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A new type of viral pneumonia was recognised in Wuhan, China in December 2019. By January 2020, this was identified as a type of coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first case of SARS-CoV-2 detected in Aotearoa New Zealand was on 28 February 2020, and on 11 March 2020 the World Health Organization formally declared a coronavirus disease 2019 (COVID-19) pandemic. Many health systems around the world were quickly overwhelmed with high rates of hospitalisations and deaths. In many countries elective surgery was suspended in order to rationalise staff and resources.[[1–4]]

In 2020, it was estimated that during the 12 weeks of peak disruption of all elective surgery across 190 countries, 28,404,603 operations would be cancelled or postponed.[[5]] This represents a cancellation rate of all elective surgeries of 72.3%. Using surgical data collected during 2020, Heckmann et al.[[6]] estimated that the nationwide volume in the United States of elective hip and knee arthroplasty cases decreased by 46.5% to 47.7% from the prior 3-year average. Furthermore, the elective hip and knee arthroplasty case volume for April 2020 was 1.9% of the volume for the same month in 2017 through 2019.

Although the New Zealand healthcare system has not been affected to the same extent as many other countries, the pandemic has still had a significant impact on most specialties and many patients. At the time of this survey—21 November 2021—there had been 9,608 cases of COVID-19 and 46 deaths with 83 patients in hospital, 5 of whom were in the intensive care unit/high dependency unit (ICU/HDU).[[7]] In comparison to most other countries, these are relatively low numbers, which is the result of multiple factors including the geography of our island nation, the high vaccination rate (83% double vaccinated as of 21 November 2021) and the control measures implemented by the government.

Mental health issues including burnout are prevalent in orthopaedics, particularly among registrars.[[8–10]] In a recent study, Verret et al.[[8]] found that 34% of orthopaedic residents reported high levels of depersonalisation compared to 9% of consultants. In a survey to assess the impact of the pandemic on the mental health of the orthopaedic workforce, Thakrar et al.[[11]] found significantly higher rates of generalised anxiety disorder and major depressive episodes when compared to the general population.

We hypothesised that COVID-19 had significantly impacted the training of Surgical Education and Training (SET) registrars. We also hypothesised that the pandemic has had a detrimental effect on the mental health of surgeons and registrars. The purpose of this study was to assess the impact of COVID-19 on orthopaedic practice in New Zealand, including the impact on orthopaedic training and the mental health of surgeons and registrars.

Methods

With the assistance and permission of the New Zealand Orthopaedic Association (NZOA), consultant orthopaedic surgeons and SET orthopaedic registrars were asked to complete an electronic survey relating to the impact of COVID-19 on their practice, training and wellbeing. This nationwide survey was conducted in November 2021 and was sent to all 385 members of the NZOA, the organisation with which all practising orthopaedic surgeons and SET registrars in New Zealand must be registered. The survey was administered using Survey Monkey (Palo Alto, CA, USA). Following the initial email, two reminder emails were sent one and two weeks later.

The survey was comprised of 27 questions relating to demographics, the effects of COVID-19 on orthopaedic departments, on orthopaedic training, on mental health and the utilisation of telehealth and online teaching. The option of adding comments as free text after each question was made available. Demographic data collected included age, training level, and location of practice. Data was collected from both the public health sector as well as the private health sector. The public sector is managed by Te Whatu Ora – Health New Zealand with funding from the Government. The private sector is funded by insurers, the Accident Compensation Corporation (ACC) or the individual. Prior to distribution, the survey was validated by a consultant orthopaedic surgeon and two orthopaedic registrars. The survey was anonymised with a response window of one month.

Significance testing was performed with Prism 8 (GraphPad, San Diego, CA, USA). Differences were determined with Fisher’s exact test or Chi-squared tests and a p-value of <0.05 was considered significant. The study methodology was reviewed by the Health and Disability Ethics Committees (HDEC) and did not require a formal ethical review.

Results

Demographics

The nationwide survey received 189 responses from the 385 NZOA members, a response rate of 49%. Responses were received from 135 of 320 orthopaedic consultants (42%), 51 of 62 SET orthopaedic registrars (82%) and 3 orthopaedic fellows. Demographic details are shown in Table 1.

Effect on practice

All respondents were vaccinated, with 188 of the 189 respondents being double vaccinated. One person had only received a single dose of the vaccine. At the time of the survey, 10.8% of respondents had treated a patient with an active COVID-19 infection and 15% had been stood down from work to self-isolate due to COVID-19 exposure. None of the respondents had tested positive for COVID-19.

Of those surveyed, 1.6% had been re-deployed to work in an area outside of orthopaedics (two consultants and one SET registrar). Overall, 14.8% felt they had been adequately trained to work outside their scope of practice, while 85.2% believed they had not received adequate training. Overall, 35.7% would be willing to be re-deployed, 30.3% stated they would not be willing to be re-deployed and 34% were unsure. Significantly fewer consultants would be willing to be re-deployed compared to registrars (31% vs 45%, respectively; p<0.05).

Effect on productivity

Overall, 51% of those surveyed felt there had been a significant reduction in theatre productivity (delays, reduced volume, longer wait times) due to COVID-19, while only 5% felt there had been no change. Of those who worked in Auckland, 70% felt there had been a significant reduction in theatre productivity compared to 41.2% of those who worked throughout the rest of New Zealand (Figure 1) (p<0.001).

Hospital preparedness

In total, 4% rated their hospital preparedness for COVID-19 as excellent, 21% as good, 48% as average and 27% as poor. Of those who worked in the North Island of New Zealand, 23% believed preparedness was good compared to 12% in the South Island. In the North Island, 6% believed it was excellent, while in the South Island no respondents felt their hospital preparedness was excellent, however, this did not reach a significant difference (p=0.147). Overall, 74% believed that health innovation (rapid tests, surveillance testing) had been used ineffectively in their hospitals.

Effect on training

Of the 51 training orthopaedic registrars surveyed, 55% felt that their training had been moderately affected, while 17% felt it had been significantly affected (Figure 2). Of the consultants surveyed, 36% and 17% felt training had been moderately and significantly affected, respectively. Of the 15 training registrars working in the Auckland region who responded to the survey, 93% felt that their training had either been moderately or significantly affected compared to 67% of training registrars throughout the rest of New Zealand, however, this did not reach statistical significance (p=0.262).

Of those surveyed, 86% had been utilising online teaching and 80% felt that these sessions were less useful than traditional in-person teaching sessions, while only 6% felt they were more useful. Remote access was felt to be the most useful aspect of online teaching (56%) followed by the ability to record the teaching sessions (34%). Only 10% felt more comfortable during online teaching, while 44.9% felt less comfortable and 45% felt there was no difference. However, 86% felt that these online sessions should continue to play a role in orthopaedic education.

Mental health

The effects of the pandemic on the mental health of those surveyed are shown in Figure 3. Sixty-five percent of all respondents felt the pandemic had had at least a mild effect on their mental health, while 3% stated COVID-19 had significantly impacted their mental health. This number was significantly higher in registrars compared to consultants (7% vs 2%; p=0.029). There were no differences between Auckland and the rest of New Zealand in terms of effects on mental health, with 24.3% of those in Auckland having a moderate or significant effect on their mental health compared to 19.3% in the rest of the country (p=0.362). Of the 135 consultants surveyed, 19.3% stated that the COVID-19 pandemic had led them to consider retirement.

Overall, 46.5% felt they were more burnt out because of the pandemic. Significantly more registrars surveyed felt more burnt out compared to consultants (51% vs 44%; p=0.029). There were no differences in the rates of burnout between consultants aged under 50 years and those over 50 years, with 46% and 44% feeling more burnt out respectively (p=0.676). Those working in a smaller district health board (DHB) region (population <200,000) reported higher rates of feeling burnt out compared to those working in a larger DHB; however, this did not reach statistical significance (58% vs 43%; p=0.259). There was no significant difference in the rates of burnout between Auckland and the rest of New Zealand (44% vs 47%, respectively; p=0.062).

With respect to concerns, 35% felt the reduction in productivity was the greatest concern, followed closely by concerns of passing COVID-19 on to family members and the impact on training (30% and 13%, respectively).

Telehealth

Of all respondents, 81% stated that telehealth phone consultations with patients were less effective than in-person consultations but still found they were valuable, while 11% felt telehealth was not useful.

View Tables 1 & Figures 1–3.

Discussion

COVID-19 has had a significant effect on training and mental health for orthopaedic surgeons and registrars in New Zealand. Around the world, elective orthopaedic surgery has mostly been suspended to reduce the spread of the virus and ensure health resources are used appropriately.[[2–4]] In New Zealand, up until the Omicron outbreak, there had been relatively few hospitalisations and deaths when compared to the rest of the world. As of 21 November 2021, when this survey was conducted, there had been 9,608 cases of COVID-19 and 46 deaths; at that time 83 patients were in hospital, 5 of which were in the intensive care unit/high dependency unit (ICU/HDU).[[7]] These comparatively low numbers were largely due to high vaccination rates and the response from the New Zealand Government, which involved the suspension of many business operations, strict social distancing measures, travel restrictions and the enforced use of quarantine.

