Referring physicians' knowledge of hand surgery.
ABSTRACT Hand surgeons rely on referrals from general providers. Appropriate referral is dependent upon referring physicians having an understanding of the problem and available treatments. This study evaluates the referring physicians' knowledge and perceptions of basic hand problems and their treatment. This study also evaluates the impact of a brief lecture on our referring physicians' understanding of hand issues. A survey instrument was administered to referring physicians. The instrument addressed general hand knowledge and perceptions toward hand surgery. The physicians also attended a lecture on general hand problems and their treatments. The survey was repeated 2 weeks post-lecture. Subjects had a pre-lecture knowledge score of 65% correct and post-lecture a score of 85%, p < 0.05. The participants were knowledgeable about common hand problems, such as carpal tunnel syndrome. Knowledge gaps did exist, for example, only 37% recognized the symptoms of basilar thumb arthritis. Initially, the referring physicians had less positive views about surgical interventions, such as surgery to help the pain of basilar thumb arthritis. After the lecture, the responders had significantly more favorable attitudes toward surgery. This study found that referring physicians had variable knowledge about common hand problems, and they had doubts relating to the efficacy of some hand surgeries. This study also found that a directed lecture improved these providers' knowledge and their perceptions of hand surgical interventions. Hand surgeons can improve their referring physicians understanding and perceptions of hand surgery through a directed grand rounds type lecture.
- SourceAvailable from: Martin Dawes[Show abstract] [Hide abstract]
ABSTRACT: To determine information seeking behavior of physicians. Systematic review of 19 studies that described information seeking behavior in a number of different settings using differing methodologies. Analysis was limited to quantitative studies describing sources of information sought by physicians. Investigators have used questionnaires, interviews and observation to identify the information seeking behavior of clinicians. The results were mainly obtained from trials in the United States and showed a wide variation in primary information sources used by physicians. The most frequent source for information used are text sources, second is asking colleagues and only one study found electronic databases to be the primary resource. Physician's desk reference is the commonest cited printed resource. Convenience of access, habit, reliability, high quality, speed of use, and applicability makes information seeking likely to be successful and to occur. The lack of time to search, the huge amount of material, forgetfulness, the belief that there is likely to be no answer, and the lack of urgency all hinder the process of answering questions. The wide variation in information seeking behavior implies a need for further categorization of information need and information sources. Careful planning of information delivery to physicians is required to enable them to keep up to date and to improve knowledge transfer.International Journal of Medical Informatics 09/2003; 71(1):9-15. · 2.72 Impact Factor
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ABSTRACT: To determine whether there is regional variation in environmental (non-medical) factors affecting referral decisions of family physicians (FPs). Cross-sectional interview survey. Nova Scotia. A random sample of 125 FPs grouped into 1 of 5 functionally defined geographic regions of Nova Scotia (25 in each group). Groupings were based on access to general hospital beds through active staff hospital appointments or to specialist consultants in the community, or both. Participants were personally interviewed on site. No physician refused an interview. In 9 cases the physician indicated that he or she did not fit the profile of the assigned group; the physician was excluded from the study and the next doctor on the list was substituted. The questionnaire was designed to test several hypotheses about factors known to potentially influence decisions about referral. Geographic differences in factors affecting referral and in decisions about 5 hypothetical cases were assessed with the use of significance tests for proportions that were sensitive to specific orders across groups. Three factors affecting referral showed unequivocal variation across the 5 groups. Access to hospital facilities and remoteness from specialist care, leading to local styles of practice or treatment policies, and the FP's relationship with specialist consultants appeared to be important nonmedical factors affecting referral decisions. For similar case scenarios the physicians living in rural areas would refer only half as often overall as those living in urban areas with tertiary care hospitals; for some cases, such as a severe asthma attack, the difference was more than 7-fold. Significant differences in nonmedical factors affecting referral, and in referral decisions about hypothetical cases, were found between the groups of FPs. Differences in access to resources, creating local styles of practice, appeared to explain most of the variation. The results may account for previously observed differences in actual rates of referral for these particular groups.Canadian Medical Association Journal 09/1997; 157(3):265-72. · 5.81 Impact Factor
