the COVID-19 pandemic has not only dra- matically altered the day to day routines of physicians, Providing timely, targeted support but that these changes have had detrimental impact on Studies have underscored the pivotal role of healthcare intrinsic perceptions of who they are and their value to institutions and offered cogent means of bolstering the others. Whilst it is clear that social media platforms are psychological resilience of physicians amidst this time brimming with insight and offer remarkable opportuni - of crisis [7–9, 30, 33]. Adopting the RToP framework ties for self-expression, negotiation and a re-establish- and building upon salient themes drawn from these ment of control, speaking up on such public interfaces reflections, a comprehensive assessment tool could be as a healthcare professional is still contentious at best. developed, validated and used to quickly detect at-risk The very act of posting on these platforms underlines a physicians with compromised self-concepts and poor desire for discourse, interaction and validation. If local coping strategies. For if prolonged, these may amplify healthcare institutions offer timely, targeted support their risk of psychopathological disorders and behav- and actively avail avenues for honest conversations, iours highlighted earlier. From an established list, phy- this may ameliorate their strong need to express their sicians could identify prevailing elements within each personal grievances online. Simply put, physicians are of their rings, their relative importance to one another requesting to be heard. Amidst the bleakness of their and the sources and strength of duress and buffers in days, addressing their concerns head-on may offer place. Whilst clinical tools such as the Hospital Anxi- them a greater semblance of hope and strengthen their ety and Depression Scale (HADS) [82], PTSD Scale-Self self-concepts, self-esteem and self-worth. Report for DSM-5 (PSS-SR5) [83] and UConn Racial/ Ethnic Stress & Trauma Survey [84] are scaled based on Abbreviation frequency or intensity of specific psychological states or RToP: Ring Theory of Personhood. events, the RToP tool instead offers a visual manifestation of their overarching personhood by illustrating  the gen- Supplementary Information eral integrity of each ring – either significantly weakened The online version contains supplementary material available at https:// doi. by personal sufferings or thickened by buffers established. org/ 10. 1186/ s13010- 021- 00113-x. Here, healthcare institutions could administer this tool and direct susceptible physicians to a dedicated team of Additional file 1: Appendix A. Search Strategy. Appendix B. PRISMA Flowchart. medical social workers for urgent, targeted intervention. Personal coping strategies such as positive reframing and the various practices of self-care outlined in Table 1 may Acknowledgements The authors would like to dedicate this paper to the late Dr. S Radha Krishna be further encouraged. whose advice and ideas were integral to the success of this study. As the full effects of this devastating pandemic may only be realised in years to come, the novel tool may also Authors’ contributions All authors were involved in data curation, formal analysis, investigation, serve as a longitudinal intervention used to assess the preparing the original draft of the manuscript as well as reviewing and editing presence and effectiveness of buffers established by local the manuscript. All authors have read and approved the manuscript. healthcare institutions. Many deficiencies have been Funding highlighted in these reflections. These include the timely No funding was received for this study. provision of adequate personal protective equipment, swab testing for high-risk physicians and up-to-date Availability of data and materials All data generated or analysed during this study are included in this published briefs to minimise feelings of professional impotence. In article and its supplementary information files. addition, childcare arrangements and lodging for those isolating from their families have proven to be much Declarations needed. As support should not only be reactive but proactively designed, nurturing intercollegial solidarity Ethics approval and consent to participate NA should be prioritised as it offers opportunities for role Chiam  et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 9 of 11 Consent for publication 12. Coronavirus changes how doctors deal with death - BBC News. 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Abstract

