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. 2020 May 6;10(5):534–552. doi: 10.1177/2192568220925783

The Impact of COVID-19 Pandemic on Spine Surgeons Worldwide

Philip K Louie 1, Garrett K Harada 2, Michael H McCarthy 1, Niccole Germscheid 3, Jason P Y Cheung 4, Marko H Neva 5, Mohammad El-Sharkawi 6, Marcelo Valacco 7, Daniel M Sciubba 8, Norman B Chutken 9, Howard S An 2, Dino Samartzis 2,✉
PMCID: PMC7359680  PMID: 32677575

Abstract

Study Design:

Cross-sectional, international survey.

Objectives:

The current study addressed the multi-dimensional impact of COVID-19 upon healthcare professionals, particularly spine surgeons, worldwide. Secondly, it aimed to identify geographical variations and similarities.

Methods:

A multi-dimensional survey was distributed to surgeons worldwide. Questions were categorized into domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions.

Results:

902 spine surgeons representing 7 global regions completed the survey. 36.8% reported co-morbidities. Of those that underwent viral testing, 15.8% tested positive for COVID-19, and testing likelihood was region-dependent; however, 7.2% would not disclose their infection to their patients. Family health concerns were greatest stressor globally (76.0%), with anxiety levels moderately high. Loss of income, clinical practice and current surgical management were region-dependent, whereby 50.4% indicated personal-protective-equipment were not adequate. 82.3% envisioned a change in their clinical practice as a result of COVID-19. More than 33% of clinical practice was via telemedicine. Research output and teaching/training impact was similar globally. 96.9% were interested in online medical education. 94.7% expressed a need for formal, international guidelines to manage COVID-19 patients.

Conclusions:

In this first, international study to assess the impact of COVID-19 on surgeons worldwide, we identified overall/regional variations and infection rate. The study raises awareness of the needs and challenges of surgeons that will serve as the foundation to establish interventions and guidelines to face future public health crises.

Keywords: COVID-19, coronavirus, spine surgeons, global, worldwide, impact

Introduction

As of April 10, 2020, the novel coronavirus, COVID-19, has spread to more than 210 countries, infecting more than 1 700 000 individuals and causing more than 100 000 deaths.1-5 Although there is enormous attention surrounding COVID-19, there is a pressing need to accelerate protocols and guidelines for testing, patient management, antiviral therapies, and effective vaccines. The medical community has provided treatment algorithms, protocols for the use of personal protective equipment (PPE), resource allocation, and collaborative efforts to mitigate the effects of the COVID-196; however, the standardization and global acceptance of such protocols remain under question, and not all centers have such resources in abundance. In addition, COVID-19 has proven to not only be a medical crisis, but a financial and social one as well.

The impact on individual subspecialists in the age of COVID-19 remains unclear, especially in epicenters where physicians’ roles are transforming to meet needs during this pandemic. Furthermore, a great deal of attention has focused on emergency and critical care specialists; however, the surgeon is often lost in the conversation. Baseline burnout rates are incredibly high in this population, and a global pandemic may negatively compound associated consequences.7,8 Because of the suspension of most elective surgeries worldwide and in-person clinics, many surgeons have had to rapidly adjust their practice and assist on frontline duties. Additionally, surgeons work in multidisciplinary teams; thus, elective surgery cancellations have downstream effects on various health care workers.

The current study addressed the multidimensional impact of COVID-19 on health care professionals, particularly spine surgeons, worldwide. Second, it aimed to identify geographical variations and similarities.

Methods

Survey Design and Content

A survey, known as the AO Spine COVID-19 and Spine Surgeon Global Impact Survey, was developed with representation of various regions. Question selection was based on a Delphi style for consensus, following several rounds of review before finalization. Questions included several domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions.

Survey Distribution

The 73-item survey was presented in English and distributed via email to the AO Spine membership who agreed to receive surveys (n = 3805 of approximately 6000 members). AO Spine is the world’s largest society of international spine surgeons (www.aospine.org). The survey recipients were provided 9 days to complete the survey (March 27, 2020, to April 4, 2020). Respondents were informed that their participation was voluntary and confidential; thus, information gained would be disseminated in peer-review journals, websites, and social media.

Statistical Analyses

All statistical analyses were performed with Stata version 13.1 (StataCorp LC, College Station, TX). Graphical representation of survey responses was performed using RStudio v1.2.1335 (RStudio Inc, Boston, MA). Percentages and means were made for count data and rank-order questions, respectively. Statistical analyses were performed to assess significant differences in count data using a combination of Fisher exact and χ2 tests, where applicable. Differences in continuous variables between groups were assessed using analysis of variance (ANOVA). The threshold for statistical significance for all tests was P < .05.

Results

In total, 902 spine surgeons responded to the survey, representing 91 distinct countries and 7 regions. The greatest number of responses were from Europe (242/881; 27.5%), followed by Asia (213/881; 24.2%) and North America (152/881; 17.3%). Most survey responses (Figure 1) were from the United States (128/902; 14.2%), China (73/902; 8.1%), and Egypt (66/902; 7.3%). More respondents were male (826/881; 93.8%) orthopaedic surgeons (637/902; 70.6%), aged 35 to 44 years old (344/895; 38.4%), and primarily practiced in academic and/or private institutions. Notably, 92.9% of all respondents currently live with a spouse, children, and/or the elderly, and 36.8% report a medical comorbidity (Table 1).

Figure 1.

Figure 1.

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Distribution of survey responses by geographic region; world map depicting number of survey responses received internationally. Color-filled countries indicate that at least 1 survey was received from that geographic region. Red, <50 surveys received; green, 51 to 100; yellow, 101 to 150; orange, 151 to 200; blue, >200; gray, no surveys received.

Table 1.

Survey Respondent Demographics.

