Unfilled quotas in TUS and the future of our health

One of the most discussed topics of the past week was the results of the Medical Specialization Examination (TUS).   

The placement results for the 1st Term of the 2024 TUS once again showed that the trend of "avoiding surgical branches" seen in recent years has not changed. As is known, new graduates from medical schools have not been choosing surgical branches for years, and furthermore, the quotas for branches that were once the most popular are now remaining empty. 

This year, at some medical congresses held recently, the agenda of physicians was also dominated by the medical specialties that are not being chosen. Both obstetricians and gynecologists, as well as neurosurgeons, have complained that their young colleagues no longer want these branches due to malpractice (medical error) lawsuits.  

CHILD HEALTH IS AMONG THE LEAST PREFERRED BRANCHES

The latest TUS results, which show that a new threshold has been reached in pediatrics—that is, child health and diseases—and pediatric surgery, also revealed a picture that serves as an alarm regarding the future of the healthcare system.  

At the Istanbul Başakşehir Çam and Sakura City Hospital, 28 of the 30 quotas opened in the department of child health and diseases remained empty, and only 1 of the 6 quotas opened for the pediatric surgery department was chosen. All 15 positions opened at the Bağcılar Training and Research Hospital, all 6 positions opened at the Istanbul Training and Research Hospital, and 13 pediatric positions opened at the Haseki Training and Research Hospital remained empty.

With the situation as it is, concerns have been raised that in the future, there will be no pediatricians or pediatric surgeons to whom we can entrust our children. The warning constantly repeated by professional organizations regarding the increased exposure of emergency physicians and surgical branches to violence is: "If these problems are not solved in the future, our patients will not be able to find surgeons to operate on them or heal them. Because in a case, the compensation amount requested in malpractice lawsuits filed against a physician can be so high that the physician could not earn it in a lifetime." 

However, this concern and prediction are not new. 

Although physician organizations and specialty associations have been drawing attention to the issue for years and warning the Ministry of Health, the ministry has chosen to ignore the problems of physicians instead of taking them into account. The problem has deepened even further in the last 10 years.

So, until 10–15 years ago, those who received the highest scores in TUS were choosing branches such as cardiology, obstetrics and gynecology, pediatrics, general surgery, and neurosurgery. How did these branches become ones that are almost never chosen? 

Turkish Medical Association (TTB) 2nd President Assoc. Prof. Dr. Ali İhsan Ökten answers our question by going to the starting point of this problem: 

"This situation began with the increase in complaints and violence as a result of the provoked health policies created by the Health Transformation Project, which was implemented around 2002. The fact that the malpractice law has not been enacted for many years, and the disproportion between income and compensation rates, caused surgical branches in particular to not be preferred.

As a very worrying situation, except for plastic surgery, otolaryngology, and ophthalmology, at least half of the quotas in other surgical branches are not being chosen. As a result, surgical branches, primarily child health and diseases, as well as pediatric surgery, neurosurgery, cardiovascular surgery, general surgery, orthopedics, and obstetrics and gynecology, have been pushed to the background."

ALIENATION FROM THE PROFESSION IS SEEN IN YOUNG DOCTORS

While some young graduates are looking for careers abroad, others start working at pharmaceutical companies without ever practicing their profession. After a difficult and long medical education, the hopelessness and resentment of young doctors seem to have increased to an unprecedented level. 

Assoc. Prof. Dr. Ökten describes the current situation with these words:

"Young graduates are rightly choosing to go abroad. Because the significant increase in complaints and violence, the decline in economic and personal rights, the severity of working conditions, malpractice lawsuits, the increasingly unqualified nature of education, the state of economic and political crisis the country is in, the lack of confidence in the future, and the fact that working and living conditions abroad are better are the main reasons that increase the migration abroad. These situations especially increase hopelessness and lead to burnout syndrome. Alienation from the profession and the desire to no longer practice the profession are becoming dominant. This situation has now become chronic. Unless there is a very serious correction by the government and the Ministry of Health, this situation—that is, resentment toward the profession, alienation, burnout, and chronicity—will continue to increase.

The Ministry of Health already determines the country's needs and employment policy. Does the country need a family physician or a specialist? In which specialty area is there a shortage? These need to be analyzed separately and a policy made accordingly. However, the ministry does not do any of this. Acting with a wholesale mentality, it wants to train specialists in series by doubling the number of residents as if there were only a shortage of specialists. However, what we need is a shortage of family physicians rather than a shortage of specialists."

