Exploring plastic and reconstructive surgery referral pathways: Insights from primary care physicians in Bahrain

Primary care physicians (PCPs) serve as the frontline of healthcare systems worldwide, acting as gatekeepers for specialist referrals. However, the absence of clear referral guidelines and complete guidance can lead to inappropriate referrals, defined as referrals that are either clinically unnecessary (e.g., referring a simple sebaceous cyst that is manageable in primary care) or misdirected to the wrong specialty (e.g., referring a hand tendon injury to orthopedics instead of plastic surgery). Such referrals overburden specialized clinics and delay care for patients who genuinely require specialist intervention. This is the first study in Bahrain to explore PCPs' perceptions and referral patterns to plastic surgery clinics.

A cross-sectional survey was conducted among PCPs who actively refer patients to plastic surgery (N = 97 eligible) within all five primary health care centers in the Muharraq governorate. Participants completed a validated 14-item questionnaire. Data were examined using descriptive statistics.

Seventy-four PCPs participated (response rate: 76.3%). Nearly one-third (31.1%) reported that no specific referral criteria existed at their health center. A substantial proportion (39.2%) relied on personal clinical judgment to determine which patients to refer. This refers to subjective assessments based on individual experience and intuition rather than evidence-based protocols. The majority (67.6%) acknowledged plastic surgery as an important specialty that is able to transform lives, while a minority perceived it as primarily cosmetic. Over half (54.1%) identified the lack of clear referral criteria as their principal challenge. Most PCPs supported standardizing referral criteria (62.2% agreed or strongly agreed) and providing additional training (66.3% agreed or strongly agreed).

PCP referral practices to plastic surgery lack standardized guidelines and frequently rely on personal judgment, which may contribute to inappropriate referrals, higher healthcare costs, and inefficient resource allocation. These findings, while derived from a single governorate in Bahrain, reflect challenges common to healthcare systems with similar primary-to-secondary care structures. Applying standardized referral algorithms and targeted PCP education could strengthen patient care, improve healthcare efficiency, and optimize resource utilization.