Self-directed learning among primary health care doctors: an analysis in light of the theory of social representations

Introduction: In a scenario of a great information availability, the production of scientific knowledge in medicine has been increasingly accelerated. The way the medical professional perceives and directs their acquisition of knowledge still lacks national studies, particularly in times of easily accessible internet. Objective: To analyze the social representations of physicians working in Primary Health Care (PHC) teams about self-directed learning. Method: This is a qualitative-quantitative study based on Moscovici’s Social Representations Theory, with a structural approach to Abric’s Central Core Theory, conducted in three municipalities of the state of Minas Gerais, Brazil. Semi-structured interviews were conducted on the subject, which were recorded and transcribed. The freely evoked words that emerged from the inducing term “medical self-learning” were analyzed with the aid of EVOC® software through the four-quadrant chart and CHIC® software analyzed the similarity. Content analysis was performed for the participants’ speeches. Results: Fifty interviews were carried out and the freely evoked words that possibly constitute the core of the representations were “knowledge”, “dedication”, “study”, “reading”, “need”, contrasting “research” and “book”. Conclusion: The results showed that the learners’ characteristics, practice as a learning locus as opposed to theory, associated with the time barrier, define the core content of the social representation of the participating physicians. In this assessed context, PHC reinforces its importance as a scenario for medical self-learning.


INTRODUCTION
Learning can be defined as the process of acquiring knowledge, skills and attitudes aimed at a behavioral change 1 . It is an eminently personal, experiential process that presupposes a change in behavior 2 . The particularities in the adult learning process, in relation to the child, has defined a new field of studies, andragogy. For scholars in the area, the adult needs to understand the reason for the need to learn something, bringing with it the influence of previous experiences. Adult learners are more thematically and more specifically oriented, focused on real tasks and problems, and have an internal motivation to improve 2-4 .
Knowles, Ill and Swansom 2 define adult learning as selfdirected, when the individual takes the initiative themselves, with or without help from others, assessing their learning needs, defining their own objectives, implementing their own learning strategy and evaluating outcomes. Another important aspect of adult learning is highlighted by Kolb 5 , who highlights the experiential learning cycle (Figure 1 and Chart 1). For the author, this process is influenced by the learner's personality, educational specificities, professional career, role in their work and adaptive skills. In this sense, knowledge is generated by the experience transformation, in which first there is a concrete experience or lived event, which brings observation and reflection, followed by the conceptualization of what occurs and its assimilation, thus modifying its performance 5 .
A deeper understanding of the process of learning and building knowledge is particularly important for the development of professionals whose training process does not end with academic activities, as in Medicine. Physicians experience learning opportunities on a daily basis. In their continuing education, the use of everyday issues, combined with real experiences, both positive and negative ones, are considered key points for their interest in acquiring knowledge 6 . A classic study by Slotnick, in the late 1990s, shows an analysis of the physician's self-directed learning, depicting four steps ( Figure 1): identification of a learning need, search for resources to deal with the learning needs, the acquisition of knowledge and the application of knowledge or gaining experience 7 .
It is understood that more passive interventions, such as classes and conferences, tend to have little interference on physician performance and patient care outcomes. The time between continuing education efforts, such as courses and training, also seem to be inversely correlated with physician performance. In other words, the longer they go without new training, the worse their performance is, reinforcing the continuous and permanent nature of the training 8,9 . Continuing education, in medical practice, is defined as any means by which the physician learns after completing their formal training, as a way to allow changes in their practice 10,11 .  Currently, the easy availability of information and rapid changes, combined with the use of technological resources to enhance learning highlight the learner's role and refer to selfdetermined learning, which reinforces the inclusion of aspects such as capacity, creativity and self-efficacy 4 . The dissemination of mobile devices has brought on a new reality for medical students and physicians [12][13][14] . Distance learning (DL), using problem-based learning methodologies, is capable of enabling the acquisition of skills and knowledge in remote areas and reaching many individuals, with similar outcomes to those of the in-person model [15][16][17] .
