How the COVID-19 outbreak affected physician-patient relationship

In addition to these effects, physicians and health care providers have been the most exposed and have experienced more mental harm than others [1,2]. Undoubtedly the most basic and important results of these effects are the potential and actual risk of exposure to infected patients and the risks of transmission of this disease. The contagion rate and mortality of physicians and healthcare providers engaged in patient care, especially in COVID-19 intensive care units, is clear [3].


Introduction
The pandemic outbreak has caused many dif iculties and signi icant damage to health, economy, and human relations. It has transformed our world and brought about fundamental changes in human relations and modern civilization.
In addition to these effects, physicians and health care providers have been the most exposed and have experienced more mental harm than others [1,2]. Undoubtedly the most basic and important results of these effects are the potential and actual risk of exposure to infected patients and the risks of transmission of this disease. The contagion rate and mortality of physicians and healthcare providers engaged in patient care, especially in COVID-19 intensive care units, is clear [3].
Physician-patient communication is the most basic element and vital skill of physicians in the diagnosis, treatment, and establishing diagnostic protocols. With good communication, physicians can build a safe, scienti ic, practical, and suitable environment for patient care [4]. To establish this environment, the main principles include: 1 Building a proper area for patient care 2 Pro iciency in setting, organizing, and practicing good physician-patient communication 3 Providing useful feedback to the patient However, many things have changed for about 77% of physicians and nearly 3/4 of nurses and healthcare workers. Health care workers establish these conditions differently for inpatient and outpatient care units.

In-patient care units
In COVID-19 care units, as the risks of contagion and viral infection are higher, physicians and health workers should establish strict protective measures. These include face masks, face shields, and special protective coats; these are known as PPE (Personal Protective Equipment). This enables physicians and patients to be completely physically isolated from each other. This is not a problem in an intensive care unit (ICU) where most of the patients are unconscious, but in other patient care units, physicians and health care workers earning protective measures can be traumatic for the patient and may lead to emotional relationship disruption [5].
environment. This deterioration is evident and different on both patient and physician sides. The patient has the fear and stress of being marked with a dangerous and untreatable disease as well as their physical condition. Being in physical quarantine from family and friends, having a serious respiratory disease, and fear of mortality ultimately lead to traumatic and painful psychosocial status.
Physicians and health care workers have different emotional reactions. Undoubtedly one of the most important aims of physicians is patients' comprehensive medical support and in this way, they use all of the available treatments, diagnostic tools, and interventions even if they suffer serious complications; but there were different circumstances during this pandemic. This new disease is almost unknown, and there is a lot of ambiguity about its pathophysiology, contagion methods and risks, symptoms, and treatment efforts, so these lead to severe ambivalence and confusion in physicians and healthcare workers [6][7][8]. Although they use all their skills and abilities for patient care, the fear of contagion, and being quarantined from family leads to their additional physiological distress. They have fear and anxiety about exposure to COVID-19 at work and bringing the infection home to family [6,9]. However the self-sacri ice and con idence of healthcare workers around the world are unforgettable; certainly, the value of this professional courage and sacri ice will never diminish. Online visits, contact using social media, and telemedicine services are embraced in some patient care units during the current pandemic. However, most patients are not willing to continue this practice. Moreover, the physician/patient relationship and their communication are somehow different from other diseases, and patients who are referred to psychologists and/or psychiatrists prefer to have unrestricted in-person visits without facial masks and social distancing. All previous surveys emphasize that face-to-face and personal interplay is most valuable for patients, rather than social and physical distancing in the current circumstances [10].

Out-patient care units
Physicians feared that a tsunami of patients would overwhelm their healthcare systems, preventing them from adequately caring for other patients and/or managing their own contagion risk [1]. Meanwhile, an accumulation of patients in the waiting room creates a dangerous environment for the possibility of spreading the disease. Following social distancing protocols, managing patients' appointments, and avoiding crowded of ices and waiting rooms are observed in most outpatient clinics. However, because of severe fear and anxiety of contagion requiring physical barriers and plastic shields, the relationships between of ice receptionists and patients become problematic. The most important disruption occurred in the waiting room. The positive attitude of patients and physicians is observed in "Field Observations". Lack of face-to-face interactions lead to a less human practice of medicine, while patient-physician relationships in most outpatient clinics are based on communication, collaboration, trust, and empathy between physicians and patients [11].
Patients value greatly the face to face and close relationships with their doctors, including facial interviews and physical examination. So social and physical distancing between physician and their patients can be remarked as a bigger toll than the risk of COVID-19 contagious [11].
Doctors, on the other hand, have serious psychological con licts between commitment to care and the risk of contagiousness of the disease. Numerous ield observations and reports indicate a very diverse behavior of physicians in this regard. Some physicians (even internal medicine and cardiologists) visit their patients with face mask and shield and with physical distancing. Some of them even refused to clinical and physical examination this was accurate even for the control of vital signs such as measuring the patient's blood pressure. Some doctors had a major problem with the face mask during the interview with the patient. This was more problematic in clinics where verbal history is very important. Having a mask had a profound effect on how the doctor and the patient spoke and listened to each other, this was most problematic when the patients have masks too. This problem is most obvious when using the N95 mask, because of confusing echo sounds during the speaking. Some patients have to remove their face mask during speaking because they think that maybe physicians can't understand them so many doctors complain, and this leads to disruption in their communications. Awareness of reciprocal facial changes, which is one of the basic principles of physician-patient communication, has been strongly in luenced, and psychiatric interviews have been used to remove the emotion or affect the index from the psychiatric description. The patient's approach to presenting medical records to the physician has sometimes been accompanied by a serious reaction from the physician, followed by a disturbance in the patient's physician relationship.

Conclusion
In conclusion, the recent outbreak is harmful sophisticated conditions, while physicians and health care workers are "The soldiers on the front lines". Even sometimes these front line soldiers didn't access appropriate PPE. Meanwhile, infected doctors and nurses have been recognized as "vector for the spread of the virus", and for those infected health care workers, the feeling of powerlessness is so painful.
However, the most important positive side of this circumstance is reminding and awareness of the most general population about professional physicians› roles and their commitment to providing care even by accepting the risks of contagious. It was obvious from the reaction of ordinary people, of icials, and journalists on social media and TV channels. Occasionally, different ceremonies and reactions taking care of health care workers were particularly emotional.