A truism that has been observed in various forms is the only time one can show courage is when one acts in the face of fear. This is what healthcare workers responding to the coronavirus pandemic are essentially doing, says Wendy Dean, MD, a psychiatrist and co-founder of Moral Injury of Healthcare.

“We have the same fears that everybody else has,” she says. “We worry for our safety, our families, and our patients. Not usually in that order. Typically, we are worried about our patients first, our families second, and ourselves last.”

Hospital Employee Health asked Dean, who has studied the concept of moral injury to healthcare workers as they attempt to protect and treat patients under difficult “normal” conditions, for more insight in the following interview.

HEH: Can to speak to what the healthcare workers’ general mindset is in a pandemic situation?

Dean: We have been kind of acculturated to manage the risk and the fear of the work that we face. We face all kinds of infectious risks all the time. The difference is that typically when we are facing those they are known entities. We know what the algorithms are for treatment or for mitigation. The difference for coronavirus is that we don’t know any of that. That does heighten our fear a little bit, or in some cases a lot, depending on what role people are filling in the hospital. I think for ED, primary care docs, infectious disease, critical care personnel, and first responders, it is a level of risk we have probably never in our careers faced — except some of the folks who responded to Ebola. It is an outsized risk, and as with anything else we are more comfortable dealing with the known — even if it is high risk — than dealing with the unknown. But we are going to face down that risk and do our jobs because that is what we have trained to do.

HEH: What to think has been the effect of reports of infections and deaths in emergency clinicians?

Dean: It is very sobering. It’s not unexpected. It is makes the whole theoretical concept become very real, very quickly. It also heightens the concern about PPE [personal protective equipment]. I think a lot of physicians, especially in those frontline specialties, are concerned about a scarcity of PPE. [Occupational infections] heighten the fact that PPE is going to be critical if we are going to avoid decimating our healthcare providers. I think this pandemic is moving much quicker than any of our bureaucratic systems can move.

HEH: If the healthcare system is overrun, there may have to be ethical decisions about which patients receive care. This has reportedly been the case in Italy, where the healthcare system has been overwhelmed by the coronavirus.

Dean: If you look at where our trend line is, we are following Italy right now. The way to fall off Italy’s curve is to isolate, have strict social distancing, and everyone stay home. If we don’t that, Italy is going to be our reality. We have as a society been averse to rationing in any way. We pretty much practice on [the model] of providing optimal care for every patient. That’s our training, that’s our culture, and so the idea that we will have to deny care to patients based on certain criteria will be exceptionally difficult. The other part of this that is going to be very hard is when you are facing a scarcity of PPE, as we saw in the Ebola epidemic. When physicians rushed in without PPE, they contracted the disease and were taken out of the healthcare workforce — either temporarily or they died. In either case, they couldn’t take care of anyone. The mantra really has got to be if you don’t have PPE, you don’t go in. I think that is absolutely anathema to most physicians, first responders — that is not how we are raised in this profession. That will be extremely hard for people.