Results of physician licence examination and scholarship contract compliance by the graduates of regional quotas in Japanese medical schools: a nationwide cross-sectional survey

The Attributes of Physicians Assigned to Rural Clinics Designated for Areas without Physicians in Japan

In Japan, there are rural clinics designated for areas without physicians to ensure the availability of medical care for rural area residents. The purpose of this study was to clarify the attributes of physicians working in the rural clinics. Using the 2018 Ministry of Health, Labour and Welfare data in Japan, we compared the attributes and board certifications of physicians in rural clinics with those of physicians in other clinics. The age group with the highest percentage of physicians was the over 70 group (16%) and the early 30s group (15%) at rural clinics; however, the highest percentage of physicians at other clinics was the 70 over group (20%) and the early 60s group (16%). The number of physicians working in the internal medicine field at rural clinics was 550 (89%). There were 147 (27%) board-certified physicians in that field. Among them, the number of board certifications in internal medicine, surgery, and other than internal medicine or surgery were 79 (54%), 17 (12%), and 51 (35%), respectively. The proportion of board-certified surgery physicians within the internal medicine field in rural clinics was significantly higher than in other clinics (5%). In rural clinics, the age distribution of physicians was different from that in other clinics, and many of the physicians worked in the internal medicine field, but some of them seemed to have a mismatch between their board-certifications and their fields of practice. Further studies are necessary to clarify what the mismatches mean in rural practice.

Association between regional quota program in medical schools and practical clinical competency based on General Medicine In-Training Examination score: a nationwide cross-sectional study of resident physicians in Japan

PURPOSE

A regional quota program (RQP) was introduced in Japan to ameliorate the urban-rural imbalance of physicians. Despite concerns about the low learning abilities of RQP graduates, the relationship between the RQP and practical clinical competency after initiating clinical residency has not been evaluated.

METHODS

We conducted a nationwide cross-sectional study to assess the association between the RQP and practical clinical competency based on General Medicine In-Training Examination (GM-ITE) scores. We compared the overall and category GM-ITE results between RQP graduates and other resident physicians. The relationship between the RQP and scores was examined using multilevel linear regression analysis.

RESULTS

There were 4978 other resident physicians and 1119 RQP graduates out of 6097 participants from 593 training hospitals. Being younger; preferring internal, general, or emergency medicine; managing fewer inpatients; and having fewer ER shifts were all characteristics of RQP graduates. In multilevel multivariable linear regression analysis, there was no significant association between RQP graduates and total GM-ITE scores (coefficient: 0.26; 95% confidence interval: -0.09, 0.61; P = .15). The associations of RQP graduates with GM-ITE scores in each category and specialty were not clinically relevant. However, in the same multivariable model, the analysis did reveal that total GM-ITE scores demonstrated strong positive associations with younger age and GM preference, both of which were significantly common in RQP graduates.

CONCLUSION

Practical clinical competency evaluated based on the GM-ITE score showed no clinically relevant differences between RQP graduates and other resident physicians. Key messages What is already known on this topic Many countries offer unique admission processes to medical schools and special undergraduate programs to increase the supply of physicians in rural areas. Concerns have been raised about the motivation, learning capabilities, and academic performance of the program graduates. What this study adds This nationwide cross-sectional study in Japan revealed clinical competency based on the scores from the General Medicine In-Training Examination showed no clinically relevant differences between graduates of regional quota programs and other resident physicians. How this study might affect research, practice, or policy The study provides evidence to support the Japanese regional quota program from the perspective of clinical competency after initiating clinical practice.

Impact of medical students' socioeconomic backgrounds on medical school application, admission and migration in Japan: a web-based survey

OBJECTIVES

The aim of this study was to clarify and compare the socioeconomic backgrounds of medical students with those of other health professions and non-health faculty students in an era of increasing inequity in Japanese society.

DESIGN

This was a quantitative nationwide study. Data were collected by a cross-sectional web-based anonymous questionnaire.

SETTING

Data from years 3 and 4 medical, health professions and non-health faculty students across Japan were collected in 2021.

