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

Yongbo An (@an_yongbo), Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
 
Vittoria Bellato (@vittoriabellat0), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
 
Gianluca Pellino (@GianlucaPellino), Department of Advanced Medical and Surgical Sciences, Universita degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy; Department of Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
 
Tsuyoshi Konishi (@yoshi_konishi), Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, Texas 77030
 
Giuseppe S Sica (@sigisica), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
 
on behalf of S-COVID Collaborative Group

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

1.         Con le nostre azioni influenziamo la vita e la morte di molte persone. https://www.ecodibergamo.it/stories/bergamo-citta/con-le-nostre-azioni-influenziamola-vita-e-la-morte-di-molte-persone_1344030_11/.

2.         Coronavirus pandemic: Tracking the global outbreak. https://www.bbc.com/news/world-51235105.

3.         Scalea JR. The Distancing of Surgeon from Patient in the era of COVID-19: Bring on the Innovation. Annals of surgery 2020.

4.         Wuhan hospitals resume regular services amid COVID-19. https://news.cgtn.com/news/2020-03-16/Wuhan-hospitals-resume-regular-services-amid-COVID-19-OTRxkICEr6/index.html.

5.         Fu D, Yu X, Wang L, Cai K, Tao K, Wang Z. Gearing back to normal clinical services in Wuhan: frontline experiences and recommendations from mental health perspective. The British journal of surgery 2020;Epub ahead of print. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11912

6.         Surgeon reveals fear of dying on frontline in coronavirus fight. https://www.examinerlive.co.uk/news/west-yorkshire-news/surgeon-reveals-fear-dying-frontline-18025220.

7.         Balasubramanian A, Paleri V, Bennett R, Paleri V. Impact of COVID-19 on the mental health of surgeons and coping strategies. Head & neck 2020.

8.         #COVID19ESCP TweetChat: Antonino Spinelli shares insights from the frontline in Italy. https://www.escp.eu.com/news/2069-covid19escp-tweet-chat-antonino-spinelli-shares-insights-from-the-frontline-in-italy.

9.         Doctors reveal they are moving into their garages and basements to isolate themselves from their own families while they fight coronavirus – as they urge others to stop going out. https://www.dailymail.co.uk/femail/article-8136037/Doctors-isolating-FAMILIES-prevent-spread-COVID-19.html.

10.       Fear, guilt, and a surgeon’s wait for Coronavirus. https://exponentsmag.org/2020/03/21/fear-guilt-and-a-surgeons-wait-for-coronavirus/.

11.       The second wave of COVID-19: another potential tsunami – prepare to avoid being swept away. https://www.escp.eu.com/news/2093-the-second-wave-of-covid-19-another-potential-tsunami-prepare-to-avoid-being-swept-away.

12.       Ielpo B, Podda M, Pellino G, Pata F, Caruso R, Gravante G, Di Saverio S. Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study. The British journal of surgery 2020. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11999

13.       Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS. Screening policies, preventive measures and in-hospital infection of COVID-19 in global surgical practices. Journal of global health 2020;10(2): 020507.

14.       Life as a vascular surgeon in Mexico during the COVID-19 pandemic. https://vascularnews.com/life-as-a-vascular-surgeon-in-mexico-during-the-covid-19-pandemic/.

15.       Tan YQ, Chan MT, Chiong E. Psychological health among surgical providers during the COVID-19 pandemic: a call to action.n/a(n/a).

16.       Vallée M, Kutchukian S, Pradère B, Verdier E, Durbant È, Ramlugun D, Weizman I, Kassir R, Cayeux A, Pécheux O, Baumgarten C, Hauguel A, Paasche A, Mouhib T, Meyblum J, Dagneaux L, Matillon X, Levy-Bohbot A, Gautier S, Saiydoun G. Prospective and observational study of COVID-19’s impact on mental health and training of young surgeons in France.n/a(n/a).

17.       An Y, Bellato V, Konishi T, Pellino G, Sensi B, Siragusa L, Franceschilli M, Sica GS, Group S-CC. Surgeons’ fear of getting infected by COVID19: A global survey.n/a(n/a).

18.       Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet (London, England) 2020.

19.       Zeidel ML, Kirk C, Linville-Engler B. Opening Up New Supply Chains. New England Journal of Medicine 2020: e72.

20.       Wuhan completes mass COVID-19 screening. http://www.chinadaily.com.cn/a/202006/03/WS5ed6f96ea310a8b24115a6a8.html.

21.       Xiong Y, Mi B, Panayi AC, Chen L, Liu G. Wuhan: the first post-COVID-19 success story.n/a(n/a).

22.       Collaborative C, Nepogodiev D, Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. BJS (British Journal of Surgery). https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11746

23.       Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS, Group S-CC. Impact of asymptomatic COVID-19 patients in global surgical practice during the COVID-19 pandemic.n/a(n/a).

24.       Kadhum M, Farrell S, Hussain R, Molodynski A. Mental wellbeing and burnout in surgical trainees: implications for the post-COVID-19 era. The British journal of surgery 2020. https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.11726

25.       Pellino G, Pellino IM, Pata F. Uncovering the Veils of Maya on defensive medicine, litigation risk, and second victims in surgery: care for the carers to protect the patients. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.

