Exemplar quotations for themes and subthemes
| Quote no. | Subtheme | Exemplar quotation |
|---|---|---|
| Accelerator for a surgical care delivery crisis | ||
| 1 | Health care system strain | “The Canadian health care system operates at maximum capacity all the time, even when there’s not a crisis, there’s no room for contingencies, right? Especially something as sustained as this. So when you run the system that tightly to stay within budget and I get it, health care is an overwhelmingly expensive proposition, but when you run on the edge of capacity all the time, you can ramp it up for a little while, like if there was a plane crash or something, people can work really hard for a week or 2, for a lot of hours but if for something like this that goes on for 2 years, the limits of our capacity become really apparent.” — Participant 003 |
| 2 | Impact on patient-centred outcomes | “They’re quality-of-life surgeries, but at some point, quality of life diminishes to the point where it becomes medically imperative to do a joint replacement, say, for severe arthritis of the hip. So we’ve had a few more patients, at least in my subjective understanding or subjective experience, in the last 7 years of my faculty position that we’ve had to bring in as an urgent pain crisis or failure to thrive for a joint replacement, which we know has less, or has inferior outcomes relative to your traditionally electively scheduled joint replacements.” — Participant 008 |
| 3 | Direct impact on care delivery | “… what’s happened as well is the number of emergencies or situations where people really need urgent care because they can no longer function or they’ve had, for example, a collapse of their joint, those numbers of cases are also increasing.” — Participant 004 |
| 4 | Access to surgery | “Like I said before, we do have other options, since there are private surgical facilities, that we can go to. They were quite good at accommodating people.” — Participant 002 |
| 5 | Direct impact on care delivery | “I think we have seen late presentations delayed to get to us, because those patients have to see their family doctor first, and then go on to see another ENT, and then get referred to us. So, that’s where I think a lot of the delays have happened, not so much once we see them to get them to the OR.” — Participant 009 |
| Health system inequity | ||
| 6 | Disproportionate burden on surgery patients | “So I feel this pandemic has disproportionately affected surgery, and I feel surgeons and our surgical patients and our surgical leaders have really made a lot of concessions and a lot of sacrifices for the greater good.” — Participant 008 |
| 7 | Disproportionate burden on nonurgent surgeries | “It felt like it was not a priority and we were being told that everything was equitable. At one point I did receive some acknowledgement from leadership that our discipline was the last to catch up or the most behind on catching up in cancelled cases. And that was both validating and infuriating because all of this time they’ve been pretending that things are equitable.” — Participant 001 |
| 8 | Resource constraint | “So just a couple of things off the top of my head, although, again, we were allowed to proceed with cancer surgery; there are some of us that do what would be considered some of the ultra radical surgeries which might take an entire day of surgery on 1 patient. And we were sort of informally told that we should not be booking these patients because it would be seen as sort of an inappropriate use of time and resources during this time. So the feeling was rather than operating on a 40-year-old to do something really aggressive in an entire day surgery, you should probably not doing that surgery and rather taking that day to do 3 cases or 3 patients.” — Participant 002 |
| 9 | Lack of transparency | “And in terms of where we’re at now, how do I feel about this? I feel a little bit like this is [provincial health system]’s fault that they could have done a better job. I saw a recent [newspaper] article where they claimed they’re not cancelling surgeries that was published 12 hours after they cancelled my OR slate. I just feel, like, angry; at least be honest with the public about what’s happening.” — Participant 001 |
| 10 | Lack of resource availability | “And I think a lot of our patients who are undergoing very life-challenging procedures have, I think, been neglected or denied having their appropriate supports with them through their voyages, at least within the hospital setting, which has been distressing.” — Participant 008 |
| System-level management of disruptions in surgical services | ||
| 11 | Inharmonious implementation of policies | “Well, I think earlier in the pandemic there were alternatives, we just didn’t know, because we cancelled some surgeries and delayed surgeries, expecting the hospital to fill up when it was not yet full, and later in the pandemic, that shifted to letting things go until it’s full, which is a slightly different paradigm, which works better because we’re getting more done, because the hospital didn’t actually fill up to the point where we had to cancel everything, which we did for a couple weeks about a year ago.” — Participant 009 |
| 12 | Response informed by experience and evidence | “I think that the surgical leadership will benefit from having to move through a pandemic and you can see it in the second and later waves, the communication and the strategies for dealing with it was more certain and more polished.” — Participant 006 |
| 13 | Stakeholder involvement in triage decision-making | “And then what’s really silly is that now they’re no longer asking the surgeons if there’s certain patients on that list, according to acuity who should be removed. So then one of my colleagues last week had a very time-sensitive cancer surgery just arbitrarily removed, and somewhat ironically, had he been able to provide input he would’ve said, “This is the one that needs to be done. The other one or two, if you’re thinking of removing one, definitely remove that one because that one’s less acute.” — Participant 002 |
