Posted by: bluesyemre | August 15, 2022

Turkish doctors emigrate amid low pay and rising violence

Copyright © 2022 ZUMA Press, Inc./Alamy Live News

The number of physicians leaving Türkiye has surged in the past decade over concerns about working conditions. Kaya Genc reports from Istanbul.

In the entirety of 2012, just 59 physicians applied to the Turkish Medical Association to receive certificates of good standing, documents that allow them to practise abroad. As of August, 1402 have left the country this year. By the end of 2022, around 3000 physicians are expected to have received good standing certificates, which represents a 50-times increase in the number of physicians leaving Türkiye compared with 2012.

Türkiye’s economic meltdown and a rise in cases of violence against health professionals are causing the phenomenon according to public health experts and analysts from the Turkish Medical Association. The Turkish lira lost nearly half its value against the dollar in the past year. In August, 2022, inflation hit a two decade high of 79·6%, according to the state-run Turkish Statistical Institute; however, the figure reported by the Inflation Research Group, a Turkish non-government organisation, is 176%.

On July 27, 2022, a group of family physicians sent a letter to Türkiye’s President Recep Tayyip Erdoğan. “As 55 000 family physicians who work closely with Türkiye’s 84 million citizens, we have not seen a determination to solve our problems from the Health Ministry”, they wrote. “We cannot afford rents of our family health centres, let alone basic costs. Family physicians stand on the line of poverty, even hunger today.” In protest, they have gone on strike five times over the past year, warning that their “family health centres are on the brink of closure, caused by our inability to pay rent”. In response Erdoğan stated: “I asked about the minimum wage of a Turkish doctor. They said it’s between 8000 and 9000 liras [£364–410]. And the maximum is between 25 000 and 30 000 [£1140–1368]. I speak openly here: if they want to leave, let them leave. We’ll employ newly graduated students in their stead.” Kayıhan Pala, a Public Health Scientist from Bursa Uludağ University, Türkiye, took issue with this approach. “Despite technological advances, medicine is a humanistic field based on master–apprentice relationships,” he told The Lancet. “If you compare a physician with 20 years of experience and knowledge to a young physician just starting, that is unacceptable and would degrade the quality of medicine in Türkiye.”

Violence is another crucial factor. Violent incidents against health professionals are rising. On July 6, 2022, a relative of a patient shot and killed cardiologist Ekrem Karakaya in his office after accusing him of causing his mother’s death during an angioplasty operation. In response, the Turkish Medical Association announced a 2-day strike on July 7–8, 2022. The White Code, a system used by health-care workers to notify security staff about developing or past violence cases, has become a necessity for doctors. In 2020, 11 942 health-care workers sought help after being subjected to violence, and 29 826 did the same in 2021, according to a report compiled by the Republican People’s Party.

The Turkish Ministry of Health’s annual activity reports show a dramatic increase in the total number of health-care workers who used the White Code since its launch in 2012: from 7751 health workers in 2017 to 46 274 in 2019 and 72 158 in 2020. In 2020, prosecutors investigated around 7000 of the incidents. In those cases, only 10% of health workers could receive legal assistance from the Ministry of Health.

“There are around five daily incidents of physical violence reported to the White Code,” said Vedat Bulut, an immunologist and the General Secretary of the Turkish Medical Association. “The verbal violence cases are six times that: around 30 each day. These numbers reflect only official complaints; there are many times more unreported cases.” While violence is one factor, the main issue, according to Bulut, is economic hardship. “In Türkiye, their [health-care professionals] work is seen as cheap labour. In terms of buying power, the physician’s wages is a third of what it was in 2003.”

For example, the rent for a typical apartment in Ümraniye, an unassuming Istanbul neighbourhood, is around 8000 lira (£366), which exceeds the wage of an entry-level physician. “This is why, aged 30, physicians need to share rented apartments with two or three of their colleagues,” Bulut explained. “Physicians think, ‘if I can’t make it in a big city and do not want to work in a small town, why shouldn’t I try working abroad?’”