Personal Demographics Practice Demographics
na Percentage   na Percentage
Age (years)   Specialty  
25-34 130 14.5 Orthopaedics 637 70.6
35-44 344 38.4 Neurosurgery 246 27.3
45-54 245 27.4 Trauma 104 11.5
55-64 150 16.8 Pediatric Surgery 17 1.9
65+ 26 2.9 Other 35 3.9
Sex   Fellowship trained  
Female 55 6.2 Yes 645 71.5
Male 826 93.8 No 257 28.5
Home demographics   Years since training completion  
Spouse at home 773 86.5 Less than 5 years 161 25.3
Children at home   5 to 10 years 141 22.2
0 250 28.2 10 to 15 years 104 16.4
1 221 24.9 15 to 20 years 117 18.4
2 266 30.0 Over 20 years 113 17.8
3 109 12.3 Practice type  
4+ 41 4.6 Academic/Private combined 204 22.9
Elderly at home 191 21.4 Academic 405 45.4
Living alone 63 7.1 Private 144 16.1
Estimated home city population   Public/Local hospital 139 15.6
 <100 000 46 5.2 Practice breakdown (%)  
 100 000-500 000 185 20.7 Percentage research  
 500 000-1 000 000 136 15.2 0-25 731 81.9
 1 000 000-2 000 000 144 16.1 26-50 129 14.5
 >2 000 000 382 42.8 51-75 21 2.4
Geographic region   76-100 12 1.3
 Africa 44 5.0 Percentage clinical  
 Asia 213 24.2 0-25 22 2.5
 Australia 8 0.9 26-50 87 9.7
 Europe 242 27.5 51-75 194 21.7
 Middle East 77 8.7 76-100 590 66.1
 North America 152 17.3 Percentage teaching  
 South America/Latin America 145 16.5 0-25 668 74.9
Medical comorbidities   26-50 152 17.0
 Cancer 4 0.4 51-75 50 5.6
 Cardiac disease 25 2.8 76-100 22 2.5
 Diabetes 45 5.0  
 Hypertension 156 17.3  
 No comorbidities 570 63.2  
 Obesity 103 11.4  
 Renal failure 5 0.6  
 Respiratory illness 35 3.9  
 Tobacco use 77 8.5  
Total respondents 902 100      
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a Number of respondents/votes.

Of the 57 who underwent viral testing, 9 (15.8%) reported testing positive for COVID-19. However, surgeons from some geographic locations were more likely to have been previously tested for COVID-19 (P < .001) and had differing opinions on whether local and/or international news outlets were providing accurate (P < .001) or excessive coverage (P = .001) on the pandemic. Variations arose regarding personal concern for region-specific entities, such as hospital capacity (P = .011), roles taken by government/leadership (P = .016), and economic consequence (P = .007; Table 2, Figure 2). Respondents reported significantly different institutional and government approaches as they related to management of COVID-19. Specifically, distinct variations were observed in quarantining (P < .001), hospital/government interventions (P < .001 to P = .024), PPE availability and type (P < .001 to P = .045), and medical staff employment (P < .001). Most surgeons had roughly similar perceptions about institutional responsiveness (P = .169 to P = .881; Tables 3 and 4; Figure 3).

Table 2.

COVID-19 Perceptions.

  Overall Africa Asia Australia Europe Middle East North America South America/Latin America P Valuea
nb/Mean Percentage/±SD nb/Mean Percentage/±SD nb/Mean Percentage/±SD nb/Mean Percentage/±SD nb/Mean Percentage/±SD nb/Mean Percentage/±SD nb/Mean Percentage/±SD nb/Mean Percentage/±SD
COVID-19 diagnosis
 Know someone diagnosed 392 46.6 12 27.9 64 33.0 2 25.0 146 63.5 29 41.4 71 48.0 65 48.2 <.001
 Personally diagnosed 9 1.1 0 0.0 2 1.0 0 0.0 2 0.9 0 0.0 2 1.3 3 2.2 .791
COVID-19 testing
 Know how to get tested 701 82.9 32 74.4 170 87.6 7 87.5 192 82.8 54 77.1 126 84.6 110 80.9 .259
 Personally tested 57 6.7 0 0.0 6 3.1 0 0.0 32 13.8 1 1.4 9 6.0 8 5.9 <.001
Reason for testing
 Direct contact with COVID-19 positive patient 49 35.5 4 57.1 9 25.0 21 44.7 3 37.5 5 41.7 6 22.2 6 4.1 .205
 Prophylactic 12 8.7 1 14.3 6 16.7 3 6.4 0 0.0 0 0.0 2 7.4 2 1.4 .369
 Demonstrated symptoms 68 49.3 2 28.6 16 44.4 20 42.6 4 50.0 7 58.3 19 70.4 19 13.1 .181
 Asked to be tested 9 6.5 0 0.0 5 13.9 3 6.4 1 12.5 0 0.0 0 0.0 8 5.5 .233
Mean worry about COVID-19 (1, not worried, to 5, very worried) 3.7 ±1.2 3.6 ±1.2 3.7 ±1.2 3.1 ±2.1 3.7 ±1.1 3.4 ±1.2 3.8 ±1.1 3.9 ±1.2 .167
Current stressors
 Personal health 358 42.5 19 44.2 97 50.5 6 75.0 84 36.4 32 45.7 55 36.9 59 43.4 .026
 Family health 640 76.0 29 67.4 146 76.0 5 62.5 183 79.2 56 80.0 110 73.8 102 75.0 .553
 Community health 370 43.9 22 51.2 95 49.5 4 50.0 97 42.0 38 54.3 50 33.6 56 41.2 .032
 Hospital capacity 352 41.8 17 39.5 71 37.0 6 75.0 117 50.6 22 31.4 61 40.9 53 39.0 .011
 Timeline to resume clinical practice 378 44.9 18 41.9 86 44.8 5 62.5 108 46.8 21 30.0 93 62.4 41 30.1 <.001
 Government/Leadership 154 18.3 6 14.0 50 26.0 2 25.0 33 14.3 6 8.6 29 19.5 27 19.9 .016
 Return to nonessential activities 116 13.8 6 14.0 19 9.9 3 37.5 35 15.2 7 10.0 33 22.1 12 8.8 .004
 Economic issues 385 45.7 17 39.5 68 35.4 4 50.0 105 45.5 34 48.6 77 51.7 77 56.6 .007
 Other 11 1.3 0 0.0 2 1.0 0 0.0 1 0.4 2 2.9 5 3.4 1 0.7 .203
Media perceptions
 Accurate coverage 407 48.5 17 39.5 98 51.0 5 62.5 115 49.8 23 32.9 90 60.8 53 39.3 <.001
 Excessive coverage 298 35.5 22 51.2 65 33.9 2 25.0 77 33.3 34 48.6 36 24.3 58 43.0 .001
 Not enough coverage 135 16.1 4 9.3 29 15.1 1 12.5 39 16.9 13 18.6 22 14.9 24 17.8 .861
Current media sources
 International news: internet 202 26.0 14 35.0 39 21.8 2 25.0 70 32.3 20 31.8 23 16.1 32 27.4 .013
 International news: television 72 9.3 7 17.5 12 6.7 0 0.0 14 6.5 17 27.0 7 4.9 12 10.3 <.001
 National/Local news: internet 224 28.8 7 17.5 53 29.6 4 50.0 62 28.6 9 14.3 61 42.7 26 22.2 <.001
 National/Local news: television 177 22.8 6 15.0 42 23.5 2 25.0 50 23.0 7 11.1 39 27.3 28 23.9 .232
 Newspaper 28 3.6 0 0.0 5 2.8 0 0.0 8 3.7 3 4.8 7 4.9 5 4.3 .787
 Social media 75 9.6 6 15.0 28 15.6 0 0.0 13 6.0 7 11.1 6 4.2 14 12.0 .004
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a Calculation of P values was performed using χ2, Fisher, and ANOVA tests. Bolded values indicate statistical significance at P <.05.

b Number of respondents/votes.

