Unsettling: Who have we been?
The COVID-19 pandemic catalyzed significant disruptions to the status quo, serving as a “wake-up call” that exposed dissatisfactions and disappointments for most participants. We identified the first domain, “Unsettling,” as asking the question: who have we been? Participants described exposures of the pandemic that served to “shine a light on” or “illuminate the underbelly” of three key areas of dissatisfaction: 1) daily workplace inefficiencies; 2) barriers to patient care; and 3) intraprofessional devaluation and loss of trust.
Daily workplace inefficiencies
As workplaces implemented social distancing and other public health precautions, many participants experienced a rapid migration to remote work and telehealth, catalyzing a reevaluation of prior in-person practices. In response to these shifts, participants spoke of a desired “rebalancing of what's important [and] how we use our time” to achieve a streamlined, more efficient practice, given the affordances of virtual work. For example, a primary complaint of pre-COVID-19 times was “useless” meetings and “fluff time,” which participants identified as ineffective and bureaucratic. By contrast, some found virtual meetings more efficient in certain ways: “People are not commuting. People are not chitchatting. People are not wasting as much time.” Participants also desired a greater sense of urgency, frustrated by what they identified as excessive steps in research study onboarding and operational change in pre-COVID-19 protocols. Energized by the swift rollout of revised telehealth regulations and licensing changes, participants hoped for similar implementation of improved telehealth practices beyond COVID-19: “We can’t just follow our usual process…and have it take a month or two to implement. We have to do this today.”
In this way, the pandemic acted as a galvanizing force for reevaluating competing urgencies, with some arguing that COVID-19 “imposed the need, at least temporarily” for resolving ineffective practices to encourage swifter responses to current barriers. Specifically, participants highlighted the inefficiencies surrounding existing needs that had been previously deprioritized: “The urgency that the pandemic has created has allowed a lot of institutions and entities to respond to needs in a way that they were not responding before, even when you could say that those needs were present already.” Others framed the pandemic as “not a time for lip service” but rather to engage in more collaborative action to refine outdated practices to advance the field and its service to patients.
Barriers to patient care
The migration to telehealth also catalyzed shifts in patient access to care, highlighting and addressing several overarching logistic and financial barriers that participants had struggled with pre-pandemic. Participants commonly marveled how “suddenly we can deliver care where there hadn't been any available means of access before.” Specific barriers included a dearth of local providers, transportation concerns, regulatory and insurance hurdles, and family dynamics. Telemedicine also revealed new concerns, such as disproportionate access to technology, both for telehealth and for education: “Some kids have access to the internet and some don't. It's not fair to punish those kids who don't have access compared to the ones who do.” Additionally, children of essential workers experienced a new strain on parental availability for appointments. These barriers placed a renewed emphasis on addressing social determinants of health as a vital feature of basic advocacy within psychiatry: “If we don't address those needs at the individual level, talking about really cool evidence-based therapy misses the mark.”
The opportunities for advocacy, long acknowledged by most, became pressing for many through growing recognition of the syndemic. Discussion of COVID-19’s racially disproportionate impact had been ongoing. However, for many participants the death of George Floyd and the subsequent surge in Black Lives Matter protests across the country mobilized an acute urgency and visibility to anti-racist work within the field. Participants spoke of the “layering of the two pandemics” and recognized systemic racism as a “public health crisis” that psychiatrists, as advocates, must address. One participant included a photograph of a protest they attended, where a demonstrator wielded a sign reading “racism is the pandemic,” noting that “I thought it was really important to have a picture that also is a timestamp to the uprisings and the way that they impacted not only the U.S. but other nations and the global impact that it had.”
Renewed confrontation of systemic racism’s place within child psychiatry specifically prompted several participants to look inwards to their own workplaces. One participant committed to investigating the disproportionate physical restraints for Black and Latinx children on their unit, and another described a deeper dive into existing data that illustrated a tenfold difference in involuntary procedures by school resource officers for Black students in the area. Like these two participants, others spoke of their ongoing and renewed commitment to psychiatry as advocacy, noting how their professional status affords them the knowledge, resources, and duty to fight for those with less representation. Several participants plainly stated that child psychiatry has not fulfilled this duty as effectively as colleagues in pediatrics: “Pediatricians have taken that mantle more aggressively and effectively than child psychiatrists.” To ensure CAP’s fulfillment of its responsibility, participants identified the need for collaboration with pediatricians and other providers, as well as interaction with insurance companies and local legislators to ensure that child wellbeing is supported by multiple stakeholders.
