Discussion

This is the first report on perceptions of family medicine residency students about their competency in treatment planning of all core diseases/clinical conditions listed in NCC in Turkey.

Despite partial improvements after graduation, the results suggest potential gaps in achieving the desired competency levels, even after 1–3 year of residency training. The residency students’ competency perceptions ranged from 10–30% to 60–80% across different diseases. This variation indicates challenges in achieving a standard baseline both among students and across medical schools. The competency perceptions of physicians at graduation were low. While these perceptions improved somewhat during family medicine residency training, they still did not reach an acceptable level. Across all conditions, perceived competency rates improved in all three groups post-graduation. This highlights the impact of residency training and practice experience. A systematic literature review on the prescribing competencies of final-year medical students revealed that many students lack the necessary preparedness, self-confidence, knowledge, and skills to prescribe safely and effectively. The review highlighted the need for a consensus on the essential prescribing competencies and called for significant changes in undergraduate clinical pharmacology and therapeutics education to improve future doctors’ prescribing abilities (Brinkman et al., Reference Brinkman, Tichelaar, Graaf, Otten R.H., Richir and van Agtmael2018).

There are various studies showing that during the six-year medical education period, the competencies targeted by national frameworks, including those related to treatment, are often not achieved at the desired level. Similar to our findings, students have expressed concerns about their basic medical competencies and practices upon graduation, indicating that they feel insufficiently prepared for the profession (Watmough et al., Reference Watmough, Taylor and Garden2009; Ross and Maxwell, Reference Ross and Maxwell2012). In a study on prescribing ability of intern doctors in South Korea, it was reported that majority of the intern doctors felt that their undergraduate education was insufficient for safe- (75.8%) and evidence-based (68.9%) drug prescription (Gu et al., Reference Gu, Kim, Lim, Lee, Rhee, Shin, Lee and Ahn2018). Thus majority of the participants in our study expressed that at the time of graduation they felt incompetent for most of the diseases in each system.

Considering the literature on rational drug use and rational treatment planning/management, it is evident that the integration of all sub-competencies is essential. However, students or new graduates may feel more or less competent in specific areas. For example, while most students can recall the names of drugs, they often struggle with determining dosages (Leape et al., Reference Leape, Brennan, Laird, Lawthers, Localio, Barnes, Hebert, Newhouse, Weiler and Hiatt1991; Barber and Dean, Reference Barber and Dean1998; Ross and Maxwell, Reference Ross and Maxwell2012). Similarly, there can be wide variations in perceived competence levels depending on the disease.

In our study, no significant differences were observed in competency levels between those who began their residency training immediately after graduation and those who worked elsewhere for at least six months before starting training. Similarly, there were no meaningful differences among residency students in their second and third years of family medicine residency training for most diseases. These findings suggest that while family medicine residency training offers some improvement, its impact is insufficient. Furthermore, the consistently low competency levels at graduation across nearly all systems and groups indicate that six years of medical education is inadequate for planning the treatment of core diseases effectively.

Research focusing on primary care diseases, which are commonly managed in family medicine practice, has reported similar results. For instance, in a study examining the effectiveness of dermatology education during family medicine residency training, 72% of participants stated they struggled with diagnosing skin diseases, and 70.3% found treatment challenging. While 69.2% reported being capable of diagnosing and treating acne vulgaris, only 52.6% felt confident in the differential diagnosis and treatment of oral ulcers (Sönmez, Reference Sönmez2021).

In this study, the highest perceived competency levels among residents for dermatological and soft tissue diseases were reported as follows: 65.2% for drug selection, 62.1% for prescription writing, 72.1% for management and patient counseling, and 67.7% for non-pharmacological recommendations. In another study involving primary care physicians, fewer than two-thirds of participants reported confidence in diagnosing (61.8%) and managing (58.0%) common dermatological conditions such as eczema, allergies, drug eruptions, and cutaneous infections (Lam et al., Reference Lam, Sun, Chao, Yu and Griffiths2011).

In our study, prescription-writing skills were not assessed through practical application; instead, competency perceptions regarding elements of prescription were evaluated. These elements included appropriate drug selection, prescription-writing skills, dose determination, frequency of use, the active ingredient in pharmaceutical forms, dose amount, and the route of administration. The highest competency levels for drug selection and prescription writing were observed during residency training, with rates of 88.5% for selecting appropriate medication and 86.5% for prescribing in iron deficiency anemia. Similarly, in vitamin D deficiency, competency rates were 85.3% for drug selection and 86.4% for prescription writing. For common diseases like essential hypertension, the rates reached a maximum of 60.6% for drug selection and 56.7% for prescribing, while for diabetes mellitus, these rates were 59.6% and 57.3%, respectively. Overall, the competency rates for most systemic diseases were approximately one-third or less at graduation but increased to between one-half and two-thirds during residency training.

