COVID‐19: Current and future challenges in spine care and education ‐ a worldwide study

Abstract Background The COVID‐19 pandemic has impacted spine care around the globe. Much uncertainty remains regarding the immediate and long‐term future of spine care and education in this COVID‐19 era. Study design Cross‐sectional, international study of spine surgeons. Methods A multi‐dimensional survey was distributed to spine surgeons around the world. A total of 73 questions were asked regarding demographics, COVID‐19 observations, personal impact, effect on education, adoption of telemedicine, and anticipated challenges moving forward. Multivariate analysis was performed to assess factors related to likelihood of future conference attendance, future online education, and changes in surgical indications. Results A total of 902 spine surgeons from seven global regions completed the survey. Respondents reported a mean level of overall concern of 3.7 on a scale of one to five. 84.0% reported a decrease in clinical duties, and 67.0% reported a loss in personal income. The 82.5% reported being interested in continuing a high level of online education moving forward. Respondents who personally knew someone who tested positive for COVID‐19 were more likely to be unwilling to attend a medical conference 1 year from now (OR: 0.61, 95% CI: [0.39, 0.95], P = .029). The 20.0% reported they plan to pursue an increased degree of nonoperative measures prior to surgery 1 year from now, and respondents with a spouse at home (OR: 3.55, 95% CI: [1.14, 11.08], P = .029) or who spend a large percentage of their time teaching (OR: 1.45, 95% CI: [1.02, 2.07], P = .040) were more likely to adopt this practice. Conclusions The COVID‐19 pandemic has had an adverse effect on surgeon teaching, clinical volume, and personal income. In the future, surgeons with family and those personally affected by COVID‐19 may be more willing to alter surgical indications and change education and conference plans. Anticipating these changes may help the spine community appropriately plan for future challenges.

indications and change education and conference plans. Anticipating these changes may help the spine community appropriately plan for future challenges.

K E Y W O R D S
COVID-19, coronavirus, education, future, guidelines, healthcare, impact, spine

| INTRODUCTION
The COVID-19 pandemic has affected both patients and healthcare providers worldwide. At the time of this study's completion, inpatient hospital and intensive care unit demand have far exceeded capacity for many regions. Hospitals have made drastic alterations to care structures, including prioritizing different types of procedures and deferring elective surgeries. 1,2 In addition, many spine and orthopedic surgeons have been asked to help provide care outside of their area of expertise, including the emergency department and intensive care unit. 3,4 For many, the length of time that these changes will remain in place is unknown, and the pandemic may continue to unfold in stages. 4,5 The long-term repercussions of the pandemic and its effects on healthcare providers are fraught with uncertainty.
As highlighted by Louie et al, spine surgeons around the globe have been affected by these aforementioned changes. 6 Many have experienced diminished clinical productivity, adverse effects on personal income, and travel bans. In some cases, they have even been reassigned to work on the front lines. 3,7 Limitations from hospital systems have made it difficult for spine surgeons to effectively treat their patients. Many with myelopathic symptoms, worsening radicular pain, and motor weakness have been forced to struggle through continued conservative treatment. 8,9 An understanding of the challenges faced by spine surgeons in this current pandemic and their attitudes towards the future may help to guide resource allocation moving forward. Similarly, embracing positive changes that have resulted from this unique time may stimulate a new age of virtual learning and global collaboration. Thus, the aim of the present study was to elicit the attitudes, stresses, and future anticipations of spine surgeons around the globe as they pertain to patient care and education in response to the COVID-19 pandemic, and to present tangible plans to address the challenges and concerns as they return to their clinical practices in the postCOVID-19 era.

| Survey distribution
The 73-item survey was presented in English and distributed via email to the AO Spine membership who agreed to receive surveys (n = 3805). AO Spine is the world's largest society of international spine surgeons (www.aospine.org). The survey recipients were provided 9 days to complete the survey (27 March 2020 to 4 April 2020).
Respondents were informed their participation was voluntary, and information gained would be disseminated publicly and in peer-review journals.

