Lower self-reported anxiety levels were associated with hospital support (OR 0.83, 95%CI 0.76-1 0.91) and use of positive reframing as an active coping strategy (OR 0.88, 95%CI 0.81-0.95).
2 Take home Message: 3 The survey identified several areas where vascular surgeons can be supported at institutional, 4 regional, and national societal levels. hardships related to changes in practice patterns such as the cancellation of cases and clinics as 10 well as the possibility of redeployment to duties outside their specialty. [3] [4] [5] [6] This survey was 11 designed to examine the impact of COVID-19 by assessing the related anxiety of vascular 12 surgeons, the coping strategies they employed, and their use of available support structures. The 13 survey was made available from 4/14/2020 to 4/24/2020, during which the case numbers 14 increased from 1.8 to 2.6 million people infected worldwide. with self-reported anxiety levels (defined as no, mild, moderate, and severe anxiety) by the 1,259 4 respondents who completed the GAD-7 survey. The multivariable model was built in a two-step 5 process. The first step allowed for all factors that were significant on a univariable analysis to be 6 considered for entry into the model using a stepwise selection process (with the exception of the 7 coping strategies from the Brief COPE survey). A significance level of 0.05 was required to 8 allow a variable into the model and to stay in the model. The second step allowed for variables 9 selected in the first step to be retained and the stepwise selection was performed on the coping 10 strategies. Special considerations were made for the variables that were highly correlated, 11 specifically, the hospital support variables "Operating Room protocols", "Adequate Personal 12 Protective Equipment (PPE)", "pre-operative testing of patients", and "Opportunities to interact 13 with leadership" were highly correlated. The responses to the hospital support variable 14 "Transparency from leadership about COVID management and planning" were nearly identical 15 to those for "Opportunities to interact ..." and as such the two were considered interchangeable.
A new variable, "Summative Hospital Support" was created as a sum of the 4 significant 17 individual hospital support variables. The variables in which responses were limited due to the 18 "does not apply" option (specifically the following variables: "Lack of PPE", "Terminating 19 contracts of some of my employees", and "The impact of hiatus on my career advancement") 20 were not included in the model as they did not represent the entire population of the respondents. The narrative responses to the open-ended questions were systematically analyzed using 1 qualitative thematic analysis by two independent investigators (KW and NM). Open coding was 2 used to derive first-cycle codes consisting of short phrases directly from the data. Next, the initial 3 codes were analyzed to determine how the codes could be grouped into themes that succinctly 4 captured the important pattern in the data. Themes were reviewed to ensure minimal overlap and 5 to identify any sub-themes that may be contained within a given theme. The size of the potential respondents/audience by mode of dissemination and estimated 9 response rate is detailed in Supplement Table 1 . The survey was opened 1,867 times. Of those, 10 258 records were excluded either due to no-response (N=253) or duplicated status (N=5), leaving 11 a total of 1,609 unique survey responses (70.5% male) from 58 countries eligible for analysis 12 (Supplement Figure 1) . The majority of the respondents were from the United States (N=699, 13 43.4%), Brazil (N=493, 30.6%), and Mexico (N=104, 6.5%). Most were board-certified vascular 14 surgeons in practice (N=1328, 82.5%), followed by vascular surgeons in training (N=236, 15 14.7%, Table 1 ). A small number (N=45, 2.8%) were board certified in another specialty who 16 perform vascular surgery interventions and were included with the board-certified vascular 17 surgeons group for analysis given no differences in responses between the two groups.
