Minor surgical procedures in primary care in Bahrain: Attitudes, barriers, and implications

Abstract

Background:

Minor surgical procedures (MSPs) are integral to the primary health care, offering efficient and cost-effective treatment for common ailments. This study investigates the current state of MSPs within local health centres in Bahrain, exploring primary care physicians’ (PCPs) attitudes toward these procedures and identifying the challenges they face.

Methods:

A cross-sectional study was conducted among 367 PCPs in Bahrain using a validated questionnaire. The questionnaire explored PCPs’ demographics, their attitudes toward performing MSPs, the frequency of performing MSPs, and perceived barriers to conducting these procedures.

Results:

The study revealed that 75.1% of PCPs in Bahrain perform MSPs. While most PCPs expressed a positive attitude towards performing MSPs and recognised their benefits to the patients, several barriers were identified. Lack of training (90.5%), lack of clinical experience (78.6%), and insufficient time (72.6%) were perceived as the most significant obstacles. Female physicians reported facing significantly higher barriers compared to males.

Conclusion:

This study highlights the need for greater support for PCPs performing MSPs in Bahrain. Addressing barriers such as the lack of training, time constraints, and concerns about complications through targeted interventions, including enhanced training programs and the provision of dedicated time and resources, can empower PCPs to confidently expand their scope of practice and deliver comprehensive patient-centred care.

Introduction

Minor surgical procedures (MSP) are known worldwide to be within the scope of primary health care. MSP has always been provided as a service in the Kingdom of Bahrain’s Primary care. Minor procedures are defined as ‘procedures that are minimally invasive and require a short period. They usually involve the use of local anaesthesia and encompass a few complications and no major risks’.[1,2] Studies have shown that in the United Kingdom, general practitioners (GPs) frequently conduct MSPs such as skin lesion excisions and joint injections, supported by structured training programs.[3] Similarly, in Australia, primary care physicians perform a broad range of MSPs, including dermatological and musculoskeletal procedures, contributing to the efficient healthcare delivery.[4]

There are many types of minor surgical procedures conducted in the Kingdom of Bahrain such as wound suturing, gynaecological procedures like intrauterine contraceptive device insertion, and dermatological such as cryotherapy for warts.[5]

It has been shown that performing procedures in primary care rather than secondary care leads to a decrease in the number of referrals to secondary care.[6] Also, this improves the patient’s emotional well-being, decreases their nervousness, and helps them cope with prolonged waiting times.[1,5,7] Moreover, it decreases health costs, being of benefit both to the patient and the health care system.[1,5,7] Furthermore, it has been shown to enhance physician-patient rapport and trust.[1,5,7]

In 1993, a study published in the Kingdom of Bahrain examined the practice, attitude, and barriers of minor surgical procedures in primary health care. Primary care physicians frequently performed minor surgical procedures, such as suturing lacerations, draining abscesses, and removing foreign bodies from the eyes, ears, and nose. However, the study found, that limitations in facilities, time constraints, and training gaps hindered the delivery of these services.[5]

An international observational study conducted in Croatia and published in 2008 reported a significant increase in the number of surgical procedures performed in primary care settings. The number of procedures rose from 503 to 906 following a 40-hour practical surgical course led by surgeons and specialized family physicians for primary care doctors.[8] Likewise, a 6-month study conducted in Ireland in 2020, found that experienced GPs can safely perform a variety of minor surgical procedures, including both invasive and non-invasive techniques, within the community. This approach helps reduce hospital workload and improves patient access to surgical services.[9]

Despite proven benefits, several barriers restrict minor surgeries at primary care centres. Studies in Saudi Arabia and Bahrain report limitations due to insufficient physician training, time constraints, staff shortages, and medicolegal concerns.[1,2,10]

Studies have shown that involving primary care physicians in dedicated surgical training courses significantly increases the number of procedures they perform.[8] Additionally, primary care physicians generally express a positive attitude toward performing MSPs and frustration with referring patients to secondary care for these procedures.[1,2,5,7]

This study aims to examine the attitudes of family physicians toward conducting MSPs in primary care settings in Bahrain, while also identifying the key barriers they face. These challenges may include training limitations, time constraints, staff shortages, and medicolegal concerns. Specifically, the study seeks to describe primary physician’s perspective on performing MSPs in local health centres and explore the difficulties they encounter when carrying out various types of procedures.

