The New Normal: ACS Associate Fellows Continue to Feel the Effects of COVID-19

Highlights

• Summarizes the findings of an ACS survey of young surgeons and the effects of COVID-19
• Describes both diminished career opportunities and fluctuations in operative volume as a result of the pandemic
• Outlines the challenges associated with virtual CME learning and telehealth platforms
• Identifies the effect of the pandemic on mental health and wellness, including burnout and reduced job satisfaction

The transition from residency and fellowship training to becoming an attending and an Associate Fellow of the American College of Surgeons (ACS) can be a daunting proposition. Associate Fellows are surgeons who have completed their training but are not yet eligible or have not yet applied to be a Fellow. Learning to operate autonomously, navigating a new electronic health record (EHR) system, billing, coding, and engaging in continuing medical education (CME) are just a few of the areas young surgeons must navigate when starting a new position. The jump from residency to independent practice is complex, and it can take a while for Associate Fellows to find confidence and stability in their new role.

Creating further obstacles in this difficult transition period, the World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020.¹ Associate Fellows were tasked not only with the obligations cited earlier but also had to perform their duites in the face of a pandemic. The Centers for Medicare & Medicaid Services (CMS) issued new criteria regarding what operations could be performed.² As a result, depending on one’s specialty, a surgeon may have been unable to operate at all or only able to operate on urgent or emergent cases.

This article describes how Associate Fellows have been affected by the pandemic in terms of diminished job prospects, loss in operative volume, challenges associated with virtual learning platforms, and maintaining mental health and wellness. A total of 486 Associate Fellows responded to the ACS Survey of Young Surgeons: Effects of COVID-19 Pandemic on Clinical, Educational, and Personal Experience. The results of that study are further analyzed in this article.

Job Prospects

The goal of most surgical trainees is to enter independent practice as soon as possible. Even in the best of times, finding your first job can be an arduous and convoluted process. Although some areas of healthcare, such as the pharmaceutical sector,³ have seen an increase in employment opportunities as a result of the COVID-19 pandemic; anecdotally, surgeons have not had this experience.

Many of us have colleagues whose jobs were rescinded at the start of the pandemic or had difficulty finding jobs after graduation.⁴ Some new graduates were unfortunately forced to take the first job that came along or accept terms of employment that were less than ideal because of concerns about the pandemic’s effects on the job market. The main factor in decreased job opportunities is the loss of hospital revenue resulting from a decrease in surgical volume.⁵ According to the latest results of the ACS Survey of Young Surgeons, there were reported reductions of 85% in elective cases and 45% in emergency surgery. Without the revenue generated by a high volume of surgical procedures, many surgery departments and group practices were unable to secure the funds to hire new surgeons.

For young surgeons unable to secure satisfactory permanent positions, many turned to locum tenens work to bridge the gap between graduation and full-time employment or unexpected time between jobs. Consequently, some new graduates were practicing outside of their preferred specialty, forced to spend more time away from family, or felt that they were delaying the advancement of their careers.

As we transition to the new normal of the pandemic, many hospitals have returned to prepandemic volumes of elective and emergency cases, although the financial losses will take much longer to recuperate. Perhaps the increase in caseloads will translate into a rise in the availability of jobs for newly trained surgeons; however, return to prepandemic compensation is unlikely as hospitals continue to grapple with the repercussions of COVID-19.

For the 2021−2022 academic year, more than one-third of survey respondents reported a decrease in compensation compared with the pre-COVID era. Hopefully, as the healthcare arena continues to adapt to this new reality, graduating surgeons will have less difficulty finding suitable jobs, and recent graduates will have the opportunity to transition to their ideal job or renegotiate any suboptimal contract terms, resulting in better compensation.

Loss in Operative Volume

Although many surgeons have seen drastic changes in their practices during the COVID-19 pandemic, new graduates have no prior experience with which to compare their current practice. Gaining confidence with diminished operative and clinical volumes was challenging for many Associate Fellows. As new attendings, they anticipated being able to hit the ground running and build a practice, but instead were thrown one obstacle after another.

The fluctuations in operative volume had a substantial impact on the necessary repetition and autonomy that many fellows and residents normally would have had in their final year of training. Surgical departments struggled to find operative times for their current staff, let alone new surgeons. This situation made negotiating block time difficult, leading to significantly decreased operative volumes for individuals trying to build a practice and gain operative confidence as new attendings.