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ABSTRACT: This report describes ambulatory care visits to hospital outpatient departments (OPDs) in the United States. Statistics are presented on selected hospital, clinic, patient, and visit characteristics. Highlights of trends in OPD utilization from 1997 through 2000 are also presented. The data presented in this report were collected from the 2000 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. Trends are based on NHAMCS data from 1997 through 2000. During 2000, an estimated 83.3 million visits were made to hospital OPDs in the United States, about 30.4 visits per 100 persons. Females had higher OPD visit rates than males (35.3 versus 25.2 visits per 100 persons). The OPD utilization rate for black persons was higher than for white persons (48.3 versus 28.0 visits per 100 persons). Of all visits made to hospital OPDs in 2000, private insurance (38.5 percent), Medicaid (22.1 percent), and Medicare (16.9 percent) were listed as the leading primary expected source of payment. Approximately 21 percent of OPD visits reported that patients belonged to an HMO. There were an estimated 9.5 million injury-related OPD visits in 2000. Since 1997, the percent of OPD visits that were for injuries increased by 24% (from 9.2 percent to 1.4 percent). Most of these visits were for unintentional injuries (57.6 percent), including those caused by falls (12.9 percent). Medications were prescribed at 64.0 percent of visits. On average, 1.6 medications were ordered at each OPD visit. In 2000, patients saw one or more physicians (i.e., staff physician, resident/intern, or other physician) at approximately 79 percent of visits. Most patients were given an appointment to return to the clinic (57.2 percent).Advance data 07/2002;
Referring Physicians’ Knowledge of Hand Surgery
Catherine M. Curtin & Jeffrey Yao
Received: 2 November 2009 /Accepted: 29 December 2009 /Published online: 27 January 2010
# American Association for Hand Surgery 2010
Abstract Hand surgeons rely on referrals from general
providers. Appropriate referral is dependent upon referring
physicians having an understanding of the problem and
available treatments. This study evaluates the referring
physicians’ knowledge and perceptions of basic hand
problems and their treatment. This study also evaluates
the impact of a brief lecture on our referring physicians’
understanding of hand issues. A survey instrument was
administered to referring physicians. The instrument
addressed general hand knowledge and perceptions toward
hand surgery. The physicians also attended a lecture on
general hand problems and their treatments. The survey was
repeated 2 weeks post-lecture. Subjects had a pre-lecture
knowledge score of 65% correct and post-lecture a score of
85%, p<0.05. The participants were knowledgeable about
common hand problems, such as carpal tunnel syndrome.
Knowledge gaps did exist, for example, only 37%
recognized the symptoms of basilar thumb arthritis.
Initially, the referring physicians had less positive views
about surgical interventions, such as surgery to help the
pain of basilar thumb arthritis. After the lecture, the
responders had significantly more favorable attitudes
toward surgery. This study found that referring physicians
had variable knowledge about common hand problems, and
they had doubts relating to the efficacy of some hand
surgeries. This study also found that a directed lecture
improved these providers’ knowledge and their perceptions
of hand surgical interventions. Hand surgeons can improve
their referring physicians understanding and perceptions of
hand surgery through a directed grand rounds type lecture.
Hand surgery is a specialized field that relies upon general
providers to evaluate and refer patients. Referring physi-
cians often act as the gatekeepers to access to a hand
surgeon. For this hierarchical system to function, these
referring physicians must have basic knowledge of upper
limb problems and understand what treatment options hand
surgeons may offer to care for their patients. Limitations in
the understanding of hand surgery by referring physicians
will hamper timely and appropriate referrals.