The GAD-7 scale was completed by 1,518 (94.3%) respondents (Supplement Figure 2) . 19 There were no differences in GAD-7 completion rates between vascular surgeons in practice and 20 training, nor by gender, but there were regional variations with more respondents from the 20 Nearly half (47.8%) of the respondents knew someone who died due to COVID-19, 21 including a family member (N=92, 5.7%) or a medical provider from their own hospital (N=330, 22 20.5%). Worrying that family and friends or colleagues would get infected with COVID-19 was 23 a significant stressor for 65.8% and 59.8% of the respondents respectively. In the month prior to 1 the survey, 35.9% of the respondents reviewed or made their will, designated or re-discussed 2 their medical power of attorney, or reviewed/applied for disability and/or life insurance. Over a 3 third of the respondents (36.9%) discussed dying with family and/or friends. Financial concerns were stressful to the majority of respondents (1098/1314, 83.5%).
There was significant variation in the degree of perceived financial stress by type of practice 14 with those in solo or outpatient-based practices reporting the highest perceived stress levels 15 (Supplement Figure 5) . Additionally, among those who had employees (N=750), 58% reported 16 stress over terminating their contracts.
Coping strategies and support structures 18 The Brief COPE survey was completed by 1,366 respondents (84.9%, Figure 2) . Overall, univariable regression to examine the association between stressors and support structures and 10 the odds of increased self-reported anxiety ( Table 2) . As the hospital support increased, the odds 11 of greater anxiety decreased (odds ratio=OR=0.84, 95% Confidence Interval [CI]:0.78-0.89).
More specifically for every one unit increase in the summative hospital support the odds of no emotions that ranged from seeing the positive aspects of the pandemic such as "Despite all the 2 uncertainty and challenges, the time is exciting to be part of as a provider in deciding on how 3 best to care for a 'new' disease" and offering the perspective of the surgeon that we "do more 4 things than operate" to despair "It's a total disaster on all levels of my life". Three broad themes 5 were identified in the responses: (1) worry and concern for others, (2) stress associated with 6 uncertainty, and (3) financial implications ( Table 3) . 7 The most prevalent theme was concern for others, most commonly patients. Participants 8 expressed fear for patients due to the consequences of delays in care from postponed operations, 9 closed clinics, and patients being afraid to come to the hospital for medical emergencies. Family, 10 friends, and colleagues, particularly those who work on the front lines of the pandemic, were a 11 major source of worry for vascular surgeons. Respondents also conveyed anxiety for trainees, 12 especially those who were redeployed to the front lines, and for the potential impact that lack of 13 operative experience during the pandemic may have on training.
14 The second theme was the stress associated with uncertainty, which had three sub-15 themes. First, uncertainty regarding the disease process, particularly asymptomatic carriers, 16 which is related to the stress of not having enough PPE to be able to protect oneself to the extent The psychological impact of the COVID-19 on healthcare providers cannot be overstated. 6 Over half the survey respondents reported some degree of anxiety, and 23.3% reported moderate 7 or severe anxiety. Using the threshold score for moderate/severe anxiety, the GAD-7 scale has a 8 sensitivity and specificity of 89% and 82% respectively for generalized anxiety disorder and is 9 moderately good at screening for post-traumatic stress disorder (66% sensitivity, 81% Routines to minimize family contact with contaminated clothing such as a having a change of 16 clothes available upon return from the hospital, immediate access to laundry and shower 17 facilities upon arrival home have been adopted by some to combat these concerns. In our survey, 18 after-work routines involving separation from the family were associated with higher self-19 reported anxiety levels. Unsurprisingly, concern regarding lack of PPE and the stress of 20 donning/doffing PPE was also associated with higher anxiety levels, as found in earlier 21 studies. 12-14 While provision of adequate PPE has been challenged by rapid depletion, hospital patients had higher self-reported anxiety levels. One might hypothesize that they are at risk for 6 moral injury, which occurs when we perpetrate, bear witness to, or fail to prevent an act that 7 transgresses our deeply held moral beliefs. 15,16 As physicians, our deeply held moral belief is 8 always to prioritize the needs of patients first (a theme that was obvious in the qualitative 9 analysis of the free text). Potential adverse outcomes in patients could ensue following the 10 cancellation of scheduled surgical cases, due to the reluctance of patients to present to the 11 hospital because of COVID-19-related fear, or in the context of COVID-19-induced resource 12 scarcity. Every time physicians are forced to make a decision that transgresses their patients' best 13 interests, they may feel moral injustice. This amasses with repetition into moral injury, a discrete 14 phenomenon from burnout. 