Guest post: Angst among surgeons during the COVID-19 crisis

The epicentre of the SARS-CoV2 outbreak has been shifting from place to place, hitting many countries in the world. The feelings of angst, distress and desperation have also spread along with the virus among healthcare workers (HCW). It is hard to forget the early voices from the frontline HCW, the rapidly worsening situation during the escalating phase,¹which seems to be occurring again in countries that are being hit by the second wave.²

1/ I may be repeating myself, but I want to fight this sense of security that I see outside of the epicenters, as if nothing was going to happen “here”. The media in Europe are reassuring, politicians are reassuring, while there’s little to be reassured of. #COVID19 #coronavirus

— Silvia Stringhini (@silviast9) March 9, 2020

The early working experience originally narrated by an Italian doctor Daniele Macchini. English translation by Silvia Stringhini on twitter.

Surgeons’ fear of getting infected by SARS-CoV-2 and developing COVID-19, as well as the change of their daily surgical practice, has been described since the early stage of the pandemic.³ Despite the varying rates of infected people among countries, surgeons have experienced globally a common angst about the virus due to their high-risk job. 

China, as the first country facing the virus, had limited previous knowledge and experience about COVID-19 to refer to. The HCW were immediately frightened by what they witnessed: emergency rooms filled with patients infected by an unfamiliar type of virus, followed by overwhelmed intensive care units. Since the escalation of the epidemic in Wuhan was so rapid, most elective surgeries in China were cancelled and not resumed until mid-March 2020.⁴ The fear of the unknown had forced most hospitals to stop surgical practice, leading to a serious backlog of surgical patients. Due to lack of staff, many surgeons were frequently re-employed to work in intensive care unit or fever clinic, causing a feeling of inadequacy to work in a medical area for which they were not trained. During the post-epidemic period, the mental stress among surgical staff persisted due to the extensive surgical backlog and the additional work involved in ensuring a safe environment for newly hospitalized patients through creation of selective safe routes and adequate personal protective equipment (PPE) adoption.⁵

Surgeons in Europe have probably suffered even worse situations. Fear of getting infected has led HCW to feel a threat to their life because of their work. In the early phase, a vascular surgeon from the UK spoke out about such dreads, and acknowledged the importance of looking after surgeon’s mental well-being.⁶ Otolaryngology-ENT, and maxillofacial specialties were regarded as those at highest risk, therefore, a team from the Head and Neck Unit of the Royal Marsden NHS Foundation Trust and Lewisham Child and Adolescent Mental Health Services analysed the impact of COVID-19 on the mental health of surgeons. The fear of contracting the virus and transmitting to family members represented important factors affecting mental health of HCW during the pandemic.⁷ Many HCW were self-isolating from their family and many decided to left their homes, while others moved into their garages and basements.^{8, 9}

In US, where the pandemic hit in the summer, surgeons also expressed their angst during work. Shortage of PPE and lack of a coordinated pandemic plan from the central government further exacerbated the fear. During the early phase of the pandemic, surgeons from US declared “guilt and fear are to some extent pervasive in medical practice”, “any provider during this time that says they aren’t impacted is not being truthful with themselves”.^{10, 11}

Another key element that has generated stress among doctors has been the uncertainty of how to treat a completely unknown disease. Data were lacking and indications were changing frequently, causing confusion and misinformation. An explicative example is given by guidelines on use of surgical masks: WHO and many governments initially banned the use of adequate PPE in hospital daily practice when dealing with asymptomatic people, due to lack of scientific evidence and lack of stock of PPE.

Surveys among HCW have become a fast and effective way to provide updated data to guide medical choices during this unprecedented time.^{12, 13} A survey from Mexico investigated personal feelings among 150 vascular surgeons; with ten short but detailed questions, the results of the survey showed that the greatest fear was to infect their families. More than half of the respondents thought that PPE supply was inadequate and 61% of the respondents did not agree with the way government and the Health secretary have handled the pandemic.¹⁴

Life as a vascular surgeon in Mexico during the COVID-19 pandemic https://t.co/HI7135xRL7

— Rebeca Reachi Lugo (@rbkreachi) May 14, 2020

A survey among 150 vascular surgeons from Mexico, investigating their feelings and life during COVID-19 pandemic.

Another regional survey from a tertiary academic centre in Singapore investigated psychological health condition among 45 surgical providers during the pandemic. The results revealed that 77.8% of respondents were experiencing fear of contracting COVID-19, and 88.9% reported fear of spreading the virus to their families. Doctors in training suffered worse mental health condition than other colleagues;¹⁵ a national survey explored factors associated mental health disorders among 1001 young surgical residents and fellows in France, finding that enough PPE supply and sufficient training on preventing COVID-19 could decrease the possibility of developing anxiety, depression and insomnia.¹⁶During early April 2020, the S-COVID Collaborative conducted a global survey among surgeons from 71 countries, revealing that the fear of getting infected by COVID-19 or infecting others was indeed very common among the respondents from all over the world. Furthermore, the analysis showed that shortage of surgical masks, dissatisfaction towards hospital’s preventive measures and experiencing in-hospital infections were associated with surgeon’s fear.¹⁷

Surgeons’ fear of getting infected by COVID19: A global survey https://t.co/JfwzvgPmsD

— Yongbo An (@an_yongbo) August 20, 2020

A global survey of surgeons’ fear of getting infected by COVID-19, conducted by S-COVID group

Indeed, factors associated with surgeons’ fear, elicited from the above global survey, are preventable. Since comprehensive meta-analysis and reviews have clarified the effectiveness of face masks,¹⁸ and additional supply strategies have been established,¹⁹ the shortage of face masks and other PPE could be fully managed. Another action which could reduce anxiety and stress of the HCW would be intensive SARS-CoV-2 screening. In Wuhan, universal screening for all 10 million residents was completed in May. “The physical lockdown on the city was lifted on April 8, and after the testing campaign was finished, the psychological lockdown on Wuhan people has also been lifted.” Such universal screening would also reassure the surgeons as well as other HCW.^{20, 21}

Unfortunately, before the normal life and work could be resumed (even if known as “new normality”), the second wave of the pandemic started. Sentiments of fear, angst, anxiety are likely to impact heavily citizens and HCW. The surgical staff is already facing heavier workload due to the backlog of surgical patients during the pandemic – which might be even worse, as many did not have enough time to recover from the first wave. If one takes into account that more than 28 million elective surgeries have been cancelled or postponed worldwide,²² the resulting picture is extremely worrisome. Besides the upcoming enormous workload, asymptomatic COVID-19 patients are still acting as threats for hospitals, making the daily work of surgeons harder than usual.²³

It is well acknowledged that surgeons are always working under great pressure, burnout due to work is a common finding among surgeons.²⁴ However, the pandemic has generated an unprecedented situation, in which HCW are being overwhelmed by their angst and fears. Medical litigations are also likely to increase in the next months, adding to HCW sense of uncertainty and inappropriateness.²⁵ It is mandatory that the public opinion, the press and social media contribute to offer a balanced and realistic overview of the conditions in which HCW are being forced to work; and that societies and entities collaborate to create strategies to prevent such conditions,²⁶ and to help HCW who are struggling, left alone.