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. 2020 Oct 22;15(10):e0238842. doi: 10.1371/journal.pone.0238842

Physician preparedness for resource allocation decisions under pandemic conditions: A cross-sectional survey of Canadian physicians, April 2020

Brian Dewar 1, Joanna E Anderson 2, Edmund S H Kwok 3, Tim Ramsay 1, Dar Dowlatshahi 1,4, Robert Fahed 1,4, Claire Dyason 4, Michel Shamy 1,4,*
Editor: Ritesh G Menezes5
PMCID: PMC7580904  PMID: 33091015

Abstract

Background

Under the pandemic conditions created by the novel coronavirus of 2019 (COVID-19), physicians have faced difficult choices allocating scarce resources, including but not limited to critical care beds and ventilators. Past experiences with severe acute respiratory syndrome (SARS) and current reports suggest that making these decisions carries a heavy emotional toll for physicians around the world. We sought to explore Canadian physicians’ preparedness and attitudes regarding resource allocation decisions.

Methods

From April 3 to April 13, 2020, we conducted an 8-question online survey of physicians practicing in the region of Ottawa, Ontario, Canada, organized around 4 themes: physician preparedness for resource rationing, physician preparedness to offer palliative care, attitudes towards resource allocation policy, and approaches to resource allocation decision-making.

Results

We collected 219 responses, of which 165 were used for analysis. The majority (78%) of respondents felt "somewhat" or "a little prepared" to make resource allocation decisions, and 13% felt “not at all prepared.” A majority of respondents (63%) expected the provision of palliative care to be “very” or “somewhat difficult.” Most respondents (83%) either strongly or somewhat agreed that there should be policy to guide resource allocation. Physicians overwhelmingly agreed on certain factors that would be important in resource allocation, including whether patients were likely to survive, and whether they had dementia and other significant comorbidities. Respondents generally did not feel confident that they would have the social support they needed at the time of making resource allocation decisions.

Interpretation

This rapidly implemented survey suggests that a sample of Canadian physicians feel underprepared to make resource allocation decisions, and desire both more emotional support and clear, transparent, evidence-based policy.

Introduction

Under the pandemic conditions created by COVID-19, physicians around the world have faced difficult choices around the allocation of scarce resources, including but not limited to critical care beds and ventilators [1, 2]. Making these decisions has left Italian physicians “weeping in hospital hallways,” [3] and emerging reports suggest that American physicians have been similarly affected [4] by the emotional toll of the "toughest triage" [5]. One such resource specific to this region, predicted a worst-case scenario of more than 13,000 Ontario patients left to die due to insufficient resources [6] and another predicted the possibility of an insufficiency of intensive care unit (ICU) beds [7]. While many ethical frameworks exist for allocating resources in pandemics [8–11], we have few empirically-based insights into physicians’ attitudes and beliefs surrounding resource allocation decisions in the era of COVID-19 [12].

In early April 2020, we launched a survey of physicians practicing in the region of Ottawa, Ontario, Canada. Ottawa is the national capital, a cosmopolitan and bilingual city of approximately 1 million. We sought to capture physician preparedness to make resource allocation decisions, their anticipated approach to these decisions, their awareness of existing guidelines, their comfort with the provision of palliative care under pandemic circumstances, and their desire for services to support their decision-making. We hypothesized that our respondents would not feel prepared to make these decisions, would be unaware of any specific guidelines, and would use commonly cited factors such as age and comorbidities to make resource allocation decisions.

We timed our survey to predate the expected surge of COVID-related hospitalizations in our region. At the time the survey was launched, there were approximately a dozen patients with COVID-19 admitted to The Ottawa Hospital, the academic tertiary care centre in our region. We kept the survey open only for only 10 days so as to capture a specific moment in time when resource allocation was a foremost concern. As a reflection of how quickly the field was moving, the province of Ontario issued a guideline on triaging access to critical care beds during the time we were designing the survey [13]. Under hypothetical “surge” conditions that were ultimately never met, patients would be excluded from critical care according to disease-specific mortality thresholds that become increasingly more stringent as resources become more limited.

Methods

Data for this study were collected via an online survey (S1 Appendix) administered via the Qualtrics XM survey platform (Denver, Colorado) [14] between April 3 and 13, 2020. Approval from the Ottawa Health Sciences Network Research Ethics Board (application 20200208-01H (2118)) was sought and obtained. Prior to fielding, the survey was piloted on a convenience sample to determine its length and resolve areas of ambiguity. Survey respondents did not receive any incentive and participation was voluntary. The survey included eight questions on four main themes: physician preparedness for resource rationing, physician preparedness for palliative care, attitudes towards resource allocation policy, and approaches to resource allocation decision-making.

