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NEEDS ASSESSMENT FOR EDUCATION OF FAMILY DOCTORS

1. FAMILY DOCTORS NEED EDUCATION

1.1. Requirements for determining the education needs :
• Knowing the job definition of Family doctor (FD) discipline – understanding that it’s different from Health Center (HC) doctors. • The doctor should know what is being expected of him • The public should know which services they can get from the family doctor • The government should make the position of family doctors clear in the grand scheme of health service presentation organization. One of the important points which was brought to attention in meetings was that the participants expressed their lack of information about what the family doctor is as a discipline, and the job description of a family doctor. Even though the first stage (BB) doctors felt that being a family doctor is different from being a traditional health center doctor, they couldn’t quite understand what it meant. Generally they understood that being a general practitioner meant being obliged to first stage as a result of not becoming an expert, and that family doctor is an expert field of this area, they lacked a broader sense of information. “In the current situation, I think the biggest shortcoming is this: We don’t know that being a first stage doctor or family doctor means. We really are civil servants and SO doctors. That means first application family doctor who works in first stage. We can provide consulting services, give education, we can give a little something to those people for all their needs, these are the things we can do. But we don't realize that we have a mission like this." “The most important thing about education is to know exactly what does family doctor mean, both as a discipline and in practice”. The doctors’ perception about a family doctor is true enough; they see the family doctor field more as a difference in approach and as a responsibility, rather than a knowledge expertise. “We have to take the responsibility of being a family doctor. For that to happen, we must change our approach from HC doctor to FD (Family doctor).” “But as you get more involved, you know we always say biopsychosocial approach. for example, last week a patient that I always attend, came to be again with the complaint that his body down from the back doesn't function. He went to physical treatment, he got all the injections. He says "my legs won't work". The fact that I know he has got a dog gave me a great advantage. When I asked him "So you are ill. and how is your dog?", he told me his dog also got paralyzed, and that it was in animal hospital. Right then, you think to yourself "Yes. I am doing something else". What the physician expert does is different from what you do, but it also requires an expertise. And it requires a great deal." But it is not if only the doctors know this discipline, the public and the management should also know something about it. “The public and the ministries don’t know about this. I think what needs to be done first is to explain it.” “You say that family doctors doesn’t know this as well as public and government. I agree that government doesn’t know about this. But I disagree that public and family doctors don’t know about it. I get many requests now, for example a lot of requests for education. The patients aren’t ignorant as much as they used to be, because we wrote it everywhere. “Look, we don't just treat patients and write prescriptions. We give consulting service for pregnant women. We wrote those in big letters. So if I wrote something like this and hang it on the wall, that means I wish to give those services. So, the family doctor knows about this. And the public sees it, too. There are people who come to me, looking for information." This situation creates problems about the expectations of public from the doctors, and prevents the ministry of health and politicians to create service presentation models suitable for family doctors. In such an unknown state, it seems difficult for practitioners to state their education needs. “How can we determine what should we learn if we know nothing about it?” “If I am to organize the public accordingly, I should know first what I am doing. For example, I should know my job description or what should I do for a pregnant woman, how and when. We have already talked this issues before. First I should know my surroundings, and then education comes.” In Figure 1, it is shown that job description needs to be clarified as a pre-condition for education need.
FIGURE 1. PRE-CONDITIONS FOR DETERMINING EDUCATION NEEDS
The doctor should know what is being expected of him The publis’s knowledge about what services The government should make the position of family doctors clear in the grand scheme of health service presentation organization
1.2. Obstacles in determining the education needs :
• The fact that doctors are not aware that they need education • The fact that it is not a priority in the service presentation model • The fact that Social Security Institution (SGK) doesn’t reward education or preventing to implement the learned knowledge
The other pre-condition for assessing the education needs is to realize that they “need”
education. The doctors don’t have enough awareness that they have a requirement like this in
daily practice and that there is a pattern for this in family doctor discipline.
“Our family doctor friends should think that they need this. I realized in the adapting training
that they are not aware of this. I mean, they don’t think they need this. They didn’t need to
know about communication or what does first stage mean and should the approach be like. I
observed those situations. If one person doesn't need something, it would be very hard to give
it to him. First, there must be a something which will make them realize it.”