Background: The COVID-19 pandemic has changed the healthcare landscape drastically. Stricken by sharp surges in morbidity and mortality with resource and manpower shortages confounding their efforts, the medical community has witnessed high rates of burnout and post-traumatic stress amongst themselves. Whilst the prevailing literature has offered glimpses into their professional war, no review thus far has collated the deeply personal reflections of physicians and ascertained how their self-concept, self-esteem and perceived self-worth has altered during this crisis. Without adequate intervention, this may have profound effects on their mental and physical health, personal relation- ships and professional efficacy. Methods: With mentions of the coronavirus pervading social media by the millions, this paper set out to collate and thematically analyse social media posts containing first-person physician reflections on how COVID-19 affected their lives and their coping mechanisms. A consistent search strategy was employed and a PRISMA flowchart was used to map out the inclusion/exclusion criteria. Results: A total of 590 social media posts were screened, 511 evaluated, and 108 included for analysis. Salient themes identified include Disruptions to Personal Psycho-Emotional State, Disruptions to Professional Care Delivery, Concern for Family, Response from Institution, Response from Society and Coping Mechanisms. Conclusion: It is evident that the distress experienced by physicians during this time has been manifold, multi- faceted and dominantly negative. Self-concepts were distorted with weakened self-esteem and perceived self-worth observed. The Ring Theory of Personhood (RToP) was adopted to explain COVID-19’s impact on physician personhood as it considers existential, individual, relational and social concepts of the self. These entwined self-concepts serve as ‘compensatory’ to one another, with coping mechanisms buffering and fortifying the physician’s overall personhood. With healthcare institutions playing a vital role in providing timely and targeted support, it was further proposed that a comprehensive assessment tool based on the RToP could be developed to detect at-risk physicians and evaluate the presence and effectiveness of established support structures. *Correspondence: lalit.radha-krishna@liverpool.ac.uk Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool L3 9TA, UK Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Chiam et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 2 of 11 Keywords: COVID-19, Physicians, Reflections, Personal experiences, Social media, Self-concept, Personhood, Ring Theory of Personhood Introduction Reddit, KevinMD and Medium. Physicians were lim- The COVID-19 global pandemic has raged devastations ited to those involved in the care of COVID-19 and/or on economies, social practices and have overwhelmed non-COVID-19 patients both  in-person and/or through healthcare systems like never before in modern times [1– telemedicine during the pandemic. Only first-person 4]. Unprecedented waves of morbidity and mortality have reflections contained within social media posts including seen a whirlwind of attempts to contain the infection those from personal interviews and published between 1 amidst shortages in manpower and personal protective January 2020 and 26 May 2020 were selected in line with equipment [5, 6]. With their professional responsibilities increasing global awareness of the virus. To accommo- pushed to the fore, it is perhaps easy to take for granted date time constraints faced by the research team, only the profound humanity of these healthcare workers and social media posts in the form of written text or audio- the acute distress they are called to shoulder. Rates of visual video, and in English or translated into English, burnout and post-traumatic stress have been astronomi- were included. No restrictions were placed on geographi- cal [7–10]. Although  BBC interviews [11, 12] and various cal location and searches were carried out between 21 podcasts [13, 14] have provided glimpses into their har- May 2020 and 26 May 2020. The search strategy may be rowing professional lives, no review conducted thus far found in Additional file 1: Appendix A. has given sufficient voice to their deeply personal stories - in particular, how the crisis has affected their perceptions Extracting and charting results of themselves. This notion of self-concept is significant as Sandelowski and Barroso’s (2006) [27] approach to it is tied closely to self-image, self-esteem, and perceived ‘negotiated consensual validation’ was used to achieve self-worth [15–19]. Without adequate intervention, this consensus on the final list of social media posts through may have longitudinal ramifications on their mental and reiterative and collaborative discussions between team physical health, personal relationships and professional members.  