Responses were entirely anonymous and no identifying information such as IP addresses or emails was collected. The risk of repeat participation was minimized in two ways: First, using an option within the survey platform that prevents duplicate participants with a browser cookie; and second, by removing responses that were less than 40% complete.

The population of interest included staff physicians in the Ottawa region, with a sample frame defined by membership in a Facebook group for local physicians and/or mailing lists belonging to the following groups: the Departments of Medicine, Anesthesia, Critical Care and Emergency Medicine at The University of Ottawa / Ottawa Hospital; the Divisions of Neurology and Palliative Care; the Regional Ethics program; and the Ottawa Hospital Research Institute. This group was selected to capture a broad cross-section of physicians within a defined geographic area.

Analysis was primarily descriptive, but appropriate inferential statistics were performed where comparisons between groups or responses were indicated. Pairwise between-group comparisons were corrected using Tukey’s honest significant difference test. For more information about survey procedures, please see S1 Checklist, the completed Checklist for Reporting Results of Internet E-Surveys (CHERRIES) checklist [15]. Responses regarding the content of guidelines were thematically analyzed by two independent reviewers.

Results

The initial sample included 219 partial and complete responses. Of these, 54 were less than 40% complete and were removed prior to analysis to minimize data duplication. This left a final sample of 165 for analysis (Table 1). The majority of responses (70.3%) came from departmental mailing lists, 29.1% came from the Facebook group and 0.6% from a link for participants referred to the survey by previous respondents.

Table 1. Demographic characteristics of sample.

Count Percentage
Age
 Under 35 29 19%
 35–44 48 31%
 45–54 45 29%
 55–64 26 17%
 65+ 7 5%
 Unspecified 10
Gender
 Male 82 53%
 Female 71 46%
 Non-binary* 1 1%
Speciality
 Critical Care / Anesthesia 21 14%
 Emergency Medicine 27 18%
 Family Medicine 20 13%
 Laboratory Medicine* 0 0.0%
 Medicine 64 43%
 Obstetrics/Gynecology* 2 1%
 Pediatrics* 1 1%
 Psychiatry* 1 1%
 Surgery 13 9%
 Unspecified 16
Total 165 100%
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Note. Groups with under 10 respondents (indicated with asterisks above) were excluded from demographic analyses to protect their anonymity.

Physician preparedness for resource rationing

Respondents were asked, “Imagine that you have two patients who require a ventilator but only one ventilator is available. How prepared do you feel to determine who will receive the ventilator?” (Fig 1). The majority of respondents endorsed being “somewhat” or “a little prepared” (78%). However, more than one in ten (13%) described themselves as “not at all prepared.” When analyzed by specialty groups with at least 10 respondents (Fig 2), critical care/anaesthesia physicians described themselves as being significantly more prepared to make decisions on ventilator allocation than all other specialities (all ps ≤ .05). Family medicine practitioners described themselves as less prepared than all other specialties with the exception of surgery (vs. surgery: p = .94; vs. others: all ps < .05). No other statistically significant correlations were found with regards to specialty.

Fig 1. Physician preparedness.

Fig 1

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Self-reported physician preparedness to make resource allocation decisions, measured on a 4-point scale from 1 (not at all prepared) to 4 (very prepared).

Fig 2. Physician preparedness by specialty.

Fig 2

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Self-reported physician preparedness to make resource allocation decisions by specialty, measured on a 4-point scale from 1 (not at all prepared) to 4 (very prepared). Note. Responses were measured on a 4-point Likert-type scale ranging from 1, not at all prepared, to 4, very prepared.

Respondents were asked to express in one word how they would feel when making a decision about allocating a ventilator (Fig 2). Responses were coded into 11 categories, with the most common categories being "anxious" (29%), "sad" (19%), and "awful" (12%). Less common responses included "calm" (9%), "resolved" (9%), and “confident” (6%). A parallel question asked participants to imagine their feelings after having made such a decision. Respondents predominantly mentioned feelings of sadness (24%) and guilt (19%), followed by acceptance (12%).

Physician preparedness for palliative care

Respondents were asked how they expected to feel about providing palliative care to a patient who had been denied life-saving treatment because of resource allocation (Fig 3). A substantial majority (63%) expected this situation to be “very” or “somewhat difficult.” Most respondents (55%) described being "somewhat" or "very comfortable" with having goals of care conversations, though respondents were substantially less comfortable with having a goals of care conversation with the patient’s family via telephone or videolink, with 22% of respondent describing themselves as “not at all comfortable” doing this.

Fig 3. Expected emotional difficulty of providing palliative care.

Fig 3

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Expected emotional difficulty of providing palliative care to patients under pandemic conditions, measured on a 4-point scale from not at all difficult to very difficult.

