|Year : 2015 | Volume
| Issue : 2 | Page : 67-73
Primary healthcare physicians' attitude and perceived barriers regarding minor surgeries
Ali Wahab A Alfaraj1, Abdulaziz Mohammad Sebiany2, Waleed Alharbi3
1 Qatif Primary Healthcare Centers, Public Health, Ministry of Health, Eastern Province, Dammam, Saudi Arabia
2 Department of Family and Community Medicine, College of Medicine, University of Dammam, Dammam, Saudi Arabia
3 Family Medicine Postgraduate Program, Public Health, Ministry of Health, Eastern Province, Saudi Arabia
|Date of Web Publication||30-Apr-2015|
Ali Wahab A Alfaraj
P.O. Box 261, Qatif 31911, Eastern Province
Objectives: To determine the importance of minor surgical procedures that could be done by physicians or general practitioners at Primary Healthcare Centers (PHCC) and to determine the important and major obstacles for physicians' inability to perform minor surgeries (MS) at PHCC.
Methodology: Data was collected through a self-administered questionnaire distributed to all primary healthcare physicians in 26 PHCC in Al-Qatif by the official mail of Al-Qatif PHCC Administration. Data was also collected by filling a checklist by the researcher. The data was analyzed using Statistical Package for Social Science.
Results: A total of 61, out of 70 physicians working in Al-Qatif PHCC, completed the self-administered questionnaire which yielded an overall response rate of 87%. 42 (68.6%) participants found themselves as competent to practice MS, and 19 (31.2%) found themselves as not competent to practice MS at PHCC. The highest mean for the degree of importance and confidence, when comparing both, was the insertion of sutures with a statistically significant P value (0.000). Coded surgical referral in all Al-Qatif PHCC over 1-year was 6,187 (25.4%) out of 24,369.
Conclusion: Most of the physicians in Al-Qatif PHCC are interested and feel competent in performing MS and they encourage establishing MS program in the PHCC. However, majority of the physicians in Al-Qatif PHCC are not confident in practicing most of the procedures listed in the survey, although they believe that these procedures are important in their practice.
Keywords: Ambulatory surgeries, day surgeries, minor surgeries, primary healthcare, primary minor surgeries
|How to cite this article:|
Alfaraj AA, Sebiany AM, Alharbi W. Primary healthcare physicians' attitude and perceived barriers regarding minor surgeries. J Health Spec 2015;3:67-73
|How to cite this URL:|
Alfaraj AA, Sebiany AM, Alharbi W. Primary healthcare physicians' attitude and perceived barriers regarding minor surgeries. J Health Spec [serial online] 2015 [cited 2018 Nov 14];3:67-73. Available from: http://www.thejhs.org/text.asp?2015/3/2/67/156111
| Introduction|| |
Minor surgeries (MS) can be defined as short procedures which can be done under local anaesthesia, are minimally invasive and require the common characteristics in surgical techniques. 
Surgical illnesses which require MS intervention are very commonly encountered in family practice setting. In many situations this intervention could cure the problem and put an end to patients' suffering by evading long waiting list in the referral hospitals. This would also strengthen doctor-patient relationship and give the physician more professional self-satisfaction.
In Saudi Arabia, provisions for appropriate treatment of common injuries and MS at Primary Healthcare Centers (PHCC) is the seventh element of Primary Health Care (PHC),  and is considered an essential health service in primary healthcare reform project.  Therefore, MS is an integral part of general practice. ,,
Despite the fact that it has obvious benefits and is also well-recognized by health policy makers, since the establishment of PHC in the Kingdom of Saudi Arabia (KSA), evidence has revealed that MS procedures offered at PHCC in KSA are still in its infancy. 
Minor surgeries are highly recognized within primary care setting in different parts of the world. In UK, general practitioners (GP) performing MS has been welcomed by patients as they can receive treatment for their minor lesions promptly, in familiar surroundings, by a doctor they know well, with follow-up by nurses whom they already know.  The similar advantages have been reported worldwide including USA and Canada. ,,,,
Research conducted in PHC has shown MS benefits that include its safety, cost-effectiveness, decreases in referral rate, and also improved patient satisfaction. , MS also satisfies physicians because it provides an opportunity to treat their patient, not only through medicine, but also by their expertise. 
