Responses

Overall, 1024 provided complete responses to our survey. As we solicited responses through social media and other modalities without a clear denominator, we were unable to calculate a response rate.

Demographics

Complete data on demographics is available in Table 1. Overall, respondents represented 80 countries. Notably, a slight majority of respondents (n = 564, 55%) were from North America, with 510 (50%) of all respondents from the United States (US), 36 (3.5%) from Canada, and 14 (1.4%) from Mexico. Meanwhile, 302 (29%) respondents were from Europe, with the greatest representation from Italy (n = 63, 6.1%), the United Kingdom (n = 55, 5.3%), and Romania (n = 40, 3.9%). Moreover, 116 (11%) of respondents were from Asia, with the greatest representation from India (n = 31, 3.0%), Japan (n = 19, 1.9%), and South Korea (n = 8, 0.8%). Finally, 21 (2.1%) participants were from South America, 16 (1.6%) were from Africa, and five (0.5%) were from Oceania. Though our respondents were predominantly from the US and Europe, we had strong representation across both geographies. Our respondents comprised 46 US states and 30 European countries (Fig. 2).

Table 1 Respondent demographicsFig. 2

Number of respondents by A U.S. State and B European country. Darker shades indicate more respondents

A slight majority of respondents (n = 518, 51%) practiced in academic hospitals, while fewer practiced in community or private teaching hospitals (n = 265, 26%) and community or private non-teaching hospitals (n = 121, 12%). Fewer still practiced in public access hospitals (n = 100, 10%), military hospitals (n = 15, 1.5%), or Veterans Affairs hospitals (n = 5, 0.5%). A large majority of respondents practiced in larger hospital settings, with 421 (41%) practicing in hospitals with 100 to 500 beds and 407 (40%) practicing in hospitals with greater than 500 beds.

We asked respondents to select the specialties in which they practiced, allowing for more than one selection if applicable. With this context, the most represented specialties were Abdominal Wall and Hernia Surgery (n = 508), Acute Care or Emergency General Surgery (n = 440), Bariatric or Minimally Invasive Surgery (n = 440), and Colon and Rectal Surgery (n = 412). We similarly allowed respondents to choose multiple roles within the hospital, if applicable. To facilitate our analysis, we assumed that respondents who chose senior roles such as “Chair” or “Program Director” were also attending surgeons and backfilled this option if not selected. In the updated dataset, most respondents were consultants or attending surgeons (n = 830), of which 159 were division chiefs, 149 were program or associate program directors, 142 were chairs or vice chairs, and 16 were sustainability leads. On the other hand, 167 respondents were trainees, of which 97 were residents or house staff, 68 were fellows, and two were medical students. Of note, four respondents listed both “resident” and “fellow” as roles. We reclassified these respondents as fellows alone to avoid double counting. Two respondents did not list a role, and 50 respondents listed a role of “Other.” Upon manual review of “Other” roles, most were attending surgeons, though some were research assistants, PhD students, or physicians’ assistants.

The median age of all respondents was 44 (IQR 37–54) while median years in practice was 10 (IQR 3–20).

General attitudes toward sustainability

Most respondents (n = 643, 63%) felt that operating room waste is a critical problem, and a similar number (n = 648, 63%) were motivated to improve the sustainability of their practice. On the other hand, fewer (n = 422, 41%) felt that climate change was a critical problem for the health of their patients. Of note, only 168 (16%) felt they had a choice in the supplies used during their operations (Fig. 3).

Fig. 3

General attitudes and education levels about sustainability. The proportion of respondents who chose the top two Likert options is highlighted

Ability to estimate carbon footprint

When inquiring about respondents’ current knowledge about metrics used to measure sustainability, a small minority could estimate the carbon footprint of a surgical procedure (n = 79, 7.7%) or surgical supply (n = 67, 6.5%) (Fig. 3).

