Confidence of family physicians in performing office procedures – a cross-sectional survey from public primary care clinics in Hong Kong

Henry HH Wong 黃衍熹，Lap-kin Chiang 蔣立建，Susanna LL Hung 孔樂霖，Ka-ming Ho 何家銘，Yim-chu Li 李艷珠， Catherine XR Chen 陳曉瑞

HK Pract 2025;47:72-79

Summary

摘要

Introduction

Family Medicine (FM) is a broad-spectrum specialty that encounters a wide variety of diseases including conditions requiring office procedures. In fact, office procedures have been an integral part of primary care worldwide.^1-6 The scope of office procedures vary widely from country to country and is likely defined by the medical tradition and the primary care boundary of that country. It ranges from simple procedures such as suturing, cryotherapy, joint injection, ultrasound, to more advanced ones such as excision of skin lesions, reduction of fractures, even to major operations done under general anaesthesia.⁶

Provision of office procedures has been shown to be favourably received by patients, reduce referrals to hospital care^7-8,10 and reduce overall medical cost.⁹ Nevertheless, a prospective randomised trial has found that the quality of minor surgeries done in the primary care setting is not as high as that carried out in hospitals, especially for malignant lesions.¹⁰ It signifies the importance of procedural skill training for primary care doctors to ensure patient safety.

However, difficulties exist when it comes to providing procedural skill training.^11,12 First, there is a lack of procedural knowledge and skills in graduating medical students and family medicine residents entering training.^13-16 Second, while core procedural skills in family medicine training are well defined in countries such as US, Canada and Australia^1-3, there is a lack of specific training standards in procedural skills for family medicine residencies in Hong Kong. Third, constraints in time, manpower and resources can limit such training in the public health care setting.¹⁹ Lastly, the benefit of procedural skills training may be lost over time, unless there is an ongoing chance to practice and master those learned skills.²⁰ While several studies commonly identified a lack of confidence in performing office procedures among FPs worldwide^16-18, there is currently no data exploring such confidence among FPs locally. To fill this knowledge gap, this study aims to evaluate the selfreported confidence in performing office procedures among FPs working in the public primary care setting and to explore its association with FPs’ demographics and training experience.

Method

Study Design

Cross-sectional questionnaire survey conducted from 6/2021 to 12/2021. An invitation email with a link to the survey questionnaire was sent to all selected FPs. FPs completed online questionnaire via Google forms anonymously.

Subjects

All FPs working in the Hospital Authority (HA) Kowloon Central Cluster (KCC) Department of Family Medicine and General Out-patient Clinics (GOPCs) were invited to join this study. Part time doctors were excluded as they may not have acquired their procedural skills from the cluster and would not be involve in providing office procedures with their clinical duties.

Sample size calculation

The confidence in performing office procedures of local FPs is unknown. A pilot study among ten FPs estimated 30% FPs are confident in office procedures in general. Using an online sample size calculator, assuming 30% of FPs competent in performing office procedures, with alpha value 0.05, estimated effect size 1 and absolute precision 0.1, the minimal sample size was 81. To allow room for exclusion and incomplete data (approximately 20%), 101 FPs were required as the sample size for testing. In total there are 130 FPs working in the Department, excluding 22 part-time doctors, all remaining 108 doctors were invited to join this study.

Survey instrument

As there was no validated local questionnaire available, the author developed a questionnaire with reference to local and international training requirements for family physicians, expert opinions and literature reviews.^13-16 It consisted of two parts. The first part gathered basic information on demographics and past training experience related to office procedures of the respondents. The second part contained a list of office procedures specifically for FPs. The author and a group of family medicine specialists involved in training activities reviewed all the priority skills listed in the basic training logbook by the Hong Kong College of FPs (HKCFP). Adopting the definition of an office procedure according to the Royal Australian College of General Practitioners³, 25 procedures were identified. After core group review, the list of procedure was further simplified and refined through a consensus process according to practical considerations and was finalised to ten procedures (Appendix 1). For each procedure, FPs were asked on how many times they have performed them in the past, how confident they are in performing them, whether they think it is important to family medicine, and whether they are interested in further training. The level of self-reported confidence was rated using a 5-point Likert scale (1 = no confidence; 2 = minimal confidence; 3 = can do it, if supervised; 4 = can perform it independently; 5 = can teach the procedure to others). It has been shown that self-confidence scale is psychometrically valid to represent doctors’ selfconfidence during surgical training.²¹

Appendix 1. Flow chart of office procedures selection process

Questionnaire Validity and Reliability

A core group consisted of experienced FM trainers, FM specialists and family physicians had been invited to comment and review on the questionnaire for relevance and content validity. The questionnaire was pilot-tested in a group of 5 FPs for face validity. Internal reliability analysis was performed on the responses on the number of times performed and self-reported confidence in the 10 office procedures. The internal consistency of the responses was assessed with the Cronbach’s alpha value, which showed the survey had an acceptable level of reliability (alpha value 0.880 [number of times performed] and 0.908 [confidence scale]).

