Internal Medicine: Global Perspectives
Erdal H. Akalin, MD, FACP
President, Turkish Society of Internal Medicine
The country of Turkey is rich with history. It is home to some of the greatest battlegrounds, ruined castles and palaces of empires past. Here, Alexander the Great slashed the Gordion Knot, and Achilles battled the Trojans in Homer’s Iliad. Modern-day Turkey has its own challenges, health care among them. While the health status of Turkey has improved in recent years, it still remains poor compared to the rest of the WHO European region. Population growth has steadily declined since the 1980s, while urbanization has accelerated in the last 40 years. Sixty-eight percent of the population currently lives in urban areas due to migration from the east. Erdal Akalin, president of the Turkish Society of Internal Medicine, discusses the challenges and rewards of leadership and the society’s efforts to revitalize internal medicine.
Source: World Health Organization
What inspired you to become a physician?
When I was in the 4th grade, I played a doctor in a school play. In the play, I treated soldiers during our independence war, and it left an impression on me. Later on after the experience, I felt that I should be helping people in need, and decided to go to medical school. While in medical school I knew quite early that I would go into internal medicine. I found internal medicine very challenging, with its spectrum of diseases, and I got the sense that it was really the foundation for good medical practice.
What is the role of “internist” in Turkey? What do people expect and want from their internists?
We struggle with the same issues internists all over the world struggle with. For a long time in Turkey, internists were considered “doctors of doctors” and were the most influential physicians in the hospitals and the community, because of their broad spectrum of knowledge and practice. They were the consultants for both physicians and patients. However, this has changed within the last 10-15 years. There are several reasons for that: sub- specialization in medicine, the changing definition of a primary care physician, and dynamic changes in knowledge and the practice of medicine. We are currently trying to revitalize internal medicine as many other countries are trying to do, including the U.S.
What are your responsibilities as president of the Turkish Society of Internal Medicine?
The president is the chief executive officer of the society. Wearing this hat, I have to manage the day-to-day activities of the society with the help of other members of the executive committee. The president is also responsible for the implementation of the strategic plan of the society. We have revised our strategic plan last year, and are proceeding accordingly.
The president is the face of the society to the public, so I am responsible for introducing and presenting our views on several issues related to our membership to the public. This may include discussing health care issues with policy makers, for example, or representing the society in meetings when necessary. I have great help from executive committee members with many of these activities.
Internal medicine is in need of a new kind of leadership. There are many serious issues facing our discipline, including the infrastructure for education, core educational programs, and the performance system. Additionally, we are struggling with the role of internists in primary care, as consultants, the relationship between internists and sub-specialists, and the relationship between internists and family physicians.
The Turkish Society of Internal Medicine was founded in 1995, so it is a young society still. We have 1,400 members; in Turkey there are about 6,500 internists, including both general and sub-specialists. We are trying to increase our membership.
What motivated you to take the role?
Our society is a young society, and I was one of the founders. During my academic career, I always felt like I was a part of general internal medicine, even though my sub-specialty is infectious disease. When I saw the diminishing role of general internists and increasing importance of sub-specialists, I could not resist the calls for taking a role.
How long have you been serving as president and what have you accomplished during your tenure that you are proud of?
The executive committee and I were elected one year ago, and we have one more year to go. (The term for presidency is two years, and one can be elected one more term, a total of four years).
We have been successful in our efforts revisiting the strategic plan and developing a new one for the next five years. One of the most important projects was and still is the “revitalization of internist,” similar to the ACP “doctors for adults” program. The feedback has been very impressive, both from our membership and the public. We are hoping to continue this program indefinitely.
We also established a strong link with sub-specialty societies, with whom we plan to develop common programs for education, practice guidelines, and health policy issues. We are also the host for the 8th Congress of European Federation of Internal Medicine (EFIM).
What have you found to be the most challenging part of leadership? The most rewarding?
First of all, although I am president, I consider myself to be a team member. I like to work as a team member wherever I work, or whatever position I have. The most challenging part of this position is dealing with policy makers. It is really challenging! However, the most rewarding part of this role is the appreciation I get from our members. They take the time to acknowledge our efforts, which makes me feel as though I’ve been able to actually do something for them.
What are the most common chronic illnesses and how do they affect the day-to-day job of an internist?
The Ministry of Health cites cardiovascular disease and cancer as the most significant in impact because of frequent cause of death and burden of illness in Turkey. Acute infectious diseases are still a significant cause of death in children. There are several epidemiological studies performed by medical societies that emphasize the importance of chronic diseases in adults, and according to a report from the Ministry of Health, there are at least 22 million adults with one or more chronic diseases—about one third of the adult population of Turkey.
In our recent strategic plan, we underlined the importance of this finding and correlated it with the importance of internists. We believe that internists must be the care coordinator for patients with chronic diseases. They should be the referral physicians to take care of these patients, and gatekeepers between family physicians and sub-specialists. Internists are becoming more important and effective in the planning and implementing of care in patients with chronic diseases in our country.
How has the growth of private health care in Turkey affected internists?
Over the last four to five years, the government encouraged the private health sector to absorb some of the burden from state health care providers. The health care expenditure has increased substantially within the last three years, and the private health care sector’s share has increased—almost tripled—when compared to previous years. Internists, especially general internists, are needed both in the private and public sector, because of the sub-specialization and a disproportionate representation of internists across the country. This is true for all physicians in Turkey.
Turkey is in the middle of a health care reform program, which began in 2003. Some of the major changes include the adoption of universal health care insurance, a family physicians system, an effective referral system, cost-effective medical practice, and emphasis on preventive medicine. The system relies on integration of all health care provider resources, including the private sector.
Are there enough young physicians choosing to be internists? What makes them do so? What are the barriers?
When we look at the matching results, we see that almost all internal medicine residency positions are filled. So there is enough interest in internal medicine in new graduates. However, when asked what their future plans include, most answer that they would like to train in one of the sub-specialties of internal medicine. The barriers are difficulties in practicing general medicine, better pay for sub-specialists, the referral system in sub-specialty practice, and a large need for sub-specialists in several areas.
Do you admire the health care systems of other countries and if so which ones and why?
For some time I considered myself to be somewhat of an amateur health care policy expert, so I have a strong opinion on this subject! Health care improvement is a big issue anywhere you go, and we must study and learn from other countries and systems. I don’t believe that there is a single best system of health care. For example, the U.S. is going through reform and many countries in Europe are having difficulties in their systems as well. Even Canada and Australia are trying to improve their systems—and not only for patients, but for providers, physicians and nurses as well. This is a very complex system, and I believe there is no best answer that will fit all. Studies show that about 60 percent of people say they are not happy with the health care they are receiving. I believe this is the nature of what we do. So what solutions can we offer? We have to evaluate the care that we are giving, very carefully and in detail, and then we have to find methods to improve it.
Is access to electronic information or products influencing what patients want from their doctors in Turkey?
Where there is widespread access to the internet, you do have patients coming to their physicians with certain demands. This can be an issue for physicians working in the private sector, where most patients are wealthy and educated. I believe there is a large spectrum of quality online on medical issues. Our job is to educate our patients to choose the right source for information, and medical societies have a responsibility to provide such a source. We are trying to develop both electronic and other sources of published health education for the public. This will be our next project.
Does your society have collaborative relationships with other societies, and if so is it beneficial to your society and how?
We are quite active in EFIM. Several members of our society have responsibilities within the organization, and we are benefitting from this collaboration by getting into projects and sending our members to educational programs. We are also discussing ways to collaborate with ACP on education resources and patient education materials.
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