Primary Health Care (PHC) has distinct characteristics, expanding aspects for the training of undergraduate and graduate medical competences. In it, the student is able to experience the relationship of the individual, their community in a territory, the expansion of the clinical scope and its integration with other knowledges and professionals, having contact over time as an ally during this process 18,19 . Different from the hospital-centric aspect, cultural aspects, popular These actions are conducted by Federal Universities, which offer free continuing education processes using the distance learning model as advanced training, qualification or specialization courses, providing permanent education opportunities that can fit the learning needs identified by health professionals. Therefore, the learning strategy is focused on know-how, in which learning objectives are centered on everyday actions and provide learning for practice 17,23,24 .
There are few national studies that have assessed the learning process in physicians and these professionals' perception of the individual learning process. In the context of strengthening and rapid expansion of PHC services registered in Brazil in recent years, it is relevant to know the perceptions of physicians who work in these services about self-learning. This information can facilitate the continuing education process for these professionals, potentiating the actions of health managers and reducing costs. Therefore, the aim of this study was to analyze the social representations of physicians working in PHC teams on self-directed learning. The three open questions were recorded and later transcribed for analysis. By analyzing the spontaneously spoken words, it is possible to collect elements that constitute the representation content, according to Abric 28,29 .

RESULTS
Fifty interviews were carried out from December 2018 to February 2019, in the three proposed municipalities. Of the 23 non-interviewed individuals, three refused to participate and 20 met the exclusion criteria, such as being on vacation leave and working mainly as a preceptor to undergraduate students.
There was a slight predominance of females among the study participants, with age ranging from 25 to 54 years. The time elapsed since graduation in medical school was on average 64.1 months, with a maximum time of 300 and a minimum of 6 months. Regarding the title, approximately two-thirds of the physicians were general practitioners (Table 1).
Of the participants, 50% reported working in some activity rather than the FHS and 60% of the respondents did some activity  In the upper left quadrant represented in Figure 2, which consists of the elements considered as likely to be central, are the expressions: "knowledge", "dedication", "study", "reading", and "necessity", being the possible core elements of the Social The first and second peripheries comprise seven evocations: "internet", "practice", "time", "scientific articles", "confidence", "case discussion", "experience", "interest", "improvement".
Subsequently, the 16 evocations present in the fourquadrant chart were submitted to hierarchical similarity analysis generated from the CHIC software, creating the Hierarchical Similarity Tree shown in Figure 3.
It can be observed in the similarity tree that there are three large groups that do not show any connection with each other, one comprising "knowledge", "confidence", "reading" and "practice"; the second consisting of "dedication", "time" and "interest". And, finally, a larger group comprising "study", "improvement", "necessity", "experience", "internet", "scientific articles", "case discussion", "book" and "research". The expression "study" appears in the central core and was the most frequently evoked word (12 times) with a "rang" of 2.083 and, in this research, it was associated with Study as a resource/tool for updating and improving patient care; a proactive and often solitary action, a connotation of theory acquisition; as a synonym for scientific research and its product;    The expression "reading" appears in the central core and was the second most frequently evoked word along with knowledge (10 times) with a "rang" of 2.1 and, in this research, it was associated with an action for those seeking knowledge, such as the path to theory. The expression "knowledge" appears in the central core and was the second most frequently evoked word (10 times) with a "rang" of 2.4 and, in this research, it was associated with base, substrate, foundation for evolution, being something that is continuously acquired and as something that is infinite, which cannot be depleted. It is considered an accumulation of experience and can be transmitted. The expression "dedication" is the fourth evocation of the central core, with a "rang" of 1.889, which was evoked 9 times and, in this study, it was associated with a characteristic of the individual of renouncing something to keep the focus, stay motivated, and is related to an inner strength, also the idea of purpose, as only those involved are dedicated and know why.  The expression "necessity" is the fifth evocation of the central core and a "rang" of 2.000, which was evoked 7 times. In this study, the expression was associated with an inconvenience generated by changes, by the desire to perform a good practice, creating a necessity. The expression "practice" is the first evocation of the 1 st periphery, which was evoked 10 times with a "rang" of 3.700, as a stimulus for learning and for its fixation, as a counterpoint to theory, as a "validator" of the theory. The expression "internet" is the second evocation of the 1 st periphery, which was evoked 8 times with a "rang" of 2.875.
Although evoked, it does not explicitly appear in the speeches, but it was considered a democratic, easily accessible locus, with a lot of content and information.