As the pandemic has evolved, Associate Fellows have continued to adapt their operative and clinical schedules to accommodate their institutions’ various needs. As previously mentioned, 85% of Associate Fellows reported a reduction in the elective operative volume. Although clinical schedules were changed during the pandemic, 51% of respondents reported that their schedules within the last year have yet to stabilize. Many Associate Fellows reported changes in outpatient clinic schedules as well, such as decreased clinic load and more telehealth visits. Although almost half of Associate Fellows have now reported a return to normal schedules, the question remains: Do we really know what normal is, or is this the “new normal” for surgeons during the ongoing pandemic?

Transition to a Virtual Platform

CME is required to maintain your medical licensure, and requirements vary by state and certifying body. During the pandemic, many in-person CME classes transitioned to virtual platforms. Overall, virtual settings had many advantages. Participants could attend from the comfort of offices and homes, it was possible to add more flexibility to schedules, and overhead costs declined. One negative effect many Associate Fellows mentioned in the survey was a lack of opportunity to network with peers.

The survey asked whether young surgeons had found other opportunities to connect with peers locally or nationally. The answers varied greatly. Twenty percent of Associate Fellow respondents said they had less peer interaction. They indicated that they felt overburdened by work, isolated, and unable to engage on virtual platforms. Another 20% of respondents indicated that while networking opportunities suffered, they had more time for family, research, and reading.

Fifty-six percent of the surveyed Associate Fellows said they continued to pay dues to professional societies, and 59% stated they had less involvement in professional societies during the pandemic. Whether these finding are attributable to a lack of in-person meetings or an increase in personal or work stressors is unknown. Decreased engagement has been apparent in many national organizations, including the Resident and Associate Society of the ACS (RAS-ACS).

Many mentoring and multidisciplinary relationships suffered as well during the pandemic due to limited in-person interactions. With the refinement of virtual meetings improving accessibility, surgeons are now reporting improved connections with other surgeons and other subspecialties in virtual tumor boards and meetings.

Telehealth visits also increased during the pandemic. While this transition worked well for some specialties, many surgical specialties rely on a thorough physical exam to aid in diagnosis. A push was made to do follow-up appointments virtually, but an in-person visit was conducted if any concerning findings arose. Some providers have reported increased use and satisfaction with telehealth visits, but many report difficulty conducting these types of visits.

With COVID-19 physical restrictions in place, networking and outreach to build referral patterns and grow one’s practice also were difficult for many new surgeons at the beginning of the pandemic. Many Associate Fellows did not think virtual meetings were equal substitutes to one-on-one meetings, which facilitate relationship building and fortify referral patterns. With decreasing COVID-19 numbers, it is anticipated that in-person networking events and meetings will continue to increase, but given the emergence of multiple variants, telehealth visits could continue to present challenges.

Mental Health

The COVID-19 pandemic has had a significant impact on the mental health of healthcare professionals, including surgeons. Finding a job and transitioning to independent practice already is a stressful and a tumultuous time in a young surgeon’s life, and the difficulties of doing so during the pandemic have compounded the repercussions on their mental health. To help explore these challenges, the ACS Survey of Associate Fellows included evaluation of several aspects of mental health, including burnout and symptoms of depression and anxiety, as well as the reasons for and consequences of the pandemic’s influence on these variables.

Burnout, which encompasses the symptoms of emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment, has become a popular term in the medical literature. It may serve as an overall indicator of an individual’s mental health and has been associated with an increased rate of medical errors and decreased career satisfaction among surgeons.^4-6

Nearly one-third (32%) of Associate Fellows acknowledged experiencing new or worsening emotional exhaustion over the past year, and 34% had a decreased sense of personal accomplishment. Although these data do not differ significantly from the previously reported rate of burnout among surgeons (40%),⁷ 60% of Associate Fellows expressed a new or worsening sense of depersonalization because of the pandemic, potentially affecting quality of care (see Figure 1).

Burnout is highly correlated with depression, so it is of little surprise that 38% of Associate Fellow survey respondents also reported new or increased symptoms of depression. More than half of Associate Fellows experienced new or increased symptoms of anxiety, and approximately 40% had weight changes or difficulty concentrating. The cumulative effects of the pandemic and its impact on emotional well-being and mental health likely played a role in almost half of survey respondents reporting that they considered changing jobs, employers, or roles, or leaving medicine altogether during the 2021–2022 academic year.

