Establishing the Essential Role of Household Extenders for Surgeon Wellbeing.

OBJECTIVE: The aim of this study was to investigate the association between a change in household support during the Covid-19 pandemic and surgeon stress. BACKGROUND: The hours and unpredictability of surgical practice often necessitate the employment of household extenders (eg, child caregivers) to maintain a safe home environment for surgeons and their families. The Covid-19 pandemic destabilized these relationships and provided an opportunity to reflect on the role that household extenders play in a surgical household. METHODS: A multi-institutional telephone survey of surgeons practicing at five geographically diverse academic institutions was conducted (May 15, 2020-June 5, 2020). Surgeons were classified by change in household extenders (HE) during the pandemic (decrease, increase, no change, or none). The primary outcome was self-reported surgeon stress level. Multivariable linear regression was used to examine the relationship between change in HE and surgeon stress, adjusting for training and relationship status, the presence of pets and children in the household, and study site. RESULTS: The majority (182, 54.3%) of surgeons employed HE before the pandemic; 121 (36.1%) reported a decrease in HE during the pandemic, 9 (2.7%) reported an increase, and 52 (15.5%) reported no change. Stress scores varied significantly by change in HE group (P = 0.016). After controlling for potential confounders, having an increase in HE was associated with a higher stress score (+1.55 points) than having no decrease in HE (P = 0.033), and having a decrease in HE was associated with a higher stress score (+0.96 points) than having no decrease (P = 0.004). CONCLUSIONS: Household extenders play a vital and complex role in enabling the healthcare workforce to care of the population. Surgeons who experienced a change in household extenders reported the highest stress levels. We suggest that health systems should proactively support surgeons by supporting the household extender workforce.

Longitudinal evaluation of the surgical workforce experience during the Covid-19 pandemic.

BACKGROUND: An updated examination of the surgeon experience during the Covid-19 pandemic is lacking. This study sought to describe how surgeon stress levels and sources of stress evolved over the pandemic. METHODS: An electronic survey was administered to surgeons at four academic hospitals at 6-months and 12-months following an initial telephone survey. The primary outcome was stress level and secondary outcomes were the individual stressors. Thematic analysis was applied to free text responses. RESULTS: A total of 103 and 53 responses were received at 6-months and 12-months, respectively. The mean overall stress level was 5.35 (SD 1.89) at 6-months and 4.83 (SD 2.19) at 12-months. Mean number of stressors declined from 3.77 (SD 2.39) to 2.06 (SD 1.60, P < 0.001), though the "finances" stressor increased frequency (27.2% to 34.0%). Similar qualitative themes were identified, however codes for financial and capacity challenges were more prominent at 12-months. CONCLUSIONS: The surgical workforce continues to report elevated levels of stress, though the sources of this stress have changed. Targeted interventions are imperative to protect surgeons from long-term psychological and financial harm.

Endocrine Surgical Procedures During COVID-19: Patient Prioritization and Time to Surgery.

BACKGROUND: We tracked endocrine surgery patients with treatment delays due to COVID-19 to investigate the relationship between physician assigned priority scoring (PAPS), the Medically Necessary, Time Sensitive (MeNTS) scoring system and delay to surgery. MATERIAL & METHODS: Patients scheduled for endocrine surgery or clinically evaluated during COVID-19-related elective surgery hold at our institution (2/26/20-5/1/20) were prospectively enrolled. PAPS was assigned based on categories of high, moderate, or low risk, consistent with the American College of Surgeons' priority system. MeNTS scores were calculated. The primary outcome was delay to surgery. Descriptive statistics were performed, and receiver operator characteristic (ROC) curves and area under the curve (AUC) values were calculated for PAPS and MeNTS. RESULTS: Of 146 patients included, 68% (n = 100) were female; the median age was 60 years (IQR:43,67). Mean delay to surgery was significantly shorter (P = 0.01) in patients with high PAPS (35 d), compared with moderate (61 d) and low (79 d) PAPS groups. MeNTS scores were provided for 105 patients and were analyzed by diagnosis. Patients with benign thyroid disease (n = 17) had a significantly higher MeNTS score than patients with thyroid disease which was malignant/suspicious for malignancy (n = 44) patients (51.5 versus 47.6, P = 0.034). Higher PAPS correlated well with a delay to surgery of <30 d (AUC: 0.72). MeNTS score did not correlate well with delay to surgery <30 d (AUC: 0.52). CONCLUSION: PAPS better predicted delay to surgery than MeNTS scores. PAPS may incorporate more complex components of clinical decision-making which are not captured in the MeNTS score.