Figure 2.

Figure 2.

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COVID-19 Worldwide Impact Surgeon Infographic highlighting key finding surrounding surgeon perspectives of the media, institutional and governmental policy enactment, and occupational hazard risks from the AO Spine COVID-19 and Spine Surgeon Global Impact Survey.

Table 3.

Institutional/Government Impact.

  Overall Africa Asia Australia Europe Middle East North America South America/Latin America P Valuea
nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage
Quarantined 193 22.9 4 9.3 28 14.7 1 12.5 42 18.1 8 11.4 27 18.1 77 57.0 <.001
Institution
 Formal guidelines in place 452 60.4 25 56.8 122 57.3 7 87.5 118 48.8 36 46.8 90 59.2 50 34.5 <.001
 Adequate PPE provided 415 49.6 12 27.3 110 51.6 3 37.5 112 46.3 28 36.4 96 63.2 50 34.5 <.001
 N95 451 54.0 10 23.3 106 55.2 6 75.0 115 50.4 23 33.3 123 83.7 62 45.9 <.001
 Surgical mask 738 88.4 38 88.4 174 90.6 8 100.0 213 93.4 63 91.3 130 88.4 100 74.1 <.001
 Face shield 415 49.7 15 34.9 99 51.6 7 87.5 123 54.0 18 26.1 107 72.8 42 31.1 <.001
 Gown 491 58.8 25 58.1 102 53.1 8 100.0 142 62.3 44 63.8 113 76.9 53 39.3 <.001
 Full face respirator 95 11.4 2 4.7 24 12.5 1 12.5 27 11.8 3 4.4 28 19.1 10 7.4 .013
 Ventilators 343 41.0 3 6.8 84 39.4 3 37.5 114 47.1 14 18.2 80 52.6 41 28.3 <.001
 Other 55 6.6 2 4.7 12 6.3 1 12.5 14 6.1 8 11.6 8 5.4 8 5.9 .663
 None 33 4.0 3 7.0 6 3.1 0 0.0 5 2.2 1 1.5 4 2.7 14 10.4 .003
Hospital interventions
 Quarantine after international travel 507 60.9 21 48.8 131 68.2 8 100.0 125 54.6 30 43.5 104 72.2 82 60.7 <.001
 Limitations on domestic travel 483 58.0 23 53.5 120 62.5 8 100.0 126 55.0 28 40.6 104 72.2 68 50.4 <.001
 Nonessential employees work from home 558 67.0 21 48.8 98 51.0 6 75.0 175 76.4 42 60.9 124 86.1 84 62.2 <.001
 Cancellation of all educational/academic activities 689 82.7 30 69.8 153 79.7 8 100.0 208 90.8 55 79.7 121 84.0 101 74.8 <.001
 Cancellation of hospital meetings 674 80.9 29 67.4 138 71.9 8 100.0 200 87.3 53 76.8 130 90.3 105 77.8 <.001
 Cancellation of elective surgeries 714 85.7 33 76.7 131 68.2 8 100.0 217 94.8 62 89.9 140 97.2 113 83.7 <.001
 None of the above 17 2.0 1 2.3 5 2.6 0 0.0 0 0.0 4 5.8 1 0.7 6 4.4 .020
Medical staff furlough
 Yes 307 40.5 17 44.7 70 40.0 1 12.5 81 38.8 25 41.0 40 28.2 67 58.8 .020
 Potentially 165 21.8 10 26.3 22 12.6 4 50.0 51 24.4 10 16.4 44 31.0 23 20.2 .001
 No 286 37.8 11 29.0 83 47.4 3 37.5 77 36.8 26 42.6 58 40.9 24 21.1 <.001
Medical staff unemployment
 Yes 67 8.8 4 10.0 11 6.3 1 12.5 9 4.3 2 3.3 23 16.4 17 14.7 <.001
 Potentially 108 14.2 5 12.5 14 8.0 2 25.0 27 12.9 6 9.8 23 16.4 28 24.1 <.001
 No 586 77.0 31 77.5 151 85.8 5 62.5 173 82.8 53 86.9 94 67.1 71 61.2 <.001
Perception of hospital effectiveness
 Acceptable/Appropriate 477 61.4 14 35.0 125 69.8 5 62.5 129 59.5 30 48.4 105 73.4 63 53.9 <.001
 Excessive/Unnecessary 17 2.2 1 2.5 4 2.2 0 0.0 5 2.3 1 1.6 5 3.5 1 0.9 .881
 Disarray/Disorganized 68 8.8 1 2.5 11 6.2 0 0.0 26 12.0 6 9.7 10 7.0 14 12.0 .169
 Not enough action 215 27.7 24 60.0 39 21.8 3 37.5 57 26.3 25 40.3 23 16.1 39 33.3 <.001
Frequency of updates from hospital
 Multiple times per day 160 20.7 7 17.5 33 18.5 1 12.5 41 19.0 8 12.9 52 36.6 15 12.8 <.001
 Once a day 366 47.3 17 42.5 85 47.8 5 62.5 108 50.0 22 35.5 74 52.1 52 44.4 .330
 2-3 Times per week 106 13.7 5 12.5 30 16.9 1 12.5 33 15.3 4 6.5 18 12.7 14 12.0 0.523
 Once per week 44 5.7 1 2.5 15 8.4 1 12.5 11 5.1 3 4.8 3 2.1 9 7.7 .204
 Less than once per week 10 1.3 1 2.5 3 1.7 0 0.0 2 0.9 0 0.0 0 0.0 3 2.6 .474
 Not at all 142 18.4 12 30.0 29 16.3 0 0.0 37 17.1 27 43.6 4 2.8 30 25.6 <.001
Government
 Cancel elective surgery 646 77.2 27 62.8 122 63.9 8 100.0 201 87.4 58 84.1 124 83.8 95 70.4 <.001
 Shelter/Self-protection 570 68.1 21 48.8 123 64.4 7 87.5 169 73.5 42 60.9 119 80.4 80 59.3 <.001
 No gatherings > 50 people 365 43.6 25 58.1 88 46.1 6 75.0 74 32.2 34 49.3 76 51.4 58 43.0 .001
 No gatherings > 100 people 458 58.3 16 37.2 118 61.8 4 50.0 150 65.2 27 39.1 117 79.1 49 36.3 <.001
 No gatherings > household 371 44.3 13 30.2 70 36.7 6 75.0 151 65.7 22 31.9 61 41.2 46 34.1 <.001
 Closure of nonessential business 727 86.9 34 79.1 152 79.6 7 87.5 206 89.6 59 85.5 139 93.9 119 88.2 .003
 Closure of schools/universities 795 95.0 40 93.0 175 91.6 7 87.5 225 97.8 66 95.7 144 97.3 125 92.6 .045
 Closure of dine-in restaurants 711 85.0 33 76.7 129 67.5 8 100.0 215 93.5 58 84.1 142 96.0 113 83.7 <.001
 Closure of public transportation 239 28.6 12 27.9 96 50.3 2 25.0 36 15.7 24 34.8 34 23.0 29 21.5 <.001
 Restrict elderly to home 426 50.9 15 34.9 94 49.2 4 50.0 143 62.2 22 31.9 54 36.5 91 67.4 <.001
Perception of government effectiveness
 Acceptable/Appropriate 456 58.5 17 42.5 114 63.7 5 62.5 130 59.9 41 65.1 68 47.6 74 62.7 .017
 Excessive/Unnecessary 20 2.6 0 0.0 4 2.2 0 0.0 7 3.2 0 0.0 7 4.9 2 1.7 .346
 Disarray/Disorganized 88 11.3 2 5.0 13 7.3 1 12.5 24 11.1 5 7.9 28 19.6 13 11.0 .019
 Not enough action 215 27.6 21 52.5 48 26.8 2 25.0 56 25.8 17 27.0 40 28.0 29 24.6 .038
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a Calculation of P values was performed using χ2 and Fisher exact tests. Bolded values indicate statistical significance at P < .05.