In a study evaluating prescription-writing competencies, the self-efficacy levels of general practitioners regarding ‘practical skills’ from the NCC were assessed. The competency levels for ‘writing accurate, appropriate, and legible prescriptions’ were reported as follows: 24.9% master level, 44.2% highly competent, 24.7% moderately competent, 3.6% minimally competent, and 1.6% completely incompetent (Ceylan, Reference Ceylan2009). Another study involving primary care physicians from various regions of Turkey assessed their competency perceptions regarding the skills outlined in the NCC. Prescription writing was among the highest-rated skills, with 83% of participants feeling competent. However, this study evaluated overall perceptions rather than disease-specific competencies as in our study (Coşkun et al., Reference Coşkun, Şenol, Aslan, Yılmaz and Kanık2021).

A study in Ireland involving graduates from five different medical faculties found that 91% of new graduates felt unprepared for all required skills/competencies during their internship. For prescription-writing competency, the rate of ‘highly competent’ was 7% before graduation and 32% during the internship. The rate of ‘competent’ was 47% before graduation and 54% during the internship, while the rate of ‘incompetent’ was 46% and 14%, respectively (Hannon, Reference Hannon2000).

Lifestyle modifications are a critical component of non-drug treatment planning. It is well-established that medication alone is often insufficient for managing many diseases, and lifestyle changes must accompany pharmacological interventions. For instance, in the treatment planning of essential hypertension, recommendations such as weight loss, regular aerobic exercise, salt restriction, and dietary modifications are highly significant. Failure to adhere to these changes may prevent the prescribed medication from achieving its expected efficacy. Guidelines on the non-pharmacological treatment of hypertension emphasize these recommendations (Mancia et al., Reference Mancia, Kreutz, Brunström, Burnier, Grassi, Januszewicz, Muiesan, Tsioufis, Agabiti-Rosei, Algharably, Azizi, Benetos, Borghi, Hitij, Cifkova, Coca, Cornelissen, Cruickshank, Cunha, Danser, Pinho, Delles, Dominiczak, Dorobantu, Doumas, Fernández-Alfonso, Halimi, Járai, Jelaković, Jordan, Kuznetsova, Laurent, Lovic, Lurbe, Mahfoud, Manolis, Miglinas, Narkiewicz, Niiranen, Palatini, Parati, Pathak, Persu, Polonia, Redon, Sarafidis, Schmieder, Spronck, Stabouli, Stergiou, Taddei, Thomopoulos, Tomaszewski, Van de Borne, Wanner, Weber, Williams, Zhang and Kjeldsen2023). In addition to chronic diseases, non-drug suggestions, such as adequate fluid intake, exercise, and maintaining body temperature, are also provided for some acute conditions. This study investigated students’ perceptions of competency regarding non-drug treatment planning alongside other sub-competencies. A significant improvement was observed in their perceived competency levels in non-drug treatments during their residency compared to their graduation.

For diseases like essential hypertension, asthma, and chronic obstructive pulmonary disease (COPD), where non-drug treatments are indispensable according to guidelines, some students mistakenly believe that these treatments are not applicable. For example, among second- and third-year residents, 28.6% believed there was no non-pharmacological treatment for COPD, while 45.0% of those who acknowledged its existence felt competent in planning such treatments. COPD guidelines emphasize non-pharmacological strategies, such as smoking cessation and avoiding harmful environmental exposures (Singh et al., Reference Singh, Agusti, Anzueto, Barnes, Bourbeau, Celli, Criner, Frith, Halpin, Han, López Varela, Martinez, Montes de Oca, Papi, Pavord, Roche, Sin, Stockley, Vestbo, Wedzicha and Vogelmeier2019). Yet, in this study, less than half of the participants recognized non-pharmacological treatments for COPD, with only one-third feeling partially or fully competent in this area.