Intraprofessional devaluation and loss of trust
Adjustment to the new pandemic workplace created friction between colleagues and highlighted the shifts in intraprofessional relationships. These shifts made legible the long-standing divisions across departments and in turn revealed a tacit metric of professional value. Early administrative choices created conflict as some departments were deprioritized for PPE, left off key leadership emails, or given conflicting instructions about confidentiality protocol. Participants also frequently touched on a “differential of sacrifice” within departmental workforces. Given the complexity of scheduling in-person versus virtual shifts in an equitable way, they described a “level of entitlement” not previously seen. In one department, attendings shouldered the initial burden of in-person care to shield their inpatient team from early risk, only to receive a startling lack of reciprocal investment from team members. Some described colleagues as reluctant to risk the danger of working in person without being seen as “abandoning ship during a crisis.” As one participant from a hard-hit urban hospital system narrated:
“It was pretty evident very early on who took the attitude of, ‘Let's jump in there. Let's do everything we can to help. Let's be on site, let's be present. Let's battle.’ And others who are like, ‘Get me out of here. I'm really concerned about myself. I'm really concerned about a family member. I'm really concerned about my kid. I want to be as far away, and as safe as possible.’”
The discrepancy in investment created disappointment and a loss of trust; but as one participant stated, “sunlight is a great disinfectant.” The revelation of previously hidden conflicts allowed space for healing and the need for “mutual sacrifices” among colleagues when distributing the workload to soothe rifts and “remain unified collectively.” Workplace rifts were common but not universal: several participants emphasized gratitude for their colleagues’ commitment and hard work. However, the wide expressions of gratitude were bound to a degree of disenchantment with psychiatry, finding an unsatisfying answer to the “who have we been?” question.
Some discontent stemmed from healthcare hierarchies in general, laid bare by pandemic decision-making and discussions of equity in medicine; and some were more specific to psychiatry, such as the “reactive-not-proactive” status quo (“Why aren't we doing the outreach instead of waiting for people to come to us in crisis?”). Others reflected on psychiatry’s failures in social justice, limited training perspectives, shifting work values of trainees, and the manner of compensation that hampers effective collaboration. This discontent diminished some participants’ enjoyment of their careers and even triggered a reevaluation of one’s place in the field entirely, with one participant “questioning whether even my involvement in [professional organizations] is the best way to be using my resources.” Another noted that after two weeks of telemedicine, “I was just like, ‘I just want to do my laundry. I don’t want to be a psychiatrist today.’” Some identified this disenchantment as a pre-COVID-19 phenomenon, stating that “we've clearly been requiring a revolution in terms of medicine for a long time… and that has nothing to do with COVID-19 in my view.”
Adaptation: Who are we now?
In response to these shifts and exposures, participants reported a wide range of adaptations to their personal and professional lives. We identified the second domain, “Adaptations,” as asking the question who are we now?, and is answered in three themes: 1) operational adjustments; 2) the affordances and limitations of virtual work; and 3) the evolution of professional and personal identity.
Operational adjustments
Like most sectors, the COVID-19 workplace upended daily norms and protocols for most participants. Even for those not working from home, physical workspaces evolved to include utilizing open-air playgrounds for inpatient viral testing, driving out to homeless populations instead of hosting indoor clinics, and holding telehealth appointments in cars between childcare duties. Inpatient unit censuses dropped for multiple participants, even leading to an accelerated closure of child services in one location during a building transition. Masks and other PPE created communication barriers: foggy goggles, muffled voices, and obscured facial expressions. At times, PPE had to be altered for certain patients, such as using face shields for children who could not tolerate masks.
For those who did switch to work-from-home, delineating the workday from home life (or not) created a new operational challenge. Participants reflected on the “occupational-residential merge,” manifested as converted office bedrooms or living among stacks of patient files, as well as the challenge of balancing a professional home workspace with family needs: spouses also working from home, students completing online school, and young children requiring supervision. Those who previously maintained stricter work-home boundaries depicted their divides as increasingly “permeable” and “frayed at the edges.” Some leaned into the dissolution of boundaries by being more available to patients after hours or emailing late into the night, while others sought to underline the end of the workday: keeping the laptop shut, creating an end-of-day dog-walking routine, or using a downtime app to limit evening phone use.
