Abstract
Background: Inadequate family physicians’ knowledge of plastic surgery might be a barrier for patients to benefit from plastic surgery treatments reimbursed by the Polish National Health Service (NHS).
Objectives: The aim of this study was to assess family physicians’ awareness of the indications for plastic surgery, and their knowledge of conditions that are treated without extra costs for the patient in plastic surgery outpatient clinics (OCs).
Methods: An e-mail survey was carried out in a group of 100 out of 378 randomly selected primary care doctors currently practicing in Lodz, central Poland. Respondents were asked to fill in a questionnaire, which contained questions about conditions with reimbursed treatments in plastic surgery OCs. We also provided them with a list of diseases and asked them to which OC they would refer a patient in such case.
Results: 58 primary care physicians responded: 30 specialists in family medicine and 28 residents in the final year of their specialization in family medicine. Respondents had good knowledge of the range of conditions managed in plastic surgery OCs. They were also aware of most of the medical procedures not being reimbursed by the Polish NHS. However, some indications for plastic surgery as well as the free availability of relevant medical procedures were known by less than half of the respondents (e.g. lipoma 47%, gynaecomastia 28%, and xanthelasma palpebrarum 16%).
Conclusion: To improve collaboration between plastic surgeons and family physicians basic information regarding plastic surgery might be included in residency programmes in family medicine.
KEY MESSAGE(S):
In general, Polish family physicians know what conditions are managed by plastic surgery outpatient clinics
Some reimbursed indications for plastic surgery are less well known: lipoma, gynaecomastia and xanthelasmatum palpebrarum
Information on plastic surgery might be included in residency programmes in family medicine
Introduction
The Polish health care system is based on primary care provided by family physicians. These doctors provide patients with basic health services, and play the role of gatekeepers to the other levels of the health care system. Therefore, family physicians need to possess a comprehensive knowledge of disorders treated by particular specialists, and of ways of referring patients for further diagnosis or treatment.
Plastic surgery covers a broad spectrum of conditions such as congenital abnormalities, post-traumatic deformities and skin diseases, including benign and malignant tumours. Plastic surgery outpatient clinics (OCs) provide various surgical procedures contracted by the Polish National Health Service (NHS). To obtain treatment without extra costs, the patient must have a referral to a Plastic Surgery OC issued by the treating physician. The other domain of plastic surgery is aesthetic surgery and a wide range of aesthetic procedures provided by Plastic Surgery OCs is not reimbursed by the Polish NHS. In general, medical indications cover cases in which body function is disturbed or cases with a risk of malignancy. Aesthetic procedures are performed in some patients with post-traumatic deformities or congenital syndromes, not affecting body functions. Cosmetic indications are difficult to precise as they are connected with patients’ subjective assessment of their body appearance.
To enable wide access to plastic surgery therapies for their patients, family physicians need to recognize differences between medical, aesthetic and cosmetic indications. However, in a group of patients a clear division between these indications is problematic or even impossible. A mutually felt problem regarding difficult referrals can be a reason for the fact that only half of the patients treated in Plastic Surgery OCs are referred to by family doctors (Citation1). The aim of this study was to assess family doctors’ awareness of the indications for plastic surgery, and their knowledge of diseases that are treated without extra charge in plastic surgery OCs within the Polish NHS.
Methods
A study questionnaire was sent by e-mail to 100 randomly selected out of 378 primary care doctors currently practicing in Lodz, central Poland. Respondents were asked to choose out of 23 given conditions, which of them are treated in plastic surgery OCs without extra costs for the patient. They were also presented different clinical scenarios to find out to which specialist OC they would refer these patients:
a man with gynaecomastia
a man with gynaecomastia and excluded endocrinological aetiology
a woman after mastectomy who wants to undergo reconstructive breast surgery
post-traumatic face deformities
post-traumatic nose deformities with breathing disturbances
patients with scars or keloids
malignant skin lesions
children with congenital malformations
Finally, the questionnaire contained four questions related to respondents’ age, sex and specialization status.
Results
Respondents
58 primary care physicians (43 women, mean age 37.4 ± 8.5) returned a completed questionnaire. 30 were family medicine specialists, the others were residents in the final years of specialization in family medicine, being already specialized in paediatrics (14), internal medicine (13), or otolaryngology (Citation1).
Awareness of reimbursed plastic surgery procedures
Respondents’ answers to the question of conditions that are treated in plastic surgery OCs in Poland without extra charge are presented in . The respondents correctly identified six out of eight medical procedures that are not reimbursed by the Polish NHS, i.e. aesthetic rhinoplasty, breast augmentation, protruding ears in adults, reduction and lifting of breasts, face lifting, and aesthetic eyelid surgery. Only a small minority were wrong in believing that abdominoplasty (7% wrong) and transsexualism treatment (16% wrong) are reimbursed. The percentages of correct knowledge of reimbursed plastic surgery procedures varied between 16% and 95%. Most of the respondents correctly considered cleft lip/palate, polydactyly, and syndactyly as treated without extra costs (95%, 91%, and 90%, respectively). However, the awareness of free availability of some other procedures, such as xanthelasma palpebrarum (16% correct), gynaecomastia (28%), and lipoma (47%) was much lower.