In essential hypertension, the proportion of participants acknowledging non-drug treatments ranged from 75.0% to 77.8%, while the percentage of those feeling competent in this domain ranged from 62.2% to 67.1%. Another common clinical issue in Turkey is mechanical low back pain, for which treatment guidelines recommend measures such as exercise and precautions when lifting heavy objects (Qaseem et al., Reference Qaseem, Wilt, McLean, Forciea, Denberg, Barry, Boyd, Chow, Fitterman, Harris, Humphrey and Vijan2017). In this study, 71% to 91.4% of participants recognized the existence of non-drug treatments for mechanical low back pain, while the highest rate of perceived competency in planning such treatments was 64.8%. This indicates a gap in achieving adequate competency in incorporating non-drug recommendations for managing mechanical low back pain, a prevalent condition in the community. Similarly, in dermatitis treatment, guidelines emphasize non-pharmacological recommendations, such as avoiding provoking factors and maintaining dietary precautions (Wollenberg et al., Reference Wollenberg, Kinberger, Arents, Aszodi, Avila Valle, Barbarot, Bieber, Brough, Calzavara Pinton, Christen-Zäch, Deleuran, Dittmann, Dressler, Fink-Wagner, Fosse, Gáspár, Gerbens, Gieler, Girolomoni, Gregoriou, Mortz, Nast, Nygaard, Redding, Rehbinder, Ring, Rossi, Serra-Baldrich, Simon, Szalai, Szepietowski, Torrelo, Werfel and Flohr2022). In this study, the proportion of participants who believed in non-pharmacological treatments for dermatitis was 70.0% to 72.2% during the first year of residency, but this decreased to 65.2% in subsequent years. The percentage of those feeling competent in this domain did not exceed 61.1%.

Studies evaluating rational drug use often examine whether non-pharmacological recommendations are included in patient education. In a study conducted among primary care physicians in Ankara, 74.3% reported providing non-pharmacological advice, while 25.7% indicated they only ‘sometimes’ make such recommendations (Doğukan, Reference Doğukan2008). These findings highlight the need for enhanced emphasis on non-pharmacological treatment strategies during medical training, particularly in chronic disease management, where these interventions are critical for comprehensive patient care.

Knowledge competence for medication and management of treatment processes are different areas of competence. Accordingly, a study investigating the relationship between factual drug knowledge and treatment appropriateness among final-year medical students found a weak positive correlation between the two. This suggests that while factual drug knowledge is necessary, it is not sufficient for making appropriate treatment choices. The study emphasizes the need for training in therapeutic reasoning and decision-making including prescription writing, rather than solely focusing on factual knowledge (Brinkman et al., Reference Brinkman, van Rossem, Tichelaar, Richir and van Agtmael2017). Students’ factual drug knowledge has limited influence on the appropriateness of their treatment decisions. Poor relationship between drug knowledge and the quality of treatment choices among general practitioners and recent medical graduates were previously demonstrated (Grad et al., Reference Grad, Tamblyn, McLeod, Snell, Illescas and Boudreau1997; Harding et al., Reference Harding, Britten and Bristow2010). Making appropriate treatment decisions is a complex cognitive skill that requires higher-order thinking processes. To develop this skill, medical students need structured, step-by-step training, such as the WHO Guide to Good Prescribing, which explicitly teaches students to assess the suitability of their treatment decisions for individual patients (de Vries et al., Reference de Vries, Henning, Hogerzeil and Fresle1994; Brinkman et al., Reference Brinkman, Monteiro, Monteiro, Richir, van Agtmael and Tichelaar2021).

A study validating a competence-based 360-degree assessment for advanced undergraduate medical students demonstrated that such assessments could effectively measure students’ performance in clinical contexts. The assessment, which included consultation hours, patient management, and patient handover phases, proved to be a valid tool for evaluating the competencies required for beginning residents. This approach underscores the importance of performance-based assessments in ensuring that medical students are well-prepared for real-world clinical challenges (Prediger et al., Reference Prediger, Schick, Fincke, Fürstenberg, Oubaid, Kadmon, Berberat and Harendza2020). In another study his study evaluating how different levels of realism in learning contexts affect medical students’ prescribing competencies, it was demonstrated that increasing the realism of the learning context, particularly by involving students in patient care, significantly enhances prescribing competencies. Integrating real-world responsibility for patient care into training can have a substantial impact on improving students’ rational prescribing skills (Tichelaar et al., Reference Tichelaar, van Kan, van Unen, Schneider, van Agtmael, de Vries and Richir2015).

The core competencies that are essential for medical education are well-documented. However, there are potential challenges of assessing and developing these skills. It is important that rather than compartmentalizing competencies, it is more beneficial to adopt a holistic and integrated approach to conceptualize, facilitate, and assess these skills in the context of real-world complexities. In the study of Xiangyun Du et al. (Reference Du, Kassab, Al-Moslih, Abu-Hijleh, Hamdy and Cyprian2019), ten key profession-related competencies that should be incorporated into the early stages of medical education are reported. Six of these – collaboration, communication, problem-solving, integrity, responsibility, and respect – were unanimously agreed upon by all participants, aligning with global literature and graduate attributes. However, planning and time management, critical thinking, and reflectivity were identified as areas needing improvement. Divergence arose around empathy and medical ethics, with faculty expressing concerns over how to effectively teach and assess these skills. These findings call for reforms in medical curricula to integrate essential skills early in students’ careers.