Because that is where, I think, there is more content to seek. And where you have more information with access. (Interviewee 23) The expression "time" is the third evocation of the 1 st periphery, which was evoked 7 times with a "rang" of 3.0. It brings the idea of a finite resource in the speeches, requiring management; moreover, it brings the idea of accumulation in the form of experience. The expression "experience" is the first evocation of the 2 nd periphery, which was evoked 6 times with a "rang" of 2.833. One can perceive a sense that experience is the result of experimentation, a repeated practice leading to consolidated learning. The expression "improvement" is the second evocation of the 2 nd periphery, which was evoked 5 times with a "rang" of 3.4. Its meaning, in the speeches, is to become more complete, able to carry out the work more fully, to have more knowledges and experiences. The expression "scientific article" is the third evocation of the 2 nd periphery and was evoked 4 times with a "rang" of 2.750.
It reinforces an idea of confidence, as it is something "scientific", in addition to being more current and applicable to a more "real" situation, it brings an idea of evidence, once again constituting a sense of something that is more practical and less theoretical.  The expression "interest" is the fourth evocation of the 2 nd periphery and was evoked 4 times with a "rang" of 4,000.
Its meaning is more associated with in the word 'interesting' , something that arouses one's curiosity, the unknown that exists as a desire to become known, the opposite of simple, being the complex, the most interesting, difficult.
Although there are diseases that we end up thinking are not important, but they are very important, just because they are very prevalent. [...] Medicine is like that, right... some colleagues, I do not know if all of them. I think there are many who also like it, right. You think, for instance, that hypertension is not interesting, but you see that many people even have difficulty to manage hypertension... (Interviewee 12) The expression "confidence" is the fifth evocation of the 2 nd periphery and was evoked 4 times with a "rang" of 4,250. In the speeches, the word confidence does not appear, but some speeches in which the expression was evoked seem to indicate the sense of feeling safe to take an action.
Because based on knowledge, I will feel confident to take action, make the correct diagnosis, manage the patient and feel like a more complete professional. (Interviewee 43) The expression "case discussion" is the sixth evocation of the 2 nd periphery and was evoked 4 times with a "rang" of 4,250.
It points to the sense of contextualization and idea structuring format, in addition to a perspective of exchanging experiences with another person.
[...] when you're discussing a case [...] it seems that you... you assimilate more, you... more doubts arise. When you are going to explain something, also any doubts... a colleague of yours is discussing with you. (Interviewee 25) The first element of contrast is the word "research", evoked 5 times with a "rang" of 2,200. The word brings the meaning of the search for knowledge, of structured actions to find some information.
[...] But with me it is like that, I think you only assimilate it when you are there researching and experiencing that, right... then, in a way, if that brings you any doubts, you will research, you will want to know, you will study, right... and from that point on, it gets fixed in your memory... (Interviewee 34) The second element of contrast is the word book, which was evoked 5 times with a "rang" of 2,400; it brings the sense of a source of knowledge, the objectification of the theoretical, as a contrast to what is "outside of the book", which brings the idea of practice.

DISCUSSION
The analysis of the results allows us to infer that "knowledge" is the objective to be achieved by the physician who directs their learning. It brings "confidence" to "practical" actions and the more experienced they become, the more they accumulate knowledge and confidence. Kolb 5 reinforces this concept by explaining the learning cycle, demonstrating that adult learning is based on experience, followed by reflection, conceptualization and new interaction. For this process, the meaning that the study physicians bring on is that individual characteristics of "dedication", "interest" and "motivation" are essential factors for change and, in this case, an "improvement" of their performance. Knowles, Ill and Swansom 2 verify that adults can be influenced by external motivational factors, such as better remuneration and jobs; however, internal motivational factors such as personal satisfaction, accomplishment in what they do, meaning in what they do, influence more the adult to learn, as shown by the analyses.
The first periphery of the social representations identified here shows procedural aspects of the search for knowledge. The interviewees point out that searching or "researching" for new information, which can occur through the "internet", by reading "books" and/or "scientific articles" or "case discussion" help in the theoretical consolidation, or "study", and its application in "practice". Kolb 5 shows, in the Experiential Learning Theory, the so-called conceptualization, that after living and reflecting, the adult seeks to consolidate knowledge for a new application. This concept, also present in the definition of SR, is reinforced by the first periphery, as shown in the results.
The "practice", which appears in the first periphery, lives up to its effect of strengthening the central core because, based on the participants' understanding, it is where the perception of knowledge necessities is triggered and, at the same time, when knowledge is consolidated -or its application.