17 Prevention of such must be prioritized. predict under the pandemic circumstances. It is possible that the response rate is lower among 7 those most severely impacted due to time restraints and feeling overworked at the peak of the 8 pandemic. Alternatively, those most severely impacted by the pandemic may have had a higher 9 desire to respond, thus taking the 15-20 minutes time to complete this survey to share their 10 experience. We addressed sampling by broad dissemination methods. Due to the wide and 11 multimodal dissemination, we are unable to account for an exact response rate; however, this 12 sacrifice ensured a significant participation in the survey. We did not specifically focus on 13 regional variation in this manuscript due to space limitations; however, additional analysis will 14 be performed to evaluate the differences by region. Lastly, the survey was only available in 15 English, potentially limiting the involvement of surgeons who have another primary language. 16 This survey is a first step in understanding the psychological impact of COVID-19 on the 17 vascular surgeons. Survey respondents reported using more active than avoidant coping 18 strategies. Less than 20% of respondents engaged in avoidant strategies with the exception of 19 "self-distraction". This is highly relevant as active coping is considered a more effective way to 20 deal with stress while avoidant coping often exacerbates stress by ignoring the source of stress. 19 Lastly, strategies to combat the prolonged time of uncertainty, decreased production, fear 20 of a second surge, and exhaustion created from ongoing anxiety will need to be considered as we 21 continue to adapt to the rapid changes brought on by COVID-19. We look for guidance and 22 support from national organizations as we proactively adjust our lives and careers through the 23 pandemic. Future survey evaluations of new guidelines and support systems are warranted. 1 Perhaps the most important contribution of this work is allowing vascular surgeons to understand 2 that they are not alone and that the COVID-19 pandemic is associated with increased anxiety and 3 stress to a group of surgeons who are well adapted to functioning in high stress environments.
Acknowledging this fact may allow surgeons to seek help when needed. *Summative Hospital Support was created as a sum of the in the significant individual Hospital Support variables which include "Operating Room protocols", "Adequate Personal Protective Equipment (PPE)", "pre-operative testing of patients", and "Opportunities to interact with leadership" as they were all correlated. "Transparency from leadership about COVID management and planning" was not included as the responses were nearly identical to "Opportunities to interact with leadership". 
Patients "A big concern for me is the indefinite postponement of semi-elective procedures, such as fistulas or revascularization for stable non-healing wounds/very short distance claudication"
"Many primary care docs have closed entirely making access to care more difficult for patients"
"I continue to be concerned about the response to COVID patients, specifically the impacts on racial and ethnic minority patients affected by this virus" "Patients will die from MI, CVA, ruptured aneurysm, aortic valve stenosis, etc. because they are too afraid to come to the hospital"
There is concern for capability to service the pent up demand created by the delay in vascular care
"Upsetting to follow from afar close friends and colleagues being inundated and at risk and little we can do to help. Feel very distant and helpless with family, aging parents across the country and banned from visiting, helping"
"The nurses and ancillary staff taking care of these patients are the truly exceptional people in this pandemic. They often have limited resources and have the most intimate contact with these patients and serve as the primary sources of information for multiple people including physicians and patient families"
"We have decreased their time physically in the hospital to limit exposure but I don't think they are actually using their time away to read or better themselves from a surgeon standpoint. I worry that a lot of them will fall behind and that they won't get their required numbers" "Worried about graduating experience given complete stoppage of elective vascular cases"
Disease process "The big challenge is that a number of patients may be positive and yet be asymptomatic or low symptoms, making it difficult to know. Clearly until we have vigorous testing, we are all in the dark" "The constant stress to know that many patients Could be asymptomatic covid-19 carriers" "I am disturbed by the lack of PPE, the expectation that providers work without adequate PPE" J o u r n a l P r e -p r o o f Future ""The unknown is the worst part. The unknown of how long this is going to be affecting my practice, affecting our lives"
"I´m aware that this is a long term condition, and we have to adapt to it. PPE is going to be there for at least 2 years or even more. We should learn to work and live with it"
Lack of guidelines that account for variation in disease severity.
