Quality and safety issues in procedural rural practice: a prospective evaluation of current quality and safety guidelines in 3000 colonoscopies.

INTRODUCTION: Colonoscopy remains the gold standard for the investigation and management of bowel pathology. A 2009 National Bowel Cancer Screening Program Quality Working Group report revealed that small rural towns in inner regional Victoria, Australia, for example Echuca (Rural and Remote Metropolitan Areas [RRMA] 4), registered 10.5 colonoscopies per 1000 population versus 18.5 per 1000 in the state capital Melbourne. Reasons for this discrepancy include lack of skilled practitioners in rural communities and travel time for patients to attend larger centres when the required bowel preparation or mobility issues limit access. Ideally, services are high quality, safe and local. This study assessed the quality and safety of a rural GP colonoscopy service. METHODS: The indications, findings, caecal intubation rates, complications and completion time were recorded for 3000 serial colonoscopies performed by one rural procedural GP from 1995 to 2011 in Victorian Echuca. Quality was assessed using caecal intubation rate, polyp and colorectal carcinoma detection rates, and completion time. Safety was determined by complication rates. RESULTS: The caecal intubation rate was 97% (excluding stenosing lesions), polypectomy detection rate was 39%, carcinoma detection rate was 2%, and the average time to completion was 17 min. Re-admission rates were 1.6/1000 for haemorrhage and 1.2/1000 for perforation. There were no deaths. CONCLUSIONS: The results from this study compare favourably with published international standards, validate Australian general practice procedural training standards, and validate the additional quality measure of 'colonoscopy completion time'. Rural GPs can provide a safe and high quality service. Extending this service model to similar settings could improve reduced access to colonoscopy for rural Australians.

A proposal for funding and monitoring medical education supervision in expanded clinical settings--a 'meducation' card.

CONTEXT: Entry to practice medical programs (graduate- and undergraduate-entry) in Australia are under considerable pressure to provide clinical training as a result of increased student numbers. At the same time modern medical curricula require the development of active placements in expanded settings to achieve graduate medical practitioners who are clinically able. These dual imperatives require a mechanism to fund and maintain the quality of clinical placements outside the traditional hospital setting. ISSUE: For teaching outside traditional teaching hospitals the Australian government's Practice Incentives Program (PIP) currently provides a student-related payment of AU$100 for each half-day teaching session in a general practice setting. This payment is not linked to the quality of the placement and does not support clinical placements in other settings, for example specialist consulting rooms or allied health practices. SOLUTION: This short communication proposes a 'meducation' card as an efficient funding mechanism to facilitate an expansion of quality clinical placements in expanded settings including specialist and allied health practices. This student meducation card would use current Medicare Australia infrastructure to facilitate the payment of clinical teachers in expanded settings. Meducation payments would only be available to practitioners and practices that maintain quality teaching practices certified by medical or allied health schools.

Developing the accredited postgraduate assessment program for Fellowship of the Australian College of Rural and Remote Medicine.

INTRODUCTION: Accreditation of the Australian College of Rural and Remote Medicine (ACRRM) as a standards and training provider, by the Australian Medical Council (AMC) in 2007, is the first time in the world that a peak professional organisation for rural and remote medical education has been formally recognised. As a consequence, the Australian Government provided rural and remote medicine with formal recognition under Medicare as a generalist discipline. This accreditation was based on the ability of ACRRM to meet the AMC's guidelines for its training and assessment program. METHODS: The methodology was a six-step process that included: developing an assessment blueprint and a classification scheme; identifying an assessment model; choosing innovative summative and formative assessment methods that met the needs of rural and remote located medical practitioner candidates; 21 rural doctors and academics developing the assessment items as part of a week-long writing workshop; investigating the feasibility of purchasing assessment items; and 48 rural candidates piloting three of the assessment items to ensure they would meet the guidelines for national accreditation. RESULTS: The project resulted in an innovative formative and summative assessment program that occurs throughout 4 years of vocational training, using innovative, reliable, valid and acceptable methods with educational impact. The piloting process occurred for 3 of the 6 assessment tools. Structured Assessment Using Multiple Patient Scenarios (StAMPS) is a new assessment method developed as part of this project. The StAMPS pilot found that it was reliable, with a generalisability coefficient of >0.76 and was a valid, acceptable and feasible assessment tool with desired educational impact. The multiple choice question (MCQ) examination pilot found that the applied clinical nature of the questions and their wide range of scenarios proved a very acceptable examination to the profession. The web based in-training assessment examination pilot revealed that it would serve well as a formative process until ACRRM can further develop their MCQ database. CONCLUSIONS: The ACRRM assessment program breaks new ground for assessing rural and remote doctors in Australia, and provides new evidence regarding how a comprehensive and contemporary assessment system can work within a postgraduate medical setting.

