Assiss. Prof. Gülpembe Ergin Oğuzhan
7.1. Introduction
In this chapter, information regarding the organizational aspects of the use of disposable circum-cision hand tools will be presented within the framework of the findings obtained as a result of the systematic literature review. No study was yielded on the subject matter in the systematic sc-reening of the organizational aspects of circumcision. For this reason, an expert opinion has been taken. Interviews were held between 08.01.2018 and 15.01.2018 with a physician, urology spe-cialist and pediatric surgeon who use disposable circumcision tools. A semi structured interview form has been used as the data collection tool. In order to obtain comparative results, the preferred semi-structured interview form was developed in accordance with the information in the body of literature and the questions in the section titled “Organizational Aspects” in the HTA Core Model®
for Medical and Surgical Interventions.
7.2. Evaluation
Semi structured interviews were held with three people, that is; a physician, urology specialist and pediatric surgeon who use disposable circumcision tools. Physicians who frequently perform cir-cumcision procedures were preferred in the election of the ones to be interviewed. The physician who uses a disposable circumcision tool performs the procedure in a special clinic, the urology specialist in a secondary level public hospital and the pediatric surgeon in a public training and research hospital. Fourteen questions in accordance with the ones in accordance with the informa-tion in the body of literature and the quesinforma-tions in the secinforma-tion titled Organizainforma-tional aspects in the STD Core Model have been prepared. In this section, the answers given by the physicians to these questions and their opinions about the subject matter have been given.
The first question to the physicians is “How does technology affect the current process?” The physi-cian using the technology states that this technique has reduced the duration of the process from 45 minutes to 5 minutes, minimized the complications, facilitated the doctor’s work and did not distract the participant from his daily routine. The urologist and the pediatric surgeon think that this technology does not affect the current process.
The second question is, “Is there a demand for new technologies?” The physician who uses the technology says that there is a demand and that it is increasing through the users. In 2002, 1,500 circumcisions were performed with this method and today this number has reached 80,000 per year. Other physicians think that they have not met any demands in this regard but that demands can be created with the guidance of the physicians. The participant group is usually constituted by children. Furthermore, the urology specialist stated that only one circumcision case was encounte-red per year in the former military hospitals.
The third question is “What do patients/participants have to do to use this technology?” The phy-sician using the technique stated that demand could be created with the recommendation of the participants who were circumcised with this method whereas the other physicians expressed that the physicians performing circumcision procedures could guide the patients to use this technology.
The fourth question is, “How the personnel who will apply this technology should be trained?”
The physician using the technology indicates that every physician who can apply the conventional method can use this method, that it is sufficient to monitor only one or two procedures and that no special training is needed. The urologist thinks that having good command of the surgical method is enough. The pediatric surgeon states that the physician who will apply the method must go th-rough a professional training process, especially for correct placement and removal of the device.
He adds that if this method is applied without training, then a surgical aesthetic intervention would be needed again.
The fifth question is “How should communication be established with Ministry of Helath and how should the cooperation be for this procedure?” The physician applying the technology states that as circumcision is not a compulsory process, it is considered as a cosmetic procedure in the world and by the Ministry of Health. He also states that the doctors in the Ministry of Health use the con-ventional method and are not looking for a new method. The pediatric surgeon also thinks that the Ministry of Health will not have a positive look on this because he believes this method will incur an additional cost. The urologist does not support this method at all. For this reason, he does not favor establishing any communication or cooperation.
The sixth question is, “In what way should the quality assurance and monitoring system in the new technology be organized?” The common view of the three physicians is that the follow-up process should be done by physicians. Quality assurance should be provided by the supervision of the Mi-nistry of Health.
The seventh question is, “How does the requirement for decentralization or centralization influence the implementation of technologies?” The opinion of the physician who practices the technology is that this method should be applied at one reference hospital in all provinces and the method could be popularized this way. The urologist states that the procedure could be done at any private hospi-tal with a license recognized by the Ministry of Health. The pediatric surgeon states that it could be performed in private hospitals as well but as valid for all medical procedures, should be supervised by the Ministry of Health and emphasizes the requirement of tracking the procedures.
The eighth question is, “How should people who are circumcised have access to this technology?”
