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

Procedural skills workshops for primary care physicians in Israel: a comprehensive analysis

BACKGROUND

Some of the most common complaints addressed by primary care physicians (PCPs) require manual procedures, such as lacerations repair, abscesses drainage, ingrown toenails removal, dry needling for myofascial pain syndrome, and Epley maneuver for treating benign paroxysmal positional vertigo (BPPV). The aim of this study was to describe the procedural skills workshops program for PCPs implemented in Maccabi Healthcare Services and to investigate how many PCPs have participated and used the skills since the program's inception in 2017.

METHODS

In this observational study, we followed all participants in courses from 2017 to 2021. We extracted all procedures performed during these years by PCPs who learned the skill in MHS.

RESULTS

During the study period, 620 PCPs participated in workshops for dry needling, soft-tissue and joint injections, BPPV treatment, minor surgical procedures, and spirometry. Most procedures performed were dry needling (average annual number 3,537) and minor surgical procedures (average annual number 361). The average annual use per physician was highest for dry needling (annual average use per physician who used the learned skill was 50.9), followed by soft tissue and joint injections (16.8), minor surgical procedures (14.8), and BPPV treatment (7.5).

CONCLUSION

procedural skills workshops may expand PCPs' therapeutic arsenal, thus empowering PCPs and providing more comprehensive care for patients. Some manual skills, such as dry needling, soft tissue injections, and the Epley maneuver, were more likely to be used by participants than other skills, such as spirometry and soft tissue injections.

Office-Based Minor Surgery: An Ever-Increasing Challenge Not Only for the Dutch General Practitioner

BACKGROUND AND OBJECTIVES

Office-based minor surgery (OBMS) refers to all surgical procedures performed under local anesthetic in the office setting. It is cost effective for the health economy, safe, and appreciated by patients. It is not yet fully understood why some general practitioners (GPs) perform OBMS and others do not, while there is a growing demand for OBMS. Therefore, we explored factors that influence the performance of OBMS by GPs. The aim of this study is to explore the facilitators and barriers that influence GPs in deciding whether to perform OBMS.

METHODS

We performed a qualitative study using focus groups consisting of GPs and GP trainers. Two researchers analyzed the data independently.

RESULTS

The analysis resulted in a comprehensive list of facilitators and barriers. Besides already known factors such as financial consequences and geographic location, the most important factors influencing the decision to perform OBMS were training and the role of the GP trainer; fear of having to work alone and having to solve unexpected complications; and the influence of collaboration, organization, and facilities in the GP's own practice.

CONCLUSIONS

The increasing demand for OBMS in primary care centers requires more attention to training aspects, the existing fear, adequate reimbursement for special accreditation, and collaboration and organization. We expect that addressing these factors will result in the strengthening of primary care, improving patient safety, lower referral rates, and a reduction in health care costs.

Minor surgery in general practice in Ireland- a report of workload and safety

BACKGROUND

The provision of minor surgical services is an established part of the task profile of general practitioners (GPs) in many countries in Europe and elsewhere. This study aimed to collect data on the clinical process and outcomes for specified minor surgical procedures undertaken in Irish general practice by GPs experienced in minor surgery in order to document the scope and safety of minor surgery being undertaken.

METHODS

Over a six-month period, 24 GPs in 20 practices recorded data on a pre-determined list of procedures undertaken in adults (aged 18 and older); procedures for ingrown toenails were also recorded for those aged 12-18 years. Clinical data were rendered fully anonymous by the participating GPs, entered onto the Excel database template and returned to the project team monthly.

RESULTS

On average, each practice undertook 212 procedures in a six-month period. The four most frequent procedures include two relatively non-invasive procedures (cryosurgical ablation of skin lesions and aspiration and/or injection of joints) and two more invasive procedures (full thickness excision of skin lesion and shave, punch or incisional biopsy). Overall, 83.8% of relevant specimens were submitted for histology. Combining benign and malignant cases, there was an overall 87% clinical and histological concordance; 85% of malignancies were suspected clinically. A complication was recorded in 0.9% after 1 month.

CONCLUSIONS

Irish GPs with experience in minor surgery can provide a range of surgical services in the community safely.

