specialty training in respiratory medicine in turkey
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1
SPECIALTY TRAINING IN RESPIRATORY MEDICINE IN
TURKEY
Ali Kocabaş, Oya İtil, Can Sevinç,Hacer Arı, Eyüp Sabri Uçan,Numan Ekim
2
Specialty Training in Medicine
• Specialty training is an organized educational training program presented to the medical student / assistant under guidance and supervision.
• During this process, while safe and appropriate health service is offered to the patients, occupational, ethical and personal development is provided for the assistants.
• Qualities of education and patient care are related with each other and should be balanced.
3
Specialty training
Service Education
National Standards and extrencic control
International Standards
4
Problems in European Specialty Training
• Exposure of assistants excessively long working hours without regarding their educational needs.
• Inadequate financial support of the governments• Inadequate training planning on the basis of
institution that give the training and the person who takes it.
• Absence of pedagogic sufficiency of the trainers• Organization disorders of the education system.
*Borman E, O’Grandy P. Postgraduate training. Medical Education. 1997,31:3-8
5
Assistants and Their Problems
6
Trainer Trainee
Training institution
Standards
7
• Should have infrastructural facilities (Completely equipped hospital)
• enough bed capacity• a determinate number of patients (In-patient /
outpatient)• a determinate number of interventions (Operation /
Application)• Education / Investigation/Service should be the targets • Sufficient man power• Should have an educational program in the related
branches.
FEATURES OF TRAINING INSTITUTIONS
8
• Structure and organization of specialty training in our country has been given to the Ministry of Health with the law numerated as 1219 in April 11,1928.
• 1949 : Tuberculosis Specialty
• 1960: Respiratory Medicine and Tuberculosis Specialty
• 2002: Respiratory Medicine Specialty
9
• Turkish Board in Pneumology was established in 2000 in order to provide standardization and to increase the quality of Specialty Training in Respiratory Medicine.
• Board exams were started to be carried out since 2002.
10
• However,the Specialty Training Program prepared in 2002 by the Turkish Board in Pneumology couldn’t be realized.
• It’s always recognized that there is no standardization among the institutions giving Respiratory Medicine Specialty training in Turkey and this is not been supported by scientific data till now.
11
Aim
• The aim of the present study conducted by Turkish Respiratory Medicine Board is to form and realize the specialty education program by detection of the current state and problems of institutions in Turkey giving Respiratory Medicine Specialty Training.
12
Method
• June-July 2005: Preparation of a questionnaire including 89 items by the Executive Committee of the Board.
• July- September 2005: Sending and collection of the questionnaires to all university departments of Respiratory Medicine and to government training hospitals of the Health Ministry.
• October-November 2005:Analysis of all data
13
Content of the questionnaire
• Physical infrastructure
• Health staff capacity
• Functional capacity
• Educational infrastructure
14
Results
• 41 university Respiratory Medicine Departments and 9 government training hospitals of the Health Ministry enrolled the study.
• Some questions were incompletely answered by some of the Heads of the university Chest Departments and Clinical Chiefs of the Government Hospitals.
15
Institutions Giving Respiratory Medicine Specialty Training
• A. University Respiratory Medicine Departments:41
- Ankara,İstanbul,İzmir:11
- Anatolia:30(2 of the universities have no assistants)• B. Health Ministry Government Training Hospitals or
clinics:9
Training Hospital:5
Respiratory Clinic:4
16
Physical Infrastructure
3 (% 33.3)
258 (15-873)
2319
29 (% 96.7)
26 (4-83)
473
6 (% 54.5)
71 (26-147)
638
In the central hospital
Bed number
Total Bed Number
Training
Hospitals
N= 9
University
Anatolia
(n= 30)
University
Big city
(n= 11)
Feature
Total number of beds in the university chest clinics: 1381Total number of beds in government chest clinics: 2319Total: 3700
17
Are there the following branches in your hospital ?
