www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
What
do
otolaryngologists
want
to
learn?
An
educational
targeted
needs
assessment
study
夽
Mustafa
Dalo˘
glu
∗,
Mustafa
Kemal
Alimo˘
glu
AkdenizUniversity,FacultyofMedicine,DepartmentofMedicalEducation,Antalya,Turkey
Received2July2018;accepted5December2018 Availableonline31December2018
KEYWORDS Otolaryngology; Needsassessment; Education; Residency Abstract
Introduction:Targetedneedsassessmentwhichincludesidentifyingtheneedsoflearnersisa keystepofprogramdevelopment.However,thisstepiscommonlyunderestimatedin postgrad-uatemedicaleducationprograms,includingotolaryngologyresidencytraining.Determiningthe needsofotolaryngologistsmayhelpeducatorstodesignmorepurposefulcontinuingmedical educationtrainingprograms.Furthermore,needsofspecialistsmayprovideaclearerinsight abouteffectivenessoftheresidencyprogramsinthatspecialty.
Objective: Todeterminetrainingneedsofotolaryngologyspecialistsandtoidentifydeficiencies inotolaryngologyresidencytrainingprograms.
Methods:Seventy-eight otolaryngologyspecialists, who completed all data gatheringforms properly,wereincludedinthisdescriptive,cross-sectionalstudy.Demographicdataofthe parti-cipantswerecollected.Trainingneedsoftheparticipantsweredeterminedinsevenbasicareas ofotolaryngologyviatwo-roundDelphimethod.Thebasicareaswereotology---neurotology, rhi-nology,laryngology,headandnecksurgery,pediatricotolaryngology,sleepdisordersandfacial plasticsurgery.Additionally,weaskedanopen-endedquestiontoinvestigatethereasonswhy theparticipantsperceivedthemselvesincompetentandundereducated,orwhytheyneeded furthertraininginsomeofthebasicotolaryngologyareas.
Results:Facialplasticsurgery,otology-neurotologyandheadandnecksurgerywerethemost citedtrainingareasintheneedsassessment.Trainingneedsdifferedaccordingtoexperience and place ofwork. Financial expectations, deficiencies inresidency training, regression in knowledge andskills, and special interestwere effective determinants ondecisionsofthe participantswhiledeterminingtheirtrainingneeds.
夽 Pleasecitethisarticleas:Dalo˘gluM,Alimo˘gluMK.Whatdootolaryngologistswanttolearn?Aneducationaltargetedneedsassessment
study.BrazJOtorhinolaryngol.2020;86:287---93.
∗Correspondingauthor.
E-mail:drmustafadaloglu@gmail.com(M.Dalo˘glu).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2018.12.001
1808-8694/©2018Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Conclusion:Otolaryngologistsneedfurthertraininginsomeareasoftheirfieldduetodifferent reasons.Determiningtheseareasandreasonswillhelpindesigningmoreeffectivecontinuous medicaleducationactivitiesandresidencytrainingprogramsinotolaryngology.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Otorrinolaringologia; Avaliac¸ãodas necessidades; Educac¸ão; Residência
Oqueosotorrinolaringologistasqueremaprender?Umestudodeavaliac¸ãodas
necessidadeseducacionaisespecíficas
Resumo
Introduc¸ão:A avaliac¸ãode necessidadesespecíficas, queinclui aidentificac¸ão das necessi-dadesdosalunos,éumpassofundamentalnodesenvolvimentodeprogramaseducacionais.No entanto,essaetapacostumasersubestimadaemprogramasdepós-graduac¸ãoemeducac¸ão médica,inclusivenaresidênciaemotorrinolaringologia.Determinarasnecessidadesdos otor-rinolaringologistas pode ajudar os educadores a projetar programas mais direcionados de treinamentoemeducac¸ãomédicacontinuada.Alémdisso,aanálisedasnecessidadesdos espe-cialistaspode oferecer uma visão clara sobreaeficácia dosprogramas deresidência nessa especialidade.
