- Email: [email protected]
Current Status of Neurosurgery in Turkey
Continental Editor’s Message
Necmettin M. Pamir, M.D Professor and Chairman of Neurosurgery, Department of Neurosurgery Acibadem University, School of Medicine
Current Status of Neurosurgery in Turkey Necmettin M. Pamir and Koray Özduman
With a population of more than 70 million, Turkey has a large demand for neurosurgery. Neurosurgery is provided by a socialized health care system partly supported by private institutions. There are more than 1200 neurosurgeons practicing in Turkey, and sophisticated surgical procedures are performed in most large cities. Residency training is provided at universities and training hospitals, and the quality of care is supported by two neurosurgical societies.
HISTORY OF NEUROSURGERY IN TURKEY
M
odern surgery in Turkey started at military hospitals at the end of the 19th century in the Ottoman Empire; only limited procedures in neurosurgery were performed by general surgeons at the time (2, 4). Cemil Topuzlu had an important role in establishing modern surgery in the Ottoman Empire (2, 4). Topuzlu presented the neurosurgical drainage of a brain abscess at the French Surgery Society meeting in 1894 and subsequently published this report in a French surgical journal. After formation of the new Turkish Republic in 1923, the first neurosurgical clinic was established by Abdulkadir Cahit Tuner. Tuner was originally a neuropsychiatrist, but he was trained in neurosurgery by Förster in Breslau, Germany, and on returning to Istanbul he performed the first laminectomy for a spinal tumor in Turkey and craniotomies for brain tumors and neurosurgical treatment for trigeminal neuralgia (2, 4). The first Turkish surgeon to train in neurosurgery was Hami Dilek. Dilek trained in France under Clovis Vincent, Thierry de Martel,
Key words 䡲 Neurosurgery 䡲 Residency training 䡲 Private practice 䡲 University
Abbreviations and Acronyms MRI: Magnetic resonance imaging
and Guillaume (1). Dilek played an important role in establishing modern neurosurgery in Turkey (1). The first training program started in 1940, and Cemil S¸erif Baydur wrote the first neurosurgical textbook in Turkey (2, 4). With the influence of Hami Dilek, the bylaws for specialty training in medicine were accepted in 1947, and neurosurgery became an official discipline (4). The first neurosurgical journal was published by Cafer Tayyar Kankat. Mustafa Sakarya trained with Walter Dandy. Feyyaz Berkay was trained in the United States and became the first board-certified Turkish neurosurgeon; on returning to his home country, he established an independent neurosurgery clinic at Istanbul University (2, 4). In the early 1950s, the first neurosurgery clinics were located in Istanbul. After the establishment of neurosurgery clinics in Istanbul, modern neurosurgery programs were started in Ankara by Nurhan Avman and Aykut Erbengi. These two neurosurgeons were trained in Boston under Poppen (2, 4). In Turkey, Nurhan Avman established the neurosurgery department at Ankara University, and Aykut Erbengi established the neurosurgery department at Hacettepe University. During the establishment of the neurosurgery department at Hacettepe University, Pool, Sachs, and Wilson served in Ankara and contributed to the growth of the department (2, 4). In 1967, Erdem Tunçbay established the neurosurgery department at Ege University in I˙zmir. In the late 1960s, these three departments brought renewed energy to Turkish neurosurgery. After the 1980s, international ties and collaborations increased significantly. Increased numbers of neurosurgeons visited and were trained at international centers, and many world-renowned neurosurgeons came to Turkey to share their experience. Scien-
From the Department of Neurosurgery, Acıbadem University, School of Medicine, Istanbul, Turkey To whom correspondence should be addressed: Necmettin M. Pamir, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2010) 74, 4/5:398-401. DOI: 10.1016/j.wneu.2010.10.030 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Elsevier Inc. All rights reserved.
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WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.10.030
CONTINENTAL EDITOR’S MESSAGE
tific research also increased rapidly, and Turkish neurosurgeons had significant roles in the international collaboration for the advancement of neurosurgery. At the present time, all modern neurosurgical procedures are performed in Turkey at 53 university hospitals, 67 governmental teaching hospitals, 202 governmental general hospitals, and private institutions.
