Orthopedics

Feature Article Supplemental Data

The Effect of COVID-19 on Orthopedic Practices and Surgeons in Louisiana

Nisha N. Kale, BA; Akshar H. Patel, MD; Michael J. Leddy III, MD; Felix H. Savoie III, MD; William F. Sherman, MD, MBA

Abstract

This study was performed to analyze the effect that coronavirus 2019 (COVID-19) has had on orthopedic surgeons' practices, their patients, and orthopedic surgeons themselves through a survey distributed to members of the Louisiana Orthopaedic Association (LOA). An anonymous 22-question online survey was created and distributed to 323 LOA members. Of the 323 recipients of the survey, 99 (30.7%) responded. As a part of a multiple response set, in which respondents could choose more than one answer, the majority reported delayed care for routine orthopedic injuries (81 of 97, 83.5%). Almost every surgeon (n=95, 96.0%) reported stopping or delaying elective surgery because of COVID-19 and an increase in pain/disability/deformity in patients due to delay in elective procedures (73 of 97, 75.3%) and delay in seeking care (66 of 97, 68.0%). The majority reported an increased use of telehealth visits (68 of 97, 70.1%), a decrease in patient volume (88 of 97, 90.7%), and a reduction in income (79 of 98, 80.6%) during the past 6 months. A majority of surgeons (58 of 98, 59.2%) reported that they had applied for government assistance or took out loans. Via a multiple response set, respondents indicated that as a result of the pandemic, telehealth will become more widespread (64 of 98, 65.3%) and hospitals will exert a stronger influence over health care (64 of 98, 65.3%). The COVID-19 pandemic has had lasting effects on orthopedic surgeons in Louisiana and their practices, with a substantial decrease in the number of patients treated (90.5%), surgical volume, and revenue (80.6%). Orthopedic surgeons affected by the pandemic could use these data to further understand future challenges with patient care and changing orthopedic practice dynamics during this unique time. [Orthopedics. 2020;43(6):351–355.]

Abstract

This study was performed to analyze the effect that coronavirus 2019 (COVID-19) has had on orthopedic surgeons' practices, their patients, and orthopedic surgeons themselves through a survey distributed to members of the Louisiana Orthopaedic Association (LOA). An anonymous 22-question online survey was created and distributed to 323 LOA members. Of the 323 recipients of the survey, 99 (30.7%) responded. As a part of a multiple response set, in which respondents could choose more than one answer, the majority reported delayed care for routine orthopedic injuries (81 of 97, 83.5%). Almost every surgeon (n=95, 96.0%) reported stopping or delaying elective surgery because of COVID-19 and an increase in pain/disability/deformity in patients due to delay in elective procedures (73 of 97, 75.3%) and delay in seeking care (66 of 97, 68.0%). The majority reported an increased use of telehealth visits (68 of 97, 70.1%), a decrease in patient volume (88 of 97, 90.7%), and a reduction in income (79 of 98, 80.6%) during the past 6 months. A majority of surgeons (58 of 98, 59.2%) reported that they had applied for government assistance or took out loans. Via a multiple response set, respondents indicated that as a result of the pandemic, telehealth will become more widespread (64 of 98, 65.3%) and hospitals will exert a stronger influence over health care (64 of 98, 65.3%). The COVID-19 pandemic has had lasting effects on orthopedic surgeons in Louisiana and their practices, with a substantial decrease in the number of patients treated (90.5%), surgical volume, and revenue (80.6%). Orthopedic surgeons affected by the pandemic could use these data to further understand future challenges with patient care and changing orthopedic practice dynamics during this unique time. [Orthopedics. 2020;43(6):351–355.]

In approximately December 2019, a novel zoonotic virus (later determined to be severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) was implicated in the emergence of a pneumonia that was first recognized in Wuhan, People's Republic of China.1 Subsequently, the disease caused by this virus (coronavirus 2019 [COVID-19]) spread rapidly, with the first documented case in the United States occurring on January 20, 20202 and the World Health Organization (WHO) declaring the outbreak a global pandemic on March 11, 2020.3 Because of concerns over rapid community transmission, many states issued stay-at-home mandates to mitigate potentially overwhelming health care resources.4 The first documented case of COVID-19 in Louisiana was on March 9, 2020, at the Veterans Administration in New Orleans. As the state increased its capacity for testing, a University of Louisiana at Lafayette study reported that the nonlinear growth of cases in Louisiana was among the highest in the world, with 4 parishes ranking among the top 6 counties in the United States to have the most per capita COVID-19 deaths by the end of March 2020.5 Louisiana currently has 158,826 confirmed cases of COVID-19— the fifth-highest count per capita.6,7 As allocation of resources became more sparse, 35 states placed moratoriums on elective procedures.8 The Louisiana Department of Health issued an order on March 18, 2020, dictating that only medical and surgical procedures that treated “emergent medical conditions” were allowed, limiting elective surgical cases and recommending closure of all nonessential businesses statewide with a tiered system of closures.7,9

