Open Access

Minor surgical procedures and musculoskeletal injections by primary care physicians - an Israeli experience

Israel Journal of Health Policy Research20143:12

https://doi.org/10.1186/2045-4015-3-12

Received: 4 November 2013

Accepted: 1 March 2014

Published: 25 March 2014

Abstarct

Background

Since minor surgical and musculoskeletal problems are commonly seen in primary care, primary care physicians are expected to possess the skills required to perform minor surgical procedures (MSP) and musculoskeletal injections (MSI).

Objective

To evaluate the performance of MSP and MSI by primary care physicians in the Southern District (Negev) of Clalit Health Services (CHS) health maintenance organization (HMO) in Israel.

Methods

A structured self-report questionnaire was sent to all 277 primary care physicians, other than pediatricians, working in the Southern District (Negev) of CHS HMO.

Results

One hundred fifty one of the 277 questionnaires (54%) were completed and returned. Sixty five percent of the primary care physicians perform any MSP and 46% perform any MSI. The main barriers reported for performing MSP and MSI were lack of time (74% and 66%, respectively) and training (41% and 60%, respectively). Forty percent of the physicians cited remuneration as a potential motivating factor. A logistic regression model showed that male physicians and physicians who work full or part-time in rural areas, are more likely to perform MSP (Odds ratio 2.12 and 2.24, respectively). Male physicians, especially board-certified family physicians, are more likely to perform MSI (Odds ratio 2.86 and 7.0 respectively).

Conclusion

MSP and MSI are practiced by only some primary care physicians. HMOs and individuals responsible for designing training curricula in family medicine and primary care can encourage primary care physicians to perform MSP and MSI by providing courses, specific compensation, and dedicated time. This can strengthen the bond between primary care physicians and patients, reduce waiting time for patients, and save money for HMO’s.

Keywords

Health maintenance organizationMinor surgical proceduresMusculoskeletal injectionsPrimary care physicianBarriers

Background

Skin and subcutaneous lesions (nevi, fibromas, lipomas), lacerations, ingrown nails and abscesses[13], and musculoskeletal problems like arthritis, bursitis, trigger points, entrapment neuropathies and tendinitis,[413] are frequent complaints encountered by primary care physicians, who are expected to have the basic treatment skills required to perform minor surgical procedures (MSP) and musculoskeletal injections (MSI). There are several advantages to performing MSP and MSI in the primary care setting[1416] including: (a) anxiety reduction, since the procedure is performed by the patient’s family physician and not a stranger, (b) greater convenience for the patient, due to proximity to and familiarity with the clinic, (c) financial savings, since procedures conducted in primary care clinics are less expensive than hospital procedures, and (d) shorter waiting times. Conducting these procedures in the primary care setting can improve the physician-patient relationship and enable primary care physicians to increase the spectrum of their work, enhance their work satisfaction, and help them avoid burnout.

The performance of MSP requires appropriate equipment and is time-consuming. In addition, MSP and MSI require prior training. Without specific compensation for these procedures, primary care physicians may not be motivated to perform them. A survey of 309 primary care physicians from Northern Ireland, published in 2003, reported that only 46% of the physicians performed any MSI[17], and a survey from Croatia reported that fifty percent of the physicians did not perform any surgical procedures on their patients, irrespective of their prior training[18].

Primary care services are provided in the Israeli health system by four health maintenance organizations (HMOs). Currently, there are no formal MSP and MSI courses during the residency program and no postgraduate instructional courses on the subject in Israel.

The goal of the present survey was to evaluate the extent to which primary care physicians treating adults in southern Israel, who work for the largest HMO in Israel - Clalit Health Services (CHS HMO), perform MSP and MSI.

Methods

Setting

At the time of this study, 54% of the Israeli population (3,774,600 enrollees) was insured by CHS HMO. The Southern District (Negev) of CHS HMO insures about 280,000 persons above the age of 16 in southern Israel.

