Advanced rural skills training: are recently qualified GPs using their procedural skills?

INTRODUCTION: The number of GPs providing procedural services in rural areas is declining; however, few studies have investigated issues directly relevant to recently qualified doctors. Limited published data and anecdotal reports in Australia suggest that a large proportion of doctors leave rural procedural practice soon after training. This study aimed to: (1) describe where GPs practice in the 5 years after advanced rural skills training; (2) describe the proportion of doctors using their advanced skills; (3) measure doctors' ratings of the quality of support and how critical the year directly following training is in future career choices; and (4) measure the association between support and use of advanced skills. METHODS: A cross-sectional, postal survey was undertaken of doctors who had completed advanced rural skills training in Queensland between 1995 and June 2009. Data were collected on a three-page, structured questionnaire. General practice colleges, the three Queensland regional training providers and one national training provider were approached in order to identify and mail questionnaires to eligible doctors. Descriptive statistics were prepared for practice history information, and attitudinal ratings. A χ(2) test was used to analyse the association between support and use of skills. RESULTS: Sixty-one completed questionnaires were returned resulting in an unadjusted response rate of 51.7%. Respondents had completed a range of training posts: obstetrics and gynaecology (37.7%), anaesthetics (18%), anaesthetics and obstetrics and gynaecology (11.5%) and Aboriginal and Torres Strait Islander health (11.5%). Thirty-nine respondents (63.9%) were using skills related to their advanced training at the time of the study. In the first 5 years after training, the percentage of doctors using their advanced rural skills decreased from 75.4% to 61.1%. The year directly following advanced training was rated as 'critical' or 'very critical' in their future career choices by 68.9% of respondents. However, ratings of the quality of support received in that year were varied, with 21.4% reporting 'very poor' support. There was a statistically significant association between ratings of support in the year directly following training and the use of skills 3 years after training (χ(2) = 8.715, df = 2, p = 0.013). CONCLUSIONS: This study has shown that while the majority of doctors are using skills related to their advanced rural skills training, there is room for improvement through training and career planning support, extending formal support mechanisms into the first year after training, improving opportunities to use advanced skills and improving systems to re-engage doctors into procedural practice.

Fusobacterium necrophorum-induced sepsis: an unusual case of Lemierre's syndrome.

Classical Lemierre's syndrome is characterized by severe sepsis with metastatic abscess formation in young, previously fit people from a primary head or neck focus. The causative organisms are the anaerobic fusobacteria, most commonly Fusobacterium necrophorum. We describe the evaluation, therapeutic interventions and management of a patient with Lemierre's syndrome who presented in septic shock with multiple organ dysfunction. The patient required immediate interventions including endotracheal intubation and mechanical ventilation, fluid resuscitation, inotropic support, bilateral thoracostomy tube drainage of empyemata and antimicrobial therapy. The unexpected isolation of Fusobacterium necrophorum from blood cultures and empyema fluid necessitated a change of antibiotic regime to provide anaerobic cover. The patient required 4 weeks of intensive support including prolonged antimicrobial therapy, and after a further 2 weeks was discharged home from hospital. This case highlights the need to raise the awareness of 'the forgotten disease': Lemierre's syndrome. Its diagnosis may, as in this case, be confounded by a lack of symptoms of pharyngitis at the time of presentation, and end-organ dysfunction associated with severe sepsis, possibly suggesting an alternative source of infection. As appropriate antibiotics reduce mortality dramatically, clinicians need to be alert to Lemierre's syndrome and include it in the differential diagnosis in young but otherwise healthy patients presenting with severe sepsis.