For many surgeons, career satisfaction significantly influences mental health. The myriad effects of the COVID-19 pandemic on healthcare delivery have directly and indirectly contributed to decreased career satisfaction among surgeons and thus negatively affected their mental health and well-being. According to the results of the survey, firing support staff, rescinding vacations, and assigning physicians to nonsurgical services have all been key factors.

Adequate surgical volume, which is particularly important to a surgeon’s career development, has declined because of the pandemic. Personal factors, such as school closures and difficulty arranging childcare, also have taken a toll on the well-being of young surgeons, with 88.6% of respondents reporting childcare issues. Finally, the survey demonstrated that 31.8% of respondents feared spreading COVID to family members, which also has affected mental health. These results are consistent with other studies that showed an increased prevalence of depression and anxiety among healthcare workers who feared infecting their family members or losing their jobs because of the pandemic.⁸

Despite the clearly negative effects of the pandemic on mental health and well-being, only a third of respondents reported that their employer instituted any new formal mechanisms to support wellness and promote resiliency. Of those respondents, only 27% used those resources. Similarly, 26% of Associate Fellows who responded to the survey were aware of wellness or resiliency resources available from the ACS or other organizations, but only 20% used these resources.

Given these data, undoubtedly there is an opportunity for programs and institutions to address both the systemic and pandemic-specific catalysts of burnout and mental illness to better support their faculty. Additionally, societies such as the ACS may be able to fill the gap for those individuals at institutions that lack these types of resources.

Conclusion

Transitioning to practice after finishing surgical training is challenging, and graduates during the COVID-19 pandemic have had to overcome new barriers such as limited job prospects, changes in job structure, virtual networking, and increasing mental health concerns. Associate Fellows are still navigating many of these challenges, and it is unclear when the healthcare sector will recover from the effects.

As we adapt to a new normal, we must rely on each other to navigate these uncharted waters. The ACS has an extensive resource center (facs.org/for-medical-professionals/covid-19) that trainees, new attendings, and established surgeons can use to support their colleagues and practices as we continue to work through these unprecedented times.⁹ Unfortunately, COVID-19 is here to stay, so we must continue to work together to achieve the professional outcomes that recent surgical graduates deserve.

References

1. World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19. March 11, 2020. Available at: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020. Accessed June 22, 2022.
2. Centers for Medicare & Medicaid Services. CMS adult elective surgery and procedures recommendations: Limit all non-essential planned surgeries and procedures, including dental, until further notice. April 7, 2020. Available at: https://www.cms.gov/files/document/covid-elective-surgery-recommendations.pdf. Accessed June 22, 2022.
3. Bachmann M, Enodien B, Frey DM, Taha-Mehlitz S, Taha A. The development of healthcare jobs in the COVID pandemic—A new economic market. Front Public Heal. April 4, 2022. Available at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.848636/full. Accessed June 22, 2022.
4. Culp BM, Frisch NB. COVID-19 impact on young arthroplasty surgeons. J Arthroplasty. 2020;35(7S):S42-S44.
5. Aranda-Michel E, Serna-Gallegos D, Arnaoutakis G, et al. The effect of COVID-19 on cardiac surgical volume and its associated costs. Semin Thorac Cardiovasc Surg. April 2, 2022. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8976579. Accessed June 22, 2022. [Epub ahead of print].
6. Al-Ghunaim TA, Johnson J, Biyani CS, et al. Surgeon burnout, impact on patient safety and professionalism: A systematic review and meta-analysis. Am J Surg. December 27, 2021. [Epub ahead of print].
7. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
8. Huarcaya-Victoria J, Villarreal-Rao B, Luna M, et al. Factors associated with mental health outcomes in hospital workers during the COVID-19 pandemic: A mixed-methods study. Int J Environ Res Public Health. 2022;19(9):5346. Available at: https://www.mdpi.com/1660-4601/19/9/5346. Accessed June 22, 2022.
9. American College of Surgeons. COVID-19 Resource Center. Available at: https://www.facs.org/for-medical-professionals/covid-19. Accessed June 22, 2022.

Dr. Christina Colosimo is a trauma fellow at Cooper University Hospital, Camden, NJ.