Table 1. Hospitals That Provide Neurosurgical Care in Turkey Total no. all hospitals in Turkey*
1350
Total no. governmental hospitals in Turkey
847
Governmental teaching hospitals
67
Governmental teaching hospitals with neurosurgery clinics
41
PATIENT CARE
Governmental teaching hospitals with neurosurgery residency programs
20
Organization of Health Care in Turkey
Governmental general hospitals
401
Turkey is situated at the crossroads between Europe and Asia; it has an area of 783,562 km2 and is the 37th largest country in the world (8). Among all European countries, Turkey has the third largest population after Russia and Germany. As of December 2009, the Turkish population was 72,561,312 (8). The population is fairly young with an annual growth rate of 1.45; 26% of the population is younger than 14 years, and half of the population is younger than 28.8 years (8).
Governmental general hospitals with neurosurgery clinics
202
The Turkish Republic has a socialized health care system. Although there is a well-developed private health care sector, most health care is provided by the state. The total sum of health care expenses constitutes 6% of the gross domestic product (as of 2007). Most of the population (85.48%) is covered under governmental insurance provided by the Social Security Institution (5). A few people (0.45%) are covered by private insurance (7). People who are not covered by any insurance (14.52%) are treated free of charge at governmental hospitals when they can officially document that they are too poor to afford insurance (7). The population is served by 113,151 physicians (50.4% specialists, 31.6% general practitioners, and 18% residents) (3, 5); this corresponds to 1.58 physicians per 1000 persons (among different parts of the country, this ranges from 0.98 –3.04 per 1000). There are 1350 hospitals and 188,065 hospital beds in Turkey, and this corresponds to 26.3 beds per 10,000 persons (3). Intensive care unit beds constitute 8.1% of this number. There are 517 magnetic resonance imaging (MRI) machines (138,331 persons per MRI machine) and 758 computed tomography scanners (94,225 persons per machine) available. Radiation therapy is provided in large cities. There are three centers that perform Gamma Knife radiosurgery, and a few centers perform CyberKnife radiosurgery. Three centers in Turkey currently have intraoperative MRI.
Total no. university hospitals
400
*University hospitals, governmental hospitals, and private hospitals and others. From Mollahaliloglu S, Kosdak M, Eryilmaz Z: Ministry of Health of Turkey Health Statistics Yearbook 2008. Ankara: The Ministry of Health of Turkey; 2010.
To obtain neurosurgical care, individuals who have governmental insurance can go to governmental hospitals or university hospitals. University hospitals are the referral centers for all other hospitals in Turkey; however, they also accept patients for primary neurosurgical evaluation and treatment. Governmental insurance covers neurosurgical care at most, but not all, private institutions. Most of these institutions ask for compensation to treat patients with governmental insurance. The private insurance system is rapidly growing in Turkey. Private university hospitals and private hospitals provide high-quality neurosurgical care. Specialized care in neurooncology, neurovascular diseases, pediatric neurosurgery, spinal neurosurgery, functional neurosurgery, neurologic intensive care, radiosurgery, and radiation therapy is provided by most university hospitals and large private hospitals and large governmental hospitals. There are 1358 active neurosurgeons in Turkey (Table 2). This number is continuously increasing; at the present time, 514 neurosurgical residents are in training (5). The number of neurosurgeons per 10,000 population is 1.7 in Turkey, which is higher
Table 2. Neurosurgeons and Their Affiliations in Turkey Total no. active neurosurgeons in Turkeya Neurosurgeons at governmental hospitals in Turkey
Neurosurgical Care in Turkey Active neurosurgeons in Turkey work at universities, at governmental hospitals (governmental teaching hospitals and governmental general hospitals), or at private hospitals (Tables 1 and 2). A small fraction of neurosurgeons practice in the Armed Forces. There are 53 university neurosurgery departments in Turkey; 244 academicians and 333 residents serve at university hospitals (5). There are 847 governmental hospitals; nearly 8% (67 of 847) are governmental teaching hospitals (3). Of all 67 governmental teaching hospitals, 41 (61.2%) have neurosurgery departments, and 253 neurosurgeons practice at these governmental teaching hospitals. There are 181 residents being trained at governmental teaching hospitals at the present time. Of 401 governmental general hospitals, 202 (50.4%) provide neurosurgical care, and 408 neurosurgeons practice at these centers (3).