The effects on the state's orthopedic surgeons and patients were immediate and lasting. The aim of this research was to evaluate the effect that COVID-19 has had on the state's orthopedic surgeons' practices and patients, the orthopedic community, and orthopedic surgeons themselves through a survey distributed to members of the Louisiana Orthopaedic Association (LOA).

Materials and Methods

Survey Population

After institutional review board exemption was obtained, an anonymous 22-question online survey was distributed to 323 members of the LOA. The total collection period for the survey data was August 15 to September 16, 2020, with reminder emails sent to participants after the first and third weeks. Six questions were in multiple response format, where respondents could choose more than one option. Therefore, percentages may not add up to 100%. The survey was created and distributed using Qualtrics software (Table A, available in the online version of the article).

COVID-19 SurveyCOVID-19 SurveyCOVID-19 SurveyCOVID-19 SurveyCOVID-19 SurveyCOVID-19 Survey

Table A:

COVID-19 Survey

Statistical Analysis

The de-identified survey data were analyzed with SPSS Statistics version 24 software (IBM Corp). Categorical thresholds were analyzed by examining distributions of the raw data. Binomial logistic regressions were used to determine the effects of demographic variables on outcome variables. Univariate analysis of categorical variables was performed using the chi-square test, and univariate analysis of dichotomous variables was performed using Fisher's exact test. Ordinal variables were analyzed using a Mann–Whitney U test. Statistical significance was set at an alpha level of 0.05.

Results

Demographics of Respondents

Of the 323 orthopedic surgeons surveyed, 99 (30.7%) responded. There were 95 (96.0%) respondents who identified as male and 4 (4.0%) respondents who identified as female. The majority of respondents practiced in a private practice/community-based setting (n=61, 61.6%) or an academic setting (n=25, 25.3%). Every orthopedic subspecialty was represented in this survey, with the majority of respondents being general orthopedic surgeons (n=26, 26.3%) (Table 1).

Demographics of Survey Respondents (N=99)

Table 1:

Demographics of Survey Respondents (N=99)

A binomial logistic regression was run to determine the effects of demographic variables, including sex, specialty, and practice setting, on nominal outcome variables. Logistic regression models were statistically significant below the 0.05 level. Surgeons who had been in practice 15+ years had 4.7 higher odds (95% confidence interval, 0.21–4.80) of reporting that telemedicine was not effective in treating patients during the pandemic. All other factors were not significant.

COVID-19 Effects on Patients

As reported by a multiple response set, the majority of the sample reported that COVID-19 delayed care for routine orthopedic injuries (81 of 97, 83.5%) and increased pain/disability/deformity in patients due to delay in elective procedures (73 of 97, 75.3%) and delay in seeking care (66 of 97, 68.0%). The majority (67 of 97, 69.1%) also reported reduced postoperative care for patients due to difficulty with follow-up and scheduling physical therapy appointments (Figure A, available in the online version of the article). Two surgeons wrote in responses that patients were afraid to come to the clinic because of COVID-19 concerns.

COVID-19 Effects on Orthopaedic PatientsaaThe total number of responses is 99, this n (%) value is based on a multiple response set and may not necessarily add up to 100%

Figure A:

COVID-19 Effects on Orthopaedic Patientsa

aThe total number of responses is 99, this n (%) value is based on a multiple response set and may not necessarily add up to 100%

COVID-19 Effects on Orthopedic Practices

Almost every surgeon (95 of 99, 96.0%) reported stopping or delaying elective surgery because of COVID-19. The majority of the sample also reported an increase in surgery cancellations due to COVID-19 concerns (n=91, 91.9%), a decrease in referrals (n=81, 81.8%), and having to reduce staff (n=63, 63.6%), resulting in delays in seeing patients (n=57, 57.6%) (Figure B, available in the online version of the article). Because of the pandemic, 5 (5.1%) surgeons reported having to rescind 1 job offer.