A required rural health module increases students' interest in rural health careers.

INTRODUCTION: The Australian Commonwealth Department of Health and Ageing has funded University Departments of Rural Health (UDRHs) to facilitate student placements with the goal of encouraging students to choose rural health practice. The objective of this article is twofold: first, to report student feedback regarding The University of Melbourne-UDRH required 4 week Rural Health Module based in Shepparton, Victoria, at the School of Rural Health, with placements in communities in rural northeast Victoria; and second, to identify students' attitudes about practising in rural areas at the completion of the course. METHODS: Student evaluations conducted at the completion of the program were analysed utilising both quantitative and qualitative survey questions. RESULTS: Of 393 students who completed the course, 93% participated in the evaluation. Over half (70%) said that the course increased their interest in rural health issues more than 'somewhat', and 47% stated that the course increased their interest in practising rurally more than 'somewhat'. Students valued their community placements highly but wanted greater clinical focus. CONCLUSIONS: A required community-based rural health course positively influences many medical students' reported intention toward rural practice and increases most students interest in rural health. Rural general practice placements are in short supply. This course offers valuable rural experience to students without depending significantly on GPs, but student feedback has increased efforts to make the course more clinically focussed.

Medical students' perceptions of barriers to training at a rural clinical school.

INTRODUCTION: In response to concerns about the decreasing rural health workforce, the Australian Government has funded a number of clinical schools in rural locations across Australia. The University of Melbourne established its Rural Clinical School (RCS) in 2000, at Shepparton, population 42,000, 175 km north of Melbourne, Victoria. The University of Melbourne also has three metropolitan-based clinical schools. Rural clinical schools in Australia generally have experienced difficulty in recruiting students. This has also been the experience of the University of Melbourne's Shepparton-based RCS. This study focuses on student perceptions in an attempt to understand the reasons behind this difficulty. METHODS: All medical students at The University of Melbourne were sent an internet-based questionnaire and invited to participate in this study. The survey included information-gathering questions focused on the following areas: demographic details, whether or not the student chose to study at the RCS, factors that were of importance to them in selection of a clinical school, and the reasons why they did or did not prefer the RCS. Participants were asked to rank their three most important issues and were then asked to comment on what would make training at the University of Melbourne RCS attractive to them. RESULTS: The response rate was 49% (n = 785 of 1599). The most common concerns relating to the students' selection of a clinical school were the quality of teaching and education at the school, transport and location issues, and patient access. Other major issues included the ability to obtain the student's preferred internship, family and partner issues, and the lack of incentives, such as financial incentives. The most common issues for students who did not chose the RCS were of a non-clinical nature, such as family and partner commitments, financial issues, and housing commitments. The most common factors students identified as making the RCS more attractive to them were greater financial support and incentives, demonstrating value-added teaching, and teaching that was seen as better than that available in the metropolitan centres, and improvement in the flow of information, and promotion of the RCS's programs. Finally, students who chose to study at a RCS are more likely to be female, of graduate entry, and of rural origin. CONCLUSIONS: Although little can be done regarding family and financial issues, these remain important concerns for students when considering relocation to a RCS. In addition, academic results and quality of teaching remain important concerns for students, despite evidence that, for the RCS, these are equal to or better than at The University of Melbourne metropolitan clinical schools.