Approximately 2,000 primary care physicians work in one of the four HMOs in Israel. About half of them are board certified in family medicine. The rest are general practitioners or board certified internists. Most of the primary care physicians are salaried employees. In CHS HMO primary care physicians are not compensated for the MSP and MSI that they perform. Each primary care physician has a practice of about 1300 persons that he/she is responsible for.

Selection of study subjects

During the year 2010 a self-report questionnaire was sent by HMO internal mail to all 277 primary care physicians who treat adults in the Southern District (Negev) of CHS HMO. The human resources section of the HMO’s district administration provided the list of physicians. Two months later a reminder was sent to physicians who had not responded. The study included residents and specialists in family medicine, general practitioners without formal training in family medicine, and specialists in internal medicine.

Measurements

The questionnaire included socio-demographic data, questions relating to the performance of MSP and MSI, and barriers to their performance.

Statistical analysis

Data was analyzed using the SPSS statistical software package (SPSS, Inc., Version 17.0, Chicago, IL). T-tests and chi-square tests were used to assess statistically significant differences for continuous and categorical variables, respectively. Two-tailed p-values below 0.05 were considered statistically significant. Two logistic regression models were developed to predict MSP and MSI. The models included demographic variables that were significantly associated with MSP and MSI in bivariate data analysis.

The study was approved by the IRB of the Meir Medical Center, Kefar Saba, Israel.

Results

Study population compared to all primary care physicians in the southern district (negev) of the CHS HMO

Of the 277 physicians who received the questionnaires by email, 151 returned them (54.5% response rate). The characteristics of the study physicians are presented in Table 1. The study population included significantly more graduates of israeli medical schools, more specialists in family medicine, more veteran physicians, and more physicians who worked in larger sized practices compared to the overall physician population in the district. Fifty nine percent of the physicians in the study population indicated that their main work place was in an urban clinic.
Table 1

Demographic characteristics of the study population (N = 151), compared with all primary care physicians in the Negev district

 

Study population (n = 151)

Primary care physicians in the CHS* Negev district** (n = 277***)

P value

 

N

%

N

%

Gender

     

Male

73

48.3%

129

46.6%

0.725

Female

78

51.7%

148

53.4%

 

151

 

277

 

Age

     

Mean ± SD

48.37 ± 8.95

48.5 ± 8.79

0.557

Range

32-65

31-68

 

149

(mis = 2)

277

 

Country of birth

     

Israel

35

24.1%

67

24.2%

0.99

Other

110

75.9%

210

75.8%

 

145

(mis = 6)

277

 

Country of medical studies

     

Israel

34

23.6%

39

14.1%

0.014

Other

110

76.4%

238

85.9%

 

144

(mis = 7)

277

 

Professional status

     

Specialist in family medicine

86

57.0%

104

37.6%

<0.0001

Resident in family medicine

25

16.6%

54

19.5%

General practitioner

22

14.6%

105

37.9%

Expert in internal medicine

14

9.3%

14

5.0%

Other

4

2.6%

0

0.0%

 

151

 

277

 

Years in practice as a physician

     

1-10

15

10.4%

  

<0.0001

11+

129

89.6%

  

Mean ± SD

23.49 ± 9.54

10.35 ± 12.28

Range

3-43

0-38

 

144

(mis = 7)

277

 

Average number of patients per physician

     

Mean ± SD

1476 ± 500

1340 ± 445

0.001

Range

250-3000

250-3723

 

131

(mis = 20)

277

 

* Southern District (Negev) of Clalit Health Services-health maintenance organization.