57
Total no. private hospitals
1358 661
Neurosurgeons at governmental teaching hospitals
253
Neurosurgeons at governmental general hospitals
408
Neurosurgeons at universities and private hospitals
697
Neurosurgeons at university hospitals
244
Neurosurgeons at private hospitals
455
Total no. neurosurgery residents
514
Residents at university departments
333
Residents at governmental teaching hospitals
181
a
University hospitals, governmental hospitals, and private hospitals and others. From (OSYM) SSaPC: [The 2009-2010 academic year higher education statistics]. 4, 2010 [in Turkish].
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CONTINENTAL EDITOR’S MESSAGE
Table 3. Universities and Neurosurgery Residency Training in Turkey Total no. universities in Turkey State-owned
154 102
Foundation-owned private universities
52
Total no. medical facilities
65
Medical facilities with neurosurgery departments
53
RESIDENT TRAINING Organization of Neurosurgery Training in Turkey
Figure 1. Neurosurgeons per 100,000 population in Europe.
than the European mean of 1.2 (6). A comparison with other European countries is provided in Figure 1. Of the entire population of Turkey, 17.8% live in Istanbul and 29.4% live in the three largest cities—Istanbul, Ankara, and ˙Izmir (3). When neurosurgeons working at university hospitals and private practice are considered, 27.2% of all neurosurgeons in Turkey are based in Istanbul, and 39.9% work in the three largest cities. With the current socialized system, neurosurgeons work at university hospitals, at governmental hospitals, or in private practice operating at private institutions. Government-employed neurosurgeons are allowed to work at private institutions after hours. Of neurosurgeons, 80% work full-time, and the rest also work after hours at private institutions. Of neurosurgeons working parttime, 8% are academicians.
Neurosurgical Board Examination and Subspecialization in Neurosurgery in Turkey To increase the quality of service and standardize care, a Neurosurgical Board has been introduced by the Turkish Neurosurgical Society, which currently has no binding power. Individuals who pass this oral and written board examination are given a certificate. There is no formal, subspecialization for neurosurgery that is overseen by the government in Turkey. Several departments have internal organizations, however, so that some neurosurgeons preferentially or exclusively focus on certain aspects of neurosurgical care. This informal subspecialization is supported by both neurosurgical societies in Turkey, both of which have working groups in subspecialties. Several meetings and symposia in these subspecialties occur throughout the year organized by universities and teaching hospitals and the working groups of the two professional societies. Both societies provide information on the yearly schedule of these meetings.
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Neurosurgery was officially recognized as a medical specialty in 1947 with the bylaws for specialty training in medicine. Specialty training in neurosurgery is given after obtaining a medical degree. Admission to residency is granted with a National Medical Specialty Examination, which is a centralized, written, multiplechoice examination (5). A certain percentage of residency positions are reserved for foreigners, who are allowed to enter the National Medical Specialty Examination and receive residency training if they are successful. Foreigners are not allowed to perform neurosurgery after finishing residency training, however, unless they obtain Turkish citizenship. Residency candidates do not undergo interviews. Residency programs are either university or teaching hospital departments. The training is overseen by the chairperson of the department and is at least 5 years in duration. In most centers, the residency training time is 6 years to be compatible with the regulations of the European Union. Chairpersons are entitled to increase the length of training up to 2 extra years. For final evaluation of their proficiency, residents who have completed their program undergo written and oral examinations. Resident working hours are regulated by the governmental officer regulations and are currently 40 hours a week. Time spent during calls is not included in this. Call schedules are not standard and are regulated by the local chairperson. All residents are paid and insured by their employing institution (governmental and private universities or by the state if they are working at governmental teaching hospitals). At the present time, the number of neurosurgeons in Turkey is fairly high (Figure 1). There is 1 neurosurgeon for every 56,000 persons, which is higher than the European Union (1 neurosurgeon for every 121,000 persons) and the United States (1 neurosurgeon for every 81,000 persons) (3, 6). There is a growing sentiment to decrease residency admissions and increase and standardize training quality. As of 2010, there are 154 universities in Turkey (Table 3); 66.2% of these are state universities, and the rest are private universities led by foundations (5). There are 65 university neurosurgery departments (Table 4); 119 professors, 58 associate professors, and 66 assistant professors are employed in these departments (5). There are 333 residents in training in university neurosurgery departments. Trainer-to-trainee ratio for university neurosurgery programs is 0.976 (Figure 2). The Turkish armed forces have a military medical academy that has two neurosurgery departments training residents in Ankara and Istanbul. There are 43 governmental teaching hospitals in Turkey; 8 professors, 33 associate professors, 2 assistant professors, and
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.10.030
CONTINENTAL EDITOR’S MESSAGE
Table 4. Instructors in Neurosurgery Total no. academicians at university departments Professors
244 119
Associate professors
58
Assistant professors
67
Total no. academicians and instructors at governmental teaching hospitals Professors
253 8
Associate professors
33
Assistant professors
2
Chief interns
4
Attending physicians
206
224 neurosurgery attending physicians work in these departments. Training hospital programs have 181 residents. Trainerto-trainee ratio for university neurosurgery programs is 1.72 (Figure 2).
