Investigation of the Changing Trends in Emergency Medicine Specialization Preferences in Medical Residency Choices for the Year 2023

INTRODUCTION:

In Turkey, physicians who acquire the title of “medical doctor” after a six-year medical education must succeed in the Medical Specialty Examination (TUS) to specialize. The significance of specialization training is paramount, as it directly contributes to the competence of specialist physicians in areas such as human health, disease diagnosis, and treatment outcomes1.

The TUS was first conducted in 1987 and has been held regularly twice a year since then. The preferences of physicians for TUS have started to change, influenced by certain laws and practices implemented as part of the Health Transformation Project initiated in Turkey in 20031.

For approximately 20 years, specialized training in Emergency Medicine (EM) has been provided in Turkey. Unfortunately, despite being widely popular in the United States and featured in television series worldwide, EM Specialization has not attained the recognition it deserves in Turkey2. Each year, the TUS placement results reveal significant vacancies in specialized training positions, with a considerable portion of these vacancies pertaining to Emergency Medicine specialization positions.

In our country, there are limited studies regarding the status of EM specialization in the TUS placement results.

Given the mentioned information, there arises a need to determine whether there is any change in the TUS quotas and scores specifically for EM and the direction of this change. This research aims to examine the EM TUS quotas and scores for the year 2023 and analyze changes over the period. Thus, we believe that contributing to the decisions of the emergency medicine community and physicians opting for emergency medicine will be facilitated.

MATERIALS AND METHODS:

To examine the variation in placement scores of the EM specialization over the years, numerical data from the results of the TUS related to EM were obtained from the official website of the Student Selection and Placement Center (Known as ÖSYM in Turkish – https://www.osym.gov.tr/). In this context, the placement results for the year 2023 were analyzed as data for the year 2023, considering both the TUS 1st term and TUS 2nd term results. The “Numerical Information Regarding Placement Results” and “Minimum and Maximum Scores in Placement Results” documents related to the two TUS exams held in 2023 were downloaded from the ÖSYM website, and research data were extracted and recorded in electronic format.

Institutions providing EM education were categorized as university hospitals, training and research hospitals, city hospitals, and military hospitals. For placements in these institutions, the minimum and maximum scores, as well as the fill rates of quotas, were recorded. The main outcome criterion for the research was the base scores. Additionally, the average placement score, calculated from the smallest and largest placement scores and the number of placed individuals, was recorded. Quotas for foreign national specialization students and additional placement results were excluded from the study.

The study did not obtain ethical committee approval, as it was conducted on data obtained from the official website of the Student Selection and Placement Center (Known as ÖSYM in Turkish – https://www.osym.gov.tr/).

ANALYSIS:

Microsoft Excel software and the online statistical calculation tool pvalue.io were utilized for the analyses. Results were presented using descriptive statistics (mean ± standard deviation (SD) for numerical variables, n (%) for categorical variables), and independent samples t-test and chi-square test were employed. A significance level threshold of <0.05 was considered.

RESULTS:

In the 2023 TUS 1st term, the number of available positions was 12,703, the number of candidates was 8,466, the number of placed candidates was 7,744, and the number of unfilled positions was 723 (reference: ÖSYM website). In this period, a total of 733 positions were opened for the EM branch in the training programs of 110 institutions, and 99.6% of these positions (n=730) were chosen. Numeric data for the 2023 TUS 1st term are provided in Table 1.

In terms of placement, no significant difference was observed between University Hospitals and Training and Research Hospitals (TRH), University Hospitals and City Hospitals (CH), and TRH and CH (Sequentially, p=0.93, p=0.95, and p=0.99; Chi-square test). The distribution of placement status according to educational institutions is provided in Table 2.

Regarding the average base placement score, no significant difference was found between universities and TRH, universities and CH, and TRH and CH (Sequentially, p=0.35, p=0.15, and p=0.45; Independent samples t-test). The distribution of average lowest placement scores according to educational institutions is presented in Table 3. The distribution of average highest placement scores according to educational institutions is presented in Table 4.

In the 2023 TUS 2nd term, a total of 948 positions were opened in the training programs of 113 institutions for the EM specialty. Of these, 67% (n=635) were chosen, and the vacancy rate for the positions was determined as 33%. The numerical information for the 2023 TUS 2nd period is provided in Table 5.

In terms of placement status, no significant difference was observed between universities and TRH (p=0.55; Chi-square test). However, a significant difference was found between universities and CH and between TRH and CH (p<0.05 for both comparisons; Chi-square test). The distribution of the placement status for the positions based on educational institutions is presented in Table 6.