**Pediatricians were not included.

*** The list of physicians was extracted from the human resources section of the HMO’s administration.

Primary care physicians’ performance of MSP and MSI

Sixty five percent of the primary care physicians reported that they perform any MSP, and 46% perform any MSI. Table 2 shows the spectrum of MSP and MSI performed by the study physicians. The performance rate of MSP and MSI was lower than the actual training rate of the physicians.
Table 2

A comparison of physicians trained to perform minor surgical procedures and musculoskeletal injections and those who actually do so

 

Trained (n = 151)

Actually performed

n

%

mis

n

%

mis

Minor surgery procedures

      

Suturing of wounds

88

58.7%

1

72

48.0%

1

Drainage of abscesses

78

52.3%

2

76

51.0%

2

Removal of ingrown nails

78

52.0%

1

42

28.4%

3

Excision of cyst or subcutaneous nodule

44

29.3%

1

31

20.8%

2

Excision of nevi

25

16.7%

1

15

10.0%

1

Excision of skin tumors

17

11.3%

1

9

6.1%

3

Drainage of thrombosed hemorrhoids

14

9.3%

1

9

6.1%

3

Musculoskeletal injections

      

Tennis elbow

85

57.4%

3

52

34.9%

2

Drainage of knee effusions

75

51.0%

4

42

28.4%

3

Plantar fasciitis

75

51.0%

4

54

35.8%

0

Rotator cuff tendinitis

72

48.6%

3

30

19.9%

0

Trigger finger

66

44.6%

3

44

29.1%

0

De Quervain’s tenosynovitis

65

43.9%

3

34

22.7%

1

Golfer’s elbow

59

40.1%

4

34

22.5%

0

Prepatellar bursitis

59

40.1%

4

31

21.4%

6

Acromioclavicular osteoarthritis

57

38.5%

3

23

15.2%

0

Olecranon bursitis

57

38.5%

3

38

25.3%

1

Carpal tunnel syndrome

54

37.0%

5

31

20.5%

0

Biciptal tendinitis

53

35.8%

3

24

15.9%

0

Trochanteric bursitis

35

23.6%

3

23

15.2%

0

Meralgia parasthetica

31

20.9%

3

17

11.3%

1

Dupuytren’s contracture

29

19.6%

3

17

11.3%

1

Ischiogluteal bursitis

22

15.0%

4

11

7.4%

2

Other - cutaneous nerve entrapment

not asked

2

1.3%

0

Other - osteoarthritis of knee

not asked

2

1.3%

0

Other - trigger points

not asked

3

2.0%

0

Other - abdominal or thoracic wall

not asked

1

0.7%

0

Primary care physicians who do not perform MSP usually refer most cases to specialists, except for lacerations that require suturing, which are referred, in 67% of the cases, to the emergency room. The other cases are referred to another primary care physician who does perform suturing. For abscess drainage 61% are referred to a specialist surgeon and 34% to the emergency room. For the different MSI, 80-90% of the patients are referred to a specialist if the primary care physician does not do it. Physicians who performed MSP were more likely to perform MSI (p < 0.0001).

Facilitating factors and barriers to MSP and MSI performance

The reasons reported for performance or non-performance of minor surgical procedures and injections by the participating physicians are shown in Table 3. Factors reported by all the participating physicians that could facilitate their performance of MSP and MSI included: (a) having dedicated time for these procedures (70%), (b) having undergone a training course (58%), (c) having participated in a demonstration on patients (52%), (d) receiving remuneration (42%), and (e) training on mannequins (40%).
Table 3

Reasons for performance or nonperformance of minor surgical procedures and musculoskeletal injections

 

Minor surgical procedures (N* = 98)

Musculoskeletal injections (N* = 70)

 

n

%

MIS

n

%

MIS

Main reason for performance (more than one answer possible0029)

      

It’s an integral part of a family physician’s work

65

75.6%

12

55

84.6%

5

Decreased waiting time for the procedure, compared to secondary care

58

67.4%

12

3

4.6%

5

An opportunity to vary the family physician’s work, thus increasing job satisfaction

54

62.8%

12

50

76.9%

5

Increased patient confidence in the clinic’s medical staff

47

54.7%

12

42

64.6%

5

Decreased patient anxiety level because of treatment by a familiar and trusted staff

36

41.9%

12

32

49.2%

5

Procedures performed in the primary care clinic are less expensive than in secondary care