PARTICIPANTS

Participants were 1991 students from medical schools, 224 from dental, 419 from pharmacy, 326 from nursing, 144 from other health professions and 207 from non-health faculties.

RESULTS

The proportion of high-income families (>18 million yen: ca. US$140 000) among medical students was 25.6%, higher than that of pharmacy (8.7%) and nursing students (4.1%) (p<0.01). One-third of medical students had a physician parent, more common than in non-medical students (p<0.01). Students who only applied to public medical schools and a regional quota 'Chiiki-waku' students with scholarship had lower family income and physician parents compared with those who applied to private medical schools (p<0.01), but they still had higher physician parents compared with non-medical students (p<0.01). Logistic regression revealed that having a physician parent (p<0.01), aspiring to the present profession during elementary school (p<0.01) and private upper secondary school graduation (p<0.01) predicted the likelihood of studying medicine. There were regional differences of backgrounds among medical students, and 80% of medical students with urban backgrounds intended to work in urban localities after graduation.

CONCLUSIONS

This study provides evidence that medical students in Japan hail from urban and higher income classes and physicians' families. This finding has implications for the health workforce maldistribution in Japan. Widening the diversity of medical students is essential for solving physician workforce issues and meeting broad healthcare needs.

Does regional quota status affect the performance of undergraduate medical students in Japan? A 10-year analysis

OBJECTIVES

This study aims to determine whether there is a difference in the academic performance of medical students based on admission type and examine the extent to which entrance examinations predict their performance.

METHODS

This observational study utilized existing data from Asahikawa Medical University. Participants were 1057 medical students who had enrolled between 2010 and 2019. Analysis of variance and Tukey's test were utilized to identify differences between admission types. The multiple linear regression explored predictors of cumulative grade point average for each type.

RESULTS

Analysis of variance showed significant differences in the National Center Test (F_{(3, 1053)} =70.78, p <0.001) and cumulative grade point average (F_{(3, 1053)} =3.93, p <0.01). Tukey's post hoc test revealed that two types of general admission students (M=83.52, SD=3.22; M=85.57, SD=3.01) were significantly higher on the National Center Test than two types of regional quota students (M=81.61, SD=3.93; M=80.65, SD=3.61). The cumulative grade point average of a regional quota group (M=2.23, SD=0.34) was significantly higher than two types of general admissions (M=2.11, SD=0.36; M=2.12, SD=0.34). High school grade point averages and females were significant in predicting cumulative grade point averages for each admission (16.0-28.3% variance).

CONCLUSIONS

Regional quota students earned a higher cumulative grade point average than those from general admissions, despite their significantly lower scores on the National Center Test. Enhanced utilization of regional quota admissions could become an effective strategy to increase the rural physician workforce.

Education policies to increase rural physicians in Japan: a nationwide cohort study

BACKGROUND

Japan has established comprehensive education-scholarship programs to supply physicians in rural areas. Their entrants now comprise 16% of all medical students, and graduates must work in rural areas for a designated number of years. These programs are now being adopted outside Japan, but their medium-term outcomes and inter-program differences are unknown.

METHODS

A nationwide prospective cohort study of newly licensed physicians 2014-2018 (n = 2454) of the four major types of the programs-Jichi Medical University (Jichi); regional quota with scholarship; non-quota with scholarship (scholarship alone); and quota without scholarship (quota alone)-and all Japanese physicians in the same postgraduate year (n = 40,293) was conducted with follow-up workplace information from the Physician Census 2018, Ministry of Health, Labour and Welfare. In addition, annual cross-sectional survey for prefectural governments and medical schools 2014-2019 was conducted to obtain information on the results of National Physician License Examination and retention status for contractual workforce.

