Bariatric surgeons' experiences of working in the first year of the pandemic

Abstract Background The first year of the Covid‐19 pandemic saw drastic changes to bariatric surgical practice, including postponement of procedures, altered patient care and impacting on the role of bariatric surgeons. The consequences of this both personally and professionally amongst bariatric surgeons has not as yet been explored. Aims The aim of this research was to understand bariatric surgeons' perspectives of working during the first year of the pandemic to explore the self‐reported personal and professional impact. Methods Using a retrospective, two phased, study design with global participants recruited from closed, bariatric surgical units. The first phase used a qualitative thematic analytic framework to identify salient areas of importance to surgeons. Themes informed the construction of an on‐line, confidential survey to test the potential generalizability of the interview findings with a larger representative population from the global bariatric surgical community. Findings Findings of the study revealed that the first year of the pandemic had a detrimental effect on bariatric surgeons both personally and professionally globally. Conclusion This study has identified the need to build resilience of bariatric surgeons so that the practice of self‐care and the encouragement of help‐seeking behaviors can potentially be normalized, which will in turn increase levels of mental health and wellbeing.

19 was a source of stress, especially for bariatric surgeons, which could potentially result in reduced mental wellbeing. 6,7 The psychological engagement of staff within the workplace is a fundamental issue for all healthcare providers. Presenteeism is defined as people attending work despite not being mentally engaged, which can be attributed to both physical or mental ill health 8 One of the causative factors of presenteeism is the impact of often unexpected and enforced levels of psychosocial stress, characterized by workplace change and uncertainty 9 such as with the Covid-19 pandemic. 10 It is these aspects of psychosocial stress that mean continuing to work in a world dominated by Covid-19. These may have consequences for optimal surgical performance in relation to the potential for emotional labor, moral injury and compassion fatigue, 4 all of which may lead to burnout levels of which are evidenced to be high among all surgical specialties. 11 The impact of Covid-19 on bariatric surgical practice has served to highlight the necessity of understanding the mental wellbeing of bariatric surgeons if they are to be optimally supported in their roles. For many reasons, including the social construct of a surgeon as one who is in control and invokes trust, 12 mental health issues are not always easy to discuss, there are acknowledged low presentation rates of poor mental wellbeing among surgeons. 13 The aim of this study was to explore bariatric surgeons' perspectives of working during the first year of the pandemic to understand the impact this has had on surgeons both personally and professionally. This may inform planning and provision of long-term support and care for the wellbeing of bariatric surgeons.

| METHODS
This study used a retrospective, two phased, study design with participants recruited from closed, global bariatric surgical professional Facebook® groups (The Upper Gastrointestinal Surgery Society [TUGSS]). Eligibility criteria for inclusion in the study were practicing bariatric surgeons. Other members of the bariatric surgical multidisciplinary team, retired surgeons or trainees were excluded from this study to be able to focus on surgeons and their wellbeing.
The first phase used a qualitative thematic analytic framework, to identify salient areas of importance to the participants. Qualitative research is appropriate for understanding the why's and how's of social phenomena, and especially useful when exploring areas where little is known on the subject. 14,15 With the long-term impact of COVID-19 on the wellbeing of bariatric surgeons a relatively unknown entity, this methodological approach was deemed to be appropriate to conduct the first phase of the study. A thematic analytic framework was used to analyze the interview data 15 guided by a framework adaptation of the method advocated by Braun and Clarke. 16 Data were collected through confidential, face to face semistructured interviews, assisted by a topic guide. The interviews took place video (Teams® or Zoom®) at a time convenient to each participant. Each participant provided written consent; the interview was audio-recorded and transcribed verbatim and lasted between 20-45 min. The interviews were all carried out by the same female researcher, who was experienced in qualitative research and works as a researcher in a bariatric surgical unit.
A constant comparative approach was used with the interview data, meaning data collection and analysis were undertaken concurrently, with analysis guiding further sampling 10 . The researcher also took written notes during the interview, to document any areas of interest, and identify areas of importance to the participants, which could be to be explored further during the interview, clarifying any ambiguity to ensure that interpretation of data was veracious to the participants' experience and to minimize potential for researcher bias. Data collection and analysis continued until no new concepts were identified, meaning data was saturated and recruitment to phase 1 could be ceased. The concepts were discussed with the research team and a consensus on the core set of emergent themes was identified and agreed between all researchers. The findings of the thematic analysis were used to construct the survey for the second phase, which formed the questions for the on-line, confidential survey which would test the generalizability of the interview findings with a larger cohort of bariatric surgeons. Consent was implied for the survey; completing the survey was taken as consent to participate in the study.
Data were collected from May-December 2021. Ethical approval was granted from the University of Sunderland Research Ethics Committee.