Although it is time-consuming in PHC, it is more cost-effective than the same intervention performed a hospital setting. The cost of MS in a general practice setting is 15 times less than the same procedure performed in a hospital setting, which offers great saving,  consequently decreasing the financial burden on the health system; moreover, this gives a high doctor and patient satisfaction.
To the best of our knowledge, there is very limited published evidence on reasons exploring the improper utilization of PHC resources to optimize MS procedures in KSA. Therefore, our aim was to investigate physicians' perception, attitude, readiness, and barrier for not performing MS procedures in PHC settings.
The study was conducted in Al-Qatif area, located in northeastern KSA, over the Al-Qatif petroleum field with a population of >500,000 people. The estimated number of PHCC in Al-Qatif is 26 PHCC and 3 referring hospitals, one of which is a secondary referring hospital.
| Methodology|| |
This is a cross-sectional study. The preparation for the study was started in October 2006 and the fieldwork, including the distribution and collection of the questionnaire, was conducted from April to May 2007 in Al-Qatif area, Saudi Arabia.
As there was no available validated questionnaire, and to our knowledge, this is the first study of its kind in KSA, a specially designed self-administered questionnaire with a 5-points Likert scale was used.
Questionnaire's contents were formulated by extensive literature review, in addition to, reviewing the General Practice settings of both international and local experiences as well as experts' consultation working in both surgical and family practice settings.
Moreover, a pilot study was conducted on 7 residents in the 4 th year of Saudi Board of Family Medicine residency who commented on the following measures: ease of use, clarity, competence, and relevance. The comments were incorporated into the final questionnaire.
Potential study procedures were chosen based on resources mentioned previously. A list of many procedures was obtained, from which we selected the most relevant, feasible to perform and important procedures to Saudi PHC setting.
After considering the ethical aspects and applicability (current and future), we formulated the questionnaire.
The questionnaire included: Demographic data and physician's highest qualification, physician's and level of satisfaction and interest in performing MS procedures at PHCC or referring patients to a hospital, the most important reasons for not performing MS procedures at PHCC, physician's feedback on the most important reasons preventing the practice of MS in PHCC setting as well as the important procedures commonly encountered in PHC, moreover the PHCC physician's degree of competence in performing these procedures.
All the Saudi and non-Saudis physicians working in the 26 Al-Qatif PHCCs, both males and females were included in this study.
The questionnaire was distributed after attaining permission from PHC Administration located in the eastern province of Saudi Arabia. Accordingly an official circular was issued by Al-Qatif Primary Healthcare Administration to all PHCC physicians requesting their cooperation in completing the questionnaire.
Opaque envelops were mailed to each centre through the official mail of Al-Qatif Primary Healthcare Administration, containing the exact number of questionnaires corresponding to the number of physicians working at each centre.
After answering the questionnaires, they were returned to the researchers by the same mail. Follow-up letters and calls to non-responding doctors were made several times. Distribution and collection of questionnaires were also done by the researchers. In some instances, assistance from staff in the PHCC or/and Administration of PHCC staff were utilized.
All the data were checked during the study for accuracy, completeness and were accordingly coded. Data was entered into a personal computer and the Statistical Package for Social Science (SPSS) version 13.0 (IBM, Armonk, New York)(2005) was used for appropriate statistical analysis.
All Saudis and non-Saudis physicians working in the clinical field in Al-Qatif PHCC, males and female, were included. Exceptions included physicians on leave, physicians in exclusively administrative practice, refusal and if the physician's work experience was <6 months.
| Results|| |
The questionnaire was distributed to 70 physicians working at different PHCC in Al-Qatif region, 61 (87.2%) subjects consented to participate and sent the completed drafts that were used for interpretation. Among those who did not participate [9 (12.8%) physicians], many of them were on annual leave and only one form was returned incomplete.