The difference in the vacant quota status between the universities and TRH was not found to be significant (p=0.40; Chi-square test). However, a significant difference was observed between the university and CH, as well as between TRH and CH (p<0.05 for both comparisons; Chi-square test). The distribution of vacant quota status according to educational institutions is presented in Table 7.

There is a significant difference in the average placement base scores between the universities and TRH and between CH and TRH (p<0.05; Independent samples t-test). The distribution of the average lowest placement scores according to educational institutions is provided in Table 8.

There is a significant difference in the average placement ceiling scores between the universities and CH and between CH and TRH (p<0.05; Independent samples t-test). The distribution of the average highest placement scores according to educational institutions is provided in Table 9.

In our study, the lowest and highest placement scores determined for each institution in both TUS 1st term and TUS 2nd term were also examined. According to this analysis, there was no significant difference in terms of institution-based lowest and highest scores (p=0.084 and p=0.522, respectively; Independent samples t-test). The institution-based minimum and maximum scores for the EM specialty according to the 2023 TUS placement results are presented in Graph 1.

In the 2023 TUS 1st term, out of 733 Acute Medicine specialization positions, only 3 remained vacant, while in the 2nd term, out of 948 positions, 315 were left unfilled. The institution-based vacant positions for the EM specialty according to the 2023 TUS placement results are illustrated in Graph 2.

In the 2023 TUS 1st term, the occupancy rate for Acute Medicine specialization positions was 99.6%, while in the 2nd term, this rate was determined to be 67%. The institution-based filled positions for the EM specialty according to the 2023 TUS placement results are presented in Graph 3.

DISCUSSION:

The EM specialty is inherently one of the challenging fields for physicians, and this is reflected in the ongoing TUS placement results. For many years, EM Departments have struggled to fill their positions, and a significant portion of the available positions has remained vacant. This lack of preference has been the subject of academic discussions, with an article exploring the reasons behind the unpopularity of the emergency medicine field. The study identified five main reasons, including lack of recognition, violence, working conditions, intensity, and education. This research sheds light on the fact that even the interventions and efforts of emergency services and personnel, which save thousands of lives, have not increased the value attributed to emergency services. It highlights the alarming statistic that 70% of positions in the medical specialization exam remain unfilled2.

World Health Organization (WHO) emphasizes that the achievement of a country’s health goals is directly linked to the knowledge, skills, and motivation of its health workforce (HW). Therefore, the quantity and efficient organization of the health workforce play a pivotal role in determining the fate of a country in achieving its targeted health outcomes3.

According to the 2023 projection of the Ministry of Health, the estimated number of physicians needed in our country is 200,062, which corresponds to a physician-to-population ratio of 2.37 per 1000 people for the year 2023. In Turkey, the ratio of specialist physicians to general practitioners was 1.81 in the year 2017 (80,951 / 44,649). However, the projected ratio of needed specialist physicians to general practitioners for 2023 is estimated to be 9.63 (181,257 / 18,806)4.

In Turkey, physicians graduating from medical faculties face two options: either working as a general practitioner for a certain period within the framework of the mandatory government service (DHY) or taking the TUS to start specialization in a medical field. Following the DHY and specialization training processes, physicians continue to provide services within the Ministry of Health, private sector, or university settings5.

Since 1987, ÖSYM has conducted the TUS, an exam for placing students into the available positions in various medical specialties. Physicians make preferences for specialties based on the scores they achieve in this exam, and they are placed into their preferences according to the ranking. TUS is conducted twice a year, with the total number of available positions ranging from 3,000 to 4,500 per term. The number of applicants varies between 14,000 and 16,0006, 7. Approximately half of the applicants make preferences. It’s essential to note that TUS is not a proficiency exam but a ranking exam5.

The preferences for specialization areas based on TUS base scores have shown different trends over the years. A study examining preferences from 2007 to 2013 indicated that branches providing inpatient services, surgical services, and those frequently encountering patients were less preferred1.

In another study analyzing TUS results before and after the Health Transformation Program, it was observed that physicians’ preferences for specialization changed. This shift is believed to indicate potential challenges in the coming years regarding the health services provided to the public. The system has been observed to direct physicians from major surgical branches towards internal branches, more diagnostic branches, and even basic sciences. It was found that successful medical graduates tend not to prefer “high-risk” branches8.