Objetivo:Determinarasnecessidadesdetreinamentodeespecialistasemotorrinolaringologia eidentificardeficiênciasnosprogramasderesidênciaemotorrinolaringologia.
Método: Esteestudodescritivoetransversal incluiu78especialistasem otorrinolaringologia quepreencheramtodososformuláriosdecoletadedadosadequadamente.Osdados demográ-ficos dos participantes foram coletados. Asnecessidades de treinamento dos participantes foramdeterminadasem seteáreas básicasdaotorrinolaringologiacomométodoDelphi em duasrodadas.Asáreasbásicasforamotologia/neurotologia,rinologia,laringologia,cirurgiade cabec¸aepescoc¸o,otorrinolaringologiapediátrica,distúrbiosdosonoecirurgiaplásticafacial. Alémdisso, umaperguntaabertafoiusada parainvestigarosmotivospelosquaisos partici-pantesconsideravamterpoucoconhecimentoouserincapazesdeatuarnessaárea,ouporque precisavamdemaistreinamentoemalgumasdessasáreasbásicas.
Resultados: Naavaliac¸ão das necessidades,cirurgia plástica facial, otologia-neurotologia e cirurgiadecabec¸aepescoc¸oforamasáreasdetreinamentomaisrelatadas.Asnecessidades de treinamento variaram de acordocoma experiência e olocal de trabalho.Expectativas financeiras,deficiênciasnotreinamento durantearesidência,regressãodoconhecimentoe habilidades,alémdeinteresseespecial,foramdeterminantesefetivosnasdecisõesdos partic-ipantesaoidentificarsuasnecessidadesdetreinamento.
Conclusão:Por diferentes motivos,os otorrinolaringologistasprecisam demais treinamento em algumasáreas.Adeterminac¸ãodessasáreasemotivos ajudaráaplanejaratividadesde educac¸ãomédicacontinuadaeprogramasdetreinamentoemresidênciaemotorrinolaringologia maiseficazes.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
AccordingtoasurveyconductedintheUK,17%ofreferralsin primarycareintheadultpopulationand50%inthepediatric populationaremadetootolaryngologists.1 This showsthe importanceof undergraduate and postgraduate education inthefieldofotolaryngologyintermsofcommunityhealth. In early 2000s, the Turkish Association of Otorhinolaryngology-Head and Neck Surgery (TAO-HNS) started studies to develop a core curriculum for 5 year otolaryngology residency training in Turkey. Goals and objectives of the sample core residency training curricu-lum were set considering the healthcare needs of the
community. The association hasalso provided suggestions about educational strategies and implementation of the coreresidencycurriculum.
In developing a medical education curriculum at any level, the six step approach suggested by Kern is a com-monlyreferencedmodel.Thestepsare:(1)Generalneeds assessment, (2)Targetedneeds assessment,(3) Goalsand objectives,(4)Educationalstrategies,(5)Implementation, and(6)Evaluationandfeedback.2Whenwetriedtomatch thestepsofKern’smodelandhistoryofdeveloping acore otolaryngologyresidencytrainingcurriculuminTurkey,we found some attempts that could be placed in every step except for one. The ultimate goal of any undergraduate
or postgraduate medicaleducation curriculum is to solve healthproblemsofthecommunity.Therefore,thefirststep isgeneralneedsassessmentwhichincludesidentifyingthe healthcareproblemsthatwillbeaddressedbythe curricu-lum. While settinggoals andobjectives (thethird stepin themodel)theTAO-HNStookcommonlyseenEar,Noseand Throat(ENT)diseasesintheTurkishpopulationintoaccount as an attempt for the first step (general needs assess-ment).TAO-HNSalsosuggestedsomeeducationalstrategies (Step4),implementation(Step5)andevaluation (Step6) methods for the departments. For example, in order to achieve minimum acceptable