According to a survey conducted in the UK, 17% of referrals in primary care in the adult population and 50% in the pediatric population are made to otolaryngologists.1 This shows the importance of undergraduate and postgraduate education in the field of otolaryngology in terms of community health.

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 curriculum were set considering the healthcare needs of the community. The association has also provided suggestions about educational strategies and implementation of the core residency curriculum.

In developing a medical education curriculum at any level, the six step approach suggested by Kern is a commonly referenced model. The steps are: (1) General needs assessment, (2) Targeted needs assessment, (3) Goals and objectives, (4) Educational strategies, (5) Implementation, and (6) Evaluation and feedback.2 When we tried to match the steps of Kern's model and history of developing a core otolaryngology residency training curriculum in Turkey, we found some attempts that could be placed in every step except for one. The ultimate goal of any undergraduate or postgraduate medical education curriculum is to solve health problems of the community. Therefore, the first step is general needs assessment which includes identifying the health care problems that will be addressed by the curriculum. While setting goals and objectives (the third step in the model) the TAO-HNS took commonly seen Ear, Nose and Throat (ENT) diseases in the Turkish population into account as an attempt for the first step (general needs assessment). TAO-HNS also suggested some educational strategies (Step 4), implementation (Step 5) and evaluation (Step 6) methods for the departments. For example, in order to achieve minimum acceptable standards nationwide, resident log-books were prepared by the association to be used in every department.3 However, the second step, “targeted needs assessment”, which includes identifying the needs of learners, has been ignored, i.e. learning needs of the otolaryngology residents have not been studied to date. Self-directed learning is a commonly preferred method for medical residents to learn throughout residency training process. Therefore, determining learning needs, special areas of interest or personal expectations may help educators support the professional development of the resident.4

The TAO-HNS also offers Continuing Medical Education (CME) activities for otolaryngology specialists. Targeted needs assessment lacks in the development process of such programs as well. Adult learning theory assumes that adults are motivated to learn as they experience needs and interests that learning will satisfy; therefore, these are the appropriate starting points for organizing adult learning activities.5 Consequently, it is clear that needs assessment of the target learner group, in other words, the process of identifying the gap between the current and ideal situation, is an important step in curriculum development and deserves every kind of effort. Although the concept and value of needs assessment is well accepted, relevant literature-based information in postgraduate medical education is limited.6

This study focuses on needs assessment of the specialists with the research question “What are the learning gaps and training needs of otolaryngology specialists?” Our expectation was that the answers to this question may also provide some indirect information about the learning needs of the residents who are the specialists of the near future. Therefore, the aim of this study was to determine training needs of otolaryngology specialists and to identify areas for further emphasis in the otolaryngology residency training programs.

The mean age was 44.3±12.1 (29–72) years and female/male ratio was approximately 1/2 in the study group. Mean duration of the experience as a specialist was 13.7±11.2 (1–36) years. The distribution of the participants according to duration of the experience and work places can be seen in Table 1.

In the first round of Delphi implementation, seven training areas in the list were sorted regarding priorities of participants in the following order: (1) Facial plastic surgery, (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 reevaluation of the ranking of the list by the participants in the second round (Table 2).

In Table 3, mean training scores and ranks of each training area in experience groups of 10 years or less, and over 10 years were provided. The unique difference between mean training need scores of these two experience groups was found in sleep disorders area in favor of the group with experience over 10 years (Student t test, p=0.003).

Table 4 provides mean training scores and ranks of each training area in participant groups working in different workplaces. Mean scores for the areas of facial plastic surgery, sleep disorders, laryngology and pediatric otolaryngology differ among the workplace groups (One Way ANOVA, p<0.05 for all).

Four themes emerged from the answers to the open-ended question about the reasons behind why the participants perceived themselves incompetent and undereducated, or why they needed training in some of the basic areas of otolaryngology. These themes were financial expectations (n=31), deficiencies in residency training period (n=44), regression in knowledge and skills throughout post-training period (n=19), and special interest with the area (n=40). Among the participants with financial expectations, most preferred (81%) training area was facial plastic surgery while it was head and neck surgery (47%) among those who explain the reason behind their training needs as knowledge and skill retention. The majority of the participants (47%) who needed training because of deficiencies in residency training period preferred facial plastic surgery, which is also most frequently preferred (38%) special interest area.

This study was conducted with the aim of determining training needs of otolaryngologists and identifying areas for further emphasis in the otolaryngology residency training programs. Facial plastic surgery, otology-neurotology and head and neck surgery were found to be the leading training areas that the participants perceived themselves incompetent and/or needed further training.

Health care professionals are expected to meet certain patient requirements as well as the use of the latest evidence-based approaches.10 As attention is focused on maintaining physician competency and eliminating medical errors, CME is becoming more highly regulated, and CME providers are being held to higher standards.11 When creating or revising a curriculum, targeted needs assessment is an integral step prior to developing appropriate goals and objectives.2 Teaching institutions and educators should 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 evaluation of the residency programs from which those specialists graduated. In other words, common perception of incompetence and requirement of further training in some areas of the specialty may demonstrate the defects in residency training. As a commonly referred model, Kirkpatrick's Four Level Program Evaluation approach measures (1) The learner's reaction to the program (satisfaction), (2) The learning that takes place (confirmed by assessment process), (3) The change in behavior (transfer of the gained knowledge and skills to practice), and (4) Results achieved in service taking population.13 Our study results provide information for the third level of Kirkpatrick's program evaluation model by determining the areas of the residency training content that the participants felt themselves well or poor equipped for proper performance in real life.