Methods

Materials and methods

A structured and validated questionnaire was used to collect data, and the methodology was designed to ensure scientific rigor and ethical compliance. The questionnaire was divided into four sections:

1. Demographic data

2. Attitudes toward performing minor surgical procedures

3. Current practice of minor surgical procedures

4. Perceived barriers.

Study setting

The study was conducted in Primary Care Health Centres across the Kingdom of Bahrain.

Study duration

A manual literature search was conducted in February 2022 to inform the study design and develop the data collection tool. Questionnaire distribution and data collection took place in April 2023.

Study design

This was a cross-sectional study aimed at assessing the attitudes, current practices, and perceived barriers related to MSPs among primary care physicians.

Sample size and sampling

The target population consisted of 399 Primary Care physicians practicing in Primary Care Health Centres in Bahrain as of April 2023. Physicians, who had recently retired, were on leave, or held administrative roles within the Ministry of Health were excluded. The final study population, after exclusions, included 367 physicians. A complete enumeration approach (census sampling) was employed, whereby all eligible physicians were invited to participate.

Data collection

Data were collected using a structured, self-administered questionnaire adopted from previous research conducted in the Kingdom of Saudi Arabia. The tool had been piloted, validated, and tested for reliability in the original study. Permission to use the questionnaire was obtained from the original authors via email.

Attitude scores ranged from 9 to 18, with higher scores indicating more favourable attitudes. Perceived barriers were assessed using a 5-point Likert scale, with total scores ranging from 9 (fewer barriers) to 45 (greater barriers).

Each participant received a hard copy of the questionnaire along with a verbal explanation of the study’s objectives. Participation was voluntary, and written informed consent was implied upon questionnaire completion.

Data analysis

Collected data were checked for completeness, coded, and entered the Statistical Package for Social Sciences (SPSS), version 26. Descriptive statistics, including means and standard deviations, were used for continuous variables, while frequencies and percentages were used for categorical variables. Inferential statistics were applied using independent sample t-tests for comparisons between two groups and one-way ANOVA for comparisons among three or more groups. A confidence level of 95% was applied, and a P value of < 0.05 was considered statistically significant.

Ethical issues

Scientific and ethical approval was obtained from the Research Ethical Committee of Primary Health Care. The study adhered to the ethical principles outlined in the Declaration of Helsinki. Anonymity and confidentiality of participants were ensured throughout the study. Participation was voluntary, and data collected were used solely for academic and medical research purposes.

Guidelines for reporting

This study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional studies.

Results

A total of 367 physicians were approached to complete the questionnaire. The Number of physicians, who responded were 338. The response rate was 91.97% Table 1.

Table 1.

Socio-demographic characteristics of participants (Total=338)

Characteristics		n (%)
Age
25–34 years		113 (33.4)
35–44 years		126 (37.3)
≥45 years		99 (29.3)
Sex
Male		75 (22.2)
Female		263 (77.8)
Nationality
Bahraini		315 (93.2)
Non-Bahraini		23 (6.8)
Qualification
MBBS		55 (16.3)
Diploma		17 (5)
Board		266 (78.7)
Years of experience
<1 year		16 (4.7)
1–5 years		60 (17.8)
>5–10 years		78 (23.1)
>10 years		184 (54.4)
Receiving training in surgical skills
Yes		252 (74.6)
No		86 (25.4)
Minor surgery facility at the PHC
Yes		311 (92)
No		27 (8)
Protected time to perform minor surgical procedures
Yes		202 (59.8)
No		136 (40.2)

Most participants were experienced, board-certified, female Bahraini physicians. While most reported having training and access to facilities for minor surgical procedures, a notable proportion lacked protected time to perform them—highlighting a key operational gap despite sufficient qualifications and infrastructure Table 2.

