key: cord-1037974-9ojl54jp authors: Coleman, Julia R.; Abdelsattar, Jad M.; Glocker, Roan J. title: COVID-19 Pandemic and the Lived Experience of Surgical Residents, Fellows, and Early-Career Surgeons in the American College of Surgeons date: 2020-10-16 journal: J Am Coll Surg DOI: 10.1016/j.jamcollsurg.2020.09.026 sha: 6cac575f3d19b038197cf5cb033ac6eeb74cb63c doc_id: 1037974 cord_uid: 9ojl54jp BACKGROUND: To better understand how the COVID-19 pandemic has affected surgical trainees’ and early-career surgeons’ professional and personal experiences, a survey of the membership of the American College of Surgeons (ACS) Resident and Associate Society (RAS) and Young Fellows Association (YFA) was performed. STUDY DESIGN: An anonymous online survey was disseminated to members of RAS and YFA. Descriptive analyses were performed, and factors associated with depression and burnout were examined with univariate and multivariable stepwise logistic regression. RESULTS: Of the RAS/YFA membership of 21,385, there were 1,160 respondents. The majority (96%) of respondents reported the COVID-19 pandemic having a negative impact on their clinical experience, with 84% residents reporting >50% reduction in operative volume and inability to meet minimum case requirements. Respondents also reported negative impacts on personal wellness. Nearly one third reported inadequate access to personal protective equipment (PPE), and depression and burnout were pervasive (≥21% of respondents reported yes to every screening symptom). On multivariable analysis, female gender (OR 1.54 for depression, OR 1.47 for burnout) and lack of wellness resources (OR 1.55 for depression, OR 1.44 for burnout) predicted depression and burnout. Access to adequate PPE was protective against burnout (OR 0.52). CONCLUSION: These data demonstrate a significant impact of the COVID-19 pandemic upon the lives of resident and early-career surgeons. Actionable items from these data include mitigation of burnout and depression through increasing PPE access and provision of wellness programs, with a particular focus on high-risk groups. Surgical residents, fellows, and early-career surgeons face unique challenges during the SARS-CoV-2 or "COVID-19" global pandemic. In the face of rapid disease spread and resource disparities, healthcare systems have been forced to adapt and, in turn, the downstream effects have resulted in restructuring of surgical training, reduction of non-emergency surgical cases, and the reassignment of trainees to different clinical rotations. These actions interrupted the standard educational curricula, reduced the number of surgical cases, and limited trainees' ability to meet mandatory graduation requirements established by the Accreditation Council for Graduate Medical Education (ACGME) and other certifying licensing agencies (1) (2) (3) . In order to overcome the loss of clinical and operative opportunities, many surgical training programs implemented technologic-based solutions such as virtual didactics. These novel adaptations have assisted in the continued education of residents and fellows while maintaining social distancing(4, 5). Collectively, the stressors of the work environment amidst the COVID-19 pandemic are potential threats to surgeons' own well-being. Ethical decision-making regarding interactions with and treatment of COVID-19 patients have led to increased anxiety and feelings of burnout amongst physician trainees (6) . Many health care providers also fear contracting COVID-19 themselves, and more frequently, passing the disease to their loved ones (6, 7) . Exacerbating these stressors is the lack of adequate personal protective equipment (PPE), which not only drastically limits trainees' learning opportunities but can aggravate feelings of burnout (2, 7) . Despite the ongoing, unprecedented epidemic and these stressors, surgical residents and fellows are still expected to achieve pre-determined clinical and educational milestones. Review Board and received exempt status. The resulting survey data were aggregated on a secure spreadsheet for ACS administrative use only. Descriptive analyses were performed of the entire respondent cohort, followed by a stratified analysis by Resident or Early-Career Surgeons status. Following this, a comparison was made between resident and early-career surgeon responses to assess variations in impact of the pandemic by level of training of the respondent. Lastly, depression and burnout were assessed by standardized questions as mentioned above, and factors associated with high number depression or burnout symptoms were determined. Descriptive statistics were reported with percentages. Univariate analysis was performed with Chi-square and Fisher Exact tests. In order to better determine factors predictive of depression and burnout, in addition to univariate analysis, a multivariable stepwise logistic regression was performed after controlling for