Facial Plastic Surgery was at the top of the training needs list of our participants. Recently, there has been a growing interest in facial aesthetic procedures especially among young adults.14 Turkey is 9th in the world regarding aesthetic face and head procedures with 132,564 cases (3.1% of all cases worldwide) per year.15 If demand determines the supply, then it is clear that there is a serious amount of workload and pressure that otolaryngologists have to face in facial plastic surgery. This workload and/or pressure might be the reason for facial plastic surgery to be the most needed training area in our study. We know from the literature that higher income expectations play a motivating role in selection of training area among specialists.16 The increasing demand for aesthetic procedures may also be perceived as an extensive market with better income opportunities among otolaryngologists. This may be another factor carrying the facial plastic surgery to the top of the training need list. As a supporting data, we found that facial plastic surgery was the most preferred area (81%) among participants, who reported financial expectations as the main reason for their training needs. Finally, deficiencies in residency period might be another reason for top priority of facial plastic surgery. We found facial plastic surgery as the most preferred area among our participants, who reported deficiencies in residency period as the main factor 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, are more focused on challenging cases of the fields such as otology-neurotology or head and neck surgery.

Otology-neurotology was the second most preferred training area in our study group. This may be explained by significant technological developments in diagnosis and treatment of the diseases in the field.17 Besides the fast-growing theoretical knowledge, the number of procedural competencies is also multiplying. The complex nature of otology-neurotology procedures may lead to a prolonged learning processes. For this reason, the desired expertise level may be challenging in 5 year residency training program. Thus, inadequate residency training in the field of otology-neurotology might be the underlying reason for common training need in this area among our participants.

Physicians in all specialties care for gradually increasing number of cancer patients and survivors.18 This basically emphasizes the growing importance of head and neck surgery (third most needed training area in our study) among the other otolaryngology subspecialties. The programs of head and neck surgery rotations in residency training are usually structured intensely and the procedures are complicated and time- consuming. There are studies reporting that residents in head and neck surgery rotation have significantly fewer hours of sleep and higher hours of work per week compared to other rotations.19 Excessive workload of the residents may lead to burnout which could lower the quality of residency training via a motivational behavior, and it can also lower the quality of care for patients.20 So, our participants might have selected head and neck surgery as a prominent training need area since they were not well educated in the field during residency. Additionally, besides expertise, head and neck surgery also requires infrastructure and special equipment to be performed. The specialists working in hospitals that are not well-equipped for head and neck surgery naturally avoid the sophisticated and tiresome interventions of head and neck region in order to avoid any risk. This avoidance may lead to regression in both knowledge and surgical skills. We know that loss of competence occurs in even much simpler clinical skills in time if those skills are not performed after training.21 Consequently, loss of competence to some degree might be another reason for common need to head and neck surgery training. This point of view is also supported with the finding that head and neck surgery was the most preferred area (47%) among the participants who reported knowledge and skill regression as the main reason for their training needs.

Our participants with experience over 10 years reported more training needs in the area of sleep disorders compared to their less experienced colleagues. The reason might be associated with history of sleep medicine in Turkey. Sleep medicine has been the focus of interest in otolaryngology community especially in recent decade.22 Then experienced specialists in our study group were not trained in this field during their residency period, since sleep disorders were missing in their training curriculum. There should be some additional areas which are not missing but deficient in residency training periods of our participants. Thus, 56% of the study group pointed out deficiencies in residency training period as the main reason for training needs. Such deficiencies were reported in the literature. For example, Baugh et al. has shown that, despite the accreditation requirements on minimum numbers for key indicator procedures, residents have graduated without meeting these minimums.23

As seen in Table 4, interest level of the participants to some training areas differed according to the workplaces where they practiced. We have already mentioned the possible reason of less interest to facial plastic surgery among those working in training and research hospitals. However, less interest in sleep disorders and pediatric otolaryngology among participants who worked for state hospitals or low level of interest to laryngology among those working in private hospitals or practices are findings which may not be explained easily. These may be the areas, in which the participants may feel themselves highly competent, or patient profile may change depending on the institutions worked for and the physicians may not need any further training on rarely seen cases.

Further qualitative data would give valuable information about the reasons behind our findings. Therefore, shortage of qualitative part is the first limitation of the study. The second prominent limitation is about generalizability of the results. Results obtained from a limited number of otolaryngologists in a single country cannot be generalized.

In conclusion, we found that facial plastic surgery, otology-neurotology and head and neck surgery were the leading training areas that the Turkish otolaryngologists perceived themselves inadequately prepared and/or needed further training. The underlying factors were problems with learning processes, financial and social preferences and personal experience and interest of the otolaryngologists. Better designed studies using a mix of qualitative and quantitative methods with larger populations from different countries and cultures are needed to have more reliable results. Insights from such studies will help planning more target-oriented CME activities for otolaryngologists and better structured training programs for residents.

The authors declare no conflicts of interest.

Both Daloglu M. and Alimoglu M.K. designed and performed the study; analyzed the data; wrote the manuscript. All authors read and approved the final manuscript.