22

25.6%

12

13

20.0%

5

Other - Immediate help to the patient

Not asked

5

7.1%

0

Main reasons for nonperformance (more than one answer possible)

      

Lack of time

104

74.3%

11

85

65.9%

22

Lack of knowledge

57

40.7%

11

78

60.0%

21

Lack of equipment

48

34.5%

12

27

20.8%

21

Fear of complications

48

34.3%

11

52

40.0%

21

Other specialists are more qualified to perform the procedures and injections

46

32.9%

11

57

43.8%

21

Lack of remuneration

34

24.5%

12

25

19.5%

23

No personal interest

15

10.7%

11

15

11.5%

21

It’s an integral part of the family physician’s work

10

7.1%

11

12

9.2%

21

Negative experience in the past

5

3.6%

11

5

3.8%

21

Lack of experience

2

1.3%

 

1

0.7%

 

*Only by the performing physicians.

Male physicians were more likely than female physicians to perform MSP (75% vs. 55%, p < 0.007) and MSI (55% vs. 38%, p < 0.032). Physicians born in Israel performed more MSP than physicians born elsewhere (89% vs. 58%, p < 0.001). While this was also the case for MSI, the difference did not reach statistical significance. Graduates of israeli medical schools performed more MSP and MSI than those who graduated from medical schools outside of israel. Specialists in family medicine performed more MSI than residents in family medicine, general practitioners, and specialists in internal medicine (63% vs. 33%, p < 0.0001). This was also the case for MSP, but the difference did not reach statistical significance. Physicians practicing in rural areas performed more MSP than physicians practicing only in urban areas (78% vs. 58%, p < 0.01), while the difference was not significant for MSI. Age, seniority as a physician, the number of patients in the practice, and the number of patients seen in the course of a day were not associated with the performance of MSP and MSI.

Table 4 presents a logistic regression model predicting performance of MSP and MSI. All demographic variables that were significantly associated with MSP and MSI in the bivariate analysis were entered into this model. Age, which was not significantly associated with MSP and MSI, was added to the model nonetheless for variable stratification. Being a male physician and working in a rural clinic (full or part-time) predicted performance of MSP (OR = 2.12, 95% CI 1.04-4.35 and OR = 2.24, 95% CI 1.01-4.99, respectively). Being a male family physician, and especially being board-certified in family medicine predicted performance of MSI (OR = 2.87, 95% CI 1.35-6.10 and OR = 7.01, 95% CI 3.15-15.58, respectively).
Table 4

Logistic regression model predicting the performance of MSP and MSI by primary care physicians

Variable

OR

95% CI

P-value

Minor surgical procedures model

   

Gender (male)

2.124

1.036-4.351

0.04

Age

1.004

0.961-0.044

0.859

Main practice in rural setting

2.245

1.011-4.987

0.047

Musculoskeletal injections model

   

Gender (male)

2.868

1.348-6.101

0.006

Age

0.961

0.921-1.003

0.07

Specialty in family medicine

7.009

3.153-15.577

<0.0001

Discussion

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.

Conclusion

Although the majority of primary care physicians state that MSP and MSI should be an integral part of their work and its performance is cost effective, it is practiced by primary care physicians at lower rates than expected.

Implications for clinical practice

HMOs and individuals responsible for training curricula in family medicine could encourage primary care physicians to perform MSP and MSI by conducting dedicated courses, with practical “hands-on” experience on actual patients, specific remuneration, and dedicated time. An emphasis should be placed on women and primary care physicians working in urban areas. These procedures should be taught in the framework of residency programs as well as postgraduate continued medical education (CME) in primary care.

Implementation of these recommendations could save money for the healthcare system and time for patients, while strengthening the bond between primary care physicians and their patients.

