Respiratory training in Turkey

Entry into respiratory medicine

Respiratory medicine is more often recognised by the term “chest diseases” in Turkey. After studying in a faculty of medicine for 6 years, to be able to obtain a licence to practise, graduates are required to work in primary healthcare facilities around the country for 1–2 years. However, all graduates are welcome to enter a medical speciality exam, whether they are continuing or discontinuing their compulsory health service, or are currently in a training programme that does not fulfil their expectations. The participants get placed in the training programmes of their choice, depending on the scores they receive as well as the demand trends of medical specialities. A system determining the speciality only by the score from a general exam may be questionable, since prior achievements or failures during medical school are ruled out. Furthermore, the trainee may not necessarily acquire the qualifications for the relevant speciality requiring subtle skills, perfect senses or frequent night shifts.

In Turkey, respiratory medicine is counted as a separate speciality rather than a subspeciality of internal medicine like in most countries. As there is a growing trend of medical speciality preferences to side with having the minimum number of night shifts, less intervention and low risk of malpractice, it would not be hard to infer that respiratory medicine is not among the most popular specialities in Turkey. However, it is widely preferred by graduates seeking a specific branch of internal medicine as well as willing to gain experience in intensive care units besides performing certain interventions. The training, which lasts approximately 4–5 years, takes place either in training and research hospitals (which are affiliated with the Ministry of Health) or in state or private university hospitals. Among training and research hospitals in big cities, some serve specifically as chest diseases hospitals and are also important referral centres. However, speciality-specific hospitals are not valid for most specialities. The establishment of chest diseases hospitals is largely associated with high incidence rates of tuberculosis in Turkey in the early 1900s. Therefore, they are still the most experienced centres in managing complicated cases of tuberculosis. Tuberculosis also accounts for chest diseases being a separate speciality of its own, as well as chest physicians officially being given the title of “chest diseases and tuberculosis specialist”, in Turkey. Likewise, some chest departments in old university hospitals can be seen in separate buildings apart from the main building, so that patients with tuberculosis could be isolated and treated with special care. As a result of the invention of anti-tuberculosis treatment as well as vaccination strategies, a dramatic decrease in the frequency of tuberculosis occurred in the following years. However, unfortunately, respiratory medicine has never lost its popularity among patients, especially due to the consequences of biomass fuel exposure and the common consumption of tobacco in Turkey. Hence, the intense daily work routine can be challenging for chest specialists as well as residents, and requires dedication.

Training programme

The training programme for residents is carried out according to the regulations of the Turkish Pulmonary Diseases Competency Board. The 4-year training programme involves a 1-year period of training in internal medicine. By the end of the training programme, the residents are required to pass an oral examination in front of a three-member committee of professors to receive their license to practise. A pulmonologist is expected to be capable of interpretation of lung function tests, chest radiographs and computed tomography of the thorax, of performing flexible bronchoscopy, monitoring patients in the intensive care unit, assessing patients with sleep disordered breathing and overall managing all aspects of airway and lung diseases in terms of diagnosis and treatment. The board also holds exams for certifying the pulmonologists and renewing senior physicians' certificates.

The training programme is a full-time job and working in other private institutions is prohibited. During training in inpatient clinics, residents are responsible for monitoring the patients in the ward. Every day, in company with the professors or senior specialists, the residents examine the patients, evaluate the treatment and perform the necessary bronchoscopic and pleural interventions. In university hospitals, medical faculty students also join patient visits and observe the interventions performed. The diagnosis of the patients visiting chest clinics may vary depending on the subspecialisations of the professors and specialists. However, most of the time, residents have the opportunity to examine patients with airway diseases, lung cancer, bronchiectasis, tuberculosis, interstitial lung disease and pleural diseases throughout their training. As most of the patients in the ward have comorbidities, the residents learn a multidisciplinary approach and consult the relevant clinics when necessary.

All trainees develop experience in flexible bronchoscopy. Depending on the experience of the centre, trainees may develop further experience in endobronchial ultrasound, cryotherapy, or endobronchial stent, valve and coil placement. Trainees also get experience with ultrasonography-guided thoracentesis, chest tube insertion and pleural biopsy. Residents are also expected to spend at least 60 days in intensive care units and learn to manage patients with respiratory failure through noninvasive and invasive ventilation algorithms. Not all chest departments own sleep laboratories. Chest physicians are required to attend a theoretical course as well as spend at least 30 days in a sleep laboratory, to be able to get a certificate proving that they can make diagnoses of sleep-related breathing disorders and manage treatment.

Night shifts in pulmonary diseases are usually challenging for the trainees. A junior resident has approximately eight night shifts per month. Besides being in charge of all the patients in the ward and the intensive care unit, the trainees frequently get called from other departments and emergency services for consultations and they also have new patient admissions. Hereby, the trainee becomes proficient in the differential diagnosis of dyspnoea and pulmonary emergencies. The trainee continues routine work the following day. Despite all the hard work and exhaustion, night shifts play a great role in the education of the resident.

Education

Every chest department has different educational programmes. Usually, there are weekly seminars where updates in the literature and current algorithms in relevant topics are presented by the residents and specialists. There are also council meetings, where complicated patients are discussed with physicians from different departments.

Though not mandatory, residents are also encouraged to conduct studies and present them in national and international congresses. The Turkish Thoracic Society and Turkish Respiratory Society are the oldest and largest two national societies organising seminars, workshops and annual congresses regularly. They also have connections with international societies as well as foreign health professionals. The societies support the education of the trainees by providing them with sponsorship for the meetings. The residents are obliged to conduct a thesis study and present it by the end of their training.

Being a pulmonologist in Turkey

After finishing the training programme, the pulmonologist is obliged to work in a state hospital as a part of the compulsory health service assigned by the Ministry of Health. Pulmonologists in state hospitals examine approximately 60–80 patients in outpatient clinics every day. Sometimes they also have patients in the inpatient ward as well as critical care unit. Despite the heavy workload, the pulmonologists gain a lot of experience during compulsory health service, where they also have the chance to examine patients with diseases such as asbestosis, mesothelioma, silicosis, coal miner's pneumoconiosis and alveolar echinococcosis, which are related to regional environmental and cultural factors. If the pulmonologist wishes to have further specialisation, he/she can enter an exam for subspecialisations of allergy, critical care or occupational diseases. After finishing compulsory health service, the pulmonologists can receive their diplomas and are free to resign and work privately. Further options, other than working in the current state hospital, are applying assays for other state hospitals or getting involved in university hospitals for an academic career. The options abroad are unfortunately limited for chest physicians, since equivalency can be difficult, although not impossible.

Future directions

The future for chest diseases seems directed towards subspecialities like oncology, sleep disorders, critical care, allergy and occupational diseases. The professional societies and chest physicians are working hard for a better future for chest diseases by getting involved in global networks, offering the residents educational activities as well as encouraging and inspiring them towards new horizons. The residents should make good use of their time during training by trying to practise in all areas, improve interventional skills, stay up to date and get inspired from senior specialists as well as professors.

In conclusion, chest diseases is a challenging speciality that requires hard work and dedication in Turkey, similar to other countries. Sociocultural factors may influence the burden of pulmonary diseases as well as the working conditions in hospitals in Turkey for both trainees and physicians. Incidentally, the trainees in Turkey should not dismiss the fact that they are particularly lucky in having the chance to enjoy the good weather, beautiful nature and tasty traditional food in Turkey in their spare time after work! As hospitality is one of the most well-known characteristics of Turkish culture, each reader should know that they will always be welcome!

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Views of the campus of Yedikule Chest Diseases Hospital, Istanbul, Turkey.