covariates identified on the univariate (p<0.20). Statistical analyses were performed using R software(13). All tests were two-tailed, with significance established at p<0.05. Overall, out of the membership of 21,385 (13,232 RAS members, 8 from Canada, 2% overseas on military duty, and 1% unemployed. A majority of respondents 64% were married, 31% were single, and 5% were divorced. Less than 1% identified as LGBTQ+ (n=6). Approximately half (49%) had children. Overall, of the 10,991 RAS resident members, there were 465 respondents (Table 1) , for a response rate of 4.2%. In describing their hospital status of COVID-19 admissions, responses were mixed, with 41% reporting numbers are still increasing ("uptick" in curve) and 40% reporting numbers are decreasing. When asked about the status of elective surgery at the peak of the first wave of the COVID-19 pandemic, the majority (84%) reported a reduction of at least 50% in non-emergency case volume, and another 19% reported a decrease in emergency case volume ( Table 2 ; complete survey responses in eTables 1-4). A variety of schedule changes were reported by residents (Table 2) , with the majority reporting being grouped into staggered shifts (70%) and several also reporting being completely removed from services (31%), having vacations being rescinded (33%), and being deployed to nonsurgical services to fill medical system needs (35%). Lastly, resident participation in outpatient clinic during the COVID-19 pandemic has been impacted, with more reporting no residents allowed in clinic (27%) or limited number of residents in clinic (chief and senior residents only) (20%). Only 24% report resident participation in virtual/telemedicine clinic. Overall, majority of residents reported COVID-19 pandemic response having a negative response of their clinical experience (Table 2) . Seventy four percent of respondents reported a negative or extremely negative impact on their clinic experience. The impact appeared to be greatest, however, on operative volume. Ninety six percent reported a negative or extremely negative impact on elective operative experience, and nearly one fourth of residents (24%) reported that the COVID-19 pandemic negatively impacted their ability to meet ACGME minimum case requirements. Response to impact of the COVID-19 pandemic on resident education were widely mixed among respondents ( Table 2 ). The majority of respondents (61%) reported a negative or extremely negative impact on their didactic educational programming; however, interestingly, 21% reported a positive or extremely positive impact on their didactic experience. When asked to what degree a resident's institution has employed innovative education and training solutions during COVID-19, the majority answered "somewhat" (55%) or "to a great extent" (18%). When asked about specific educational programming that was adapted (suspended, transitioned to virtual format, pre-recorded for viewing later, etc), the majority reported adaptations to Morbidity & Mortality conference, Grand Rounds, Visiting Professorships, Tumor Board, research conferences, and simulation training and center accessibility. When asked to what extent the COVID-19 pandemic has impacted expected progression of operative autonomy, the majority of residents reported either "to a great extent" (17%) or "moderately" (42%). Sixty percent of residents reported no change on feedback on clinical performance/assessment, whereas 37% reporting a negative or extremely negative impact. J o u r n a l P r e -p r o o f Nearly half of residents (47%) reported COVID-19 pandemic having an extremely negative or negative effect on their physical health (Table 2) . Similarly, half of residents (53%) reported COVID-19 pandemic having an extremely negative or negative effect on their sense of physical safety. Lastly, 70% of residents reported a negative or extremely negative impact on mental health. A majority (82%) of residents reported taking care of a known COVID-19 positive patient, and 66% reported performing an interventional procedure and/or surgery on a known COVID-19 positive patient. Residents were asked to cite their biggest concern during the COVID-19 pandemic from the following list: education, clinical competency, surgical case volume, ethical considerations, fear of contracting COVID-19, or spread of infection to family. The top two cited concerns were spread of infection to family (37%) and surgical case load (28%). When asked if programs have made arrangements to reduce risk to residents' families, nearly half (46%) reported their programs had not, whereas 32% reported alternative housing or living arrangements. When asked to what degree a resident's institution has demonstrated sensitivity to specific concerns of residents, 51% reported "somewhat" and 41% reported "to a great extent." Seventy nine percent of respondents reported that their program provided COVID-19 testing for