Health Related Absenteeism of Family Physicians in the Negev Region of Israel: A Cross-Sectional Study

Physicians tend to treat their own illnesses differently than the general population, sometimes continuing to come to work when ill. To assess whether family physicians continue to work when ill. A cross-sectional study with a convenience sample. A self-administered, anonymous questionnaire, that included socio-demographic data, questions relating to illness, and reasons for work absenteeism, was completed by family physicians in the Negev region of Israel. 107 physicians participated in the study including 46 women (43 %). The mean age was 45.1 ± 11.4. Forty physicians (37.4 %) said they come to work with an acute illness, 47 (43.9 %) answered that they do so some of the time, and 19 (17.8 %) said that they did not come to work ill. On a scale from 1 to 10 the mean score for the question as to whether physicians are liable to infect their patients was 7.4, with a higher score meaning more likely to infect. Older physicians were more likely to say that the decision to stay away from work was related to the lack of available physicians (P = 0.002), while board certified physicians were more likely than residents to stay away from work due to an acute illness (P = 0.023). Family physicians in the Negev sometimes work when they are ill. This finding has positive sides related to dedication to patients and the work place, but one cannot ignore the fact that patients may be infected by their physicians. Behavioral guidelines, including social, legal, and ethical aspects, should be formulated on this issue.

Referral patterns of Israeli pediatricians of common primary care office procedures

BACKGROUND

Pediatric primary care is the cornerstone of health care services for children. Performance of common office procedures is an integral part of primary care. Ideally, the community-based primary care pediatrician provides comprehensive health care services and only refers a small minority of patients for consultation. However, knowledge regarding Israeli pediatricians' practices of office procedures is scant.

OBJECTIVES

To describe primary care pediatricians' patterns in the provision of common office procedures and to analyze factors associated with performance or referral.

METHODS

DESIGN

Self-completed structured questionnaire consisting of 1) demographic variables; 2) practice characteristics description; 3) List of ten procedures (treatment of subungual hematoma, laceration suturing and adhesive closure, elbow subluxation/reduction , urinary bladder catheterization, supra-pubic aspiration, inguinal hernia reduction, umbilical granuloma and labial fusion treatment, and short lingual frenulum management) followed by questions regarding referral practice for each procedure; and 4) causes and indications for referral when relevant.

PARTICIPANTS

Primary care pediatricians attending anational pediatric conferences.

ANALYSIS

Descriptive statistics and association assessment.

RESULTS

The questionnaire was completed by 162 primary care pediatricians, 58.7 % male; mean age 53 ± 9 years, 88.4 % board certified. Of the respondents, 57 % worked in group practices and the remainder solo; salaried employees 68.2 %, independent contractors 31.8 %. Referral rate varied by procedure; least likely to be referred was labial fusion (7.7 %) and most likely was short lingual frenulum (81.3 %). For most procedures, the most frequent non-performance cause was lack of expertise followed by lack of appropriate conditions. The overall number of procedures in which the response selected was out-of-clinic referral was not associated with demographic or employment characteristics. However, association was found for certain specific procedures (e.g. experience with catheterization, gender with suturing and adhesive closure).

CONCLUSIONS

Many common office procedures are referred out of primary care pediatric community settings in Israel. Considerable variability was found among procedures. Lack of experience or lack of appropriate conditions were frequently reported causes for referral and need to be addressed in reducing unnecessary referral with its attendant costs and patient inconvenience. Possible approaches include updates in pediatric residency training, focused in-service training, time allocation and work environment reorganization.

Extending the boundaries of family medicine to perform manual procedures

A recent survey by Menahem and colleagues revealed that 65% of the surveyed primary care physicians reported that they performed any minor surgical procedures, and 46% reported performance of any musculoskeletal injections. Lack of allocated time and lack of training were the main reported barriers confronting higher performance rates. Healthcare systems are shifting large chunks of traditional hospital-centered activities to competent and comprehensive community-based structures. These changes are very well aligned with key trends in modern consumerism that prefer a close to home availability of medical services. Minor surgical procedures and musculoskeletal injections are good examples of medical activities that had been performed mainly by hospital and community based specialists. The syllabus of specialty training in Family Medicine in Israel includes these skills and trainees should acquire them during the residency program. We estimate that hundreds of family physicians obtain different levels of such training. Yet, only few family physicians have allocated protected time for performance of the procedures. For the skilled physician, performance of such relatively simple procedures extends his professional boundaries and the comprehensiveness of his service. For the healthcare system the "extra effort" and investment needed for performance of minor surgical procedures in primary care clinics is small. The results of the present study reflect on wider issues of care delivery. This study highlights the need for formalized and documented training of family physicians together with allocation of managerial and technical requirements needed to encourage these and similar medically and economically justified endeavors that seem to be perfectly aligned with the wishes of healthcare consumers.