| Statistical analysis
All statistical analysis and data processing were performed using open-source packages through the Python v3.7 programming language. Survey responses were summarized via collection of raw count data and respective calculation of percentages, means, and standard deviations. Multivariate logistic regression analysis was performed to assess variations in survey responses focusing on patient care/education and included reported interest level in online spine education, likelihood of attending a medical conference in 1 year, and inclination to use increased nonoperative measures prior to surgery in 1 year.
Model covariates believed to be relevant to dependent variables of interest based on the opinions of senior co-authors, and included all collected baseline survey respondent demographics and practicespecific characteristics. Results of the multivariate models were summarized via calculation of odds ratios (ORs), 95% confidence intervals (CIs), and P-values. A P-value <.05 was used to establish statistical significance for all tests.

| RESULTS
In total, 902 surgeons completed the survey, with an overall response rate of 23 Respondents reported a moderate-to high-level of overall concern regarding the COVID-19 outbreak, with a mean score of 3.7 on a scale of one to five. The three most common stressors identified were family health (76.0%), economic concerns (45.7%), and timeline to 64.0% anticipated more than 4 weeks and 26.5% anticipated more than 8 weeks before a return to "baseline" status is possible.
There is also concern that the presence of the virus may be felt for years to come. When asked how this outbreak will impact patient care 1 year from now, 57.9% said they will have a heightened awareness of hygiene, and 45.8% will increase use of personal protection equipment. Providers may be more hesitant to offer surgical intervention going forward, as 20.0% reported they plan to pursue an increased degree of nonoperative measures prior to surgery and 38.0% will have patients reschedule if they feel sick. Furthermore, when asked if they would attend a scheduled medical conference 1 year from now, 33.7% reported being either unsure or not likely.  (Table 3). Lastly, surgeons reporting larger clinic-based practices were more likely to express interest in online spine education (OR: 2.56, CI: [1.07, 6.12], P = .034) ( Table 4).

| DISCUSSION
The findings of the present study suggest that spine surgeon's worldwide share in the concern surrounding the COVID-19 pandemic. Clinical volume has diminished, daily routines have been altered, and revenues have decreased. There is uncertainty as to what both the immediate and distant future holds. Despite these concerns, there has been a renewed interest in telemedicine, virtual learning, and global collaboration. Guidelines are necessary to help spine surgeons meet the challenges of current and future patient care, in addition to maintaining efforts aimed at education and collaboration ( Table 5).
F I G U R E 1 Distribution of survey respondents by geographical region

| Spine care in the future
In regards to spine care moving forward, roughly one in five surgeons reported that they plan to attempt longer courses of conservative care before committing to surgical intervention 1 year from now. This may be reflective of surgeons' hesitancy to bring patients to the hospital, exposing both patients and care teams to the potential for pathogen transmission. A more likely explanation, however, may be an effort to avoid overwhelming a stressed healthcare system with unplanned hospital or ICU admissions. 10 This practice of attempting a longer course of conservative therapy was more likely to be adopted by those with a spouse at home, likely reflective of an overarching desire to avoid spreading COVID-19 to the home environment. 11,12 Interestingly, this practice was also more likely to be adopted by clinicians who identified as spending a large portion of their time in resident and fellow education, and less likely to be adopted by those who did not expect the pandemic to impact their salary. In addition to minimizing exposure of residents and fellows to COVID-19, this finding is consistent with the higher likelihood of providers in academic settings receiving a fixed-salary rather than reimbursement based solely on surgical volume. 13 Regardless, forced consideration of elective surgeries moving forward may help providers to better identify patients that can be treated sufficiently with nonoperative care. 9 States. 15 All three reported an expected loss in revenue and income for the practice and care providers that last until the third quarter of the 2020 fiscal year, assuming that elective surgeries are able to restart in the summer of 2020. Each had enacted work hour restrictions or furlough for ancillary staff. The timeline for these changes remains unclear, and is dependent largely on the easing of surgery restrictions. Furthermore, when spine surgeons are able to perform elective procedures once again, their patient population may be considerably different from the prepandemic population. That is, patients may not have the same health insurance that they previously carried, patients may not have time to seek elective surgery following an extended period of diminished or no income, and many will simply not wish to seek care in a hospital setting where COVID-19 is present. 16  becomes available or herd immunity can be realized. 18 In addition, despite the fact that a minority of surgeons reported working at an institution that had guidelines for the pandemic, nearly all respondents believed that such guidelines should be a priority and in place moving forward. Clearly there is a need for evidence-based protocols.
Hospitals and medical centers must disclose anticipated needs and provide solutions to local government, at which point data can be gathered from multiple centers within a region. Plans can be developed at the local, regional, and national levels around the world to provide formal guidelines that are evidence-based and aligned with the research and experience of the COVID-19 pandemic.