b Number of respondents/votes.

Table 4.

Practice Impact.

Overall Africa Asia Australia Europe Middle East North America South America/Latin America P Valuea
nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage
Still performing elective surgery 149 18.5 12 27 84 39.4 0 0.0 24 9.9 9 11.7 6 4.0 14 9.7 <.001
Essential/Emergency spine surgery 700 87.3 35 80 159 74.7 7 87.5 199 82.2 56 72.7 137 90.1 98 67.6 <.001
Percentage cancelled surgical cases per week
 0-25 69 8.6 8 20 41 22.0 1 12.5 12 5.4 1 1.5 3 2.1 6 4.8 <.001
 26-50 123 15.3 6 15 20 10.8 0 0.0 15 6.7 12 18.2 2 1.4 12 9.7 <.001
 51-75 72 9.0 7 17 34 18.3 0 0.0 28 12.6 21 31.8 16 11.1 15 12.1 .002
 76-100 539 67.1 20 49 91 48.9 7 87.5 168 75.3 32 48.5 123 85.4 91 73.4 <.001
Impact on clinical time spent
 Increased 46 5.7 1 2 10 5.4 1 12.5 13 5.8 2 3.0 2 1.4 15 12.1 .008
 Decreased 675 84.0 38 93 152 82.2 6 75.0 180 80.7 61 91.0 138 95.2 92 74.2 <.001
 Stayed the same 83 10.3 2 5 23 12.4 1 12.5 30 13.5 4 6.0 5 3.5 17 13.7 .021
Perceived impact on resident/fellow training
 Not currently training residents/fellows 268 33.7 14 35 68 36.8 0 0.0 67 30.5 30 44.8 42 29.6 43 35.0 .096
 Hurts training experience 450 56.5 25 63 96 51.9 6 75.0 127 57.7 35 52.2 88 62.0 67 54.5 .439
 Improves training experience 30 3.8 1 3 8 4.3 0 0.0 9 4.1 1 1.5 2 1.4 8 6.5 .370
 No overall impact 48 6.0 0 0 13 7.0 2 25.0 17 7.7 1 1.5 10 7.0 5 4.1 .053
Medical duties outside specialty 183 22.8 9 21 34 16.0 1 12.5 70 28.9 3 3.9 34 22.4 34 22.4 <.001
Warning patients if the surgeon is COVID-19 positive
 Absolutely 595 74.2 27 68 140 75.7 8 100.0 160 72.4 43 63.2 114 78.6 94 75.8 .117
 Likely 106 13.2 4 10 23 12.4 0 0.0 35 15.8 11 16.2 16 11.0 16 12.9 .661
 Less likely 43 5.4 4 10 12 6.5 0 0.0 11 5.0 6 8.8 5 3.5 4 3.2 .370
 Not at all 58 7.2 5 13 10 5.4 0 0.0 15 6.8 8 11.8 10 6.9 10 8.1 .492
Research activities affected
 No research engagement 206 27.0 9 23 42 24.1 2 25.0 60 28.4 22 36.1 28 19.6 37 32.2 .147
 Complete stop 122 16.0 7 18 31 17.8 1 12.5 35 16.6 10 16.4 16 11.2 19 16.5 .793
 Decrease in productivity 247 32.4 15 38 64 36.8 3 37.5 61 28.9 16 26.2 56 39.2 31 27.0 .186
 No change 108 14.2 6 15 24 13.8 2 25.0 30 14.2 10 16.4 23 16.1 12 10.4 .833
 Increase in productivity 80 10.5 3 8 13 7.5 0 0.0 25 11.9 3 4.9 20 14.0 16 13.9 .197
Surgery impact
 Advise against 561 70.4 26 63 119 64.3 6 75.0 157 71.7 53 80.3 104 72.2 87 70.7 .253
 Proceed with standard precautions 138 17.3 8 20 46 24.9 1 12.5 26 11.9 15 22.7 13 9.0 28 22.8 <.001
 Absent during intubation/extubation 322 40.4 10 24 52 28.1 5 62.5 92 42.0 23 34.9 82 56.9 56 45.5 <.001
 Additional PPE during surgery 428 43.7 16 39 105 56.8 4 50.0 117 53.4 38 57.6 78 54.2 67 54.5 .583
Income impact
 Losing income 308 40.5 22 55 46 26.3 7 87.5 80 38.3 30 49.2 50 35.5 68 58.6 <.001
 No impact, salary 244 32.1 12 30 70 40.0 1 12.5 83 39.7 15 24.6 51 36.2 9 7.8 <.001
 No impact, compensation-based 7 0.9 0 0 0 0.0 0 0.0 3 1.4 2 3.3 1 0.7 1 0.9 .382
 Planned reduction, salary 138 18.1 6 15 48 27.4 0 0.0 32 15.3 9 14.8 12 8.5 28 24.1 <.001
 Planned reduction, compensation-based 64 8.4 0 0 11 6.3 0 0.0 11 5.3 5 8.2 27 19.2 10 8.6 <.001
Percentage personal income affected
 0-25 219 28.9 6 15 62 35.4 1 12.5 77 37.4 6 9.8 53 37.9 10 8.6 <0.001
 26-50 226 29.9 16 40 49 28.0 1 12.5 61 29.6 29 47.5 26 18.6 44 37.9 <.001
 51-75 142 18.8 10 25 34 19.4 3 37.5 36 17.5 12 19.7 25 17.9 20 17.2 .754
 76-100 170 22.5 8 20 30 17.1 3 37.5 32 15.5 14 23.0 36 25.7 42 36.2 <.001
Percentage hospital income affected
 0-25 169 22.3 8 20 42 24.1 2 25.0 64 30.6 7 11.7 26 18.7 15 12.9 .003
 26-50 199 26.3 13 33 47 27.0 2 25.0 62 29.7 19 31.7 24 17.3 31 26.7 .188
 51-75 207 27.3 11 28 53 30.5 2 25.0 48 23.0 19 31.7 41 29.5 33 28.5 .710
 76-100 182 24.0 8 20 32 18.4 2 25.0 35 16.8 15 25.0 48 34.5 37 31.9 .001
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a Calculation of P values was performed using χ2 and Fisher exact tests. Bolded values indicate statistical significance at P < .05.