Table 2.

Physicians performing minor surgical procedures

		Frequency		Percent		95% CI
Valid
Yes		254		75.1		70.3-79.5
No		84		24.9		20.5-29.7
Total		338

A total of 367 physicians were approached to complete the questionnaire. The Number of physicians who responded were 338. The response rate was 91.97% Table 3.

Table 3.

Physician’s attitude towards minor surgical procedures in PHC (Total=338)

		n (%)		95%CI
PHCC encourages establishing a minor surgery program\training		311 (92)		88.8-94.5
The belief is that patients would be more satisfied if their minor surgical illnesses were managed in PHC		309 (91.4)		88.1-94.1
PHCC physicians encourage establishing minor surgery at PHCC		300 (88.8)		85.1-91.8
Interest in practicing minor surgical procedures		266 (78.7)		74.1-82.8
Competency to practice minor surgical procedures		168 (49.7)		44.4-55.0
Satisfaction with referring patients to hospitals for minor surgical illness		127 (37.6)		32.5-42.8
Belief that minors surgery is difficult to manage on PHC level		70 (20.7)		16.7-25.3

Physicians expressed strong support for integrating minor surgical procedures into primary care and showed high interest in performing them. However, only half felt competent, highlighting a need for further training. Few preferred referring patients or viewed these procedures as too complex for primary settings Table 4.

Table 4.

Barriers of not performing minor surgical procedures among physicians (Total=84)

		n (%)		95% CI for %
Lack of training		76 (90.5)		(82.8-95.4)
Lack of clinical experience		66 (78.6)		(68.9-86.3)
Lack of time		61 (72.6)		(62.4-81.3)
Fear of complications		56 (66.7)		(56.2-76.1)
Shortage of staff		48 (57.1)		(46.5-67.3)
Medico-legal issues		46 (54.8)		(44.1-65.1)
Lack of facilities		40 (47.6)		(37.2-58.2)
It is easier to refer the patient		38 (45.2)		(34.9-55.9)
Difficulties in establishing the diagnosis		15 (17.9)		(10.8-27.1)

Among physicians not performing minor surgical procedures in PHC, the main barriers were lack of training, clinical experience, and time. Other moderate concerns included fear of complications, staff shortages, medico-legal issues, and inadequate facilities. The least reported obstacle was difficulty in diagnosing conditions Table 5.

Table 5.

Association between socio-demographic characteristics and attitude towards performing minor surgical procedures (n=338)

		Attitude Mean (SD)		95% CI of the MD		P		Effect size*
Sex
Male		4.8 (0.9)		0.27 (0.02–0.52)		0.032		0.27
Female		4.5 (1.1)
Qualification
MBBS/Diploma		4.9 (0.9)		0.40 (0.15–0.65)		0.002		0.40
Boards		4.5 (1.1)
Receiving training in surgical skills
Yes		4.4 (1.1)		0.28 (0.02–0.53)		0.037		0.26
No		4.7 (1.0)
Availability of minor surgical facility at the PHC
Yes		4.6 (1.1)		0.20 (−0.22–0.61)		0.353		0.18
No		4.4 (1)
				95% CI of the mean
Age
1. 25-34 years		4.7 (0.9)		4.57-4.91		0.014		0.16
2. 35-44 years		4.4 (1.1)		4.17-4.57
3. ≥45 years		4.7 (1.1)		4.47-4.90
Years of Experience
1. <1 year		4.8 (0.8)		4.34-5.16		0.306		0.11
2. 1-5 years		4.6 (0.9)		4.41-4.86
3. >5-10 years		4.7 (1.1)		4.50-4.99
4. >10 years		4.5 (1.1)		4.33-4.66

Effect size Eta Squared 0.01=small, 0.06=moderate, 0.14=large

Male physicians, those with lower qualifications, and those without prior training showed significantly more positive attitudes toward performing minor surgical procedures. No significant difference was found based on the availability of surgical facilities or years of experience. However, age was a contributing factor, with younger physicians showing a more favourable attitude Table 6.

