K·r·kkale University Medical School Department of Family Practice

Introduction:

The medical schools of Turkey are going through a process of restructuring in line with the recent developments in medical education worldwide. This process includes the establishment of national standards in medical education and formation of basic core curricula in medical schools; introduction of comprehensive examinations prior to graduation; the decrease in the number of students in big medical schools; the preparation of need and priority reports before any new medical school is established; and encouragement of learner centered /active learning. Over the last 5-6 years, these improvements have been progressively made on the basis of national consensus .

Current Situation: Problems and Restructuring Process

Medical education lasts six years in Turkey. Medical students are selected from among high school graduates through a nation-wide exam. One does not need to have a BA degree in order to apply for medical education in Turkey.

There are 47 medical schools in Turkey. All but three of them still utilize traditional and integrated systems. Dokuz Eylul University Medical School was the first to implement the problem-based learning curriculum in 1997-98 academic year. It has been followed by Pamukkale University Medical School . Ankara University Medical School, the oldest medical school of Turkey’s capital city, which has been utilizing the traditional method since its foundation in 1945, also implemented the problem-based learning curriculum in 2002.

In the last decade due to some political concerns new medical schools were established almost in each province with no proper infrastructure and staff. The increase in the number of students together with the insufficiency of the infrastructure of these medical schools has had a negative effect on the quality of medical education and medical school graduates in Turkey.

Some of the largest medical schools in Turkey decided to accept fewer students than they did before, so the total number of medical students has dropped from 33,000 to 31,000 between the years of 1997 and 2000 (1). It is believed that limiting the number of the new students by about 200 would improve the quality of the medical education in Turkey. At the other hand , there are too many new graduates (approximately 4600 per year) (2) and if it keeps going on, those young physicians will have a risk of unemployment in future. 

The total number of assistant professors, associate professors and professors is 6592 in Turkish medical schools. 2030 of them are assistant professors (3). Because of the need for instructors in the newly established medical schools, the number of assistant professors is increasing. Due to financial difficulties, most of the instructors prefer to have a second job outside of the university. As a result, the number of full-time teachers is decreasing. This is one of the major problems the medical education is facing right now.

85% of the instructors are in the clinical, and the remaining 15% are in the basic sciences (1). Instructors in the basic science areas have lower incomes and they get less funding for their work. These problems result in a shortage of available basic science instructors. Most of the instructors work at the medical schools of the three largest cities (Ankara, Istanbul and Izmir). 79% of the new medical schools do not have any professor or associate professor other than the dean himself/herself (3).

The most difficult stage in the academic career of faculty members in Turkey is associate professorship. The High Education Council (HEC) which is the central authority in the appointment and promotion in universities has a number of laws and regulations on this issue. An assistant professor must have at least three original research publications in journals included in SCI in order to become an associate professor. (In actuality this number is between 5 to 15 as 3 publications is never seen as sufficient). Once the publication requirement is met, an oral examination follows. The members of the examination committee is determined by the HEC. Once the title of associate professor is given, the faculty member has to make a total score determined by her own university. In almost all promotion regulations of medical schools, the score for research publications has a much higher percentage than the score for teaching activities in this total score. Therefore if an assistant professor is not personally interested in becoming a better instructor, her teaching records have almost no effect on her academic promotion. Assistant professors are overwhelmed by the work they need to do for original and internationally acceptable research and the effort to get the associate professor title (one of the two tenure positions - the other being ‘professor’).

Programs for faculty development and improvement of teaching skills generally increase in number and frequency in periods of transition to problem-based curriculum or periods when there are discussions on whether to include these programs into the curriculum partially or totally(4,5,6,7). It is interesting, for instance, that Turkey-based international publications have mostly originated from Turkish medical schools where problem-based education is already implemented, just beginning to be implemented or being discussed . The same is true with papers presented to national congresses on medical education (10,11) . This is because new responsibilities are inflicted upon faculty members in periods of transition to new curricula, and this brings new educational needs on the part of these faculty members.

In medical schools where problem-based education can not be implemented, that is in most of the medical schools in Turkey, programs for faculty development and improving teaching skills are seen as activities carried out by a limited number of volunteers. In those medical schools where problem-based, active teaching is implemented, the volunteer participants are generally junior faculty members (12).

The continuous medical education programs in Turkey are carried out by the Turkish Medical Association and other medical speciality associations in cooperation with the related departments of universities. These programs include national or regional congresses, symposiums and periodicals. Also some medical schools have post-graduate training programs open to all physicians. The participation of a faculty member in these congresses and CME activities at the national and international level is limited because their financial resources do not allow them to pay the participation fees (13).

During the first and second National Medical Education Congresses of 1998 and 2001, there have been broad discussions on the problems of medical education in Turkey for the first time. In these congresses, a recommendation was adopted for establishing medical education departments and implementing problem-based learning curriculums. The outcomes of these two congresses can be summarized as follows:

1-Most medical faculty members accept the need for training programs to improve their teaching and they believe that they benefit from existing programs.

2-Teaching performance of faculty members is generally evaluated through student feedback.