Family physicians are often the first to detect symptoms of chronic diseases and are responsible for ongoing management. They play a major role in handling these diseases and risk factors. The bulk of hypertension, diabetes, and respiratory illness should be managed by family doctors, not by specialists. Symptoms and signs of cardiovascular disease and cancer, such as chest pain, loss of appetite, and weight loss, are often noted by family physicians first. The nature of family practice is such that counseling regarding healthy diet, physical activity, and substance abuse is an integral part of a family practitioner’s work. Keeping this in mind, the family physician should be a central stakeholder. However, it is also demonstrated in other studies that there is need for more comprehensive training that includes early detection, patient education, and coordination of care with specialists (Kalra, Reference Kalra2009).

In our study, group 2 consistently shows strong post-graduation gains, particularly in mechanical low back pain, allergic rhinitis, and dermatitis. Group 3 often reflects the highest or competitive post-residency competency rates, particularly for hypertension, diabetes mellitus, and depression. While there is marked progress, the overall percentages (30–70% range) imply a need for further educational and training strategies to enhance confidence and readiness in treatment planning for certain conditions.

Similarly, a study investigating the self-efficacy beliefs of newly graduated physicians, especially regarding their perceived competency in managing conditions with the highest DALYs in Turkey, less than 70% of physicians reported feeling competent in most of the evaluated areas, highlighting substantial gaps in professional self-efficacy. They reported 50.4% of competency in diagnosis of diabetes, 39.5% competency in treatment of lower respiratory diseases and 42.3% competency in preventive measures for ischemic heart disease. Physicians reported relatively higher self-efficacy in management of low back pain (72.9%), neck pain (65.5%) and post-traffic accident cases (46.5%, though still suboptimal) (Aker and Midik, Reference Aker and Midik2020).

In addition, moderate gains post-graduation indicates that managing chronic conditions such as Hypertension, Diabetes Mellitus and COPD might need more targeted and integrated training approaches, considering the multifaceted nature of these diseases.

The relatively low post-graduation competency in treating depression – especially in Group 2 – suggests gaps in mental health education or clinical exposure. Tailored modules in psychiatry could help. Skin and Allergic Conditions show significant post-graduation gains, particularly in Group 2, but remain areas where competency development may benefit from more practical exposure. Also there revealed a need for enhanced focus during training programs on treatment planning for respiratory conditions.

A survey of U.S. physicians revealed that most felt their training in chronic illness care was inadequate across multiple competencies, including geriatric syndromes, chronic pain, and patient education. Family practitioners reported better training compared to other specialists but still found gaps in several areas (Darer et al., Reference Darer, Hwang, Pham, Bass and Anderson2004).

Training in lifestyle medicine, which focuses on modifying behaviors such as diet and physical activity, has shown promise. A program in Israel found that training in lifestyle medicine significantly improved physicians’ confidence and ability to counsel patients on healthy behaviors (Polak et al., Reference Polak, Shani, Dacey, Tzuk-Onn, Dagan and Malatskey2016). In our study, a significant proportion of diseases were thought not be treated by non-drug treatment or lifestyle modifications by all groups.

The findings of this study have several implications for future curriculum development and competency-based medical education. First, the consistently low competency perceptions across several common clinical conditions indicate that treatment planning should be integrated longitudinally throughout undergraduate and residency education rather than being confined to isolated pharmacology or clinical clerkships. Second, competency gaps identified in chronic diseases, mental health, respiratory diseases, and non-pharmacological management support the development of targeted educational interventions, including case-based learning, simulation-based prescribing activities, workplace-based learning, and structured feedback. Third, assessment strategies should move beyond knowledge-based examinations toward authentic competency assessments, such as Objective Structured Clinical Examinations (OSCEs), workplace-based assessments, Mini-CEX, Direct Observation of Procedural Skills (DOPS), prescribing assessments, and Entrustable Professional Activities (EPAs). Such approaches would better evaluate learners’ ability to integrate clinical reasoning, pharmacotherapy, patient counseling, and shared decision-making in real clinical settings. Finally, the disease-specific competency profile generated in this study may help curriculum committees prioritize educational resources, identify areas requiring additional clinical exposure, and support future revisions of the NCC for both undergraduate and family medicine residency education.