Insights from outstanding rural internal medicine residency rotations at the University of Washington.

PURPOSE: Despite being well suited to provide the breadth of care needed in rural areas, few general internists become rural physicians. Little formal rural residency training is available and no formal curricula exist. For over 25 years the University of Washington School of Medicine has provided elective WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) rural residency rotations to expose residents to the rewards and challenges of rural practice. This study identified the characteristics of outstanding rural residency rotations. METHOD: The key preceptors at three outstanding rural residency sites were interviewed about their experiences, teaching strategies, and opinions about curriculum. Their responses were categorized. Seven university-based residents and eight training at WWAMI sites recorded and rated the value of over 1,500 learning encounters. RESULTS: The preceptors agreed that outstanding rotations were led by enthusiastic preceptors who served as role models for excellence. These preceptors provided residents with meaningful responsibilities and emphasized independent decision making based on the history and physical examination. They stressed supervised independence and self-directed learning with frequent structured feedback for residents. The residents rated the learning value of patient encounters in rural locations significantly higher than that of those in university clinics. CONCLUSIONS: Exceptional rural residency experiences involve excellent role models who provide meaningful responsibility and emphasize core skills using a learner-centered approach. Rural training experiences should be supported, and the suggestions of outstanding preceptors should be used to develop and disseminate a curriculum that will better prepare residents for rural practice.

Primary care residency graduates' reported training needs.

Primary care residency graduates were surveyed about their satisfaction with their training. The respondents desired more training in outpatient knowledge and procedures, psychosocial skills, and business skills.

What influences career choices among graduates of a primary care training program?

OBJECTIVE: To identify factors that influence primary care residents to become generalists or specialists. DESIGN: Structured survey and interview. SETTING: A large university-based, internal medicine residency program in primary care. PARTICIPANTS: Of 92 residency graduates who completed training between 1979 and 1993, 88 (96%) participated. MAIN RESULTS: Although 82% of the participating graduates reported themselves very committed to primary care at the beginning of residency, only 68% pursued generalist careers. Factors influencing career choice that were more important to generalists than specialists included breadth of knowledge used in primary care practice (p = .04), breadth of clinical problems in practice (p = .001), and opportunity for continuity of care (p = .01). Although salary was rated "not important," 50% of generalists and specialists advocated increased salaries for generalists as a way to increase interest in primary care. Other promoting factors included mentors, increased prestige for generalists, community-based training, lifestyle changes, and decreased paperwork. Seventy-three percent of participants felt it was easier to be a specialist than a generalist. CONCLUSIONS: A substantial minority of primary care residents pursue specialty careers. To produce more generalists, graduates recommend addressing income inequities, providing generalist role models, increasing community-based teaching, and increasing prestige for generalists.

Endocarditis in injection drug users.

Injection drug use is an important risk factor for endocarditis. The clinical manifestations of endocarditis associated with injection drug use differ from those in person who do not use drugs. Endocarditis in drug users more often affects the right side of the heart and presents with fever and pulmonary emboli rather than left-sided emboli. Blood cultures and echocardiography are the mainstay of diagnosis; these tests are particularly helpful in identification of endocarditis associated with injection drug use because of the high frequency of right-sided valvular involvement and the low incidence of culture-negative endocarditis in this population. Since staphylococcal species are the dominant causative organism, penicillin and an aminoglycoside are the treatments of choice. Injection drug users with left-sided endocarditis or with symptomatic human immunodeficiency virus infection have poor prognoses.

Electrosurgical loop excision of the cervical transformation zone: the experience of family physicians.