A total of 590 posts were screened, 511 full efficacy [20–23]. posts evaluated, and 108 full posts included for analy- As George Agich observed, reflections serve as sis. The PRISMA flowchart which maps out the inclu - the intellectual concomitant of adaptive and coping sion/exclusion criteria  may be found in Additional behaviours in the face of internal and external disrup- file 1 : Appendix B. tions to habitual routines [24]. On 28 February 2020 Whilst dominantly from the United States, social alone, Forbes reported that 6.7 million people mentioned media posts from physicians based in the United King- coronavirus on social media [25] and analytics company dom, Australia, Philippines, Singapore, China and India Sprinklr reported over 19 million mentions of corona- were also included. The data extracted and charted were virus-related terms just weeks later [26]. Some  of these garnered from physicians from Emergency Medicine, were from personal reflections written by physicians. Critical Care, Anaesthesiology, Internal Medicine, Family This paper thus  set out to collate social media posts Medicine, Obstetrics and Gynaecology, Paediatrics and containing first-person physician reflections on how the Psychiatry. precarious climate has affected their personal and pro - fessional lives. In tandem, it looked at the coping mecha- Ethics nisms that have fortified them. In the process, the paper This study was granted exemption by the SingHealth identified a key conceptual framework that may elucidate Centralised Institutional Review Board (CIRB Ref ways in which healthcare institutions could better proffer 2020/3055: Changing Self-concept in the Time of timely and targeted support. COVID-19: A Close Look at Physician Reflections on Social Media). Whilst data was gathered from pub- Methodology licly available domains, concerted efforts were made to Searching remove personal identifiers through searches on Google The research team searched for the keywords, ‘physi - and the social media platform that the data was derived cians’, ‘COVID-19’, ‘experience’, ‘reflection’, ‘lives’ and from. Identifiable direct quotations were  presented only their permutations and focused on the following social where cited in news articles or interviews. media platforms: YouTube, Twitter, Instagram, Facebook, Chiam  et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 3 of 11 prolonged periods on-call, with some shifting into auto- Results pilot and experiencing a sense of depersonalisation. With Physicians’ experiences all aspects of life, social media and medicine focused on Salient themes from these reflections have been grouped the COVID-19 pandemic, one physician acknowledged into the following: Personal Psycho-Emotional State, Pro- that her struggles were rooted in her inability to discon- fessional Care Delivery, Concern for Family, Response nect due to the pandemic’s  intrusive presence. Lack of from Institution, Response from Society and Coping time for self-care for another saw rashes burgeoning all Mechanisms. over his chest, neck and arms. Whilst this lack of reprieve was recognised as unsustainable, one acknowledged that Disruptions to personal psycho‑emotional state her sleep deprivation and lack of time off were products Confrontation with own susceptibility and mortality of her own choosing, a necessary trade-off. With hospital wards saturated with the critically ill and dying, physicians observed a heightened confrontation Disruptions to professional care delivery with their own mortality, their patients’ cadaverous bod- Sense of unpreparedness, helplessness and inadequacy ies presaging their own human fallibility. ‘You walk in and This tumultuous climate also saw helplessness per - you can smell fear, you can smell death,’ one described. vade the wards with physicians grappling with their Whilst many likened the raging COVID-19 devastations own appraisals of their professional adequacy. One physi- to a war zone, persistent risk of their own infection dur- cian described his inability to stop COVID-19’s devastat- ing patient care delivery saw them ruefully reflect that ing disease progression in his patients as akin to watching they did not enter medicine to risk their lives. With one a train crash played out in slow motion. Even critical care resigning himself to the fact that it was only a matter of specialists armoured with the experience of witnessing time before he fell victim to the disease, others formu- the sickest of the sick in their day to day were left feel- lated their contingency plans. ‘We’ve talked about who ing  ‘out of their wheelhouse’, untrained and unprepared. gets our pets…which is somewhat of an easier discussion With contradicting recommendations leaving them than who gets your children,’ one bitterly noted. disoriented, piecemeal knowledge on the virus led to poignant statements on their feelings of ‘impotence’ and Pervasive guilt ‘futility’ as well as questions as to whether they had made Guilt was also commonplace amongst healthcare work- a difference at all. ers. In particular, those who were not shoulder to shoulder on the frontlines agonised over their own inef- Adaptations and disruptions fectuality, guilt-ridden for voicing their hardships in their The speed at which adaptations to clinical practice was better off positions.  