One of the most important obstacles in front of this awareness is the patient density. Service
offer model wasn't done by taking education into consideration.
“I hardly take care of 50 patients a day. When you take care of 50 patients a day, even though
I was a teacher myself, and I love education, I desist myself from going to those education
activities.”
“If you have time. When you take care of 85-90 patients a day, you won’t have time for
this.”
“When you give service to a population of 3000 – 4000, you can’t realize the need for
education on that working schedule.”
On the other hand, paying agents are an important obstacle in assessing the need for
education. The fact that medicine or enterprises are not paid for can cause doctors to limit
their knowledge with the rules of Social Security Institution (SGK).
1.3. The ways to assess the educational needs of doctors:
• New practice fields or equipments (USG, EKG vs) • Discussion with the colleagues, conversation • The anxiety to create a standard service The methods doctors use to determine their educational needs generally comes from the practices being used. The doctors can make out what they know from their previous experiences, and determine educational topics according to new patient groups or requests. The doctors state that there should be a certain knowledge and skill standart, and reaching that standard would contribute in determining the educational needs.
“I never worked in first stage. I worked in the security policlinic, and I was in a internal
disease policlinic. A person really should know that he has weak points. I knew what my weak
points were. Because I didn’t see babies or pregnant women where I worked. I am a doctor
for 10 years now, but I was in a policlinic, internal diseases. I mean, what should we do
when we are monitoring pregnant women? What should we do when monitoring babies?
What should we do when dealing with kids? I didn’t know any of that.”
“If I were a patient, I would like to have the same service on every health center. For
example. the doctor who has more older patients needs an education about taking care of
hospitalized patients. But I may be going to him as a young man. So, he needs the current
knowledge about the young patient, too. First we need to find a way to create the standards.
.”

Difficult situations or missed cases are important methods to assess educational needs.
“I want to tell something about medicine usage. A patient came to me, and I asked what is
wrong with you. The patient can’t tell his complaints. I want to give him stomach medicine.
What were you using? That one. I looked at his papers, he has been using lansoprazol for
eight months. I mean why do you use it for a long time? You shouldn’t have used it for that
long, your complaints should have been over by now. I didn’t write the medicine. I told him
that he should definitely go see a gastroenterology and that he should have an endoscopy, and
after that we act accordingly. Turned out, he has a stomach cancer. And he had been using
that medicine for eight months. Our friend was probably too busy. He comes with the
complaint of stomach hurt. The doctor asks what do you use? He says when he uses that
medicine, it makes the pain go away. So, let's write that in prescription. The man had stomach
cancer. God knows which grade it is. This is the patient’s status. Would it be different if it
were discovered 7 months ago? Maybe it wouldn’t be different, but that mistake wouldn’t had
been made. Now when I’m prescribing a medicine, I look to the back pages of the health
record. One should be really careful when prescribing…”


2. THEY VALUE HOW THE EDUCATION SHOULD BE MADE, RATHER THAN
ITS CONTENT

At the discussions of education, content and method has been the prominent issue. The point
which drew attention about the content was that rather than biological topics, behaviors,
approach related topics and protecting and developing the health were highlighted.
“If I am to speak on my behalf, it is definitely communication with handicapped patient and
speaking with the family. I have handicapped patients and I can’t communicate with the
family. I can’t communicate with the boy, either. Clearly, I don’t know what to do. They
realized something is wrong with the child, but I don't know how to take care of it. The child
says he has pain, but I cannot understand what it is from the body language. Where does it
hurt? The family say he has fever, I measure it and it is normal. Did he have fever at home? I
think there are deficiencies in this subject.”


“I have also encountered something else: the use of substances. nowadays a lot of children
use that. They can easily access these substances. But we can catch those children before they
become addicted, just in time when they use it. I have caught a few children like that myself.”

“I think there is definitely a need of education for quitting smoking. I have received a lot
requests in that regard.”

“ …and educating the patients themselves. We must be aware of this, too. We should place it
somewhere in the policlinic service. We must form this understanding, and take time to it. We
should do this. I think this is the most important one. “

