LAUSR

The COVID pandemic has interfered with many aspects of daily life that have been taken for granted. Traveling or going to a restaurant seems to be more affected than cardiac surgery. The concern of many cardiac surgeons has been that—due to a “medical lockdown”— they could not continue their regular activities but had to wait for the initial onslaught of the pandemic to pass by. In some institutions cardiac surgeons participated in the ICU management of COVID patients, in others they ended up idling because units were closed or patients too afraid to have their acute cardiovascular diseases treated in‐hospital. With the first wave has passed in most European countries, life seemingly continues as normal. Protective measures, however, are still part of our routine, such as wearing masks, distancing, or variable travel restrictions. Since we cardiac surgeons are used to working with masks, we may believe that at least our professional lives have returned to normal. A careful look at some details regarding our patients will give us a different view, and this is primarily related to the psychological aspects of having the cardiac disease and requiring surgical treatment. Most operations in cardiac surgery are performed for vital, that is, life‐ threatening reasons. It is well‐known that patients will develop a high anxiety level once they understand their diagnosis. The anxiety increases even further when they hear they have to undergo cardiac surgery. The moment the surgeon first sees the patient, he is therefore faced with a patient who has a high level of anxiety. Among other things, it is the responsibility of the surgeon to overcome this anxiety and to generate trust to bring the patient to the point where he or she agrees to undergo the necessary treatment. Anxiety has different facets. It does have a rational part, related to the objective risks of intervention. In addition, there is the subconscious part, which is more difficult to deal with. The patient experiences loss of control over his situation; there may be cognitive incongruence in that the patient wants the positive aspects of his therapy but wants to avoid risks or consequences of the intervention. This psychological internal conflict may lead to irrational decisions, such as preferring PCI over coronary surgery irrespective of the facts, or believing that a TAVI is the best solution despite young age and objective facts speaking a different language. During the first encounter with the patient, the cardiac surgeon has to inform him in a rational and understandable way, in addition, he also has to build up trust. This is done through adequate communication, both verbal and nonverbal. Both protective masks and distancing may present difficulties in verbal communication, both to the patient and the surgeon. Through a mask the voice loses clarity, it sounds muffled. Even more important, a variable part of understanding speech comes through watching lip motion, which is lost when wearing a mask. Such problems are aggravated by hearing deficits and communication in a nonnative language. It can be expected that a variable degree of information is lost by communication under these circumstances. Also, nonverbal communication is limited by masks and distance. This nonverbal communication is an essential part of dealing with emotions, such as the anxiety that the patient presents with. Trust develops based on verbal and nonverbal communication. Wearing a mask may limit the “first impression.” First impression formation has been shown in general and occupational psychology to have an important and lasting influence on judgment and further reception. This is formed by the initial reception, in which facial mimics play an important role. It has not been studied yet but appears conceivable that first impression formation is influenced by not being able to see the other person's face fully. More importantly, unconscious reading of the facial movements contributes to nonverbal communication by sensing the emotional components of the sender of a message, and also the recipient. It is thus more difficult for the surgeon to sense fears, excitement, hope, or other emotional states. More importantly, the surgeon will have difficulty to transmit confidence and empathy to the patient. Thus, wearing the mask will limit communication for the patient and the cardiac surgeon. Having said this, it is clear that certain protective measures have to be taken, and masks are an apparently effective means of limiting COVID spread. On the other hand, we have to focus on dealing with communication under these circumstances. Regarding verbal communication, the hurdle can theoretically be overcome by speaking more slowly and louder. We will have to investigate how we can best minimize the limiting effect on nonverbal communication. It is unclear whether, for instance, transparent masks facilitate the reception of facial movements while still providing protection against the current viral challenge. Thus, COVID has been and still is a challenge to human interaction. It affects the patient–physician interaction, it also limits the traditional ways of information transfer, such as traveling to a meeting to hear someone speak rather than follow her or his message from a distance, that is, through a publication or a blog. We should focus on these hurdles to communication, and incorporation