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Perspective
July 27, 2020

Sideline Guilt

Author Affiliations
  • 1Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles
JAMA Intern Med. 2020;180(9):1150-1151. doi:10.1001/jamainternmed.2020.2746

Like all of my colleagues these days, almost all of my visits with outpatients are conducted by telephone or video. Although these visits lack the intimacy of face-to-face visits, patients have been extremely appreciative, thanking me for thinking of them and for taking time from my busy day to connect with them. A few moments into the visit, they almost always ask how I am doing, and it is clear that this is more than just a courtesy. They genuinely want to know about my health and, I suspect, are curious about my role in the fight against the pandemic. I acknowledge that I am doing well, and they thank me profusely for being part of the health care team that is doing so much for those stricken with the virus. Hearing those words, the guilt sneaks in. Although I have cared for patients in the hospital who have been tested, have interacted with nurses and staff who were later diagnosed, and have had some patients hospitalized with COVID-19, I have never had an in-person visit with a patient infected with the virus.

The widespread media coverage of health care professionals who are engaged in hand-to-hand combat and the praise I have received for my presumed efforts have generated a feeling of “sideline guilt.” This emotion, similar to survivor guilt, is a feeling of dysphoria because I am not doing all I possibly could do on the front line of care delivery. Sideline guilt differs from dysphoria about the general disruption of our lives, and specifically relates to our professional roles and feeling disconnected to something that should be integral to our work. This feeling has no rational basis, but guilt is often irrational and usually nonproductive. A therapist once described it to me as “the wasted emotion.” However, guilt does surface and weigh on many of us.

The source of sideline guilt stems from ongoing efforts to cope with the pandemic and provide the best patient outcomes while simultaneously protecting the workforce and public. For example, our health system has isolated patients with the virus to dedicated units with dedicated COVID-19 teams. In our case, the physicians are all hospitalists. This reflects sound thinking to contain spread and allow a smaller number of physicians to rapidly become experienced with the disease and its nuances. This approach differs from other epidemics, such as the early experience with AIDS in the early 1980s, when all of us were directly caring for infected patients.

Those of us who are not assigned to direct care of COVID-19–positive patients have been consumed with providing care remotely and with meetings aimed at developing and disseminating local policies to test for infection, care for affected patients, and prevent spread. Yet most of these meetings have been taken from the safety of our own homes and make us question whether we should be doing more. Some have traveled to work in the most hard-hit areas but many of us have not maintained the acute care skills that are needed. Nor can we relinquish other responsibilities to engage in full-time COVID-19 care. Despite the urgent need for clinicians at the COVID-19 bedside, there is also great need for physicians to conduct the daily work that needs to be done to preserve the diverse functions of an academic medical center, including providing non-COVID-19 clinical care, as well as maintaining training activities and research.

What can be done about sideline guilt? The first step is to acknowledge it as a normal reaction and feel free to discuss it among colleagues, many of whom may endorse similar feelings. If guilt becomes consuming or interferes with the ability to perform work or daily functions, health care professionals should seek professional help. In this time of crisis, local and national resources1 have been created to help health care professionals with the stress and anxiety accompanying the pandemic. Second, health care professionals can support their colleagues who are at the front line with acts of gratitude, generosity, and kindness. Our faculty recently contributed personally to purchase gift cards for the nursing unit staff working on the geriatrics special care unit. We have also worked to secure philanthropic contributions for personal protective equipment for community nursing homes that care for our patients. Third, we can recognize that what we are doing contributes to the overall effort. Although we might feel better about ourselves by joining the front lines, this may not be where our strength lies. Rather, focusing on where we can contribute most is the efficient and ethical thing to do. It also transforms the effort from alleviating personal guilt to creating a societal benefit. For me, this means the countless hours spent trying to get a study that provides care for persons living with dementia back into the field. For one of my partners, this has meant updating information on COVID-19 daily for the on-call physician. Every one of us can identify something in our work or personal life that we are doing to help the effort, even if it is not tightly linked to COVID-19. Fourth, we can provide support to physicians who are caring for our infected patients by relating information about them based on our longstanding relationships with them, making video visits to those who are hospitalized, and communicating with family members, if that is helpful to the inpatient team. Fifth, we can stay away. This means not interfering with the work of those providing direct care and keeping our physical distance by not going on units where COVID-19 patients are clustered. By staying away, we are contributing to the health of others.