Figure 2. Comparison of number of trainer-residents at universities versus governmental teaching hospitals.
nal and peripheral nerve surgery, neuro-oncology, stereotactic and functional neurosurgery, neurovascular surgery, neurotrauma and neurologic intensive care, surgical neuroanatomy, and education of trainers). The Nervous System Surgery Society was founded in 2005 in Istanbul with an aim to increase the quality of neurosurgery. The Nervous System Surgery Society has 109 members, organizes annual scientific meetings, and publishes and distributes the Journal of Nervous System Surgery in Turkish and in English (http://www.sscdergisi.org/eng/jvi.aspx).
PROFESSIONAL SOCIETIES There are two neurosurgical societies in Turkey. The Turkish Neurosurgical Society was founded in 1985; it has 961 members and is based in Ankara. It organizes annual scientific meetings and publishes and distributes the Turkish Neurosurgical Journal in Turkish and in English (http://www.turkishneurosurgery.org.tr/ index.php3). The Turkish Neurosurgical Society has 24 regulatory committees and 8 teaching groups (pediatric neurosurgery, spi-
REFERENCES 1. Elmacı I: [Dr Hami Dilek: A pioneer in neurosurgery]. Istanbul: Seyhan Publications; 2001 [in Turkish]. 2. Erbengi A: [Development of neurosurgery in the world and in Turkey]. In: Aksoy K, Palaog˘lu S, Pamir MN, Tuncer R, eds. Temel Nöros¸irürji. Ankara: Türk Nöros¸irürji Derneg˘i Publications; 2005 [in Turkish]. 3. Mollahaliloglu S, Kosdak M, Eryilmaz Z: Ministry of Health of Turkey Health Statistics Yearbook 2008. Ankara: The Ministry of Health of Turkey; 2010.
CONCLUSIONS Neurosurgery is a well-established medical specialty in Turkey that closely follows as well as leads technical and scientific advances of global neurosurgery. The main aim in Turkey is to increase quality and ensure standardization of patient care and residency training.
4. Naderi S, Erbengi A: History of neurosurgery and neurosurgical applications in Turkey. Surg Neurol 64:S115-S122, 2005.
8. Turkish Statistical Institute PM, Republic of Turkey: [Address based population registration system, Population census results—2009]. Press release no. 15, 2010 [in Turkish].
5. (OSYM) SSaPC: [The 2009-2010 academic year higher education statistics]. 4, 2010 [in Turkish]. 6. Piirto J, Ivan D, Johansson-Augier A, Lang V: Europe in Figures: Eurostat Year Book 2010. Available at: http://epp.eurostat.ec.europa.eu/portal/page/portal/ product_details/publication?p_product_code⫽KSCD-10-220. Accessed November 15, 2010. 7. Turkish Social Security Institution (SGK): [2008 annual statistics]. 2009 [in Turkish].