In its study on physicians leaving Türkiye, the Turkish Medical Association identified a rise in the number of medical scholars and specialist physicians leaving the country, issuing a warning about a possible shortage of physicians in surgery, internal medicine, child health, anaesthesia, radiology, and ophthalmology. “Especially in the fields of anaesthesia, emergency care, otorhinolaryngology, and gynaecology, there is a big trend in leaving Türkiye”, Bulut said. “Another thing we have observed from February onwards was medical scholars leaving the country. Numerous individuals who hold associate professorships or professorships sent in their requests to leave.” These developments, Bulut said, would come at the cost of qualified human capital in Türkiye and a deficit in specialised fields. “Just last month, 16 anaesthesia specialists left. As you know, anaesthesia and intensive care were crucial in Türkiye’s fight against COVID-19”, Bulut continued.

Saliha Erdem, an Internal Medicine Resident at Wayne State University in Detroit, MI, moved to the USA in 2019. “Growing up in Türkiye, I never had the idea of going to a different country,” she told The Lancet. “It was definitely a life-changing decision for me to leave my country and friends, and not an easy one,” she said. “It took me about 2 years to make a final decision to come here”. After graduating from Gazi University School of Medicine, Ankara, Türkiye, Erdem worked as a general practitioner in a tertiary care hospital in eastern Türkiye. While she admired how accessible and cheap the Turkish health-care system was, Erdem said she did not like “how open it is to being abused. For instance, in Türkiye, you cannot legally turn down a patient coming to the emergency department, whether the case is an emergency or not. This tremendously increases the case volume and does not give physicians enough time for proper examination and explanation.” She added that the health system in Türkiye “renders health-care workers more susceptible to fatigue and burnout”.

Pala suggested the scope of the exile might not affect the health system immediately. “2000 physicians who leave Türkiye, out of more than 180 000, does not have the potential to create a big service deficit at this point.” However, Pala pointed to the willingness of EU countries to employ Türkiye’s well trained physicians. “If this movement abroad continues over the next 10 years, the system will face serious difficulties.” While the exile will not affect the first stage of health services at this moment, Pala said, “Türkiye has a larger problem of planning its health-care personnel. There are more brain surgeons per person than the average in the EU. Still, in some fields, like psychiatry, that figure is meagre (2·5 vs 15·5 in Europe), and fields like occupational diseases are almost non-existent (0·007 vs 5). The problem of planning physician numbers according to demographics and health necessities is as crucial as the exile of doctors.”

Pala recently polled sixth year students at Bursa Uludağ University. “Half of them said they intended to work abroad. More than one-third have applied for German language classes. Among my students, the top destinations are Germany, the UK, and the USA.”

Turkish government ministers have responded to criticisms by pointing to Türkiye’s 126 medical faculties, which have around 16 000 medical graduates every year. However, after the 2022 Proficiency in Medicine Exam, which graduates use to choose their specialisation, 1859 positions of 12 294 were left unfilled. Most unfilled positions were in surgical departments, including 127 of 279 brain surgery posts according to the Ankara Medical Chamber.

“In fields like brain surgery, it’s becoming difficult to find doctors willing to teach,” said Bulut. “In 10 years, when the current staff retires or dies, there will be a service gap. Many people will experience problems and face a health service offering quantity albeit with a reduced quality.”

Bulut proposed a 200% wage increase to recreate a sense of belonging for exiled doctors. “If Türkiye’s educated people can face the future with trust, and government policies can only achieve that trust, then the exile of physicians from Türkiye will decrease,” he said.”

Every time I see or hear about violent news toward health-care workers in Türkiye, it deeply upsets me and reinforces my decision to stay here,” Erdem said. “I tell myself that Türkiye is unfortunately no longer a safe place to practise for physicians.” She added, “I don’t like to call the process a brain drain. Every person has a different reason and story to practise medicine in another place… Leaving your country, friends, and family members behind is never an easy decision and it should not be only connected to health-care problems. However, in a country, if physicians are starting to leave the country solely due to problems in the health-care system, this is pretty concerning, and should promote officials to take appropriate measures promptly.”

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