Declarations

Authors’ Affiliations

(1)
Department of Family Medicine, Faculty of Health Sciences, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev
(2)
Clalit Health Services – South District

References

  1. De Delva PE, McCabe CJ: Minor surgical office procedures for skin problems. Primary Care Medicine. Edited by: Goroll AH, Mulley AG JR. 2009, Philadelphia: Lippincot Williams and Wilkins, 1232-1235. 6Google Scholar
  2. Chaves MC, Maker VK: Office surgery. Textbook of Family Medicine. Edited by: Rakel RE. 2007, Philadelphia: Saunders Elsevier, 627-649. 7Google Scholar
  3. Show JC: General dermatologic therapy. Textbook of Primary Care Medicine. Edited by: Noble J. 2001, St. Louis, Missouri: Mosby Inc, 754-758. 3Google Scholar
  4. Cardone DA, Tallia AF: Joint and soft tissue injection. Am Fam Physician. 2002, 66 (2): 283-288.PubMedGoogle Scholar
  5. Cardone DA, Tallia AF: Diagnostic and therapeutic injection of the elbow region. Am Fam Physician. 2002, 66 (11): 2097-2100.PubMedGoogle Scholar
  6. Tallia AF, Cardone DA: Diagnostic and therapeutic injection of the wrist and hand region. Am Fam Physician. 2003, 15;67 (4): 745-750.Google Scholar
  7. Mauromatis JK: Pain in the shoulder, neck and arm. Office Practice of Medicine. Edited by: Branch WT, Smith C. 2003, Philadelphia: Saunders Elsevier, 799-817. 4Google Scholar
  8. Cardone DA, Tallia AF: Diagnostic and therapeutic injection of the hip and knee. Am Fam Physician. 2003, 67 (10): 2147-2152.PubMedGoogle Scholar
  9. Tallia AF, Cardone DA: Diagnostic and therapeutic injection of the ankle and foot. Am Fam Physician. 2003, 68 (7): 1356-1362.PubMedGoogle Scholar
  10. Tallia AF, Cardone DA: Diagnostic and therapeutic injection of the shoulder region. Am Fam Physician. 2003, 67 (6): 1271-1278.PubMedGoogle Scholar
  11. Jupiter JB, Ring D: Approach to the patient with shoulder pain. Primary Care Medicine. Edited by: Goroll AH, AG Mulley JR. 2006, Philadelphia: Lippincot Williams and Wilkins, 977-984. 5Google Scholar
  12. Bland JH: Disorders of the shoulder. Textbook of Primary Care Medicine. Edited by: Noble J. 2001, St.Louis, Missouri: Mosby, Inc., 1154-1156. 3Google Scholar
  13. Mandl LA: Elbow, hand, knee, hip and foot pain. Office Practice of Medicine. Edited by: Branch WT, Smith C. 2003, Philadelphia: Saunders Elsevier, 819-840. 4Google Scholar
  14. George S, Pockney P, Primrose J, Smith H, Little P, Kinley H, Kneebone R, Lowy A, Leppard B, Jayatilleke N, McCabe C: A prospective randomized comparison of minor surgery in primary and secondary care. The MiSTIC trial. Health Technol Assess. 2008, 12 (23): iii-iv. ix-38View ArticlePubMedGoogle Scholar
  15. Shvartzman P, Oren B, Din Y: Minor surgery in family medicine. Harefuah. 1988, 114 (11): 540-541.PubMedGoogle Scholar
  16. Cornell SJ: Minor surgery in general practice. Update. 1985, 31: 925.Google Scholar
  17. Gormley GJ, Corrigan M, Steele WK, Stevenson M, Taggart AJ: Joint and soft tissue injections in the community: questionnaire survey of general practitioners’ experiences and attitudes. Ann Rheum Dis. 2003, 62 (1): 61-64. 10.1136/ard.62.1.61.PubMed CentralView ArticlePubMedGoogle Scholar
  18. Gmajnic R, Pribic S, Lukic A, Barbara E, Nikola Č, Ivana MI: Effect of surgical training course on performance of minor surgical procedures in family medicine physicians’ offices: an observational study. Croat Med J. 2008, 49 (3): 358-363. 10.3325/cmj.2008.3.358.PubMed CentralView ArticlePubMedGoogle Scholar