26.       Pellino G, Vaizey CJ, Maeda Y. The COVID-19 pandemic: considerations for resuming normal colorectal services. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.

worried woman in mask looking out of the window

Guest post: Mental health and BRCA

Exploring psychological consequences for BRCA+ women in the post-Covid era

by Grace Brough1, Douglas Macmillan2, Kristjan Asgeirsson2, and Emma Wilson1
1Division of Epidemiology and Public Health, University of Nottingham
2Nottingham Breast Institute, Nottingham University Hospitals NHS Trust

Whilst the global female population has a 12.5% overall lifetime risk of developing breast cancer and a 1.3% risk of ovarian cancer (Howlader et al), the risk for those with a pathogenic BRCA1 or BRCA2 mutation is 60-70% and 10-20% respectively (van Egdom et al). BRCA1 mutation carriers have a particularly high incidence of triple-negative breast cancer (TNBC) (Greenup et al) for which treatment options are more limited and always include chemotherapy (Bianchini et alCollignon et al). 

In the NHS, asymptomatic women with at least a 10% estimated chance of having a BRCA mutation are offered testing (NICE).  Knowing you are at high risk of breast cancer and the increased likelihood of TNBC is a well-documented  cause of anxiety (Wenzel et al) and many women describe having a BRCA gene mutation as living with a ‘ticking time bomb’. Bilateral mastectomy with or without reconstruction is the only proven method of drastically decreasing risk and can improve quality of life (McCarthy et al) and decrease anxiety (Rebbeck et al) for correctly selected cases, despite its potential negative outcomes (Gahm et al). 

The strongest predictor for choosing to undergo risk reducing mastectomy is having a first or second degree relative die from breast cancer (Singh et al), a factor associated with fear, anxiety and vulnerability to this disease.  Most women choosing it have clear and long-considered reasoning and have been prepared for it through well-established pathways guided by genetic counsellors, specialised surgeons and nurses.  It is however, classified as elective surgery. As such, waiting lists for risk reducing mastectomies are impacted by other healthcare challenges and needs. 

Being on NHS waiting lists causes anxiety across all specialities (Carr et al). With an estimated 10 million people on NHS waiting lists in the post-COVID era, levels of health-related anxiety within the population are anticipated to significantly increase. For BRCA mutation carriers, the prevailing fear is that they will develop breast cancer whilst on the waiting list.  This reality is related to the length of time on the waiting list and represents potential conversion of a risk reducing scenario to one of chemotherapy and cancer surgery, often with other treatments, and all the life changing and life threatening implications of cancer diagnosis.   

In pre-COVID times, there was a 18 week target time from referral to treatment for risk reducing mastectomy (UK GOV). Due to COVID, the majority of elective surgery has been put on hold and Breast Units now anticipate at least a 2-year waiting list for non-cancer surgery, such as risk reducing mastectomies, delayed reconstructions, and revisional surgery. Prioritisation is a difficult necessity.

In addition, breast screening services ceased or were significantly curtailed as a result of COVID related restrictions, and this adds to an already complex situation for BRCA mutation carriers.  Not only may they now get breast cancer whilst on the waiting list, but they are denied the reassurance afforded by negative screening, or potentially a diagnosis may be delayed (Maringe et al). 

Combining pre-existing anxieties of being a BRCA mutation carrier, new waiting list anxieties, and wider COVID general health anxieties, the post-COVID era has the potential to see significant levels of psychological burden in this population, which could negatively impact mental health and quality of life. Providing additional psychological support is likely to be the short-term solution, though this is also resource limited. In reality the collateral impact of pandemic related consequences for healthcare in this particular group may not be realised for some time. 

Pre-operative testing for SARS-CoV-2 infection

Research in plain English

Scientific research can be challenging to follow, especially for those who are not experts in the field. There is lots of interest in COVID-19 from the public. The authors of the paper published in the BJS have provided a plain English summary to help people understand the work.

Background

As we continue in and between subsequent pandemic waves, and patients are booked for surgery, the CovidSurg cancer study data can help to identify where services can best spend resources to protect patients. This paper, published in the BJS evaluates the associations between SARS-CoV-2 testing before operations and serious breathing problems afterward.

SARS-CoV-2 swab testing before planned surgery reduces serious breathing complications

Context

At least 28 million operations were delayed during the first COVID-19 pandemic wave. As we resume operating, we need the ability to identify patients with pre-symptomatic infection and postpone surgery to keep those patients safe. We also need to use resources wisely by testing in situations where it will likely provide a benefit.

Aim

To understand the value of preoperative SARS-CoV-2 testing to prevent serious breathing problems after surgery.

Impact

To maximise the benefits for patients and guide the use of resources, this study looks at where and when swab testing can change patient outcomes.

Strategy

Surgical team members in 432 hospitals in 53 countries collected anonymised data for all patients having planned cancer surgery during the pandemic up to 19 April 2020. We included all patients with data about preoperative testing. Patients suspected of having the infection pre-operatively were excluded. Researchers recorded if a patient died or had serious breathing problems up to 30 days after their operation.

Results

2303/8784 patients (23%) were tested for SARS-CoV-2 before their operation. 1458 had a swab test, 521 a CT scan of their chest and 324 had both tests. 6746 major operations and 1087 minor operations were performed in high SARS-CoV-2 risk areas and a minority of operations took place in low risk areas.

Overall, 4% of patients experienced serious breathing problems following surgery. The rate was higher in patients with no test or CT scan-only testing. At least one negative swab before operation reduced the risk of serious breathing problems after surgery. Having repeated swabs did not add extra benefit.

The data showed that swab testing reduced breathing problems in high risk COVID areas but not in low risk areas. It also showed that a swab before major surgery reduced breathing problems but not before minor surgery. 

How many patients must be swabbed to prevent one patient having serious breathing problems?