standards nationwide, resi-dentlog-bookswerepreparedbytheassociationtobeused ineverydepartment.3However,thesecondstep,‘‘targeted needs assessment’’, which includes identifyingthe needs of learners, has been ignored, i.e. learning needs of the otolaryngology residents have not been studied to date. Self-directedlearningisacommonlypreferredmethodfor medical residents to learn throughout residency training process. Therefore, determining learning needs, special areasofinterestorpersonalexpectationsmayhelp educa-torssupporttheprofessionaldevelopmentoftheresident.4 The TAO-HNS also offers Continuing Medical Education (CME) activities for otolaryngology specialists. Targeted needsassessmentlacksinthedevelopmentprocessofsuch programsaswell.Adultlearningtheoryassumesthatadults aremotivatedtolearnastheyexperienceneedsand inter-ests that learning will satisfy; therefore, these are the appropriate starting points for organizing adult learning activities.5Consequently,itisclearthatneedsassessment of the target learner group, in other words, the process of identifying thegap between thecurrent and ideal sit-uation, is an important step in curriculum development and deserves every kind of effort. Although the concept andvalue of needs assessment is well accepted,relevant literature-basedinformationin postgraduatemedical edu-cationislimited.6
Thisstudyfocusesonneedsassessmentofthespecialists withtheresearchquestion‘‘Whatarethelearninggapsand trainingneedsofotolaryngologyspecialists?’’Our expecta-tionwasthattheanswerstothisquestionmayalsoprovide someindirectinformationaboutthelearningneedsof the residentswhoarethespecialistsofthenearfuture. There-fore,theaimofthisstudywastodeterminetrainingneeds ofotolaryngologyspecialistsandtoidentifyareasforfurther emphasisintheotolaryngologyresidencytrainingprograms.
Methods
StudydesignThisdescriptive,cross-sectionalstudywasperformedamong otolaryngology specialists to determine training needs of theparticipantsforsevenpreviouslydeterminedbasicareas of otolaryngology diseases via two-round Delphi method. Additionally, we investigated the reasons behind why the participantsperceivedthemselvesincompetentand under-educatedorwhytheyneededtraininginsomeofthebasic areasofotolaryngology.
Participantsandethicalissues
Our target population was the entire otolaryngology spe-cialty in Turkey. However, considering the difficulties in reachingallofthem,wepreferredtostudyasample popula-tionthatmayrepresentdifferentages,experience,careers
or affiliation groups. We tookthe nationalcongress asan opportunitytoreachandencounterasmuchspecialistsas possible.Wedeliveredthedatagatheringformsto118 per-sons.Finally,78specialistswhocompletedalldatagathering formsproperlyinallroundscomposedthestudygroup. Ethi-calapprovalforthestudywasgrantedbyAkdenizUniversity BoardofEthicsonNoninvasiveClinicalHumanStudies (Refe-renceNo.06.10.2016/515).
Datagatheringformsandprocess
We developed a written data formincluding three parts: (1)Demographic data(askingfor age, gender, durationof experience as a specialist, and the institution the par-ticipant worked for); (2) A list to be ranked by priority order,and(3)Open endedquestions.Thelistincludesthe titlesof seven basic areas ofotolaryngology: (1) Otology-Neurotology, (2) Rhinology, (3) Laryngology, (4) Head and NeckSurgery,(5)PediatricOtolaryngology,(6)Sleep Disor-dersand(7)FacialPlasticSurgery.The listwasgenerated regardingbasicareasofcontinuingmedicaleducation activ-itiescalledENTschoolswhichareorganizedbyTAO-HNS.
