bridge over troubled water: the experience of turkey to access … · 2018-05-07 · bridge over...
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Bridge over troubled water: The experience of Turkey in providing
high-quality nationwide radiotherapy service
Yavuz ANACAK
Access to high quality care: challenges and possible solutions SESSION 13A
Ege University School of Medicine Izmir - Turkey
Turkey: Main indicators of an upper-middle income country
History of Radiotherapy in Turkey
• The medical use of radiation arrived to Turkish soil very early • 1897: One year after the Roentgen’s discovery locally
produced x-ray tubes were used for diagnostic purposes in Medical School of Istanbul
• 1897: Earliest use of x-rays to detect bullets and schrapnels in war wounds
Nevsali Afiyet, page 226, 1897
History of Radiotherapy in Turkey
• 1898 – the first radiology book in Turkish was published
Röntgen Şu’â’âtı ve Tatbikat-ı Tıbbiye ve Cerrahiyesi, 76 pages, 1898
History of Radiotherapy in Turkey
• Turkey is among the first countries in the World having a radiotherapy service!
• Prof.Cemil Topuzlu published his experience with radiotherapy on 30 patients in 1 January 1904 at Gazette Medicale d'Orient
History of Radiotherapy in Turkey • 1923 - Republic of Turkey • 1930s - The rise of Nazism, German intellectuals and scientists
seek refuge in Turkey • 1933 - University reform
Paul Hindemith Carl Ebert Rudolf Belling
Clemens Holzmeister
Ernst Reuter
Alexander Rüstow
Einstein letter to Ataturk
Prof.Friedrich Dessauer in Turkey 1934 -1937
• Prof. Dessauer was a physicist, a philosopher, a socially engaged entrepreneur, a journalist and a member of the parliament. He was imprisoned by the Nazis when they came to power for his opposition to Hitler.
• He was released at request of the Turkish government, who invited him to the University of Istanbul, where he was made chair of the Radiology Institute.
• Dessauer is the father of the «Modern Radiotherapy» in Turkey
Çapa Institute of Radiology and Biophysics Today’s «Istanbul University Oncology Institute»
• The institute became one of the leading cancer institutes worldwide, where new equipment used and new techniques were developed, such as rotational chair technique for TBI
1930-1995 • Very few improvements until
1990s • Radiotherapy was limited to 6-
7 major towns • Only cobalts, 1-2 linacs, 2-3
brachy systems • Less than 30 radiation
oncologists, less than 20 physicists
• No standartization for education, training and practice
Radiation Oncology in Turkey 1930-2017 Period of stagnation followed by booming
1995-2017 • Open-economy • Booming of radiation oncology • Public and private investments • Radiotherapy departments in
almost all cities • Modern linacs replaced
cobalts completely • İncrease in the number of staff • Projects on standartization of
education, training and practice
• National cancer control plan • Turkish Society for Radiation
Oncology
Public university
Private centers & universities Min.of Health
135 radiotherapy centres in 40 towns More centers in planning & construction
Radiation Oncology in Turkey in 21st Century Radiotherapy Centers
Radiation Oncology in Turkey in 21st Century Teletherapy Machines
• Heterogenous distribution throughout the country
• 54 centers operate with single machine
• Fragmentation of the services
• High-tech machines with inadequate staffing
• Replacement of the aging machines is a problem
• Maintenance quality is not good
Goksel F et al. Asian Pacific Journal of Cancer Prevention, Vol 12, 2011
Radiation Oncology in Turkey in 21st Century Radiation Oncology Manpower
148.000 new cancers/year 90.000 needs radiotherapy
IAEA guidelines for infrastructure and manpower
Lievens Y et al. Radiotherapy staffing in the European countries: Final results from the ESTRO-HERO survey. RadiotherOncol (2014),
Radiation Oncology in Turkey in 21st Century Radiation Oncology Manpower
Radiation Oncology in Turkey in 21st Century Projection to 2023 (Centennial of the Republic)
2023 Population 82.000.000 Population +45 27.800.000 – 33,8% Cancer incidence (1.000) 3-3,2 New cancers/year 245.000-265.000 Need for radiotherapy 170.000-185.000
From the report: Restructuring the Oncology Services in Turkey 2010-2023
Staffing needs in 2023 • RO: 850-925 • MP: 425-462
350 – 400 radiation oncologists and 200-250 medical physicists should be trained until 2023
Radiation Oncology in Turkey in 21st Century Aproaching shortage of radiation oncologists
More than 100 radiation oncologists will retire in 10 years!