Need guidelines for small office practice where risks are extremely low (one patient in office at a time). Currently restrictions are overkill in this setting"
"The outbreak is local and regional and different institutions have different readiness, etc. and are able to be more flexible in not forgetting about the rest of the population needing health care" 
"I fear for the ability of our private practice to endure through this financially. I personally won't have the financial means to carry myself for any extended amount of time in order to carry the practice."
"Our large academic hospital-owned physician group announced likelihood of salary cuts starting end April. So more stress, insult to injury, and bad news to come" "Last month (March) I took a 40% pay cut. This month I am not getting any salary but still working as a vascular surgeon. We furloughed more than half our office staff including US techs and nurses in our OBL…The exposures to COVID-19 from placing lines continues but it doesn't pay the bills".
"I don't know how long I can keep going without operating. I was just starting to build a practice in my area and I worry that this is going to be a big setback for practice development"
J o u r n a l P r e -p r o o f Supplement Figure 4 . The degree of self-reported anxiety (no anxiety, mild, moderate, and severe anxiety) associated with COVID-19 related modifications of home routine after work (N=1518). The difference in self-reported anxiety degree was statistically significant (P<.001).
Supplement Figure 5 . The degree of stress associated with COVID-19 related financial concerns by vascular surgeons (N=1314). The difference in self-reported stress level was statistically significant by type of practice (P<.001).
Tables Supplement Table 1 . Multimodal survey dissemination, potential audience, and estimated response rate. Table 2 . Pearson Chi-square analysis of factors associated with differences in selfreported anxiety degree (defined as no anxiety, mild, moderate, and severe anxiety). The P-value represents the significance of the difference in the degree of anxiety when comparing each set of factors.
J o u r n a l P r e -p r o o f Supplement 
Over the last week, how often have you been bothered by the following problems 1 = Not at all 2 = several days 3 = Over half the days 4 = Nearly every day 24.
Feeling nervous, anxious, or on edge 25.
Not being able to stop or control worrying 26.
Worrying too much about di erent things 27.
Trouble relaxing 28.
Being so restless that its hard to sit still 29.
Becoming easily annoyed or irritable 30.
Feeling Table 1 . Description of the Society for Vascular Surgery Wellness Task Force 1,609 survey 2 respondents 3 Table 2 . Univariable and multivariable ordinal logistic regression using a proportional-odds 4 cumulative logit model of factors associated with increasing degree of self-reported anxiety (no 5 anxiety, mild, moderate, and severe) by 1,259 respondents who completed the GAD-7 survey.
The model was built in two steps. First, allowing all factors that were significant on the 7 univariable analysis (also listed in Table 2 , Figures 2, 3 , 4, and 5) to be considered for entry into 8 the model using a stepwise selection process (with the exception of the active and avoidant 9 coping strategies from the Brief COPE survey). Second, allowing for variables selected in the 10 first step to be retained and the active and avoidant coping strategies were included in a stepwise 11 selection process. 12 *Summative Hospital Support was created as a sum of the in the significant individual Hospital 13 Support variables which include "Operating Room protocols", "Adequate Personal Protective 14 Equipment (PPE)", "pre-operative testing of patients", and "Opportunities to interact with 15 leadership" as they were all correlated. "Transparency from leadership about COVID 16 management and planning" was not included as the responses were nearly identical to 17 "Opportunities to interact with leadership".
18 Table 3 . The three broad themes identified in the qualitative analysis of the free text responses.
19 20