Table 4.

Theme 3: discord and estrangement

Quotation number	Participant ID, US region	Exemplar quotation
Alienation from clinical role
52	M, Pacific	That’s what I do as a doctor. Not being able to go in and listen to a patient or to actually talk face-to-face to a patient, that was very foreign to me, so I think that made me feel like we can’t take care of patients…I felt like I wasn’t actually totally seeing a person or totally evaluating a person because I couldn’t talk to them face-to-face to actually listen to them.
53	K, Northeast	People come into the hospital to get help, right?…Even though everyone deserves help and we want to help everyone, that we’re just physically not able to. And that’s really like a wartime thought process, and I am not in the army. That is not how I approach medicine.
54	GG, Pacific	I usually have a target at the beginning of the day; things I want to accomplish and accomplish in a certain way. And if I come home and I hit the target, I feel good about myself…Now, even if I come home and I hit the target, I’m not actually sure if that was the target I should’ve been shooting for, as we try to balance differing, competing obligations.
55	X, Northeast	At the height of the pandemic, there were a lot of people that weren’t that old. We usually say like these are ‘salvageable’ patients and we’re going to try everything to keep them alive. But this was just a lot of times unsuccessful, like we’re fighting hard and they would just die…It was difficult emotionally to deal with that amount of suffering and dying. And sort of the inability to prevent these people from dying…I would come home at night and feel really defeated. That was unique in the…20+years of ICU care, it never felt like that.
56	G, Pacific	I know it sounds really morbidly weird, but I was a little disappointed because I was looking forward to being busy, being productive and holding peoples’ hands and contributing to just doctoring…Here I was less busy than I’d ever been because patients weren’t showing up to clinic…[I was] feeling guilty that other people were working so hard while my schedule is easier than ever…Here’s my chance to make a difference and to help people during this period and I saw like 3 COVID patients.
57	R, Pacific	To minimize COVID exposure, or to minimize PPE…The attendings have been going to see the patients on their own…I feel almost guilty about that. There’s always the sense that the trainees should be doing most of the work.
Interprofessional power differentials
58	MM, Pacific	We have a structure, we have an ordering and responsibility hierarchy. Well holy cow, in academic medicine, it’s got to be the least hierarchical…I think that cultural shift into, ‘We appreciate you, you’re brilliant, but you’re going to do it this way.’ That is not our way. We are not a military institution.
59	P, Northeast	As an ICU doctor who’s used to having the whole patient to themselves…I’m used to being able to have the final say. I’ll take input from everybody, but I’m deciding. And the triage team was taking over that role.
60	II, Pacific	[I said] ‘this is what this patient needs. Let's talk about how were going to get it.’ And there was no discussion, it was just like, ‘nope, not gonna happen’…Here we are, we're defining a new disease process, we’re having an emerging evolving pandemic…I really feel like I'm pretty rational about this, and you haven't told me anything, it's sort of like arguing with a toddler.
61	V, Northeast	Nephrology should absolutely have a say in CRRT vs not. And what was told to us was that, well it's really going to be the ICU teams that are driving these decisions. And we were like well, how does that work, it's not their specialty…It feels weird to not be an integral part of that decision…We understand that this is critical care, this is critical care space, but we should be a part of those decisions.
62	II, Pacific	I get it now, that infection prevention is like, we have to sit on these resources and we have to guard them and use them wisely. But again, that's where the messaging wasn't there. The messaging was just “No”…So it did feel more of an us-against-them. Like are we really on the same team? Are we really working toward the same end point of keeping our staff safe and treating the patient?
63	Q, South	Particularly as a consulting physician, a nephrologist, you kind of have the luxury of doing everything remotely. I really think that the nurses have taken the brunt during all of this.
64	C, Northeast	COVID is highlighting the potential tensions that might already exist between nurses and physicians…Power dynamics or what have you. My colleague felt empowered in some ways to say, ‘This is how I’m going to change my practice.’ Our dialysis staff probably don’t have that power to say, ‘this is how I’m going to do my nursing practice.’
65	B, Pacific	There's no housekeeping allowed in patient rooms in the hot zone. So, nursing…has been doing all the tasks like wiping down the rooms twice a day, cleaning out the bathroom…So, there's a lot more basic tasks put on nursing.
Exposing value conflicts
66	JJ, Pacific	You think you can kind of say this is how all pulmonary critical care docs behave, is how all physicians behave…Actually, some people, what makes them happy is taking care of patients and going home at the end of the day. Then I have to think about what my expectations are for people.