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Citation: World Neurosurg. (2010) 74, 4/5:398-401. DOI: 10.1016/j.wneu.2010.10.030 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
401
Necmettin M. Pamir, M.D Professor and Chairman of Neurosurgery, Department of Neurosurgery Acibadem University, School of Medicine
Current Status of Neurosurgery in Turkey Necmettin M. Pamir and Koray Özduman
With a population of more than 70 million, Turkey has a large demand for neurosurgery. Neurosurgery is provided by a socialized health care system partly supported by private institutions. There are more than 1200 neurosurgeons practicing in Turkey, and sophisticated surgical procedures are performed in most large cities. Residency training is provided at universities and training hospitals, and the quality of care is supported by two neurosurgical societies.
HISTORY OF NEUROSURGERY IN TURKEY
M
odern surgery in Turkey started at military hospitals at the end of the 19th century in the Ottoman Empire; only limited procedures in neurosurgery were performed by general surgeons at the time (2, 4). Cemil Topuzlu had an important role in establishing modern surgery in the Ottoman Empire (2, 4). Topuzlu presented the neurosurgical drainage of a brain abscess at the French Surgery Society meeting in 1894 and subsequently published this report in a French surgical journal. After formation of the new Turkish Republic in 1923, the first neurosurgical clinic was established by Abdulkadir Cahit Tuner. Tuner was originally a neuropsychiatrist, but he was trained in neurosurgery by Förster in Breslau, Germany, and on returning to Istanbul he performed the first laminectomy for a spinal tumor in Turkey and craniotomies for brain tumors and neurosurgical treatment for trigeminal neuralgia (2, 4). The first Turkish surgeon to train in neurosurgery was Hami Dilek. Dilek trained in France under Clovis Vincent, Thierry de Martel,
Key words 䡲 Neurosurgery 䡲 Residency training 䡲 Private practice 䡲 University
Abbreviations and Acronyms MRI: Magnetic resonance imaging
and Guillaume (1). Dilek played an important role in establishing modern neurosurgery in Turkey (1). The first training program started in 1940, and Cemil S¸erif Baydur wrote the first neurosurgical textbook in Turkey (2, 4). With the influence of Hami Dilek, the bylaws for specialty training in medicine were accepted in 1947, and neurosurgery became an official discipline (4). The first neurosurgical journal was published by Cafer Tayyar Kankat. Mustafa Sakarya trained with Walter Dandy. Feyyaz Berkay was trained in the United States and became the first board-certified Turkish neurosurgeon; on returning to his home country, he established an independent neurosurgery clinic at Istanbul University (2, 4). In the early 1950s, the first neurosurgery clinics were located in Istanbul. After the establishment of neurosurgery clinics in Istanbul, modern neurosurgery programs were started in Ankara by Nurhan Avman and Aykut Erbengi. These two neurosurgeons were trained in Boston under Poppen (2, 4). In Turkey, Nurhan Avman established the neurosurgery department at Ankara University, and Aykut Erbengi established the neurosurgery department at Hacettepe University. During the establishment of the neurosurgery department at Hacettepe University, Pool, Sachs, and Wilson served in Ankara and contributed to the growth of the department (2, 4). In 1967, Erdem Tunçbay established the neurosurgery department at Ege University in I˙zmir. In the late 1960s, these three departments brought renewed energy to Turkish neurosurgery. After the 1980s, international ties and collaborations increased significantly. Increased numbers of neurosurgeons visited and were trained at international centers, and many world-renowned neurosurgeons came to Turkey to share their experience. Scien-
From the Department of Neurosurgery, Acıbadem University, School of Medicine, Istanbul, Turkey To whom correspondence should be addressed: Necmettin M. Pamir, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2010) 74, 4/5:398-401. DOI: 10.1016/j.wneu.2010.10.030 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Elsevier Inc. All rights reserved.
398
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.10.030
CONTINENTAL EDITOR’S MESSAGE
tific research also increased rapidly, and Turkish neurosurgeons had significant roles in the international collaboration for the advancement of neurosurgery. At the present time, all modern neurosurgical procedures are performed in Turkey at 53 university hospitals, 67 governmental teaching hospitals, 202 governmental general hospitals, and private institutions.
