Opinion

Surgery and COVID-19

VIEWPOINT

Melina R. Kibbe, MD The coronavirus disease 2019 (COVID-19)pandemichas Surgical patients have unique risks due to COVID-19.
Department of Surgery had a substantial effect on surgeons and patients who re- Operating on patients with either asymptomatic or symp-
and Department of quire surgical care. Providing care for patients with sur- tomatic COVID-19 increases the risk for perioperative mor-
Biomedical
gical disease requires a unique and intimate relationship bidity and mortality. In a case-control analysis from Italy,
Engineering, University
of North Carolina at between the patient and surgeon, and this interaction and Doglietto et al3 showed that the 30-day risk of mortality
Chapel Hill; and Editor, contact cannot be replaced by telehealth. As such, the sur- for patients with COVID-19 undergoing surgery (n = 41),
JAMA Surgery. gical workforce has faced distinct challenges compared compared with patients without COVID-19 (n = 82), was
with nonsurgical specialties during the COVID-19 pan- significantly higher (19.51% vs 2.44%; odds ratio [OR], 9.5
demic. Specific issues include the best approach to pro- [95% CI, 1.8-96.5]). The odds for perioperative pulmo-
tect health care personnel and the patient; the ability to nary complications also were significantly higher (OR, 35.6
Viewpoints
efficiently regulate delivery of surgical care; the detrimen-[95% CI, 9.3-205.6]), as were the odds of thrombotic
pages 1131-1155 and
Editorial page 1159 tal effects on patients with surgical disease; the financial complications (OR, 13.2 [95% CI, 1.5 to ⬁]).
implications of the pandemic on health care systems; the To protect both patients and health care workers,
management of surgical workforce shortages; the impli- many institutions are testing all patients for severe acute
cations for education, research, and career develop- respiratory syndrome coronavirus 2 (SARS-CoV-2) prior
ment; and the emotional toll to all involved. to operations or other procedures.4,5 Lin et al4 reported
First and foremost, to deliver surgical care, a healthy a mean preoperative COVID-19 positive testing rate of
and functional surgical workforce is needed. This re- 0.93% (12 of 1295 patients) for pediatric patients, and
quires providing adequate protection for all health care Morris et al5 reported a mean preoperative COVID-19 posi-
personnel. In the beginning of the pandemic, the short- tive testing rate of 0.74% (18 of 2437 patients) for adult
age of appropriate personal protective equipment (PPE) patients. At the University of North Carolina, data from
provided challenges to many health care systems. aninternaldatabaseshowthatthepreoperativeCOVID-19
As supply chains and the availability of PPE have positive testing rate has remained at approximately
0.86% (61 of 7100) since testing was ini-
tiated. Although COVID-19 preoperative
positive test result rates vary from re-
The surgical disciplines face substantial gion to region depending on the preva-
challenges during the COVID-19 lence of COVID-19 in the community, it is
pandemic, and the effects on the imperative to identify asymptomatic pa-
tients with SARS-CoV-2 infection so their
surgical profession will be lasting. surgerycanbesafelypostponed.Thispro-
cess protects the patient and the health
improved, so has the ability to protect the workforce. care worker by avoiding unnecessary exposure to pa-
Through well-conducted research studies it has be- tients infected with SARS-CoV-2.
come clear that adopting universal pandemic precau- Another major challenge for surgery has been the
tions is in everyone’s best interest.1,2 This includes main- need to effectively and safely stop nonurgent and non-
taining physical distance when possible, wearing a well- emergency surgery. With the ramp-down in the operat-
fitted mask over the nose and mouth, frequent hand ing rooms, programs also need to restructure how per-
hygiene, wearing gloves for patient contact, regular sur- sonnel are deployed to deliver care to patients with
face disinfection, and use of eye protection for all pa- COVID-19. Several institutions have shared best prac-
tient encounters.1,2 These measures not only limit the tices on how to restructure surgical residency programs
spread of COVID-19 from those infected to others but and provide care to patients with SARS-CoV-2 while
also reduce the risk of acquiring COVID-19 from those minimizing risk to noninfected patients and other
who are infected.1 health care professionals.6 Some institutions advo-
In the operating room, universal use of smoke evacu- cated for adopting an incident command center model
ators to suction away the smoke plumes generated by within their institution, whereas others shared their
Corresponding
Author: Melina R. electrocautery has been encouraged to minimize the risk broad experience while managing patient care in the
Kibbe, MD, of exposure to health care personnel of aerosolized epicenter in New York.7,8 Others have pointed out that
Department of Surgery, tissue.2 Special precautions should be taken for all sur- partnerships with the military during pandemics can
University of North
Carolina at Chapel Hill,
gical cases that involve the airway and digestive tract, provide additional resources that may not be otherwise
101 Manning Dr, and minimally invasive procedures that require the cre- available.9 Sharing these experiences in real time has
Burnett Womack Bldg, ation of a pneumoperitoneum must be safely managed provided valuable best practices that may work well in
Ste 4041, Chapel Hill,
or avoided if possible. Overall, it is imperative that uni- other institutions.
NC 27599-7050
(melina_kibbe@med. versal pandemic precautions, including appropriate PPE, The need to resume and ramp-up surgical services
unc.edu). are observed whenever surgical care is delivered. has become imperative as PPE supplies have improved

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 Opinion Viewpoint

and testing has increased. Many patients with surgical diseases have
avoided care because of concerns of acquiring COVID-19 at hospi-
tals or in clinicians’ offices. Nonurgent and nonemergency care has
been delayed and has created a large backlog of patients who re-
quire 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 sur-
gical workforce in a time during which there is likely a greater need
for surgical care. International medical graduates encounter addi-
tional challenges with obtaining visas and being prevented from en-
tering the US, which has further consequences for the surgical work-
force 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 impera-
tive to the viability and solvency of health care institutions.
The COVID-19 pandemic has also created challenges in the edu-
cation 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 shut-
down of nonurgent, nonemergency surgery, residents were no lon-
ger gaining experience in the operating room and clinic. The impli-
cations 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 medi-
cal 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 pur-
suing 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. Fur-
ther, more residents may graduate who are not fully prepared to en-
ter 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 af-
fected research and career development. All research, including clini-
cal trials, has slowed or stopped. The ultimate effect of this shut-
down on new scientific discovery and innovation is not clear. Further,
the COVID-19 pandemic has increased the disparity that already ex-
ists between male and female health care providers with children, with
female parents shouldering more of the home and childcare respon-
sibilities than their male counterparts. An analysis of manuscripts sub-
mitted to JAMA Surgery revealed a proportional decrease in submis-
sions 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 promo-
tion and tenure in the future. There is also a great need to put pro-
cesses 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 sur-
gical resident experience have changed. Health care systems are fac-
ing unprecedented financial challenges. Surgical private practices
have closed, and some surgeons have retired early or left the pro-
fession. 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 deliv-
ery 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.

ARTICLE INFORMATION
Conflict of Interest Disclosures: None reported.
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