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September 22/29, 2020

Surgery and COVID-19

Author Affiliations
  • 1Department of Surgery and Department of Biomedical Engineering, University of North Carolina at Chapel Hill
  • 2Editor, JAMA Surgery
JAMA. 2020;324(12):1151-1152. doi:10.1001/jama.2020.15191

The coronavirus disease 2019 (COVID-19) pandemic has had a substantial effect on surgeons and patients who require surgical care. Providing care for patients with surgical disease requires a unique and intimate relationship between the patient and surgeon, and this interaction and contact cannot be replaced by telehealth. As such, the surgical workforce has faced distinct challenges compared with nonsurgical specialties during the COVID-19 pandemic. Specific issues include the best approach to protect health care personnel and the patient; the ability to efficiently regulate delivery of surgical care; the detrimental effects on patients with surgical disease; the financial implications of the pandemic on health care systems; the management of surgical workforce shortages; the implications for education, research, and career development; and the emotional toll to all involved.

First and foremost, to deliver surgical care, a healthy and functional surgical workforce is needed. This requires providing adequate protection for all health care personnel. In the beginning of the pandemic, the shortage of appropriate personal protective equipment (PPE) provided challenges to many health care systems. As supply chains and the availability of PPE have improved, so has the ability to protect the workforce. Through well-conducted research studies it has become clear that adopting universal pandemic precautions is in everyone’s best interest.1,2 This includes maintaining physical distance when possible, wearing a well-fitted mask over the nose and mouth, frequent hand hygiene, wearing gloves for patient contact, regular surface disinfection, and use of eye protection for all patient encounters.1,2 These measures not only limit the spread of COVID-19 from those infected to others but also reduce the risk of acquiring COVID-19 from those who are infected.1

In the operating room, universal use of smoke evacuators to suction away the smoke plumes generated by electrocautery has been encouraged to minimize the risk of exposure to health care personnel of aerosolized tissue.2 Special precautions should be taken for all surgical cases that involve the airway and digestive tract, and minimally invasive procedures that require the creation of a pneumoperitoneum must be safely managed or avoided if possible. Overall, it is imperative that universal pandemic precautions, including appropriate PPE, are observed whenever surgical care is delivered.

Surgical patients have unique risks due to COVID-19. Operating on patients with either asymptomatic or symptomatic COVID-19 increases the risk for perioperative morbidity and mortality. In a case-control analysis from Italy, Doglietto et al3 showed that the 30-day risk of mortality for patients with COVID-19 undergoing surgery (n = 41), compared with patients without COVID-19 (n = 82), was significantly higher (19.51% vs 2.44%; odds ratio [OR], 9.5 [95% CI, 1.8-96.5]). The odds for perioperative pulmonary complications also were significantly higher (OR, 35.6 [95% CI, 9.3-205.6]), as were the odds of thrombotic complications (OR, 13.2 [95% CI, 1.5 to ∞]).

To protect both patients and health care workers, many institutions are testing all patients for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) prior to operations or other procedures.4,5 Lin et al4 reported a mean preoperative COVID-19 positive testing rate of 0.93% (12 of 1295 patients) for pediatric patients, and Morris et al5 reported a mean preoperative COVID-19 positive testing rate of 0.74% (18 of 2437 patients) for adult patients. At the University of North Carolina, data from an internal database show that the preoperative COVID-19 positive testing rate has remained at approximately 0.86% (61 of 7100) since testing was initiated. Although COVID-19 preoperative positive test result rates vary from region to region depending on the prevalence of COVID-19 in the community, it is imperative to identify asymptomatic patients with SARS-CoV-2 infection so their surgery can be safely postponed. This process protects the patient and the health care worker by avoiding unnecessary exposure to patients infected with SARS-CoV-2.

Another major challenge for surgery has been the need to effectively and safely stop nonurgent and nonemergency surgery. With the ramp-down in the operating rooms, programs also need to restructure how personnel are deployed to deliver care to patients with COVID-19. Several institutions have shared best practices on how to restructure surgical residency programs and provide care to patients with SARS-CoV-2 while minimizing risk to noninfected patients and other health care professionals.6 Some institutions advocated for adopting an incident command center model within their institution, whereas others shared their broad experience while managing patient care in the epicenter in New York.7,8 Others have pointed out that partnerships with the military during pandemics can provide additional resources that may not be otherwise available.9 Sharing these experiences in real time has provided valuable best practices that may work well in other institutions.

The need to resume and ramp-up surgical services has become imperative as PPE supplies have improved and testing has increased. Many patients with surgical diseases have avoided care because of concerns of acquiring COVID-19 at hospitals or in clinicians’ offices. Nonurgent and nonemergency care has been delayed and has created a large backlog of patients who require surgical care. The effects on patients with cancer or chronic debilitating disease and patients awaiting organ transplant have yet to be defined. Thus, each institution needs to develop an algorithm to ramp surgical services up and down in a manner that is nimble and works within their local environment.

The financial implications of the surgical shutdown have been far-reaching. Many health care employees have been affected by pay cuts, furloughs, and layoffs. Surgical private practices that could not bear the financial challenges of the pandemic have been forced to shut down. Some surgeons have retired early or decided to leave the surgical profession. All of these problems further influence the surgical workforce in a time during which there is likely a greater need for surgical care. International medical graduates encounter additional challenges with obtaining visas and being prevented from entering the US, which has further consequences for the surgical workforce in the US. Because surgical services are a foundational component of the health care system, providing surgical care in a manner that protects the patient and health care worker is imperative to the viability and solvency of health care institutions.