Table I. Family physicians’ knowledge of reimbursed plastic surgery procedures (n = 58).
Referral patterns for selected medical conditions
Choosing a target clinic for a man with gynaecomastia, almost all respondents (97%) pointed at an endocrinology OC. In cases with excluded endocrinological aetiology, 84% of the respondents would refer this patient to a plastic surgery OC for treatment.
Patients with malignant skin lesions in most cases would be referred to an oncologist (86%). However, when asked to consider patient's mental comfort, 48% of the respondents declared referral to a dermatologic OC, and only 26% to a plastic surgery OC.
Most doctors (90%) would refer a patient with post-traumatic face deformities to a plastic surgery OC, as well as a woman after mastectomy who wants to undergo reconstructive breast surgery (66% of the respondents).
Patients with scars and keloids would be referred to a plastic surgery, general surgery, or dermatology OC by 57%, 21%, and 12% of the respondents, respectively. Almost all of respondents (95%) would refer patients with post-traumatic nose deformities with breathing disturbances to the ENT OC, and only 3% to a plastic surgery OC.
Finally, children with congenital malformations would most often be referred to a paediatric surgery OC (50%) or to a plastic surgery OC (40%).
Discussion
Main findings
Our findings point at fairly good knowledge of family physicians of the range of conditions managed in plastic surgery OCs. However, some indications for plastic surgery (e.g. gynaecomastia, reconstructive breast surgery) are not perfectly well known, as well as the free availability of relevant medical procedures for patients in Poland.
International reports
Medical knowledge of family doctors is a crucial precondition for the accurate outpatient referral process. However, we are aware of only a few studies assessing family doctors’ knowledge and perception of plastic surgery. A survey conducted among primary care physicians in Great Britain showed they were well informed of the range of conditions managed by plastic surgeons, and they most often referred patients with scars, burns, malignant melanoma, and for skin grafts to plastic surgery OCs. However, most family doctors would consider the ENT surgeon to perform a post-traumatic rhinoplasty rather than a plastic surgeon. In that study, respondents did not associate plastic surgeons with hand surgery, and these procedures were believed to be performed by orthopaedic surgeons first of all (Citation2).
An Australian study examining a course of treatment of superficial basal cell carcinoma cases diagnosed by family physicians, found that family physicians managed most lesions themselves, and referred patients to other specialists only in case of a problematic lesion (site or size), or on a patient's request. Most often, these patients were referred to plastic surgeons, and rarely to dermatologists (Citation3).
In a US survey of residents of internal medicine, family medicine, and paediatrics, who were asked to choose the specialist they perceived to be an expert for several conditions, including skin cancer of the face, rarely indicated plastic surgeons at the first place (Citation4).
Strengths and limitations
The main limitation of our survey is its limited geographical coverage—the survey was conducted in only one region of Poland. Since the examined group was quite small and the response rate (58%) was moderate, we checked whether our sample could be representative for the population of family physicians in Lodz by comparing our data with adequate data received from the Polish NHS. We found no relevant differences in sex and age structure between the sample and the total group of family physicians practicing in Lodz. Furthermore, we did not find any differences in respondents’ answers in relation to their sex, age and specialization status (specialist versus resident). Assuming random selection of study participants, this study provides useful insight into Polish family physicians’ needs regarding the scope and availability of plastic surgery services.
Implications
In Poland, some specialties (e.g. general surgery, ENT) have courses in plastic surgery included in their specialization programmes. However, current residency curricula of family medicine in Poland do not include a training course in plastic surgery. Bearing in mind the moderate knowledge of indications for plastic surgery and their availability for primary care patients, revealed by the results of this survey, it might be worth adding basic information regarding plastic surgery to residency programmes in family medicine in Poland. This might be true for other European countries as well, but we could not find published studies on this topic. Better knowledge of plastic surgery might result in better collaboration between family physicians and plastic surgeons.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Related Research Data
References
- O'Donnell CA. Variation in family physician referral rates: What can we learn from the literature? Fam Pract. 2000;17:462–71.
- Dunkin CS, Pleat JM, Jones SA, Goodacre TE. Perception and reality—a study of public and professional perceptions of plastic surgery. Br J Plast Surg. 2003;56:437–43.
- Raasch B, Woolley T. Management of primary superficial basal cell carcinoma. Aust Fam Physician 2006;35:455–8.
- Tanna N, Patel NJ, Azhar H, Granzow JW. Professional perceptions of plastic and reconstructive surgery: What primary care physicians think. Plast Reconstr Surg. 2010;126: 643–50.