In Turkey intensive care was not a separate specialty for years, and was managed mainly as a subspecialty of anaesthesiology. In 2009 a new regulation was announced by the Ministry of Health (MoH) in which intensive care medicine (ICM) was recognised as a supraspecialty. Regarding this regulation, ICM education has a duration of three years after primary specialty training in anaesthesiology, pulmonology, internal medicine, general surgery, neurology and infectious diseases. The MoH also founded a “Scientific Committee of ICM” to establish the intensive care training curriculum that is consistent with the Competency Based Training programme in Intensive Care Medicine for Europe (CoBaTrice). This regulation has evoked several debates.
There are more than 1000 anaesthesiologists and other specialists such as pulmonologists, general surgeons, neurologists, chest surgeons and cardiovascular surgeons working in and directing ICUs in Turkey, who do not have the MoH Diploma of Intensive Care. The Diploma of Intensive Care has been given to only 208 physicians after initial assessment. A number of scientific activities, including papers published in international publications covered by the Science Citation Index in addition to some educational activities (e.g. editorship or associate editorship for books or journals, authorship for book chapters, editorship for book translation, at least five activities in a congress, adviser for thesis etc.) are required for the diploma, which is not the case for the majority of these people, who are only clinicians, and not scientists or educators. Thus there are still more than 800 experienced doctors, mainly anaesthesiologists and also some other main specialties, who do not have the diploma and work on ICUs. What will happen to them? Do they have enough enthusiasm to carry on their functions in ICU? Who will be responsible in case of legal problems? How can we employ these un-certified intensivists in intensive care, and how can we employ them as trainers for intensive care residents in teaching hospitals? And so on. There are several unanswered questions and as a result several statements of claim at courts.
Because of these problems, the MoH has proposed a draft act to parliament. According to this, a documentation of clinical performance in an ICU of at least 3-5 years plus an examination appears to be a good solution, in order to give the MoH intensive care diploma to these applicants, but it is still a subject that needs to be debated in parliament and, more importantly, between intensivists.
Intensive Care Education
The duration of education for the supraspecialty in intensive care has been decided as three years. However, one year of the anaesthesiology residency period is still dedicated to ICM. Residents in anaesthesiology argue that this is unfair for two reasons: first, if they are not intending to make a supraspecialty education, this year would make no sense; and second, if they intend to make this supraspecialty fellowship, their education should be 2 years.
On the other hand, colleagues who have started the supraspecialty education ask whether they will have a “difference” compared to older colleagues who do not “officially” have the ICM diploma, but have directed an ICU for years.
Determining the curriculum, organising the “board”, and similar questions remain also as issues of discussion between the Turkish Society of Intensive Care (TSIC) and other societies. Around eighty-five percent of intensivists who have the diploma are members of TSIC and anaesthesiologists. A “scientific board” has to be founded with a fair and rational distribution among the different disciplines, taking into consideration the distribution of the intensivists in the country.
Currently, the most important problems appear to be the “official” ones, but there are also other problems like the shortage of nurses and other personnel such as physiotherapists and clinical pharmacists. This shortage leads usually to non-optimal management; causing a further financial problem. On the other hand there is no formal education for intensive care nurses.
Previously, dealing with ICM was a “prestige” among the physicians. Today, increased workload leads often to burnout: the combination of relatively low income and longer working hours has made the supraspecialty unattractive.
There is a shortage of level 3 ICU beds in Turkey. The ratio of ICU beds/ hospital beds has to be increased, which is also planned by the MoH. The lack of “post- ICU care” (e.g. home care, nursing homes) is an issue, leading to an unnecessary increase in ICU stay, the need for further ICU beds and personnel and increased cost.
Last, but not least, the insufficient and irrational payment of General Health Insurance to ICM has led to the fact that the hospital management does not want to invest in ICUs. Reimbursements are not case-sensitive and are standardised according to the patient’s care requirement level graded by the insurance system according to the level of ICU. Therefore, more serious patients with increased expenses result in pecuniary loss for intensive care units and hospitals.
According to the general health insurance system in Turkey reimbursement mainly depends on days of stay in the ICU. Therefore, additional therapeutic approaches, advanced therapies, increased use of antibiotics all increase the expenses but not the income of ICUs.
The TSIC and MoH are planning new strategies for some of these problems.
MoH’s act proposing re-certification of intensivists will be put on the agenda of the Turkish Parliament within a few months.
MoH is targeting the number of ICU beds to be ten percent of hospital bed capacity, and plans to regenerate palliative care units. With the new system ICU beds will be used more efficiently.
TSIC is changing its structural organisation. Several new working groups and a dynamic feedback system interacting with intensivists and intensive care units of the country will be the principal source for determination of future policies. In addition to national activities, international relations will be improved to restate the active role of the society. The diversity, frequency, contents, and organisational structure of scientific and educational activities will be re-evaluated and re-organised according to reports from relevant working groups in addition to extended advisory boards.
TSIC has organised a new activity together with the Global Sepsis Alliance and MoH to increase sepsis awareness, increase education of healthcare staff, and decrease prevalence and mortality of sepsis in Turkey. On 12 September 2014 the first stage of the programme started with the simultaneous appearance of Dr. Mehmet Müezzinoğlu, Minister of Health, in the 14 biggest hospitals in 13 cities of Turkey. A TSIM working group and very powerful trainer team, including approximately 215 intensivists mainly from teaching hospitals and university hospitals, will continue planned educational activities in every city of Turkey for years to come under the organisation of the Ministry of Health.