For one ER physician, feelings of required of physicians proved to be physically and psy- remorse persisted even though her late term pregnancy chologically demanding. With the persistent need to don necessitated her stepping away from her overwhelmed their personal protective equipment, some experienced team. One observed the double bind of the profession – dehydration, headaches, painful abrasions and feelings that absence from family and dying patients alike evoked of claustrophobia. A move towards telemedicine also led feelings of culpability. to back-to-back schedules which heavily fatigued some. One psychiatrist who conducted consultations from Overwhelming sorrow home saw the blurring of her home and work life. Yet, Amidst mounting uncertainties, staggering caseloads and multiple physicians notably reported greater disconnect having to watch patients die alone, permutations of the from their patients, either due to the lack of human touch word ‘heartbreaking’ surfaced repeatedly. Some physi- afforded by these online interactions or their diminished cians expressed their grief through moments of tears personability when suited up in protective gear. One with one ER physician crying for the ones who had died, described a dementia patient cowering in fear and wail- for the families who could not see them die and for the ing upon seeing her – ‘I wasn’t human,’ she observed. ones waiting in the lobby yet to know of their demise. The distortion of their faces, muffling of their voices and Many described their sorrow and weeping as unprec- inability to maintain eye contact intervened with their edented with some left deeply distraught and unable to duty and desire to care and comfort. Fear for their own contain their emotions in front of their patients. lives also saw physicians taking pause – ‘it is harder to save your patients’ lives when you are trying to save your Sacrificing self‑care own,’ one explained. Conversely, some deeply worried Finding avenues for stress relief proved difficult as inces - that they would infect and compromise the safety of the sant exposure to patients on the verge of crashing led to vulnerable. Chiam et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 4 of 11 Fraught ethical decision‑making through an iPad – ‘I desperately...wanted to be the person Most pertinently, scarcity in manpower, ventilators, he was walking toward’. beds in the intensive care unit and key medications such as  sedatives and opioids saw the need for wartime tri- Disruptions to family arrangements and rituals age and fraught ethical decision-making. The question With mass closure of stores and services, one single as to whether to abide by the rhetoric of first come first mother bemoaned that her inability to find childcare served or ‘apply a cruel and horrible utilitarian calcu- arrangements interfered with her professional commit- lus’ in the discerning of who to treat or let die saw some ments. Social distancing measures and travel restrictions physicians reiterating their moral distress – ‘I definitely also saw funeral rituals, meant to be a ‘ceremony of a cel- did not go into the practice of medicine to play God ebration of life’, severely modified, shortened or carried and nor do I want to’. In addition, with more healthcare out in their absence. One mourned the knowledge that workers required to be in the thick of things, team lead- her mother, diagnosed with COVID-19, had died at an ers were faced with the difficult dilemma of sending their assisted living facility out of state, her burial attended by colleagues into close contact with COVID-19 patients just ten people, without her. without sufficient protection. A heavy weight that led to  feelings of both terror and guilt, one senior  physi- cian  voiced her desire to make contact with  COVID-19 Response from institution cases volunteer-only, that she would otherwise see to Failure in duty to protect these patients herself in order to protect her people. Expected to toil in hazardous settings for long hours without adequate protective equipment, many believed that  the duty of care they were owed was severely lack- Concern for family ing under the current for-profit medical system. Won - Worry for close relations dering if their Hippocratic oaths equated to a moral duty With the tenacious spread of COVID-19, many physi- that would not see them treated in kind, one perceived cians expressed deep worry for their close relations – himself as a commodity, an  expendable cog within the close colleagues, friends and family. Whilst some were machinery of the larger economy. Instructed to wear terrified at the eventuality of receiving news that their trash bags and bandanas in place of proper medical gear, good friends on the frontlines had died, for others, the many physicians felt undervalued, ill-protected and let lonely deaths of their patients culminated in a transfer- down. Likening the pandemic to an incoming tsunami, ence of fear. One new mother reportedly suffered from one physician expressed dismay that a life buoy was all ‘crippling anxiety’ whenever anyone came into close that their federal