0
10
20
30
40
50
60
70
80
90
100
Central Univ. 100 100 100 100 82 100 100 100 100 82 91
Perypheral Univ. 100 100 100 73 40 100 100 80 87 57 87
Govern.hos. 33,3 0 33 0 0 22 33 0 22 11 33
Internal Medicine
Cardiology Infection Oncology Allergy Pathology Radiology NükleerThoracic Surgery
Rad OncIntern. Intens.
18
Official Scientific Branches
18
9
13
3,3
02468
101214161820
Allergy Intensivecare
Oncology
Central Univ.
Peripheral Univ.Training Hosp.
19
Evaluation I
• In 50 institutions offering Respiratory Medicine Specialty Training in Turkey there are 3700 beds and 63 % of these are in the government training hospitals
• Some clinics required for specialty training are absent in training
• Units like intensive care, allergy and oncology are being established recently.
20
B. Health Staff Capacity
38
54
3430
83
9
55
25
35
0
10
20
30
40
50
60
70
80
90
Professor Assoc.Prof. Assist.Prof. Chief Assistant Chief Head assist.
University Big City (n=11)
University Anatolia (n=30)
Training Hospital (n=9)
21
B. Number of assistants
10,7
107
27
17
6,5
189
55
31
14,5
116
37 34
0
20
40
60
80
100
120
140
160
180
200
Mean Total (412) Number of new assistants (2005)(119)
Number of specialists (2005)(82)
University Big City (n= 11)
University Anatolia (n=30)
Training hospital (n=9)
22
B. Other Health Staff
25 29
99
411
5 313
1 1 2
263
48
27
124
3 1
207
158
216
0
50
100
150
200
250
300N
urs
e
Tec
hn
icia
n
Sec
reta
ry
Oth
er h
ealt
h s
taff
Ph
ysio
ther
apis
tt
Lib
rary
Off
icer
Oth
er
Üniversity Big City(n= 11)
University Anatolia (n=30)
Training Hospital (n=9)
23
Evaluation II
• 363 trainers are giving specialty training and 147 (41% ) of them are in training hospitals.
• 28% of 412 assistants are in the training hospitals.
• A trainer has 1.3 assistants in the universities , but the same rate is 0.8 in the training hospitals.
24
25
C. Functional Capacity
Feature University
Big City
(n= 11)
University
Anatolia
(n=30)
Training Hospital
(n=9)
Having in-patient clinics
With outpatient clinics
Yearly outpatient number (2004)
Yearly in-patient number (2004)
8 (% 73)
11 (% 100)
130 134
10 905
18 (% 60)
30 (% 100)
138 753
17 564
9 (% 100)
9 (% 100)
576 217
53 867
6039 (TB)
26
2,5
37
4
92
106
216
20
67
20
0
50
100
150
200
250
Outpatient roomnumber
Dailypatient
number
Daily numberof patients
hospitalized
Bed fullnessrate
Mean durationof hospitalization
University N= 41Training Hospital N=9
Outpatient and In-patient Clinical Activities
27
Intensive Care Units and Sleep Laboratories
0%
10%
20%
30%
40%
50%
60%
70%
80%
With intensive care unit With sleep laboratories
University Big city (n= 11)
University Anatolia (n=30)
Training Hospital (n=9)64 %
40 %44 %
64 %
40 %
67 %
28
Intensive Care units
Physical infrastructure University
N= 41
Training Hospital
N=9
With intensive care units
Number of beds of these units
Yearly patient number (2004)
Bed fullness rate
Mortality rate
Where do the assistants take education if there is no unit ?
No education
Rotation to another institution
19 (% 46)
4 (0-12)
1835
75 (0-100)
31 (0-54)
2 (% 5)
2 (% 5)
4 (% 44)
9 (3-15)
648
57 (1-85)
36 (17-58)
1 (% 11)
1 (% 11)
29
Sleep Laboratories
Physical infrastructure University
N= 41
Training Hospital
N=9
With sleep laboratories
Yearly patient number(2004)
Bed fullness rate
Where do the assistants take education if there is no unit ?