EM Residency Training covers a 4-year period according to current regulations. Issues such as workload and violence in the current state of emergency services in our country negatively affect the attractiveness of this specialty. Physicians are not inclined to choose EM as their specialty training. Moreover, when EM is considered as a surgical branch, it aligns with the trend of surgical branches being less preferred in TUS results.

Our research revealed significant changes in the placement results for EM in the two TUS sessions in 2023. According to the results of TUS 1st term, almost all EM positions were preferred (99.6%). However, in the placement results of TUS 2nd term, it was observed that approximately one-third of the EM positions remained vacant (33%). In the 2023 TUS 1st term, 12,703 positions were opened, whereas in the previous term, the 2022 TUS 2nd term, 9,477 positions were opened. We believe that the 99.6% placement rate we observed in the 2023 TUS 1st term resulted from the increase in the number of opened positions. However, in the 2023 TUS 2nd term, despite more EM positions being opened compared to the 1st term, the fact that one-third of these positions remained. Excluding the almost 100% fill rate of Emergency Medicine positions in the 2023 TUS 1st term, the increase in the number of vacant positions in the 2nd term placement results suggests a continued decline in interest in emergency medicine, vacant suggests a return to the situation where EM is not a preferred specialty.

In a study, reasons such as “TUS score,” “department’s risk/malpractice ratio,” and “working hours arrangement” have been suggested as influential factors in physicians’ TUS specialty preferences5. We also believe that the fact that EM positions remain vacant is related to these factors. Furthermore, in the study conducted by Yapalak et al., EM e was identified as one of the least preferred specialties5. The same study revealed that factors such as “likelihood of exposure to violence, department workload and stress, working hours arrangement, number of shifts, and intensity” were found to be influential in specialty preferences5. Unfortunately, EM encompasses all these negative factors.

Incidents of violence, believed to be on the rise in the healthcare sector, are among the factors negatively affecting work motivation9-11. Intensive and long working hours can also be indicators of burnout syndrome10, 12-14. In the EM field, these negative factors are already present. Measures addressing these concerns can enhance workforce motivation in the healthcare sector, thereby increasing satisfaction with healthcare services and the job satisfaction of employees. Furthermore, regulations in these areas could elevate the EM specialty to a more desirable position.

Under the Mandatory Financial Liability Insurance for Medical Malpractice (ZMSS), specialties are divided into four risk groups based on the level of risk, with Group 1 being the lowest risk and Group 4 the highest15. In Group 4, there are specialties such as Emergency Medicine, Anesthesiology and Reanimation, Neurosurgery, General Surgery, Thoracic Surgery, Obstetrics and Gynecology, Cardiovascular Surgery, Orthopedics and Traumatology, and Plastic and Reconstructive Surgery17. As observed, EM is classified in Group 4. In a study, the lowest scores in TUS placement results were found in specialties belonging to Group 48. In another study examining the base scores of 10 TUS exams conducted twice a year over a five-year period from 2009 to 2013, the base scores for Group 4 were significantly lower than those for other groups16.

The main reasons for physicians increasingly avoiding specialties in Group 4 include the recent rise in violence against healthcare professionals, which directs them towards non-clinical branches. Additionally, the higher risk of medical malpractice compared to other groups, resulting in an increasing number of lawsuits and higher awarded compensation amounts, might lead physicians to believe that their earnings are not proportionally increasing with the risks they face.

It is well-known that the most powerful factor influencing defensive medical practices is the fear of being sued4. While there is ongoing debate among physicians about the increasing prevalence of defensive medicine, this study reveals that this situation is even reflected in the preferences of prospective specialist physicians16.

In a study conducted by Budakoğlu and colleagues in 2011-2012 with final-year medical students, it was noted that the specialist fields previously more frequently preferred, such as Plastic and Reconstructive Surgery, General Surgery, Cardiovascular Surgery, and Pediatrics, are now being replaced by fields considered less risky in terms of the probability of medical errors, such as Dermatology, Psychiatry, and Radiology17.

In our study, excluding the situation where EM positions were almost 100% filled in the 2023 TUS 1st period, the increase in the number of vacant positions in the 2nd period placement results suggests that this decline in EM may continue. Although the TUS score and the fill/vacancy rates of specialty positions may not have a direct correlation with qualified and good medical practice, they still indicate the priorities of prospective specialist physicians.

This study has limitations, including the inclusion of only the placement results of the two TUS periods in 2023. Examining the TUS placement results from previous years and comparing them with the results of our study could provide more information regarding Emergency Medicine preferences.