government had  offered. The prospect proximity to her immunocompromised newborn child. of being detained for whistleblowing also underscored Another recalled deliriously pleading with her husband the skewed priorities of government bodies in placing not to die. Due to the high-risk nature of their job, some national image over safety. worried about contagion risk to older family members who were  more susceptible to infection, morbidity and mortality. Some physicians resorted to stripping off their Response from society scrubs and changing in the hospital parking lot before Ignorance and flippancy returning home. Due to a  pervasive fear of the hospital environment, late presentations of non-COVID-19 conditions  in patients Enforced self‑isolation resulted in a sharp increase in complex emergency cases, To reduce compromising their loved ones, many placed further overwhelming physicians. The questionable veracity themselves under enforced isolation, ‘trading one touch of travel declarations made by patients also resulted in much for another’ as patients became their primary source of distress as these implicated safety and triaging procedures. human contact. Whilst one psychiatrist made the diffi - The casual ignorance and lack of adherence to social distanc - cult  decision to stop breastfeeding, another critical care ing measures by members of the wider society also caused physician voluntarily left home  to safeguard his family physicians much grief as they threatened to nullify progress – sleeping in his car, the hospital call room, and finally made with containing the spread of infection. In turn, the a tent in his garage, uncertain as to  how long it would spread of misinformation, labelling of COVID-19 as a polit- be his homestay. Such self-quarantine measures also led ically-driven hoax and aggressive protests for freedom not to important family milestones being missed with one only undermined their concerted healthcare efforts but trivi - internist lamenting having only caught his son’s first steps alised their pain and the innocent deaths they were forced to bear witness to. Chiam  et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 5 of 11 Overt hostility and racism useful in alleviating their anguish (Table  1). Communal Some healthcare workers were reportedly viewed as a support offered by friends and family, fellow healthcare health threat and thus shunned by the public, verbally professionals and the wider society were also seen from and physically abused with their children told not to these reflections as having bolstered them in their time of return to school. The wave of anti-Chinese sentiment duress (Table 2). that reverberated across the globe also saw a plethora of ethnically Asian physicians reflecting upon the rampant Discussion racism they experienced and witnessed in their commu- All‑consuming effects on personhood nity. These ranged from microaggressions to threatened From these reflections, it is clear that the distress expe - or explicit harm. Slanderous accusations of being ‘a dis- rienced by physicians during the COVID-19 pandemic gusting, filthy bat-eater’ and ‘a selfish disease carrier’ saw has been manifold, multi-faceted and dominantly nega- further disparaging remarks that they had no right to tive. Indeed they resonate with findings from prevail - be in their country. One physician described his ordeal ing literature [7–10, 28–31] and that of the 2015 Middle as having made him hyperaware of himself – ‘the racism East Respiratory Syndrome (MERS) [32] and 2003 Severe conjured by COVID-19 has made it impossible to forget Acute Respiratory Syndrome (SARS) outbreaks [33–36]. my Asian self when with my patients. I am now highly Implicit is the struggle they face with their perceived self- conscious of who I am’. worth and their prevailing sense of having fallen short – as a physician, colleague, mother, daughter, person Coping mechanisms [37, 38]. This is perplexing as burnout, post-traumatic In response, physicians described various coping strate- stress, depression and anxiety disorders are already com- gies that they either personally adopted or recognised as monplace in their ordinary line of work [39–43]. When Table 1 Personal coping strategies discerned from physicians’ social media reflections Personal Coping Strategies Taking Action Speaking out ▪ Expressing personal emotions and grievances ▪ Honouring and mourning deaths of colleagues and patients ▪ Emphasising shared humanity and taking a stand against discrimination ▪ Spreading awareness of COVID-19’s severity ▪ Sharing COVID-19 information and dispelling myths ▪ Illuminating ways in which healthcare workers could be directly supported Practising self‑ care by disconnecting from medicine ▪ Distancing from social media ▪ Engaging in religious activities and prayer ▪ Immersing in hobbies such as exercise, reading and other home projects ▪ Indulging in humour by creating light-hearted videos and viral challenges Adapting with an open