Physicians and resource allocation policy

A slight majority (53%) of respondents were aware of any existing policy about resource allocation in pandemics; of those, 61% were aware of the provincial triage policy that had been released the week the survey was launched. Most respondents (83%) either strongly or somewhat agreed that there should be policy to determine who should receive critical care resources in the event of scarcity. Virtually all participants (96%) stated that they would follow such a policy if it aligned with their own values. However, in the hypothetical case that a policy did not align with their own values, the percentage of respondents who stated that they would follow the policy in all circumstances decreased from 32% to 9%, though the majority (65%) would still follow the policy in "all" or "most circumstances" (Fig 4).

Fig 4. Physician willingness to follow resource allocation policy.

Fig 4

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Physician willingness to follow an institutional policy on resource allocation, measured on a 4-point scale from in all circumstances to never, differentiated by whether the respondent mostly agrees with the policy or mostly does not agree with the policy.

Policy recommendations

When asked to define what would be most important to include in a policy on resource allocation, explicitness on how to follow it (20%) and transparency in how the policy was designed (18%) emerged as the most common themes. Other frequent responses included some statement on what would be expected of physicians when enacting these policies (9%), the importance of including an evidence-base in the policy (8%), and the importance of addressing issues of legal culpability (3%) (Table 2). Some respondents (20%) wanted to remove decision-making responsibility (and thereby guilt and emotional responsibility) from individual physicians, while other respondents (9%) preferred a more flexible policy that would allow physicians the leeway to make choices in line with their individual values.

Table 2. What is the most important aspect of a policy on resource allocation?

Count Percentage
Age
 Explicitness 24 20%
 Transparency 21 18%
 Statement on Expectations of Physicians 11 9%
 Ethics Support 11 9%
 Evidence-Based 10 8%
 Flexibility 9 8%
 Preemptoriness 6 5%
 Inclusiveness 5 4%
 Consideration of Legal Issues 4 3%
 Other 17 16%
Total 118 100%
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Physician decision-making during resource scarcity

To assess which factors would most strongly influence resource allocation decisions, we asked respondents to make a series of choices about which of two patients should receive a ventilator using a 5-point Likert-type scale with the points Definitely Patient A, Probably Patient A, Unsure, Probably Patient B, and Definitely Patient B. Each choice differentiated the two patients on just one or two factors (e.g., age, comorbidities), and stated that all else should be considered equal between them.

This choice paradigm was intended to reveal the importance of different patient characteristics for the average respondent. However, we also directly asked respondents to rate the importance of key factors. Thus, these two questions provide us with both revealed and stated importance ratings.

Fig 5 below shows the average likelihood of choosing the patient on the right for each of the choices. Note that 3 was the midpoint (“unsure”) of the scale. In all cases, physicians were significantly more likely, on average, to choose the patient characteristics described on the right (all ts > |3.3|, ps < .001), with one exception: gender (t[163] = 1.9, p = .06).

Fig 5. Physician preference in allocation decisions.

Fig 5

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Under hypothetical conditions where there is 1 ventilator for 2 potential patients, physicians were asked to report their preference in allocating this ventilator, all else being equal. Responses were scored on a 5 point scale where 1 was definitely patient A and 5 was definitely patient B. Notes. The patient descriptions and means have been reverse-coded in some cases for clearer presentation. The response options were: 1 = definitely Patient A, 2 = probably Patient A, 3 = unsure, 4 = probably Patient B, 5 = definitely Patient B.

However, as the figure makes clear, physicians prioritized survival, cognitive status, comorbidity severity and age when making resource allocation decisions. The mean score for likelihood of survival is close to the maximum value of “definitely Patient B [who has a higher survival chance]”, while the age-related item (age 72 versus 40), at 4.0, averages exactly on the scale point of “probably Patient B [the younger patient].”

In an attempt to provide a closer behavioural test of how physicians prioritize between some of the key factors such as age and comorbidities, pairings combining these factors (Fig 6) were included. In these cases, respondents tended to prioritize both survival and presence of comorbidities over age.

Fig 6. Physician prioritization of important factors.

Fig 6

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Decisions under hypothetical conditions where there is 1 ventilator for 2 potential patients, physicians were asked to report their preference in allocating this ventilator. Responses regarding the impact of age, function and likelihood of survival were cross-compared. Notes. The patient descriptions and means have been reverse-coded in some cases for clearer presentation. The response options were: 1 = definitely Patient A, 2 = probably Patient A, 3 = unsure, 4 = probably Patient B, 5 = definitely Patient B.

Finally, participants directly rated the importance of various patient characteristics (Fig 7). Respondents’ stated order of importance reflected their approach to the patient comparisons in that likelihood of survival, comorbidities and dementia were the strongest determinants.