Previous work has shown that the referral process for
some highly specialized hand care is problematic. Referring
physicians have been shown to have negative perceptions or
misinformation about surgical interventions for tetraplegia
and rheumatologic hand problems [1, 6]. These studies
found a general bias toward nonsurgical treatments, which
negatively impacted appropriate referrals to surgeons.
Perhaps general practitioners have similar misperceptions
about more common hand surgical problems.
This study had two aims: firstly, to clarify referring
physicians’ knowledge and perceptions of basic hand
problems and their treatment and, secondly, to assess
whether a lecture given by a hand surgeon on common
C. M. Curtin
Division of Plastic Surgery, Stanford University Medical Center,
770 Welch Rd.,
Palo Alto, CA, USA
Department of Orthopedic Surgery,
Stanford University Medical Center,
770 Welch Rd.,
Palo Alto, CA, USA
C. M. Curtin (*)
Suite 400, 770 Welch Rd.,
Palo Alto, CA 94304, USA
HAND (2010) 5:278–285
hand problems would improve referring providers under-
standing of hand pathology and positively affect their
perceptions toward surgical interventions.
The study began with a focus group of hand surgeons and
primary care providers. This group discussed hand topics and
made a list of topics that seemed relevant to both disciplines.
From these discussions, eight multiple-choice questions on
hand topics were designed using described educational
techniques (Appendix 1) . These questions addressed
several common hand complaints, such as carpal tunnel
syndrome, trigger fingers, mallet fingers, and basilar thumb
arthritis. The survey also asked questions about perceptions
of hand treatments using a five-point Likert scale (1=strongly
agree, 5=strongly disagree). Finally the survey included
questions about the practice patterns and the level of previous
musculoskeletal training of the referring physicians. The
focus group reviewed the questions to determine face validity
of the survey. The survey was designed to take approximately
5 min to complete. These questions were designed to provide
information on the subject’s knowledge and perceptions
toward hand problems and their care.
The next phase of the study was the intervention, which
was a standard 1-h grand rounds type lecture on the diagnosis
and treatment of common hand problems based on the best
available evidence in the current literature. One author (JY)
gave this presentation during regular conferences to the
physician groups, who commonly refer to our university hand
practice. The survey was offered to all who attended the
conferences and included physicians from the university
student health center, the department of internal medicine, the
family practice department, and from physical medicine and
rehabilitation. Prior to the lecture, the providers completed
the survey (Appendix 1). Two weeks following the lecture,
the providers were asked to complete a second survey of the
same questions as a post-test to assess information retention
and assess if perceptions toward hand treatments had
changed. The analysis consisted of comparison of means of
the test scores between the two time-points (pre- and post-
lecture). A p value less than 0.05 was considered significant.
The tests were anonymous, and since these data were of
a nonsensitive nature, formal written informed consent was
waived. The University Medical Center Institutional Re-
view Board approved this study.
Thirty-one physicians completed the pre-test, and 24
completed the post-test, for a retention rate of 77.4%. The
practice information of respondents is shown in Table 1.
The majority of the physicians were new to practice, which
likely is secondary to the academic nature of this
institution. Interestingly, whereas 100% of the Physical
Medicine and Rehabilitation Medicine physicians indicated
they had a musculoskeletal rotation during their residency
training, only 21% of the Internal Medicine and Family
Practice physicians had such training. The providers were
asked what were the most common hand problems seen in
their practices: carpal tunnel (78%), tendinitis (13%), and
arthritis (8%). Upper extremity complaints were common
with 39% of these physicians seeing more than ten patients
in the past month for these complaints and 26% sending up
to ten patients to a hand specialist within the past month.
