key: cord-0684511-tncff6u7
authors: Sahu, Dipit; Agrawal, Tushar; Rathod, Vaibhavi; Bagaria, Vaibhav
title: Impact of COVID 19 lockdown on orthopaedic surgeons in India: A survey()
date: 2020-05-12
journal: J Clin Orthop Trauma
DOI: 10.1016/j.jcot.2020.05.007
sha: a98f7137d2c32e3f113e89e50d31ce81ea259e1a
doc_id: 684511
cord_uid: tncff6u7

BACKGROUND: In the fight against COVID 19, the government of India announced a 3 weeks lockdown of the entire country of 1.3 billion people on 24(th) March 2020. METHODS: One week after the lockdown was announced, we conducted an anonymous online survey of the orthopaedic surgeons in India through social media platforms to assess the impact of the lockdown during COVID 19. The survey had a total of 13 questions with (3–5) options and was designed with an aim to understand the perception and the state of mind of the Orthopaedic surgeons in the lockdown situation. RESULTS: The survey was completed by 611 orthopaedic surgeons from 140 cities in India. There were 22.5% orthopaedic surgeons who said that they were definitely stressed out, and 40.5% who said they were mildly stressed out. As the age decreased, the percentage of orthopaedic surgeons feeling “definitely stressed out” increased. Disruption of life-work balance and uncertainties regarding return to work were other strongly associated factors with the “definitely stressed out” group. CONCLUSION: The psychological impact of the lockdown during COVID 19 on orthopaedic surgeons may become a potential concern that will require addressal through open discussion. LEVEL OF EVIDENCE: diagnostic level 4.

Coronavirus disease (COVID 19) caused by the severe acute respiratory syndrome coronavirus-2 26 (SARS-CoV-2), had started in China in the month of December 2019, but has overwhelmed the 27 health care systems across the world (1) . As of 15 th April 2020, 1,914,916 people around the world 28 had tested positive for . Studies from China have shown that mitigation measures 29 like isolation and social distancing were effective ways to stop the spread of the virus (3) . In India, 30 by March 24 there were 563 patients who had tested positive for COVID 19 (4) . The government 31 of India had announced a complete lockdown of the entire country for 3 weeks from March 24 th 32 and further extended it till 3 rd May on 14 th April (4) . This early lockdown was unprecedented as it 33 was a lockdown of 1.3 billion population (5) , but a complete lockdown was the only way which 34 was expected to potentially limit the spread of COVID 19. Although essential services were not 35 closed during the lockdown, there were clear guidelines for the orthopaedic surgeons to reduce 36 their outpatient department workflow and non-urgent surgeries (6, 7) . However, the orthopaedic 37 surgeons were still not the frontline workers for care of the COVID patients as the disease had 38 not yet overwhelmed the health services in India (8) . In India the health system is in the hands of 

From 31 st march to 4 th April (7 th to 12 th day of the lockdown announcement), we conducted an 49 online anonymous survey using non-probability snowball sampling technique. The survey 50 consisted of 3 mandated demographic questions and 10 other optional questions that were shared 51 with orthopaedic surgeons across a social media platform (WhatsApp) in India ( between the age group of 60 -70 years and 9 (1.5%) surgeons were above 70 years( Figure 1a ).

Out of the total 611 orthopaedic surgeons, 266 (43.5%) were working in a private corporate or normal after a few weeks or months after the lockdown period, but some also thought that 83 everything will be back to normal as soon as the lockdown ends [169 (28.8%)] , or some thought 84 it will hard to recover from the disruption caused by the lockdown [86 (14.7%)] , while few of 85 them thought they will never get back to the same again. Although all age groups felt they were "definitely stressed out", there was a significantly higher 117 percentage in the younger age groups than the older age group, with the percentage decreasing as 118 the age increased. (Figure 4 ) 119 There was a significantly higher percentage of orthopaedic surgeons in the "it will be hard to 120 recover from the disruption" (45.1%) group and "they will never recover" (41.7%) group 121 ( Figure 5 ) who felt that they were definitely stressed out than in the group who thought they 122 might recover once the lockdown is lifted (13.8%).

There were also significantly more orthopaedic surgeons in "there is no balance" (34.4%) and 124 "did not know where they were going" (33.3%) group who felt that they were definitely stressed 125 out. (Figure 6 )

Our study showed that 22.5 % of the orthopaedic surgeons were definitely stressed out and this 130 was significantly more in the younger age groups. The younger Orthopaedic population are 131 either starting out in their Orthopaedic practice or they are in the initial few years of their 132 practice and would need more support in these extraordinary times. A complete lockdown and 133 social distancing also means removal of significant social and financial support (10) . Although loss 134 of social support may also affect the older age groups, but an uncertain future may be adversely 135 affecting the younger age group. A previous study on COVID 19 lockdown by Wang et al also 136 showed that people younger than 40 years had a higher risk of anxiety during this period (11) .

Significantly more orthopaedic surgeons who were "definitely stressed out" also felt that their 138 professional life will never be back to the same way again or it will be hard to recover from the 139 disruption. The stress may be due to loss of practice, financial burden, family health risk or the 140 anxiety that they may be asked to work on the frontline care (12) . Many physicians have had to 141 close their offices and their hospitals have to shut down, but they are still keeping their support 142 staff employed (12) . All these changes were increasing the mental stress in the Orthopaedic 143 fraternity.

The life work balance has also been disrupted with no balance at all in this lockdown and this 145 factor was significantly associated with the feeling that they were definitely stressed out. Family 146 support and emotional balance may be disrupted due to social distancing in lockdown which may 147 further aggravate the mental stress (10) . There may also be concerns of risking the health of their 

There is a 15.6% prevalence of clinical depression in the physician population (15) . Hebert-Davies 161 et al had acknowledged that our orthopaedic profession is exposed to mental health 162 vulnerabilities and more open conversations are needed (16) . There is also a stigma attached to 163 doctors who seek help for mental stress due to professional or personal reasons (16)(15) . We are 164 expected to be in control of our professional life and our personal life (16) . In this unique 165 lockdown situation, even though the orthopaedic surgeons are not the frontline workers, their 166 stress may be due to professional, personal and financial factors that cannot be ignored. Since and not a face to face questionnaire. However, since our survey was anonymous, we believe that 201 the participants were truly honest in declaring how they were feeling.

In the next few days, we may see other mitigation steps and extended lockdown measures in 205 order to contain the spread of the COVID 19 pandemic. In our study, 22.5% of Orthopaedic 206 surgeons said they were definitely stressed out in this lockdown period due to COVID 19. Even will be hard to recover from the disruption" and "Yes, I will never be back to the same again" No, I don't think so. Everything will be back to normal as soon as the lockdown is over

No. I think it will be back to normal after few weeks / month Yes, I think it will be hard to recover from the disruption Yes, I will never be back to the same again 13. Are you happy with your country's response to COVID19 pandemic Mark only one oval.

I'm very happy with it I'm completely unhappy with it.

I'm ok with it but it could have been better

TI Novel Coronavirus COVID-19