Outcome assessment

The primary outcome of the study was to identify the proportion of FPs reporting confident (>/= 4) in performing each of the 10 selected office procedures, and to identify whether there was any association between self-reported procedural confidence and the FPs’ demographics or past training experience. The secondary outcome was to assess the opinion of FPs on the perceived importance in family medicine and willingness to receive further training in each of the procedures.

Statistical analysis

Analysis was performed using IBM SPSS Statistics (version 26). Descriptive statistics was used to report demographics and past training experiences of FPs. For each procedure, the numbers and percentages of FPs who have performed, the reported confidence in performing, the perception of the importance in family medicine, and the willingness to receive training in doing it were listed. A confidence score of more or equal to 4 was considered confident. Student’s t-test and ANOVA test were used for analysing continuous variables and Chi-square test for categorical data. All variables with p-value < 0.2 in the univariate analyses were entered into a multivariate logistic regression to look for the associated factors of better confidence level in performing the office procedures. P-values of less than 0.05 were considered statistically significant.

Research ethics

The study was approved by the Hospital Authority Research Ethics Committee (Reference: KC/KE-20- 0370/ER-1).

Potential conflicts of interest

The authors have declared that there are no potential conflicts of interest.

Results

A total of 89 FPs (response rate 82.4%) completed the questionnaire. Table 1 summarises the characteristics of the respondents. 40 of the FPs (44.9%) were male, 68 (76.4%) graduated locally, 42 (47.2%) had either another degree or medical diploma, 38 (42.7%) had completed basic vocational training in FM, and 69 (77.5%), 61 (68.5%) and 56 (62.9%) had completed hospital rotations in Surgery, O&G and Orthopaedics respectively. 50 (56.2%) had attachments to office procedure training that consisted of dedicated clinic sessions performing lump excision, steroid injection, cryotherapy and ear syringing. This is also locally known as minor operations (MOT).

Table 1: Demographics and past training experience of the respondents

MOT: minor operation

The number of times performed, confident in performing, perceived importance in and training interest in each of the ten procedures are shown in Table 2. Two procedures, i.e. pap smear and ear syringing, were performed more than five times by more than half of the respondents. On the other hand, skin scraping was the least performed procedure, with 64 (71.9%) respondents reported never doing it before. Pap smear was the procedure most respondents were confident in doing (n = 61, 68.5%). The other nine procedures had less than half of the respondents reporting confidence in performing, with skin scrapings being the least (n = 19, 21.3%). All procedures were regarded important by more than 80% of respondents. Steroid injection had the most respondents interested in further training in (n = 74, 84.1%).

The mean (SD) of the confidence score in 10 office procedures was 2.99 (0.97). Using the median confidence score (3.2) as a cut-off, respondents were divided into two groups, below median as non-confident group and above median as the confident group. The confidence score according to FP’ demographic data and training experience was studied and summarised in Table 3. Completion of FM basic vocational training, hospital rotation in Surgery, O&G and Orthopaedics and attachment to MOT were significantly associated with above-median confidence score while gender, age group, practicing year, graduation location, and possession of another degree or medical diploma were not. Logistic regression for association factors with p value less than 0.2 showed completion of FM basic vocational training, surgical rotation and attachment to MOT were independently associated with being above the median confidence score (Table 4).

Table 2: No. of times previously performed, confidence in performing, perceived importance in, and training interest in 10 procedures

I&D: Incision and drainage of a superficial abscess

Table 3: Mean confidence score with respect to demographics and past training experience

MOT: minor operation

Table 4: Logistic regression analysis for associated factors for FPs’ confidence in performing office procedures

Figure 5 shows the distribution of respondents being confident in performing each of procedures. There were 87 respondents in total, more than half of the respondents (45 out of 87, 51.3%) expressed confidence (confidence score ≥ 4) in three or less procedures. Twelve FPs (13.8%) reported being confident in none of the procedures, and 4 of them (4.6%) reported being confident in all of the 10 office procedures.