  19. O’Cathian A, Brazier JE, Milner PC, Fall M: Cost effectiveness of minor surgery in general practice: a prospective comparison with hospital practice. Br J Gen Pract. 1992, 42 (354): 13-17.Google Scholar
  20. Arribas Blanco JM, Gil Sanz ME, Sanz Rodrigo C, Morón Merchante I, Muñoz-Quirós Aliaga S, Lòpez Romero A, Gonzalez-Baylin Monje ML, Laguna Delgado L, Verdugo Rosado M: Effectiveness of dermatologic minor surgery in the office of the family physician and patient satisfaction in relation with ambulatory surgery. Med Clin (Barc). 1996, 107 (20): 772-775.Google Scholar
  21. Wetmore SJ, Rivet C, Tepper J, Sue T, Michel D, Paul R: Defining core procedural skills for Canadian Family medicine training. Can Fam Physician. 2005, 51: 1365.PubMed CentralGoogle Scholar
  22. Wetmore SJ, Agbayani R, Bass MJ: Procedures in ambulatory care. Which family physicians do what in Southwestern Ontario?. Can Fam Physician. 1998, 44: 521-529.PubMed CentralPubMedGoogle Scholar
  23. Sempowski IP, Rungi AA, Seguin R: A cross sectional survey of urban Canadian family physician’s provision of minor office procedures. BMC Fam Pract. 2006, 19 (7): 18.View ArticleGoogle Scholar
  24. Al-Shammari S, Khoja T: Minor surgery at primary care centers in Riyadh, Saudi Arabia. Ann Saudi Med. 1996, 16 (5): 534-538.PubMedGoogle Scholar
  25. Liddell WG, Carmichael CR, MeHugh NJ: Joint and soft tissue injections: a survey of general practitioners. Rheumatolgy (Oxford). 2005, 44 (8): 1043-1046. 10.1093/rheumatology/keh683.View ArticleGoogle Scholar
  26. Glazier RH, Daldy DM, Badley EM, Hawker GA, Bell MJ, Buchbinder R: Determinants of physician confidence in the primary care management of musculoskeletal disorders. J Rheumatol. 1996, 23 (2): 351-356.PubMedGoogle Scholar
  27. Gormley GY, Steele WK, Stevenson M, McKane R, Ryans I, Cairns AP, Pendleton A, Wright GD, Taggart AJ: A randomized study of training programs for general practitioners in the techniques of shoulder injection. Ann Rheum Dis. 2003, 62 (10): 1006-1009. 10.1136/ard.62.10.1006.PubMed CentralView ArticlePubMedGoogle Scholar
  28. McKenna C, Bojke L, Manca A, Adebajo A, Dickson J, Helliwell P, Morton V, Russell I, Torgerson DT, Watson J: Shoulder acute pain in the primary health care: is retraining GPs effective? The SAPPHIRE ramdomized trail: a cost-effectiveness analysis. Rheumatology. 2009, 48 (5): 558-563.View ArticlePubMedGoogle Scholar
  29. Jansen JJ, Grol RP, van der Vieuten CP: Effect of a short skills training course on competence and performance in general practice. Med Educ. 2000, 34 (1): 66-71. 10.1046/j.1365-2923.2000.00401.x.View ArticlePubMedGoogle Scholar
  30. Bakewell CJ, Gardner GC: A survey of arthrocentesis and soft-tissue injection procedures performed in primary care practice: effect of resident training and using data to shape curriculum. J Rheumatol. 2011, 38 (9): 1986-1989. 10.3899/jrheum.110041.View ArticlePubMedGoogle Scholar
  31. Al-Ahaideb A, Khoshhal K, Alsiddiky A, Heissam K, Alzakari A, Alsaleh K: Patterns and obstacles of provision of minor orthopedic procedures among primary care physicians in Saudi Arabia. Int J Health Sci (Qassim). 2012, 6 (1): 13-21.View ArticleGoogle Scholar

Copyright

© Menahem et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Advertisement