Surgery for those who are positive for COVID-19 involves additional planning, extra equipment and intensive operating theatre cleaning, which is significantly time and resource consuming. Many hospitals have converted operating rooms to “COVID theatres”, dedicated to the treatment of only those with COVID-19. This is necessary to keep patients safe but comes at the expense of reduced operating capacity, resulting in delayed or cancelled surgery for other patients. We found that 51% of those surveyed felt there had been a significant reduction in theatre productivity. Several other studies from multiple countries have also shown significant reductions in both elective and trauma orthopaedic surgery case volumes during the pandemic.[[1,12,15–18]] A study of 43 Hong Kong public hospitals found a reduction in elective orthopaedic operations of 73.5%.[[15]] In Europe, survey results from orthopaedic surgeons suggested that 68.4% of elective orthopaedic surgery and 92.6% of arthroplasty surgery had been suspended.[[2]] In the United States, there are estimates that 30,000 arthroplasty operations have been cancelled each week.[[4]] It has been estimated that the backlog of patients around the world needing elective surgery could take over one year to clear.[[5]] Delayed or cancelled surgeries have a substantial physical and/or emotional impact on patients.[[19]]

Reductions in orthopaedic surgical and clinical volume also has a detrimental effect on training and education.[[2,5,12,13]] In our study, 72% of registrars and 53% of consultants felt that their training had been affected either moderately or significantly. In the United Kingdom, 69% of orthopaedic trainees felt the pandemic would result in a delay in completion of their orthopaedic training.[[16]] Similar surveys of orthopaedic trainees have found that 45.5% felt they would not acquire the expected surgical skills and as many as 25% believed an additional year of training was necessary.[[12]] Orthopaedic residency directors have expressed concerns about the negative impact of COVID-19 on training.[[13,20]] Education has also suffered through the cancellation of conferences and courses; online teaching has become commonplace during the pandemic, but both our study and others have found satisfaction with this is lower than traditional in-person teaching.[[21]]

The issue of surgeon burnout has received significant attention in recent years. As a specialty, orthopaedics has one of the highest rates of burnout with rates ranging from 40% to 60%.[[9,10,22,23]] Orthopaedic surgeons also have the highest prevalence of surgeon suicides among surgical specialties, comprising 28.2% of surgeon suicides from 2003 to 2017.[[24]] Our study found that nearly half of those surveyed felt more burnt out because of the pandemic. This is a significant finding given the already high rates of burnout in orthopaedics.

Recent research shows the stress and social isolation brought about by the pandemic has had a negative impact on the mental health of healthcare workers.[[25–27]] Chang et al.[[21]] found that the quality-of-life score for an orthopaedic registrar in South Korea decreased from 68.9 out of 100 prior to the pandemic to 61.7 during the pandemic. Our findings are similar to the current literature with 65% of consultants and registrars stating the pandemic had a mild or moderate effect on their mental health.

Our study also found that 75% of orthopaedic surgeons and training registrars believed their hospitals preparedness for COVID-19 was either average or poor. In a survey of the Polish Society of Orthopaedics and Traumatology in 2020, 82.6% believed the Polish healthcare system was not well prepared for the pandemic.[[12]] We also found that 84.9% of those surveyed felt they had not been adequately trained to provide non-orthopaedic care in the case of re-deployment. In a survey of 327 orthopaedic and trauma trainees throughout Europe, 60.3% had not been given any COVID-19 specific training.[[2]] Fortunately, only 1.6% of respondents in our study had been re-deployed— significantly fewer than many other institutions around the world, where between 15% and 25% of orthopaedic residents were re-deployed.[[1,12–14]]

There are limitations to this study. Despite the high response rate, response bias is inherent to any survey. Those affected by burnout may be less likely to respond as they are too busy. Conversely, they may be more likely to respond as they are most affected. The COVID-19 virus and the response to the pandemic are rapidly evolving and this survey provides only a snapshot of one point in time. This survey was completed approximately one month prior to the first community case of the Omicron variant and prior to the removal of the "red traffic light" restrictions. Now, the impact of service delivery and training has been felt across wider areas of New Zealand. Therefore, the results of this survey may not reflect the current situation in New Zealand. We intend on repeating this survey to gain further insight into this changing landscape.

This is the first study assessing the effects of COVID-19 on orthopaedic practise and training in New Zealand. Despite the comparatively low number of COVID-19 cases, hospitalisations and deaths by the time of this study, it is clear that the effects on orthopaedic surgeons and training registrars have been significant. It is crucial that as we work during this stressful and often frustrating time, there is an awareness of the impact the pandemic has had on the mental health of healthcare workers. Counselling services such as the Employment Assistance Programme need to be promoted and utilised. Additional counselling services and courses on managing stress and anxiety would be greatly beneficial.

The reductions in surgical efficiency and volume will have a significant impact on the New Zealand health system and the training of the next generation of surgeons. Strategies to facilitate training include online “virtual” teaching sessions which have now become commonplace in many hospitals and training programmes, including orthopaedic training in New Zealand. There are also significant learning opportunities in the private sector that have the potential to provide valuable experience for training registrars given the significant reduction in elective surgery in the public health system. In order to continue to provide the highest quality care to our patients, we must create innovative solutions and adapt to this ever-changing situation.

Summary

Abstract

Aim

This study aimed to assess the impact of COVID-19 on orthopaedic practice in New Zealand, with a focus on training and mental health.

Method

An online survey was sent to the 385 consultant orthopaedic surgeons and registrars in New Zealand registered with the New Zealand Orthopaedic Association (NZOA). The survey consisted of 27 questions relating to demographics, the effects of COVID-19 on orthopaedic departments, on training, on mental health and the utilisation of telehealth and online teaching.

Results

In total, 189 of 385 NZOA members (49%) completed the survey. Of the 51 orthopaedic registrars surveyed, 55% felt that their training had been moderately affected, while 17% felt it had been significantly affected. Of those surveyed, 65% felt the pandemic had at least a mild effect on their mental health. Seven percent of registrars described a significant impact on their mental health compared to 2% of consultants (p=0.029). Overall, 46.5% felt they were more burnt out because of the pandemic, which was significantly higher in registrars compared to consultants (51% vs 44%, respectively; p=0.029).

Conclusion

Despite the comparatively low number of COVID-19 cases, hospitalisations and deaths, the effects for orthopaedic surgeons and training registrars have been significant.

Author Information

Matthew J Bowman: Department of Orthopaedic Surgery, Hawkes Bay Fallen Soldiers Memorial Hospital, Camberley, Hastings, New Zealand. Scott M Bolam: Department of Orthopaedic Surgery, Auckland City Hospital, Grafton, Auckland; New Zealand Faculty of Medical and Health Sciences, The University of Auckland, Grafton, Auckland, New Zealand. Mark Wright: Department of Orthopaedic Surgery, Auckland City Hospital, Grafton, Auckland, New Zealand.

Acknowledgements

Correspondence

Dr Matthew J Bowman: Department of Orthopaedic Surgery, Hawkes Bay Fallen Soldiers Memorial Hospital, 398 Omahu Road, Camberley, Hastings, New Zealand.

Correspondence Email

mattbowmannz@gmail.com

Competing Interests

All authors have nothing to disclose. This research received no external funding. The study has been performed in accordance with the ethical standards in the 1964 Declaration of Helsinki.

1) Haffer H, Schömig F, Rickert M, Randau T, et al. Impact of the COVID-19 Pandemic on Orthopaedic and Trauma Surgery in University Hospitals in Germany: Results of a Nationwide Survey. J Bone Joint Surg. 2020 Jul 15;102(14):e78.

2) Thaler M, Khosravi I, Hirschmann MT, Kort NP, et al. Disruption of joint arthroplasty services in Europe during the COVID-19 pandemic: an online survey within the European Hip Society (EHS) and the European Knee Associates (EKA). Knee Surg Sports Traumatol Arthrosc. 2020 Jun;28(6):1712-9.

3) An TW, Henry JK, Igboechi O, Wang P, et al. How Are Orthopaedic Surgery Residencies Responding to the COVID-19 Pandemic? An Assessment of Resident Experiences in Cities of Major Virus Outbreak. J Am Acad Orthop Surg [Internet]. 2020 Jun 1 [cited 2022 Mar 27];Publish ahead of print. Available from: https://journals.lww.com/10.5435/JAAOS-D-20-00397.

4) Brown TS, Bedard NA, Rojas EO, Anthony CA, et al. The Effect of the COVID-19 Pandemic on Electively Scheduled Hip and Knee Arthroplasty Patients in the United States. J Arthroplasty. 2020 Jul;35(7):S49-55.

5) COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans: Elective surgery during the SARS-CoV-2 pandemic. Br J Surg [Internet]. 2020 Jun 13 [cited 2022 Apr 3]. Available from: https://academic.oup.com/bjs/article/107/11/1440-1449/6139510.

6) Heckmann ND, Bouz GJ, Piple AS, Chung BC, et al. Elective Inpatient Total Joint Arthroplasty Case Volume in the United States in 2020: Effects of the COVID-19 Pandemic. J Bone Joint Surg [Internet]. 2022 Mar 11 [cited 2022 May 29]; Published ahead of print. Available from: https://journals.lww.com/10.2106/JBJS.21.00833.

7) Ministry of Health. 12 DHBs pass 90% first dose vaccinations; over 1 million My Vaccine Passes created; 83 in hospital & five in ICU; 149 cases [Internet]. Health.govt.nz. 2021. Available from: https://www.health.govt.nz/news-media/media-releases/12-dhbs-pass-90-first-dose-vaccinations-over-1-million-my-vaccine-passes-created-83-hospital-five.

8) Verret CI, Nguyen J, Verret C, Albert TJ, et al. How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents? Clin Orthop Relat Res. 2021 Feb;479(2):251-62.

9) Shanafelt TD, Balch CM, Bechamps GJ, Russell T, et al. Burnout and Career Satisfaction Among American Surgeons. Ann Surg. 2009 Sep;250(3):463-71.

10) Arora M, Diwan AD, Harris IA. Prevalence and Factors of Burnout among Australian Orthopaedic Trainees: A Cross-Sectional Study. J Orthop Surg. 2014 Dec;22(3):374-7.

11) Thakrar A, Raheem A, Chui K, Karam E, et al. Trauma and orthopaedic team members’ mental health during the COVID-19 pandemic. Bone Joint Open. 2020;1(6):10.

12) Megaloikonomos PD, Thaler M, Igoumenou VG, Bonanzinga T, et al. Impact of the COVID-19 pandemic on orthopaedic and trauma surgery training in Europe. Int Orthop. 2020 Sep;44(9):1611-9.

13) Heaps BM, Dugas JR, Limpisvasti O. The Impact of COVID-19 on Orthopedic Surgery Fellowship Training: A Survey of Fellowship Program Directors. HSS J. 2022 Feb;18(1):105-9.

14) Culp BM, Frisch NB. COVID-19 Impact on Young Arthroplasty Surgeons. J Arthroplasty. 2020 Jul;35(7):S42-4.

15) Wong JSH, Cheung KMC. Impact of COVID-19 on Orthopaedic and Trauma Service: An Epidemiological Study. J Bone Joint Surg. 2020 Jul 15;102(14):e80.

16) Khan H, Williamson M, Trompeter A. The impact of the COVID-19 pandemic on orthopaedic services and training in the UK. Eur J Orthop Surg Traumatol. 2021 Jan;31(1):105-9.

17) Zahid M, Ali A, Baloch NJ, Noordin S. Effects of coronavirus (COVID-19) pandemic on orthopedic residency program in the seventh largest city of the world: Recommendations from a resource-constrained setting. Ann Med Surg. 2020 Aug;56:142-4.

18) Probert AC, Sivakumar BS, An V, Nicholls SL, et al. Impact of COVID ‐19‐related social restrictions on orthopaedic trauma in a level 1 trauma centre in Sydney: the first wave. ANZ J Surg. 2021 Jan;91(1–2):68-72.

19) Sequeira SB, Novicoff WM, McVey ED, Noble DM, et al. Patient Perspectives on the Cancellation of Elective Primary Hip and Knee Arthroplasty During the COVID-19 Pandemic. J Am Acad Orthop Surg [Internet]. 2021 Feb 1 [cited 2022 Apr 3]; Published ahead of print. Available from: https://journals.lww.com/10.5435/JAAOS-D-20-00765.

20) Levidy MF, Dobitsch A, Luis J, Fano AN, et al. A Review of Orthopaedic Resident Case Logs to Identify Fluctuations in Exposure to Adult Orthopaedic Procedures. JBJS Open Access [Internet]. 2021 [cited 2022 Mar 27];6(3). Available from: https://journals.lww.com/10.2106/JBJS.OA.21.00023.

21) Chang DG, Park JB, Baek GH, Kim HJ, et al. The impact of COVID-19 pandemic on orthopaedic resident education: a nationwide survey study in South Korea. Int Orthop. 2020 Nov;44(11):2203-10.

22) Sargent MC, Sotile W, Sotile MO, Rubash H, et al. Stress And Coping Among Orthopaedic Surgery Residents And Faculty: J Bone Joint Surg. 2004 Jul;86(7):1579-86.

23) Saleh KJ, Quick JC, Conaway M, Sime WE, et al. The Prevalence and Severity of Burnout Among Academic Orthopaedic Departmental Leaders*: J Bone Joint Surg. 2007 Apr;89(4):896-903.

24) Elkbuli A, Sutherland M, Shepherd A, Kinslow K, et al. Factors Influencing US Physician and Surgeon Suicide Rates 2003-2017: Analysis of the CDC-National Violent Death Reporting System. Ann Surg [Internet]. 2020 Nov 4 [cited 2022 Jun 8]; Published ahead of print. Available from: https://journals.lww.com/10.1097/SLA.0000000000004575.

25) Shen M, Xu H, Fu J, Wang T, et al. Investigation of anxiety levels of 1637 healthcare workers during the epidemic of COVID-19. Aboelhadid SM, editor. PLoS One. 2020 Dec 22;15(12):e0243890.

26) Luo M, Guo L, Yu M, Jiang, et al. The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public – A systematic review and meta-analysis. Psychiatry Res. 2020 Sep;291:113190.

27) Kannampallil TG, Goss CW, Evanoff BA, Strickland JR, et al. Duncan J. Exposure to COVID-19 patients increases physician trainee stress and burnout. Murakami M, editor. PLoS One. 2020 Aug 6;15(8):e0237301.

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A new type of viral pneumonia was recognised in Wuhan, China in December 2019. By January 2020, this was identified as a type of coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first case of SARS-CoV-2 detected in Aotearoa New Zealand was on 28 February 2020, and on 11 March 2020 the World Health Organization formally declared a coronavirus disease 2019 (COVID-19) pandemic. Many health systems around the world were quickly overwhelmed with high rates of hospitalisations and deaths. In many countries elective surgery was suspended in order to rationalise staff and resources.[[1–4]]

In 2020, it was estimated that during the 12 weeks of peak disruption of all elective surgery across 190 countries, 28,404,603 operations would be cancelled or postponed.[[5]] This represents a cancellation rate of all elective surgeries of 72.3%. Using surgical data collected during 2020, Heckmann et al.[[6]] estimated that the nationwide volume in the United States of elective hip and knee arthroplasty cases decreased by 46.5% to 47.7% from the prior 3-year average. Furthermore, the elective hip and knee arthroplasty case volume for April 2020 was 1.9% of the volume for the same month in 2017 through 2019.

Although the New Zealand healthcare system has not been affected to the same extent as many other countries, the pandemic has still had a significant impact on most specialties and many patients. At the time of this survey—21 November 2021—there had been 9,608 cases of COVID-19 and 46 deaths with 83 patients in hospital, 5 of whom were in the intensive care unit/high dependency unit (ICU/HDU).[[7]] In comparison to most other countries, these are relatively low numbers, which is the result of multiple factors including the geography of our island nation, the high vaccination rate (83% double vaccinated as of 21 November 2021) and the control measures implemented by the government.

Mental health issues including burnout are prevalent in orthopaedics, particularly among registrars.[[8–10]] In a recent study, Verret et al.[[8]] found that 34% of orthopaedic residents reported high levels of depersonalisation compared to 9% of consultants. In a survey to assess the impact of the pandemic on the mental health of the orthopaedic workforce, Thakrar et al.[[11]] found significantly higher rates of generalised anxiety disorder and major depressive episodes when compared to the general population.

We hypothesised that COVID-19 had significantly impacted the training of Surgical Education and Training (SET) registrars. We also hypothesised that the pandemic has had a detrimental effect on the mental health of surgeons and registrars. The purpose of this study was to assess the impact of COVID-19 on orthopaedic practice in New Zealand, including the impact on orthopaedic training and the mental health of surgeons and registrars.

Methods

With the assistance and permission of the New Zealand Orthopaedic Association (NZOA), consultant orthopaedic surgeons and SET orthopaedic registrars were asked to complete an electronic survey relating to the impact of COVID-19 on their practice, training and wellbeing. This nationwide survey was conducted in November 2021 and was sent to all 385 members of the NZOA, the organisation with which all practising orthopaedic surgeons and SET registrars in New Zealand must be registered. The survey was administered using Survey Monkey (Palo Alto, CA, USA). Following the initial email, two reminder emails were sent one and two weeks later.