Table 6.

Analysis of surgical barriers depending on participant demographics (n=338)

		Barriers Mean (SD)		95% CI of the MD		P		Effect size
Sex
Male		31.3 (6.1)		−1.87 (−3.40-−0.34)		0.017		0.32
Female		33.2 (5.9)
Qualification
MBBS/Diploma		32.4 (5.6)		−0.52 (−2.01-1.04)		0.511		0.09
Boards		32.9 (6.1)
Receiving training in surgical skills
Yes		32.5 (6.0)		−1.03 (−2.50-0.43)		0.167		0.18
No		33.6 (6.0)
Availability of minor surgical facility at the PHC
Yes		32.6 (6.0)		−1.84 (−4.20-0.52)		0.125		0.33
No		34.5 (5.6)
				95% CI of the mean
Age
25–34 years		33.3 (5.1)		32.36-34.24		0.114		0.12
35–44 years		33.2 (6.2)		32.05-34.25
≥45 years		31.7 (6.5)		30.44-33.04
Years of Experience
<1 year		33.6 (6.4)		30.16-36.96		0.290		0.11
1–5 years		33.2 (4.9)		31.95-34.49
>5–10 years		33.6 (6.1)		32.25-35.01
>10 years		32.2 (6.2)		31.32-33.12

Effect size Eta Squared 0.01=small, 0.06=moderate, 0.14=large

Female physicians and those without access to surgical facilities reported significantly higher barriers to performing minor procedures. Training status and age showed some influence, though not statistically significant, while qualification level and years of experience appeared to have minimal effect.

Discussion

This study provides significant insights into the current state of MSPs in Bahrain’s primary care system, which are typically short, involve local anaesthesia, and carry a low risk of complications,[11] building substantially on the 1993 research while offering new perspectives on contemporary challenges and opportunities. The high response rate of 91.97% (338 out of 367 physicians) not only demonstrates the strong engagement of Bahrain’s primary care physicians but also enhances the reliability of our findings, particularly given the anonymous nature of the survey.[12]

Building on previous research

This study finds that 75.1% of primary care physicians (PCPs) are performing MSPs, a significant evolution from the 1993 Bahrain study conducted in Bahrain by Saab and Zurba,[3] which highlighted the practice and barriers of MSPs in primary care. This high participation rate suggests a growing acceptance of MSPs in primary care settings despite persistent challenges. Unlike previous studies that primarily focused on facility limitations, our research reveals a more complex interplay of barriers, particularly highlighting the critical role of training and gender-specific challenges.

Gender dynamics and cultural considerations

The study provides novel insights into gender-specific patterns in MSP performance, an aspect not deeply explored in previous research. Male physicians demonstrated greater willingness to perform MSPs (mean score 4.8 vs. 4.5, P = 0.032), which may be attributed to better stress-coping mechanisms and higher interest in surgical interventions. Female physicians, who comprise 77.8% of our sample, reported significantly higher barriers (mean score 33.2 vs. 31.3), particularly focusing on gynaecological procedures such as intrauterine device insertion. This gender disparity appears to be influenced by cultural sensitivity and religious considerations, a finding that adds new dimensions to our understanding of MSP implementation in conservative societies.

Training and competency

Our research reveals a critical paradox in training and competency. While 74.6% of physicians reported receiving surgical training, 90.5% identified lack of training as the primary barrier to performing MSPs. This apparent contradiction suggests that existing training programs may not adequately address the practical needs of PCPs. The finding that 92% of physicians believe proper surgical training workshops would benefit them, and their patients indicates a clear path forward for educational interventions.

Systemic barriers and practice environment

The study identifies several systemic barriers that significantly impact MSP implementation:

• 72.6% report insufficient time

• 66.7% express concerns about complications

• 57.1% cite staff shortages

• 54.8% worry about medico-legal issues.