Regardless of their in-person or virtual status, most participants reported grappling with novel demands: “It turns out COVID-19 didn’t take away any of my responsibilities… It just added a couple jobs on top.” Directors navigated pay cuts, safety planning, and newly-limited inpatient capacity to prevent infectious spread. Virtual meetings were scheduled for early mornings, late nights, and weekends. Collaborations evolved both within the profession, such as increased participation in professional listservs or international projects, and across specialties, such as improved ER virtual consults. Participants also adapted to new educational demands. Across multiple institutions, training directors altered orientation, team-building, and graduation exercises to meet the needs of their now-virtual cohorts, incorporating breakout rooms for presentations and virtual diploma hand-offs; and medical school deans became “Grand Central Station for questions” for anxious medical students worrying about how their education could adapt to a pandemic.
Despite these increased educational demands, multiple training directors and educators savored the new opportunities for connection with trainees. In tele-adapted events, online platforms provided different yet equally meaningful ways to engage personally. One participant celebrated the new ability to engage more members of the trainee’s world, citing a mixed in-person/online graduation ceremony in which a small group of trainees and family members enjoyed an in-person celebration, followed by food delivered to each family’s location for a socially distanced meal and a “big Zoom graduation with 80 or 90 people from around the world that happened a couple of hours later.” Echoing the unexpected joy of a more intimate ceremony, another participant described how their Zoom graduation allowed the space for family members to share stories about their graduates during the ceremony, making the event “one of the most meaningful graduations I have ever been a part of.”
Affordances and limitations of virtual work
Beyond requiring adaptations to virtual workdays and training, telehealth afforded alternative avenues for communication and care. Virtual visits increased accessibility and decreased no-show rates, with one participant celebrating the marked decline in no-shows for mothers with post-partum depression given the lower activation energy necessary for session attendance: “Before… they just couldn't get it together to come.” Participants also reported increased family member engagement and valuable insights into the patient’s home environment. Video backgrounds offered a novel source of contextual information, such as pets or artwork, which provided “meaningful connections to who they are as a person, which may not have come out in an in-person visit”. As for participants’ own backgrounds, most maintained firm boundaries with patients: “It's clear that it's my home…but I have really tried to maintain that it's not overly personal.”
The affordances of increased connectivity, however, became a double-edged sword. Participants reported fatigue from back-to-back meetings, the intense focus of videoconferencing, and the constant flood of emails encouraged by a nonstop virtual workday. Put simply, “there was no turning off.” Participants also worried about the privacy afforded and the suspicion aroused by virtual backgrounds, along with the implications of pet or family member interruptions for professionalism, and the need for new boundary-setting with patients given the visibility of clinician homes or the settings of virtual care (e.g. addressing personal questions, patients attending sessions while driving). Some participants opted to continue going into the office for virtual visits to address these concerns. Increased visibility also necessitated a “different set of parameters” for acute intervention in the event of visible emergencies on camera, and the benefits of telehealth only extended to families with adequate internet connectivity and access to private spaces. Some mused about the long-term efficacy of telehealth, noting missing “emotional engagement” with some patients and not wanting to “settle” for a lower level of care in the future: “Tele is not a substitute for in-person visits. It’s an alternate treatment modality, but where exactly does it fit?”
The substance of each session adjusted to pandemic life, in both content and modality, depending on age group: “Early childhood mental health is a very physical kind of sport, and those tools are all out the window with Zoom.” Participants reported increased reliance on parental involvement for younger children: requesting pre-session email updates, focusing on the dyad, or leaning on virtual play and parental coaching. Discussions with older children highlighted struggles like concern for loved ones, others’ failure to social distance, and social development, including confusion about quarantine friendship protocols: “Are you on the level where you can FaceTime? Do you have those privileges?”