REASONS FOR PREFERENCE DIFFERENCES BETWEEN HOSPITALS 

Differences can also be seen between hospitals in TUS preferences. 

City hospitals are not preferred because the workload in the pediatric branch is higher than in medical faculties, outpatient clinics and clinics are very busy, and shifts are difficult. However, the situation is the exact opposite for surgical branches. Assoc. Prof. Dr. Ali İhsan Ökten explains the reason for this as follows: 

"First of all, city hospitals or other training and research hospitals affiliated with the Ministry of Health are more attractive, especially in terms of surgical branches, because the number of cases is high and there is more opportunity to practice. Another reason is that the revolving fund income is better in city hospitals. Therefore, physicians who pass the TUS primarily prefer city hospitals or other training and research hospitals affiliated with the Ministry of Health. In this case, the preference rates of medical faculties will remain low. They are already taking fewer residents, and when they are not preferred, the number of residents decreases even more. In this case, the workload of the colleagues working there increases even more. Sometimes resident quotas are not opened consecutively, or residents do not choose them. In this case, even the closure of that clinic can come to the agenda. Examples of this were previously experienced at the Urfa Harran University Faculty of Medicine. Nine departments faced the danger of closing.

First of all, there is a need for urgent intervention in branches such as child health and diseases, neurosurgery, general surgery, and obstetrics and gynecology. The TTB and specialty associations convey this situation to the Medical Specialization Board and the relevant units of the Ministry of Health. However, the ministry needs to work more seriously on identifying and solving the problems in this regard. While doing these, it should establish good communication with specialty associations, primarily the TTB, and unions in the health sector, listen to them, and find a way to solve the problem with common sense."

THOSE GRADUATING WITH HONORS TURN TO MEDICAL AESTHETICS 

Current conditions force new graduates to adopt the idea of not taking the TUS and even to change their dreams. 

So much so that a young doctor I met recently was almost a living example of the subject. She graduated from the medical faculty of a foundation university with honors. However, as she witnessed incidents of violence against physicians almost every day while doing her emergency internship, she decided not to take the TUS. Instead, she received medical aesthetics training and chose to work as a medical aesthetics specialist at a private center. 

Based on this example, Assoc. Prof. Dr. Ali İhsan Ökten shares his observation: 

"There are many physicians who work as general practitioners after graduation or become specialists and later enter the field of medical aesthetics. Some of them open their own places, while others work in another center. Those who get the highest scores in TUS prefer plastic surgery or dermatology departments. Some of these colleagues can later shift to the field of medical aesthetics."

FAVORITE OF THOSE WITH HIGH SCORES: PHYSICAL THERAPY 

Physical therapy and rehabilitation, which is the most preferred in TUS, is one of the 3–4 branches that have come to the fore in recent years. 

Dr. Demirhan Diracoğlu, 2nd President of the Physical Therapy and Rehabilitation Association, also stating that those who get the highest scores in TUS are now coming to the field of physical therapy and rehabilitation, says, "In preference rankings, physical therapy and rehabilitation is in the top 3–4 branches along with plastic surgery, dermatology, and radiology. The demand of young physicians for our field has increased significantly in recent years."  

THE PROBLEM IS NOT IN THE TUS RESULTS BUT IN THE SYSTEM ITSELF

The TUS results seem to be putting the healthcare system in a difficult position more than ever. However, according to Assoc. Prof. Dr. Ali İhsan Ökten, the problem is not in the TUS results, but in the system itself. 

Stating that "as long as this continues, the problems of the health services that citizens will receive and the physicians and all healthcare workers who provide health services will increase exponentially," Ökten emphasizes that the implemented health system must change completely. He lists the suggestions they have brought for this as follows; 

1-A step-based system must be adopted, 

2-Preventive health services should be at the forefront, 

3-The primary care level should be strengthened, 

4-The number of family physicians should be increased, the population registered to a family physician should be reduced, and a region-based system should be adopted, 

5-Therapeutic health policies should be abandoned, 

6-Unqualified, physically and academically insufficient medical faculties and training clinics should be closed, 

7-An employment policy based on need should be followed.