Choice or chance! The influence of decentralised training on GP retention in the Bogong region of Victoria and New South Wales.

INTRODUCTION: Attracting, training and retaining GPs in rural communities has long been the subject of intense interest and debate in medical and political circles. Government reviews and policy decisions, including the introduction of the ten-year moratorium (a strategy to place overseas-trained doctors in rural locations), have been implemented to address workforce shortages in rural Australia. In a landmark decision in 1998, a government assessment of GP training recommended dissolution of centralised general practice education and, in 2003, regional training providers began training GP registrars in a decentralised environment. This study examines the impact of the decentralised model of GP training on the retention of GPs who trained with Bogong Regional Training Network between 2004 and 2009. The study also explores the differences in perspectives of Australian and overseas-born GPs as these relate to remaining in rural practice. METHODS: Registrar file data were examined and socio-demographic profiles of GPs compiled. Of a total sample of 61 doctors who had completed their GP training with Bogong, 30 agreed to participate in semi-structured interviews to discuss career path decisions. Each doctor was offered a small honorarium for participating. A response rate of 58.8% was achieved for those doctors who could be contacted. The data sets were then analysed to identify and examine themes associated with GP career path decision choices. RESULTS: At the end of 2009, more than 42% (n=24) of the doctors who had completed their vocational training were in rural general practice; 32% (n=18) remaining in the Bogong region. There was a significant relationship between the place of birth and remaining in rural practice, with almost three-quarters (73% n=16) of the Australian-born respondents and almost one-quarter (23% n=8) of the overseas-born respondents remaining in rural practice after fellowship (χ² = 13.68 p<0.001); but of the nine overseas-born, Australian-trained medical graduates, only one has remained in rural practice. CONCLUSIONS: The decentralised training model has had a positive influence on retention rates in rural practice in the Bogong region. There are cultural and regulatory differences between Australian and overseas-born doctors that profoundly influence the decision to locate and remain in rural communities with Australian-born doctors significantly more likely to remain in rural practice after the completion of training. For Australian-born doctors, informed choice draws them to rural general practice, while for overseas-born doctors, chance is a major contributing factor that influences their decisions to locate in the region. This study supports the continued development of decentralised and rural specific training pathways for Australian doctors as an effective method for attracting and retaining doctors in rural Australia during and after general practice training.

GP Proceduralists: 'the hidden heart' of rural and regional health in Australia.

INTRODUCTION: General practitioner proceduralists are a distinct and highly trained cohort of doctors who provide procedural services in hospitals and emergency rooms throughout Australia. However, their value is not well recognised in the wider system of primary health care. Consequently, an understanding of the landscape of GP procedural practice is an essential element of health service planning now and in the future. Therefore, empirical data from a 2008 study of GP procedural medicine in the Bogong region of north-east Victoria and southern New South Wales is presented. The implications of shifting trends in the demand for and supply of the GP procedural workforce on future health services is examined. A comprehensive literature review established past and future trends in procedural medicine and provided a context for three research questions: (1) What procedures are being performed by GP proceduralists in the Bogong region? (2) What procedures are no longer performed and why? (3) What is the likely future of GP procedural practice in the next 5 to 10 years? METHOD: A qualitative case study methodology was chosen to explore the factors that influence the nature of GP procedural medicine. A population of 70 GPs were initially identified as practising obstetric, surgical or anaesthetic procedures. Of these, 38 participated in structured interviews, 21 were electronically surveyed and 11 were excluded from the study. Combined interview and survey responses gave a response rate of 81%. Five health service executives and a senior Department of Human Services manager were interviewed to gather their perspectives about the research questions. Content and thematic analysis revealed key issues of importance. Data-sets were examined to analyse themes associated with trends in GP procedural medicine over time. RESULTS: General practitioner proceduralists are attracted by diversity, challenge and passion for procedural work. However, there has been a gradual but sustained decline in the volume and complexity of procedural work due, in part, to shifts in community demography, changing medical practices, the rise of specialisation, the centralisation of services, infrastructure and other costs, and fear of litigation. Moreover, an ageing workforce and a shift in the demographic profile of GPs and the pressures of procedural life have contributed to a decline in GP proceduralist numbers. Nevertheless, there remains a substantial demand for GP procedural medicine in rural communities. CONCLUSIONS: Rural towns are dependent upon GP proceduralists to ensure the continuing health and sustainability of local communities. However, the existence of a viable and robust workforce of GP proceduralists is at a 'breaking point'. Until GP proceduralists are recognised and counted as a distinct cohort of valued and highly trained medical practitioners they will remain the 'hidden heart' of primary care in rural and regional Australia. An holistic approach must be adopted to attract, train, maintain and recognise the GP proceduralists' unique place in rural health. With the Australian health system under government review, there are opportunities to revitalise GP procedural practice as a long term, viable and challenging career choice and ensure on-going support for rural in-patient and emergency department services.