“The important thing is to know the approach, and to know what is being expected of us.
Otherwise, knowing what the cure is for HT is not the primary issue here. ”
“I want to have that point of view. I mean, to be able to look at the big picture. Generally
what is being done to mistake is an intervention, an operation. Something is made. How
should we approach the patient after doing something? In its following, what should we pay
attention to? I should know the approach. Whether it is RIA, injection or anything else.”
“We need to know where to stop. For example, with a patient who had his second cystitis,
instead of giving medicine and sending away, we should consider sending him to a higher
step for determining vesicourethral reflu. I mean, that is something I just thought right now.
There must be certain criteria.”
In a lot of study and sessions done with first stage doctors, the expression of educational
needs generally emerge as a short recap of the medical school. In this study, participants are
well aware that clinical subjects are not different in first stage, only the method of using the
information is different. Rather than the latest written information about biology, they wish to
know how they can eliminate the problems rising during the health care practice, and to learn
the methodology of using their existing medical knowledge to overcome these problems.
3. THERE ARE VARIOUS FACTORS PLAYING AN IMPORTANT ROLE IN
EDUCATION
3.1. Factors affecting education:
Doctors' motivation is considered as an important condition for the development of learning. “There are hundreds of sources, such as Internet and books, which could be read, on the other hand, we do not even open one and read one. In fact, we do not read maybe because we do not feel such need. Generally and probably, most of us just check some things in relation with the subjects we are curious about from time to time. No matter how they are changed, some things should attract us. We can only search, read or reach a certain level when a curious feeling assisted with the experiences of our associates is born in us.” Although awards are on the top of the list of the things motivating doctors, it is thought that different acquisitions may improve their motivation even more. “…Why did everyone want to be a family doctor? Every one of us was hesitating at the beginning. We checked what we have… We were already working on the first stage and there was nothing different in what we did. We just improved ourselves a little more, we aspired but we had a great increase in our financial incomes. This was a nice motivation. Consequently, we thought about education we will get in the future…” “If this education here makes a difference among people, the person, himself, is the one who will realize this first. Then, his patients and healthy people will realize his difference. Consequently, his doctor associates will be aware of his difference as being told by these patients and healthy people. What you do and what you make different are always noticed… If you make this difference with your education and if you begin doing something different than others, be sure that everyone will notice and appreciate this”. Applicable information motivates learning. “….In fact, I am more concerned about avoiding motivation loss rather than improving motivation. Therefore, if you are able to reap what you sow, if your time and salary are worth of your efforts and if you can benefit from its advantages, this prevents you from motivation loss…” “I got a huge deal of education (Laughing…) and I do not think of getting any more education. What I have is already enough. What I want is to practice what I have been taught. I do not practice every single thing I learnt. Therefore, I already began to forget… When unpracticed, everything is forgotten…Too much education is also not good…” The most important factor motivating education is person’s feeling necessity for such information and talent which can only be achieved via education. Knowledge and talent required by any doctor and the level of such knowledge and talent differ from person to person. For this reason, such educations where this fact is ignored result in disappointment and alienation from such trainings. “On the other hand, priorities differ from person to person. My priority is different than yours. And your priorities are different from others’. In such an education, first of all, regional and personal priorities should be addresses. Once personal and regional priorities are determined, new training programs addressing such needs can be planned. If a person is not in need of an education program addressing such priorities, this person cannot benefit from such education.”
3.2. How should education be?
• Should not be mandatory – mandatory voluntariness • Determining knowledge and talent of the participants • Participants from different levels should not be educated together • Appropriate for participants’ free times • Since we do not read, let’s discuss As well as content of the education, educational form also motivates learning and improves doctors’ service quality. It is especially important to apply specific educational forms appropriate for participants’ learning objectives and to concern principles for adult education. The participants claim that their previous educations were based on social and popular aspects rather than proper educational principles and such trainings were highly expensive and inefficient. If such trainings are organized locally for smaller groups on their free times, this would promote participation to such training programs. Participants claim that such education given to family doctors is not planned well in this context and therefore, it creates an educational mass and pollution. “For example, when we went to Urla for a training program, a woman held a child-baby chart and asked me "Do you recognize this chart?". You know what? I have been filling this chart for 13 years.” “For example, we participated to a training program about ICD. Most of these participants were from hospitals. The instructors just talked about how to code cesarean, how to code this and that… On the other, she only answered 10% of my needs and expectations that we talked before this program. The information I obtained in this training would not exceed three sentences. For just three sentences, half of my day was wasted. My friends taking care of my patients wasted one or two days. Depending on an overwhelming day in the hospital, they would not be totally conscious on the next day. It was such a coincidence that it really was a busy day. Such things should be planned well.” As well as participants’ needs, what a training program will change and which applicable differences it will make should also be addressed while planning training programs.
If an education cannot provide participation, this situation will result in mandatory education
and therefore, benefit of such training will be extremely limited. On the other hand,
voluntarily participation is only possible with a right understanding of education.
3.3. Learning materials and sources of information
• There should be resources containing standard minimum information. • Experiences of our associates and sharing such experiences • INTERNET – highly unorganized, it is hard to access required information
Although participants emphasize different ideas on education, it was not hard to determine
general principles. Doctors have difficulty in accessing information. For this reason, a new
system similar to specialty education containing comprehend sources of information is
required.