COVID-19 Effects on Orthopaedic PracticesaaThe total number of responses is 99, this n (%) value is based on a multiple response set and may not necessarily add up to 100%

Figure B:

COVID-19 Effects on Orthopaedic Practicesa

aThe total number of responses is 99, this n (%) value is based on a multiple response set and may not necessarily add up to 100%

As determined by a multiple response set, 70.1% (68 of 97) of surgeons reported that COVID-19 increased the use of telehealth visits in their practices, with the majority of these reporting 1% to 25% of their practice has currently switched to telemedicine (n=48, 70.6%) because of the pandemic. Of those who indicated telemedicine was effective in treating orthopedic patients during the pandemic (n=11, 16.2%), a significant majority of these respondents were academic surgeons (6 of 11, 54.5%; P=.01). A significant majority of respondents who indicated that telemedicine was “maybe” effective (n=33, 48.5%) were private practice/community physicians (22 of 33, 66.7%; P=.01). The majority of surgeons who thought that telemedicine was not effective (n=24, 35.3%) were also private practice/community physicians (16 of 24, 66.7%; P=.01). Almost every respondent reported that their patient volume had decreased during the past 6 months because of the pandemic (86 of 95, 90.5%). The significant majority of private practice/community-based physicians indicated that their patient volume had decreased by 1% to 25% (34 of 51, 66.7%; P<.001), whereas the significant majority of academic surgeons (10 of 16, 62.5%; P<.001) and hospital-based surgeons (9 of 14, 64.3%) indicated that their patient volume had decreased by 26% to 50% (P<.001).

A majority of surgeons (58 of 98, 59.2%) reported that they had applied for government assistance or taken out loans to sustain their practices. The majority of practice/community-based physicians indicated that they took government assistance/loans to sustain their practices (54 of 57, 94.7%; P<.001), whereas significantly more academic (15 of 18, 83.3%) and hospital-based (15 of 16, 93.8%) surgeons indicated that they did not require financial assistance to sustain their practices (P<.001). As indicated by a multiple response set, most surgeons in the sample (55 of 97, 56.7%) indicated that they had received Paycheck Protection Program (PPP) loans, and that these funds were enough to help their practices stay open (Figure C, available in the online version of the article).

COVID-19 Economic Loans and Government Assistance for Orthopaedic PracticesaaThe total number of responses is 99, this n (%) value is based on a multiple response set and may not necessarily add up to 100%. PPP=Paycheck Protection Program

Figure C:

COVID-19 Economic Loans and Government Assistance for Orthopaedic Practicesa

aThe total number of responses is 99, this n (%) value is based on a multiple response set and may not necessarily add up to 100%. PPP=Paycheck Protection Program

COVID-19 Effects on Physicians

As reported by a multiple response set, a large proportion of surgeons (48 of 98, 49.0%) in the sample reported having to change their practice dynamics significantly because of COVID-19. Physicians also reported being under increased mental/emotional distress (39 of 98, 39.8%) due to the pandemic, as well as having deteriorating situations at home due to increased pandemic-related stress (18 of 98, 18.4%) (Figure D, available in the online version of the article). Two surgeons wrote in responses indicating that they had tested positive for COVID-19 and had to be quarantined for 14 days as a result.

COVID-19 Effects on Orthopaedic PhysiciansaaThe total number of responses is 99, this n (%) value is based on a multiple response set and may not necessarily add up to 100%

Figure D:

COVID-19 Effects on Orthopaedic Physiciansa

aThe total number of responses is 99, this n (%) value is based on a multiple response set and may not necessarily add up to 100%

The majority of the sample (79 of 98, 80.6%), including a significant majority of private practice/community-based (51 of 56, 91.1%), academic (16 of 19, 84.2%), and hospital-based (11 of 16, 68.8%) surgeons, reported experiencing a reduction in income during the past 6 months because of COVID-19. Most respondents indicated that their income had decreased by 11% to 25% during the past 6 months because of COVID-19 (44 of 79, 55.7%).

COVID-19 Effects on Communities

When asked of a multiple response set what lasting effects COVID-19 could have on how health care is organized and delivered in their communities, the majority of respondents indicated that hospitals will exert a stronger influence over the organization and delivery of health care (64 of 98, 65.3%) and that the use of telehealth will become more widespread (64 of 98, 65.3%). Respondents also indicated that there would be fewer independent physician practices (50 of 98, 51.0%) and a rise in more serious health conditions due to delays of care (49 of 98, 50.0%) caused by the pandemic (Figure E, available in the online version of the article).