Two-roundDelphitechniquewasusedtodetermine pri-oritiesof theparticipants in termsof trainingneeds. The Delphisurveyisagroupfacilitationtechnique,whichisan iterative multistage process, designed to transform opin-ion intogroup consensus.It is a flexible approachthat is usedcommonly withinthe health and social sciences.7 In our study we initially deliveredthe forms to the partici-pantsand asked them tocomplete the demographicpart andorderthelistregardingthedegreeoftrainingneeds(or deficiencies).Givinganumberbetween1(theareainwhich trainingisneededmost)to7(theareainwhichtrainingis neededleast)toeachitem,theparticipantssortedthelist contentregardingtheir current competency levels,needs andfrequentlyencounteredproblems.Retrievingtheforms, wearrangedthe7itemlistregardingtheprioritylevelsgiven bytheparticipants.Wereverselyscoredtheitemsmarked bytheparticipants,namely,wegave7pointsfortheitem whichwasscored1(toppriority)bytheparticipants.Then, wewereabletoarrangethelistaccordingomeanvaluesof theitems;theitemwithmaximummeanvaluetookparton thetopofthenewlist.Thenewlistthatrepresented par-ticipanttrainingprioritieswasredelivered (second round) totheparticipants10dayslater.Weaskedtheparticipants todothesametasktheydidinthefirstroundandreorder thelistonceagain.Afterthesecond-roundsuggestionshad beenevaluated,wehadafinallistoftrainingareassorted bytheparticipantsregardingtheirprioritiesattworounds. The third part of the data gathering form was an open-ended question asking the reasons behind why the participantsperceivedthemselvesincompetentand under-educatedorwhytheyneededtraininginsomeofthebasic areasofotolaryngology.
Dataanalyses
Weuseddescriptiveanalysestocalculatemeanandmedian valuesoftrainingneedscoresineacharea.Sinceliterature suggeststhat10yearsofpracticeisneededtoreachideal knowledgestructureandclinicalreasoningstrategyfor diag-nosticaccuracyandcorrectdecision-making,8,9wedivided thestudygroupinto2categoriesaccordingtodurationof theexperienceasaspecialistinthefieldas10yearsorless andover10years.WeusedStudent’sttesttocomparemean
Table1 Demographiccharacteristicsofthestudygroup. Characteristics n Age 44.3±12.1 Gender Female 27 Male 51
Durationofexperienceasaspecialist(years)
0---10 43
Over10 35
Institution
TrainingandResearchHospitals 24
StateHospital 35
Privatehospitalandpractice 19
trainingneedscoresofthesetwoexperiencegroupsineach ofthesevenareas.
Wedividedthestudygroupintothreecategories accord-ing to the institutions they worked for as research and traininghospitals(includinguniversityhospitals),state hos-pitals and private hospitals/practices. We used One Way ANOVAtesttocomparemeantrainingneedscoresofthese threegroupsineachofthesevenareas.Allstatistical anal-yses were performed with IBM SPSS Statistics Version 20. The answerstothequalitative part ofthe datagathering form (3rd part) were categorized regarding main themes mentionedinthetexts.
Results
The mean age was 44.3±12.1 (29---72) years and female/male ratio was approximately 1/2 in the study group.Meandurationoftheexperienceasaspecialistwas 13.7±11.2(1---36)years.Thedistributionoftheparticipants accordingtodurationoftheexperienceandworkplacescan beseeninTable1.
InthefirstroundofDelphiimplementation,seven train-ing areas in the list were sorted regarding priorities of participantsinthefollowingorder:(1)Facialplasticsurgery, (2) Otology-neurotology, (3) Head and neck surgery, (4) Laryngology, (5) Sleep disorders, (6) Rhinology and (7) Pediatric otolaryngology. This order did not change with reevaluationofthe ranking ofthe listby theparticipants inthesecondround(Table2).
InTable3,meantrainingscoresandranksofeach train-ingareainexperiencegroupsof10yearsorless,andover10 yearswereprovided.Theuniquedifferencebetweenmean trainingneed scores of these twoexperience groups was found in sleep disorders area in favor of the group with experienceover10years(Studentttest,p=0.003).
Table4providesmeantrainingscoresandranksofeach trainingareainparticipantgroupsworkingindifferent work-places.Mean scoresfortheareas offacialplasticsurgery, sleep disorders, laryngology and pediatric otolaryngology differamongtheworkplacegroups(OneWayANOVA,p<0.05 forall).