mind ▪ Using e-platforms to broach physical distance with loved ones ▪ Developing novel ways to comfort and communicate with patients ▪ Upskilling and learning to refashion medical equipment ▪ Supporting intensive care units as a volunteer ▪ Serving as an informal mentor to junior members of the healthcare team Reframing Thoughts Validating one’s own: ▪ Actions as morally necessary ▪ Personal strengths such as resourcefulness and resilience ▪ Past experiences as a source of knowledge and preparedness ▪ Professional commitment to caring for patients ▪ Professional duty as offering life purpose and satisfaction Focusing on gratitude for: ▪ Accessibility to personal protective equipment ▪ Job security ▪ Family’s health and safety ▪ Opportunities to witness patients recover ▪ Opportunities to work in a dynamic and skillful team ▪ Colleagues working on the frontlines Chiam et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 6 of 11 Table 2 Communal support discerned from physicians’ social media reflections Communal Support Family and friends ▪ Oer ff ing emotional outlets and confidential avenues for sharing of experiences Fellow healthcare professionals ▪ Providing intercollegial solidarity ▪ Role modelling through acts of selflessness and fearlessness ▪ Reigniting and encouraging hope ▪ Infusing work environment with humour and positivity ▪ Daily check-ins by wellness teams drawing attention to importance of mental health Wider society ▪ Online support groups offering advice and validating personal anxieties ▪ Essential workers in the service industry helping to keep public spaces safe ▪ Community members showing appreciation for healthcare efforts ▪ Community members donating food and medical resources unaddressed, these issues reportedly lead to higher rates the face of extended suffering or if they serve as sources of professional medical errors and malpractice, personal of duress themselves. substance abuse, divorce, early retirement, self-harm and suicide [44–50]. Intruding on their usual thoughts and functioning, this crisis has potentially all-consuming Innate ring effects on their personhood and may exacerbate these The Innate Ring comprises the inalienable aspects of poor outcomes. human beings – their being alive, their genetic makeup Personhood here broadly refers to one’s state of being endowing them with human features and their connec- human – an entity conferred full moral status, dignity tions with the Divine. Lost only upon death, these serve and the right to life [51–53]. Well beyond the scope of as the Core of their personhood. this paper, comprehensive overviews and diverse per- As death often inspires fear, particularly when one’s spectives have been offered by Carrithers et  al. (1985) own is intimated, confrontation with one’s own mortality [54], Sarah Bishop Merrill (1998) [55] and Huyssteen threatens the integrity of this fundamental self-concept. et  al. (2011) [56]. However only one framework to date The human features the physicians share with the griev - offers rigorous accounts of personhood with a compre - ously ill reinforces their common fallibility, foreshadow- hensive approach towards existential, individual, rela- ing not only an end, but a potential trajectory that sees tional and social concepts of the self – one that accounts them wasting away. Death anxiety has high correlations for flux and change, influenced by internal and external to burnout, depersonalisation and absenteeism [66–69] sources of duress. and may lead to wavering of religious faith previously serving as a coping mechanism [70, 71]. The Ring Theory of Personhood: a relevant, responsive Individual ring framework The Individual Ring relates to the person’s conscious Krishna and Alsuwaigh’s (2015) Ring Theory of Per - function. This includes their emotions, cognitive sonhood (RToP), originally designed for the palliative thoughts, values, beliefs, hopes and their ability for care setting, is adopted to explain COVID-19’s impact cogitation, communication and action. As such, emo- on personhood as it serves as a dynamic, clinically-evi- tional, cognitive and behavioural responses to disrup- denced and  holistic framework [57–59]. Personhood is tions within the other rings are often made manifest here broadly defined here as ‘what makes you, you’. Although where consciousness, self-awareness and human capaci- particularly pertinent to issues surrounding euthana- ties for self-expression reside. sia, abortion and dementia care [60–65], for the sen- Emotional, psychological and physical ramifications tient person, it also calls into question one’s personal such as personal guilt, sorrow, fatigue and feelings of belief in their right to life and willingness or ability to helplessness and unpreparedness in the professional live. The RToP captures evolving concepts of person - domain are expressed here. Closely associated are dis- hood through porous circles that correspond with one’s tressing thoughts, decision-making and