The COVID-19 pandemic has also created challenges in the education of the future surgical workforce. During the initial phases of the pandemic, when PPE shortages were common, most medical students were removed from clinical care rotations. With the shutdown of nonurgent, nonemergency surgery, residents were no longer gaining experience in the operating room and clinic. The implications for this are far-reaching. Regarding the medical students, their exposure to surgery is now limited. Fewer medical students may choose careers in surgery due to limited exposure. For those medical students who wanted to pursue surgery, concern related to the close patient-physician contact needed for surgery may lead them to choose a different profession. For those medical students still pursuing surgery, there may be confusion and anxiety over deciding which surgical residency program they should apply to because they could not participate in the different rotations they had planned. Regarding residents, graduating chief residents may not meet the case load requirement required to qualify for board certification. Further, more residents may graduate who are not fully prepared to enter independent practice. Credentialing agencies may have to take these factors into consideration for surgical residents graduating in 2020 and 2021.

Just as the pandemic has affected clinical care, it also has affected research and career development. All research, including clinical trials, has slowed or stopped. The ultimate effect of this shutdown on new scientific discovery and innovation is not clear. Further, the COVID-19 pandemic has increased the disparity that already exists between male and female health care providers with children, with female parents shouldering more of the home and childcare responsibilities than their male counterparts. An analysis of manuscripts submitted to JAMA Surgery revealed a proportional decrease in submissions from female authors during April and May 2020 compared with April and May 2019.10 It will be imperative for academic institutions to recognize this differential career influence with respect to promotion and tenure in the future. There is also a great need to put processes in place that will allow all clinicians with children to navigate the challenges associated with delivering care during this pandemic, especially as many schools will continue with virtual education.

The surgical disciplines face substantial challenges during the COVID-19 pandemic, and the effects on the surgical profession will be lasting. The long-term effects on patients with surgical disease have yet to be fully realized; however, it is clear that operating on patients with COVID-19 is associated with a significantly increased odds of morbidity and mortality. The surgical workforce will be strained by further shortages. Medical student education and surgical resident experience have changed. Health care systems are facing unprecedented financial challenges. Surgical private practices have closed, and some surgeons have retired early or left the profession. The effect on research and clinical trials may be significant. Although the future is uncertain, and it is not possible to predict how long this pandemic will last, hospitals and surgeons should not expect to return to the prepandemic approaches for the delivery of surgical care. Many of the changes that have been instituted during the COVID-19 pandemic are the new reality, and the surgical community must learn to evolve with and accept these changes. The future of the profession depends on it.

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Article Information

Corresponding Author: Melina R. Kibbe, MD, Department of Surgery, University of North Carolina at Chapel Hill, 101 Manning Dr, Burnett Womack Bldg, Ste 4041, Chapel Hill, NC 27599-7050 (melina_kibbe@med.unc.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Weber  DJ, Babcock  H, Hayden  MK,  et al; SHEA Board of Trustees.  Universal pandemic precautions—an idea ripe for the times.   Infect Control Hosp Epidemiol. Published online July 3, 2020. doi:10.1017/ice.2020.327PubMedGoogle Scholar
2.
Livingston  EH.  Surgery in a time of uncertainty: a need for universal respiratory precautions in the operating room.   JAMA. 2020;323(22):2254-2255. doi:10.1001/jama.2020.7903PubMedGoogle ScholarCrossref
3.
Doglietto  F, Vezzoli  M, Gheza  F,  et al.  Factors Associated with surgical mortality and complications among patients with and without coronavirus disease 2019 (COVID-19) in Italy.   JAMA Surg. 2020;155(8):691-702. doi:10.1001/jamasurg.2020.2713PubMedGoogle ScholarCrossref
4.
Lin  EE, Blumberg  TJ, Adler  AC,  et al.  Incidence of COVID-19 in pediatric surgical patients among 3 US children’s hospitals.   JAMA Surg. 2020;155(8):775-777. doi:10.1001/jamasurg.2020.2588PubMedGoogle ScholarCrossref
5.
Morris  M, Pierce  A, Carlisle  B, Vining  B, Dobyns  J.  Pre-operative COVID-19 testing and decolonization.   Am J Surg. Published online May 21, 2020. doi:10.1016/j.amjsurg.2020.05.027PubMedGoogle Scholar
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Nassar  AH, Zern  NK, McIntyre  LK,  et al.  Emergency restructuring of a general surgery residency program during the coronavirus disease 2019 pandemic: the University of Washington experience.   JAMA Surg. 2020;155(7):624-627. doi:10.1001/jamasurg.2020.1219PubMedGoogle ScholarCrossref
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Zarzaur  BL, Stahl  CC, Greenberg  JA, Savage  SA, Minter  RM.  Blueprint for restructuring a department of surgery in concert with the health care system during a pandemic: the University of Wisconsin experience.   JAMA Surg. 2020;155(7):628-635. doi:10.1001/jamasurg.2020.1386PubMedGoogle ScholarCrossref
8.
Juprasert  JM, Gray  KD, Moore  MD,  et al.  Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons from New York City.   JAMA Surg. Published online July 7, 2020. doi:10.1001/jamasurg.2020.3107PubMedGoogle Scholar
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Knudson  MM, Jacobs  LM  Jr, Elster  CEA.  How to partner with the military in responding to pandemics—a blueprint for success.   JAMA Surg. 2020;155(7):548-549. doi:10.1001/jamasurg.2020.1227PubMedGoogle ScholarCrossref
10.
Kibbe  MR.  Consequences of the COVID-19 pandemic on manuscript submissions by women.   JAMA Surgery. Published online August 4, 2020. doi:10.1001/jamasurg.2020.3917PubMedGoogle Scholar
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