b Number of respondents/votes.

Figure 3.

Figure 3.

Figure 3.

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A. Radar chart depictions of current COVID-19 government policies by geographic region: 10-sided (decagon) radar charts visually depicting cumulative percentage of responses verifying the enactment of a given COVID-19 government policy at the time of survey distribution. Queried policies are listed at the vertex of a given figure, whereby points falling on a vertex of the innermost decagon correspond to a cumulative total of 0% of survey responses received. Moving outward from one decagon to the next corresponds to a 25% increase in responses for a given category. B. Radar chart depictions of current COVID-19 hospital policies by geographic region: 7-sided (heptagon) radar charts visually depicting cumulative percentage of responses verifying the enactment of a given COVID-19 hospital policy at the time of survey distribution. Queried policies are listed at the vertex of a given figure, whereby points falling on a vertex of the innermost heptagon correspond to a cumulative total of 0% of survey responses received. Moving outward from one heptagon to the next corresponds to a 25% increase in responses for a given category.

COVID-19 had varying impact on clinical practice. Although most report cancellation of >75% of their surgical cases per week (539/803; 67.1%), differences in reported cancellation rate were seen across geographic regions (P < .001 to P = .021). Similar discrepancies are present with ongoing elective (P < .001) and emergency surgical cases (P < .001), with variation in precaution recommendations for procedures. Although there was no difference in the recommendation of additional PPE (P = .583) and/or cancellation of procedures (P = .253) between regions (Figure 4), opinions varied regarding the use of standard precautions and/or modifications during the intubation/extubation procedures (Table 4; Figure 5).

Figure 4.

Figure 4.

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Regional availability of personal protective equipment (PPE) bar chart detailing overall and regional availability of various types of PPE. X-axis: percentage of survey responses received; Y-axis: type of PPE equipment queried.

Figure 5.

Figure 5.

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A. Pie donut depictions of questions highlighting COVID-19’s impact on clinical practice graphical depictions of specific questions and distribution of responses by geographic region highlighting the impact of COVID-19 on a respondent’s surgical practice. Inner pie chart highlights the percentage of responses received for a given answer choice, whereas the outer “donut” reveals the respective geographic distribution. Regions constituting <2% of the overall pie chart area are omitted for clarity. B. Regional distribution of current COVID-19 surgical precautions bar chart detailing overall and regional practices of surgical precautions for COVID-19 positive surgical candidates. X-axis, percentage of survey responses received; Y-axis, type of surgical precaution queried.

Respondents had similar breakdowns for their allocation of time and stress-coping mechanisms. No significant differences were seen across geographic regions for spending time with family, personal wellness, resting, future planning, hobbies, or academic/clinical work. Greatest current stressors were family health (76%), followed by economic issues (45.7%), timeline to resume normal practice (44.9%), and community health (43.9%). Similarly, stress relief through reading, television, meditation, research, family, and telecommunication with friends was comparable between regions. Significant differences largely arose surrounding the cancellation of business and leisure activities (P < .001 to P = .026; Table 5).

Table 5.

Personal Impact and Future Perceptions.