Cancer of the colon and rectum in the West Midlands, 1957-1981.

Between 1957 and 1981, 49,904 patients with large bowel cancer were registered at the Birmingham Cancer Registry. The annual incidence was 24.5 per 100,000 population for colonic cancer and 18.4 per 100,000 for that of the rectum. The annual number of patients increased by 41.9 per cent. The age-adjusted 5-year survival rate was 26.4 per cent for colonic carcinoma and 28.2 per cent for rectal cancer. Between 1977 and 1981 these rates increased significantly to 30.3 and 30.0 per cent respectively (P < 0.01). Stage for stage, colonic cancer was associated with longer survival than that of the rectum. Curative and palliative resection rates increased, especially for anterior resection. The operative mortality rate remained constant at 8 per cent. Despite increases in palliative resection rates 50 per cent of these patients required a stoma. Treatment was not undertaken in 37.4 per cent of patients. The end results of treatment are little better than those reported previously from this registry.

Abdominal aortic aneurysms complicated by spontaneous iliocaval or duodenal fistulae.

Seven hundred and twenty one abdominal aortic aneurysms were treated between 1960 and 1985. Twenty one of these (2.9%) were complicated by the development of a spontaneous primary fistula, 16 (2.2%) into the vena cava or iliac veins and 5 (0.7%) into the duodenum. A correct preoperative diagnosis was made in only four instances, two aorto-caval and two aorto-duodenal fistulae. Hospital mortality was 44% for aorto-caval and 60% for aorto-duodenal fistulae. Despite the lack of a precise preoperative diagnosis in the majority of cases, the prognosis for aorto-caval fistula remained comparable to that for patients undergoing emergency surgery for uncomplicated ruptured aortic aneurysms. The mortality of spontaneous aorto-duodenal fistulae was appreciably higher and the aneurysmal contents of 4 out of these 5 cases had positive bacterial cultures.

Peripheral arterial embolism. A 20 year review.

Two hundred and forty eight peripheral arterial emboli occurring in 221 patients during a period of 20 years have been retrospectively reviewed. Best results are seen following early surgery with the balloon catheter but, in the clinical absence of tissue necrosis, late embolectomy is worthwhile. Atrial fibrillation and post-myocardial thrombus are the major sources of emboli, but tumour and septic emboli do occur and histological and bacteriological examination of retrieved material is essential. Patients who have sustained myocardial infarction have an increased risk of embolism in the first two weeks and despite modern therapy its incidence remains unchanged. Distinguishing true embolism from acute arterial thrombosis is a continuing problem and different surgical regimes for the two conditions are discussed. Embolectomy following anticoagulation has a high limb salvage rate and a low mortality; anti-coagulation as an adjuvant to surgery also improves prognosis for these patients who have lower amputation rates than those not anticoagulated.

Takayasu's arteritis: a pathogenetic role for cytotoxic T lymphocytes?

Takayasu's arteritis is an inflammatory panarteritis of unknown aetiology affecting large elastic arteries. We examined a segment of abnormal common carotid artery removed at by-pass surgery from a 23-year-old man with typical angiographic features of Takayasu's arteritis. Using monoclonal antibodies we were able to demonstrate marked infiltration of the arterial wall with OKT8 positive lymphocytes (suppressor/cytotoxic cells) but not with OKT4 positive lymphocytes (helper cells). Studies of circulating lymphocytes showed increased numbers of "activated" cells and increased in vitro cytotoxicity against cultured human umbilical cord endothelial cells, compared to normal lymphocytes. Cellular immunological mechanisms may play an important role in the pathogenesis of Takayasu's arteritis, possibly through the direct action of cytotoxic T cells on large elastic arteries.

