Patterns and Obstacles of Provision of Minor Orthopedic Procedures among Primary Care Physicians in Saudi Arabia

Introduction: Musculoskeletal disorders are common reasons for consultation with the primary care provider (PCP). For many of these disorders, treatment with minor procedures can bring about rapid and effective response with a very low complication rate. In reality, not many of these procedures are carried out in the primary care facilities in Saudi Arabia and in many other countries around.


Introduction
Primary care (general and family) physicians or providers (PCP) play an important role in performing minor office procedures.PCPs have a broad base of general medical training, which allows them to know the indications & contraindications of a given procedure and to know non-procedural treatments for a wide array of conditions.Efficient utilization of available resources -by PCPs-in meeting the needs of patients is very crucial.
Musculoskeletal disorders are common reasons for consultation in primary care settings. (1)Such disorders represent a significant cause of disability and morbidity.For many of these disorders, treatment with minor procedures canresult in a rapid and effective response with a very low complication rate. (2)any factors contribute to the apparent discordance between expected and actual procedure provision rates.In a study of Alberta family physicians 91% of respondents reported learning the procedures in medical school or during their training with a smaller percentage learning through clinical practice or continuing medical education. (3)New graduates may simply not feel confident in their technical skills due to lack of exposure during medical school or residency training.The patients' high flow rate at primary care settings may create a practice environment where the doctors are just "too busy".The high effort and cost of buying and maintaining equipment may also be an issue.
An Irish study in 2000 reported that a dramatic drop in referral of minor surgical procedures to specialists occurred after completion of educational programs.
(4) These results also supported by Lowy et, al study which showed that an increase in provision of procedures at the primary care level has not been associated with a decline in the quality of care. (5)For those who do not wish to perform the procedures, referring to another PCP who performs procedures is an option which remains relatively unexploited.
We are aware that there is a need for improvement in orthopedic and rheumatology training during GP vocational training and family medicine residency programs.Physicians who work in the primary care setting lack the confidence in managing musculoskeletal problems.Vocational training for GPs, primary care structure, and access to secondary care in Riyadh, are similar to the rest of Saudi Arabia.To date there is little information about the types of injections performed in the primary care setting by PCPs, and the reasons for not providing this service.The present study aims to ascertain the numbers and types of injections performed, to know the current practice and the perceived barriers towards joint and soft tissue injection skills as an example for the minor office orthopedic procedures that can be performed in the primary care setting.

Materials and Methods
The present study is a cross sectional study aiming to determine the current practice of Saudi Arabia PCPs with respect to minor office orthopedic procedures and to determine what self-reported obstacles prevented a higher provisional practice of minor orthopedic procedures.According to core procedural skills for Canadian Family medicine in 2005, the minor orthopedic procedures include knee, shoulder and ankle injection, injection for trigger finger, plantar fasciitis, and tennis elbow, and intra-articular injection.
The collected data include age, sex, qualification, duration of practice and work place.
Also included a self-reported questionnaire composed of 22 questions that was built up on Sempowski et al questionnaire and Gormley et al questionnaire. (6,7)This questionnaire was distributed on 298 physicians working in primary care setting in Riyadh.
The questionnaire aimed to (a) quantify the number and different types of injections performed by PCPs in the past year; (b) to evaluate the level of training and how PCPs thought that this training improved their ability and confidence to perform injections.Levels of confidence were measured on a five point Likert scale with response options from "strongly agree" to "strongly disagree"; and (c) to identify barriers to PCPs performing joint and soft tissue injections in the primary care setting.Responses were measured on a five point Likert scale with options varying form "very likely" to "very unlikely".
The absolute frequency and percentages, and Chi-square and ANOVA analyses were calculated and correlation test was done to procedures obstacles and their patterns.All forms of analysis were tested for statistical significance with confidence interval 95% and significant level P<0.05, using SPSS software version 15.