The Cost of Quarantine: Projecting the Financial Impact of Canceled Elective Surgery on the Nation's Hospitals.

OBJECTIVE: We sought to quantify the financial impact of elective surgery cancellations in the US during COVID-19 and simulate hospitals' recovery times from a single period of surgery cessation. BACKGROUND: COVID-19 in the US resulted in cessation of elective surgery-a substantial driver of hospital revenue-and placed patients at risk and hospitals under financial stress. We sought to quantify the financial impact of elective surgery cancellations during the pandemic and simulate hospitals' recovery times. METHODS: Elective surgical cases were abstracted from the Nationwide Inpatient Sample (2016-2017). Time series were utilized to forecast March-May 2020 revenues and demand. Sensitivity analyses were conducted to calculate the time to clear backlog cases and match expected ongoing demand in the post-COVID period. Subset analyses were performed by hospital region and teaching status. RESULTS: National revenue loss due to major elective surgery cessation was estimated to be $22.3 billion (B). Recovery to market equilibrium was conserved across strata and influenced by pre- and post-COVID capacity utilization. Median recovery time was 12-22 months across all strata. Lower pre-COVID utilization was associated with fewer months to recovery. CONCLUSIONS: Strategies to mitigate the predicted revenue loss of $22.3B due to major elective surgery cessation will vary with hospital-specific supply-demand equilibrium. If patient demand is slow to return, hospitals should focus on marketing of services; if hospital capacity is constrained, efficient capacity expansion may be beneficial. Finally, rural and urban nonteaching hospitals may face increased financial risk which may exacerbate care disparities.

The Relationship Between Surgeon Gender and Stress During the Covid-19 Pandemic.

OBJECTIVE: To investigate the relationship between surgeon gender and stress during the Covid-19 pandemic. BACKGROUND: Although female surgeons face difficulties integrating work and home in the best of times, the Covid-19 pandemic has presented new challenges. The implications for the female surgical workforce are unknown. METHODS: This cross-sectional, multi-center telephone survey study of surgeons was conducted across 5 academic institutions (May 15-June 5, 2020). The primary outcome was maximum stress level, measured using the validated Stress Numerical Rating Scale-11. Mixed-effects generalized linear models were used to estimate the relationship between surgeon stress level and gender. RESULTS: Of 529 surgeons contacted, 337 surgeons responded and 335 surveys were complete (response rate 63.7%). The majority of female respondents were housestaff (58.1%), and the majority of male respondents were faculty (56.8%) (P = 0.008). A greater proportion of male surgeons (50.3%) than female surgeons (36.8%) had children ≤18 years (P = 0.015). The mean maximum stress level for female surgeons was 7.51 (SD 1.49) and for male surgeons was 6.71 (SD 2.15) (P < 0.001). After adjusting for the presence of children and training status, female gender was associated with a significantly higher maximum stress level (P < 0.001). CONCLUSIONS: Our findings that women experienced more stress than men during the Covid-19 pandemic, regardless of parental status, suggest that there is more to the gendered differences in the stress experience of the pandemic than the added demands of childcare. Deliberate interventions are needed to promote and support the female surgical workforce during the pandemic.

Exploring the Experience of the Surgical Workforce During the Covid-19 Pandemic.

OBJECTIVE: To explore the impact of the Covid-19 pandemic on the stress levels and experience of academic surgeons by training status (eg, housestaff or faculty). BACKGROUND: Covid-19 has uniquely challenged and changed the United States healthcare system. A better understanding of the surgeon experience is necessary to inform proactive workforce management and support. METHODS: A multi-institutional, cross-sectional telephone survey of surgeons was conducted across 5 academic medical centers from May 15 to June 5, 2020. The exposure of interest was training status. The primary outcome was maximum stress level, measured using the validated Stress Numerical Rating Scale-11 (range 0-10). RESULTS: A total of 335 surveys were completed (49.3% housestaff, 50.7% faculty; response rate 63.7%). The mean maximum stress level of faculty was 7.21 (SD 1.81) and of housestaff was 6.86 (SD 2.06) (P = 0.102). Mean stress levels at the time of the survey trended lower amongst housestaff (4.17, SD 1.89) than faculty (4.56, SD 2.15) (P = 0.076). More housestaff (63.6%) than faculty (40.0%) reported exposure to individuals with Covid-19 (P < 0.001). Subjects reported inadequate personal protective equipment in approximately a third of professional exposures, with no difference by training status (P = 0.557). CONCLUSIONS: During the early months of the Covid-19 pandemic, the personal and professional experiences of housestaff and faculty differed, in part due to a difference in exposure as well as non-work-related stressors. Workforce safety, including adequate personal protective equipment, expanded benefits (eg, emergency childcare), and deliberate staffing models may help to alleviate the stress associated with disease resurgence or future disasters.