“But we need standardization. In other words, everyone should know certain things. Their
personal knowledge is also important but I really think that standardization is the key factor.”
“You may find one hundred links in relation with a certain subject but such resources should
be accessed in an organized manner. A family doctor should be able to access minimum
information required for his study via a practical resource. This can be a web based
software.”
On the other hand, such information should come from a reliable and accurate resource.
Especially, medicine companies find educational relations annoying.
“Ministry of National Education, Police Department and Military Authorities… When there is
an innovative idea, it updates every personnel. On the other hand, there is not such an update
in health sector. Something happens and then, they say the medicine you advice is not sold
anymore. I do not want to hear this from a pharmacist.”

“I do not want to be informed about it in a meeting organized by a medicine company….”

“For example, I am always annoyed of something. I doubt about the reliability of the
information. And sometimes I ask myself: There is another meeting held by another medicine
company. Are they telling about something different there? In other words, there is no
standard.”

Hybrid proposals are also recommended concerning personal needs of the participants and
online education opportunities on a certain subject.
They are not actually successful in using internet based on lack of knowledge and experience
in this field and they have difficulty in accessing general information sources, such as books
and internet resources.

“We cannot access already. For example, they should help me for such an accession. Reading
articles is something expensive. It is really expensive… If you built this system, you should

offer your library to me so that I can follow updated articles. I can only pay a small amount of
money…”

Moreover, they mostly prefer learning through sharing experiences in stead of learning by
reading. They indicate that education is an interactive action and all parties will benefit from
such an interaction.
“In my opinion, the missing thing is sharing such information. In other words, when I am
doing something, I should be able to compare what Aynur does. Actually, this is what i miss in
education. I benefit from her experience. I learn something from her. Generally, standards for
insulin treatment are clearly determined. You begin to this treatment. When you are
performing all necessary procedures, you watch your friend; how she is giving medicine,
when she is giving, how she approaches to the patient, etc… Actually, it is very nice to know
what they think. Benefitting from each other’s experiences…This is what we miss!”
“Hospitals take care of their patients in accordance with well known standards. There are on
the second stage. They have to plan their own procedures in accordance with this. They have
certain standards. They never exceed their standards and limits. But we are different;
treatment for an 80-year old man would differ from a 50-year old man’s treatment. We do not
have a certain age group. Our patients’ biopsychosocial approach is different. We should
approach differently to each patient. We achieve this thanks to our experiences. You say it in
a manner, another person uses another style. You learn a lot from each person. You form
your own experience. You unite yourself with obtained information. In my opinion, experience
sharing is highly important.”

Although they sometimes miss a hierarchy in their educations, they are highly successful in
experience sharing, friend-to-friend teaching, discussing with specialists and generating
concepts on patients.
“… If additional meetings are organized in order to present different cases, if universities can
also participate into such presentations, if we are able to discuss about what we do, we will
learn what is right and what is wrong and when we need to stop. We should not exceed our
limits.”

This may be caused by that such trainings are essential factors in learning on the first stage.
3.4. How to access information
Should the information be given to doctors or should doctors try to access information on
their own?
Although every one of them thinks that they have personal and different requirements, they all
ask for capsule information. This should be based on insufficiency while accessing
information because they do not use Internet although there are related entries. They do not
know any foreign language and there is lack of Turkish resources. On the other hand, the most
important thing is that they are not reading.
3.5. Obstacles in front of education:
• Ministry of Health does not perform their tasks properly
4. LEARNING SUBJECTS ARE HIGHLY VARIABLE

Subjects are highly harmonic with AH Discipline:
• What is a sick person – a healthy person? • Patient-Doctor Relation and Patient-Doctor Conversations • Treatment of bedridden patients at home • Training on determination of educational needs • Communication with handicapped patients and their families • Approach to dying patients and their families • How can we improve quality of early diagnosis areas? • How can we help chronic patients to live with their problems? • Approach to a patient suffering from low back pain • What is a First Stage Doctor? How should it be? Where should we stand? • What kind of people should we be? What kind of people we are is important because.
For one year, one and half years and two years, a training program on only above mentioned
concerns should be executed.
RESULT

In accordance with disciplines of family health, general practitioners working as Family
Doctors say that they may get additional education in order to improve their service. It will be
better to give such education in rather smaller groups in accordance with the principles of
adult education based on experience sharing.

Source: http://www.esta-bw.de/fileadmin/user_upload/Bilder/international_corporation/Family_Med/EducationOfFamilyDoctors.pdf