employees. However, 34% of residents reported not having adequate access to PPE during the COVID-19 pandemic. A small fraction of respondents (8%) reported that programs asked residents to provide their own PPE. Residents were asked if they felt the type of care and risk of exposure they were being asked to take on was commensurate with their level of training. The majority (80%) reported "yes". When asked if they felt the surgical attending and/or clinical educators were taking on the same level of risk as compared to residents, 44% reported that they felt their attendings were taking on a decreased level of risk, 40% reported the same level of risk, and only 14% reported an increased level of risk. When asked if residents felt that their program has treated residents equally as compared to attending surgeons during the pandemic, and 38% reported unequal treatment, whereas the majority (57%) reported equal treatment. The vast majority of residents (80%) reported their hospital system had not provided residents with any bonus or "hazard pay." Residents were then screened for new or increased symptoms of depression. The results demonstrate a majority of residents had new or increased depression symptoms, with 31% reporting depressed mood, 54% reporting anxiety, 37% reporting change in sleep habits, 22% reporting change in appetite, 31% reporting decreased interest or happiness in activities, 39% reporting weight changes, and 35% reporting difficulty in maintaining attention. Residents were also screened for new or increased symptoms of burnout. Similar to depression, the endorsement of burnout feelings was notable. Over half (55%) of residents reported feeling emotional exhaustion, 39% reported depersonalization, and 45% reported decrease in sense of personal accomplishment. Approximately half (52%) of residents reported that their program instituted formal mechanisms to support resident wellness and resiliency during the COVID-19 pandemic. Only 13% reported utilizing wellness or resiliency resources offered by the ACS or other professional societies during the pandemic. J o u r n a l P r e -p r o o f (Table 3) , for a response rate of 4.2%. In terms of the status of COVID-19 admissions, half reported admissions are still increasing (50%), whereas 30% reported decreasing (Table 4; complete survey responses in SDC2). When asked about the status of elective surgery at their peak of the COVID-19 pandemic, the majority reported a reduction of 76-100% (38%) in elective case volume or 51-75% reduction (19%), with few reporting a decrease in emergent case volume (Table 4) . With regards to scheduling changes as a result of the COVID-19 pandemic, the most common reported changes were vacations being rescinded (29%) or administrative staff or clinical staff being furloughed (29% and 28% respectively). Additionally, only 5% reported physicians being fired. The majority (68%) of respondents reported taking care of patients with known COVID-19 infection, and half (52%) reported performing surgery and/or an invasive procedure on patients with known COVID-19 infection. Early-career surgeons were asked to cite their biggest concern during the COVID-19 pandemic from the same list as residents (Table 5 ). The top two cited concerns were spread of infection of family (40%) and surgical case load/practice concerns (18%). Over half (56%) of respondents reported a decrease in compensation during the pandemic, with the majority reporting either a 0-10% (35%) or 10-20% (27%) decrease in annual income this coming year as compared to the previous year. Only 11% of respondents reported receiving hazard pay. A majority of respondents (86%) reported that COVID-19 added or increased personal stressors due to decreased availability of school, childcare, or other activities. When asked if a respondent's institution or department had instituted any formal mechanisms to support faculty wellness and promote resiliency during the COVID-19 pandemic, only half (53%) reported "yes", and even less reported utilizing those wellness resources (18%). Only 34% reported being aware of ACS wellness resources, and even less (15%) reported using those resources. The majority of respondents (78%) reported feeling as though they did not have adequate PPE access. Nearly a quarter (21%) of respondents reported that their institution asked providers to supply their own PPE. The majority (77%) reported COVID-19 testing being provided by their institution. Early-career surgeons were then screened for new or increased symptoms of depression. Much like the response from residents, there were a remarkable number of respondents who reported new or increased depressive symptoms, with 31% reporting depressed mood, 61% reporting anxiety, 42% reporting change in sleeping habits, 21% reporting change in appetite, 36% reporting lack of interest in previously enjoyed activities, 44% reporting change in weight, and 34% reporting