To prevent one patient having serious breathing problems after major surgery, in a high risk area, 18 patients had to be swabbed; 48 had to be swabbed before minor surgery in a high risk area. This increased to 73 patients swabbed before major or 387 before minor surgery in low risk areas, to prevent one patient having breathing problems.

Some evidence also suggested there was a lower death rate among patients who were swabbed before their surgery.

Conclusion

The study group was able to recommend that ‘A single preoperative swab should be performed for patients with no clinical suspicion of COVID-19 before major surgery in both high and low risk areas and before minor surgery in high risk population areas’. 

Swab testing before surgery is likely to benefit patients by identifying pre-symptomatic or asymptomatic COVID-19 infection prior to admission. A positive swab result triggers operation delay, protects patients from severe breathing problems after surgery and helps protect other patients from in-hospital infection. Swabs together with other strategies, should be used to protect patients from COVID-19 during hospital care.

Global surgical collaboration to support data driven decision making during the COVID-19 pandemic.

Maria Picciochi, Harvinder Mann, Sam Lawday, James Glasbey

On behalf of the COVIDSurg Collaborative

What are the GlobalSurg & COVIDSurg Collaboratives?

GlobalSurg was born in 2013 as a group of frontline surgeons around the world with the aim of improving outcomes for their patients by joining together to collect high-quality  data. The CovidSurg collaborative represents the COVID-19 response of the NIHR Global Health Research Unit at the University of Birmingham. The CovidSurg group is made up of an international collaborating group of surgeons, anaesthetists and researchers. They capture and share real world data for international multi-centre research studies. These groups overlap and are an expanding network aiming to improve global surgical care through collaborative research. 

Since March the CovidSurg collaborative has run three prospective cohort studies and launched one randomised control trial:

(1) CovidSurg, an international cohort study assessing the outcomes of surgery in patients diagnosed with COVID-19

(2) CovidSurg-Cancer, an cohort study to assess the impact of COVID-19 on cancer surgery 

(3) SURG-Week, which took place in October 2020. This set out to determine the optimal timing for surgery following a SARS-CoV-2 infection

(4) PROTECT-Surg, an international platform adaptive randomised trial to evaluate the effectiveness of chemoprophylaxis for SARS-CoV-2 infection in surgical patients.

SURG-WEEK

The CovidSurg Collaborative is proud to announce it has captured outcomes for over 150, 000 patients from 2000 hospitals in 130 countries for these studies to date.  

The SURG-Week study is set to be the largest international prospective collaborative study ever conducted, with over 15000 collaborators participating. It is an incredibly exciting time for collaborative research in surgery, encouraging colleagues internationally to take part in research and helping improve surgical outcomes in such unprecedented times.

COVID-19 in surgical patients

Our first study, published in the Lancet, demonstrated severe impact of COVID-19 in patients undergoing surgery. This found that patients with a positive perioperative SARS-CoV-2 test had a 30-day mortality rate was as high as 23.8%. Pulmonary complications occurred in 51.2% of patients and accounted for 81.7% of all deaths. 

Certain patient groups were at higher risk. Male sex, older age, ASA grade 3-5, cancer indiciation, emergency, and major surgery, were all associated with postoperative death. These findings have allowed surgeons to optimise selection for surgery. They have already been implemented into several guidelines, and featured in over 400 news articles around the world.

Learning from this data, the COVIDSurg steering group rapidly synthesize evidence to provide a pragmatic global surgical guideline to provide care for surgical patients during the early phases of the pandemic.

The growing problem of cancellation elective surgery

The COVID-19 pandemic has disrupted surgical services worldwide. A modelling study from the COVIDSurg Collaborative published in BJS aimed to estimate the impact on surgical activity around the world. This estimated that 28.4 million elective surgeries would be cancelled or postponed around the world in the first 12 weeks of the pandemic; to clear this backlog, surgical providers would have to provide 120% operative capacity for over one year. With a second wave and lockdown of countries around the world, this is likely to be a gross underestimate. Many patients face progression of time-dependent conditions, or significant delays of quality of life surgery. 

These data generated a significant media response, featuring in the global press including the Economist, New York Times and Daily Mail.

Rescheduling and prioritising operations presents a huge challenge to providers. COVIDSurg is supporting decision making in several ways:

  1. COVIDSurg-Cancer will examine the impact of delay on cancer surgery. It will also look at the impact of neoadjuvant therapy on early oncological outcomes to inform prioritisation once surgery restarts.
  2. COVIDSurg and COVIDSurg-Cancer data are being used to create risk stratification scoring systems. These will use principles of machine learning to allow high-fidelity risk estimation and support patient consent.

How to protect patients and safely upscale surgery during COVID-19 waves

COVIDSurg-Cancer provides an opportunity to identify best practises to optimise protective measures for patients during the second SARS-CoV-2 wave and beyond. Our first analysis, published in the Journal of Clinical Oncology demonstrated the use of COVID-19 free surgical pathways to protect patients from perioperative SARS-CoV-2 infection and subsequent complications. COVID-19 free zones throughout the hospital could be created in dedicated hospitals for elective surgery only, and major acute hospitals treating COVID-19 free patients; however, less than a third of patients received their care in totally COVID-19 free zones.

We have also been able to identify best practices for preoperative testing of patients for SARS-CoV-2. In our screening paper, released in BJS on 11th November 2020, obtaining a single negative preoperative nasopharyngeal swab testing was demonstrated to reduce subsequent postoperative pulmonary complications; this was likely due to a reduction in presymptomatic carriage of SARS-CoV-2 into the perioperative setting. Swab testing was most beneficial before major surgery and in high SARS-CoV-2 risk areas. The use of CT imaging for preoperative testing or serial swab testing was, however, had no proven benefit. 