The results of the knowledge portion of the survey are
displayed by question in Table 2. The knowledge test
revealed that subjects had a pre-lecture overall knowledge
score of 65% correct. There was wide variability in pre-test
knowledge among the different hand topics. For example,
almost all physicians (97%) surveyed knew the median
nerve is the nerve involved in carpal tunnel syndrome but
only 35% of respondents knew that elbow flexion exacer-
bates the symptoms of cubital tunnel syndrome, and only
37% of subjects recognized the symptoms of basilar thumb
arthritis. After the lecture, all of the knowledge questions
scores increased. The overall post-test score knowledge
score increased to 85% correct (p<0.005).
We found that after the lecture, the respondents changed
their answers about the value of hand surgery (Table 3).
There were significant improvements in the referring
physicians’ perceptions toward the utility of surgery in the
treatment of common hand problems, such as thumb
carpometacarpal joint arthritis (p<0.05), carpal tunnel
syndrome (p<0.01), and ganglion cysts (p<0.001). Fol-
Table 1 Demographics of respondents.
Type of practice 35% internal medicine/family practice
26% University Health Center
68% less than 5 years
16% 5–10 years
7% 10–20 years
9% greater than 20 years
0% no patients
26% 1–5 patients
39% >10 patients
16% no patients
45% 1–5 patients
26% 6–10 patients
13% greater than 10 patients
Years in practice
Number of patients in month
with UE complaints
Number of patients referred
to a hand specialist in the
HAND (2010) 5:278–285279
lowing the lecture, all of the responses were more positive
toward surgical intervention for these problems.
Referring physicians are critical partners for hand surgeons;
yet they may have misconceptions or knowledge deficien-
cies that may hamper a smooth referral process. We found
that referring physician providers were knowledgeable
about many common hand problems, but some areas of
weakness were present. Few providers knew the symptoms of
basilar thumb arthritis or arm positions to avoid with cubital
tunnel syndrome. It is clear that improving referring physi-
cians’ understanding of these common hand ailments would
improve primary care and facilitate recognition of surgical
problems for prompt referral.
Musculoskeletal complaints are one of the most common
causes for the utilization of medical care [12, 14]. Yet
medical school musculoskeletal education has been shown to
have deficiencies [8, 16]. Freedman et al. performed a study,
which highlighted the deficiencies in musculoskeletal educa-
tion. They gave a cognitive exam to recent medical school
graduates and found that 82% of their participants failed to
have a basic understanding of orthopedic issues . Matzkin
found that those participants who had taken an orthopedic
elective had significantly higher musculoskeletal scores .
Unfortunately, the availability of these electives may be
limited with the increasing demands by other mandated
medical school courses. Hand surgeons need to be aware that
their gatekeepers and primary referral sources may not be as
familiar with common hand problems. This means that given
the current limitations of the education process if surgeons
want the most efficient referral process, surgeons need to
make efforts to educate their colleagues on the field of hand
surgery. This teaching could be done in a simple 1-h
lunchtime lecture to referring providers. This will not only
improve the referring physicians’ understanding of hand
problems but will also familiarize them with their local hand
surgeons’ treatment algorithm.
Mistrust of surgical interventions by nonsurgical providers
is a particularly vexing problem that may be more common
than expected. Several studies have shown that nonsurgical
providers doubt the efficacy of surgical interventions, and this
can impede the referral process [1, 2, 6]. We found that prior
to the lecture, providers had less positive views of surgical
interventions and more positive views about conservative
measures. Before the lecture, respondents generally believed
that physical therapy could resolve most symptoms of carpal
tunnel syndrome despite a 2003 Cochrane review that
showed that surgical intervention had statistically better
outcomes than nonsurgical treatment . After exposure
to an evidence-based lecture, respondents had more favor-
able views of surgery. The power of this one intervention to
affect opinions is not surprising because the specialist and
referring doctor relationship continues to be important to
appropriate and timely referrals [10, 11, 15]. Physicians
heavily rely on their colleagues as sources for information
and adoption of new technology [4, 5, 7, 17].