a decrease in attention maintenance. Similarly, the majority reported new or increased burnout symptoms, with 56% reporting emotional exhaustion, 30% reporting depersonalization, and 45% reporting decrease in sense of personal accomplishment. A comparison of demographics and shared question responses was performed between residents and early-career surgeons (eTables 1-4). Early-career surgeons were more likely to report an "uptick" in COVID-19 numbers at their institution versus residents (50% versus 41%, p=0.003). However, early-career surgeons reported less decrease in elective case volume. Residents, compared to early-career surgeons, were more likely to report taking care of known COVID-19 positive patients (82% versus 68%, p<0.001) and performing surgery or interventional procedures with known COVID-19 positive patients (66% versus 52%, p<0.001). In this context, interestingly, more residents reporting receiving hazard pay than early-career surgeons (19% versus 11% fellows, p<0.001). There were differences in the concerns expressed as the most pressing during the COVID-19 pandemic. While both residents and early-career surgeons most cited concern was spread of infection to family, this was reported with a slightly higher percent by early-career surgeons (40% versus 37%, p<0.001). Although both residents and early-career surgeons reported a high rate of new or increased depression and burn out symptoms, residents were more likely to report depersonalization (39% versus 30%, p=0.002). In order to better understand factors associated with high number of depression (≥4 positive answers to depression symptoms) and burnout (≥2 positive answer to burnout symptoms) symptoms, a comparison of demographic and COVID-19 specific responses was performed (Table 5 ). Those who reported high levels of depression were more likely to be female (53% versus 44%, p<0.007) and less likely to report wellness resources at their institution (46% versus 56%, p=0.001). Those who reported high number of depression symptoms were less likely to report access to adequate PPE (62% versus 72%, p=0.001) and more likely to report their institution requesting they provide their own PPE (22% versus 13%, p<0.0001). When examining burnout, similar associations were observed ( likely to report taking care of known COVID-19 positive patients and were more likely to report depersonalization symptoms. Lastly, those who reported high depression and burnout symptoms were more likely to be female, less likely to report availability of wellness resources, more likely to report taking care of known COVID-19 positive patients, and less likely to report access to adequate PPE. In which has been shown to be independently associated with higher levels of anxiety, fear, depression, and work exhaustion (7, 31) . The damaging effect is further amplified when combined with concern about PPE availability, which was reported in 35% of our respondents, and is a concern echoed by other health care providers who have reported similar shortages and the re-using of PPE(32). Residents and early-career surgeons also reported fear of contracting the virus, a concern not without legitimacy given reports describing up to 25% COVID-19 positivity rate in surgical consultants(33) and the high rate of potential exposure with residents and earlycareer surgeons continuing to serve on the frontlines of COVID-19 patient care(17, 34). However, the prime concern for both early-career surgeons and residents was transmission of infection to family. This concern has been similarly reported, seeming to take a priority over trainees' and early-career surgeons' concern for their own infection risk (14, 17, 35) . Unfortunately, despite prevalence of the concern for transmission to family, many respondents reported no programming to enhance protection of family, highlighting a potential area for future policy makers as this pandemic continues. There are distinct challenges faced by residents compared early-career surgeons. While academic professional life (in addition to personal life aspects) which were not specifically measured in our survey(49-51). However, these data collectively underscore the need for directed programming and further research to better understand the risk female gender poses to higher rates of burnout, depression, and other associated disparities during such times. While many health institutions' main focus is protecting the physical safety and wellbeing of their workers, less emphasis is placed on supporting the emotional well-being of workers, which is a cause for concern as highlighted by our results and others. The working conditions during the peak COVID-19 pandemic, and the heightened stress, resource limitations, uncertainty of physical safety, and significant patient morbidity and mortality, has been compared to battlefield conditions. This environment enmeshes providers in uncertainty and anxiety that