Most benefits of virtual care did not extend to virtual school collaborations in this study. Apart from one district that reworked an existing mental health curriculum for COVID-19 and grief coping, the closure of schools and school-based care hindered –and in some cases eliminated– child mental health care. Participants reported decreased interaction with teachers, perhaps due to reduced behaviors due to the different environment or increased direct communication with parents (“I cannot remember having spoken to any teacher since COVID-19 happened”) and a loss of special education services. Adherence to Individualized Education Programs (IEPs) suffered, given the difficulties of virtual school, and students who are nonverbal or with significant developmental disabilities were left without the specialists or much-needed services that special education programs provide. For all children, the attentional demands of virtual school were an unavoidable challenge: “It’s torture for an adult; just imagine for a kid.”
Evolution of personal and professional identity
In metabolizing the syndemic, participants reflected on their personal histories as part of a broader reflection on their identities and roles. Many contextualized the COVID-19 pandemic and social justice activism within prior experiences, “like another verse of a song that I’d experienced or heard before,” citing the AIDS epidemic, Hurricane Katrina, or Pearl Harbor as guiding analogies. Participants also connected community responses and activism to events familiar to their families or communities: local school shootings, community suicide clusters, regular hurricane seasons, and activist spirit passed down through generations. These histories encouraged reflection on one’s roles and identities, since, as one participant stated, crises make you “revisit or rethink your priorities and your values; who we are now.”
One such revisitation included the ethical charge of physicians and the role of that identity for each participant: What does it mean to be a doctor during a pandemic? We identified a strong sense of duty and responsibility to the public, despite personal risk, as strongly tied to a physician’s job description: “I was surprised by how quickly people shed their identity as a physician, to hunker down and worry only about themselves and their family. This is a national crisis, you're a physician, you're expected to play a role in helping people.” Participants also underscored the importance of “going in,” continuing to work in the hospital despite infection risk and advances in telehealth: “You just can’t be a doctor taking care of patients in this setting without coming in.” Despite this commitment to physician duty, participants overwhelmingly refused to claim the “healthcare hero” narrative, with one stating that “I've been careful not to lump myself in with that group because I just haven't taken those same risks.” Many attributed this difference to working in pediatrics and behavioral health, stating that “as psychiatrists, we are not true COVID-19 front-liners,” downplaying their own contributions in relation to other specialties like emergency medicine.
The question of physician identity seemed a particularly provocative one for psychiatrists, who felt that initially, “our nation had called us to do something very, very different, which we hadn’t been trained for.” Participants felt capable of answering the psychological demands of the pandemic, but some felt helpless in the face of an infectious disease crisis, noting how in the early days, “the psychological impact hadn’t fully hit yet. We didn’t have a major role then.” Some expressed a particular sensitivity to this worry, given the stereotype of psychiatrists as too far removed from the rest of medicine: “We have worked hard to be seen as physicians, … [to have] a bidirectional sense of mutual respect.” Yet as the pandemic progressed, participants emphasized that psychiatrists are “uniquely trained for this COVID-19 moment,” becoming frontrunners in telehealth adoption and tending to the psychosocial impacts of the national crisis. One training director told new trainees, “You are all physicians. You know how trauma and distress impact human functioning. You have the perfect training.”
Alongside a meditation on one’s duty as a physician, participants considered how much of their own identity was ascribed to that role: “How much of you as a person or identity is being a doctor… and how much are you allowed, as a human being, to take care of yourself, separate from being a doctor?” The question of coexisting roles surfaced in discussions of work-life balance (or life-life balance, as one participant put it), as well as discussions of how to best apply one’s expertise. Given the shortage of CAP providers, one participant touched on the difficult decision of taking non-clinical roles given potential “obligations… of being available to people.” Another participant countered, “I’m not naïve. I don’t think that the best use of [my] 40 hours a week is seeing patient after patient” at the expense other roles in research, education, and leadership.
Within meditations on work-life balance, multiple participants reflected on their family lives. In light of the uncertainties and revelations of the pandemic, one early career participant reconsidered their past decision to postpone having a child due to the demands of work; now, they have decided to try to start a family. For others, increased time at home with kids completing online school offered new perspectives, such as one participant struck by the image of their son, home from college, in the backyard: “He used to play in that yard, and I used to look from that window… and here it was, he was home again under very different circumstances.” Moments of novel, unexpected visibility into a new phase of their children’s lives were at times bittersweet, but also motivating and humbling. One participant discovered their son manufacturing plastic face shields for essential workers in the basement, sparking the reflection that “among these unsung heroes… are the kids, who are going to be leading us, not the other way around.” Participants also grappled with supporting family members virtually, such as siblings, parents, and grandparents, through safety concerns and isolation, as well as navigating losses and illnesses from afar.
