The Family Medicine Specialist Surgical Clinic - a new project to benefit the patient, hospital specialist, family physicians and the private sector in the community

Kin-wai Chan 陳建偉, Peter T K Ng 吳子敬, Ching Chan 陳貞, Ching-luen Ng 吳清聯, Yuk-kwan Yiu 姚玉筠

HK Pract 2009,31:24-29

Summary

Objective: To study the outcome of the Family Medicine Specialist Surgical Clinic (FMSC) at the Ha Kwai Chung GOPC in addressing the problem of long waiting time of the Specialist Out-patient Department Surgical Unit.

Design: A cross-sectional study.

Subjects: Patients complaining of upper or lower gastro-intestinal symptoms, referred to Princess Margaret Hospital Surgical SOPD were triaged to the Family Medicine Specialist Surgical Clinic and managed by family physicians. Patient outcome and satisfaction were analyzed by case note review and questionnaires respectively.

Main outcome measures: Waiting time for initial FMSC appointment, disease profile, investigations as well as procedures performed, diagnosis and patient outcome.

Results: The average waiting time of the FMSC was around 4 weeks. 83.9% were managed in FMSC without the need of SOPD referral. Most of the cases suffered from dyspepsia, haemorrhoid or per rectal bleeding. We performed rubber band ligation on 50 suitable haemorrhoid cases. The family physicians involved also performed rigid or flexible sigmoidoscopy, or referred the patient to the relevant hospital specialist for colonoscopy or Ba enema. 103 cases (69%) could be closed or discharged after an average of 2.2 consultations. Among these 103 closed cases, 49 (33%) of them were referred back to and be followed up by the community general practitioners.

Conclusion: The FMSC can benefit the patients by shortening their waiting time, providing a safety net for early diagnosis of serious or malignant and pre-malignant disease, relieve the hospital specialists' workload, enhance family physician's role in performing surgical endoscopy and treatment procedure as well as providing a platform for the promotion of public-private interfacing. Generalizations of this study model to surgical diseases other than GI disease can be considered.

Keywords: Family medicine specialist clinic, surgery, endoscopy, haemorrhoid rubber band ligation

摘要

目的： 在下葵涌GOPC內設立家庭醫學專家外科門診（FMSC），以縮短專科門診SOPD病人的等候時間。

設計： 橫斷面研究。

研究對象： 將主訴上、下消化道症狀而被轉介到瑪嘉烈醫院外科專科門診（SOPD）的病人，分流到家庭醫學專家外科門診，由家庭醫生診治。通過病例審閱和問卷的方法分析患者的結果及滿意度。

主要測量內容： FMSC的等候時間，疾病類型，開展的檢查及診治服務，診斷及患者的結果。

結果： FMSC門診的平均等候時間約為4周。83.9%的患者在FMSC門診接受治療后無需轉至SOPD；其中大多數為消化不良、痔瘡或直腸出血病例。我們對50例條件合格的痔瘡病人實施了皮圈套扎。家庭醫生還開展了硬管或纖維乙狀結腸鏡檢查，或將病人轉給醫院專科醫生進行結腸鏡或鋇灌腸檢查，以查明病因。有103名病人（69%）在FMSC診所平均2.2次診治後問題得到解決，其中49人(33%）在結案後由社區全科醫生繼續隨訪。

結論： FMSC門診可以提供針對惡性疾病及其癌前疾病的早期診斷使患者獲益，同時減輕了醫院專科醫生的工作負擔，加強了家庭醫生在開展內窺鏡外科檢查及治療方面的作用，並為促進公私合作提供了一個平臺。可以考慮將此方法進一步推廣到消化道疾病之外的外科疾病。

主要詞彙： 家庭醫學專家門診，外科，內窺鏡檢查，痔瘡，皮圈套扎。

Introduction

Heavy workload and a long waiting time have always been a problem for the Hong Kong Government Hospital Authority's Specialist Outpatient Department (SOPD), especially its surgical unit, in Hong Kong's public health sector. In May 2006, the median waiting time for a first appointment for non-urgent cases in the various specialty units of the SOPD was more than 30 weeks. For the surgery unit at the SOPD, the waiting time was 34 weeks.¹ The worst situation was noted in the case of its gastro-intestinal (GI) team, whose waiting was 134 weeks.

In response to this situation, the Department of Family Medicine at the Kowloon West Cluster of the Hospital Authority and the Department of Surgery at the Princess Margaret Hospital piloted a Family Medicine Specialist Surgical Clinic (FMSC) in Ha Kwai Chung General Outpatient Clinic (GOPC) in August 2007 to address the issue.

Patients having upper or lower gastro-intestinal (GI) symptoms and referred to the Princess Margaret Hospital Surgical SOPD were screened by two surgical consultants of the hospital. Cases that belonged to Category 3 (non-urgent referrals), which had an average waiting time of 129 weeks, were triaged to the Family Medicine Specialist Surgery Clinic and were managed by family physicians.