Unanswered research questions

There are several research questions outstanding,.

SURG-Week unites the COVIDSurg and GlobalSurg Collaborative networks for the first time. It will address the evidence gap about the optimal of surgery for patients previously infected with SARS-CoV-2. Early pilot data from 122 patients published in BJS demonstrated a signal that a minimal interval of at least 4 weeks protected patients from severe complications of SARS-CoV-2.

It will also determine key global surgical indicators for future benchmarking and modelling studies.  All hospitals and all surgical specialties can take part and will collect data from all patients operated regardless of their SARS-CoV-2 status during a 7-day period in October. The follow-up will occur at 30 days and will include mortality, pulmonary complications and surgical complications. With 15000 collaborators from over 2000 registered to date, it is set to be the largest prospective study ever to be undertaken. You can read more about this ongoing study on our website: www.globalsurg.org/surgweek.

Plain English Abstract: Trends in deaths from abdominal aortic aneurysms

Mortality from abdominal aortic aneurysm: trends in European Union 15+ countries from 1990 to 2017

Abdominal Aortic Aneurysm or AAA is an abnormal swelling of the aorta, the biggest artery in the body. It usually occurs people over 65, especially men. An AAA can occasionally burst, leading to life-threatening bleeding. An AAA can be easily detected using a simple ultrasound scan. AAA screening programmes are now available in a number of countries, such as the United Kingdom and the United States. These AAA screening programmes have allowed us to better understand how many people in society have an AAA. In the last decade, it has become apparent in some countries that the number of people who have an AAA is decreasing. Some research suggested that the number of people who die due to AAA is also dropping. This was, however, never assessed in European countries using data of high-quality. 

In this open access article, researchers accessed information from the “Global Burden of Disease Study Global Health Data Exchange”. This source allows us to understand how many people might be dying due to a certain medical problem. The researchers then reported how many people die due to AAA every year per country, also taking people’s age into account. The study found that between the years 1990 and 2017 the death rate from AAA decreased in all 19 European Union countries for women, and in 18 of 19 countries for men. An increasing death rate due to AAA was observed only for men in Greece. The largest decreases were observed in Australia and Canada. Interestingly, in the last few years (after 2012) there seem to be small increases again in the rates of death due to an AAA in most of these countries. Overall, this study shows that AAA has become a less common cause of death in most European and Western countries in the last 27 years. 

Visual Abstract: Clean Cut programme

A success story in global surgery

Recently published as open access in BJS, this prospective quality improvement study showed a reduction in surgical site infections using an adaptive, multimodal surgical infection prevention programme for low-resource settings. Further information can be found at the Lifebox website.

Plain English Summary: How the first COVID‐19 wave affected UK vascular services

Global overall mean service reductions, worldwide response, and service reduction scores in the UK and the Americas
Global overall mean service reductions, worldwide response, and service reduction scores in the UK and the Americas

The COVID-19 pandemic has impacted healthcare around the world. Patients who have vascular disease (problems with their arteries or veins), are at high-risk of having complications if they develop COVID-19. This is because patients with vascular disease usually have many medical problems. Some of them are also elderly and might be frail. We do not know how the COVID-19 pandemic might have affected the care of patients with vascular disease. 

The COVER study is an international study trying to assess how the COVID-19 pandemic changed the medical care of patients with vascular disease. The first part of the COVER study was an internet survey. In this survey, doctors and healthcare professionals were asked questions (every week) about the care of vascular patients at their hospital. The results were published in this article.

The results showed that the COVID‐19 pandemic had a major impact on vascular services worldwide. Most of the 249 hospitals taking part from 53 countries, reported big reductions in numbers of operations performed and the types of services they could offer to patients with vascular disease. Almost half of the hospitals stopped doing routine scans to detect artery problems and a third had to stop all clinics in the height of the pandemic. There were major changes in the resources available to treat blocked leg arteries. Most non-urgent operations, especially for vein problems, were cancelled.

In the months during recovery from the pandemic peaks, there will be a big backlog of patients with vascular disease needing surgery or review by vascular specialists.

A View of the COVID-19 Impact on Surgery: A Social Media Analysis

Sergio M Navarro, MD MBA, Kelsey A Stewart, MD, Hashim Shaikh, BS^, Matthew C, Bobel, MD, Evan J Keil, BS, Jennifer Rickard, MD MPH, Todd M Tuttle, MD MS

^ Department of Surgery, University of California San Francisco, San Francisco, CA, USA

* Department of Surgery, University of Minnesota, Minneapolis, MN, USA Please contact: Sergio M Navarro, MD MBA 420 Delaware St SE, Minneapolis, MN 55455 mnavarro@alum.mit.edu

INTRODUCTION

The Coronavirus disease 2019 (COVID-19) has rapidly evolved and impacted all aspects of health policy and healthcare delivery – including surgery. Recommendations to postpone and provide additional guidelines regarding ‘elective surgery’ has left surgeons, patients, and hospitals with questions on the definition of ‘elective,’ the proper type and use of personal protective equipment (PPE) in surgery, the ethics of delaying medically indicated procedures, and the health and psychological impacts on patients and families. Analysis of social media information enables examination of the impact of COVID-19 and associated policy changes in a unique way and gathering of real-time data more rapidly than traditional methods. [1–4]

METHODS

From March 1 to March 31, 2020, we conducted a cross-sectional analysis of associated posts on Twitter to collect data related to COVID-19 and surgery.  The public domain was queried by filtering for five hashtags: #covidsurg, #covid19surgery, #COVID-19, #Coronavirus and #surgery. A binary scoring system was used for media format, perspective of the author, tone, user and post content, based on 2-person review. Data underwent descriptive and statistical analysis. All specific author information was de-identified. Non-English and non-surgery related tweets were excluded from analysis. 