Personal Impact
  Overall Africa Asia Australia Europe Middle East North America South America/Latin America P Valuea
nb/Mean Percentage /±SD nb/Mean Percentage /±SD nb/Mean Percentage /±SD nb/Mean Percentage /±SD nb/Mean Percentage /±SD nb/Mean Percentage /±SD nb/Mean Percentage /±SD nb/Mean Percentage /±SD
Percentage leisure activities cancelled
 0-25 177 21.1 14 32.6 49 25.5 1 12.5 53 22.9 16 22.9 12 8.2 30 22.2 <.001
 26-50 98 11.7 5 11.6 25 13.0 0 0.0 26 11.3 13 18.6 3 2.0 24 17.8 <.001
 51-75 64 7.6 5 11.6 18 9.4 0 0.0 9 3.9 6 8.6 10 6.8 16 11.9 .105
76-100 500 59.6 19 44.2 100 52.1 7 87.5 143 61.9 35 50.0 122 83.0 65 48.2 <.001
Percentage business/academic activities cancelled
 0-25 98 11.6 8 18.6 21 10.9 0 0.0 34 14.7 10 14.3 6 4.0 17 12.5 .026
 26-50 116 13.8 9 20.9 31 16.1 1 12.5 34 14.7 13 18.6 7 4.7 19 14.0 .023
 51-75 76 9.0 4 9.3 21 10.9 0 0.0 17 7.4 7 10.0 4 2.7 22 16.2 .006
 76-100 553 65.6 22 51.2 120 62.2 7 87.5 146 63.2 40 57.1 132 88.6 78 57.4 <.001
Sick leave for COVID-19 4 50.0 0 0.0 0 0.0 0 0.0 2 66.7 0 0.0 0 0.0 2 100.0 .149
Hospitalization for COVID-19 1 12.5 0 0.0 0 0.0 0 0.0 1 33.3 0 0.0 0 0.0 0 0.0 .592
Intensive care unit treatment 1 12.5 0 0.0 0 0.0 0 0.0 1 33.3 0 0.0 0 0.0 0 0.0 .852
Mean personal allocation of time (1, most time; 8, least time)
 Spending time with family 2.7 ±2.2 2.4 ±2.0 2.7 ±2.1 3.0 ±1.7 3.0 ±2.4 2.8 ±2.5 2.4 ±2.0 2.4 ±2.1 .161
 Personal wellness 3.8 ±1.9 3.1 ±1.6 3.6 ±1.9 4.0 ±1.4 4.3 ±1.9 3.0 ±1.8 3.9 ±1.9 3.5 ±1.8 .846
 Resting 4.3 ±2.0 3.4 ±1.8 4.3 ±2.0 4.5 ±1.9 4.4 ±2 3.7 ±2.0 4.6 ±1.9 4.1 ±2.0 .986
 Future planning 4.6 ±1.8 4.4 ±1.8 4.8 ±1.8 4.8 ±2.8 4.5 ±1.8 5.1 ±1.8 4.3 ±1.7 4.6 ±1.9 .726
 Hobbies 5.2 ±1.9 6.1 ±1.7 5.5 ±1.9 5.3 ±1.9 5.1 ±1.9 5.0 ±2.1 5.5 ±1.7 4.7 ±2.0 .628
 Academic projects/research 4.6 ±2.1 5.2 ±2.1 4.6 ±2.1 3.9 ±1.8 4.5 ±2.1 4.6 ±1.9 4.6 ±2.3 4.5 ±2.1 .860
 Community outreach 6.3 ±2.0 6.1 ±1.8 6.1 ±2.0 6.0 ±3.1 6.1 ±2.3 6.3 ±1.5 7.0 ±1.4 6.3 ±1.9 <.001
 Spine practice/Medical center work 4.1 ±2.5 5.1 ±2.5 4.1 ±2.6 3.9 ±2.9 3.5 ±2.5 5.3 ±2.3 3.4 ±2.2 5.0 ±2.4 .616
Current stress coping mechanisms
 Exercise 463 62.9 15 38.5 110 65.9 6 75.0 119 58.3 23 39.0 115 82.1 72 66.1 <.001
 Music 330 44.8 5 12.8 81 48.5 4 50.0 96 47.1 21 35.6 53 37.9 68 62.4 <.001
 Meditation/Mindfulness 118 16.0 4 10.3 33 19.8 0 0.0 23 11.3 14 23.7 23 16.4 20 18.4 .100
 Tobacco 29 3.9 2 5.1 7 4.2 0 0.0 15 7.4 4 6.8 0 0.0 0 0.0 .005
 Alcohol 89 12.1 0 0.0 16 9.6 2 25.0 25 12.3 3 5.1 23 16.4 19 17.4 .015
 Research projects 244 33.2 13 33.3 61 36.5 1 12.5 65 31.9 15 25.4 46 32.9 42 38.5 .480
 Family 578 78.5 33 84.6 127 76.1 6 75.0 151 74.0 49 83.1 114 81.4 90 82.6 .375
 Spiritual/Religious activities 116 15.8 11 28.2 27 16.2 0 0.0 15 7.4 20 33.9 20 14.3 19 17.4 <.001
 Reading 458 62.2 25 64.1 112 67.1 5 62.5 125 61.3 32 54.2 83 59.3 69 63.3 .681
 Television 394 53.5 21 53.9 84 50.3 2 25.0 93 45.6 41 69.5 75 53.6 70 64.2 .003
 Telecommunication with friends 322 43.8 14 35.9 71 42.5 5 62.5 80 39.2 25 42.4 67 47.86 57 52.3 .227
nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage nb Percentage  
Belief that future guidelines are needed
 Yes 710 94.7 38 97.4 160 93.6 8 100.0 190 92.7 58 95.1 139 97.9 107 94.7 .418
 No 8 1.1 0 0.0 4 2.3 0 0.0 2 1.0 0 0.0 0 0.0 2 1.8 .448
 Unsure 32 4.3 1 2.6 7 4.1 0 0.0 13 6.3 3 4.9 3 2.1 4 3.5 .583
Most effective method for hospital updates
 Internet webinar 379 48.8 18 40.9 96 45.1 4 50.0 95 39.3 29 37.7 55 36.2 77 53.1 .068
 Email 486 62.6 20 45.5 69 32.4 8 100.0 166 68.6 30 39.0 125 82.2 60 41.4 <.001
 Text message 223 28.7 19 43.2 81 38.0 5 62.5 37 15.3 21 27.3 20 13.2 37 25.5 <.001
 Flyers 49 6.3 7 15.9 17 8.0 1 12.5 8 3.3 7 9.1 1 0.7 8 5.5 <.001
 Automated phone calls 43 5.5 11 25.0 19 8.9 0 0.0 3 1.2 7 9.1 0 0.0 3 2.1 <.001
 Social media outlets 218 28.1 19 43.2 78 36.6 2 25.0 33 13.6 37 48.1 11 7.2 36 24.8 <.001
Perceived impact in 1 year
 No change 133 17.7 5 12.8 24 14.0 3 37.5 47 22.8 7 11.5 30 21.1 16 14.2 .068
 Heighted awareness of hygiene 435 57.9 26 66.7 114 66.7 5 62.5 93 45.2 43 70.5 85 59.9 60 53.1 <.001
 Increase use of PPE 344 45.8 25 64.1 90 52.6 3 37.5 94 45.6 31 50.8 41 28.9 56 49.6 <.001
 Ask patients to reschedule if sick 285 38.0 15 38.5 75 43.9 3 37.5 85 41.3 17 27.9 46 32.4 38 33.6 .180
 Increase nonoperative measures prior to surgery 150 20.0 7 18.0 49 28.7 1 12.5 41 19.9 15 24.6 13 9.2 22 19.5 .003
 Increase digital options for communication 314 41.8 14 35.9 55 32.2 4 50.0 93 45.2 22 36.1 87 61.3 38 33.6 <.001
How likely to attend a conference in 1 year
 Likely 496 66.3 26 66.7 91 53.5 5 62.5 151 73.3 41 67.2 101 71.6 74 66.1 .004
 Not likely 55 7.4 1 2.6 16 9.4 0 0.0 13 6.3 3 4.9 9 6.4 11 9.8 .526
 Unsure 197 26.3 12 30.8 63 37.1 3 37.5 42 20.4 17 27.9 31 22.0 27 24.1 .012
Timeframe to resume elective surgery
 <2 Weeks 31 3.9 0 0.0 14 7.5 1 12.5 6 2.7 2 3.0 0 0.0 8 6.5 .005
 2-4 Weeks 136 16.9 4 10.0 39 21.0 0 0.0 23 10.3 15 22.4 20 13.8 32 25.8 .001
 1-2 Months 127 15.8 3 7.5 22 11.8 1 12.5 29 13.0 3 4.5 51 35.2 15 12.1 <.001
 >2 Months 33 4.1 0 0.0 7 3.8 1 12.5 9 4.0 0 0.0 11 7.6 5 4.0 .109
 No current stoppage 85 10.6 7 17.5 45 24.2 0 0.0 9 4.0 3 4.5 3 2.1 17 13.7 <.001
 Unknown 392 48.8 26 65.0 59 31.7 5 62.5 147 65.9 44 65.7 60 41.4 47 37.9 <.001
Anticipated number of weeks to resume baseline activity
 <2 Weeks 96 12.7 5 12.8 35 20.2 0 0.0 18 8.6 5 8.3 20 14.0 11 9.5 .016
 2-4 Weeks 177 23.3 12 30.8 53 30.6 2 25.0 37 17.7 17 28.3 35 24.5 19 16.4 .028
 4-6 Weeks 177 23.3 9 23.1 38 22.0 2 25.0 48 23.0 19 31.7 26 18.2 33 28.5 .386
 6-8 Weeks 108 14.2 6 15.4 19 11.0 1 12.5 34 16.3 7 11.7 18 12.6 21 18.1 .630
 >8 Weeks 201 26.5 7 18.0 28 16.2 3 37.5 72 34.5 12 20.0 44 30.8 32 27.6 .002
Percentage telecommunication clinical visits per week
 0-25 398 50.0 24 58.5 112 60.5 3 37.5 113 50.7 35 53.0 31 21.7 75 60.5 <.001
 26-50 118 14.7 8 19.5 35 18.9 3 37.5 19 8.5 18 27.3 18 12.6 15 12.1 <.001
 51-75 77 9.6 4 9.8 14 7.6 0 0.0 22 9.9 5 7.6 19 13.3 13 10.5 .632
 76-100 208 26.0 5 12.2 24 13.0 2 25.0 69 30.9 8 12.1 75 52.5 21 16.9 <.001
Interest in online spine education
 Very interested 318 42.5 16 41.0 66 38.8 3 37.5 83 40.3 28 45.9 52 36.6 65 58.0 .022
 Interested 300 40.1 15 38.5 76 44.7 4 50.0 81 39.3 26 42.6 59 41.6 35 31.3 .439
 Somewhat interested 131 17.5 8 20.5 35 20.6 1 12.5 45 21.8 6 9.8 27 19.0 7 6.3 .010
 Not interested 23 3.1 1 2.6 3 1.8 0 0.0 6 2.9 1 1.6 7 4.9 5 4.5 .675
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a Calculation of P values was performed using ANOVA, χ2, and Fisher exact tests. Bolded values indicate statistical significance at P < .05.