The main purpose of the FMSC was to reduce the number of patients presenting with upper and lower GI symptoms referred to the Surgical SOPD at the local public hospital. To fulfill this role, the FMSC had access to specialised equipments and expertise to handle simple office investigations and interventions, e.g. the rigid and flexible sigmoidoscopes, as well as to do haemorrhoid rubber band ligation. The FMSC also had special arrangements with the public hospital to be allowed direct access to certain investigations such as oesophageogastroduodenoscopy (OGD), ultrasound scan (USG) and Barium (Ba) enema examinations. In the FMSC, patients can also have the option to be referred to the outside private sector for earlier investigations.

Objectives

In this study, we set out to analyze the outcome of the patients managed in the Family Medicine Specialist Surgical Clinic (FMSC) and find out the effectiveness of this FMSC model:

1. Shortening the waiting time in routine surgical referrals.
2. Acting as a safety net in detecting malignant and pre-malignant disease from among paients categorized as non-urgent, and referring them earlier than they normally would to the surgical SOPD.
3. Coordinate the primary and secondary care system and the resources of the private and public sectors.
4. Reveal the capability of family physicians in doing office procedures in investigations and treatment of simple surgical cases.
5. Act as good gate keeper.

Methodology

A cross-sectional study on:

1. The number of patients seen in FMSC, their presenting symptoms and sources of referral within the 6 months period from August 2007 to January 2008.
2. The outcome of patients receiving office investigation or treatment procedures from family physicians in FMSC.
3. The investigation rate as well as the follow up referral rate to secondary care from FMSC.
4. The percentage of patients referred for outside investigation in the private sector.
5. The efficiency of FMSC in managing surgical diseases.

Patient outcome and satisfaction of the patients were analyzed by electronic patient records review and questionnaires respectively. (See Appendix 1)

Results

1) From Aug 2007 to Jan 2008, 160 patients were triaged to the FMSC. 11 patients (7%) defaulted the first appointment and 149 patients (93%) were managed in the FMSC clinic. The average waiting time of the FMSC was around 4 weeks. 48 cases presented with upper GI symptoms, 97 cases with lower GI symptoms and 4 cases with both upper and lower GI symptoms. (Table 1 & Table 2)

2) 83.2 % of patients were managed by the FMSC without need for a SOPD referral. The most common problems that patients had were per rectal bleeding, haemorrhoid and dyspepsia. For patients who presented with fresh rectal bleeding, rigid or flexible sigmoidoscopy was performed to rule out distal lower GI malignancy. We also performed rubber band ligation on 50 suitable haemorrhoid cases.

3) Cases suspicious of malignancy were referred to the hospital specialist in the public or private sector for colonoscopy, Ba enema or ultrasound investigations. All patients needing referrals to SOPD were offered the option of investigations in the private or the public sector. A total of 79 investigations were performed, of which 35 (44%) were done in the public sector and 44 (56%) cases in the private sector. Of those with upper GI symptoms, 35% of patients chose to have investigations in the public sector. Of those with lower GI symptoms, 13% opted for public.

4) 3 colorectal cancers and 5 neoplastic polyps were detected. Other surgical lesions like big or external haemorrhoids were also detected which were not suitable for curative treatment in the FMSC clinic. These cases made up 16.8 % of total patients, requiring referrals to the hospital specialist for further management.

5) 103 cases (69%) could be closed in the FMSC clinic after an average of 2.2 consultations. Among these, 49 (33%) were followed up by the community general out-patients or private clinics after case closed. 22 cases in FMSC defaulted follow up and 24 cases were still being followed up in the FMSC mainly because of the long waiting time for investigation to be done in the public sector.

A questionnaire was performed to survey the patients' satisfaction about the FMSC in terms of shortening of waiting time, arrangement of private investigations, referral for secondary care, and procedure performance such as haemorrhoid rubber band ligation.(Chart 1 & Chart 2) The questionnaires survey was performed via telephone in March 2008. 61 patients replied with a 41% response rate.

Discussion

Owing to escalating public demand, the traditional referral method for surgical illness has overloaded the public surgical Specialist Outpatient Department (Diagram 1), resulting in a long waiting time for surgical outpatient appointments for those with non-urgent surgical conditions. The FMSC demonstrated a new model of referral: a bi-directional referral pattern (Diagram 2). The FMSC coordinated across the boundary partnership between primary and secondary health-care system as well as resources from the public and private sectors.

In developed countries like USA and UK, family physicians with special interest often perform endoscopy in the hospital or even in their offices. This results in an increase in patient satisfaction because patients can and often prefer to stay with their own family physicians. The doctor-patient relationship is strengthened and the patients gain more confidence with their family physicians.² The FMSC can perform simple investigation procedures e.g. OGD, rigid or flexible sigmoidoscopy, and simple interventions e.g. haemorrhoid rubber band ligation, polypectomy and lesion biopsy. This will enhance the role of FMSC as a good gate keeper in the management and investigation of simple surgical diseases.