The physician applying the technology thinks that the transportation of patients can be achieved if the procedure is performed at one reference hospital in all provinces. The urologist does not sup-port this method because it is not based on scientific evidence and does not want the technology to become widespread. The pediatric surgeon thinks that if the method is evaluated positively in terms of cost and safety by the Ministry of Health, it may start to be applied in hospitals and the access to the procedure would increase with the recommendations of the physicians.
The ninth question is, “What are the costs of the processes related to acquiring and setting up a new technology?” The physician who applies the technology states that there is a cost of procuring the auxiliary device used in the method. For example, the average cost of a device is TL 15 but the cost to the user reaches TL 30 during service delivery. The other physicians indicate that manage-ment is responsible for the cost issues, so they have no information regarding this subject.
The tenth question is, “How does technology affect the need for other technologies?” The physici-an applying the technology thinks that the need for the conventional method will decrease in time
because this method decreases the complication ratios. For example, while the complication ratio of the conventional method was around 15%, this ratio has been reduced to 2% with the new te-chnology. The urologist thinks that the new technology will not have an impact on the need for the surgical method. The pediatric surgeon states that if the new technology is considered effective in international scientific studies, he would start to use it and that the need for the surgical methods will decrease. However, it takes a long time for a new system to settle.
The eleventh question is “What do you think about the cost of surgical procedure? What is your opinion about the effects of the new technology on the budget?” All three physicians think that the hospital incurs a loss in every surgical circumcision procedure performed in state hospitals. The reason for this is that circumcision has been removed from the category of non-required plastic surgery procedures and included under the required plastic surgery procedures with the new law is-sued by the government and therefore there has been a significant decrease in the reimbursement amount. The physician who applies the technology considers that it will have a positive impact on the budget. Other physicians do not have enough information about costs but they think that the new technology’s not requiring an operating room would have a positive effect on the budget.
The twelfth question is, “What are the problems and opportunities that arise in terms of management related to this technology?” The physician who applies the technology states that it would save money because no antibiotics were used and that additional costs such as sterilization costs would not be in question. In addition, since the method can be performed in the examination/medical dressing rooms, both the operating theaters will be used efficiently and the costs can be reduced because no general anesthesia would be necessary. However, the possibility of complications would still be in question despite the low probability in this method and this could lead to problems in terms of mana-gement. Other physicians think that if the method is practical, easy and if the outcome is effective, this would provide the management with opportunities, especially in terms of costs.
The thirteenth question is “What can/should be done for this technology to be accepted?” The physician applying the technology thinks that the complication rate should be further reduced by developing the technology for the method to be accepted. In addition, he expresses that the device used in the past was imported, but now it is manufactured in Turkey but due to the poor quality it should be improved and that investments have to be made in this field. The urology specialist states that the method should be proven to reduce the complication rates significantly by the studies in internationally recognized journals. The pediatric surgeon states that physicians are not open to in-novations and do not want to change the methods they are accustomed to. For them to change the-ir long-term used method, the new technology should fthe-irst be applied in university hospitals and if the results obtained here turn out to be positive then the physicians would start to use this method.
Fourteenth question is “Who may be the parties to the technology? What relation can they have?”
The physician applying the technology states that the parties would be the manufacturing company, the Ministry of Health, the users and the physician. He expresses that the Ministry of Health should supervise the manufacturer and that physicians should advise the users of the new method. The urology specialist states that the parties would be the government and physicians and that the new technology should not be supported. The pediatric surgeon likewise states that the parties would be the government and physicians and the system could be supported only if the it is proved to have positive results.
7.3. Discussion and Conclusion
No study was yielded on the subject matter in the systematic screening of the organizational aspe-cts related to the use of disposable tools in the circumcision procedure. For this reason, an expert opinion has been taken by utilizing the qualitative research technique. It can be said that the spe-cialists not using the technology do not have enough knowledge about the use of the technology.
However, they stated that the current method is a financial burden. They generally state that they need scientific evidence, that quality and safety guarantees must be provided and that supervision should be carried out by the Ministry of Health, that the process management should be performed by the Ministry of Health and the physicians. The physician who uses the technology has emphasi-zed that it is an advantageous method especially in terms of complication and cost. To sum up, it is stated that the method could be suggestible by the physicians to the participants when scientific evidence is presented and when the procedure is under the supervision of the Ministry of Health.