The survey was comprised of 27 questions relating to demographics, the effects of COVID-19 on orthopaedic departments, on orthopaedic training, on mental health and the utilisation of telehealth and online teaching. The option of adding comments as free text after each question was made available. Demographic data collected included age, training level, and location of practice. Data was collected from both the public health sector as well as the private health sector. The public sector is managed by Te Whatu Ora – Health New Zealand with funding from the Government. The private sector is funded by insurers, the Accident Compensation Corporation (ACC) or the individual. Prior to distribution, the survey was validated by a consultant orthopaedic surgeon and two orthopaedic registrars. The survey was anonymised with a response window of one month.

Significance testing was performed with Prism 8 (GraphPad, San Diego, CA, USA). Differences were determined with Fisher’s exact test or Chi-squared tests and a p-value of <0.05 was considered significant. The study methodology was reviewed by the Health and Disability Ethics Committees (HDEC) and did not require a formal ethical review.

Results

Demographics

The nationwide survey received 189 responses from the 385 NZOA members, a response rate of 49%. Responses were received from 135 of 320 orthopaedic consultants (42%), 51 of 62 SET orthopaedic registrars (82%) and 3 orthopaedic fellows. Demographic details are shown in Table 1.

Effect on practice

All respondents were vaccinated, with 188 of the 189 respondents being double vaccinated. One person had only received a single dose of the vaccine. At the time of the survey, 10.8% of respondents had treated a patient with an active COVID-19 infection and 15% had been stood down from work to self-isolate due to COVID-19 exposure. None of the respondents had tested positive for COVID-19.

Of those surveyed, 1.6% had been re-deployed to work in an area outside of orthopaedics (two consultants and one SET registrar). Overall, 14.8% felt they had been adequately trained to work outside their scope of practice, while 85.2% believed they had not received adequate training. Overall, 35.7% would be willing to be re-deployed, 30.3% stated they would not be willing to be re-deployed and 34% were unsure. Significantly fewer consultants would be willing to be re-deployed compared to registrars (31% vs 45%, respectively; p<0.05).

Effect on productivity

Overall, 51% of those surveyed felt there had been a significant reduction in theatre productivity (delays, reduced volume, longer wait times) due to COVID-19, while only 5% felt there had been no change. Of those who worked in Auckland, 70% felt there had been a significant reduction in theatre productivity compared to 41.2% of those who worked throughout the rest of New Zealand (Figure 1) (p<0.001).

Hospital preparedness

In total, 4% rated their hospital preparedness for COVID-19 as excellent, 21% as good, 48% as average and 27% as poor. Of those who worked in the North Island of New Zealand, 23% believed preparedness was good compared to 12% in the South Island. In the North Island, 6% believed it was excellent, while in the South Island no respondents felt their hospital preparedness was excellent, however, this did not reach a significant difference (p=0.147). Overall, 74% believed that health innovation (rapid tests, surveillance testing) had been used ineffectively in their hospitals.

Effect on training

Of the 51 training orthopaedic registrars surveyed, 55% felt that their training had been moderately affected, while 17% felt it had been significantly affected (Figure 2). Of the consultants surveyed, 36% and 17% felt training had been moderately and significantly affected, respectively. Of the 15 training registrars working in the Auckland region who responded to the survey, 93% felt that their training had either been moderately or significantly affected compared to 67% of training registrars throughout the rest of New Zealand, however, this did not reach statistical significance (p=0.262).

Of those surveyed, 86% had been utilising online teaching and 80% felt that these sessions were less useful than traditional in-person teaching sessions, while only 6% felt they were more useful. Remote access was felt to be the most useful aspect of online teaching (56%) followed by the ability to record the teaching sessions (34%). Only 10% felt more comfortable during online teaching, while 44.9% felt less comfortable and 45% felt there was no difference. However, 86% felt that these online sessions should continue to play a role in orthopaedic education.

Mental health

The effects of the pandemic on the mental health of those surveyed are shown in Figure 3. Sixty-five percent of all respondents felt the pandemic had had at least a mild effect on their mental health, while 3% stated COVID-19 had significantly impacted their mental health. This number was significantly higher in registrars compared to consultants (7% vs 2%; p=0.029). There were no differences between Auckland and the rest of New Zealand in terms of effects on mental health, with 24.3% of those in Auckland having a moderate or significant effect on their mental health compared to 19.3% in the rest of the country (p=0.362). Of the 135 consultants surveyed, 19.3% stated that the COVID-19 pandemic had led them to consider retirement.

Overall, 46.5% felt they were more burnt out because of the pandemic. Significantly more registrars surveyed felt more burnt out compared to consultants (51% vs 44%; p=0.029). There were no differences in the rates of burnout between consultants aged under 50 years and those over 50 years, with 46% and 44% feeling more burnt out respectively (p=0.676). Those working in a smaller district health board (DHB) region (population <200,000) reported higher rates of feeling burnt out compared to those working in a larger DHB; however, this did not reach statistical significance (58% vs 43%; p=0.259). There was no significant difference in the rates of burnout between Auckland and the rest of New Zealand (44% vs 47%, respectively; p=0.062).

With respect to concerns, 35% felt the reduction in productivity was the greatest concern, followed closely by concerns of passing COVID-19 on to family members and the impact on training (30% and 13%, respectively).

Telehealth

Of all respondents, 81% stated that telehealth phone consultations with patients were less effective than in-person consultations but still found they were valuable, while 11% felt telehealth was not useful.

View Tables 1 & Figures 1–3.

Discussion

COVID-19 has had a significant effect on training and mental health for orthopaedic surgeons and registrars in New Zealand. Around the world, elective orthopaedic surgery has mostly been suspended to reduce the spread of the virus and ensure health resources are used appropriately.[[2–4]] In New Zealand, up until the Omicron outbreak, there had been relatively few hospitalisations and deaths when compared to the rest of the world. As of 21 November 2021, when this survey was conducted, there had been 9,608 cases of COVID-19 and 46 deaths; at that time 83 patients were in hospital, 5 of which were in the intensive care unit/high dependency unit (ICU/HDU).[[7]] These comparatively low numbers were largely due to high vaccination rates and the response from the New Zealand Government, which involved the suspension of many business operations, strict social distancing measures, travel restrictions and the enforced use of quarantine.

Surgery for those who are positive for COVID-19 involves additional planning, extra equipment and intensive operating theatre cleaning, which is significantly time and resource consuming. Many hospitals have converted operating rooms to “COVID theatres”, dedicated to the treatment of only those with COVID-19. This is necessary to keep patients safe but comes at the expense of reduced operating capacity, resulting in delayed or cancelled surgery for other patients. We found that 51% of those surveyed felt there had been a significant reduction in theatre productivity. Several other studies from multiple countries have also shown significant reductions in both elective and trauma orthopaedic surgery case volumes during the pandemic.[[1,12,15–18]] A study of 43 Hong Kong public hospitals found a reduction in elective orthopaedic operations of 73.5%.[[15]] In Europe, survey results from orthopaedic surgeons suggested that 68.4% of elective orthopaedic surgery and 92.6% of arthroplasty surgery had been suspended.[[2]] In the United States, there are estimates that 30,000 arthroplasty operations have been cancelled each week.[[4]] It has been estimated that the backlog of patients around the world needing elective surgery could take over one year to clear.[[5]] Delayed or cancelled surgeries have a substantial physical and/or emotional impact on patients.[[19]]

Reductions in orthopaedic surgical and clinical volume also has a detrimental effect on training and education.[[2,5,12,13]] In our study, 72% of registrars and 53% of consultants felt that their training had been affected either moderately or significantly. In the United Kingdom, 69% of orthopaedic trainees felt the pandemic would result in a delay in completion of their orthopaedic training.[[16]] Similar surveys of orthopaedic trainees have found that 45.5% felt they would not acquire the expected surgical skills and as many as 25% believed an additional year of training was necessary.[[12]] Orthopaedic residency directors have expressed concerns about the negative impact of COVID-19 on training.[[13,20]] Education has also suffered through the cancellation of conferences and courses; online teaching has become commonplace during the pandemic, but both our study and others have found satisfaction with this is lower than traditional in-person teaching.[[21]]

The issue of surgeon burnout has received significant attention in recent years. As a specialty, orthopaedics has one of the highest rates of burnout with rates ranging from 40% to 60%.[[9,10,22,23]] Orthopaedic surgeons also have the highest prevalence of surgeon suicides among surgical specialties, comprising 28.2% of surgeon suicides from 2003 to 2017.[[24]] Our study found that nearly half of those surveyed felt more burnt out because of the pandemic. This is a significant finding given the already high rates of burnout in orthopaedics.

Recent research shows the stress and social isolation brought about by the pandemic has had a negative impact on the mental health of healthcare workers.[[25–27]] Chang et al.[[21]] found that the quality-of-life score for an orthopaedic registrar in South Korea decreased from 68.9 out of 100 prior to the pandemic to 61.7 during the pandemic. Our findings are similar to the current literature with 65% of consultants and registrars stating the pandemic had a mild or moderate effect on their mental health.