3-Faculty members regard student evaluations as necessary but limited in terms of objectivity and efficiency.

4- Medical faculty members want to improve their teaching skills but they argue that they can not do this to the extent they would like to because of financial constraints, predominance of research and publication requirements in their promotion criteria as well as their clinical duties.

5- Medical faculty members think that the responsibility for meeting their educational demands lies with the faculty administrations.

In 1997 The Medical Education Council was established as a body of The Turkish High Education Council. It is composed of university presidents who are in the medical field, and the deans of the medical schools. With the perspective of standardizing the medical education in Turkey in mind, the Council decided to recommend a gradual implementation of a basic core curriculum for all medical schools by the year 2003. Currently six of the medical schools in Turkey have a medical education department.

Conclusion
The lost confidence in the primary health care system can be restored through improving the quality in medical education and the accomplishment of the health reform prepared by the Ministry of Health. Turkish Ministry of Health is working on a draft bill for the reform of health care services in cooperation with universities, speciality associations and health care professionals’ organizations (14). The restructuring and reinvigoration of the primary health care system is a significant part of this project. The aim is to get family physicians involved as gatekeepers in the primary health care system; to equip general practitioners with the most up-to-date information and skills through vocational training and to increase their efficiency in the primary health care services; and to bring together the social security system and the delivery of health care services under a single organizational scheme. These reform attempts that are undertaken concurrently with the process of change in the medical education system can be seen as hopeful signs for Turkey where people have no confidence in the primary health care system and the health indicators are much worse than countries with lower per capita incomes. As much as we need qualified physicians who are capable of constantly renewing themselves in response to new developments, we also need medical educators who have the capacity to train those physicians. Especially newly founded medical schools with their few number of students and young faculty members who are open to change and development, like Kirikkale University Medical School, still may have a chance in this regard, since they would benefit a lot from proper faculty development programs prepared on the basis of the needs and priorities of the education as well as faculty members’ suggestions for the curriculum. This will have a direct and positive impact on the quality of the education and of the graduates.

*This article is a part of the Fulbright Research Project Study which attempts to contribute to the improvement of quality of the medical education in Kirikkale University Medical School on the basis of the University of Illinois at Chicago Department of Medical Education Short Term Fellowship.

REFERENCES

Terzi C, Saçakl·o·lu F, Sayek I. Medical Education in Turkey in the year oof 2020. Turkish Medical Association Publication, Ankara 2002.

Higher Education Statistics-2000. Turkish Higher Education Council Ankara 2000

Undergraduate Medical Education Report-2000 . Turkish Medical Association Publication, Ankara 2001.

Ozyurda F, Dokmeci F, Palaoglu O, Arda B. The role of interactive training skills courses in medical education at the Ankara University School of Medicine . Teaching and Learning in Medicine 2002; 14 (3) :189-93.

Musal B, Abacioglu H, Dicle O, Akalin E. Faculty development program in Dokuz Eylul School of Medicine : in the process of curriculum change from traditional to PBL. Medical Education Online 2002; 7(2).

Musal B, Sarioglu S, Yemiscigil A, Alici E. A Trainers’ Program for Clinical Training Skills, Journal of Dokuz Eylul Medical Faculty 1999;13:101-108.

Tekdemir ·,Acuner A, Ersoy F, , Ersoy M, Yalç·n M, Kemahl· S.An assessment of the needs of Ankara University medical faculty members to improve their teaching skills” in Ist. National Congress on Medical Education, 1998.

Tekdemir ·,Acuner A, Ersoy F, Ersoy M, Yalç·n M, Kemahl· S.An assessment of the teaching/learning process in the undergraduate program of Ankara University Medical School. Ist. National Congress on Medical Education, 1998

Tekdemir ·,Acuner A, Ersoy F, Ersoy M, Yalç·n M, Kemahl· S .An assessment of the student evaluations in the undergraduate program of Ankara University Medical School” .Ist. National Congress on Medical Education, ,1998

Tekdemir ·, Acuner A, Ersoy F, Ersoy M, Yalç·n M, Kemahl· S. An assessment of teaching/learning techniques used by faculty members in the undergraduate program of Ankara University Medical School Ist. National Congress on Medical Education, 1998.

Dikicio·lu E, Be·er E, Ba·ak O, Gürel A. Teaching development activities in Adnan Menderes Univeristy Medical School in IInd. National Congress on Medical Education, 2001

Özyurda F, Dökmeci F, Palao·lu Ö, Kemahl· S.An assessment of the teaching development courses in Ankara Üniversitesi Medical School IInd National Congress on Medical Education, 2001

Yaman H. Continuing medical education in Turkey: Recent developments. BMC Med Educ 2:6, 2002.

Health Care Reform Project, A Publication of Turkish Ministry of Health, 1995, Ankara.

ABSTRACT:

There are profound discussions going on as to the nature of ideal/optimal medical education in Turkey. Medical education as a main discipline is increasingly becoming instutionalized in many universities. In this article we reviewed the most important factors affecting the quality of medical education in Turkey and restructuring process in Turkish medical schools.