Atherosclerosis in vascular grafts for peripheral vascular disease. Part 2. Synthetic arterial prostheses.

Thirty-nine synthetic (32 Dacron and 7 Teflon) arterial prostheses (from 38 patients with peripheral arterial disease) removed after periods between 2 months and 18 years, were examined by histology and immuno-histology. The grafts were initially permeated by thrombus containing platelet antigens and this became organised and converted to granulation, and then to fibrous, tissue. The newly-formed tissue contained 'foreign-body' giant-cells in contact with the plastic prosthesis and showed evidence of permeation by plasma proteins. In grafts of over 2 years duration, this reactive tissue no longer contained platelet antigens but invariably revealed bound lipid, identifiable as apolipoprotein-B-containing lipoproteins (LpB), and fibrinogen-related antigens (FRA), in a distribution resembling that seen in atherosclerotic arteries. LpB and FRA were also seen in organised, or partially organised, mural thrombi in older grafts. The oldest grafts additionally showed stenosis, calcification or aneurysm formation. Lipid deposition increases with the age of grafts; is independent of the nature of the plastic fibre used or its mode of fabrication; and sometimes contributes to graft failure. Immuno-histology indicates that this is an insudative process indistinguishable from 'true' atherosclerosis which occurs in graft-linings of prostheses of long duration and in old mural thrombi in grafts and that the lipid in these lesions derives from plasma LpB rather than from platelets. This source for the lipid suggests that the insudative and thrombogenic theories of atherogenesis can be reconciled.

Perioperative complications of in-situ vein bypass.

Experience with 146 in-situ vein bypass procedures for obliterative arterial disease are reviewed to determine the specific complication of the technique. Vein wall injury with the Hall valvulotome occurred in 6 patients (4%) and vein patching of a stenosed femoral vein was required in 2 patients. Residual arteriovenous fistulae occurred in 24 patients (16.5%) of whom 9 had an associated graft thrombosis distal to the fistula of which 6 were corrected by thrombectomy and fistula ligation. Perioperative thrombosis occurred in 29 grafts (20%) and was more common in the femoropopliteal group (23/80) than in the femorocrural group (6/66) (P less than 0.01, X2 = 7.55). Fourteen of the femoropopliteal and two of the femorocrural thromboses were corrected resulting in an immediate patency of 89% and 94% respectively with the cumulative patency at one year being 77.5% and 79%. Complications of the in-situ bypass technique remain despite having largely overcome the problems of valve disruption. However, until a standard method emerges careful note must be made of technique and complications when considering reports of in-situ bypass patency.

Crohn's disease involving the penis.

Perianal complications of Crohn's disease occur in 25-70% of patients but perineal and genital lesions are rare. Treatment is controversial and there is a risk of recurrent or persistent disease. We report two cases of Crohn's disease involving the penis, one with multiple scrotal urinary fistulae, partial destruction of the proximal urethra, and ulceration of the penile shaft; the other with metastatic cutaneous ulceration of the penile shaft. The second case is particularly unusual in that the patient presented at the VD clinic as a case of syphilis.

Problems in diagnosis of popliteal aneurysms.

Clinical features and errors in diagnosis have been assessed in a retrospective study of 62 popliteal aneurysms in 40 patients, 22 of whom had bilateral aneurysms. Only 29% of patients complained of pain or swelling behind the knee, while 31% of aneurysms had produced distal ischaemia presenting as intermittent claudication, 9 aneurysms had thrombosed producing ischaemic rest pain in 6 legs, and 4 aneurysms had ruptured. Although 94% of aneurysms were suspected or confidently diagnosed by palpation alone, only 43% of patients had had the correct diagnosis made at the time of initial referral. Treatment was delayed in 12 patients, 8 of whom subsequently required amputation. Popliteal aneurysm should be suspected in patients with a prominent popliteal pulse who present with intermittent claudication, and in patients with acute ischaemia of the leg who may have a thrombosed aneurysm requiring surgical exploration.

Significance of positive bacterial cultures from aortic aneurysm contents.