Our study also found that 75% of orthopaedic surgeons and training registrars believed their hospitals preparedness for COVID-19 was either average or poor. In a survey of the Polish Society of Orthopaedics and Traumatology in 2020, 82.6% believed the Polish healthcare system was not well prepared for the pandemic.[[12]] We also found that 84.9% of those surveyed felt they had not been adequately trained to provide non-orthopaedic care in the case of re-deployment. In a survey of 327 orthopaedic and trauma trainees throughout Europe, 60.3% had not been given any COVID-19 specific training.[[2]] Fortunately, only 1.6% of respondents in our study had been re-deployed— significantly fewer than many other institutions around the world, where between 15% and 25% of orthopaedic residents were re-deployed.[[1,12–14]]

There are limitations to this study. Despite the high response rate, response bias is inherent to any survey. Those affected by burnout may be less likely to respond as they are too busy. Conversely, they may be more likely to respond as they are most affected. The COVID-19 virus and the response to the pandemic are rapidly evolving and this survey provides only a snapshot of one point in time. This survey was completed approximately one month prior to the first community case of the Omicron variant and prior to the removal of the "red traffic light" restrictions. Now, the impact of service delivery and training has been felt across wider areas of New Zealand. Therefore, the results of this survey may not reflect the current situation in New Zealand. We intend on repeating this survey to gain further insight into this changing landscape.

This is the first study assessing the effects of COVID-19 on orthopaedic practise and training in New Zealand. Despite the comparatively low number of COVID-19 cases, hospitalisations and deaths by the time of this study, it is clear that the effects on orthopaedic surgeons and training registrars have been significant. It is crucial that as we work during this stressful and often frustrating time, there is an awareness of the impact the pandemic has had on the mental health of healthcare workers. Counselling services such as the Employment Assistance Programme need to be promoted and utilised. Additional counselling services and courses on managing stress and anxiety would be greatly beneficial.

The reductions in surgical efficiency and volume will have a significant impact on the New Zealand health system and the training of the next generation of surgeons. Strategies to facilitate training include online “virtual” teaching sessions which have now become commonplace in many hospitals and training programmes, including orthopaedic training in New Zealand. There are also significant learning opportunities in the private sector that have the potential to provide valuable experience for training registrars given the significant reduction in elective surgery in the public health system. In order to continue to provide the highest quality care to our patients, we must create innovative solutions and adapt to this ever-changing situation.

Summary

Abstract

Aim

This study aimed to assess the impact of COVID-19 on orthopaedic practice in New Zealand, with a focus on training and mental health.

Method

An online survey was sent to the 385 consultant orthopaedic surgeons and registrars in New Zealand registered with the New Zealand Orthopaedic Association (NZOA). The survey consisted of 27 questions relating to demographics, the effects of COVID-19 on orthopaedic departments, on training, on mental health and the utilisation of telehealth and online teaching.

Results

In total, 189 of 385 NZOA members (49%) completed the survey. Of the 51 orthopaedic registrars surveyed, 55% felt that their training had been moderately affected, while 17% felt it had been significantly affected. Of those surveyed, 65% felt the pandemic had at least a mild effect on their mental health. Seven percent of registrars described a significant impact on their mental health compared to 2% of consultants (p=0.029). Overall, 46.5% felt they were more burnt out because of the pandemic, which was significantly higher in registrars compared to consultants (51% vs 44%, respectively; p=0.029).

Conclusion

Despite the comparatively low number of COVID-19 cases, hospitalisations and deaths, the effects for orthopaedic surgeons and training registrars have been significant.

Author Information

Matthew J Bowman: Department of Orthopaedic Surgery, Hawkes Bay Fallen Soldiers Memorial Hospital, Camberley, Hastings, New Zealand. Scott M Bolam: Department of Orthopaedic Surgery, Auckland City Hospital, Grafton, Auckland; New Zealand Faculty of Medical and Health Sciences, The University of Auckland, Grafton, Auckland, New Zealand. Mark Wright: Department of Orthopaedic Surgery, Auckland City Hospital, Grafton, Auckland, New Zealand.

Acknowledgements

Correspondence

Dr Matthew J Bowman: Department of Orthopaedic Surgery, Hawkes Bay Fallen Soldiers Memorial Hospital, 398 Omahu Road, Camberley, Hastings, New Zealand.

Correspondence Email

mattbowmannz@gmail.com

Competing Interests

All authors have nothing to disclose. This research received no external funding. The study has been performed in accordance with the ethical standards in the 1964 Declaration of Helsinki.

1) Haffer H, Schömig F, Rickert M, Randau T, et al. Impact of the COVID-19 Pandemic on Orthopaedic and Trauma Surgery in University Hospitals in Germany: Results of a Nationwide Survey. J Bone Joint Surg. 2020 Jul 15;102(14):e78.

2) Thaler M, Khosravi I, Hirschmann MT, Kort NP, et al. Disruption of joint arthroplasty services in Europe during the COVID-19 pandemic: an online survey within the European Hip Society (EHS) and the European Knee Associates (EKA). Knee Surg Sports Traumatol Arthrosc. 2020 Jun;28(6):1712-9.

3) An TW, Henry JK, Igboechi O, Wang P, et al. How Are Orthopaedic Surgery Residencies Responding to the COVID-19 Pandemic? An Assessment of Resident Experiences in Cities of Major Virus Outbreak. J Am Acad Orthop Surg [Internet]. 2020 Jun 1 [cited 2022 Mar 27];Publish ahead of print. Available from: https://journals.lww.com/10.5435/JAAOS-D-20-00397.

4) Brown TS, Bedard NA, Rojas EO, Anthony CA, et al. The Effect of the COVID-19 Pandemic on Electively Scheduled Hip and Knee Arthroplasty Patients in the United States. J Arthroplasty. 2020 Jul;35(7):S49-55.

5) COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans: Elective surgery during the SARS-CoV-2 pandemic. Br J Surg [Internet]. 2020 Jun 13 [cited 2022 Apr 3]. Available from: https://academic.oup.com/bjs/article/107/11/1440-1449/6139510.

6) Heckmann ND, Bouz GJ, Piple AS, Chung BC, et al. Elective Inpatient Total Joint Arthroplasty Case Volume in the United States in 2020: Effects of the COVID-19 Pandemic. J Bone Joint Surg [Internet]. 2022 Mar 11 [cited 2022 May 29]; Published ahead of print. Available from: https://journals.lww.com/10.2106/JBJS.21.00833.

7) Ministry of Health. 12 DHBs pass 90% first dose vaccinations; over 1 million My Vaccine Passes created; 83 in hospital & five in ICU; 149 cases [Internet]. Health.govt.nz. 2021. Available from: https://www.health.govt.nz/news-media/media-releases/12-dhbs-pass-90-first-dose-vaccinations-over-1-million-my-vaccine-passes-created-83-hospital-five.

8) Verret CI, Nguyen J, Verret C, Albert TJ, et al. How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents? Clin Orthop Relat Res. 2021 Feb;479(2):251-62.

9) Shanafelt TD, Balch CM, Bechamps GJ, Russell T, et al. Burnout and Career Satisfaction Among American Surgeons. Ann Surg. 2009 Sep;250(3):463-71.

10) Arora M, Diwan AD, Harris IA. Prevalence and Factors of Burnout among Australian Orthopaedic Trainees: A Cross-Sectional Study. J Orthop Surg. 2014 Dec;22(3):374-7.

11) Thakrar A, Raheem A, Chui K, Karam E, et al. Trauma and orthopaedic team members’ mental health during the COVID-19 pandemic. Bone Joint Open. 2020;1(6):10.

12) Megaloikonomos PD, Thaler M, Igoumenou VG, Bonanzinga T, et al. Impact of the COVID-19 pandemic on orthopaedic and trauma surgery training in Europe. Int Orthop. 2020 Sep;44(9):1611-9.

13) Heaps BM, Dugas JR, Limpisvasti O. The Impact of COVID-19 on Orthopedic Surgery Fellowship Training: A Survey of Fellowship Program Directors. HSS J. 2022 Feb;18(1):105-9.

14) Culp BM, Frisch NB. COVID-19 Impact on Young Arthroplasty Surgeons. J Arthroplasty. 2020 Jul;35(7):S42-4.

15) Wong JSH, Cheung KMC. Impact of COVID-19 on Orthopaedic and Trauma Service: An Epidemiological Study. J Bone Joint Surg. 2020 Jul 15;102(14):e80.

16) Khan H, Williamson M, Trompeter A. The impact of the COVID-19 pandemic on orthopaedic services and training in the UK. Eur J Orthop Surg Traumatol. 2021 Jan;31(1):105-9.