Results
The demographic characteristics of the sample are summarized in Table 1 and the sample was matched.The present study is conducted on 298 physicians.One hundred and seventy five (58.7%) were males and 123 (41.3%) were females.Ninety five of the physicians were in the age group of 35-45 years.Statistical analysis using Chi Square test did not show significant difference between different sexes (P value = 0.915).Two hundreds and fifteen (72.1%) of the sample were family physicians and general practitioners without significant difference between different sexes (P value = 0.34), with the rest being residents in training at different levels.A hundred and eleven (37.2%) physicians worked at primary care centers (PCC) belonged to ministry of health without significant difference between different sexes (P value = 0.20).The respondents' training background is shown in Table 2 as 212 (73.1%) of the respondents answered the question; if they have taken orthopedic training during their residency program, 130 (43.6%) respondents stated that they have taken orthopedic training, while 82 (27.5%) respondents stated that they did not.Statistical analysis using Chi square test shows that there is no significant difference between different sexes (P value 0.072).Among the respondents who have taken the training during their residency; 115 (88.5%) of them had taken orthopedic training for 4 weeks, while 12 (9.2%)respondents had taken training for 6-8 weeks, and only 3 (2.3%)respondents had taken training for more than 8 weeks during their residency.Statistical analysis shows that there is no significant difference between different sexes (P value = 0.36).Fifty four (41.5%) respondents who had training during their residency stated that their training periods were enough to learn injection skills, while 76(58.5%)respondents stated that their training was not enough.Statistical analysis shows that there is no significant difference between male and female physicians in this regard (P value 0.82).Among the respondents who had training 69 (53.1%) respondents performed joint and soft tissue injections during their family medicine residency program on the other hand, 61 (46.9%) respondents did not perform any joint and soft tissue injections without significant different between different sexes (P value= 0.76).
The current study also shows in table 2 that 60 (20.8%) respondents of the whole sample had training to perform joint and soft tissue injection in the orthopedic clinics, while 229 (79.2%) respondents did not, without significant difference between different sexes (P value = 0.87).Joint and soft tissue injections that were performed by the respondents are shown in Table 3. Results show that knee injections were the most common injections performed as 48 (16.1%) respondents had performed it.Most of these knee injections 30 (35.7%) were done by the family physicians.Injections for a tennis elbow come in the second order 20 (15.4%).Sixteen (80%) of them were done by family physicians.Shoulder, ankle injections, injections of a trigger finger and injections for plantar fasciitis came in the third order of overall injections and the majority of them were also performed by the family physicians.Statistical analysis to compare different respondents qualifications using ANOVA test shows that there was significant difference as P value was <0.05.
Comparison between certified and non-certified physicians in performing joint and soft tissue injections resulted in: there are significant differences between two groups (P value<0.05)(Table 4).These results show the importance of orthopedic and rheumatology training during family medicine programs Regarding the obstacles and barriers to perform joint and soft tissue injections Table 5 shows that the responses of physicians were different according to their background as follows; the family physicians perceived the load of work in the clinic and the availability of good referral system as the main obstacles and barriers to perform such procedures.First year family medicine residents pointed out that lack of up to date skills and the referral system are the main obstacles to perform such procedures.
Finally, PCPs perceived lack of up to date skills and the clinic overload came on top of the obstacles and barriers to perform such procedures.Statistical analysis of comparing the different qualifications of the groups using ANOVA test, shows that there is a significant difference among different groups as the P value was <0.05.The correlation between obstacles and patterns of minor procedures is shown in Table 6.The present study proved that the time spent during the training to learn such procedures was significant for shoulder injection as P value was 0.02.Lack of interest was a very important factor as it was correlated to most of the procedures, as P value was <0.05.Another factor is the inability to make correct diagnosis, which was correlated with performing knee injections, as P value was 0.005.

Discussion
The present study was conducted on 298 physicians who were working in primary care settings that belong to different health sectors in Riyadh.Physicians working in primary care settings have different qualifications and training backgrounds.
Musculoskeletal disorders are common reasons for consultation in primary care setting.Such disorders represent a significant cause of disability and morbidity.)(10) Results showed that 61.3% of the physicians included in the study had training for provision of injections during their residency, 88.5% of them their training was for at least 4 weeks but 41.5% of them stated that the training period was not enough to learn how to perform such procedures.This could explain why the physicians did not perform such procedures in the primary care setting.Naismith et al described the importance of teaching minor surgical procedures as an essential component of the family medicine residency curriculum. (11)A systematic, organized and documented procedural skills curriculum at the undergraduate and at the residency level is required.The creation of national recommendations such as those recently published by the College of Family Physicians of Canada procedurals skills working group should help to create a national standard. (12)Results also, show that less than half of the sample (41.8%) did such minor surgical procedures and most of the procedures were done by the certified family physicians.Statistical analysis of the obstacles and barriers that prevented the physicians from performing such procedures in their practice was found to vary from category to another according to their qualification, training background and years of experience.Family physicians perceived the work overload at their clinic and availability of referral system stand behind why they did not perform these minor procedures (if others can do it why should I do it?).While family medicine residents, and PCPs perceived lack of up to date skills and the clinic overload as on top of obstacles and barriers.We believe that those physicians who are in need to update their skills should be targeted for workshops to perform such procedures.Britain experienced a dramatic drop in referral of minor surgical procedures to specialists after completion of educational programs.
(4) Furthermore; increased provision of procedures at the primary care level has not been associated with a decline in the quality of care. (5)

Conclusion
Many physicians working in primary care setting in Saudi Arabia refer patients requiring minor office procedures for specialist consultation.Treating patients at the primary care level can be more time and cost effective and may help to reduce the load on the hospitals and help to utilize the services of the specialist when needed."Lack of up to date skills" and "lack of time" because of work overload, were the top reasons cited for not performing such procedures in the primary care setting.

Recommendations
 Teaching minor orthopedic procedures in a family medicine residency program as an essential part of the curriculum. Developing workshops in minor orthopedic procedures to upgrade the skills of post graduates who did not get enough training during their residency programs. Accreditation of family practice minor orthopedic procedures training programs should be contingent on institutions of formal CME and maintenance of competence programs.

Table 6 : Correlation between obstacles and pattern of minor procedures Spearman test Duration of training Lack of personal interest Lack of evidence about efficacy Concerns about complications Inability to make correct diagnosis
*Correlation