Among the acute adaptations of roles and identities during the pandemic, several participants focused more intentionally on leadership roles to support colleagues and trainees. For many, shifts in leadership style were forged by the national confrontation with racism and the emotional conversations that followed, with participants adjusting their leadership style according to their own identity. A clinician of color reflected on assuming a facilitator-like leadership stance, acknowledging that “you have to take a different perspective, one that's more educational; and many times, not one that's necessarily sharing your own experiences.” The same clinician also noted the need to identify new leaders among colleagues to lead these psychologically heavy conversations about racism and bias in psychiatry, because “it’s so important that it cannot be the responsibility of every African American person to do all the education.”
Participants also emphasized the role of supporting colleagues’ wellbeing, noting the importance of caring for the carers. Many participants created or volunteered for peer support systems, wellness programs, and mental health first-aid for their peers in and beyond psychiatry, providing the additional benefit of increasing gratitude. Regarding mental health care, several participants also noted their own involvement in therapy and the importance of taking time to process the psychological effects of the pandemic. As for social support, renewed investment in social strengthening soothed a “hunger for interactions,” including more frequent check-ins with friends and family, restructured e-meetings that replicated in-person small-talk, and a deeper level of intimacy in previously casual conversations. Some participants also spoke of missing the “random” encounters of an in-person workplace and intentionally building back “incidental” work contacts, setting aside dedicated time to catch up with colleagues who were part of their daily work life despite not sharing any projects or teams.
Reimagination: Who will we become?
In our third domain, “Reimagination,” participants sought for “things to be shaken up and reinvented.” As participants looked forward and wondered, who will we become?, we organized participants’ hopes and hesitations into two themes: 1) renewal and recommitment; and 2) psychiatry as advocacy.
Renewal and recommitment
Although the syndemic placed additional demands on participants, many also noted that the year had been a very “activating time” for causes they cared about, allowing participants to restructure how they hoped to spend their time moving forward. “With the inspiration and the time, it’s been a fuel,” said one participant of their redoubled efforts against discrimination on their unit. We identified a sense of “returned time”, afforded by the elimination of the daily commute and the flexibility of virtual work. One participant marveled at the gift of walking in nature during the workday, thanks to the “space and flexibility that telepsychiatry allows, that being in person as a physician never really allowed for me.” Returned time cultivated renewed capacity, with participants digging deeper into activism, international mental healthcare volunteering, and research projects with the “energy now that I collected while being able to work from home.” Though optimism was tempered by the losses of the syndemic, several participants expressed hope for the opportunities to move forward, such as in new projects: “They’re literally exploding, and it’s exciting, and it’s thrilling, and it’s going places.”
Another source of energy for many participants was renewed gratitude for colleagues. Despite the initial challenges of intraprofessional trust experienced by some participants, the overwhelming parting message was one of appreciation for others’ hard work. “I want to say thank you to colleagues who have been on the front lines,” said one participant, “for colleagues who have been really supportive of each other during this time and supportive of the patients and families that we work with.” Appreciation extended not just to colleagues in psychiatry, but also to nursing staff and other essential workers. The renewed gratitude provided not only a positive reframing of the pandemic’s difficulties, but also as a recommitment to the profession:
“Hope, privilege, gratitude… those are kind of platitudes, but they're real. If people can constantly be oriented to this idea that, ‘I am so lucky to be able to do the work that I'm doing, because every single day, I can have an impact on somebody, and I can have an encounter that I experience as meaningful, and important, and helpful to somebody,’ there are very, very few jobs like that.”