These findings align with international research[11] and provide specific context for the Bahraini healthcare system. Furthermore, it is shown that Bahraini, board-certified medical professionals are more likely to perform minor surgeries compared to non-Bahraini and non-board-certified doctors. Likewise in a study conducted in Saudi, Saudi board-certified family physicians were remarkably, involved in such procedures compared to non-Saudi non-board certified.[10] However, despite the similarities of both populations and cultures that reflected in shared attitudes and barriers, this study differs from Andijany and Alateeq’s research, in which the latter had a positive correlation between performing MSPs with years of experience. Yet, years of experience is of no significance in this study and hence, suggesting that systemic barriers may outweigh individual experience in determining MSP participation.

Undoubtedly, training, and continuous education, in general, are fundamental, similarly, training in MSPs is a crucial part of the curriculum in family medicine residency programs worldwide,[13] but ongoing education and hands-on training even post-residency, is an influential factor in the performance of MSPs,[14] such as skin lesions removal, Intra-uterine device insertion, sutures, intramuscular injections, circumcision, and cryotherapy.

Patient-centred perspectives

A significant finding is that 91.4% of PCPs believe patients would be more satisfied with MSPs performed in primary care settings. This aligns with international literature suggesting that primary care-based MSPs can improve patient satisfaction through reduced waiting times and familiar care environments. However, the finding that 45% of participants prefer referring patients to secondary care highlights a tension between perceived patient benefits and physician confidence. Likewise, a Dutch study explored that reasons for MSP referral might be due to the lack of patient trust, patient’s preference for subspecialty, and liability of disturbances in doctor-patient relationships if any complications occurred.[14] Also, around 20.7% of respondents expressed concerns that conducting MSPs in primary care settings may be difficult due to fears of complications, lack of colleague support, inadequate equipment supply, and limited time.[14]

Moreover, our study concluded that a large portion of PCPs are encouraged to perform MSPs in their health centres and about 88.8% of them are interested in surgical procedures. However, some still do not feel competent in performing MSPs due to a lack of experience in conducting MSPs and dealing with their complications, and that is a real concern. Thus, PCPs demand more practice in the surgical area to eliminate the mentioned limitations. PCPs have expressed concerns about the lack of protected hours for MSPs, which could disrupt their workflow. Additionally, they have noted the lack of access to advanced equipment and support to effectively manage emerging emergencies.[2]

Implications for practice and policy

The successful integration of minor surgical procedures in primary care will depend on a multifaceted approach that addresses the concerns and needs of physicians. Our findings suggest several key areas for intervention:

1. Enhanced Training Programs:

   • Development of structured, hands-on training programs

   • Integration of continuous professional development

   • Special attention to gender-specific training needs

2. Systemic Support:

   • Implementation of protected time for MSPs

   • Provision of adequate support staff and resources

   • Development of clear protocols and guidelines

3. Quality Assurance:

   • Implementation of surgical checklists and audits[15]

   • Development of registries to monitor outcomes[15]

   • Regular assessment of patient satisfaction.

Study limitations

The study was conducted in the Kingdom of Bahrain. Therefore, the results may only apply to other countries in the same region. Also, data was self-reported, and actual assessment of skills or knowledge was not tested.

Conclusion

In Conclusion, the landscape of primary care is continuously evolving with an increasing demand for better care, high-quality service, and patient satisfaction in primary care, minor surgical procedures require more attention. Subsequently, continued training and exposure, dedicated time and assistance, and challenging fear with seniors’ support will enhance physicians’ confidence leading to a better attitude in performing minor surgical procedures, that is essential for the successful growth of the primary sector. By addressing these factors, more procedures can be conducted in primary care, leading to lower referral rates, reduction in the waiting time for minor procedures, higher standards of care, improved patient safety, decreased costs, and better doctor-patient relationships.[16]

Availability of the data

The data is available on reasonable request to the corresponding author.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.