Fig 7. Physician ranking of factors.

Fig 7

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Physicians ranked the factors that they felt would be most impactful on their decision-making regarding allocating ventilators, scored on a 5 point scale where 1 was not at all important and 5 was extremely important. Note. The response options were: 1 = not at all important, 2 = slightly important, 3 = moderately important, 4 = very important, 5 = extremely important.

Social support and moral injury

Respondents to this survey were asked if they felt confident that they could access necessary mental health resources at the time of making a resource allocation decision. Among respondents, 38% felt not at all confident, while only 13% felt very confident that they would be able to access these resources. However, a majority (64%) felt either "somewhat confident" or "very confident" that they would be able to access mental health resources after making an allocation decision. Physicians reported being most likely to turn to other physicians (44%), followed by family members (28%), professional counsellors (16%), religious advisors (7%) and no one (4%). The most common volunteered responses were turning to hospital ethics support and non-medical friends, both with 4 responses (3%).

Discussion

This rapidly implemented survey provides insights into physician preparedness to make resource allocation decisions utilizing a series of hypothetical conditions related to COVID-19. the effects of resource insufficiency on physician decision-making, and for healthcare policymaking in pandemics. While this topic has engendered significant debate in the medical literature and popular press in recent weeks, little empirical data has been available to provide context for this debate. Our results provide some insights, albeit from a single Canadian region, and acquired in a context of anticipation for the COVID surge. We present three major takeaways from this survey:

  1. A majority of surveyed physicians reported feeling under-prepared, described themselves as anxious or sad when imagining themselves making tough decisions around allocating resources, and anticipated guilt afterwards. Participants were generally not confident in their ability to access mental health support at the time of making these decisions, though a majority believed they would be able to access support afterwards. Our survey suggests that Canadian physicians are likely to experience similar mental health challenges to colleagues in New York, Italy and China [16] due to COVID-19. Clear guidelines on resource allocation, acknowledgement of the emotional toll of making these decisions, and robust support systems are needed may help alleviate these pressures for physicians worldwide. We suggest that local and national physician organizations should play an important role in supporting physician mental health during this difficult time [17].

  2. Respondents demonstrated a strong appetite for transparently-developed, evidence-based, and clear-to-follow guidelines to inform resource allocation decisions. Based on our results, we would encourage institutions to seek to develop documents with a solid, evolving evidence-base, that considers implementation, addresses legal issues, and provides guidance on how to communicate with patients and families.

  3. A consistent set of factors emerged as being important to most physicians’ decision-making around resource allocation: survival likelihood, cognitive function, comorbidities and daily function. However, significant disagreement existed around other factors including age and citizenship, and our ability to draw conclusions about these factors is limited. In the absence of agreement and standard practices, physicians are at risk of being influenced by unconscious biases in the way resources are rationed [18]. This tendency may be exacerbated when information about the patient or the clinical scenario is limited.

The largest limitation of this work was the fact that participants self-selected into the study rather than being recruited via probability-based sampling. The survey was distributed through several email lists as well as through two Ottawa physician Facebook groups, whose memberships overlap. As such, we are also unable to report an exact response rate, though we estimate that 10–15% of physicians employed by The Ottawa Hospital may have responded within the brief administration period. The goal of the survey was not to provide a perfectly representative picture of staff physicians in Ottawa, but to obtain input that will be useful for the creation of policy and practice. In addition, the sample was regionally limited; however, the Ottawa area is multicultural and has a strong medical academic program. As such, we posit that our results are reasonably generalizable to other regions. Finally, because of the fast-moving nature of the COVID-19 pandemic, policies on resource allocation were being written and released while this survey was recruiting participants, and this may have affected respondent knowledge of extant policies.

Future directions of research raised by this work include systematically reviewing existing frameworks for resource allocation decisions under pandemic conditions, developing methods to raise awareness of existing policies so that physicians are as well-informed as possible, and examining interventions to provide support to physicians at the time of decision-making.

Supporting information

S1 Appendix. Preparing for resource rationing under pandemic conditions.

(DOCX)

Click here for additional data file. (36.9KB, docx)
S1 Checklist. Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

(XLSX)

Click here for additional data file. (15.5KB, xlsx)

Acknowledgments

We would like to thank the participants of this study for their time and expertise during this difficult period. We would also like to thank the following individuals for supporting the distribution of our survey: Dr Phil Wells, Dr Greg Bryson, Dr Scott Millington, Dr Mike Kekewich. Most importantly, we acknowledge the dedication and selflessness of all health care workers facing the challenge of COVID-19 across Canada and around the world.