b Number of respondents/votes.

Although most practitioners envision changes to their clinical practice as a result of COVID-19 (618/751; 82.3%), they similarly recognized the need for future standardized guidelines (710/750; 94.7%) across geographic regions (P = .068 and P = .418, respectively). Respondents expressed further dissimilarities regarding the current use of telecommunication clinical visits (P < .001).

Discussion

To our knowledge, our study is the first to assess the multidimensional impact of COVID-19 on surgeons worldwide. With >900 respondents worldwide, we noted variations between regions for COVID-19 testing, government/leadership perceptions, impact of media/news outlets, hospital capacity for COVID-19, and economic consequences. We identified that 16% of all spine surgeons who underwent viral testing globally tested positive for COVID-19, and up to 13% would be less likely and not at all compelled to disclose their positive testing to their patients. The study also noted an overwhelming need for guidelines to manage patients under a pandemic. It noted that key PPEs, such as masks, face shields, gowns, and so on, were not readily available to clinicians.

COVID-19 Surveys

Few surveys have also examined specific COVID-19 domains in health care providers. Khan et al9 evaluated 302 health care workers in Pakistan on their basic knowledge of COVID-19 and found that front-line workers were not prepared for the pandemic. Lai et al10 identified high levels of psychological burden in 1257 health care workers in 34 hospitals throughout China caring for COVID-19 patients. Huang et al11 surveyed 230 medical staff in a tertiary infectious disease hospital for COVID-19 in China and discovered a high incidence of anxiety and stress among staff. Because these surveys target individuals in specific regions and domains of COVID-19 knowledge and opinions, our survey gathered responses from a “global” audience of health care providers across various domains. We also outlined regional breakdowns and demographic variables. Our goal was not to investigate the specific factors involved with the regional differences, but rather shed light on how the different regions perceived and reacted to this global crisis.

Resources and Testing

The COVID-19 outbreak demands increasing focus on resource allocation and the roles in which physicians function. In our study, 23% of the surgeons reported working outside their normal scope of practice, illustrating the unique challenges facing physicians not often at the forefront of the COVID-19 conversation, with varying levels of concern in the mounting pressure. Limitations in testing have been cited as a major shortcoming.12,13 However, 83% of our respondents stated that they have access to testing. Contact with symptomatic patients was described as the most common reason to seek testing, yet we found that only 7% of our physicians have undergone formal COVID-19 testing; 47% stated that they know someone who has been diagnosed, and only 16% of respondents tested positive. This infection rate was based on respondents who had actually undergone formal viral testing. Substantiated data on the infection rate in health care workers has not been well established because this population describes inconsistent access to testing, if not being actively discouraged to do so. Additionally, infections are being inconsistently tracked and, in some cases, uncounted at the hospital/medical center level. Based on various global news outlets, health care workers have accounted for anywhere between 14% and 30% of total positive COVID-19 tests in various regions.14,15 More widespread active COVID-19 viral (and eventual antibody) testing is a crucial focus of multiple global entities at this time because these results will help plan for return to work protocols. Overall, spine surgeons exhibited elevated anxiety and uncertainty for the future. The lower rates of testing and diagnosis among our cohort, compared with the general population, suggest surgeons’ knowledge of disease transmission and/or possible greater adherence to public health measures aimed at limiting exposure.

Surgeon Well-being

Our survey captures surgeons’ health status and age highlighting potential personal factors affecting this cohort’s susceptibility to COVID-19. We found that more than 80% of our respondents are <55 years old, with hypertension and obesity as the 2 most common comorbidities, and anxiety levels were moderately high. Although these respondents are younger and with less severe comorbidities than higher-risk populations, concerns for well-being are clearly evident. Concerns for personal well-being and family health as well as professional concerns raise awareness of the unknown psychological stressors faced by surgeons and front-line workers.

Recently, Lai et al10 assessed the mental health outcomes among Chinese health care workers exposed to COVID-19, revealing that 50% experienced depression, 34% insomnia, and 72% psychological distress. The perception of personal and community danger, present among frontline workers, is evident among surgeons worldwide. Additionally, 60% of surgeons cancelled or postponed leisure travel because of the outbreak, leading to an inability to obtain much needed respite during this stressful time. Respondents also cited predominantly spending time with family, exercise, and reading as the most common coping mechanisms, with meditation and spiritual/religious activities. The expanding impact of the outbreak will continue to challenge the importance of healthy coping mechanisms during critical times. Finally, surgeons’ evolving role in combating this outbreak adds an additional layer of strain, emphasizing the importance of mental health in reducing physician burnout.