COVID-19 Impact on Healthcare Organization and Delivery in the CommunityaThe total number of responses is 99, this n (%) value is based on a multiple response set and may not necessarily add up to 100%

Figure E:

COVID-19 Impact on Healthcare Organization and Delivery in the Community

aThe total number of responses is 99, this n (%) value is based on a multiple response set and may not necessarily add up to 100%

Discussion

The coronavirus pandemic has affected nearly every aspect of society and medicine, and orthopedic surgery is no exception. As the pandemic focuses medical attention on treating affected patients and protecting others from infection, those with non–COVID-related medical and orthopedic conditions face new barriers to care.10 The majority of surgeons in the current study reported that the COVID-19 pandemic delayed care for routine orthopedic injuries for their patients, and as a result they saw increased pain/disability/deformity (75.3%). Hartnett et al11 found a substantial decline in emergency department visits during the pandemic, suggesting that patients were also delaying care because of concerns about infection risk. Patients with nonurgent conditions, who may have previously been evaluated first by community primary care physicians prior to referral to an orthopedic surgeon, might now not seek care or present to the emergency department because of closure of primary care, orthopedic practices, or physical therapy. When urgent surgical intervention for orthopedic conditions is performed, postoperative care could also be delayed or neglected due to similar factors. Regarding nonurgent orthopedic conditions such as arthritis or rotator cuff disease, a delay in obtaining an accurate diagnosis and treatment, both nonsurgical and surgical, could worsen patient conditions as reported in this study and has been found to have other negative consequences, such as a potential increased probability for mortality in elderly patients.12 This finding is supported by a study by Kopka et al,13 who noted that 65.5% of patients believed that their orthopedic surgery postponement due to the COVID-19 pandemic had negatively impacted their physical health, and 48.2% who reported increased pain.

In addition to the adverse effects on patients, COVID-19 has had a significant negative impact on orthopedic surgery practices, particularly those in the community, which provide orthopedic care to the majority of the population. Because of the pandemic, many orthopedic private practices have been forced to furlough or permanently reduce staff, decrease clinic hours to continue operating,14 or reduce pay to avoid employee layoffs while shifting solely to telemedicine.15 The Medical Group Management Association reported in late April that 97% of medical practices have experienced a negative financial effect directly or indirectly related to COVID-19. This includes a 60% decrease in patient volume and a 55% decrease in revenue since the beginning of the pandemic, resulting in many practices being forced to furlough or lay off staff.16

This study found that all categories of orthopedic practices in Louisiana (private, academic, and hospital based) reported significant declines in patient volume. Not surprisingly, this affected private community practices the most, because they may not have a safety net from an institution or a large entity and face more difficulty staying viable because of fixed overhead costs such as rent, staff salaries and benefits, and maintaining ambulatory surgical centers.17 The current survey also found that private community practices were also the most likely to rely on federal loans such as Economic Injury Disaster Loans or PPP loans.

The sharp decline of in-person office visits has forced many orthopedic surgeons to adopt telemedicine to provide care and maintain patient volume.18 However, the implementation of telehealth services may itself involve obstacles and additional fixed costs, including infrastructure costs, the hiring of information technology personnel, communication encryption, and data protection,19,20 which may place an increased financial burden on already struggling practices. In addition, reimbursements for telehealth consultations may not be equal to those for in-person office consultations. Finally, although telemedicine may be an adequate substitute for certain types of orthopedic encounters, such as review of radiographic studies or routine postoperative wound checks,21 the current study found that the majority (66.7%) of community physicians were ambivalent as to whether telemedicine was effective. Further studies need to be conducted on both physician and patient satisfaction with telemedicine before its usefulness can truly be validated.

Orthopedic surgery is a highly demanding specialty. This study demonstrated that an additional consequence of the coronavirus pandemic is increased stress to orthopedic surgeons and their families, many of whom are facing changing practice dynamics, decreased income, and an increasingly uncertain climate for the future of health care. These concerns, added to the everyday stress of a demanding profession that has been shown to have higher rates of burnout than other subspecialties,22 have the potential to increase physician burnout, possibly resulting in earlier retirement (forced or voluntary) for many surgeons and further decreasing the quality and availability of orthopedic care for patients. With an estimated shortage of 4355 (18%) orthopedic surgeons by 2030,23 COVID-19 may have further exacerbated an already strained health care system.

