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Winter 2019 (Volume 29, Number 4)

Rheumatology Here & Away: An 18-year Journey From Istanbul to Ottawa

By Sibel Zehra Aydin, MD

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I am an adult rheumatologist, working at the University of Ottawa since 2015. Here is my personal journey through rheumatology, from Istanbul to Ottawa.

In 2001, I completed my rheumatology rotation within my internal medicine residency, at Marmara University, Istanbul, Turkey. From that moment on, I knew that I could not choose any other specialty. More specifically, I was curious about prognostic factors in spondyloarthritis. I started doing research in this area during my internal medicine training, with my very first projects being on biomarkers in spondyloarthritis, linking the gut with the radiographic damage. This was followed by my rheumatology residency in 2005, at the same university.

In 2006, in the first year of my rheumatology residency, I held an ultrasound probe for the first time. I immediately realized that I could never go back to practicing without it. I had to learn this technique, and I had to learn from the best teachers. That’s why I went to Italy to work with Professors Walter Grassi and Emilio Filippucci, the two gurus of ultrasonography, who irreversibly changed my life. Since then, ultrasound not only has been an irreplaceable tool in my clinical practice, but also has changed the course of my research significantly.

In 2009, my chief, Prof. Haner Direskeneli wisely told me that I had to experience research abroad, if I wanted to be a good researcher. That is how I ended up in Leeds, UK, to work with Prof. Dennis McGonagle, shortly after he published the synovio-entheseal complex theory. This has been an extremely productive period in my life and brought a different perspective to my research. One research question led to another and I found myself spending a decade on imaging and how that improves our assessment and understanding of these diseases.

Then, in 2014, I was invited to meet with the Division of Rheumatology in Ottawa. How lucky I was to meet with all these very nice people who were interested in hearing what I was doing and what I could offer… After a few meetings, we shook hands and my family and I moved to Ottawa in 2015. There have been challenges along the way, but I always felt fortunate to be in Ottawa. Finally, I have found myself in a place where I could contribute, surrounded by open-minded people.

Last but not least, before any of this happened, in 1992, when I was in high school, I met a boy; I knew that he was the one, and he eventually became my husband and the father of my two sons.

Further to this brief introduction, I would like to share my transition process with you. While similar aspects between Canadian and Turkish healthcare systems made my life easier, some of the differences had been difficult to adjust to. Here are some similarities and differences:

1) What patients want and need:
The patients’ needs are almost universal, therefore I have not struggled with patient care. One minor difference would be that in Turkey, medical decisions are more frequently made by the physicians, as the patients more often tend to leave the decisions to the experts. I recognize that, in Canada, there is more of a patient-centered system, reflecting cultural differences.

2) More about cultural differences:
Unfortunately, actual and attempted violence against physicians has become a major issue in Turkey. This has been recognized as a significant factor in the increase in burnout among physicians. Emotional reactions are a part of the Mediterranean culture, which may affect the patients' reactions to upsetting news, sadly sometimes leading to violent behavior.

3) Insurance:
In Turkey, all patients have public insurance, similar to Canada. Private insurance has a different meaning in Turkey, as there are also private hospitals which are not funded by the government. This gives options to patients, if they have private insurance or if they can afford it, to be able to receive service very quickly and more comfortably (five-star luxury hotel-type hospital services, if it matters). This may sound like inequality amongst people, and I believe it is; however, it also frees up space in the public system, leaving more time and spots for people who cannot afford private practice.

4) Drug coverage:
In Turkey, all drugs are covered by the public healthcare system; therefore, it would be rare to have a patient who could not afford medication.

5) Long letters:
Family physicians and rheumatologists do not communicate via letters in Turkey. Documentation is only for the specialist to be able to follow his/her own assessments, and to make sure that the physician is legally protected in case anything goes wrong, in most hospitals.

6) Waiting times to be seen by other specialists/getting imaging done:
In Turkey, patients do not have to wait for more than two months to be seen by a specialist or to have surgery performed. Similarly, an MRI would be done within two weeks, at the latest. The burden of this fast access falls on the physicians, who have to see an unrealistic number of patients every day. Protected time for doing research is a privilege that is only given to a small group of physicians; many others have 10 clinics per week.

7) High number of physical therapy and rehabilitation (PTR) specialists across the country:
In Turkey, the number of PTR specialists are probably around 10 times more than rheumatologists, and they deal with non-inflammatory causes of musculoskeletal pain, including fibromyalgia and osteoarthritis.

8) Finding 100 excuses not to learn musculoskeletal ultrasound:
The barriers are universal… So are the benefits. Regardless of where I work, when people recognize the value, barriers are not too difficult to overcome. I am very happy to see the increased uptake of ultrasound in my division, and seeing that barriers are getting smaller and smaller as time goes by.

My journey started in Turkey, led to Italy and to the UK, and now continues in Canada. I am very happy and proud to be a part of this prestigious rheumatology community and will continue to contribute to patient care, education and research, as much as I can.

Sibel Zehra Aydin, MD
Associate Professor,
Faculty of Medicine, Division of Rheumatology
Senior Clinician Investigator,
Clinical Epidemiology Program,
Ottawa Hospital Research Institute (OHRI)
Director of Research, Arthritis Center
University of Ottawa,
Ottawa, Ontario

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