Patient Care

International and governmental recommendations have curbed nonemergent surgery in order to optimize delivering care to COVID-19 patients.16,17 This has a significant impact on surgeons’ ability to meet their patients’ needs. We found that 81% of surgeons are no longer performing elective surgery, yet the majority (87%) are performing emergency/essential surgery. Thus, surgeons, although greatly affected, are adhering to national and international recommendations to limit nonessential surgery while addressing critical surgical issues. The current pause on elective surgery has brought much consideration of time frames upon which surgeons can safely resume elective surgeries. Our findings indicate that the majority of respondents (49%) have yet to receive a time frame for resuming elective cases. Returning to normal is a crucial issue because economic concerns were the second greatest stressor, and more than 67% of respondents reported decreased income during the pandemic.

One significant challenge facing surgeons is COVID-19 patients requiring surgery and how to manage this population. Such challenging issues complicate the care of these patients. When asked about performing surgery on COVID-19 patients, 70% of respondents recommended against surgery at this time. However, in the setting of urgent and emergency surgery, the decision to perform surgery has life or death implications even without the COVID-19 threat. Additionally, surgeons must consider resource allocation in light of ventilator shortages when deciding to proceed with surgery. Although operating room ventilators are not equivalent to intensive care unit ventilators, in the setting of severe shortages, physician leaders must account for all possible resources and implement uses of best practice to serve the greater good. Interestingly, 59% of surgeons felt that their hospitals did not have enough ventilators, which illustrates the difficult decision of ventilator allocation and best practice. Surgeons are in a unique position as the demands of COVID-19 patients require thoughtful consideration of the risks and benefits of these complexities.

Beyond recommendations against surgery, 44% of surgeons stated donning additional PPE during the surgery of COVID-19 patients. The allocation and utilization of PPE has become a controversial issue among leadership because shortages take on a seemingly linear relationship to rates of disease.18,19 Half of the surgeons felt that their hospitals provide adequate PPE for frontline workers, whereas the remainder stated inadequate PPE resources. Regional analysis revealed that only 27% of surgeons in Africa felt that they have adequate PPE, followed by Latin America (35%), the Middle East (36%), and Australia (38%). Of the forms of PPE provided, the following were the most common: surgical masks (88%), gowns (59%), N-95 masks (54%), and face shields (50%). Regional analysis demonstrated that North America (84%) and Australia (75%) have the greatest access to N95 masks, whereas the Middle East (33%) and Africa (23%) have the least access. Guidelines have standardized infectious disease prevention, and surgeons appear to be adherent.20 Although hospitals and governments look to optimize use and manufacturing of PPE, there clearly remain concerns across the world.6,21

Government, Media, and Future Guidelines

We found that 68% of our respondents have mandates from regional governments for citizens to self-isolate at home. Opinions of individual government responses to COVID-19 have varied. Our cohort’s perception of how their governments have been handling the pandemic was mixed, although 59% stated that the response has been acceptable and appropriate; 28% felt that their government had taken some action (but not enough), 11% found their government’s reaction to be disorganized, and the remaining 3% thought the actions were excessive and unnecessary. Perceptions of governments’ responses reveal that only 18% of respondents attributed government/leadership as a major stressor during this time point of the outbreak. The effectiveness of governmental policies may require eventual post hoc commissions. One component that continues to influence current perception of policies is media coverage, which only 48% felt has been accurate; 36% felt that coverage has been excessive and overblown. Although subjective, this information offers insight into how citizens and news outlets are responding and portraying current policies. Our data imply that the majority feel that their governments are taking appropriate action.

Minimizing mortality remains the highest priority, even at the cost of societal dynamics and economic consequences. Based on our survey, only 60% of respondents noted that guidelines exist to manage such outbreaks in their hospitals/medical centers; however, 95% declared that formal guidelines are needed to address crises for their profession. This desire for widespread guidelines for outbreaks is widely shared across the globe and has been a focus for organizations in all regions.2,22-24 Finally, the use of online technology will be paramount from an academic and patient care standpoint. International collaboration with research and development of these platforms will be critical to adapt to widespread public health changes.

Limitations

As with many survey-based studies, there are limitations to this study. The survey distribution was limited to the current AO Spine surgeon members’ network. The survey was sent out to 3805 spine surgeons worldwide; however, only 902 surgeons responded (23.7%). Perhaps a higher response rate would have been achieved with longer survey duration. Although the response rate may appear low, perhaps we have captured respondents who take special interest in this topic. As such, there may be questionable generalizability in regions in which there were few or no respondents. Potential selection bias may represent a unique makeup of those opting to receive the survey as opposed to those who did not. Previous studies have described that a low response rate does not necessarily mean that the study results have low validity, but rather a greater risk of this.25,26 So response rates can be informative but independently should not be considered a good proxy for study validity. Another limitation was response completion. The 73-item survey may have created some fatigue; thus, not all parameters were addressed by all respondents. Given the length limit of surveys in general, we were not able to capture all the possible domains related to COVID-19. However, given the variety of regional responses and COVID-19 outbreak severity, we sought to capture the majority of global regions. Despite these limitations, this remains the largest international survey to assess multiple domains of impact the COVID-19 pandemic has had among health care professions, in this case surgeons. This global sample size forms a snapshot of the current situation and provides us with foundational information that can be revisited with future studies to assess longitudinal effects.

Conclusion

This is the first international survey to assess COVID-19 impact among surgeons. Up to 16% of all surgeons who tested for COVID-19 were found to be positive. Specific geographical variations as well as similarities between surgeons were also noted. We plan to further explore these preliminary findings through more analytical approaches to understand some of the subdomains represented in this survey. Additionally, we plan to distribute a follow-up survey at 6 and 12 months to assess the longer-term impact and perform predictive modeling. In closing, findings from our study have noted that COVID-19 has had a substantial impact on surgeons. Therefore, specific attention to the needs and challenges of such a population is needed in the age of the current crisis and in any future public health crises.

Footnotes

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Philip K. Louie, MD Inline graphic https://orcid.org/0000-0002-4787-1538

Michael H. McCarthy, MD, MPH Inline graphic https://orcid.org/0000-0003-2766-6366

Jason P. Y. Cheung, MBBS, MS, MD Inline graphic https://orcid.org/0000-0002-7052-0875

Daniel M. Sciubba, MD Inline graphic https://orcid.org/0000-0001-7604-434X

Dino Samartzis, DSc Inline graphic https://orcid.org/0000-0002-7473-1311

References

Articles from Global Spine Journal are provided here courtesy of SAGE Publications

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