Although all primary care physicians frequently encounter medical problems requiring the performance of MSP and MSI, and more than two thirds of the participating physicians stated that MSP and MSI should be an integral part of the family physician’s work, about one third do not perform MSP and one half do not perform MSI. The most common MSP that primary care physicians were trained to perform, and which about half actually do perform were suturing of lacerations and draining of abscesses. The main reasons that those who performed MSP did so were to decrease waiting times for procedures for patients and to add variety to the family physician’s work. The main barriers to performing MSP and MSI, as cited by 50-70% of the physicians, were a lack of dedicated time and the absence of hands-on training programs. Male physicians and physicians working in rural clinics were twice as likely to perform MSP as female physicians and physicians working in city clinics. Male physicians were more likely to perform MSI than female physicians by a factor of 2.86. Board certified physicians in family medicine were seven-fold more likely to perform these procedures than the other physicians in the study.
Comparison with existing literature
Several surveys have addressed the issue of MSP in primary care. Two Israeli family physicians reported their experience with surgical procedures in their clinics over a 22-month period in 1984–5. They treated both rural and urban patients. In the rural setting they performed more elective surgical procedures than in the urban setting. More urgent surgical procedures were performed in the urban clinics[15]. Their complication rate was about 3%, which is the expected rate[16]. The most common surgical procedures included suturing lacerations, excision of skin lesions and sebaceous cysts, removal of nails, draining of abscesses, removal of foreign bodies, and drainage of thrombosed hemorrhoids.
A prospective survey from the United Kingdom checked the cost effectiveness of minor surgery with remuneration in general practice compared to hospital practice. Minor surgery in general practice was cost effective but general practitioners sent a smaller proportion of specimens to a histopathology laboratory, incorrectly diagnosed a larger proportion of malignant conditions as benign and inadequately excised 5% of the lesions[19].
Another prospective randomized comparison of minor surgery for 568 patients between primary and secondary care was conducted in the United Kingdom. Again, minor hospital surgery was of slightly better quality with a difference that reached statistical significance. However, the clinical importance of the difference was uncertain and the cost was higher. The complication rate was similar in both groups except for wound infection, which was higher in primary care minor surgery. Patients were more satisfied doing procedures in primary care setting because it was more convenient[14].
The results of a survey from Spain showed that the average waiting time for procedures performed by family physicians was lower by a mean of 45 days than surgeons, without any significant difference in effectiveness[20]. Several surveys from Canada reported similar findings to those of the present study. They also reported that primary care physicians in rural areas perform more surgical procedures than those in urban areas[21, 22]. In a survey from Ontario Canada, 79 family physicians were interviewed. The overall self-reported performance rates were 63.3% for dermatological excisions, 43% for knee injections, and 31.6% for shoulder injections. These rates were higher than in our survey (20.8%, 28.4%, and 19.9% respectively). Similar to our findings, the main barriers to performing these procedures were lack of updated skills and lack of time (about 50%)[23]. In Saudi Arabia, a randomly selected group of 231 primary care physicians working in Riyadh health centers completed a confidential questionnaire about their performance of minor surgical procedures. The results were similar to ours with 74% of the physicians performing some sort of minor surgery. Physicians living in remote areas performed more minor surgery compared to other areas and male physicians performed more minor surgery than female physicians (p = 0.05)[24].
In a study from Croatia, the effect of a surgical training course on the performance of minor surgical procedures was evaluated one year later in a group of 59 family physicians. There was a statistically significant increase in the number of minor surgical procedures performed, which almost doubled from baseline. Male physicians performed significantly more surgical procedures than female physicians, before and after the course. As in our study, there was no association between the number of procedures performed and the age of the participating physicians or their length of employment, but in contrast to our study there was no difference between urban and rural clinical settings. Fifty percent of the physicians did not perform surgical procedures irrespective of whether they participated in the course[18], compared to one third in the present study.