RESULTS

890 posts met the inclusion criteria. Posts an average of 629 Likes, 95 Retweets, and 1.78 hashtags per post. Author categories included physicians (39.7%), news organizations (18.4%), institution/professional organization (13.6%), and patients (11.9%). The majority of posts occurred from Twitter users based in the US (51.3%), followed by the UK (25.3%), and Canada (4.4%). Content included the cancellation of surgery (24.9%), surgical guidelines (20.2%), commentary/other (18.2%), COVID-19 education (16.2%), and PPE availability (7.4%).

1Surgeons, physicians, and health care professionals, 2 Patients and patients’ families, 3 News, media, and academic organizations. Other Countries with 1 post included Brazil, Egypt, Germany, Ghana, Japan, Republic of Korea, Malta, New Zealand, Nigeria, Pakistan, Palestine, Russia, Sweden, Switzerland, Ukraine, Venezuela, and Zimbabwe respectively

Physicians were more likely than patients or patient’s families to post content related to PPE shortages, COVID19 education, research dissemination, as well as commentaries. Patients and patient families emphasized postoperative recovery and postoperative complication. Businesses, media outlets, and institutions posted most frequently about surgery cancellations and surgical guidelines. Authors from low and middle-income countries (LMICs) accounted for 4.4% (33/755) of posts where location of the post was available.

DISCUSSION

This initial exploration of the impact of COVID19 on surgery worldwide using social media found different perspectives from physicians, patients, families, media outlets, and institutions on various topics including cancellation of surgery, types of ‘non-essential’ surgery, concerns about PPE, and dissemination of surgical guidelines and educational information.

Non-Essential Surgery Cancellations

The cancellation of ‘non-essential’ surgery was the primary focus of content among all groups (25%, 222/890) and 40% (76/191) of posts by patients and families. Physician posts on cancellation comprised only 14.8% of their overall content. Their discussion on cancellation revolved around complex decision making in the designation of ‘non-essential’ surgeries and the inevitable consequences. One healthcare professional in Italy posted about the likely morbidity following lack of access to care and a surgeon in Canada discussed the difficult but important decision to delay surgery to improve healthcare capacity and protect patients from COVID19 exposure. A Urologist in Brazil described a difficult treatment decision for a patient with poor quality of life in need of a ‘non-essential’ surgery, emphasizing just how difficult it is to define ‘essential.’

Subspecialty Surgery Cancellations

A portion of the surgical cancellation content highlighted the ethical and political consequences of possible delays in specific types of surgeries; namely cancer surgery, orthopedic surgery, surgical abortion, and transgender surgeries.[5–8] Twitter served as a platform to discuss these ethical considerations for both surgeons and their affected patients. In one tweet, attention was drawn to a 17-year-old in need of surgery and chemotherapy; however, after spiking a fever he was subject to a two-week delay in care due to awaiting COVID-19 testing results.

Changes to practice

Another individual highlighted his mother’s breast cancer journey, sharing that instead of a partial mastectomy and reconstruction, an entire mastectomy without reconstruction would be performed – all due to changing guidelines regarding procedure safety. In terms of historically politicized surgeries, several state governments made decisions to limit access to abortion and gender affirming surgeries creating dissention within patients and physicians which was highlighted in over 10% of total tweet content where specific subspecialties were mentioned. [9]

Surgical Guidelines, Education, and Changes in Clinical Management

Throughout the analyzed tweets, several changes were recommended in the routine management of surgical conditions during the COVID-19 epidemic to conserve resources, limit exposure to the virus, and limit the use of PPE. These posts were primarily (46% in total) disseminated by academic institutions, other professional organizations, and media outlets. For example, the ACS and others have recommended limiting the use of laparoscopy which has the potential to aerosolize viral particles. Physicians worldwide have recommended alternate surgical techniques to reduce the risk of exposure to COVID19 including an Otolaryngologist in France who recommended the use of hammer and chisel in place of drilling. However, these changes are not without dissention, highlighted by a bariatric surgeon in the UK who struggled to follow a new guideline that he felt would worsen outcomes for patients.

Safety and Personal Protective Equipment

Surgeons, physicians, and other health professionals focused on commentaries and discussions about safety and PPE more than the other groups- giving insight that they see safety of patients and healthcare workers as the more important information surrounding the COVID-19 pandemic. One post from a trauma surgeon described lessons learned from performing emergency surgery on patients with COVID-19 and the need for clear guidelines and safety measures. The Columbia Chair of Surgery provided updates daily outlining the future need of PPE and justification for supplying a single mask per provider per day even at an early point in the COVID-19 outbreak.

Regional Differences

Concerns surrounding the COVID-19 pandemic vary in different regions and countries given their specific burden of disease and capacity to mount a public health response to the disease.[10–13]. High-income countries (HICs) made up an overwhelming majority of the posts and thus a complete picture of the global burden of disease and changes to surgery across the globe may not be able to be formed. It is known that LMIC authors are often underrepresented in the global social media sphere in regard to global surgery which we further affirm here.[14] Inclusion of LMICs in both the discussion and dissemination of global guidelines in regard to the COVID-19 pandemic ought to be a priority by the global surgical community. Some of the emphasized concerns from LMICs include internet outages that impact accessing surgical guidelines, hospital exposure of patients to the virus, as well as the dissemination of guidelines from other countries.