BACKGROUND: Electrosurgical loop excision of the cervical transformation zone (ELECTZ) is an excisional surgical procedure for treatment of premalignant cervical disease and the abnormal transformation zone by wire loop electrodes. The purpose of this study was to describe and assess the clinical experiences and complications of family-physician-performed ELECTZ and ELECTZ conization. METHODS: Women who were scheduled for the ELECTZ or ELECTZ conization procedures were enrolled in the study between March 1992 and March 1993, inclusive. Subjects were recruited from the practices of six family physician colposcopists located at five sites. The ELECTZ and ELECTZ conization procedures were performed on patients with abnormal Papanicolaou (Pap) smears or abnormal histologic results and abnormal colposcopic findings. Procedural complications were documented. Subjects were serially assessed during the first postoperative year by Pap smears, colposcopy, and, when necessary, by biopsy to determine therapeutic cure. RESULTS: Of 198 subjects enrolled in the study, 148 women were assessed at least once in follow-up by Pap smear and colposcopy. Only 7.6% of women were defined as treatment failures by subsequent histologic assessment. Women treated by ELECTZ conization were older (32.2 vs 25.1 years, P = .02), were more likely to develop posttreatment cervical stenosis (25.9% vs 3.8%, P = .001), and were more likely to have the postoperative squamocolumnar junction positioned in the endocervical canal (32.4% vs 8.7%, P = .002) than were women treated by ELECTZ: Loop excision specimen margins demonstrated dysplasia for 27 (13.6%) subjects. Significant operative bleeding (> 25 mL) was noted in 6.8% of subjects. Histologic thermal artifact was reported for 9.6% of specimens. One case of microinvasive cancer and one case of invasive cancer were identified unexpectedly by ELECTZ conization. CONCLUSIONS: Electrosurgical loop excision of the cervical transformation zone and ELECTZ conization may be safely and effectively performed in office settings by family physicians. Complications and treatment failure rates for the ELECTZ and ELECTZ conization procedures were similar to those experienced by other clinicians.

Earlobe keloids.

Earlobe keloids are a challenging management problem. These benign, fibrous proliferations develop in predisposed persons at sites of cutaneous injury or as the result of ear piercing, burns or surgical procedures. Earlobe keloids usually appear as shiny, smooth, globular growths on one or both sides of the earlobe. Patients frequently complain of cosmetic embarrassment, but also may report pruritus, pain or paresthesias. No single therapeutic modality is best. The location, size, depth and duration of the earlobe keloid influence the choice of therapy. Surgical treatment for earlobe keloids generally includes core excision with low-tension wound closure, and shave excision. Surgical repair with corticosteroid injections and postoperative pressure on the incision site usually provide good cosmetic results. Patients must be counseled about recurrence, palpable postoperative nodules and the need for close monitoring.

The fusiform excision.

The fusiform excision of a skin lesion is a common procedure in outpatient care. The appearance of the final scar is improved by orienting the excision parallel to resting skin tension lines with at least a 3:1 length-to-width ratio, undermining the lateral wound edges and using absorbable subcuticular sutures. A properly designed fusiform excision can be closed primarily and infrequently results in the formation of excessive mounds of tissue at the wound ends, known as "dog-ears."

Skin damage associated with the Norplant contraceptive.

Three cases of localized skin reaction in the first month after implantation of the Norplant contraceptive resulted in a partial implant expulsion and removal in one patient, and implant removal in another. Clinical evidence of infection was absent in all patients. While lidocaine with epinephrine was used in all three patients, the cause for these skin reactions remains unclear. Physicians should be alerted to the possibility of significant skin reactions associated with this procedure.

Dyspareunia. Tracing the cause.

Difficult or painful sexual intercourse is a sensitive topic for most women. The causes range from inflammation of the vulva and interstitial cystitis to marital discord. To exclude an organic disorder, a detailed pelvic examination with good lighting and magnification is in order. Dr DeWitt describes the technique for meticulous examination and discusses the diagnoses that need to be considered.