| RESULTS
A total of 120 surgeons took part in the study, with five recruited to phase one (interviews) and 115 respondents to the second phase survey. For the interviews, participants (2 females, 3 male) consented to be interviewed. Participants were from Italy, China, Spain, France, and Chile and worked in public hospitals, with two engaging in private practice. Participants had been practicing bariatric surgeons for between 6 and 14 years.
There were five themes constructed from the interview data (See Table 1), which informed the construction of questions for the survey, which was the second phase of the study.
The majority of the respondents were male (87.9%, n = 102) and 11.2% (n = 13) stated their gender as female. One fifth of the respondents had been practicing as a bariatric surgeon for 3-5 years (17.5%, n = 20) and there was consistent representation across years in practice, with only 6.1% (n = 7) in practice between 18 and 20 years (see Table 2).
To delineate the person from the profession, participants were asked how they felt on a personal level when Covid 19 was announced as a pandemic. The responses were free text, with 111 responses (3 declined to respond). The most common feeling (74%, n = 82) was that of worry, in the context of self, co-workers and family. Nearly 14%% (n = 15) respondents felt that the situation would be short-term for example, 2-3 months, stating they were not too worried. The remaining 12% (n = 13) reported feeling comfortable about the pandemic.
Participants were asked the same question, but in their professional capacity as a bariatric surgeon. Of the 113 responses (2 skipped the question), over three quarters of respondents (81%, n = 91) felt worried about the impact the pandemic, with the main areas of concern being patient care, effect on performance of bariatric surgical procedures and risk of infection. Fifteen percent (n = 13) felt that they had to adapt to the situation, and felt comfortable doing so, but acknowledged an element of adaptation of working practice and environment. The remaining nine responses did not offer sufficient information to be included.
During the pandemic, some participants reported being transferred from bariatric surgery into other areas of care (see Table 3).  Table 4).
Participants were asked if enough is being done to support the overall wellbeing of bariatric surgeons, with 29% (n = 34) reporting there is support at work if they require this. Equally, 24% (n = 28) GRAHAM ET AL.
-331 stated not having support, with the same number stating that awareness of mental wellbeing and resilience needs to be increased.
Nearly one quarter (21%, n = 24) felt that personal mental wellbeing is a subject that bariatric surgeons tend not to speak about.
When asked if they felt their mental wellbeing has suffered because of the pandemic, 51% (n = 59) said no, and 48% (n = 55) stated yes. When asked if they had accessed any support for their wellbeing, formally or informally in the first year of the pandemic, 76% (n = 89) had not, but nearly one quarter (23%, n = 27) had.
At the time of data collection, 50% (=58) stated that bariatric surgical services were running, but not at pre-pandemic levels, 46% (n = 54) reported that all bariatric surgical services were operational at pre-pandemic levels, 4% (n = 5) stated services were not running and 1 reported "other".
When asked what the future provision of bariatric surgery will look like, nearly half (46%, n = 52) stated that telephone and video consultations will remain, with less face to face appointments, and comparatively (24%, n = 28) it was felt that both services will return T A B L E 1 Five themes constructed from interviews to how they were pre-pandemic, or there will be an increase in bariatric surgical procedures performed. The remaining 5% (n = 6) stated they felt that less bariatric surgery will be performed.
In terms of their career as a bariatric surgeon as a result of the pandemic, 92% (n = 105) would continue in their role, with 3% (n = 4) considering a change to another type of surgical career, and 3% (n = 2) were considering leaving the profession and doing something else. Of the remaining two participants, one stated they would retire in the next year, and the other participant reported considering retiring earlier than planned.
Finally, participants were asked to comment on any aspect of the impact of the pandemic on bariatric surgery and anything that they  In terms of the ecological validity of our own study, and its potential transferability to other contexts, a survey of 220 Latin-American trauma surgeons reported that 127 (57.7%) participants felt emotionally overextended, anxious and exhausted, especially due to the COVID-19 social isolation and uncertainties of how long it will take for life to "return to normal". 22 The universal experience of this phenomenon was tangible in the outcomes of our own study and it is notable too, that a review of the impact of Covid-19 on vascular surgery reported high levels of anxiety, attributed to exposure to the virus, moral injury, changes to practice and financial issues, 23 all of which were noted in our study.
Ear, Nose and Throat (ENT) specialists are a high-risk group for Covid-19 and potentially increased psychological harm. An Irish survey of 38 ENT specialists found that 34% (n = 13) screen positive for anxiety, and 84% (n = 32) felt that they had increased exposure to the virus compared with other specialties, with 32% (=12) feeling unable to protect themselves from Covid-19. 24 The rates of burnout and increased risk of poor outcomes for 684 orthopedic surgeons in a cross sectional survey across five countries was found to be high irrespective of healthcare system. 25 This has important repercussions for bariatric surgeons who may experience parallel issues in terms of the context specificity of their own work.
The pandemic has provided a context of complex ambiguity for the discipline of bariatric surgery, which has entailed adaptation from usual practice and then a gradual re-adaptation back to a "new normal" which has ensured no direct resolution of psychological challenge. In terms of emotional labor, for many, this has created a culture of uncertainty, where each iterative wave of the virus presents new challenges and the need for constant change. In terms of the psychological burden this places upon all bariatric surgeons 334globally, this is clearly an issue for address if a sustainable number of colleagues are to remain in active surgical roles.
Mental health and wellbeing is an area of health which is often difficult for healthcare professionals to admit and/or discuss 26