Factors affecting the choice of medical specialties in Turkiye: an analysis based on cross-sectional survey of medical graduates | BMC Medical Education

Modern healthcare systems require the right mix of clinical specialties to improve quality of healthcare services and the health status of population. With epidemiologic transition, economic progress and technological development, the degree of specialization among healthcare providers increase and consumers tend to increase the demand for highly specialized services. Medical specialists often plan, supervise and evaluate the implementation of care, conduct trainings, carryout research to further improve technical quality and effectiveness of healthcare services. Therefore, investment in medical specialization improves healthcare delivery system, enhance technical innovation and improve quality and effectiveness of specialized medical services and interventions [1].

Despite the increasing demand for medical specialists, several specialist-types are in short supply in some countries of the world, implying that it is important to identify the barriers to entry to medical specializations, especially for the ones that are likely to see rapid increase in demand with improved economic status and ageing of the population. Health systems need to develop and implement policy options for encouraging physicians to select the medical specializations society will need in the near future. In Turkiye, medical specialization includes specialists as shown in Table 1. Note that general practice is not considered a medical specialization.

In the last few decades, Türkiye has seen significant improvements in healthcare delivery with improved service quality and access to care. The Health Transformation Program of 2003 accelerated improvements in population health, geographic distribution of health services and healthcare coverage by reforming social security and strengthening the health infrastructure and management. Lack of specialists was considered as one of the main concerns during the implementation of Health Transformation Program. To address this concern, Türkiye adopted the strategy of increasing the training slots in the existing specialty residency programs and establishing new residency programs in medical schools [2]. The number of specialists per 100,000 population increased in the country from 68 in 2002 to 105 in 2020 but still, Türkiye lags behind high-income countries of the Organization for Economic Cooperation and Development [3].

The availability of residencies by medical specializations and preference patterns of graduating medical students determine the distribution of specialist-types trained. A good system of matching medical graduates with their preferred medical specialties should improve job satisfaction and career development. Ensuring training of adequate number of medical specialists consistent with the needs of the population should improve access to specialized care and overall effectiveness of health care system. In addition to general shortages of medical specialists, a lack of alignment between health system needs for specialized medical care and specialty preference of medical graduates has been a problem for several countries of the world [4]. Avoidance of specific specialties by medical graduates due to factors other than societal needs may further amplify physician maldistribution by geographic location and mix of specialties [5]. Even in countries with relatively high availability of specialists, some specific specializations are in short supply [6]. France, for example, shows shortages of obstetrics and gynecology while pediatric surgery, anesthesiologist, orthopedics are in short supply in Spain [7].

It has been well documented that earning potential as well as social recognition and reputation encourage the choice of medical specialty but there are many other factors that influence the decision-making. In recent years, healthcare providers are facing increasing risk of workplace violence [8]. Violence against healthcare workers has become an important problem in the Turkish healthcare system as well. Consistent with the definition adopted by the National Institute for Occupational Safety and Health (NIOSH), the survey defined violence as “physical and verbal violence”. This does not include sexual violence. Violence against healthcare providers imply “client-on-worker violence” not worker-on-worker violence, family dispute-related violence or interpersonal violence due to criminal activity unrelated to the profession. Since not all medical specialties are equally susceptible to workplace violence, increasing risk of violence may influence choice of certain high-risk medical specialties. Anecdotal evidences suggest that the likelihood of facing violent encounters with patients and/or their family members have affected selection of medical specialties in Türkiye [9]. Another related factor is the intensity and severity of medical malpractice lawsuits faced by different medical specialists. Risk-averse individuals may prefer to select relatively low-risk specialties [10]. Studies evaluating choice of specialties in Türkiye suggest that the perception of increasing violence against healthcare professionals and medical lawsuits discourage medical graduates from selecting surgery-related specialties [11].

Selection of medical specialties is also affected by medical graduates’ self-appraisal of their abilities, skills and aptitudes [12, 13], financial expectations [14], prestige of the specialty [15], career development opportunities [16], work load during residency [17] length of residency years [18, 19] and opportunity to teach [20]. A validated instrument included patient care characteristics (multidisciplinary, acute and continuous) and specialty characteristics (challenging nature, surgical based) as additional factors in the choice of medical specialization [21]. A scoping study on the choice of specialty education by medical students in low- and middle-income countries listed “immigration opportunities” as an important factor [22]. Medical graduate’s preference for primary care over advanced care also affect type of specialties chosen later on [23]. Only a limited number of analyses included factors that negatively affect the choice of specialization such as malpractice risk, risk of legal complaints and low level of satisfaction in professional life [18, 24, 25]. Violence towards physicians has also been examined as a potential factor in recent years [26, 27]. This study intends to examine various positive and negative factors, including violence against healthcare providers and malpractice risk, in the choice of medical specialties.