Geographical variation in COVID-19 Surgery twitter activity.

CONCLUSION

In this cross-sectional analysis, surgeons, physicians, and organizations expressed concerns about the impact of COVID-19 on surgical guidelines, the delay and cancellation of surgery, and the availability of PPE while disseminating COVID-19 education and information. We found minimal variation in the levels of mention regarding the impact of COVID-19 on surgical cancellations or delays, but the community of surgeons and physicians made more mention of PPE availability to conduct surgeries. These findings provide an indicative sampling of the key surgical perceptions of COVID-19 on these important populations.

REFERENCES

1.        Sorice SC, Li AY, Gilstrap J, Canales FL, Furnas HJ. Social Media and the Plastic Surgery Patient. Plast Reconstr Surg. 2017;140: 1047–1056. doi:10.1097/PRS.0000000000003769

2.        Navarro SM, Haeberle HS, Cornaghie MM, Hameed HA, Ramkumar PN. The Impact of Social Media in Medicine: An Examination of Orthopaedic Surgery. Social Media: Practices, Uses, and Global Impact. 2017.

3.        Ni hIci T, Archer M, Harrington C, Luc JGY, Antonoff MB. Trainee Thoracic Surgery Social Media Network: Early Experience With TweetChat-Based Journal Clubs. Annals of Thoracic Surgery. 2020. doi:10.1016/j.athoracsur.2019.05.083

4.        Henderson ML, Adler JT, Van Pilsum Rasmussen SE, Thomas AG, Herron PD, Waldram MM, et al. How Should Social Media Be Used in Transplantation? A Survey of the American Society of Transplant Surgeons. Transplantation. 2019. doi:10.1097/TP.0000000000002243

5.        Couloigner V, Schmerber S, Nicollas R, Coste A, Barry B, Makeieff M, et al. COVID-19 and ENT Surgery. Eur Ann Otorhinolaryngol Head Neck Dis. 2020. doi:10.1016/j.anorl.2020.04.012

6.        Iyengar KP, Jain VK, Vaish A, Vaishya R, Maini L, Lal H. Post COVID-19: Planning strategies to resume orthopaedic surgery –challenges and considerations. Journal of Clinical Orthopaedics and Trauma. 2020. doi:10.1016/j.jcot.2020.04.028

7.        Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. American Journal of Obstetrics and Gynecology. 2020. doi:10.1016/j.ajog.2020.02.017

8.        Nepogodiev D, Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020. doi:10.1002/bjs.11746

9.        Bayefsky MJ, Bartz D, Watson KL. Abortion during the Covid-19 Pandemic – Ensuring Access to an Essential Health Service. N Engl J Med. 2020. doi:10.1056/NEJMp2008006

10.      Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet. 2020;395: 1225–1228. doi:10.1016/S0140-6736(20)30627-9

11.      Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020. doi:10.1016/S0140-6736(20)30566-3

12.      Fauci AS, Lane HC, Redfield RR. Covid-19 – Navigating the uncharted. New England Journal of Medicine. 2020. doi:10.1056/NEJMe2002387

13.      Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet. 2020. doi:10.1016/S0140-6736(20)30567-5

14.      Navarro SM, Mazingi D, Keil E, Dube A, Dedeker C, Stewart KA, et al. Identifying New Frontiers for Social Media Engagement in Global Surgery: An Observational Study. World J Surg. 2020. doi:10.1007/s00268-020-05553-8

Management of Crohn’s Disease. The shiny medical sports car or the worn out surgical banger?

Professor Steven R Brown, Sheffield Teaching Hospitals.

Based on the BJS Lecture at ACPGBI 2020

A success story

There is more and more convincing evidence that the number of patients undergoing surgery for Crohn’s disease is decreasing substantially (1,2). Of course this as a huge success story and testament to tremendous advances in medical therapy occurring particularly over the last 20-30 years, isn’t it? Not necessarily. Some would suggest the newer medications have made little to no difference in reducing the need for surgery (3,4). Other factors may be more pertinent. To give gastroenterologists credit, earlier recognition of disease and potential complications and better disease monitoring are likely to have played a role. On the other hand it may be nothing to do with medical care and there is a simple epidemiological explanation; for instance there are less smokers now than there was 30 years ago (5).

Or is it?

There is another more concerning explanation. The plethora of medical options for patients with Crohn’s disease continues to expand. As a simple surgeon it is difficult to keep up with the various biosimilars, protein kinase, IL , CAM and JAK3 inhibitors that are available or being developed. It is like a candy shop of choice for the physician and a huge temptation for the patient to at least try one or more of these cutting edge medical therapies. Give medical treatment ‘just one more go’ is an obvious impulsion. But the medical literature is consistent in suggesting over 70% of patients with Crohn’s Disease eventually come to surgery (6). This can only mean that an increasing proportion of those undergoing surgery have experienced protracted medical therapy and are likely to have more complex disease. Although difficult to confirm this is certainly the perception of many in the surgical community (7-9).

Naturally all clinicians strive for the ultimate goal of never requiring surgery for Crohn’s Disease, but we are not there yet. Indeed some argue that the trend for less surgery should be reversed and surgery offered for more patients much earlier in their treatment pathway.