67	G, Pacific	People had been shamed for wearing masks a few weeks ago, and then I wondered if it was some kind of, ‘I’m not going to use PPE,’ like it was just for weak people. I’m not sure. But I was really shocked…They were all sitting around talking, and I walked by with a mask, and it almost seemed like they kind of looked at me funny.
68	BB, Pacific	There was this incident about one of the physicians at the hospital being reported about wearing a mask by the nurses…The hospital administrators felt like he was giving a message that this is more serious than it is and everybody should be masked. So, it was a big thing that the physician had to justify why he was wearing a mask…I felt better wearing a mask…It's better for my mental health,…but I did feel guilty about it.
69	G, Pacific	The patient is probably very scared, and if they look up and see me too scared to come in the room to see them, then what kind of doctoring is that?…At the beginning it had to do with conserving PPE, that we weren’t going in. But [now] there’s plenty of PPE…So I’m kind of surprised that we’re not, at least once, physically seeing each patient.
70	N, Northeast	Everybody else was not seeing patients…I would go back to my office and everybody treated me like a disease. Everybody freaked out when they saw me, in my scrubs and with my little baggie of PPE. They all like backed away from me, and I’m like, ‘Ok, we work together you guys, c’mon…What do you think? It’s going to hop off of me and go onto you?’ And they said ‘yes!’
71	J, Northeast	I’ve known these people forever…A couple of people just said, ‘my doctor said I have asthma, I can’t work for the next 6 weeks’…I’m disappointed, I mean, I feel like she let us down.
72	JJ, Pacific	There were members of our group who were really afraid, and really freaking out, and really like, ‘I have a two year-old, I can't do this.’ Which is normal, but also when you have a small group [of colleagues] it's not helpful. People are having their own anxiety and you kind of need everyone on board, you signed up for this, you kinda have to get over it.
73	AA, Northeast	If you're not going to go into the room, how are you gonna go ask your nurse to go sit in there for 2 hours. I just think that's not right.
74	C, Northeast	She sent out an email to let the dialysis staff, the whole team know that she’d be rounding virtually. It was interpreted as, ‘you’re on your own, dialysis nurses. I am supposed to be the leader here in my role as a physician, and I don’t have your back.’
Mistrust of leadership
75	Y, Pacific	Where I heard the most, I don't know, complaints or staff unhappiness, was with the unit that was not as aggressive with PPE…Even though [the institution] was following the [CDC] guidelines. But I think that it just made the staff feel better…I think they felt like maybe they weren't being cared for and as appreciated as they should be.
76	N, Northeast	I just felt like it wasn’t transparent. I mean, communication issues have always been a problem, especially in big organizations. I’ve brought it up before. People were in denial about it. It’s a leadership problem. I personally don’t trust my leadership…I’ve been working in this hospital for a long [enough] time that I slowly started to understand that peoples’ motivations aren’t good in healthcare…People were kind of motivated by their own self-interests and by greed.
77	Q, South	We asked multiple times if there was a triage command centre or a plan for what would occur if we got to the point where we had to triage resources. They said there was, but they wouldn’t provide it to us…What is it? Where is it? I just felt a total lack of support from the administration.
78	F, Pacific	Something that you used to make me use for my safety and the patient’s safety [masks], and suddenly you’re like, you don’t need it anymore…You have these policies in place because they’re evidence-based, and a bunch of people sat down and thought about it and said this is the safest way to provide care for people. And then suddenly you’re like, you don’t need to do that because we don’t have enough. And it really isn’t that we don’t need to do it, it’s really that you should, but we don’t have the supplies, so we can’t do it. If they had explained it like that, not that that’s any better, but it’s at least being honest. I feel like they’re downplaying a lot of things.
79	B, Pacific	Universal vs not universal masking. That one has been a little harder for most of us to understand…Why were we making it optional a few weeks ago and now it's becoming a universal protocol? I think I understand what the rationale is, especially with a higher incidence of staff infections. But I think it's hard to go from…where we were kind of lenient before, to something that's not so lenient with everybody on board. And I think since there's been such an emphasis on resource allocation and not using up limited PPE, some people are concerned that this is going to use up a lot of PPE.
80	O, Midwest/Mountain West	She was reprimanded by the VP for Medical Affairs because she was wearing a mask…You’re a physician administrator who doesn’t have any patient contact, so you’re the last person who should be giving advice.
81	JJ, Pacific	I think physicians everywhere were wanting to help and be helpful. A lot of it was coming from hospital administrators being nervous about what this would mean for their hospital and wanting to protect their own beds so in case they have their own surge.

CDC, Centers for Disease Control and Prevention; CRRT, continuous renal replacement therapy; ICU, intensive care unit; PPE, personal protective equipment; VP, vice president.