forced adap- Innate, Individual, Relational and Societal Ring. The tations, out of the physician’s locus of control. Whilst RToP draws attention to whether the elements that professional roles and obligations are established in the presently ‘make you, you’ will suffice to bolster you in Chiam  et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 7 of 11 Fig. 1 Compensatory Nature of Rings wider Societal Ring in accordance with institutional This ring notably confers to physicians their basic and enculturated expectations, it is difficult for one to rights and social value. It is clear that care owed to them fully  separate  their personal values, beliefs and hopes by local governments and host institutions have been  from their professional selves. With entwined self-con- lacking severely, with evidence rooted in poor national cepts affected, heightened despair may result in mala - responses to the viral outbreak and injustice entrenched daptive coping strategies such as indulging in alcohol, in prevailing healthcare systems. The ignorance and hos - gambling or avoidance behaviours such as emotional tility of the wider community also threatens to under- withdrawal if appropriate avenues are not made known mine them as persons deserving dignity and respect. [72–75]. As social creatures, membership and approval deeply influence one’s self-concept and sense of worth. Societal Relational ring indifference or malevolence may  heighten feelings of The Relational Ring comprises close relationships, a priv - insignificance and inadequacy [18, 78–81]. ilege conferred to others by virtue of their being family, or established through personal and positive interactions. Adaptive and ‘compensatory’ nature of rings This extends to good friends or even close colleagues and The greatest strength of the RToP framework is that it their importance is determined by the person themselves. encaptures personhood as an individualised, situation- One’s concept of personhood is also keenly associated specific and evolving concept. Here, sizes of the rings to the joys and afflictions experienced with  these close correspond to the number of elements contained within relations. These enduring ties forged by mutual affec - them, the most important positioned closest to the cen- tion, dependence and the  desire for mutual beneficence tre. If long-standing spiritual beliefs once ingrained no are upheld through the fulfilment of explicit or implicit longer have significant bearings on the physician’s per - duties. With the intent of minimising harm and the sonhood, this element may be removed from their Innate spread of infection, however, drastic modifications have Ring, thus shrinking its size. If colleagues once distant been made to family and home living arrangements, grow closer due to shared harrowing experiences in the interfering with the physician’s ability to provide comfort COVID-19 pandemic, these colleagues may shift from and support to their loved ones. Reduced accessibility to the Societal Ring to the Relational Ring. usual support systems may further intensify their grief In addition, the presence of coping strategies account and sense of isolation beyond the physical [76, 77]. for the rings’ ‘compensatory’ nature. Whilst various forms of suffering serve as tensions that threaten the Societal ring integrity of specific rings, coping strategies may serve as The Societal Ring comprises of less intimate relation - ‘buffers’ which continue to fortify the physician’s overall ships such as more distant family, friends, colleagues concept of personhood. An example is visualised in Fig. 1 and members of the wider community. In addition, it where the overall size of the rings are maintained despite also contains enculturated roles and expectations that internal changes. As death anxiety threatens their spir- the person is bound to by virtue of their presence within itual faith, the Innate Ring shrinks in size and influence. society. It obliges the person to comply with legal, ethical As fraught ethical triaging disintegrates the cogency of and sociocultural standards. their moral values and as racial attacks threaten their Chiam et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 8 of 11 societal membership, the Individual and Societal Ring modelling and the mutual trading of life experiences, also shrink. However, the presence of strong intercol- advice and lighthearted camaraderie. The institution of legial support from close co-workers may imbue them such support structures will affirm these physicians that with a sense of personal value through validation of their their needs are valid and their lives valued. efforts. The Relational Ring thus successfully buffers against loss of integrity in the other rings. This encapsu - Conclusion lates the paramount importance of providing physicians Framed through The Ring Theory of Personhood, it is with timely and targeted support. clear that the COVID-19 pandemic has not only dra- matically