The long-term effects of COVID-19 on health care and on the practice of orthopedic surgery are yet to be determined. However, evidence from this study and previous literature analyzing shifts in practice dynamics during the pandemic15,18,19,24 indicates that telehealth services could increase in place of in-person office visits. It is also likely that larger corporate hospital entities will gain an increased influence and market share because they have and reserve assets to prepare for extended declines in patient and/or elective surgery volume, whereas private orthopedic practices may not be able to sustain themselves long term without taking out extensive private loans or relying on government assistance.25 In the event of a resurgence of the pandemic or lack of an effective COVID-19 vaccine, community-based orthopedic surgeons and practices will be the most vulnerable. The pandemic may be a harbinger of the decline of and continued threat to the private practice orthopedic surgery model as it currently exists.

There were several limitations to this study. This study did not specifically ask about the age and health status of the orthopedic surgeons, which could have potentially influenced their willingness to work during the pandemic. Of the 323 orthopedic surgeons to whom the survey was distributed, only 99 (30.7%) surgeons responded. The response rate could have been improved with a longer study. However, because of the time-sensitive nature of this survey, the duration of the study and follow-up emails were limited to decrease survey fatigue. The possibility of selection bias existed given the low response rate, but the power was adequate to obtain significance in all relevant questions presented in the survey. There may have also been bias in random sampling because the study cohort was mostly male (96.0%) vs female (4.0%), although this distribution was representative of that within the greater field of orthopedics.26 In addition, this study only demonstrated the effect of COVID-19 on one of the most affected US states. This study did not include any questions related to race or cultural background; therefore, the authors could not determine whether these factors could influence a surgeon's response to the COVID-19 pandemic. Finally, this study was conducted during a period when the pandemic was active. Future research and repeat surveys need to assess the significant and lasting effects that the pandemic has had on orthopedic practice.

Conclusion

The COVID-19 pandemic has had temporary and likely lasting effects on orthopedic surgeons in Louisiana and on their practices. It has decreased the number of patients treated, surgical volume, and revenue, as well as negatively affected orthopedic surgeons' emotional well-being. The pandemic will undoubtedly change the future practice of orthopedic surgery. It may result in a significant increase in corporate health care and a decrease in private community-based practice. Private practices affected by the pandemic and graduates from orthopedic residencies and fellowships could use these data to further understand future challenges with patient care and changing orthopedic practice dynamics during this unique period.

References

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  24. O'Connor CM, Anoushiravani AA, DiCaprio MR, Healy WL, Iorio R. Economic recovery after the COVID-19 pandemic: resuming elective orthopedic surgery and total joint arthroplasty. J Arthroplasty. 2020;35(7S):S32–S36. doi:10.1016/j.arth.2020.04.038 [CrossRef] PMID:32345566
  25. Rubin R. COVID-19's crushing effects on medical practices, some of which might not survive. JAMA. 2020;324(4):321. doi:10.1001/jama.2020.11254 [CrossRef]
  26. Van Heest AE, Agel J. The uneven distribution of women in orthopaedic surgery resident training programs in the United States. J Bone Joint Surg. 2012;94(2):e9(1). doi:10.2106/JBJS.J.01583 [CrossRef]

Demographics of Survey Respondents (N=99)

CharacteristicNo.
Sex
  Male95 (96.0%)
  Female4 (4.0%)
Years in practice
  0–510 (10.1%)
  6–1019 (19.2%)
  11–1523 (23.2%)
  15+47 (47.5%)
Specialty
  General26 (26.3%)
  Hand7 (7.1%)
  Shoulder/elbow2 (2.0%)
  Foot/ankle7 (7.1%)
  Total joints20 (20.2%)
  Orthopedic trauma5 (5.1%)
  Sports medicine19 (19.2%)
  Spine7 (7.1%)
  Pediatric orthopedics2 (2.0%)
  Other (please specify)4 (4.0%)
Practice settinga
  Private practice/community based57 (61.6%)
  Academic19 (25.3%)
  Hospital-based16 (18.2%)
  Veterans Administration5 (5.1%)

COVID-19 Survey

Q1 What effect did COVID-19 have on your patients? (Choose all that apply)

Delaying care for routine orthopaedic injuries (sprains/strains)

Increased pain/disability/deformity due to delay in elective procedures

Reduced post-op care due to difficulty with follow up and scheduling physical therapy

Increased use of telehealth visits

Unable to see primary care provider, resulting in delayed referrals/authorizations

Loss of insurance due to COVID-19 economic impacts

Decrease in preventative care for elderly/at-risk patients

Increased pain/disability/deformity due to delay in seeking care

Other (please specify) ________________________________________________

Display This Question:  If Q1 = Increased use of telehealth visitsQ2 If your practice utilized telemedicine, what % of your practice has currently switched to telemedicine due to COVID-19?