If some knowledge is applied satisfactorily in practice, it brings confidence, it generates experience. In adult learning, the orientation for learning focused on tasks to be performed or problems is defined, which make more sense for the student to face their reality, as also explained in the results regarding the performance in practice in environments aimed at the resolution of most of the problems 2,3,32,33 .
It is also reinforced, in some speeches, that the result of the practical application is also an increase in the resolution of problems and satisfaction of the person being attended, an important conceptual factor in professionals working in PHC, who deal with complex problems, take care throughout time and, ideally, show a high level of effectiveness 32 . This aspect is also explained in the results regarding the practical work to solve most of the problems. The continued care of people in PHC makes the patient always return to this level of care whenever their problem has not been solved 2,3,32. Another very important element of the first periphery is "time", pointed out both as a scarce resource by physicians and as a factor for measuring "experience" (those working on something for a longer time would have more experience).
It reinforces core elements such as "dedication", in the sense of "spending" time to develop knowledge in reading and studying. Moreover, considering the fact that self-learning is a necessity, as the doctors point out, time needs to be preserved and prioritized, as it is considered a scarce resource. Therefore, it ends up being considered a barrier as well. Heutagogy also reinforces the influence of time, both as a limiting factor and as a measure of what the student wants to learn and, therefore, they dedicate themselves to what makes sense and seek to direct their own needs. Time as a barrier, such as it occurs in the social representations of the study physicians, is also mentioned by Knowles as an obstacle or motivation blockade 2-4 .
The contrast zone of the four-quadrant chart consists of elements with low frequency but considered important by the subjects. Therefore, they reinforce the concepts present in the first periphery, being able to point out the contrast of some element that is being missed by a social representation or indicate the existence of a minority subgroup carrying a different representation 34 . In the present study, the word "research", as the search for information, seems to reinforce several aspects of the first periphery, such as the "internet", a possible locus of research. The word "book", considering its space in the social representations of these subjects (contrast zone), seems to demonstrate that learning through books, as a source of consultation, of research, may be an element that might soon come out of this representation. On the other hand, it can also be indicative of a minority subgroup. The The results show that about a third of the participants who performed some activity related to distance learning, a fact that, associated with a context of abundance of information, may reflect the "necessity", as shown in the interviews, of not being outdated, of keeping up with the evolutions of knowledge. It should be considered a warning the fact that the other learning activities mentioned by the physicians demonstrate educational formats with an instructional design more focused on the teacher's needs to meet learning objectives and less on the autonomy advocated by heutagogy authors 4,35 .

CONCLUSIONS
The way physicians learn has been changing with the inclusion of technology both for care and for knowledge acquisition. Evidence-based practice reinforces the need to create competences related to learning and not just knowledge, since the professional has to creatively deal with the scarcity of time, changes in scientific evidence and excess of information, which may not be reliable or require cautious interpretation.
Although permanent education is at present predominantly based on guidelines, summaries of evidence and protocols, "scientific articles" carry a symbolism of power and scientific evidence that is confused with the very search for knowledge as a validation mechanism for clinical practice.
Medical knowledge implies applying knowledge for the care of those who come to consult, supporting and empowering their practice within a socially constructed and culturally recognized locus, precisely through the process of knowing how to access and interpret this information.
It is necessary to expand knowledge about more autonomous forms of learning that do not involve only the teacher-centered environment, with distance learning being such an example. This premise is especially true in PHC, in which the physician finds little opportunity for discussion with his professional category peers, given the isolation of each unit, when compared, for instance, with specialty clinics or hospitals.
It is worth pointing out here the limitation that the absence of exchanges between peers brings, placing the model based on individual practices as a form of learning. On the other hand, the ability brought on by the internet to connect with other professionals and collaboration also bring different elements for a broader and more satisfactory training into this reality.
The need to understand how this learning process determined by the individual occurs and how the influence of individual and social factors and context can provide better training and inclusion in formal training curricula, such as undergraduate and graduate school, is emphasized. This process will necessarily take place by the fundamental task of teaching physicians to learn, that is, teaching them how to access information, evaluate its quality, analyze the evidence and apply it to the current situation, grounding their practice on the best available information, establishing contextual and meaningful learning. Additionally, they should be able to selfassess, improving their ability to learn in a continuous and effective manner.