Participants also offered specific post-COVID-19 hopes for operational and patient care improvements. Multiple participants hoped for organized pushback against insurance companies’ desire to roll back telehealth affordances, arguing that continued use of telehealth could sustain the increased access to care afforded to many patients, and provide innovative care. Several imagined CAP’s seating “at the head of the table” for the evolution of telehealth, given the field’s success in the early days of the pandemic. In the reimagining of psychiatry’s next steps, we identified a common thread of creativity, with many desiring innovative adjustments to existing practices. Examples included more collaborative virtual teaching (“sharing our crayons”) and utilizing technology to deepen connections (such as in-school observations used as a therapeutic and teaching tool for families, e-consultation models to distribute psychiatric resources more equitably and effectively, and more personal hybrid graduation celebrations). The aperture for creativity also opened a deeper concern, with some participants fearing the perilous potential for unregulated, for-profit telemedicine, or an inevitable return to the status quo.
Within reimagining, we identified a subtheme of recommitment to the profession and its purpose. Some participants reflected on their “origin story” in psychiatry, with several recalling their motivation as wanting to address disparities, to “make things better for people who have, for many reasons, limited access to the resources they need.” Consequently, some desired for CAPs to both serve as more prominent leaders and collaborators and become liaisons not just to children’s health but to families’ well-being, “because we really have the capacity to understand how relationships build brains, how society and social determinants of health have such an enormous impact on human functioning.” Several participants also hoped to “banish the term ‘med check,’” finding it an insufficient descriptor of CAP’s deeply interpersonal work: “The best kept secret is, we don't prescribe as bots…Your story matters to me.”
Psychiatry as advocacy
As the syndemic emerged, multiple participants identified the field as being at “a critical crossroads,” with COVID-19 and renewed confrontations with system racism as “accelerants,” as forces “pushing” the field to reckon with existing issues and adapt to necessary change. One such tension is balancing psychiatry’s complicity in and response to systemic racism, with the view of the field as a profession of advocacy. As participants looked toward the future of CAP, we identified conflicting assessments of the field’s ongoing social justice work, and divergent mindsets toward the hope for lasting change.
Increased recognition of the Black Lives Matter movement created space for renewed activism and dialogue between colleagues. One Black participant noted a slight shift in the burden of initiating emotionally heavy conversations about racism, remarking that the shared horrific experience of George Floyd’s death opened an overdue dialogue that more directly acknowledged racism:
“It was also important for people to say it because for the people who have been victims of these experiences for many years, the response has always been, ‘Well, why do you think it's racism? Or why do you think that's what it is?’ And to have others recognize how horrible it was without having to be the one to say it, I think was really important.”
Multiple participants described workplace participation in White Coats for Black Lives demonstrations, formation of diversity, equity and inclusion (DEI) committees, and increased activity of identity-based caucuses. Several training directors emphasized the role of social justice education in their residency and fellowship curricula. Attitudes towards professional organizations’ responses differed, with some participants appreciating the immediate strong condemnation and others feeling dissatisfied by the lack of concrete action.
Participants grappled with the call to action based on their own identities but overwhelmingly reflected a motivation for change. Several white leaders reflected on the complexity of supporting trainees, colleagues, and communities of color from a position of racial privilege, such as one respondent “trying to be a good leader in that area as a white man.” Another reflected on the existence of collected data on health disparities that had not been explored: “We should have been looking at this.” For multiple Black participants, the call to action was not a new one, but rather an amplification of the work they had engaged in for years: “I don't want to make it seem like they're just now noticing. People have been noticing, and people have been experiencing this for a long time.”
Alongside this delayed collective acknowledgement of systemic racism, fear of institutional inertia and loss of focus also interfered with some participants’ hopes for lasting improvement to post-pandemic psychiatry’s role in social justice work, as well as generally. “Is it an opening?” asked one participant. “Sure. Are we going to take advantage of that opening? We'll see.” For many, faith in valuable change hinged on concrete action. “We don’t just want to say a statement,” said one Black participant of their institution’s response to the Black Lives Matter protests; “We want to do something and then say, this is what we’re doing, versus ‘we stand behind diversity.’” Additionally, some participants expressed frustration over the necessity of pandemic catalysts in the first place: “It’s also just a bit ridiculous, that it takes the murder of a man to be filmed for people to reckon with what we’ve known.” Consequently, although the pandemic figured as a “pivot point” or “fulcrum” for growth, disappointment and frustration tempered optimism about the possibility of meaningful change and highlighted the significance of CAP’s follow-through. As one participant encapsulated the overall outlook, “it's a fertile time for progress in a positive direction; but like anything, only if we choose to do it as such.”