Figure 5: No. of procedures the respondents were confident in performing

Discussion

FM doctors are expected to achieve competency in performing common off ice procedures upon completion of vocational training of HKCFP. All of the ten procedures selected from the training logbook were perceived to be important to the practice of FM by most of our respondents (> 80%). This showed that the view of FPs in our study was in line with the expectation of the HKCFP. However, more than half of FPs in this study could only perform three or less office procedures independently. Alarmingly, 12 FPs (13.8%) have no confidence in doing any of the procedures. This reflects that local FPs generally have a significant deficiency in the skills needed for performing important office procedures. This finding is consistent with studies on FPs elsewhere.^16-18 The mean confidence score in performing office procedures of local FPs (i.e. 2.99) was comparable to two studies, with one ranged from 2.34 to 3.73¹⁶, and another one at 3.2.¹⁸ although the scope of studied office procedures may be widely different.

The reasons contributing to this lack of confidence in performing office procedures are multi-factorial. First of all, there is limited hands-on exposure in performing office procedures in the public primary care clinics. For example, I&D of a simple abscess can be performed by the family physician in the clinic. However, due to time constraints and inadequate of facilities, the patients were usually referred to AED for further management. Of the ten studied procedures, only two were performed more than five times by more than half of the respondents. Secondly, consultation time constraint and manpower limitations in the public primary care setting is another important barrier to the provision of adequate office procedures during our daily practice.¹⁹ The average consultation time allocated for each case in GOPCs is about 6 to 7 minutes, which had posed a great challenge to the FP if he or she has to finish the consultation as well as the procedure within such a short time. Thirdly, some doctors included in this study were relatively junior and have not received adequate training. For example, 57.3% of the respondents have not completed basic FM vocational training. Additional procedural training for FPs may be necessary to enhance their exposure to common office procedures. Our study identified completion of basic FM vocational training, hospital rotation in Surgery, and attachment in MOT were the only three factors associated with a higher confidence score. While it is not surprising that basic FM vocational training and surgical rotation have important roles in procedural skills training, our study suggested the potential training value of MOT sessions in order to enhance the procedural skills of our FPs. Unlike surgical rotation which is only accessible through vocational training programmes, MOT sessions could be available to all FPs regardless of training status. Considering around half of our respondents have never had any attachment for office procedure training, setting up more MOT sessions in various community clinics and the provision of regular procedural training attachments for our doctors could open up more opportunities for them to learn and practice common office procedures. It could also satisfy the high training interest of doctors in our survey for steroid injections. A follow-up study comparing the pre and post-attachment confidence level may be needed to further confirm the training role of MOT sessions.

Strength and limitations

This is the first study in Hong Kong to explore the confidence of FPs in performing office procedures and has provided important background information for HKCFP as well as HA to further improve its training and service development. In addition, the study’s good response rate, i.e. 84.2%, has significantly geared a strength for this survey.

However, there are several limitations of this study. First, as all FPs were recruited from one local cluster in the public primary care setting, the findings of this study may not be generalised to all FPs or private doctors in Hong Kong. Second, as the reliability and validity of the survey questionnaire had not been fully evaluated, accuracy of these findings need to be interpreted with caution. Lastly, the self-reported number of times performed and confidence levels may have a recall bias. Future studies with more FPs from both public and private sectors, and a wider range of studied office procedures are necessary to better reflect the procedural confidence of FPs in Hong Kong.

Conclusion

Despite office procedures being an important aspect of FM practice, our study found that FPs working in the public primary care setting had limited experience and confidence in performing these common procedures. To fill in this service gap and to meet the increasing service demand, additional training programmes targeting at improving FPs’ procedure skills in HA is recommended. Set-up of minor operation sessions in primary care clinics and enhanced training via regular clinic attachment will help enhance FPs’ confidence in performing common office procedures in primary care.