Buying a car

I like to think that the choice of surgery or medical therapy is analogous to buying a car. When making such a decision there are various factors that should be considered. These include safety, comfort, reliability, cost and perhaps most important of all what your partner thinks. The car may seem perfect in terms of all of these factors but he/she does not like the salesman, the brand or the colour.  

So when it comes to the choice of the medical or surgical ‘car’ option, safety is in some respects paramount. There is a justifiable fear of surgery and a dread by many for the need for a stoma. However, optimisation of the patient, use of minimally invasive techniques, minimal resection and enhanced recovery mean that many of these fears are unfounded in the majority of patients (10). Indeed there are not insignificant risks associated with the alternative long-term immunosuppression.

Car comfort translates to quality of life. We know from the LIRIC study that quality of life is pretty much equivalent when it comes to medical or surgical options (11). No obvious winner here. However, when it comes to reliability or the chance of needing surgery there is an outright winner. As mentioned earlier the universally consistent literature suggests a greater that 70% chance of Crohn’s patients eventually needing surgery despite enhanced medical therapy (6). The ‘shiny medical sports car’ is very likely to break down. Compare with the ‘banger’ that is the surgical car. This just keeps going.

Additionally, long-term studies suggest at least 50% of patients will be symptom free 10 years after resection and two thirds will avoid further surgery (6). If this were the data for a new drug it would undoubtedly become a best seller. Furthermore it may be possible to customize the surgical ‘banger’ to make it even more reliable and attractive to the discerning customer. The Kono-S anastomosis and more radical mesenteric resection have both been touted as techniques that may reduce recurrence even further (12,13).

What does the data say?

Two recent publications back up these observations. A recent meta-analysis comparing early surgery with medical therapy decreases the risk of overall relapse (OR 0.53) , surgical relapse (OR 0.47) and the need for biological maintenance therapy (OR 0.24) whilst showing no difference in morbidity (14). Perhaps more significantly, long term analysis of the LIRIC data suggests nearly half of those treated with biological end up having surgery within 5 years and the rest remain on medication, switch or escalate treatment. Compare that with the surgical group were although about a quarter of the group required medical therapy for symptomatic recurrence, no one has required further surgery (15) Add to that cost, another clear winner for the surgical ‘banger’. Data again from LIRIC suggests it is €9000 cheaper than the medical option and almost 100% likely to be cost effective (16).

Therefore, it seems that the surgical car is cheaper, more reliable and, despite the looks, is as comfortable and safe as the shiny new medical sports car. However, the unpredictable factor is of course what your partner (patient) thinks. A study by Scott and Hughes (17) suggested about 80% of patients who underwent iloecaecal resection for Crohn’s disease said they ‘wished they had had surgery sooner’. Whilst a pre-biological era study and full of potential bias, many surgeons would be familiar with this phrase from the happy patient sitting in front of them, having undergone successful resection.

How do we proceed?

So there is a quandary here. Every doctor, regardless of specialty, wishes to reduce the need for surgery in Crohn’s but I would argue the evidence points to this being a less favorable option in many. The solution in my view lies in the underlying principle of good care for IBD, a multidisciplinary approach. Patients with Crohn’s Disease who require escalation of treatment should be fully informed of the risks and benefits of both medical and surgical options and make their own mind up. The only way this can be done fully and in an unbiased fashion is by meeting the surgeon earlier, preferably together with the physician in a joint clinic.

References

  1. Kalman TD, Everhov ÅH, Nordenvall C, et al. Decrease in primary but not in secondary abdominal surgery for Crohn’s disease: nationwide cohort study, 1990-2014 [published online ahead of print, 2020 May 26]. Br J Surg. 2020;10.1002/bjs.11659.
  2. Beelen EMJ, van der Woude CJ, Pierik MJ, et al. Decreasing Trends in Intestinal Resection and Re-Resection in Crohn’s Disease: A Nationwide Cohort Study [published online ahead of print, 2019 Jun 10]. Ann Surg. 2019;10.1097/SLA.0000000000003395.
  3. Lakatos PL, Golovics PA, David Get al. Has there been a change inthe natural history of Crohn’s disease? Surgical rates and medicalmanagement in a population based inception cohort from Western Hungary between 1977–2009. Am J Gastro2012;107: 579–88.
  4. Jeuring SF, van den Heuvel TR, Liu LY, et al. Improvements in the Long-Term Outcome of Crohn’s Disease Over the Past Two Decades and the Relation to Changes in Medical Management: Results from the Population-Based IBDSL Cohort. Am J Gastroenterol. 2017;112(2):325-336.
  5. Cosnes J. Smoking and diet: impact on disease course? Dig Dis. 2016;34:72–77
  6. Latella G, Caprilli R, Travis S. In favour of early surgery in Crohn’s disease: a hypothesis to be tested. J Crohns Colitis. 2011;5:1-4.
  7. Buskens CJ, Bemelman WA. The surgeon and inflammatory bowel disease. Br J Surg. 2019;106:1118-1119
  8. Macfie J. Commentary: Changing trends in surgery for abdominal Crohn’s disease. Colorectal Dis. 2019;21:208.
  9. Mege D, Garrett K, Milsom J, Sonoda T, Michelassi F. Changing trends in surgery for abdominal Crohn’s disease. Colorectal Dis. 2019;21:200-207.
  10. 2015 European Society of Coloproctology (ESCP) collaborating group. Patients with Crohn’s disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications’ rate. World J Gastrointest Surg. 2019;11:261-270.
  11. Ponsioen CY, de Groof EJ, Eshuis EJ, et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: a randomised controlled, open-label, multicentre trial Lancet Gastroenterol Hepatol. 2017;2:785-792.
  12. Alshantti A, Hind D, Hancock L, Brown SR. The role of Kono-S anastomosis and mesenteric resection in reducing recurrence after surgery for Crohn’s disease: a systematic review [published online ahead of print, 2020 May 17]. Colorectal Dis. 2020;10.1111/codi.15136.
  13. Coffey CJ, Kiernan MG, Sahebally SM, et al. Inclusion of the Mesentery in Ileocolic Resection for Crohn’s Disease is Associated With Reduced Surgical Recurrence. J Crohns Colitis. 2018;12:1139-1150.
  14. Ryan ÉJ, Orsi G, Boland MR, et al. Meta-analysis of early bowel resection versus initial medical therapy in patient’s with ileocolonic Crohn’s disease. Int J Colorectal Dis. 2020;35:501-512.
  15. Stevens TW, Haasnoot ML, D’Haens GR, et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastro hepatol. 2020 Available on line 30 June.
  16. de Groof EJ, Stevens TW, Eshuis EJ, et al. Cost-effectiveness of laparoscopic ileocaecal resection versus infliximab treatment of terminal ileitis in Crohn’s disease: the LIR!C Trial. Gut. 2019;68(10):1774-1780.
  17. Scott NA, Hughes LE. Timing of ileocolonic resection for symptomatic Crohn’s disease–the patient’s view. Gut. 1994;35:656-657.

