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.