Table 1. Hospitals That Provide Neurosurgical Care in Turkey Total no. all hospitals in Turkey*
1350
Total no. governmental hospitals in Turkey
847
Governmental teaching hospitals
67
Governmental teaching hospitals with neurosurgery clinics
41
PATIENT CARE
Governmental teaching hospitals with neurosurgery residency programs
20
Organization of Health Care in Turkey
Governmental general hospitals
401
Turkey is situated at the crossroads between Europe and Asia; it has an area of 783,562 km2 and is the 37th largest country in the world (8). Among all European countries, Turkey has the third largest population after Russia and Germany. As of December 2009, the Turkish population was 72,561,312 (8). The population is fairly young with an annual growth rate of 1.45; 26% of the population is younger than 14 years, and half of the population is younger than 28.8 years (8).
Governmental general hospitals with neurosurgery clinics
202
The Turkish Republic has a socialized health care system. Although there is a well-developed private health care sector, most health care is provided by the state. The total sum of health care expenses constitutes 6% of the gross domestic product (as of 2007). Most of the population (85.48%) is covered under governmental insurance provided by the Social Security Institution (5). A few people (0.45%) are covered by private insurance (7). People who are not covered by any insurance (14.52%) are treated free of charge at governmental hospitals when they can officially document that they are too poor to afford insurance (7). The population is served by 113,151 physicians (50.4% specialists, 31.6% general practitioners, and 18% residents) (3, 5); this corresponds to 1.58 physicians per 1000 persons (among different parts of the country, this ranges from 0.98 –3.04 per 1000). There are 1350 hospitals and 188,065 hospital beds in Turkey, and this corresponds to 26.3 beds per 10,000 persons (3). Intensive care unit beds constitute 8.1% of this number. There are 517 magnetic resonance imaging (MRI) machines (138,331 persons per MRI machine) and 758 computed tomography scanners (94,225 persons per machine) available. Radiation therapy is provided in large cities. There are three centers that perform Gamma Knife radiosurgery, and a few centers perform CyberKnife radiosurgery. Three centers in Turkey currently have intraoperative MRI.
Total no. university hospitals
400
*University hospitals, governmental hospitals, and private hospitals and others. From Mollahaliloglu S, Kosdak M, Eryilmaz Z: Ministry of Health of Turkey Health Statistics Yearbook 2008. Ankara: The Ministry of Health of Turkey; 2010.
To obtain neurosurgical care, individuals who have governmental insurance can go to governmental hospitals or university hospitals. University hospitals are the referral centers for all other hospitals in Turkey; however, they also accept patients for primary neurosurgical evaluation and treatment. Governmental insurance covers neurosurgical care at most, but not all, private institutions. Most of these institutions ask for compensation to treat patients with governmental insurance. The private insurance system is rapidly growing in Turkey. Private university hospitals and private hospitals provide high-quality neurosurgical care. Specialized care in neurooncology, neurovascular diseases, pediatric neurosurgery, spinal neurosurgery, functional neurosurgery, neurologic intensive care, radiosurgery, and radiation therapy is provided by most university hospitals and large private hospitals and large governmental hospitals. There are 1358 active neurosurgeons in Turkey (Table 2). This number is continuously increasing; at the present time, 514 neurosurgical residents are in training (5). The number of neurosurgeons per 10,000 population is 1.7 in Turkey, which is higher
Table 2. Neurosurgeons and Their Affiliations in Turkey Total no. active neurosurgeons in Turkeya Neurosurgeons at governmental hospitals in Turkey
Neurosurgical Care in Turkey Active neurosurgeons in Turkey work at universities, at governmental hospitals (governmental teaching hospitals and governmental general hospitals), or at private hospitals (Tables 1 and 2). A small fraction of neurosurgeons practice in the Armed Forces. There are 53 university neurosurgery departments in Turkey; 244 academicians and 333 residents serve at university hospitals (5). There are 847 governmental hospitals; nearly 8% (67 of 847) are governmental teaching hospitals (3). Of all 67 governmental teaching hospitals, 41 (61.2%) have neurosurgery departments, and 253 neurosurgeons practice at these governmental teaching hospitals. There are 181 residents being trained at governmental teaching hospitals at the present time. Of 401 governmental general hospitals, 202 (50.4%) provide neurosurgical care, and 408 neurosurgeons practice at these centers (3).
