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 firstname.lastname@example.org
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]
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.
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%).
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.
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. 
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.
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. 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.
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.
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