CONCLUSION:

This study’s findings indicate a changing trend in physicians’ preferences for the EM specialty throughout the year. While there were almost no vacant positions in the EM slots during the first period of the 2023 TUS, just one period later, in the TUS 2nd period, despite an increase in the number of EM positions compared to the first period (from 733 to 948), it is observed that one-third of these positions remained vacant (315 out of 948). Adjusting TUS quotas in line with changing conditions and implementing regulations such as improving physicians’ rights and emergency service working conditions could help prevent potential disruptions.

REFERENCES:

1. Abdulkadir, K., Aktürk, Z., Çayır, Y., & Taştan, K. (2013). Medical Specialty Exams between 2007-2013: A Trend Analysis. Ankara Medical Journal, 14(2).

2. Satar, S., Cander, B., Avci, A., Acikalin, A., Orak, M., Acin, M., … & Karakilic, M. E. (2013). Why speciality in emergency medicine is not preferred? Eurasian Journal of Emergency Medicine, 12(4), 234.

3. World Health Organization. Density of physicians (total number per 1000 population, latest available year) (Internet). Accessed on: 16.01.2024. Available from: https://www.who.int/gho/health_workforce/physicians_density/en/

4. Bora Başara B, Soytutan Çağlar İ, Aygün A, Özdemir TA. Health Statistics Yearbook 2017. Ankara: Health Information Systems General Directorate, Ministry of Health; 2018. 257 p. Report No. 1106.

5. Yapalak, A., Abdullah, U., Servet, Y., & Ömer, A. (2021). Evaluation of Factors Influencing the Selection of Medical Specialization. Journal of Istanbul Faculty of Medicine, 84(1), 120-129.

6. Measurement, Selection, and Placement Center Presidency. TUS: Specialty in Medicine Entrance Exam (Internet). 2016 Accessed on: 16.01.2024. Available from: http://www.osym.gov.tr/TR,4520/tus-ile-ilgili-sorular.html

7. Measurement, Selection, and Placement Center Presidency. 2018 TUS 2nd Period Placement Results – Numerical Information (Internet). Accessed on: 16.01.2024. Available from: https:// dokuman.osym.gov.tr/pdfdokuman/2018/TUS2DONEM/ SayisalBilgiler11102018.pdf

8. Yavuz, I., Çamsari, U. M., & Arisoy, Y. (2017). The Impact of Health Transformation Program on Medical Specialty Preferences. Turkey Clinics Journal of Medical Sciences, 37(2), 53.

9. Büyükbayram A, Okçay H. Sociocultural Factors Influencing Violence Against Healthcare Workers. Journal of Psychiatric Nursing 2013;4(1):46-53.

10. Yeşiltaş A, Erdem R. A Qualitative Study on Violence and Defensive Medicine Practices. ASOS Journal 2018;74:486-500.

11. Saglik-Sen R&D Unit. Research on Violence Against Healthcare Workers. Ankara: Health-Sen; December 2013. 152 p.

12. Erşan EE, Doğan O, Doğan S. Analyzing factors related to burnout in health professionals of Sivas Numune Hospital. Cumhuriyet Medical Journal 2011;33:33-41.

13. Tekir Ö, Çevik C, Arık S, Ceylan G. Examination of burnout, job satisfaction levels, and life satisfaction among healthcare workers. KÜ Tıp Fak Derg 2016;18(2):51-63.

14. Ozkula G, Durukan E. Burnout syndrome among physicians: the role of socio-demographic characteristics. Dusunen Adam 2017;30(2):136-44.

15. Regulation on the Institution Contribution to the Compulsory Financial Liability Insurance for Medical Malpractice.” (July 21, 2010), Official Gazette of the Republic of Turkey, (Issue: 27648). Accessed on: 16.01.2024. Available from: http://www.resmigazete.gov.tr/ eskiler/2010/07/20100721-17-1.htm

16. Kasap, H., Akar, T., Demirel, B., Dursun, A. Z., Sarı, S., Özkök, A., & Aydemir, Ö. (2015). Change in preferences for specialty fields with high risk of medical malpractice in the years in the medical specialization exam. Forensic Medicine Bulletin, 20(1), 34-37.

17. Budakoglu I, Karabacak O,, Coskun O, Karabacak N, Personality and Learning Styles of Final-Year Medical Students and the Impact of these Variables on Medical Specialty Choices, Gazi Medical Journal, 2014; 25:138-141

Table 1.