Data Availability

As our data include responses that are potentially identifiable due to low numbers in some categories, we have chosen to limit access by making our data available upon request. The data underlying the results presented in the study are available from Zenodo: Shamy, Michel; Dewar, Brian. (2020). Dataset for Physician Preparedness for Resource Allocation Decisions Under Pandemic Conditions: A Cross-Sectional Survey of Canadian Physicians, April 2020 (Version 1) [Data set]. Zenodo. http://doi.org/10.5281/zenodo.4008146.

Funding Statement

The project was funded by University of Ottawa Department of Medicine Special Pandemic Agile Research Competition (SPARC) Grant. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

References

Decision Letter 0

Ritesh G Menezes

Transfer Alert

This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present.

15 Jul 2020

PONE-D-20-15128

Physician Preparedness for Resource Allocation Decisions Under Pandemic Conditions: A Cross-Sectional Survey of Ottawa-Area Physicians, April 2020

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Reviewer #1: This is a valuable study of the preparedness of physicians with regard to the COVID-19 pandemic. The study employs a mixture of qualitative and quantitative methods to provide a holistic assessment of physicians' subjective perceptions of preparedness at the time immediately preceding the onset of a surge in COVID-19 cases in Canada.

Nonetheless, there are a number of methodological difficulties that should be clarified prior to the publication of this study.

First, the authors have asked research participants the following survey question:

"Imagine that you have two patients who require a ventilator but

only one ventilator is available. How prepared do you feel to determine who will receive the

ventilator"

and further

"how they expected to feel about providing palliative care to a patient

who had been denied life-saving treatment because of resource allocation"

And have inferred from these answers that physicians feel unprepared to respond to the pandemic with their present resources. The difficulty here is that the insufficiency of present resources is one of the conclusions drawn by the researchers, but the lack of sufficient resources is integrated to the premises of the questions (i.e. the physicians are asked to gauge their response to a lack of resources).

I would recommend that the authors reformulate their conclusions such as to clearly demonstrate that they are evaluating the effects of resource insufficiency on physicians in Canada's healthcare sector, rather than evaluating whether physicians consider resource insufficiency to be present prior to the onset of the pandemic.

Further, the researchers have relied on insufficient scholarship to demonstrate the veracity of their premise that resources are insufficiently available to provide care during COVID-19. The majority of the resources cited to this effect are newspaper articles and ethics or decision-science articles that assess how a lack of resources should be addressed. If available, more scholarship demonstrating the lack of healthcare sector resources in the face of Canada's COVID-19 pandemic should be included.

Second, the methodology section (p. 3) is very sparse, and while the methodology selected is clearly described in the ensuing body paragraphs, a more expansive description of the selection criteria, study design, and the perceived strengths and weaknesses of the methods employed would strengthen the article and enable the reader to critically assess how well the study results can be generalized.

The data collected overall provides a nuanced and unique snapshot into the COVID-19 pandemic response and I would heartily recommend publication.

Further, I consider the following conclusion to be overstated or impossible to draw from the data collected:

"Respondents demonstrated a strong appetite for transparently-developed, evidence-based,

and clear-to-follow guidelines to inform resource allocation decisions."

I assume that the above conclusions were drawn from the responses to the questions on pages 5, 6, and 7 of the survey questionnaire. I consider it to be appropriate to draw conclusions therefrom as to the desire of physicians to rely on policy guidelines as opposed to personal, value-driven approaches in making decisions regarding the allocation of limited resources. However, the questions asked in the survey, in my view, do not permit the drawing of conclusions regarding the content that respondents hope to see reflected in such resource-allocation policies.

I note that there is a significant over-representation of laboratory medicine specialists among respondents. It is not required, but add to the depth of insight provided by the study, for respondents to note if any correlations appear among their results regarding the specializations studied. More generally, considerable demographic information appears to have been collected about the participants, but no conclusions are drawn with regard thereto. Resources and space permitting, the authors should consider adding information with regard to the correlation emergent from this data.

Last, the results provided appear to suggest that research participants would slightly favor the allocation of resources to Canadian citizens over non-Canadian citizens. This could have serious implications for the potential for Canada's pandemic response and potential systemic discrimination or bias - the researchers should consider highlighting this conclusion and its implications for pandemic response in their findings.

These caveats aside, the study presents a crucial portrait of a critical moment in the evolution of the COVID-19 pandemic, and both the results collected and the insights drawn therefrom will be of great value for the future of this pandemic response effort and future pandemic response efforts.