Four themes emerged from the answers to the open-ended question about the reasons behind why the participantsperceivedthemselvesincompetentand under-educated,orwhytheyneededtraininginsomeofthebasic areasofotolaryngology.Thesethemeswerefinancial expec-tations (n=31), deficiencies in residency training period (n=44), regression in knowledge and skills throughout
post-training period(n=19), andspecialinterest withthe area(n=40).Amongtheparticipantswithfinancial expecta-tions,mostpreferred(81%)trainingareawasfacialplastic surgery while it was head and neck surgery (47%) among those whoexplain thereason behindtheir training needs asknowledgeandskillretention.The majorityofthe par-ticipants(47%)whoneededtrainingbecauseofdeficiencies inresidencytrainingperiodpreferredfacialplasticsurgery, whichisalsomostfrequentlypreferred(38%)special inter-estarea.
Discussion
This study was conducted with the aim of determining trainingneedsofotolaryngologistsandidentifyingareasfor further emphasis in the otolaryngology residency training programs. Facial plastic surgery, otology-neurotology and headandnecksurgerywerefoundtobetheleadingtraining areasthattheparticipantsperceivedthemselves incompe-tentand/orneededfurthertraining.
Health care professionals are expected to meet cer-tainpatientrequirements aswell asthe useof thelatest evidence-based approaches.10 As attention is focused on maintainingphysiciancompetencyandeliminatingmedical errors, CME is becoming more highly regulated, and CME providersarebeing heldtohigherstandards.11 When cre-ating or revising acurriculum, targetedneedsassessment is an integral step prior to developing appropriate goals andobjectives.2Teachinginstitutionsandeducatorsshould be cognizant of the needs of learners.12 Targeted needs assessment for CME activities among specialists not only provides information about learner needs, but also helps evaluationoftheresidencyprogramsfromwhichthose spe-cialistsgraduated. In other words,common perception of incompetenceandrequirementoffurthertraininginsome areasofthespecialtymaydemonstratethedefectsin resi-dencytraining.Asacommonlyreferredmodel,Kirkpatrick’s FourLevelProgramEvaluationapproachmeasures(1)The learner’s reaction to the program (satisfaction), (2) The learningthattakesplace(confirmedbyassessmentprocess), (3)Thechangeinbehavior(transferofthegainedknowledge andskills topractice),and (4)Resultsachievedinservice taking population.13 Ourstudy results provideinformation forthethirdlevelofKirkpatrick’sprogramevaluationmodel bydeterminingtheareasoftheresidencytrainingcontent thattheparticipantsfeltthemselveswellorpoorequipped forproperperformanceinreallife.
Facial Plastic Surgery was at the top of the training needs listof our participants. Recently, therehasbeen a growing interest in facial aesthetic procedures especially amongyoungadults.14 Turkeyis9thintheworldregarding aesthetic face and head procedures with 132,564 cases (3.1%of allcasesworldwide)per year.15 Ifdemand deter-mines the supply, then it is clear that there is a serious amount of workload and pressure that otolaryngologists havetofaceinfacialplasticsurgery.Thisworkloadand/or pressuremightbethereasonforfacialplasticsurgerytobe themostneededtrainingareainourstudy.Weknowfrom theliteraturethathigherincomeexpectationsplaya moti-vatingroleinselectionoftrainingareaamongspecialists.16 The increasing demandfor aestheticprocedures mayalso be perceived asan extensive market with better income opportunitiesamongotolaryngologists.Thismaybeanother factor carryingthefacialplasticsurgerytothetopof the trainingneedlist.Asasupportingdata,wefoundthatfacial plastic surgery wasthe most preferred area(81%) among participants, who reported financial expectations as the
Table2 TherankingsmeanandmedianscoresoftheareasintwoDelphirounds.