References

1. Nothnagle, M., Sicilia, J. M., Forman, S., et al. Required procedural training in family medicine residency: a consensus statement. Family medicine. 2008 Apr;40(4):248-252.
2. Wetmore, S. J., Rivet, C., Tepper, J., et al. Defining core procedure skills for Canadian family medicine training. Can Fam Physician. 2005 Oct 10;51(10):1365.
3. Sylvester, S., Magin, P., Sweeney, K., et al. Procedural skills in general practice vocational training - what should be taught?. Australian family physician, 2011 Jan-Feb;40(1-2):50-54.
4. ní Riain, A., Maguire, N. & Collins, C. Minor surgery in general practice in Ireland- a report of workload and safety. BMC Fam Pract. 2020 Jun 23;21(1):115. doi: 10.1186/s12875-020-01186-x.
5. Flägel Kristina, Brandt Bettina, Goetz Katja., et al. Which procedures are performed by general internists practicing primary care in Germany? - a cross-sectional study. BMC Family Practice. 2020 Apr 29;21(1):73. doi: 10.1186/s12875-020-01136-7.
6. Erumeda, N. J., Couper, I. D., & Thomas, L. S. A self-assessment study of procedural skills of doctors in peri-urban district hospitals of Gauteng, South Africa. Afr J Prim Health Care Fam Med. 2019 May 28;11(1):e1-e8. doi: 10.4102/phcfm.v11i1.1975.
7. López Santiago, A., Lara Peñaranda, R., de Miguel Gómez, A., et al. Cirugía menor en atención primaria: la satisfacción de los usuarios [Minor surgery in primary care: consumer satisfaction]. Aten Primaria. 2000 Jun 30;26(2):91- 95. doi: 10.1016/s0212-6567(00)78617-3.
8. van Dijk, C. E., Verheij, R. A., Spreeuwenberg, P., et al. Minor surgery in general practice and effects on referrals to hospital care: observational study. BMC Health Serv Res. 2011 Jan 4;11:2. doi: 10.1186/1472-6963-11-2.
9. Nelligan, I., Montacute, T., Browne, M. A., et al. Impact of a Family Medicine Minor Procedure Service on Cost of Care for a Health Plan. Fam Med. 2020 Jun;52(6):417-421. doi: 10.22454/FamMed.2020.334308.
10. George, S., Pockney, P., Primrose, J., et al. A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial. Health Technol Assess. 2008 May;12(23):iii-iv, ix-38.
11. Langner, S., Deffenbacher, B., Nagle, J., et al. Barriers and methods to improve office-based procedural training in a family medicine residency. International journal of medical education, 2016 May 29;7:158–159. doi: 10.5116/ijme.573a.364c
12. Alfaraj, Ali & Sebiany, Abdulaziz.. Primary healthcare physicians’ attitude and perceived barriers regarding minor surgeries. Journal of Health Specialties. 2015;3(2):67. doi:10.4103/1658-600X.156111.
13. Dehmer, J. J., Amos, K. D., Farrell, T. M., et al. Competence and confidence with basic procedural skills: the experience and opinions of fourth-year medical students at a single institution. Acad Med 2013 May;88(5):682-687. doi: 10.1097/ACM.0b013e31828b0007.
14. Dickson, G. M., Chesser, A. K., Woods, N. K., et al. Family medicine residency program director expectations of procedural skills of medical school graduates. Family medicine, 2013;45(6), 392–399.
15. Garcia-Rodriguez, J. A., Dickinson, J. A., Perez, G., et al. Procedural Knowledge and Skills of Residents Entering Canadian Family Medicine Programs in Alberta. Fam Med. 2018 Jan;50(1):10-21. doi: 10.22454/ FamMed.2018.968199.
16. Goertzen J. Learning procedural skills in family medicine residency: comparison of rural and urban programs. Canadian family physician Medecin de famille canadien, 2016;52(5), 622–623.
17. Schwill, S., Krug, K., Poppleton, A., et al. How can competencies in minor surgery in general practice be increased? Assessing the effect of a compact intervention in postgraduate training: a mixed-methods study. BMJ Open. 2022 Jul 28;12(7):e060991. doi: 10.1136/bmjopen-2022-060991.
18. Andijany, M. A., & AlAteeq, M. A. Family medicine residents in central Saudi Arabia. How much do they know and how confident are they in performing minor surgical procedures?. Saudi medical journal;2019,40(2), 168–176. https://doi.org/10.15537/smj.2019.2.23914
19. Kenny, Kung, Wong, Samuel, Wong, Carmen, et al. Family Medicine Training in Hong Kong’s public health care system: a focus group study. HK Pract 2011;33:97-106.
20. MacKenzie, M. S., & Berkowitz, J. Do procedural skills workshops during family practice residency work?. Canadian family physician Medecin de famille canadien, 2010;56(8), e296–e301.
21. Geoffrion, R., Lee, T., & Singer, J. Validating a self-confidence scale for surgical trainees. Journal of obstetrics and gynaecology Canada 2013;35(4), 355–361. https://doi.org/10.1016/S1701-2163(15)30964-6.