17) Zahid M, Ali A, Baloch NJ, Noordin S. Effects of coronavirus (COVID-19) pandemic on orthopedic residency program in the seventh largest city of the world: Recommendations from a resource-constrained setting. Ann Med Surg. 2020 Aug;56:142-4.

18) Probert AC, Sivakumar BS, An V, Nicholls SL, et al. Impact of COVID ‐19‐related social restrictions on orthopaedic trauma in a level 1 trauma centre in Sydney: the first wave. ANZ J Surg. 2021 Jan;91(1–2):68-72.

19) Sequeira SB, Novicoff WM, McVey ED, Noble DM, et al. Patient Perspectives on the Cancellation of Elective Primary Hip and Knee Arthroplasty During the COVID-19 Pandemic. J Am Acad Orthop Surg [Internet]. 2021 Feb 1 [cited 2022 Apr 3]; Published ahead of print. Available from: https://journals.lww.com/10.5435/JAAOS-D-20-00765.

20) Levidy MF, Dobitsch A, Luis J, Fano AN, et al. A Review of Orthopaedic Resident Case Logs to Identify Fluctuations in Exposure to Adult Orthopaedic Procedures. JBJS Open Access [Internet]. 2021 [cited 2022 Mar 27];6(3). Available from: https://journals.lww.com/10.2106/JBJS.OA.21.00023.

21) Chang DG, Park JB, Baek GH, Kim HJ, et al. The impact of COVID-19 pandemic on orthopaedic resident education: a nationwide survey study in South Korea. Int Orthop. 2020 Nov;44(11):2203-10.

22) Sargent MC, Sotile W, Sotile MO, Rubash H, et al. Stress And Coping Among Orthopaedic Surgery Residents And Faculty: J Bone Joint Surg. 2004 Jul;86(7):1579-86.

23) Saleh KJ, Quick JC, Conaway M, Sime WE, et al. The Prevalence and Severity of Burnout Among Academic Orthopaedic Departmental Leaders*: J Bone Joint Surg. 2007 Apr;89(4):896-903.

24) Elkbuli A, Sutherland M, Shepherd A, Kinslow K, et al. Factors Influencing US Physician and Surgeon Suicide Rates 2003-2017: Analysis of the CDC-National Violent Death Reporting System. Ann Surg [Internet]. 2020 Nov 4 [cited 2022 Jun 8]; Published ahead of print. Available from: https://journals.lww.com/10.1097/SLA.0000000000004575.

25) Shen M, Xu H, Fu J, Wang T, et al. Investigation of anxiety levels of 1637 healthcare workers during the epidemic of COVID-19. Aboelhadid SM, editor. PLoS One. 2020 Dec 22;15(12):e0243890.

26) Luo M, Guo L, Yu M, Jiang, et al. The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public – A systematic review and meta-analysis. Psychiatry Res. 2020 Sep;291:113190.

27) Kannampallil TG, Goss CW, Evanoff BA, Strickland JR, et al. Duncan J. Exposure to COVID-19 patients increases physician trainee stress and burnout. Murakami M, editor. PLoS One. 2020 Aug 6;15(8):e0237301.

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A new type of viral pneumonia was recognised in Wuhan, China in December 2019. By January 2020, this was identified as a type of coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first case of SARS-CoV-2 detected in Aotearoa New Zealand was on 28 February 2020, and on 11 March 2020 the World Health Organization formally declared a coronavirus disease 2019 (COVID-19) pandemic. Many health systems around the world were quickly overwhelmed with high rates of hospitalisations and deaths. In many countries elective surgery was suspended in order to rationalise staff and resources.[[1–4]]

In 2020, it was estimated that during the 12 weeks of peak disruption of all elective surgery across 190 countries, 28,404,603 operations would be cancelled or postponed.[[5]] This represents a cancellation rate of all elective surgeries of 72.3%. Using surgical data collected during 2020, Heckmann et al.[[6]] estimated that the nationwide volume in the United States of elective hip and knee arthroplasty cases decreased by 46.5% to 47.7% from the prior 3-year average. Furthermore, the elective hip and knee arthroplasty case volume for April 2020 was 1.9% of the volume for the same month in 2017 through 2019.

Although the New Zealand healthcare system has not been affected to the same extent as many other countries, the pandemic has still had a significant impact on most specialties and many patients. At the time of this survey—21 November 2021—there had been 9,608 cases of COVID-19 and 46 deaths with 83 patients in hospital, 5 of whom were in the intensive care unit/high dependency unit (ICU/HDU).[[7]] In comparison to most other countries, these are relatively low numbers, which is the result of multiple factors including the geography of our island nation, the high vaccination rate (83% double vaccinated as of 21 November 2021) and the control measures implemented by the government.

Mental health issues including burnout are prevalent in orthopaedics, particularly among registrars.[[8–10]] In a recent study, Verret et al.[[8]] found that 34% of orthopaedic residents reported high levels of depersonalisation compared to 9% of consultants. In a survey to assess the impact of the pandemic on the mental health of the orthopaedic workforce, Thakrar et al.[[11]] found significantly higher rates of generalised anxiety disorder and major depressive episodes when compared to the general population.

We hypothesised that COVID-19 had significantly impacted the training of Surgical Education and Training (SET) registrars. We also hypothesised that the pandemic has had a detrimental effect on the mental health of surgeons and registrars. The purpose of this study was to assess the impact of COVID-19 on orthopaedic practice in New Zealand, including the impact on orthopaedic training and the mental health of surgeons and registrars.

Methods

With the assistance and permission of the New Zealand Orthopaedic Association (NZOA), consultant orthopaedic surgeons and SET orthopaedic registrars were asked to complete an electronic survey relating to the impact of COVID-19 on their practice, training and wellbeing. This nationwide survey was conducted in November 2021 and was sent to all 385 members of the NZOA, the organisation with which all practising orthopaedic surgeons and SET registrars in New Zealand must be registered. The survey was administered using Survey Monkey (Palo Alto, CA, USA). Following the initial email, two reminder emails were sent one and two weeks later.

The survey was comprised of 27 questions relating to demographics, the effects of COVID-19 on orthopaedic departments, on orthopaedic training, on mental health and the utilisation of telehealth and online teaching. The option of adding comments as free text after each question was made available. Demographic data collected included age, training level, and location of practice. Data was collected from both the public health sector as well as the private health sector. The public sector is managed by Te Whatu Ora – Health New Zealand with funding from the Government. The private sector is funded by insurers, the Accident Compensation Corporation (ACC) or the individual. Prior to distribution, the survey was validated by a consultant orthopaedic surgeon and two orthopaedic registrars. The survey was anonymised with a response window of one month.

Significance testing was performed with Prism 8 (GraphPad, San Diego, CA, USA). Differences were determined with Fisher’s exact test or Chi-squared tests and a p-value of <0.05 was considered significant. The study methodology was reviewed by the Health and Disability Ethics Committees (HDEC) and did not require a formal ethical review.

Results

Demographics

The nationwide survey received 189 responses from the 385 NZOA members, a response rate of 49%. Responses were received from 135 of 320 orthopaedic consultants (42%), 51 of 62 SET orthopaedic registrars (82%) and 3 orthopaedic fellows. Demographic details are shown in Table 1.

Effect on practice

All respondents were vaccinated, with 188 of the 189 respondents being double vaccinated. One person had only received a single dose of the vaccine. At the time of the survey, 10.8% of respondents had treated a patient with an active COVID-19 infection and 15% had been stood down from work to self-isolate due to COVID-19 exposure. None of the respondents had tested positive for COVID-19.

Of those surveyed, 1.6% had been re-deployed to work in an area outside of orthopaedics (two consultants and one SET registrar). Overall, 14.8% felt they had been adequately trained to work outside their scope of practice, while 85.2% believed they had not received adequate training. Overall, 35.7% would be willing to be re-deployed, 30.3% stated they would not be willing to be re-deployed and 34% were unsure. Significantly fewer consultants would be willing to be re-deployed compared to registrars (31% vs 45%, respectively; p<0.05).

Effect on productivity

Overall, 51% of those surveyed felt there had been a significant reduction in theatre productivity (delays, reduced volume, longer wait times) due to COVID-19, while only 5% felt there had been no change. Of those who worked in Auckland, 70% felt there had been a significant reduction in theatre productivity compared to 41.2% of those who worked throughout the rest of New Zealand (Figure 1) (p<0.001).

Hospital preparedness

In total, 4% rated their hospital preparedness for COVID-19 as excellent, 21% as good, 48% as average and 27% as poor. Of those who worked in the North Island of New Zealand, 23% believed preparedness was good compared to 12% in the South Island. In the North Island, 6% believed it was excellent, while in the South Island no respondents felt their hospital preparedness was excellent, however, this did not reach a significant difference (p=0.147). Overall, 74% believed that health innovation (rapid tests, surveillance testing) had been used ineffectively in their hospitals.