57
Total no. private hospitals
1358 661
Neurosurgeons at governmental teaching hospitals
253
Neurosurgeons at governmental general hospitals
408
Neurosurgeons at universities and private hospitals
697
Neurosurgeons at university hospitals
244
Neurosurgeons at private hospitals
455
Total no. neurosurgery residents
514
Residents at university departments
333
Residents at governmental teaching hospitals
181
a
University hospitals, governmental hospitals, and private hospitals and others. From (OSYM) SSaPC: [The 2009-2010 academic year higher education statistics]. 4, 2010 [in Turkish].
WORLD NEUROSURGERY 74 [4/5]: 398-401, OCTOBER/NOVEMBER 2010
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CONTINENTAL EDITOR’S MESSAGE
Table 3. Universities and Neurosurgery Residency Training in Turkey Total no. universities in Turkey State-owned
154 102
Foundation-owned private universities
52
Total no. medical facilities
65
Medical facilities with neurosurgery departments
53
RESIDENT TRAINING Organization of Neurosurgery Training in Turkey
Figure 1. Neurosurgeons per 100,000 population in Europe.
than the European mean of 1.2 (6). A comparison with other European countries is provided in Figure 1. Of the entire population of Turkey, 17.8% live in Istanbul and 29.4% live in the three largest cities—Istanbul, Ankara, and ˙Izmir (3). When neurosurgeons working at university hospitals and private practice are considered, 27.2% of all neurosurgeons in Turkey are based in Istanbul, and 39.9% work in the three largest cities. With the current socialized system, neurosurgeons work at university hospitals, at governmental hospitals, or in private practice operating at private institutions. Government-employed neurosurgeons are allowed to work at private institutions after hours. Of neurosurgeons, 80% work full-time, and the rest also work after hours at private institutions. Of neurosurgeons working parttime, 8% are academicians.
Neurosurgical Board Examination and Subspecialization in Neurosurgery in Turkey To increase the quality of service and standardize care, a Neurosurgical Board has been introduced by the Turkish Neurosurgical Society, which currently has no binding power. Individuals who pass this oral and written board examination are given a certificate. There is no formal, subspecialization for neurosurgery that is overseen by the government in Turkey. Several departments have internal organizations, however, so that some neurosurgeons preferentially or exclusively focus on certain aspects of neurosurgical care. This informal subspecialization is supported by both neurosurgical societies in Turkey, both of which have working groups in subspecialties. Several meetings and symposia in these subspecialties occur throughout the year organized by universities and teaching hospitals and the working groups of the two professional societies. Both societies provide information on the yearly schedule of these meetings.
400
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Neurosurgery was officially recognized as a medical specialty in 1947 with the bylaws for specialty training in medicine. Specialty training in neurosurgery is given after obtaining a medical degree. Admission to residency is granted with a National Medical Specialty Examination, which is a centralized, written, multiplechoice examination (5). A certain percentage of residency positions are reserved for foreigners, who are allowed to enter the National Medical Specialty Examination and receive residency training if they are successful. Foreigners are not allowed to perform neurosurgery after finishing residency training, however, unless they obtain Turkish citizenship. Residency candidates do not undergo interviews. Residency programs are either university or teaching hospital departments. The training is overseen by the chairperson of the department and is at least 5 years in duration. In most centers, the residency training time is 6 years to be compatible with the regulations of the European Union. Chairpersons are entitled to increase the length of training up to 2 extra years. For final evaluation of their proficiency, residents who have completed their program undergo written and oral examinations. Resident working hours are regulated by the governmental officer regulations and are currently 40 hours a week. Time spent during calls is not included in this. Call schedules are not standard and are regulated by the local chairperson. All residents are paid and insured by their employing institution (governmental and private universities or by the state if they are working at governmental teaching hospitals). At the present time, the number of neurosurgeons in Turkey is fairly high (Figure 1). There is 1 neurosurgeon for every 56,000 persons, which is higher than the European Union (1 neurosurgeon for every 121,000 persons) and the United States (1 neurosurgeon for every 81,000 persons) (3, 6). There is a growing sentiment to decrease residency admissions and increase and standardize training quality. As of 2010, there are 154 universities in Turkey (Table 3); 66.2% of these are state universities, and the rest are private universities led by foundations (5). There are 65 university neurosurgery departments (Table 4); 119 professors, 58 associate professors, and 66 assistant professors are employed in these departments (5). There are 333 residents in training in university neurosurgery departments. Trainer-to-trainee ratio for university neurosurgery programs is 0.976 (Figure 2). The Turkish armed forces have a military medical academy that has two neurosurgery departments training residents in Ankara and Istanbul. There are 43 governmental teaching hospitals in Turkey; 8 professors, 33 associate professors, 2 assistant professors, and
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.10.030
CONTINENTAL EDITOR’S MESSAGE
Table 4. Instructors in Neurosurgery Total no. academicians at university departments Professors
244 119
Associate professors
58
Assistant professors
67
Total no. academicians and instructors at governmental teaching hospitals Professors
253 8
Associate professors
33
Assistant professors
2
Chief interns
4
Attending physicians
206
224 neurosurgery attending physicians work in these departments. Training hospital programs have 181 residents. Trainerto-trainee ratio for university neurosurgery programs is 1.72 (Figure 2).