Similarly, several surveys have addressed MSI performance by primary care physicians. A survey from the United Kingdom explored joint and soft tissue injections by 251 general practitioners. Factors associated with higher levels of injection activity were: male gender, more than 10 year’s experience, a special interest in rheumatology or orthopedics, and working in a rural or mixed practice. The most important barriers to carrying out injections were lack of practical training, lack of confidence, and inability to maintain skills. The most injected musculoskeletal problems were tennis elbow, knee joint and glenohumeral joint[25].
In a survey among 798 primary care physicians from Ontario, Canada who completed a questionnaire about their level of confidence in treatment of musculoskeletal disorders rural physicians were more confident than urban physicians about doing a joint injection/aspiration (Odds ratio 2.24)[26]. In a study conducted in Northern Ireland 46% of the 309 participating physicians did not perform MSI at the time of the study. Five percent of the primary care physicians carried out most of the injections done in the community. Injections into the shoulder, knee and lateral epicondyle were the most commonly performed. The physicians preferred to train on “real patients” rather than on mannequins. The barriers to performing injections included (in descending order): inability to maintain injection skills, inability to make the correct diagnosis, medico-legal concerns, concerns about complications, cost/time involved in training, time needed to do the procedure, lack of evidence about efficacy, and lack of personal interest[17]. In our survey lack of time was the main barrier.
In a randomized study from Northern Ireland of two different training programs for general practitioners in the techniques of shoulder injection, physicians that received training on real patients were significantly more confident in performing injections than physicians who were trained using mannequins[27]. Two more studies from the United Kingdom and the Netherlands showed that training programs for primary care physicians on shoulder injections techniques increase their performance rate[28, 29]. Another survey of primary care internists from the United States showed that a training program in outpatient primary care could increase MSI performance[30].
A survey of 298 physicians working in a primary care setting in Riyadh, Saudi Arabia reported their MSI experience. The conclusion was that many physicians working in primary care settings in Saudi Arabia refer patients who require musculoskeletal injections to specialists for consultation, even though treating these patients at the primary care level is more time- and cost effective[31].
Interpretation of the study results in relation to existing literature
In our survey, as well as those reported from other countries, MSP and MSI performance rates were higher in male physicians and those who work in rural areas. The best performance improvement reported in the literature resulted from a course in which physicians practiced on actual patients. The physicians in the present study ranked setting aside dedicated procedure time and a training course as the most important facilitating factors, while they ranked live demonstrations on patients as third.
The performance rate for MSP and MSI was not associated with the physician’s age, years in practice, the number of patients in the practice, or the number of patients seen by the physician over the course of a day. This consistent finding suggests that those primary care physicians who are used to performing MSP and/or MSI continue to do so as they gain experience and confidence and manage to find the time despite their heavy work burden.
Strengths and limitations
Our study has some limitations. First, only 54% of the eligible physicians in the Southern District (Negev) of CHS HMO responded to the survey. Second, self-report is less accurate than actual measurement of performance and physicians may overestimate their performance. Third, those who answered the questionnaire could be more interested in the subject and tend to perform procedures more than those who did not. Forth, the study was limited to the south of Israel and included physicians from only one HMO, albeit the largest in the region. Potential socio-demographic differences between all primary care physicians in the Southern District (Negev) CHS HMO and those who participated in the study could affect the results, since our study population consisted of a higher percentage of specialists in family medicine and graduates of Israeli medical schools compared to all primary care physicians in the south. Thus, the performance rate for all primary care physicians might actually be lower than the observed rate in this study. Sending specimens to histopathological examination could be a barrier to MSP performance that was not addressed in the questionnaire.
However, the results of the present survey are similar to those of studies from other countries, a finding that strengthens the reliability of the results for our region.
Health policy implications of the findings
More than two thirds of the primary care physicians in the study stated that MSP and MSI should be an integral part of their job. In actual practice, the overall performance rate was low. By providing courses for residents and post-graduates and providing appropriate compensation, time and equipment, the performance of MSP and MSI could be increased. This would save money for the HMOs, which function in a setting of an ongoing financial crisis in the healthcare system in Israel and in other countries where specialist fees are much higher than those of primary care physicians, even though they have longer waiting times.