Effect on training

Of the 51 training orthopaedic registrars surveyed, 55% felt that their training had been moderately affected, while 17% felt it had been significantly affected (Figure 2). Of the consultants surveyed, 36% and 17% felt training had been moderately and significantly affected, respectively. Of the 15 training registrars working in the Auckland region who responded to the survey, 93% felt that their training had either been moderately or significantly affected compared to 67% of training registrars throughout the rest of New Zealand, however, this did not reach statistical significance (p=0.262).

Of those surveyed, 86% had been utilising online teaching and 80% felt that these sessions were less useful than traditional in-person teaching sessions, while only 6% felt they were more useful. Remote access was felt to be the most useful aspect of online teaching (56%) followed by the ability to record the teaching sessions (34%). Only 10% felt more comfortable during online teaching, while 44.9% felt less comfortable and 45% felt there was no difference. However, 86% felt that these online sessions should continue to play a role in orthopaedic education.

Mental health

The effects of the pandemic on the mental health of those surveyed are shown in Figure 3. Sixty-five percent of all respondents felt the pandemic had had at least a mild effect on their mental health, while 3% stated COVID-19 had significantly impacted their mental health. This number was significantly higher in registrars compared to consultants (7% vs 2%; p=0.029). There were no differences between Auckland and the rest of New Zealand in terms of effects on mental health, with 24.3% of those in Auckland having a moderate or significant effect on their mental health compared to 19.3% in the rest of the country (p=0.362). Of the 135 consultants surveyed, 19.3% stated that the COVID-19 pandemic had led them to consider retirement.

Overall, 46.5% felt they were more burnt out because of the pandemic. Significantly more registrars surveyed felt more burnt out compared to consultants (51% vs 44%; p=0.029). There were no differences in the rates of burnout between consultants aged under 50 years and those over 50 years, with 46% and 44% feeling more burnt out respectively (p=0.676). Those working in a smaller district health board (DHB) region (population <200,000) reported higher rates of feeling burnt out compared to those working in a larger DHB; however, this did not reach statistical significance (58% vs 43%; p=0.259). There was no significant difference in the rates of burnout between Auckland and the rest of New Zealand (44% vs 47%, respectively; p=0.062).

With respect to concerns, 35% felt the reduction in productivity was the greatest concern, followed closely by concerns of passing COVID-19 on to family members and the impact on training (30% and 13%, respectively).

Telehealth

Of all respondents, 81% stated that telehealth phone consultations with patients were less effective than in-person consultations but still found they were valuable, while 11% felt telehealth was not useful.

View Tables 1 & Figures 1–3.

Discussion

COVID-19 has had a significant effect on training and mental health for orthopaedic surgeons and registrars in New Zealand. Around the world, elective orthopaedic surgery has mostly been suspended to reduce the spread of the virus and ensure health resources are used appropriately.[[2–4]] In New Zealand, up until the Omicron outbreak, there had been relatively few hospitalisations and deaths when compared to the rest of the world. As of 21 November 2021, when this survey was conducted, there had been 9,608 cases of COVID-19 and 46 deaths; at that time 83 patients were in hospital, 5 of which were in the intensive care unit/high dependency unit (ICU/HDU).[[7]] These comparatively low numbers were largely due to high vaccination rates and the response from the New Zealand Government, which involved the suspension of many business operations, strict social distancing measures, travel restrictions and the enforced use of quarantine.

Surgery for those who are positive for COVID-19 involves additional planning, extra equipment and intensive operating theatre cleaning, which is significantly time and resource consuming. Many hospitals have converted operating rooms to “COVID theatres”, dedicated to the treatment of only those with COVID-19. This is necessary to keep patients safe but comes at the expense of reduced operating capacity, resulting in delayed or cancelled surgery for other patients. We found that 51% of those surveyed felt there had been a significant reduction in theatre productivity. Several other studies from multiple countries have also shown significant reductions in both elective and trauma orthopaedic surgery case volumes during the pandemic.[[1,12,15–18]] A study of 43 Hong Kong public hospitals found a reduction in elective orthopaedic operations of 73.5%.[[15]] In Europe, survey results from orthopaedic surgeons suggested that 68.4% of elective orthopaedic surgery and 92.6% of arthroplasty surgery had been suspended.[[2]] In the United States, there are estimates that 30,000 arthroplasty operations have been cancelled each week.[[4]] It has been estimated that the backlog of patients around the world needing elective surgery could take over one year to clear.[[5]] Delayed or cancelled surgeries have a substantial physical and/or emotional impact on patients.[[19]]

Reductions in orthopaedic surgical and clinical volume also has a detrimental effect on training and education.[[2,5,12,13]] In our study, 72% of registrars and 53% of consultants felt that their training had been affected either moderately or significantly. In the United Kingdom, 69% of orthopaedic trainees felt the pandemic would result in a delay in completion of their orthopaedic training.[[16]] Similar surveys of orthopaedic trainees have found that 45.5% felt they would not acquire the expected surgical skills and as many as 25% believed an additional year of training was necessary.[[12]] Orthopaedic residency directors have expressed concerns about the negative impact of COVID-19 on training.[[13,20]] Education has also suffered through the cancellation of conferences and courses; online teaching has become commonplace during the pandemic, but both our study and others have found satisfaction with this is lower than traditional in-person teaching.[[21]]

The issue of surgeon burnout has received significant attention in recent years. As a specialty, orthopaedics has one of the highest rates of burnout with rates ranging from 40% to 60%.[[9,10,22,23]] Orthopaedic surgeons also have the highest prevalence of surgeon suicides among surgical specialties, comprising 28.2% of surgeon suicides from 2003 to 2017.[[24]] Our study found that nearly half of those surveyed felt more burnt out because of the pandemic. This is a significant finding given the already high rates of burnout in orthopaedics.

Recent research shows the stress and social isolation brought about by the pandemic has had a negative impact on the mental health of healthcare workers.[[25–27]] Chang et al.[[21]] found that the quality-of-life score for an orthopaedic registrar in South Korea decreased from 68.9 out of 100 prior to the pandemic to 61.7 during the pandemic. Our findings are similar to the current literature with 65% of consultants and registrars stating the pandemic had a mild or moderate effect on their mental health.

Our study also found that 75% of orthopaedic surgeons and training registrars believed their hospitals preparedness for COVID-19 was either average or poor. In a survey of the Polish Society of Orthopaedics and Traumatology in 2020, 82.6% believed the Polish healthcare system was not well prepared for the pandemic.[[12]] We also found that 84.9% of those surveyed felt they had not been adequately trained to provide non-orthopaedic care in the case of re-deployment. In a survey of 327 orthopaedic and trauma trainees throughout Europe, 60.3% had not been given any COVID-19 specific training.[[2]] Fortunately, only 1.6% of respondents in our study had been re-deployed— significantly fewer than many other institutions around the world, where between 15% and 25% of orthopaedic residents were re-deployed.[[1,12–14]]

There are limitations to this study. Despite the high response rate, response bias is inherent to any survey. Those affected by burnout may be less likely to respond as they are too busy. Conversely, they may be more likely to respond as they are most affected. The COVID-19 virus and the response to the pandemic are rapidly evolving and this survey provides only a snapshot of one point in time. This survey was completed approximately one month prior to the first community case of the Omicron variant and prior to the removal of the "red traffic light" restrictions. Now, the impact of service delivery and training has been felt across wider areas of New Zealand. Therefore, the results of this survey may not reflect the current situation in New Zealand. We intend on repeating this survey to gain further insight into this changing landscape.

This is the first study assessing the effects of COVID-19 on orthopaedic practise and training in New Zealand. Despite the comparatively low number of COVID-19 cases, hospitalisations and deaths by the time of this study, it is clear that the effects on orthopaedic surgeons and training registrars have been significant. It is crucial that as we work during this stressful and often frustrating time, there is an awareness of the impact the pandemic has had on the mental health of healthcare workers. Counselling services such as the Employment Assistance Programme need to be promoted and utilised. Additional counselling services and courses on managing stress and anxiety would be greatly beneficial.

The reductions in surgical efficiency and volume will have a significant impact on the New Zealand health system and the training of the next generation of surgeons. Strategies to facilitate training include online “virtual” teaching sessions which have now become commonplace in many hospitals and training programmes, including orthopaedic training in New Zealand. There are also significant learning opportunities in the private sector that have the potential to provide valuable experience for training registrars given the significant reduction in elective surgery in the public health system. In order to continue to provide the highest quality care to our patients, we must create innovative solutions and adapt to this ever-changing situation.

Summary

Abstract

Aim

This study aimed to assess the impact of COVID-19 on orthopaedic practice in New Zealand, with a focus on training and mental health.

Method

An online survey was sent to the 385 consultant orthopaedic surgeons and registrars in New Zealand registered with the New Zealand Orthopaedic Association (NZOA). The survey consisted of 27 questions relating to demographics, the effects of COVID-19 on orthopaedic departments, on training, on mental health and the utilisation of telehealth and online teaching.