No education
Rotation to another institution
No answer
19 (% 46)
3966
83 (0-100)
17 (%42)
3 (% 7)
2
6 (% 67)
1775
70 (31-93)
2 (% 22)
0
1
30
Lung Cancer Chemotherapy Unit
10% 10%
37%
5%
37%
44%
12%
44%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
A special unitİn the clinic
A special unitİn the outpatient clinic
General clinic Daily Careunit
A roomİn the out patient clinic
referred
University N= 41
Training hospital N=9
31
Tuberculosis Clinic
10%
5%
31%
49%
33%
11%
56%
0%
10%
20%
30%
40%
50%
60%
With tuberculosis clinic No, referred to the dispensary No, referred to the infection clinic
Other
University N= 41
Training hospital N=9
32
Units
46%
39%
21% 21%18% 16%
87%
44%
90%
28%
10%
44%
22% 22%
33%
89%
33%
89%
33%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Smok
ing ce
ssat
ion o
utpa
tient
clini
c
Asthm
a ou
tpat
ient c
linic
COPD out
patie
nt cl
inici
Oncolo
gy o
utpa
tient
clini
ci
Allegy
out
patie
nt cl
inici
Rehab
iltatio
n un
iti
PFT labo
rato
ryı
Allerg
y lab
orat
oryı
Bronc
hosc
opy u
nit
Inte
rven
tiona
l bro
ncho
scop
y unit
i
Med
ical th
orac
osco
py u
niti
University N= 41Training Hospital N=9
33
Absent equipments-1
0%
20%
40%
60%
80%
100%
120%
Rigid
brnc
hosc
opyi
Fibero
ptic
bron
chos
copy
Autof
luors
cein
bron
chos
copy
Electro
coth
er
Cryot
hera
pyi
Bronc
hosc
opic
laser
Spirom
etry
Bronc
hopr
ovoc
ation
CO diffu
sion
Plethy
smog
raph
y
Exerc
ise te
st
University N= 41
Training Hospital N=9
med
ical t
hora
cosc
opy
10%
87%
51%
81%
87%
3%
36%
64%
44%
22%
67%
56% 56%
100%
44%
11%
44%
56%56%
78%
34
Equipments-2
5%3% 3%
31%
3%5%
8%
15%
23%
5%3%
13%15%
11%
22%
44%
11%
33%
57%
11% 11%
67%
11%
22%
56%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Allerg
ic sk
in te
st
NIMV
Mec
hanic
vent
ilato
r
Poliso
mno
grap
hy
Ultras
onog
raph
y
Compu
teriz
ed to
mog
raph
y
Spiral
CT
V/Q sc
an
BT veno
gaph
yi
D-dim
er
Sputu
m A
RB smea
r
TB resis
tanc
e-cu
lture
Bacte
c
University N= 41
Training Hospital N=9
35
Evaluation III
• Of the total of 845 thousand 68 % of 50 institutions giving specialty training administered to the training hospitals.
• 56 % of 65 thousand patients hospitalized in these institutions in 2004 were in training hospitals.
• Some differences are not observed between university and training hospitals regarding technical infrastructure.