altered the day to day routines of physicians, Providing timely, targeted support but that these changes have had detrimental impact on Studies have underscored the pivotal role of healthcare intrinsic perceptions of who they are and their value to institutions and offered cogent means of bolstering the others. Whilst it is clear that social media platforms are psychological resilience of physicians amidst this time brimming with insight and offer remarkable opportuni - of crisis [7–9, 30, 33]. Adopting the RToP framework ties for self-expression, negotiation and a re-establish- and building upon salient themes drawn from these ment of control, speaking up on such public interfaces reflections, a comprehensive assessment tool could be as a healthcare professional is still contentious at best. developed, validated and used to quickly detect at-risk The very act of posting on these platforms underlines a physicians with compromised self-concepts and poor desire for discourse, interaction and validation. If local coping strategies. For if prolonged, these may amplify healthcare institutions offer timely, targeted support their risk of psychopathological disorders and behav- and actively avail avenues for honest conversations, iours highlighted earlier. From an established list, phy- this may ameliorate their strong need to express their sicians could identify prevailing elements within each personal grievances online. Simply put, physicians are of their rings, their relative importance to one another requesting to be heard. Amidst the bleakness of their and the sources and strength of duress and buffers in days, addressing their concerns head-on may offer place. Whilst clinical tools such as the Hospital Anxi- them a greater semblance of hope and strengthen their ety and Depression Scale (HADS) [82], PTSD Scale-Self self-concepts, self-esteem and self-worth. Report for DSM-5 (PSS-SR5) [83] and UConn Racial/ Ethnic Stress & Trauma Survey [84] are scaled based on Abbreviation frequency or intensity of specific psychological states or RToP: Ring Theory of Personhood. events, the RToP tool instead offers a visual manifestation of their overarching personhood by illustrating  the gen- Supplementary Information eral integrity of each ring – either significantly weakened The online version contains supplementary material available at https:// doi. by personal sufferings or thickened by buffers established. org/ 10. 1186/ s13010- 021- 00113-x. Here, healthcare institutions could administer this tool and direct susceptible physicians to a dedicated team of Additional file 1: Appendix A. Search Strategy. Appendix B. PRISMA Flowchart. medical social workers for urgent, targeted intervention. Personal coping strategies such as positive reframing and the various practices of self-care outlined in Table 1 may Acknowledgements The authors would like to dedicate this paper to the late Dr. S Radha Krishna be further encouraged. whose advice and ideas were integral to the success of this study. As the full effects of this devastating pandemic may only be realised in years to come, the novel tool may also Authors’ contributions All authors were involved in data curation, formal analysis, investigation, serve as a longitudinal intervention used to assess the preparing the original draft of the manuscript as well as reviewing and editing presence and effectiveness of buffers established by local the manuscript. All authors have read and approved the manuscript. healthcare institutions. Many deficiencies have been Funding highlighted in these reflections. These include the timely No funding was received for this study. provision of adequate personal protective equipment, swab testing for high-risk physicians and up-to-date Availability of data and materials All data generated or analysed during this study are included in this published briefs to minimise feelings of professional impotence. In article and its supplementary information files. addition, childcare arrangements and lodging for those isolating from their families have proven to be much Declarations needed. As support should not only be reactive but proactively designed, nurturing intercollegial solidarity Ethics approval and consent to participate NA should be prioritised as it offers opportunities for role Chiam  et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:1 Page 9 of 11 Consent for publication 12. Coronavirus changes how doctors deal with death - BBC News. 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Assessing racial trauma within a DSM–5 framework: the UConn racial/ethnic stress & trauma survey. Pract Innov. 2018;3(4):242–60. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions

Journal

"Philosophy, Ethics, and Humanities in Medicine"Springer Journals

Published: Jan 26, 2022

Keywords: COVID-19; Physicians; Reflections; Personal experiences; Social media; Self-concept; Personhood; Ring Theory of Personhood

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