None (1)

1–25% (2)

26–50% (3)

51–75% (4)

76–100%

Display This Question:  If Q1 = Increased use of telehealth visitsQ3 Do you feel telemedicine was effective in treating orthopaedic patients during the pandemic?

Yes

Maybe

No

Q4 What effect did COVID-19 have on your practice (Choose all that apply)

Stopping or delaying elective surgery

Delay in seeing patient due to clinic/staff shortages

Closing my practice temporarily

Reducing of staff

Decrease in referrals

Increase in surgery cancellations due to COVID-19 concerns

Delay in advancement in tenure or partnership

Increased amount of call

Closing my practice permanently

Rescinding job offers for my practice

Other (please specify) ________________________________________________

Display This Question:  If Q4 = Rescinding job offers for my practiceQ45 If you rescinded a job offer, how many offers did you rescind?

1 offer

2 offers

3 offers

> 3 offers

Q43 What impact did COVID-19 have on you personally? (Choose all that apply)

I decreased work hours because I or a family member am high risk (underlying condition or age related) for COVID-19

I retired as a result of this pandemic

I am under financial distress

I am under increased mental/emotional distress

My home situation has deteriorated due to the stresses

I have had to change my practice dynamics significantly due to Covid-19

No impact

Other (please specify) ________________________________________________

Q5 In what ways do you feel covid-19 will have lasting effects on how healthcare is organized and delivered in your community? (Choose all that apply)

There will be fewer independent physician practices as a result of this pandemic

Hospitals will exert stronger influence over the organization and delivery of healthcare

There will be a rise in more serious health conditions because patients delayed care during the lockdown

Use of telehealth will become more widespread

COVID-19 will have no long-lasting effect on my community

Other (please specify) ________________________________________________

Q6 Have you experienced a reduction in income over the past 6 months as a result of COVID-19

Yes

No

Display This Question:  If Q6 = YesQ7 If you have experienced a reduction in income over the past 6 months due to COVID-19, by what percentage has it been reduced?

Down 1–10%

Down 11–25%

Down 26–50%

Down 51–75%

Down 76% or more

Q8 Have you experienced a reduction in patient volume over the past 6 months as a result of COVID-19

Patient volume has increased

Patient volume has stayed the same

Patient volume has decreased

Display This Question:   If Q8 = Patient volume has decreasedQ9 If patient volume has decreased, by what %?

Down 1–25%

Down 26–50%

Down 51–75%

Down 76% or more

Q17 Did you apply for government assistance or take out more loans to sustain your practice?

Yes

No

Q18 Please choose all of the following that apply to your practice in regards to economic loans or government assistance

Did not apply for Paycheck Protection Program (PPP) support

Applied for PPP support but did not receive it

Received PPP, and it was enough to help us stay open

Received PPP, but it was not enough to help us stay open

Received PPP, but will have to reduce staff anyway

Took out an Economic Injury Disaster Loan (EIDL) or Small Business Administration (SBA) loan

Renegotiated contracts/asked for lease abatements, spoke with vendors about other costs

Received Provider Relief Fund

Received Tax benefits

N/A I am not in a private group setting

Q19 What is your specialty?

General

Hand

Shoulder/elbow

Foot/ankle

Total Joints

Orthopaedic Trauma

Sports Medicine

Spine

Pediatric Orthopaedics

Oncology

Other (please specify) ________________________________________________

Q20 Which of the following best describes your practice setting? (Choose all that apply)

Private practice-community based

Academic

Hospital based

Veterans administration

Military

State employee

Other (please specify) ________________________________________________

Q21 How many years have you been in practice?

0–5 years

6–10 years

11–15 years

15+ years

Q22 What is your gender?

Male

Female

End of Block: Default Question Block
Authors

The authors are from the Department of Orthopaedic Surgery (NNK, AHP, FHS, WFS), Tulane University School of Medicine, New Orleans; and Mid State Orthopaedic and Sports Medicine Center (MJL), Alexandria, Louisiana.

Ms Kale, Dr Patel, Dr Leddy, and Dr Sherman have no relevant financial relationships to disclose. Dr Savoie receives royalties from Exactech, Smith & Nephew, Zimmer Biomet, and Conmed.

Correspondence should be addressed to: William F. Sherman, MD, MBA, Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA 70112 ( Swilliam1@tulane.edu).

Received: September 18, 2020
Accepted: October 06, 2020

10.3928/01477447-20201023-01

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