36
D. Educational Infrastructure
5%
17%
49%
15%
5%
10%
22% 22%
11%
33%
11%
0%
10%
20%
30%
40%
50%
60%
No specialtytraining
0-5 years 6-20 years 21-50 years > 50 years Unresponded
University N= 41
Training Hospital N=9
37
Educational Infrastructure
15%
41%
67%
82%
22%
56%
67%
22%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
With adaptation program
With a writtenspecialty education program
With an assistant Making an assistant
exam during the education program
University N= 39
Training Hospital N=9
38
Educational infrastructure
68%
59%
93%
76%
90%
80% 80%
51%
98%93%
89%
33%
67% 67% 67%
44%
67%
56%
67%
56%
0%
20%
40%
60%
80%
100%
120%
With
a lib
rary
ope
n to
eve
ryon
e
A wor
king
phot
ocop
y
Barco
vision
Noteb
ook
Mee
ting
room
Slide
mac
hine
Overh
ead
TV-vide
o
Deskto
p co
mpu
ter
Inte
rnet
ope
n to
eve
ryon
e
University N= 39
Training Hospital N=9
39
Educational activities not done
5%
20%
12%
54%
7%
61%
56%
44% 44%
67%
56%
78%
67% 68%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Asistant seminary Education memberseminar
Case presentationMortalitymeeting
Literature hour Multidisciplinary committee
Feedback from theassistants
about education
University N= 39
Training Hospital N=9
40
41
Assistant Work load
21,7
8,2
27,5
11,5
0
5
10
15
20
25
30
Mean number of patients an assistant examines a patient in the outpatient clinic
Mean number of patients an assistant is responsible in the in-patient clinic
University N= 39
Training hospital N=9
42
Duty Status of The Assistants
8,6
7
5,8
4,7
3,4
6,7
5,4 5,4
3,7
2,5
0
1
2
3
4
5
6
7
8
9
10
First yearassistant
Second yearassistant
Third yearassistant
Fourth year assistant
Fifth year assistant
University N= 39
Training Hospital N=9
43
Rotation status
90%
66%
93%
17%
85%
49%
56%
10%
32%
10%
89%
33%
100%
11%
100%
56%
11%
22%
0%
20%
40%
60%
80%
100%
120%
Inte
rnal
Med
icine
Cardio
logy
Infe
ctiou
s dise
ases
Thora
cic su
rger
y
Radiol
ogy
Inte
nsive
care
Emer
genc
y ser
vice
Dispen
sary
TB Hos
pital Oth
er
University N= 39
Training Hospital N=9
44
Whose picture is this in your opinion ?
An educational member ?
Head of a department ?
Assistant ?
45
Scientific activities(2004)
5,35,9
5,5
8,8
1,2
7,4
1,9
6,7
20,8
13,6
21,4
1
7
3
0
5
10
15
20
25
Internationalarticle
National article InternationalCongress presentation
NationalCongresspresentation
Internationalspeaker
Nationalspeaker
Health staffSent abroad
for educationİn the last 5 years
University N= 39
Training Hospital N=9
46
Assistant activities in specialty training
1242 (400-2500)
208 (50-320)
54 (25-100)
143 (40-250)
138 (0-400)
68 (0-200)
88 (5-400)
84 (10-400)
24 (0-50)
8 (0-20)
21 (0-50)
4 (0-15)
2 (0-5)
543 (80-3000)
151 (30-500)
38 (3-250)
113 (20-500)
187 (0-1000)
78 (0-500)
58 (0-200)
75 (3-300)
26 (0-180)
12 (0-50)
13 (0-30)
10 (0-40)
4 (0-15)
Followed patient and epicrisis (35/7)
Thoracenthesis (37/8)
Pleural biopsy(37/8)
Bronchoskopy (37/8)
PFT (32/7)
Allergic skin test (30/6)
Patient follow-up at Mechanic vent. (29/5)
Patient follow-up at NIMV(35/7)
Patient follow-up in sleep lab.(18/4)
Pleurodesis (30/6)
Transthoracic needle aspiration (21/7)
Central venous catheter (19/4)
Pulmonary arterial catheterization(8/3)
Training hospital
N=9
University
N= 41
47
Evaluation IV
• There are deficiencies in training hospitals regarding educational infrastructure and activities.
• Work load and practical applications of the assistants in training hospitals is more in training hospitals.
• No significant difference was detected in scientific activities between the university and the training hospitals.
48
Society Memberships
85
20 12 8
526
137
193
6075
38
12 5
437
119
233
114
22
0
100
200
300
400
500
600
ERS ATS ACCP Other Turkish ThoracicSociety
TÜSAD TABİBODASI
TB dispensary Other
University N= 41
Training Hospital N=9
49
Conclusions-I
• In Turkey, specialty education is offered to 412 assistants with 363 trainers in 48 institutions.
• There are deficiencies in training hospitals regarding educational infrastructure and activities , but the practical appliacations of the assistants working in these hospitals are more.
50
Conclusions-II
• Standardization and accreditation have not been realized in specialty training in Respiratory Medicine yet.
• In parallel to European and Health Ministry work, specialty training program is targeted to be finished at the end of 2006 and accreditation will be at the end of 2007
• A new organization is needed for specialty training in which universities and training hospitals will work together.
51
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