| Professional and interprofessional impact | ||
| 14 | Personal protective equipment use | “I think the secondary impact was just managing new requirements for personal protective equipment in the hospital, the additional burden and time and confusion around that.” — Participant 006 |
| 15 | Additional professional tasks | “I think it’s not like the ORs closed and then we weren’t doing anything. A lot of people worked extra, they took the burden of cancelling cases, talking to the patients, hearing their concerns, rebooking them, and only to have them postponed again. And so that takes a toll, it’s frustrating and the normal flow is disrupted and that is very taxing and it’s a heavy burden.” — Participant 007 |
| 16 | Workload changes | “… many of us feel quite worried about the clinical demands that we will face to try to meet the backlog … I think many of us are worried about it being quite stressful.” — Participant 002 |
| 17 | Workload changes | “That seems to be exaggerated with the pandemic that, going into a wave, we’re halfway through a wave, all of a sudden there’s fewer people coming in, and then kind of a month after a wave finishes, then there’s this crush of patients, often with advanced disease that have been delayed. So it’s always been a challenge in this career, is that the busyness sort of comes and goes, but it’s worse now.” — Participant 003 |
| 18 | Interprofessional tension | “I would just, I think, you know, again, that concept of the haves and the have nots, right? They’ve really not even across surgical disciplines, but within departments, where you’ve got people who may be doing more benign surgery as opposed to cancer surgery. There has created quite a divisiveness, so I think that’s at a personal and on a professional level that has been kind of taxing.” — Participant 002 |
| 19 | Interprofessional tension | “I think that there is certainly some discord brewing between services because I hear that certain disciplines [flouted] the restrictions by bringing patients in through the emergency room and claiming that [their] scheduled surgeries [were], now, urgent surgeries.” — Participant 001 |
| Personal impact | ||
| 20 | Financial consequences | “It’s had a significant impact on income, which I’m sure not ... there’s not a lot of sympathy for physicians being relatively high earners, their income is down, but the factor means there’s staff that still need to be paid out of my professional income. And so things are tight, tight enough that I’ve had to take loans to keep everything afloat.” — Participant 001 |
| 21 | Public health measures | “I think it’s obviously personal restrictions, your lifestyle is significantly altered, the schooling of my children has been significantly changed, interactions with friends and family curtails and then obviously the stressors at work.” — Participant 007 |
| 22 | Anticipatory burnout | “And so it’s just sort of created a lot of stress in the sense that I am now left with a long list of patients that are all way out of window. And there’s only so much I can do in terms of OR time because you sort of have to balance access to the OR for patients with your own, sort of, life.” — Participant 001 |
| 23 | Work–life balance | “You know what, it’s been pretty amazing for me. It was nice. It was nice to take a break for a few months. It was nice to make some changes to the practice. We cancelled every appointment in our book and started fresh. We moved everybody who we’d cancelled and started fresh and kind of went down from there, but it was nice to make some changes to the schedule. It was lovely to have dinner with my family every night, instead of running kids to sports.” — Participant 002 |
| Pragmatic adaptation to health system strain | ||
| 24 | Alternative strategies for surgical care delivery | “ … our ORs were closed for a little while there too. And so we were doing a lot of the cases in minor surgery.” — Participant 005 |
| 25 | Communication modalities | “So, I think it’s more acceptable now even by families. Families kind of think, ‘Oh, I should really see the surgeon.’ I think they kind of go, ‘You know what? It’s okay not to see them.’ Because they’re so used to Zooming or telephones now.” — Participant 003 |
| 26 | Communication modalities | “And then rejigging, how patients could access chatting with us, given that they couldn’t initially come physically to the clinics. And so, a transition to much more phone or other methods of consultation.” — Participant 006 |
| 27 | Shared decision-making | “And so the example that I just gave you, if I know based on ... If my surgical executive team tells me that, ‘[Name], you and your team are going to have to cut out 5 patients from your list next week.’ Well, give us the opportunity to tell you who those patients are according to acuity, don’t just randomly start crossing off names because then that is not the right approach.” — Participant 002 |
| 28 | Alternative strategies for surgical care delivery | “So, typically, if I met a patient, I would do their surgery and follow through with them. What we had to do was decouple that because we just had much more limited OR time. And so, we wanted to prioritize within our group, the patients, not just within our individual practices.” — Participants 006 |
| 29 | Alternative strategies for surgical care delivery | “I think there are some higher ups that are thinking outside the box, whether it be using private surgical centres to catch up on elective cases. Funding these cases outside the hospital setting makes a whole lot of sense in my mind.” — Participant 005 |
Note: ENT = ears, nose and throat specialist; OR = operating room.