Reviewer #2: The authors have performed a cross-sectional survey among Canadian physicians in April 2020 to assess preparedness for necessary decisions to be made regarding resource allocation during the COVID-19 pandemic and beyond. Resource allocation decisions have taken a large toll on physicians around the world, often due to lack of preparedness training for making these decisions during crises and outbreaks. The authors are to be applauded for their important work. I have some comments to improve the manuscript:

Major comments:

1. The authors note that “At the time the survey was launched, there were approximately a dozen patients with COVID-19 admitted to The Ottawa Hospital,” which preceded the anticipated surge. Compared to overwhelmed hospitals in, for example, New York City, Lombardy, Madrid, etc. the survey was conducted at a time where the hospital (which is the largest tertiary center in the region) was far from being overwhelmed, as was intended. Can the authors comment on whether surveys will be conducted later in the outbreak or after the pandemic to assess changes in average perceptions, whether as a result of lived experiences or introduced policy changes, support mechanisms, and/or crash courses supporting these decisions?

2. Interestingly, surgical respondents were found to be among the most ill-prepared in terms of making difficult resource allocation decisions. The authors may want to discuss this point, as 1) many countries include brief critical care training in surgical training and 2) surgical teams are commonly deployed as one of the first services to support COVID-19 care (e.g., because of reduced elective services, to place cathethers or perform tracheostomies, etc.), which may be currently or in the future perceived in Canada as well in case of major surges/outbreaks.

Minor comments:

1. Abstract background and body introduction: write abbreviations (here: SARS and COVID-19) in full when using them for the first time.

2. Methods: “REB”, “HSD”, and “CHERRIES” may be unclear to the reader, write abbreviations in full before using them.

3. Results, line 2: “to prevent data duplication” should be “to minimize data duplication”; including surveys that are 50% complete may still result in duplication.

Reviewer #3: The paper by Dewar and colleagues "Physician Preparedness for Resource Allocation Decisions Under Pandemic

Conditions: A Cross-Sectional Survey of Ottawa-Area Physicians, April 2020" is very well prepared, well reported and well written.

I dont any major points to add. The paper is very important and should be released on timely manner.

The charts can be visually improved using professional software!

Reviewer #4: The manuscript addresses some challenging issues that physicians encounter while managing COVID-19 patients with limited resources. The questionnaire seems adequate. The language overall was adequate. I do recommend the study included only those who completed 66 to 75% of questionnaires.

Reviewer #5: This is an interesting evaluation of results of a survey on preparedness and attitudes regarding resource allocation decisions among Canadian physicians. Although the sample is relatively small, this study provides insight on often overlooked aspects of resource allocation decision-making. The timing of the survey is particularly interesting, as it was administered before the surge of COVID19-related hospitalizations.

The manuscript is well written and straightforward. A few minor comments are provided below.

1) Introduction (page 3): the international readership might find some demographic context on the region of Ottawa useful, as well as on the size of the COVID19 outbreak in the region.

2) Methods section (page 3): please define REB.

3) Results section (pages 4-5): why would family medicine practitioners find themselves in the position of having to allocate a ventilator?

4) Discussion: The Authors state in the Introduction that a regional guideline on triaging acces to critical care beds was issued, which is referenced. A brief comment on the guideline and the criteria selected for resource allocation might enrich the discussion, especially in light of the survey's findings.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Haitham Jahrami

Reviewer #4: No

Reviewer #5: Yes: Costanza Vicentini

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PLoS One. 2020 Oct 22;15(10):e0238842. doi: 10.1371/journal.pone.0238842.r002

Author response to Decision Letter 0

14 Aug 2020

Dear Editors,

Thank you for taking the time to review this paper. Below, please find our responses to the comments made by the peer reviewers.

Editorial comments:

1. The methods must be described in sufficient detail for other researchers to reproduce the methodology described. This is a major concern that needs to be addressed while submitting the revised draft of the manuscript. For further details kindly check the following website:

Response: Thank you for this comment. We have significantly added to the methods section and hope that these additions will allow other researchers to reproduce this methodology. Additionally, please see appendix 2 for an even deeper discussion of the methodology used to conduct this survey.

Peer Reviewer Comments:

1. I would recommend that the authors reformulate their conclusions such as to clearly demonstrate that they are evaluating the effects of resource insufficiency on physicians in Canada's healthcare sector, rather than evaluating whether physicians consider resource insufficiency to be present prior to the onset of the pandemic.

Response: Thank you for this comment. Our goal was indeed to examine the readiness for a projected situation of resource scarcity rather than to determine the respondent’s feelings on a current and demonstrable insufficiency of resources. We have amended our conclusion to bring this point forward and prevent potential misunderstanding. We have written: “This rapidly implemented survey provides insights into physician preparedness to make resource allocation decisions utilizing a series of hypothetical conditions related to COVID-19.”

