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CAMHS won't see you now

Attacks on GP minor ops are wide of the mark

I'm a GP who regularly performs minor surgical procedures in practice and in our local community hospital. I read with interest Professor John Primrose's negative comments on the ability of GPs to perform minor surgery.

I appreciate that the format of a debate is intended to polarise the issue rather than explore the fine details but I feel Professor Primrose's analysis of the issue is very wide of the mark.

He correctly identifies that most minor surgery is, in fact, joint injections, which he dismisses, saying there is 'little evidence' for the procedure.

This may well be true, but it is certainly recognised by my patients and our local consultants that they have a very significant benefit and are both cheap and safe.

His discussion of the MiSTIC trial - not yet published in a peer-reviewed journal - also raises problems.

The figures regarding lack of histology and the 'misdiagnosis' of malignant lesions take no account of the case selection that takes place before minor surgery is performed in primary care.

Very few GPs would operate on a lesion that looked likely to be malignant. Therefore it follows that all the lesions operated on in primary care have a provisional diagnosis of benign disease. These will be excised with narrow margins, to reduce the cosmetic impact.

If an unsuspected malignant diagnosis is reached the patient will immediately be referred.

Finally there is the difficult question of 'unnecessary' operations. None of the procedures will have been considered unnecessary by either the GP or the patient. But they may well not have been operated on in secondary care because secondary care is - at least in this region - not contracted to perform operations on irritating or distressing benign lesions.

The only point on which I agree with Professor Primrose is that cryotherapy for warts is probably a useless intervention, but as no better treatment exists I think it will continue to be performed when OTC medications have failed.

Dr Charles McEvoy, Ripon, Yorkshire

I am confused by Professor Primrose's argument. He quotes the MiSTIC study, of which he was a co-author. You can view this on the Health Technology Assessment website

The conclusion of this study starts: 'The quality of minor surgery carried out in general practice is not as high as that carried out in hospital, using surgical quality as the primary outcome, although the difference is not large.'

In his article in Pulse he states: 'The quality of the surgery is poor and in some cases frankly dangerous.'

If the difference between primary and secondary care minor surgery 'is not large' but primary care surgery is 'poor and in some cases frankly dangerous' are we to assume secondary care results are only average and perhaps a bit risky?

If that is so should we not ask why consultant surgeons with their training, experience, expertise and hospital back-up are doing so badly that the added value they provide over untrained GPs is not large?

Dr David Stokoe, Birkenhead, Cheshire

As a surgeon I would like to take issue on several counts with Professor Primrose's assessment of minor surgery carried out by GPs.

Lesions that are suspicious are referred for treatment by secondary care anyway, so all lesions removed by GPs are, by definition, of low suspicion.

It is only natural that there will be a higher rate of positive margins in lesions removed with a low index of suspicion that turn out unexpectedly to be malignant, compared with highly suspicious lesions.

So I would think that having clear margins in 46% of such unexpected scenarios is a major success and to have 25% margin involvement during excision of highly suspicious lesions is a serious failing on the part of secondary care.

He also alleges most small lesions do not need surgical treatment. Unfortunately, he has forgotten that it is not only the lesion that needs treating but the whole patient.

If a lesion, despite being obviously benign, is causing anxiety or other psychological problems, it must be removed.

I used to think that we cardiothoracic surgeons deserved our reputation for being the most arrogant specialists, but having read Professor Primrose's piece, I think there are others far more deserving of the title.

Mr Emre Amirak, Harrow, Middlesex

I'm a GP and clinical assistant in dermatology so I work on both sides of the fence.

I found some of Professor Primrose's comments difficult to decipher. He states that only 13% of wounds in primary care were optimum compared with 20% of wounds in hospital cases. Either way, the results appear to be poor.

Most patients tell me they are happy to put up with a scar and have the peace of mind of knowing that their lesion is benign.

Another point relates to fewer melanomas being completely excised in general practice compared with hospitals. Melanomas seen in hospital are a highly selective group that have been diagnosed and referred by a GP because of a high degree of clinical suspicion. They are more likely to be excised completely at one sitting by the hospital doctor simply because they probably are melanomas.

From my experience, the vast majority of GPs doing minor surgery are competent but there are a few who let the side down, by not following protocols or not sending all samples off for histology.

Perhaps Professor Primrose should spend some time in general practice to see what we are presented with. He may not be so keen to criticise.

Dr Keith Green, Tanworth-in-Arden, Warwickshire

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