Impact of COVID-19 Restrictions on Demographics and Outcomes of Patients Undergoing Medically Necessary Non-Emergent Surgeries During the Pandemic.

BACKGROUND: The COVID-19 pandemic has resulted in large-scale healthcare restrictions to control viral spread, reducing operating room censuses to include only medically necessary surgeries. The impact of restrictions on which patients undergo surgical procedures and their perioperative outcomes is less understood. METHODS: Adult patients who underwent medically necessary surgical procedures at our institution during a restricted operative period due to the COVID-19 pandemic (March 23-April 24, 2020) were compared to patients undergoing procedures during a similar time period in the pre-COVID-19 era (March 25-April 26, 2019). Cardinal matching and differences in means were utilized to analyze perioperative outcomes. RESULTS: 857 patients had surgery in 2019 (pre-COVID-19) and 212 patients had surgery in 2020 (COVID-19). The COVID-19 era cohort had a higher proportion of patients who were male (61.3% vs. 44.5%, P < 0.0001), were White (83.5% vs. 68.7%, P < 0.001), had private insurance (62.7% vs. 54.3%, p 0.05), were ASA classification 4 (10.9% vs. 3%, P < 0.0001), and underwent oncologic procedures (69.3% vs. 42.7%, P < 0.0001). Following 1:1 cardinal matching, COVID-19 era patients (N = 157) had a decreased likelihood of discharge to a nursing facility (risk difference-8.3, P < 0.0001) and shorter median length of stay (risk difference-0.6, p 0.04) compared to pre-COVID-19 era patients. There was no difference between the two patient cohorts in overall morbidity and 30-day readmission. CONCLUSIONS: COVID-19 restrictions on surgical operations were associated with a change in the racial and insurance demographics in patients undergoing medically necessary surgical procedures but were not associated with worse postoperative morbidity. Further study is necessary to better identify the causes for patient demographic differences.

Postdischarge Virtual Visits for Low-risk Surgeries: A Randomized Noninferiority Clinical Trial.

Importance: Postdischarge video-based virtual visits are a growing aspect of surgical care and have dramatically increased in the setting of the coronavirus disease 2019 (COVID-19) pandemic. Objective: To evaluate the outcomes of all-cause 30-day hospital encounter proportion among patients who have a postdischarge video-based virtual visit follow-up compared with in-person follow-up. Design, Setting, and Participants: Randomized, active, controlled noninferiority trial in an urban setting, including patients from a small community hospital and a large, tertiary care hospital. Patients who underwent minimally invasive appendectomy or cholecystectomy by a group of surgeons who cover emergency general surgery at these 2 hospitals were included. Patients undergoing elective and nonelective procedures were included. Interventions: Patients were randomized in a 2:1 fashion to video-based virtual visit or in-person visit. Main Outcomes and Measures: The primary outcome is the percentage of patients with 30-day hospital encounter, and we hypothesized that there would not be a significant increase in the 30-day hospital encounter proportion for patients who receive video-based virtual postdischarge care compared with patients who receive standard (in-person) care. Hospital encounter includes emergency department visit, observation, or inpatient admission. Results: A total of 1645 patients were screened; 289 patients were randomized to the virtual group and 143 to the in-person group. Fifty-three patients crossed over to the in-person follow-up group. The percentage of patients who had a hospital encounter was noninferior for virtual visits (12.8% vs 13.3% for in-person, Δ 0.5% with 1-sided 95% CI, -∞ to 5.2%). The amount of time patients spent with the clinician (mean of 8.4 minutes virtual vs 7.8 minutes in-person; P = .30) was not different, but the median overall postoperative visit time was 27.5 minutes shorter (95% CI, -33.5 to -24.0). Conclusions and Relevance: Postdischarge video-based virtual visits did not increase hospital encounter proportions and provided shorter overall time commitment but equal time with the surgical team member. This information will help surgeons and patients feel more confident in using video-based virtual visits. Trial Registration: ClinicalTrials.gov Identifier: NCT03258177.