| Education and collaboration
The COVID-19 pandemic has resulted in new sources of stress, changes to patient care, and uncertainty regarding future practice.
The education of residents and fellows, in addition to the continued learning of faculty, has not been immune to these changes 1,19 A majority of respondents in our survey noted that the education of their residents and fellows had been adversely affected, and their personal research productivity had fallen or stopped. Despite many negatives, the pandemic has stimulated a wave of web-based learning and global collaboration that has not been seen before. 20  convenience of participating and/or leading educational experiences on virtual platforms that simultaneously allow for a high-volume clinical practice. Furthermore, this may be a valuable avenue for academic departments and professional societies and to engage spine providers in educational endeavors who were previously too occupied.
Virtual meeting platforms in particular have revolutionized the way clinicians interact and learn while spending time away from their normal work environment. 21 The examples are numerous. Residency and fellowship programs in orthopedic surgery and neurosurgery have adopted online platforms for departmental conferences and meetings.
Governing bodies and subspecialty societies within spine surgery have organized and led international seminars that surgeons can access from their own home. Industry and independent education foundations have held virtual case reviews, research study group meetings, and topical debates. In response to high attendance and positive feedback, time and money invested for these endeavors has risen drastically. 22 Given the number of spine care providers that have met the learning curve and successfully adopted these platforms, our hope is that these powerful learning tools continue to serve important roles into the distant future.
Concerns regarding the spread of disease and placing spine care providers at risk has resulted in the cancellation or postponement of conferences around the world. Furthermore, once providers return to clinical practice, they may lack the financial and scheduling freedom to attend traditional in-person conferences. Many of these conferences have therefore adopted virtual formats, in which presentations and those who reported being impacted by a prior pandemic (SARS), expressed a higher likelihood of feeling comfortable. This is likely reflective of provider confidence in local governing bodies to develop policies to limit the spread of a pathogen, recover once the pandemic has resolved, and to determine if and when a medical conference is appropriate. 23,24 Although face-to-face interaction is valuable, there has been a growing interest for global collaborative platforms for spine providers that may serve a similar function to medical conferences of the past.
When asked in our survey, 34% reported they would be active readers on such a platform, and 60% reported they would both read and contribute. Spine governing bodies and subspecialty societies should consider these data when planning meetings and collaborative opportunities in a postCOVID-19 world.

| CONCLUSIONS
The effects of the COVID-19 pandemic have been far reaching, many of which have been felt by spine surgeons around the world. The present study suggests that spine surgeons share a high level of concern regarding the pandemic, with drastic changes to daily routines, finances, and methods of learning. Understanding the current attitudes, sources of stress, and unique areas of interest for spine surgeons may enable planning and anticipation for future challenges.
Web-based learning and global collaboration have seen a unique surge in utilization. Rising to meet the challenges of COVID-19 and maintaining the unanticipated benefits will help the field of spine surgery to continue moving forward.