Results

In total, 189 of 385 NZOA members (49%) completed the survey. Of the 51 orthopaedic registrars surveyed, 55% felt that their training had been moderately affected, while 17% felt it had been significantly affected. Of those surveyed, 65% felt the pandemic had at least a mild effect on their mental health. Seven percent of registrars described a significant impact on their mental health compared to 2% of consultants (p=0.029). Overall, 46.5% felt they were more burnt out because of the pandemic, which was significantly higher in registrars compared to consultants (51% vs 44%, respectively; p=0.029).

Conclusion

Despite the comparatively low number of COVID-19 cases, hospitalisations and deaths, the effects for orthopaedic surgeons and training registrars have been significant.

Author Information

Matthew J Bowman: Department of Orthopaedic Surgery, Hawkes Bay Fallen Soldiers Memorial Hospital, Camberley, Hastings, New Zealand. Scott M Bolam: Department of Orthopaedic Surgery, Auckland City Hospital, Grafton, Auckland; New Zealand Faculty of Medical and Health Sciences, The University of Auckland, Grafton, Auckland, New Zealand. Mark Wright: Department of Orthopaedic Surgery, Auckland City Hospital, Grafton, Auckland, New Zealand.

Acknowledgements

Correspondence

Dr Matthew J Bowman: Department of Orthopaedic Surgery, Hawkes Bay Fallen Soldiers Memorial Hospital, 398 Omahu Road, Camberley, Hastings, New Zealand.

Correspondence Email

mattbowmannz@gmail.com

Competing Interests

All authors have nothing to disclose. This research received no external funding. The study has been performed in accordance with the ethical standards in the 1964 Declaration of Helsinki.

1) Haffer H, Schömig F, Rickert M, Randau T, et al. Impact of the COVID-19 Pandemic on Orthopaedic and Trauma Surgery in University Hospitals in Germany: Results of a Nationwide Survey. J Bone Joint Surg. 2020 Jul 15;102(14):e78.

2) Thaler M, Khosravi I, Hirschmann MT, Kort NP, et al. Disruption of joint arthroplasty services in Europe during the COVID-19 pandemic: an online survey within the European Hip Society (EHS) and the European Knee Associates (EKA). Knee Surg Sports Traumatol Arthrosc. 2020 Jun;28(6):1712-9.

3) An TW, Henry JK, Igboechi O, Wang P, et al. How Are Orthopaedic Surgery Residencies Responding to the COVID-19 Pandemic? An Assessment of Resident Experiences in Cities of Major Virus Outbreak. J Am Acad Orthop Surg [Internet]. 2020 Jun 1 [cited 2022 Mar 27];Publish ahead of print. Available from: https://journals.lww.com/10.5435/JAAOS-D-20-00397.

4) Brown TS, Bedard NA, Rojas EO, Anthony CA, et al. The Effect of the COVID-19 Pandemic on Electively Scheduled Hip and Knee Arthroplasty Patients in the United States. J Arthroplasty. 2020 Jul;35(7):S49-55.

5) COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans: Elective surgery during the SARS-CoV-2 pandemic. Br J Surg [Internet]. 2020 Jun 13 [cited 2022 Apr 3]. Available from: https://academic.oup.com/bjs/article/107/11/1440-1449/6139510.

6) Heckmann ND, Bouz GJ, Piple AS, Chung BC, et al. Elective Inpatient Total Joint Arthroplasty Case Volume in the United States in 2020: Effects of the COVID-19 Pandemic. J Bone Joint Surg [Internet]. 2022 Mar 11 [cited 2022 May 29]; Published ahead of print. Available from: https://journals.lww.com/10.2106/JBJS.21.00833.

7) Ministry of Health. 12 DHBs pass 90% first dose vaccinations; over 1 million My Vaccine Passes created; 83 in hospital & five in ICU; 149 cases [Internet]. Health.govt.nz. 2021. Available from: https://www.health.govt.nz/news-media/media-releases/12-dhbs-pass-90-first-dose-vaccinations-over-1-million-my-vaccine-passes-created-83-hospital-five.

8) Verret CI, Nguyen J, Verret C, Albert TJ, et al. How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents? Clin Orthop Relat Res. 2021 Feb;479(2):251-62.

9) Shanafelt TD, Balch CM, Bechamps GJ, Russell T, et al. Burnout and Career Satisfaction Among American Surgeons. Ann Surg. 2009 Sep;250(3):463-71.

10) Arora M, Diwan AD, Harris IA. Prevalence and Factors of Burnout among Australian Orthopaedic Trainees: A Cross-Sectional Study. J Orthop Surg. 2014 Dec;22(3):374-7.

11) Thakrar A, Raheem A, Chui K, Karam E, et al. Trauma and orthopaedic team members’ mental health during the COVID-19 pandemic. Bone Joint Open. 2020;1(6):10.

12) Megaloikonomos PD, Thaler M, Igoumenou VG, Bonanzinga T, et al. Impact of the COVID-19 pandemic on orthopaedic and trauma surgery training in Europe. Int Orthop. 2020 Sep;44(9):1611-9.

13) Heaps BM, Dugas JR, Limpisvasti O. The Impact of COVID-19 on Orthopedic Surgery Fellowship Training: A Survey of Fellowship Program Directors. HSS J. 2022 Feb;18(1):105-9.

14) Culp BM, Frisch NB. COVID-19 Impact on Young Arthroplasty Surgeons. J Arthroplasty. 2020 Jul;35(7):S42-4.

15) Wong JSH, Cheung KMC. Impact of COVID-19 on Orthopaedic and Trauma Service: An Epidemiological Study. J Bone Joint Surg. 2020 Jul 15;102(14):e80.

16) Khan H, Williamson M, Trompeter A. The impact of the COVID-19 pandemic on orthopaedic services and training in the UK. Eur J Orthop Surg Traumatol. 2021 Jan;31(1):105-9.

17) Zahid M, Ali A, Baloch NJ, Noordin S. Effects of coronavirus (COVID-19) pandemic on orthopedic residency program in the seventh largest city of the world: Recommendations from a resource-constrained setting. Ann Med Surg. 2020 Aug;56:142-4.

18) Probert AC, Sivakumar BS, An V, Nicholls SL, et al. Impact of COVID ‐19‐related social restrictions on orthopaedic trauma in a level 1 trauma centre in Sydney: the first wave. ANZ J Surg. 2021 Jan;91(1–2):68-72.

19) Sequeira SB, Novicoff WM, McVey ED, Noble DM, et al. Patient Perspectives on the Cancellation of Elective Primary Hip and Knee Arthroplasty During the COVID-19 Pandemic. J Am Acad Orthop Surg [Internet]. 2021 Feb 1 [cited 2022 Apr 3]; Published ahead of print. Available from: https://journals.lww.com/10.5435/JAAOS-D-20-00765.

20) Levidy MF, Dobitsch A, Luis J, Fano AN, et al. A Review of Orthopaedic Resident Case Logs to Identify Fluctuations in Exposure to Adult Orthopaedic Procedures. JBJS Open Access [Internet]. 2021 [cited 2022 Mar 27];6(3). Available from: https://journals.lww.com/10.2106/JBJS.OA.21.00023.

21) Chang DG, Park JB, Baek GH, Kim HJ, et al. The impact of COVID-19 pandemic on orthopaedic resident education: a nationwide survey study in South Korea. Int Orthop. 2020 Nov;44(11):2203-10.

22) Sargent MC, Sotile W, Sotile MO, Rubash H, et al. Stress And Coping Among Orthopaedic Surgery Residents And Faculty: J Bone Joint Surg. 2004 Jul;86(7):1579-86.

23) Saleh KJ, Quick JC, Conaway M, Sime WE, et al. The Prevalence and Severity of Burnout Among Academic Orthopaedic Departmental Leaders*: J Bone Joint Surg. 2007 Apr;89(4):896-903.

24) Elkbuli A, Sutherland M, Shepherd A, Kinslow K, et al. Factors Influencing US Physician and Surgeon Suicide Rates 2003-2017: Analysis of the CDC-National Violent Death Reporting System. Ann Surg [Internet]. 2020 Nov 4 [cited 2022 Jun 8]; Published ahead of print. Available from: https://journals.lww.com/10.1097/SLA.0000000000004575.

25) Shen M, Xu H, Fu J, Wang T, et al. Investigation of anxiety levels of 1637 healthcare workers during the epidemic of COVID-19. Aboelhadid SM, editor. PLoS One. 2020 Dec 22;15(12):e0243890.

26) Luo M, Guo L, Yu M, Jiang, et al. The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public – A systematic review and meta-analysis. Psychiatry Res. 2020 Sep;291:113190.

27) Kannampallil TG, Goss CW, Evanoff BA, Strickland JR, et al. Duncan J. Exposure to COVID-19 patients increases physician trainee stress and burnout. Murakami M, editor. PLoS One. 2020 Aug 6;15(8):e0237301.

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