[Table 1] shows that there was almost equal distribution of males and females with 49.2% and 50.8%, respectively, most of them being Saudi nationals 42 (68.9%). Their work experience ranged from <1 year to >20 years with a mean of 2.6 years. Most of the physicians (83.6%) had their bachelors in medicine; few had postgraduate qualifications such as diploma and masters.
[Table 2] represents the physicians' perception, attitude, and readiness towards MS. Majority of them [53 (86.9%)] were interested to practice MS at the PHCC and many of them [42 (68.6%)] reported themselves as competent enough to perform the procedures in PHCC setting. When asked about referral, 70.5% of the physicians were not satisfied in referring their patients to the hospital. Moreover, they reported that their patients were also not satisfied when referred to the hospital in order to manage their minor surgical illness. Responding to the establishment of primary MS program at PHC, 70% of the participants were of the opinion that it should be properly established.
|Table 2: Physician's perception, attitude, and readiness toward MS (n=61)|
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[Table 3] summarizes the physician's perceived barriers preventing them from performing MS procedures in PHC setting. Majority of them agreed that lack of facilities (90.2%) was on the top of the list, followed by shortage of staff (55.8%), fear of complications (73.7%), medico-legal considerations (72.2%), lack of time (70.4%), and ease of referral (57.3%). A significant number of physicians also agreed that they lack training (80%) and experience (65.4%).
[Table 4] shows the comparisons between importance and level of PHCC physicians' competence in performing the list of 46 MS procedures included in the questionnaire. The mean degree of importance of procedures according to Likert's scale, varied between 2.08/5 for aspiration and injection of bursae to 4.54/5 for insertion of sutures. The mean degree of confidence of procedures varied between 1.50/5 for contraceptive diaphragm fitting and insertion to 4.00/5 for insertion of sutures. The highest mean for the degree of importance and confidence was for the insertion of sutures and the P value, comparing both, was statistically significant (0.000).
|Table 3: Possible causes prerenting physicians in PHCC from performing MS in Al-Qatif city (n =61)|
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|Table 4: Comparison between degree of importance and degree of confidence|
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For all procedures, the comparison between procedure importance and confidence was significant with P < 0.05 except for skin biopsy, placement of transurethral catheter, ear piercing and aspiration and injection of bursae where P > 0.05.
[Table 5] shows the workload at 26 Al-Qateef PHCC for 1-year (from Muharam to Du alhuga 1427 Hijri) and PHCC readiness to perform MS, we found during 1-year the total visits of 26 for PHCC was 535,811 out of them 65,241 (12.18%) were for surgical reasons. The total hospitals referrals in 1 year for all specialties were 24,369 about one-fourth of them 6187 (25.4%) were surgical referrals which forms the highest referrals rate among all other specialties referrals. Other specialties referrals rate came as the following: OB\GY 3884 (16.00%), dermatology 3278 (13.50%), internal medicine 3229 (13.30%), ophthalmology 3072 (12.60%), ENT 2811 (11.50%), pediatrics 868 (3.60%), and dental 484 (2.00%).
|Table 5: workload for last 1-year (Muharam till Du alhuja 1427) and PHCC readiness to perform minor surgeries|
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Regarding the readiness of PHCC, we found that at the time of survey, no centre had a MS room and only 4 PHCC out of 26 PHCC could arrange for a room which could be used as a sterile MS room. Basic surgical kits including all basic surgical instruments, parenteral anaesthesia, and oxygen supply were available in all 26 PHCC.
| Discussion|| |
An overall response rate of 87% was very good, such a high response rate of mailed self-administered questionnaire indicates the cooperation of both physicians and Al-Qatif PHCC administration. Although there were some complaints about the questionnaire's length and the presence of some unfamiliar MS procedures listed.
Experience, gender, degree of qualification, and nationality had great influence on perception and attitude of GP towards importance and confidence in performing MS, and in many circumstances, determined the behaviour of the physician in managing patients with MS illnesses.
Total patient visits to all PHCC during one Hijri in Al-Qatif PHCC workload was 535,811 [Table 4], out of which 65,241 (12.18%) were for surgical illnesses. In addition, there were certainly a significant number of patients presenting with MS illnesses, but due to official censuses, they were categorized or entitled under other specialties. However, they could still be managed under the scope and capacity of primary MS, such as: warts and navus excisions; under dermatology and excision of Chalazion under ophthalmology.