For many, a trace of sideline guilt may still linger and that is probably fine. Our hearts are in the right place and in different times or situations, we would have been right there among the band of brothers and sisters.

This crisis will pass, and the next generations will ask us what we did during the COVID-19 pandemic. Some will tell of the intensity of directly caring for infected patients. Others, like me, will say, “I was there, and I played a part.”

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Article Information

Corresponding Author: David B. Reuben, MD, Multicampus Program in Geriatric Medicine and Gerontology, Division of Geriatrics, David Geffen School of Medicine at UCLA, 10945 LeConte Ave, Ste 2339, Los Angeles, CA 90095-1687 (dreuben@mednet.ucla.edu).

Published Online: July 27, 2020. doi:10.1001/jamainternmed.2020.2746

Conflict of Interest Disclosures: None reported.

References
1.
Bowen  A. Doctors with panic attacks, anxiety and grief can call support hotline: ‘physicians are really not used to talking about their feelings.’ Accessed April 18, 2020. https://www.chicagotribune.com/coronavirus/ct-coronavirus-illinois-hotline-help-mental-health-doctors-20200414-a2bodw7renfhvcu6wossr6e474-story.html?utm_source=sfmc&utm_medium=email&utm_campaign=cfasnews&utm_content=newsletter
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    3 Comments for this article
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    You Said It!
    Arvind Joshi, MBBS MD, FCGP FAMS FICP. | Our Own Discussion Group.
    The author has put it very well.
    There are many faceless people working behind the scenes, offering great succour to the suffering lot through tele-consultations, often not charging fees at all.
    The article will help these behind the scenes workers come out of their "sideline guilt".
    Thanks again, Thanks a lot!
    Arvind Joshi,
    MBBS MD FCGP FAMS FICP;
    Founder Convener and President,
    Our Own Discussion Group,
    602-C, Megh Apartments,
    Ganesh Peth Lane,
    Dadar West,
    Mumbai,
    Maharashtra State,
    INDIA, PIN 400028.
    CONFLICT OF INTEREST: None Reported
    Sideline Guilt in Retirement
    Bernard Feldman, MD, MPH | Retired pediatrician/neonatologist; Professor and Chair Emeritus of Pediatrics, UNR School of Medicine; Board Member Healthcare Network of Southwest Florida ( a Federally Qualified Health Center)
    I am 86 years old and reside in a "continuing care community" composed of 144 independent living apartments, 46 assisted living apartments and 45 skilled nursing beds. I know almost all the residents and because I am known as a retired physician, albeit far from a geriatrician, I get many questions related to people's current medical problems. Additionally, I am able to make social visits to my friends in skilled nursing and assisted living and answer some of their concerns. I admit I obtain a small sense of personal and professional gratification from these activities although it has not seemed vital to my overall mental well being. Now that we are closed down and social distancing, that activity has been curtailed. But, now, watching the front line professionals in the hospitals and ICUs depicted on TV makes me wish I could be there and help. Thank you for your article and for letting me know that the guilt feelings I have in not being able to use my training are being felt by others as well.
    CONFLICT OF INTEREST: None Reported
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    Front Line Geriatric Hospitalist
    Michelle Stowe-Ong, MD | Iredell Memorial Hospital
    As a geriatric hospitalist on the front lines, I am exposed and caring for COVID patients. We have weeks on COVID team and weeks off. I commend the author, as even those of us on the "front lines" have that sideline guilt. Have I spent enough time in the room, as none of us can be with the patient for extended periods of time? Have I offered to pick up extra COVID days of care? Have I been as brave as I could have been going into these rooms? We are all in this together and I can not thank you enough Dr Reuben for sharing your deepest thoughts as it reveals as physicians how much we are truly alike and only human.
    CONFLICT OF INTEREST: None Reported
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