There are limitations of this study. This is a study of
small sample size in one geographical area. Practice
patterns clearly have geographical variation, and this study
does not propose that the perceptions of our referring
physicians would be generalizable. However, the physi-
cians at this academic institution drew their training from
around the country, so geographic variations may have been
mitigated. Nevertheless, preconceptions are universal, and
studies suggest that the nonsurgical specialties generally
have reservations about the efficacy of many surgeries.
Although there is often variable agreement among hand
surgeons about the treatment of basic hand problems, a local
consensus on treatment algorithms would enhance the referral
Table 2 Knowledge test results.
Knowledge topicPre-test %
Steroid therapy for trigger
Initial treatment for snuff
Nerve involved in carpal
Position of arm that exacerbates
cubital tunnel symptoms
Symptom of basilar thumb arthritis
When to refer a patient with
Dupytren’s disease to hand surgeon
Initial treatment for tennis elbow
Initial treatment for mallet finger
Table 3 Perceptions of hand treatments.
Topic Pre-test score Post-testp value
Surgery for base of thumb arthritis relieves pain
There is a low recurrence rate of ganglion after aspiration
Therapy can relieve most patients with carpal tunnel syndrome
Likert scale 1 through 5 (1=strongly agree, 5=strongly disagree)
280HAND (2010) 5:278–285
are present in referring physicians and a 1-h interaction
between surgeon and referring physicians may enhance the
consensus between these diverse specialties.
Appendix 1. Test given to providers
This first section asks some questions on your training and practice
Read each question carefully and place a check in the box that most closely reflects your experience
1.In my training, I had a rotation that focused on musculoskeletal medicine?
2. In the last month, how many patients have complained of upper extremity problems?
Greater than ten--------
3. In the last six months, how many patients have you referred to a specialist for an upper extremity
Greater than ten--------
4. How would you describe your practice’s patient population?
All ages including children
Adults all ages-------
Adults mostly older than 50
5. How many years have you been in practice?
Less than 5 years-----------
HAND (2010) 5:278–285281
This next section represents some knowledge questions on hand and upper extremity problems.
Please check the best answer
1. What is the first line of treatment for a trigger finger?
2. A patient falls on his hand and is tender to palpation in the “snuff box” (the space between the thumb
extensor and abductor tendons). Initial x-rays show no fracture. What is the initial treatment?
Splint the wrist only
Immobilize thumb and wrist
No additional treatment
3. What nerve is compressed in carpal tunnel syndrome?
Palmar cutaneous nerve
4. What are classic symptoms of basilar thumb arthritis?
Pain extending the thumb
Numbness of the thumb
Pain opening jars
Locking of the thumb
5. What arm positions aggravate the symptoms of “cubital tunnel” syndrome?
Flexing the wrist
Extending the wrist
Flexing the elbow
Extending the elbow
282 HAND (2010) 5:278–285
6. When should a person with Dupuytren’s disease see a hand surgeon?
Small contracture of the proximal inter-phalangeal joint
Multiple palmar cords but no contracture
7. How should a patient with “mallet” finger be initially treated?
Removable splint of finger
Extension splinting of distal inter-phalangeal joint only
Buddy taping to other finger
8. What is the first line of treatment for “tennis elbow”?
Counter force brace
HAND (2010) 5:278–285 283
Please fill in the blanks for the questions below
The most common hand complaint I see in practice is:
I perform the following office procedures on the upper extremity: (for example trigger injections, ganglion
After the following statements, please check one response that best represents your beliefs
Strongly Agree Neutral Disagree Strongly
Surgery for base of
1 2 3 4 5
thumb arthritis relieves
I am comfortable injecting
1 23 4 5
I am comfortable examining
1 2 3 4 5
284 HAND (2010) 5:278–285
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There is a low recurrence
1 2 3 4 5
rate of ganglion after
Therapy can relieve most
1 2 3 4 5
patients with carpal tunnel
I know a hand surgeon who
1 2 3 4 5
will see my patients
HAND (2010) 5:278–285 285