2. Further, the researchers have relied on insufficient scholarship to demonstrate the veracity of their premise that resources are insufficiently available to provide care during COVID-19. The majority of the resources cited to this effect are newspaper articles and ethics or decision-science articles that assess how a lack of resources should be addressed. If available, more scholarship demonstrating the lack of healthcare sector resources in the face of Canada's COVID-19 pandemic should be included.

Response: Thank you for this comment. Our desire was not to demonstrate that there was already or would be a situation of resource scarcity, but to explore how physicians in our health system might respond to similar conditions experienced elsewhere in the world. A number government initiatives addressed this hypothetical circumstance, not least of which were the provincial guidelines discussed in the conclusion. Since that time, a more extensive literature has developed and thus we have included Barrett (2020) and Shoukat (2020) to the introduction (references 6 and 7) to provide a more scholarly background to the projections of resource scarcity in Ontario and Canada at the time.

3. Second, the methodology section (p. 3) is very sparse, and while the methodology selected is clearly described in the ensuing body paragraphs, a more expansive description of the selection criteria, study design, and the perceived strengths and weaknesses of the methods employed would strengthen the article and enable the reader to critically assess how well the study results can be generalized.

Response: Thank you for bringing this to our attention. We have rewritten the methods section to include much more in-depth discussion of the survey methodology alongside a discussion in the conclusion section of the strengths and weaknesses of this methodology. We hope this will maximize the ability for readers to generalize our results.

4. Further, I consider the following conclusion to be overstated or impossible to draw from the data collected:

"Respondents demonstrated a strong appetite for transparently-developed, evidence-based, and clear-to-follow guidelines to inform resource allocation decisions."

I assume that the above conclusions were drawn from the responses to the questions on pages 5, 6, and 7 of the survey questionnaire. I consider it to be appropriate to draw conclusions therefrom as to the desire of physicians to rely on policy guidelines as opposed to personal, value-driven approaches in making decisions regarding the allocation of limited resources. However, the questions asked in the survey, in my view, do not permit the drawing of conclusions regarding the content that respondents hope to see reflected in such resource-allocation policies.

Response: Thank you very much for this response. We certainly do not want to overstate our conclusions. This conclusion was drawn from survey question 6A, which asked “If you were writing a guideline on resource allocation in the time of a pandemic, what would you say is the most important thing to include?”. We have now included a table (Table 2) of the most common responses in the policy recommendations section to clarify how we came to these conclusions.

5. I note that there is a significant over-representation of laboratory medicine specialists among respondents. It is not required, but add to the depth of insight provided by the study, for respondents to note if any correlations appear among their results regarding the specializations studied. More generally, considerable demographic information appears to have been collected about the participants, but no conclusions are drawn with regard thereto. Resources and space permitting, the authors should consider adding information with regards to the correlation emergent from this data.

Response: Thank you for this comment. We apologize if there was confusion but we report no respondents from laboratory medicine. Analyses for correlation between specialty and responses were performed, but did not reach the level of statistical significance. We have noted this in the results section.

6. Last, the results provided appear to suggest that research participants would slightly favor the allocation of resources to Canadian citizens over non-Canadian citizens. This could have serious implications for the potential for Canada's pandemic response and potential systemic discrimination or bias - the researchers should consider highlighting this conclusion and its implications for pandemic response in their findings.

Response: Thank you for this suggestion. We have rewritten our discussion of this point: A consistent set of factors emerged as being important to most physicians' decision-making around resource allocation: survival likelihood, cognitive function, comorbidities and daily function. However, significant disagreement existed around other factors including age and citizenship, and our ability to draw conclusions about these factors is limited. In the absence of agreement and standard practices, physicians are at risk of being influenced by unconscious biases in the way resources are rationed. This tendency may be exacerbated when information about the patient or the clinical scenario is limited.

7. The authors note that “At the time the survey was launched, there were approximately a dozen patients with COVID-19 admitted to The Ottawa Hospital,” which preceded the anticipated surge. Compared to overwhelmed hospitals in, for example, New York City, Lombardy, Madrid, etc. the survey was conducted at a time where the hospital (which is the largest tertiary center in the region) was far from being overwhelmed, as was intended. Can the authors comment on whether surveys will be conducted later in the outbreak or after the pandemic to assess changes in average perceptions, whether as a result of lived experiences or introduced policy changes, support mechanisms, and/or crash courses supporting these decisions?

Response: Thank you for this excellent suggestion! Unfortunately, this project was funded by a one-off grant, and as such funding is currently unavailable for follow-up projects. However, should funding become available, follow-up work, especially targeting physicians in populations where there was a demonstrated scarcity of resources, would be a valuable and interesting.