1stround 2ndround
Mean±SD Median Mean±SD Median
Facialplasticsurgery 5.1±2.3 6 5.1±2.2 6
Otology-neurotology 4.6±1.9 5 4.8±1.9 5
Headandnecksurgery 4.2±1.9 4.5 4.4±1.9 5
Laryngology 3.9±1.5 4 3.8±1.5 4
Sleepdisorders 3.8±2.0 4 3.8±2.0 4
Rhinology 3.7±1.9 4 3.6±1.8 4
PediatricENT 2.7±1.6 2 2.6±1.6 2
Table3 Comparisonofexperiencegroupsregardingtrainingneedscoresineacharea.
≤10years >10years pa
Rank Mean±SD Rank Mean±SD
Facialplasticsurgery 1 5.4±2.1 1 4.7±2.4 0.143
Otology-neurotology 2 4.9±1.8 2 4.6±2.0 0.449
Headandnecksurgery 3 4.5±1.8 4 4.3±1.9 0.778
Sleepdisorders 6 3.2±2.0 3 4.5±1.6 0.003
Laryngology 4 4.0±1.4 6 3.5±1.7 0.220
Rhinology 5 3.6±1.8 5 3.6±2.0 0.965
PediatricENT 7 2.4±1.3 7 2.8±1.8 0.334
a StudenttTest.
Table4 Comparisonofthetrainingneedscoresofthegroupsworkingindifferentworkplaces.
Training/Researchhospitals Statehospitals Privatehospitalsandpractices pa
Rank Mean±SD Rank Mean±SD Rank Mean±SD
Facialplasticsurgery 5 3.9±2.5 1 5.8±1.8 1 5.3±2.2 0.006
Otology-neurotology 1 4.8±1.8 2 4.9±1.9 2 4.5±2.0 0.708
Headandnecksurgery 2 4.3±2.3 3 4.7±1.6 4 3.9±1.9 0.279
Sleepdisorders 3 4.2±2.1 5 3.2±1.8 3 4.4±1.9 0.040
Laryngology 6 3.8±1.2 4 4.2±1.5 7 2.9±1.6 0.007
Rhinology 4 4.1±2.0 6 3.1±1.5 5 3.8±2.1 0.111
PediatricENT 7 2.8±1.7 7 2.1±1.3 6 3.2±1.6 0.019
a OneWayANOVA.
mainreasonfortheirtrainingneeds.Finally,deficienciesin residency periodmight beanother reasonfor top priority of facial plastic surgery. We found facial plastic surgery as the most preferred area among our participants, who reporteddeficienciesinresidencyperiodasthemainfactor in determining their training needs. Interest to facial plastic surgery was lowest among participants working in research and training hospitals, possibly due to the fact that such institutions, as tertiary care service providers, aremorefocusedonchallengingcasesofthefieldssuchas otology-neurotologyorheadandnecksurgery.
Otology-neurotology was the second most preferred training area in our study group. This may be explained bysignificant technologicaldevelopmentsindiagnosis and treatment of thediseases in the field.17 Besides the fast-growing theoreticalknowledge,the numberof procedural competencies is also multiplying. The complex nature of otology-neurotology procedures may lead to a prolonged
learningprocesses. Forthis reason,the desired expertise levelmaybechallenging in 5year residencytraining pro-gram. Thus, inadequate residency training in the field of otology-neurotologymightbetheunderlyingreasonfor com-montrainingneedinthisareaamongourparticipants.