ultimately predisposes them to stress exposure syndromes including post-traumatic J o u r n a l P r e -p r o o f stress disorder and burnout, as well as a predisposition to medical errors and suboptimal patient care(52-54). While our results identify increased PPE availability as a potential target to improve mental wellbeing in providers, there is also a need for formalized mental health promotion programs. Our results demonstrate that those who report less availability and/or use of wellness programs at their institution were more likely to demonstrate high depressive symptoms and burn out. This result is echoed in a survey of 375 neurosurgeons taking care of COVID-19 positive patients; Sharif et al found that the likelihood of depression was higher among providers who did not receive guidance about self-protection from their institution(55). These results underscore the importance of wellness programming at institutions for providers. Wellness options can include peer programming, formalized counseling, mindfulness and meditation programs, to grassroots wellness initiatives, with existing models of these from across the country serving as exemplars for more widespread adoption(56-58). The limitations of this study include a small sample size relative to the number of trainees and early-career surgeons in the United States, with a response rate of 5.4%. Additionally, this survey was sent and responses collected in a finite period (over two weeks in July), which we now recognize may be early in the pandemic and may not fully capture the present situations of trainees and early-career surgeons as institutions slowly adapt beyond the initial peak of the pandemic. There may be sampling bias in that those who are more likely to respond to the survey may have stronger opinions, either positive or negative, about their educational, clinical, and personal experience, potentially limiting generalizability. For example, junior residents and residents from Independent Academic Medical Centers appear to be underrepresented in the response group. However, to the best of our knowledge, this study has the largest sample size of trainees and early-career surgeons compared to existing survey data mentioned above that has J o u r n a l P r e -p r o o f been published around the COVID-19 pandemic. Finally, while institution-specific data was asked about the prevalence and trend of COVID-19 cases, this was not controlled for in answers and thus, it is possible that the heterogeneity of COVID-19 pandemic status in various programs biased responses across the pool of surgeons. This survey highlights the extent of the negative impact of the COVID-19 pandemic on surgical trainees' and early-career surgeons' clinical, educational, and personal experience. These data also underscore the enormous impact of the stress of the COVID-19 pandemic on surgeons' physical, emotional, and mental well-being. Importantly, the impact of the pandemic is ongoing, with nearly half of respondents reported that there is still an increase in COVID-19 cases at their hospitals. As medical professionals, our obligations extend beyond provision of care to our patients, but also to care for our colleagues and trainees. Improvements to the educational, clinical, and personal experiences of our surgeons and trainees is essential to sustaining the workforce in a pandemic without a clear endpoint. These improvements must be dynamic with short-and long-term interventions and monitoring, and also be adaptive to the feedback from resident and early-career surgeon input. These data reveal actionable items to facilitate evidence-based guidelines and responses during this major health crisis, including increasing PPE access, increased wellness resources and encouraging their utilization, and targeting high-risk demographic groups. Adapting future pandemic responses to the needs of surgical trainees and early-career surgeons and improving their educational, clinical, and personal experiences is essential to sustain the workforce through this pandemic and beyond. J o u r n a l P r e -p r o o f 6 1 Data is not shown for "prefer not to answer" or "other" responses and is included in percent calculations MIS, minimally invasive surgery J o u r n a l P r e -p r o o f 1) Authors make substantial contributions to conception and design, and/or acquisition of data, and/or analysis and interpretation of data; 2) Authors participate in drafting the article or revising it critically for important intellectual content; and 3) Authors give final approval of the version to be submitted and any revised version. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. Allowing one's name to appear as an author without having contributed significantly to the study or adding the name of an individual who has not contributed or who has not agreed to the work in its current form is considered a breach of appropriate authorship. Ghost-writing is NOT acceptable. No one, other than the authors listed below, should have contributed substantially to the writing and revising of the manuscript. Contributors who do not meet the criteria for authorship should be listed in the acknowledgment. Examples include: individuals who allowed their clinical experience to be included, a person who provided purely technical help, copyediting, proofreading or translation assistance (NO ghostwriters allowed), or a department Chair who provided only general support. Groups of persons who have contributed materially to the paper, but whose contributions do not justify authorship may be listed under a heading such as "clinical investigators" or "participating investigators," and their function or contribution should be described; for example, "served as scientific advisors," "critically reviewed the study proposal."] If you have any question about this, contact that editorial office before submitting your manuscript at jacsedit@facs.org or 312-202-5316. Please type each author's LAST NAME ONLY next to the appropriate category. Dear Young Surgeon: We invite you to participate in a brief online survey on your clinical, educational, and personal experience during the COVID-19 pandemic. The goal of this survey is 1) to describe the experiences of young surgeons during the COVID-19 pandemic (specifically focusing on your clinical, educational, and personal experience) and 2) to assist in informing future pandemic planning by highlighting the collective experiences of young surgeons. Your participation is voluntary, and your responses will not be linked to your identity in any way, and this survey is completely anonymous. By participating in this survey, you consent to your anonymized data being used for analysis, presentation to the American College of Surgeons (ACS) leadership, and/or publication. Lessons Learned at a COVID-19 designated hospital Medical and Surgical Education Challenges and Innovations in the COVID-19 Era: A Systematic Review Impact of the Coronavirus (COVID-19) pandemic on surgical practice -Part 1 What is your ethnicity? • Caucasian • African American • Hispanic/Latino Do you have children? • Yes • No • Prefer not to answer which region is your residency located? • NORTHEAST -Connecticut status of COVID-19 admissions at your hospital currently? • Numbers are still increasing • Numbers are starting to level ("flattened" part of curve) • Numbers are decreasing • Don't know Comments At the peak of the COVID-19 curve in your area, please indicate any reduction in ELECTIVE SURGERY as a result of COVID-19 pandemic At the peak of the COVID-19 curve in your area, please indicate any reduction in EMERGENCY SURGERY as a result of COVID-19 pandemic, at the institutional level. • No change • 1-25% • 26-50% • 51-75% • 76-100% • Don't know Comments 16. What scheduling changes, if any, has your program made in response to the COVID-19 pandemic NPs) • Less work is designated to advanced practice providers (PA, NPs) • Vacations have been rescinded • Residents have been re-deployed to nonsurgical services • No changes have been made • Changes were made but the schedule has now returned to "normal" 1: PROGRAM INFORMATION AND DEMOGRAPHICS 1. What is your age? • 26-30 y • 31-35 y • 36-40 y • 40-45 y • Do not want to specify 2. What is your sex? • Male • Female • Other • Do not want to specify 3. What is your sexual orientation? • Heterosexual • LGBTQ+ • Prefer not to answer 4. What is your marital status? • Married • Single • Divorced • Widowed • Prefer not to answer 5. What is your ethnicity? • Caucasian • African American • Hispanic/Latino • Asian • Other • Prefer not to answer 6. Do you have children? • Yes • No • Prefer not to answer 7 please specify SECTION 2: EFFECTS OF COVID-19 ON CLINICAL EXPERIENCE 10. What would you estimate is the status of COVID-19 admissions at your hospital currently? • Numbers are still increasing flattened" part of curve) • Numbers are decreasing • Don't know • No changes have been made • Changes were made but the schedule has now returned to Data is not shown for "prefer not to answer" or "other" responses and is included in percent calculations College of Surgeons PCT, patient care technician; PPE, personal protective equipment The authors would like to thank the American College of Surgeons for supporting the dissemination of this survey and allowing us to share the results of this membership survey. The authors would also like to thank those who contributed to overall review and suggestions for improvement on the project and paper, including Dr. Christopher Ellison, Dr. David Farley, Dr.Naveen Sangji, and Dr. Daniel Dent. prefer not to answer" or "other" responses and is included in percent calculations. *Depression: low symptoms (n = 766), high symptoms (n = 394) † Burnout: low symptoms (n = 667), high symptoms (n = 493) ACS, American College of Surgeons; PPE, personal protective equipment.