8. Interestingly, surgical respondents were found to be among the most ill-prepared in terms of making difficult resource allocation decisions. The authors may want to discuss this point, as 1) many countries include brief critical care training in surgical training and 2) surgical teams are commonly deployed as one of the first services to support COVID-19 care (e.g., because of reduced elective services, to place cathethers or perform tracheostomies, etc.), which may be currently or in the future perceived in Canada as well in case of major surges/outbreaks.

Response: Thank you for this interesting suggestion. Ultimately the difference between the surgeons and the other groups were not statistically significant, and therefore we do not believe it is warranted to draw conclusions from this finding. We have made this point clearer by adding the line: No other statistically significant correlations were found with regards to specialty.

9. 1. Abstract background and body introduction: write abbreviations (here: SARS and COVID-19) in full when using them for the first time.

2. Methods: “REB”, “HSD”, and “CHERRIES” may be unclear to the reader, write abbreviations in full before using them.

3. Results, line 2: “to prevent data duplication” should be “to minimize data duplication”; including surveys that are 50% complete may still result in duplication

Response: Thank you for this suggestion. We have amended our manuscript to ensure that abbreviations are defined on their first use, and have clarified this line in the results section as our original wording may have been misleading.

10. The charts can be visually improved using professional software!

Response: Thank you for your comment. Figures and tables were produced according to journal specifications and will be made available in the highest possible resolution.

11. The manuscript addresses some challenging issues that physicians encounter while managing COVID-19 patients with limited resources. The questionnaire seems adequate. The language overall was adequate. I do recommend the study included only those who completed 66 to 75% of questionnaires.

Response: Thank you for this suggestion that we exclude respondents who completed less than 75% of the questionnaire. However, we respectfully disagree that this will meaningfully add to our analysis as it will only serve to reduce the number of responses available and ultimately remains an arbitrary threshold.

12. Introduction (page 3): the international readership might find some demographic context on the region of Ottawa useful, as well as on the size of the COVID19 outbreak in the region.

Response: Thank you for this comment. We have included background demographic context on the Ottawa region as well as information on the expected COVID-19 outbreak in the introduction section. In early April 2020, we launched a survey of physicians practicing in the region of Ottawa, Ontario, Canada. Ottawa is the national capital, a cosmopolitan and bilingual city of approximately 1 million.

13. Methods section (page 3): please define REB.

Response: Thank you for this comment. We have defined REB and other acronyms when they are first introduced.

14. Results section (pages 4-5): why would family medicine practitioners find themselves in the position of having to allocate a ventilator?

Response: Thank you for your question. In our region, physicians trained in family medicine often work in the emergency department and in palliative care, both areas where they would be directly involved in COVID-19 related care.

15. Discussion: The Authors state in the Introduction that a regional guideline on triaging access to critical care beds was issued, which is referenced. A brief comment on the guideline and the criteria selected for resource allocation might enrich the discussion, especially in light of the survey's findings.

Response: Thank you for this comment. We have included background information on the guidelines in the introduction. Under hypothetical “surge” conditions that were ultimately never met, patients would be excluded from critical care according to disease-specific mortality thresholds that become increasingly more stringent as resources become more limited.

Attachment

Submitted filename: Response to Reviewers_Sparc.docx

Click here for additional data file. (21.9KB, docx)

Decision Letter 1

Ritesh G Menezes

26 Aug 2020

Physician Preparedness for Resource Allocation Decisions Under Pandemic Conditions: A Cross-Sectional Survey of Canadian Physicians, April 2020

PONE-D-20-15128R1

Dear Dr. Shamy,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

Academic Editor

PLOS ONE

Acceptance letter

Ritesh G Menezes

14 Oct 2020

PONE-D-20-15128R1

Physician Preparedness for Resource Allocation Decisions Under Pandemic Conditions: A Cross-Sectional Survey of Canadian Physicians, April 2020

Dear Dr. Shamy:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Prof. Dr. Ritesh G. Menezes

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Appendix. Preparing for resource rationing under pandemic conditions.

    (DOCX)

    Click here for additional data file. (36.9KB, docx)
    S1 Checklist. Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

    (XLSX)

    Click here for additional data file. (15.5KB, xlsx)
    Attachment

    Submitted filename: Response to Reviewers_Sparc.docx

    Click here for additional data file. (21.9KB, docx)

    Data Availability Statement

    As our data include responses that are potentially identifiable due to low numbers in some categories, we have chosen to limit access by making our data available upon request. The data underlying the results presented in the study are available from Zenodo: Shamy, Michel; Dewar, Brian. (2020). Dataset for Physician Preparedness for Resource Allocation Decisions Under Pandemic Conditions: A Cross-Sectional Survey of Canadian Physicians, April 2020 (Version 1) [Data set]. Zenodo. http://doi.org/10.5281/zenodo.4008146.

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