Physicians in all specialties care for gradually increas-ingnumberofcancerpatientsandsurvivors.18Thisbasically emphasizes the growing importance of head and neck surgery(thirdmostneededtrainingareainourstudy)among the other otolaryngology subspecialties. The programs of head andneck surgery rotations in residency training are usuallystructuredintenselyandtheproceduresare compli-catedandtime-consuming.Therearestudiesreportingthat residentsinheadandnecksurgeryrotationhave significan-tlyfewerhoursofsleepandhigherhoursofworkperweek comparedtoother rotations.19 Excessiveworkload of the residentsmayleadtoburnoutwhichcouldlowerthe qual-ityofresidencytrainingviaamotivationalbehavior,andit
can alsolower the quality of care for patients.20 So,our participantsmighthaveselectedheadandnecksurgeryas a prominent training need area since theywere not well educatedinthefieldduringresidency.Additionally,besides expertise,head andneck surgeryalsorequires infrastruc-tureandspecialequipmenttobeperformed.Thespecialists workinginhospitalsthatarenotwell-equippedforheadand necksurgerynaturallyavoidthesophisticatedandtiresome interventionsofheadandneckregioninordertoavoidany risk.Thisavoidancemayleadtoregressioninboth knowl-edgeandsurgical skills.Weknowthatlossofcompetence occursinevenmuchsimplerclinicalskills intimeifthose skillsarenotperformedaftertraining.21Consequently,loss ofcompetencetosomedegreemightbeanotherreasonfor commonneedtoheadandnecksurgerytraining.Thispoint ofviewisalsosupportedwiththefindingthatheadandneck surgerywasthemostpreferredarea(47%)amongthe parti-cipantswhoreportedknowledgeandskillregressionasthe mainreasonfortheirtrainingneeds.
Ourparticipantswithexperienceover10yearsreported moretrainingneedsintheareaofsleepdisorderscompared totheir lessexperiencedcolleagues.The reasonmightbe associatedwithhistoryof sleepmedicinein Turkey.Sleep medicinehasbeen the focusofinterest in otolaryngology communityespeciallyinrecentdecade.22Thenexperienced specialistsinourstudygroupwerenottrainedinthisfield during their residency period, since sleepdisorders were missingintheirtrainingcurriculum.Thereshouldbesome additionalareaswhicharenotmissingbutdeficientin res-idency training periods of our participants. Thus, 56% of thestudygrouppointedoutdeficienciesinresidency train-ing period as the main reason for training needs. Such deficiencies were reported in the literature. For exam-ple,Baughetal.hasshownthat,despitetheaccreditation requirements onminimumnumbers for key indicator pro-cedures,residents have graduated without meetingthese minimums.23
Asseen inTable4,interest leveloftheparticipants to some trainingareas differedaccording tothe workplaces wheretheypracticed.Wehavealreadymentionedthe pos-siblereasonoflessinteresttofacialplasticsurgeryamong thoseworkingintrainingandresearchhospitals.However, lessinterestinsleepdisordersandpediatricotolaryngology amongparticipantswhoworked for state hospitalsor low levelofinteresttolaryngologyamongthoseworkingin pri-vate hospitalsor practicesare findingswhich may notbe explainedeasily.Thesemaybetheareas,inwhichthe par-ticipantsmayfeelthemselveshighlycompetent,orpatient profile may change depending on the institutions worked for and the physicians may notneed any further training onrarelyseencases.
Furtherqualitativedatawouldgivevaluableinformation aboutthereasonsbehindourfindings.Therefore,shortage ofqualitative partis thefirst limitationofthe study.The secondprominentlimitationisaboutgeneralizabilityofthe results.Resultsobtainedfromalimitednumberof otolaryn-gologistsinasinglecountrycannotbegeneralized.
Conclusion
Inconclusion,wefoundthatfacialplasticsurgery, otology-neurotologyand head and neck surgery werethe leading trainingareasthattheTurkish otolaryngologistsperceived themselves inadequately prepared and/or needed further training.Theunderlyingfactorswereproblemswith learn-ingprocesses,financialandsocialpreferencesandpersonal experience and interest of the otolaryngologists. Better
designedstudiesusingamixofqualitativeandquantitative methods withlarger populations from different countries and cultures are needed to have more reliable results. Insights fromsuchstudies willhelp planningmore target-oriented CME activities for otolaryngologists and better structuredtrainingprogramsforresidents.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Author’s
contributions
BothDalogluM.andAlimogluM.K.designedandperformed the study; analyzed the data; wrote the manuscript. All authorsreadandapprovedthefinalmanuscript.
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