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SPECIALTY TRAINING IN RESPIRATORY MEDICINE IN

TURKEY

Ali Kocabaş, Oya İtil, Can Sevinç,Hacer Arı, Eyüp Sabri Uçan,Numan Ekim

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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.

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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

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Assistants and Their Problems

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Trainer Trainee

Training institution

Standards

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• 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

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• 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

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• 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.

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• 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.

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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.

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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

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Content of the questionnaire

• Physical infrastructure

• Health staff capacity

• Functional capacity

• Educational infrastructure

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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.

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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

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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

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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.

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Official Scientific Branches

18

9

13

3,3

02468

101214161820

Allergy Intensivecare

Oncology

Central Univ.

Peripheral Univ.Training Hosp.

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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.

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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)

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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)

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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)

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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.

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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

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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 %

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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

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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

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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

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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%

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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

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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.

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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

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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

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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

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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

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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

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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.

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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

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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.

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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.

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