Figure 2. Comparison of number of trainer-residents at universities versus governmental teaching hospitals.
nal and peripheral nerve surgery, neuro-oncology, stereotactic and functional neurosurgery, neurovascular surgery, neurotrauma and neurologic intensive care, surgical neuroanatomy, and education of trainers). The Nervous System Surgery Society was founded in 2005 in Istanbul with an aim to increase the quality of neurosurgery. The Nervous System Surgery Society has 109 members, organizes annual scientific meetings, and publishes and distributes the Journal of Nervous System Surgery in Turkish and in English (http://www.sscdergisi.org/eng/jvi.aspx).
PROFESSIONAL SOCIETIES There are two neurosurgical societies in Turkey. The Turkish Neurosurgical Society was founded in 1985; it has 961 members and is based in Ankara. It organizes annual scientific meetings and publishes and distributes the Turkish Neurosurgical Journal in Turkish and in English (http://www.turkishneurosurgery.org.tr/ index.php3). The Turkish Neurosurgical Society has 24 regulatory committees and 8 teaching groups (pediatric neurosurgery, spi-
REFERENCES 1. Elmacı I: [Dr Hami Dilek: A pioneer in neurosurgery]. Istanbul: Seyhan Publications; 2001 [in Turkish]. 2. Erbengi A: [Development of neurosurgery in the world and in Turkey]. In: Aksoy K, Palaog˘lu S, Pamir MN, Tuncer R, eds. Temel Nöros¸irürji. Ankara: Türk Nöros¸irürji Derneg˘i Publications; 2005 [in Turkish]. 3. Mollahaliloglu S, Kosdak M, Eryilmaz Z: Ministry of Health of Turkey Health Statistics Yearbook 2008. Ankara: The Ministry of Health of Turkey; 2010.
CONCLUSIONS Neurosurgery is a well-established medical specialty in Turkey that closely follows as well as leads technical and scientific advances of global neurosurgery. The main aim in Turkey is to increase quality and ensure standardization of patient care and residency training.
4. Naderi S, Erbengi A: History of neurosurgery and neurosurgical applications in Turkey. Surg Neurol 64:S115-S122, 2005.
8. Turkish Statistical Institute PM, Republic of Turkey: [Address based population registration system, Population census results—2009]. Press release no. 15, 2010 [in Turkish].
5. (OSYM) SSaPC: [The 2009-2010 academic year higher education statistics]. 4, 2010 [in Turkish]. 6. Piirto J, Ivan D, Johansson-Augier A, Lang V: Europe in Figures: Eurostat Year Book 2010. Available at: http://epp.eurostat.ec.europa.eu/portal/page/portal/ product_details/publication?p_product_code⫽KSCD-10-220. Accessed November 15, 2010. 7. Turkish Social Security Institution (SGK): [2008 annual statistics]. 2009 [in Turkish].
WORLD NEUROSURGERY 74 [4/5]: 398-401, OCTOBER/NOVEMBER 2010
Citation: World Neurosurg. (2010) 74, 4/5:398-401. DOI: 10.1016/j.wneu.2010.10.030 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Elsevier Inc. All rights reserved.
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