Radiation Oncology in Turkey in 21st Century Radiation Oncology Training
• Radiation oncologist • 5 year training in university centers • Core curriculum is prepared, but not officially endorsed yet • Quality is variable among centers
• Medical physicist • 2 years MSc degree is required - B.Sc degree is prerequisite • No core curriculum yet • Quality is variable among centers
• RTT • 2 year associate’s degree – no further training available • No core curriculum • Quality is variable among centers
• 800 members • Radiation Oncology core
curriculum • V.2.0. updated June 2013
• Resident’s log-book • Courses • National Congress • Educational grants • Board certification
Competence triangle of TUKMOS based on 7 main fields of competence
Radiation Oncology in Turkey in 21st Century Turkish Radiation Oncology Society (TROD)
Training Courses • 6 week-end and 3 pre-congress
courses in 2017 • Hands on e-contouring-ASTRO • Basic Radiation Physics • Radioimmunotherapy • Clinical Radiobiology • Treatment Planning & Plan
Evaluation • Lung cancer
• Post-ASTRO meeting
Radiation Oncology in Turkey in 21st Century Turkish Radiation Oncology Society (TROD)
National Radiation Oncology Congress • Every second year
• 13th UROK will be in 2018 • 3 pre-congress courses • 10 teaching sessions • Panels & sessions on education and
training
• National Cancer Congress in-between • TROD is a partner together with medical
oncology and pediatric oncology
Radiation Oncology in Turkey in 21st Century Turkish Radiation Oncology Society (TROD)
• Annually • 1 year eduation abroad for 3 young members (15.000 euro/each) • 3 months eduation abroad for 4 young members (3.750 euro/each) • 20-25 grants for ESTRO courses
Radiation Oncology in Turkey in 21st Century Turkish Radiation Oncology Society (TROD)
Proficiency exams • What do we evaluate?
• Competence which yields on • Cognitive domain
(How?)Exam blueprint, web based question bank, 100 MCQs, quality review, Nedelsky standard setting
• Skills / attidute domain (How?)Exam blueprint, question templates, 10 stations OSCE (150 mins), Modified Angoff standard setting (expert consensus on minimum acceptable level for each station)
Radiation Oncology in Turkey in 21st Century Turkish Radiation Oncology Society (TROD)
Practical Exam Objective Structured Clinical Examination-OSCE
Radiation Oncology in Turkey in 21st Century Turkish Radiation Oncology Society (TROD)
•15 minutes duration for each station
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
Starting… nervous moments… Critical reading an article…
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
Room for patient communication… Outside…
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
Big brother is listening… And watching you…
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
From one station… To another…
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
Contouring… Plan evaluation…
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
Teachers smiling… 2.5 hours passes quickly…
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
It’s over… everybody seems relaxed…
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
Candidates discuss the exam with teachers…
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
Teachers evaluate…
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
Happy end …. Not for everybody
Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE
Results
• Athough Turkey has a long history of radiotherapy, services still has the problems common to middle-income countries • Problems in manpower - availability and training
• Problems in countrywide distribution of infrastructure
• Infrastructure and quality of radiotherapy is improving
• Guidelines and minimum requirements for manpower and infrastructures should be prepared
• Training should be standartised
• TROD is a major player especially in training
• Planning of future is required – current national cncer control plan of the MoH needs revision
Conclusions
Thank you for your attention!