Therefore, certainly this percentage was underestimated although it is still an essential percentage. The total number of referrals for all the specialties in the 26 PHCC in Al-Qateef district for a period of 1-year was 24,369: Surgical referrals accounting for the highest referral rate with 6,187 (25.4%). If we considered the point discussed previously, the rate of surgical referrals would be much higher than estimated. Obviously, this rate of surgical referrals can form a huge load on the referral hospitals, not to mention the significant number of patients that may suffer from many difficulties as a result of such referrals for MS which could be handled in PHCC setting.
Physicians' attitude and perception towards MS was exhibited as follows: Two-thirds 43 (70.5%) of physicians were not satisfied with referring their patients to hospitals. Most, 28 (45.9%) of the physicians, stated that performing MS at PHCC was not difficult, most of them, 53 (86.9%), are interested to perform MS, 53 (86.9%) encourage the establishing of MS program in their working PHCC and only 17 (27.8%) of the physicians were satisfied while 43 (70.50%) were not satisfied for referring their patient with MS illnesses to hospitals; this could explain the reasons why the majority of the physicians in PHCC were not satisfied with the management of MS patients by referring them to a hospital setting. This dissatisfaction of the majority of the physicians may also be explained by the following: They are able to identify the illnesses and are competent to perform the surgical procedure, they find that performing the procedure for their patients will increase their professional satisfaction and strengthen the doctor-patient relationship, but in spite of all that, they are forced to refer their patients to hospitals.
With these positive parameters, the physicians in Al-Qatif PHCC are in good attitude and readiness to start developing a safe and efficient MS program to deliver the service as well as apply the concept of patients comprehensive (biopsychosocial) care.
The survey showed that the leading difficulties preventing the practice of MS was the lack of facilities and unavailability of a sterile room, where 55 (90.20%) physicians considered this as number one difficulty. 49 (80.30%) of physicians stated that the second difficulties was due to lack of training that may be explained by the absence of a clear view for MS at the level of PHCC, absence of MS-PHC setting training program with 34 (55.70%) of the physicians having no previous surgical experience. 45 (73.70%) of physicians found that the fear of complications was the third difficulty encountered, which could be associated with lack of facilities and training. 46 (75.40%) found that lack of experience was the fourth difficulty which could be explained by 34 (55.70%) of physicians having no previous surgical experience, recently employed and most probably recently graduated physicians, absence of training programs, and probably lack of coordination between surgical departments in referral hospitals and Al-Qatif PHCC sector.
In total, 44 (72.20%) of the physician found that the fear of medico-legal considerations was the fifth difficulty. Insufficient time was considered as the sixth difficulty by 43 (70.40%) physicians, which may be a major concern, especially in very busy PHCC. 35 (57.30%) of physicians felt that easy referrals system or easily hospital accessibility as the seventh difficult. 34 (55.80%) of the physicians stated that the shortage of staff was the eighth difficulty 23 (37.70%) of physicians considered patients incorporation as the ninth difficulty. 23 (37.70%) of the physicians believe that patients with MS problems would not come to PHCC as the tenth difficulty. Finally, 13 (21.3%) of the physicians felt that difficulty in establishing the diagnosis is the elevent.
| Conclusion and recommendations|| |
The Al-Qatif PHC sector is in an essential need to place an MS program supported by physicians' interest, encouragement, and satisfaction. The program components should include physicians training, provide and maintain essential facilities to meet physicians' satisfaction and interest. As a result, this most probably will deliver an important health service to a significant number of population in a form of a safe and efficient environment to achieve the concept and understanding of a comprehensive and biopsychosocial care.
This study may be placed as a beginning to establish the MS service in the Al-Qatif PHCC sector and other PHC sectors in Kingdom as well as to try and catch up to the same level of essential service delivered in the developed countries. Further studies are required on the outcome of many MS procedures performed in the current situation of mismatching between the importance and confidence.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]