Decision-making, regret and the surgeon

Claire Donohoe

It is a surgical aphorism that it is more difficult to decide when not to operate than when to operate.

In the study “Learning from Regret”1, surgeons contributing to Queensland’s Audit of Surgical Mortality were asked to reflect on deaths following surgery. They were asked whether they would have done anything differently in retrospect. The aim was to explore surgeon’s reflections on what might have been done differently for patients who died under their care. The secondary aim was to assess for the presence of regret – defined as the presence of personal responsibility and realisation that another decision could have been better.

Findings

Post-decision regret was explicitly identified in 16.9% of responses. One of the scenarios specifically referred to was regret surrounding with proceeding to surgery in cases where the likelihood of survival was slim (“the decision entailed the alternative of certain death rather than probable death”). The fields of behavioural economics and psychology give us several reasons why we shouldn’t reflexively regret decision-making in these types of charged scenarios – because regret is the de facto outcome of a decision to operate in this scenario.

Understanding regret

Firstly, the fact of operating rather than palliating in this scenario makes us more likely to regret it in retrospect when the outcome is poor by the mere fact of one having acted rather than not acted. Actions are more salient (i.e. easier to recall) than inaction and, therefore, more prone to regret upon reflection from a psychological perspective2. Humans also tend to regret action (acts of commission) more than inaction (acts of omission) because having acted, we then attempt to mitigate the cognitive dissonance that arises between our ideal and actual selves by reducing the dissonance by deriving lessons learned from the perceived error3.

The authors of “Learning from Regret”1 highlighted that surgical decision-making in cases associated with deaths were uncertain, complex and subject to situational pressures. In not operating, the surgeon would have to violate the norms of usual surgical behaviour4 that in the face of certain death without an operation, an operation should be performed.

Futility scenarios

In fact, in scenarios where treatment is highly likely to be futile, expected utility theory would tell us that our choices are very limited. In classical economics, expected utility theory is the theory of how rational actors make decisions. That is, that rational beings choose the option to maximise the risk: benefit ratio. When applying expected utility theory to medical decision-making, as the net treatment benefits increase, we become more uncomfortable withholding treatment even when the probability of a good outcome is relatively low and the risks are substantial. Therefore, when the counterfactual treatment outcome is certain death, if we apply traditional rational economic decision-making theory, then there are few circumstances in which the certainty of this poor outcome can outweigh the small possibility of a good outcome (especially where survival and not functional outcome is the primary outcome).

Furthermore, we increasingly recognise that medical decision-making employs dual-processing theory5. Rather than employing the neural pathways utilised in rational decision analysis, medical decision-making also draws from type 1 or emotional decision-making. This tends to make medical decision makers more risk-averse. Dual-processing of this nature also means that it is more challenging to apply rational thinking behaviours to decision involving how we must act, than it is to rationally decide how others should act6.

Summary

Clearly, aiming to avoid futile treatment that increases suffering at the end of life is an important goal in emergency surgery, however, making these types of decisions will always be difficult because surgeons are human and prone to all of the cognitive biases inherent to this state.

References

1.            Boyle FM, Allen J, Rey-Conde T, et al. Learning from regret. BJS 2020; 107(4):422-431.

2.            Gilovich T, Medvec VH. The experience of regret: what, when, and why. Psychological review 1995; 102(2):379.

3.            Gilovich T, Medvec VH, Chen S. Commission, omission, and dissonance reduction: Coping with regret in the” Monty Hall” problem. Personality and Social Psychology Bulletin 1995; 21(2):182-190.

4.            Nichols S. Norms with feeling: Towards a psychological account of moral judgment. Cognition 2002; 84(2):221-236.

5.            Djulbegovic B, Elqayam S, Reljic T, et al. How do physicians decide to treat: an empirical evaluation of the threshold model. BMC medical informatics and decision making 2014; 14(1):47.

6.            Nadelhoffer T, Feltz A. The actor–observer bias and moral intuitions: Adding fuel to Sinnott-Armstrong’s fire. Neuroethics 2008; 1(2):133-144.