Concerns about making sustainable changes

We specifically asked respondents about their level of concern that improving operating room sustainability would increase costs, decrease efficiency, reduce safety, bias surgical preferences, or have no meaningful impact on climate change. We found that most respondents were “not at all” or “slightly” concerned about these consequences. Specifically, 510 (50%) had low levels of concern about increased costs, 620 (61%) about decreased efficiency, 700 (68%) about reduced safety, 630 (62%) about biased surgical preferences. When asking respondents whether sustainability efforts would be futile in impacting climate change, 520 (52%) expressed low levels of concern. Conversely, about half of respondents each harbor at least moderate concern that improving sustainability will increase costs or have no impact (Fig. 4).

Fig. 4

Concerns about the negative impacts of improving sustainability. The proportion of respondents who were “not at all” or “slightly” concerned is highlighted

Willingness to change

Most surgeons expressed willingness to make each of the changes suggested, except giving up one hour per week to join a sustainability committee (n = 460, 45%). For example, 783 (77%) were willing to switch from a single-use instrument to a reusable instrument, 770 (75%) to switch from a single-use gown to a reusable gown, 725 (71%) to change the items on their preference cards to optimize carbon footprint, 717 (70%) to switch from a first-time use instrument to a reprocessed instrument, and 689 (67%) to ask the anesthesiologist to switch to a more sustainable anesthetic (Fig. 5).

Fig. 5

Willingness to make specific sustainable changes. The proportion of respondents who were “quite willing,” “extremely willing,” or “already doing” the proposed change is highlighted

Preferred educational modalities

Using Borda count voting, the most popular educational modality was an online webinar (4094 points), followed by an online module (4059 points), lecture (3851 points), educational video (3529 points), podcast (3002 points), and group workshop (2989 points). The most popular educational topic was waste management (3691 points), followed by supply chain (3535 points), preference card optimization (2755 points), heating, ventilation, and air conditioning (HVAC points) and lighting (2752 points), and anesthetic gasses (2627 points) (Fig. 6).

Fig. 6

Ranked choice preferences of sustainability education topics and modalities. We used a Borda count methodology. For example, if there were five options, respondents received five points for their first choice, four points for their second choice, three points for their third choice, two points for their second choice, and one point for their fifth (last choice). We added point tallies for each option

Comparing results across demographic groups

Overall, North American respondents were less motivated to improve the sustainability of their practice, had less choice in selecting surgical supplies, were less able to estimate the carbon footprint of surgical procedures and supplies, and were less willing to join a sustainability committee than respondents from Europe or other regions. On the other hand, North American respondents were less concerned about the negative effects of improving sustainability than respondents from Europe or other regions. European respondents were most willing to adopt reusable or reprocessed instruments.

Respondents in leadership roles viewed the criticality of operating room waste to a lesser degree than their non leader counterparts. Respondents in leadership roles were also more likely to report being able to estimate the carbon footprint of surgical procedures and supplies and reported more choice in selecting surgical supplies. They were more concerned about the increased cost and decreased efficiency associated with sustainable changes and also more concerned that sustainable changes would have no impact. They were less willing to adopt reusable gowns.

Trainees were less likely to report being able to estimate the carbon footprint of surgical procedures and supplies as compared to non-trainees. They also reported less choice in selecting surgical supplies. They were more willing to adopt reusable instruments. Further data regarding the proportion of respondents expressing pro-sustainability views for each question, across different demographic groups, are provided in Supplementary Table 1.

Cluster analysis

The K-means algorithm delineated three distinct clusters within our data. These clusters are visually represented in Supplementary Fig. 1, where they are plotted according to Principal Component 1 (PC1) and Principal Component 2 (PC2) (Supplementary Fig. 1). Though PCs do not independently have meaning, they help visualize the separation of respondents in our data. By measuring the relative contribution of each question to a PC, we can think of them as a weighted average variable representing multiple questions. In our case, PC1 is predominantly influenced by the general attitudes and willingness questions while PC2 is predominantly influenced by the concern questions.

Cluster 1 is characterized by the lowest levels of willingness, moderate concerns, and a less positive attitude in comparison to the other clusters. In contrast, Cluster 2 is distinguished by the highest levels of concern, greater willingness, and a more positive attitude. Cluster 3 stands out with the least concerns and the highest willingness (Supplementary Table 2). Comprehensive demographic details for each cluster are presented in Supplementary Table 3. Demographic differences between clusters can help inform future efforts by SAGES-EAES to provide tailored education and outreach related to sustainability.