For cases that require further investigations e.g. USG, colonoscopy or Ba enema, the FMSC could provide alternatives for the patient to choose from between obtaining investigations sooner in the private sector or through referral to the public sector if there were financial constraints. The investigation rate in the public sector was found to be quite reasonable: upper GI investigation rate was 35%, compared with the previously published result of 38.7% and 60% respectively in 2005 & 2007 in the Hong Kong Practitioner.^3,4 The lower GI investigation rate for those using public resources was even lower (13%). This reinforces the belief that FMSC was a good platform for a public-private interface in terms of investigation and secondary care. The FMSC also has an important role in maintaining continuity of patient care. For patients who have completed all the relevant investigations and/or treatment, the FMSC would then refer them back to the community level, either public or private, for continuing follow up and monitoring of their progress.

Three cases of cancer and five of neoplastic polyps were detected during the study period. This finding showed that even when cases were triaged as Category 3 (non urgent), some important diseases could still be missed using the traditional triage system. The FMSC had an important role as a safety net in the early detection of such cases. The affected patients would then be referred to the relevant specialty for early treatment, instead of having to wait for the normal hospital surgical Specialist Outpatient Clinic appointment.

To assure diagnostic accuracy and procedural safety (such as endoscopy), proper training is mandatory. Our FMSC clinic was staffed by senior family medicine doctors who have had previous surgical experience. For example, they would have had experience in the surgical specialty and had performed at least 50 rigid sigmoidoscopies under supervision before they were deemed capable of managing a patient independently. For other flexible endoscopic procedures, we had a session for endoscopy (OGD and flexible sigmoidoscopy) training per week in the hospital. The procedures were performed by family medicine doctors under the supervision of surgical specialists. In the case of any important suspicious findings detected during the procedure, the hospital surgeon would take over the case and transfer him/her directly to the surgical ward or clinic for the start of early intervention.

To generalize this model to the whole family medicine specialty, support from the Hong Kong College of Family Physicians can be made through collaboration with other specialties (e.g. the Hong Kong College of Surgeons) in designing a training certificate or diploma programme, concentrating on the management of common surgical diseases encountered in primary care, and endoscopic procedures that can be performed in the community.

Conclusion

The FMSC clinic can benefit patients by providing a safety net for the early diagnosis of malignant and pre-malignant disease. It can also relieve the hospital specialists' workload, enhance family physician's role in performing surgical endoscopy and treatment procedures as well as providing a platform in promoting public/private partnership.

If health-care policy makers can consider generalizing this model of service into different specialties, family medicine doctors can play an important role in the Health-care Reform. They can provide a good coordinated interface between primary and secondary health-care as well as between the private and the public sectors.

Key messages

1. Family Medicine Specialist Clinic can shorten the waiting time for the surgical Specialist Outpatient Department, thus relieving the heavy workload of hospital specialists.
2. Family Medicine Specialist Clinic can act as a safety net for the early diagnosis of pre-malignant and malignant surgical diseases.
3. With proper training and supervision, family physicians can perform investigations and procedures like endoscopy and hemorrhoid rubber band ligation.
4. The family physician is a good mediator for the public-private interface as well as primary-secondary care interface.

Appendix 1
下葵涌家庭醫學專科外科病人 "對服務水準及成效" 之電話問卷調查
調查日期:
原本覆診瑪嘉烈醫院之日期:
瑪嘉烈醫院外科轉介到下葵涌家庭醫學專科外科之日期:
後期安排覆診下葵涌家庭醫學專科外科之日期:

1. 你對能縮短覆診專科之日期的安排是否滿意?
   不滿意 滿意
2. 你是否需要安排作特別的檢查程序如胃鏡等
   是 / 否
3. 你對此安排是否滿意
   不滿意 滿意
4. 你是否需要轉介往私營的醫療機構作特別的檢查程序如大腸鏡等
   是 / 否
5. 若答案是, 你雖然要自費, 但能盡快斷症及得到適切的治療, 你是否滿意
   不滿意 滿意
6. 在斷症後, 是否需要轉介到瑪嘉烈醫院專科跟進
   是 / 否
7. 你對此安排是否滿意
   不滿意 滿意
8. 你是否有痔瘡問題
   是 / 否
9. 你是否同意手術後痔瘡病徵已得到舒援?
   可否說出有多少成舒援______________________________________
10. 你對即日能在診所裏做結紮痔瘡手術滿不滿意﹖
    不滿意 滿意
11. 你認為手術是否成功﹖
    成功 / 不成功
12. 你手術後有否出現併發症?
    是 / 否
13. 若是, 請在下面選擇適合你的答案:
    口傷口痛楚
    口 傷口大量出血而要看急症室
    口 傷口感染
14. 你對下葵涌家庭醫學專科外科診所的服務水準及成效是否滿意?
    不滿意 滿意
15. 其它意見: _______________________________________________
    _______________________________________________________