Aneurysm contents were cultured in 275 patients out of a series of 546 cases undergoing infrarenal aortic aneurysm repair between 1961 and 1981. The incidence of positive cultures was 8 per cent. Cultures were more likely to be positive if taken from ruptured (16.7 per cent) and acute (9.1 per cent) aneurysms than from elective (4.2 per cent) cases (X2 = 6.69, P less than 0.01). Gram-positive organisms predominated with Micrococcus being the commonest isolate. Positive cultures were seen at an annual rate of 1-3 cases up to 1976 since which time all have been negative and we believe this may be due to prophylactic antibiotics being given preoperatively rather than postoperatively. The incidence of subsequent graft sepsis was greater in patients with positive aneurysm contents cultures (7 out of 22) than in those with negative cultures (6 out of 253) (X2 = 32.7, P less than 0.001). We recommend the routine culture of aneurysm contents to identify patients who are at high risk of developing graft sepsis and suggest that those cases with positive cultures receive prolonged organism-specific antibiotic therapy. In addition, there is evidence that pre-operative antibiotics may eliminate organisms from aneurysms, thus reducing the subsequent risk of graft sepsis.

Atherosclerosis in vascular grafts for peripheral vascular disease. Part 1. Autogenous vein grafts.

29 autogenous vein grafts, from 26 patients with peripheral arterial disease, were studied. 4 grafts of Group I (less than 3 months duration) were patent and removed for reasons other than graft failure. These showed 'arterialisation' only; 4 grafts of Group II (duration 5-18 months) showed thrombotic occlusion; 21 grafts of Group III (duration greater than 2 years) showed impaired graft patency and lipid identifiable as apolipoprotein B-containing-lipoproteins (LpB), and fibrinogen-related antigens (FRA) were seen as intramural deposits in the thickened grafts. LpB was also seen in a perifibrous distribution on the collagen of organised thrombi. Complicated lesions in some Group III grafts showed stenosis or occlusion, ulceration, calcification or aneurysm formation. These features suggest that a process indistinguishable from 'true' atherosclerosis affects vein grafts of long duration. The ways in which such changes may: contribute to graft failure; and improve our understanding of the basic processes involved in atherogenesis, are discussed.

Acute gastrointestinal complications of infrarenal aortic aneurysm repair.

Acute gastrointestinal complications developed in 31 of 472 patients following aortic aneurysmectomy (6.6 per cent). In order of frequency these were: ischaemic intestine in nine patients, mechanical or paralytic ileus in eight patients, peptic ulceration in seven patients, undiagnosed gastrointestinal bleeding in five patients and paraprosthetic fistula in two patients. The risk of developing peptic ulcer complications was not significantly increased in patients with a previous history of peptic ulcer disease. The risk of developing an ischaemic intestine was increased if the distal limb of a prosthesis was anastomosed directly to the external iliac artery. The associated mortality was high and 21 (67.7 per cent) patients died. 33.3 per cent of the mortality occurring with elective aneurysm resection was associated with gastrointestinal complications.

Ruptured aortic aneurysms: postoperative complications and their aetiology.

A review of 198 ruptured aortic aneurysms has been undertaken, this being 36.3 per cent of all the aneurysms treated during the period 1960-81. The overall mortality rate was 42.9 per cent. The peroperative mortality was 6.6 per cent and the mortality of the patients who survived the operation was 38.9 per cent. Factors which influenced postoperative mortality were the age of the patient, the distance travelled to hospital, the presence of an intraperitoneal bleed, the duration of the operative procedure and the volume of blood transfused, but only the amount of blood transfused had a statistically significant influence on mortality. However, as the highest mortality associated with any of these risk factors was 54.9 per cent, no single factor alone can be considered a contra-indication to operation. As there are no reliable predictive factors, we believe that all cases with clinically ruptured aortic aneurysms should have a laparotomy and resection. The most common postoperative complications were varying degrees of renal and respiratory insufficiency and the occurrence of these was significantly associated with the volume of blood transfused.

Recurrent insulinoma syndrome with metastatic glucagonoma.

A case is reported of a patient who presented with symptomatic hypoglycaemia and who had three pancreatic tumours resected over the ensuing eight years. Immunocytochemistry demonstrated two of these to be insulinomas and the third to be a glucagonoma. In addition metastatic spread of cells positive for glucagon had occurred to a lymph node and multiple nodules staining positively for glucagon were present in the remainder of the pancreas.