RESULTS

Passing rate of the National Physician License Examination was highest in Jichi, followed in descending order by quota with scholarship, the other two programs, and all medical graduates. The retention rate for contractual rural service of Jichi graduates 5 years after graduation (n = 683; 98%) was higher than that of quota with scholarship (2868; 90%; P < 0.001) and scholarship alone (2220; 81% < 0.001). Relative risks of working in municipalities with the least population density quintile in Jichi, quota with scholarship, scholarship alone, and quota alone in postgraduate year 5 were 4.0 (95% CI 3.7-4.4; P < 0.001), 3.1 (2.6-3.7; < 0.001), 2.5 (2.1-3.0; < 0.001), and 2.5 (1.9-3.3; < 0.001) as compared with all Japanese physicians. There was no significant difference between each program and all physicians in the proportion of those who specialized in internal medicine or general practice in postgraduate years 3 to 5 CONCLUSIONS: Japan's education policies to produce rural physicians are effective but the degree of effectiveness varies among the programs. Policymakers and medical educators should plan their future rural workforce policies with reference to the effectiveness and variations of these programs.

Fostering student motivation towards community healthcare: a qualitative study

OBJECTIVES

This study investigated what kinds of experiences influence regional quota (chiikiwaku) medical students' motivation to practice community healthcare (CH), and the mechanism of this influence, by focusing on their experiences in a community-based medical education (CBME) programme.

DESIGN

A qualitative thematic analysis based on interviews.

SETTING

Participants were recruited from the chiikiwaku students of Kobe University, Japan, using purposive sampling.

PARTICIPANTS

Fourteen students participated. The median (IQR) age of participants was 23 (23-24); half were sixth-year and half fifth-year students.

ANALYSIS

From September to December 2018, the interviews were audiorecorded and transcribed verbatim. Data were analysed according to the 'Steps for Coding and Theorisation' method. Our theoretical framework comprised three internal motives (ie, needs, cognitions and emotions) and their subordinate motivation theories self-determination theory, expectancy-value theories, and positive and negative emotions, respectively.

RESULTS

Three mechanisms and corresponding experiences emerged. The first mechanism, envisioning and preparing for practising CH, included corresponding experiences-empathy for the community, grasping the demands for CH, understanding the practices of CH, finding a role model and diminishing the conflicts between personal life and career. The second mechanism, belonging to a supportive community, included the robust construction of students' CH community and harmonisation with community residents. The third mechanism, psychological effects included the affect heuristic and framing effect. Student experiences brought about the changes and influences described in the presented mechanisms, and had both positive and negative impacts on their motivation towards CH. These results can be interpreted through the multifaceted lenses of motivation theories.

CONCLUSIONS

The authors revealed that motivation mechanisms of medical students towards CH derived from positive interaction with community residents, healthcare professionals and other students, and from exposure to attractive community environments and cultures. These experiences should be incorporated into CBME programmes to further encourage positive attitudes towards CH.

How is increased selectivity of medical school admissions associated with physicians' career choice? A Japanese experience

BACKGROUND

During the long-lasting economic stagnation, the popularity of medical school has dramatically increased among pre-medical students in Japan. This is primarily due to the belief that medicine is generally a recession-proof career. As a result, pre-medical students today who want to enter medical school have to pass a more rigorous entrance examination than that in the 1980s. This paper explores the association between the selectivity of medical school admissions and graduates' later career choices.

METHODS

A unique continuous measure of the selectivity of medical school admissions from 1980 to 2017, which is defined as the deviation value of medical schools, was merged with cross-sectional data of 122 990 physicians aged 35 to 55 years. The association between the deviation value of medical schools and various measures of physicians' career choices was explored by logistic and ordinary least square regression models. Graduates from medical schools in which the deviation value was less than 55 were compared with those from more competitive medical schools, after controlling for fixed effects for the medical school attended by binary variables.

RESULTS

From 1980 to 2017, the average deviation value increased from 58.3 to 66.3, indicating a large increase in admission selectivity. Empirical results suggest that increasing selectivity of a medical school is associated with graduates having a higher probability of choosing a career in an acute hospital as well as having a lower probability of opening their own clinic and choosing a career in primary health care. Graduating from a highly competitive medical school (i.e., deviation value of more than 65) significantly increases the probability of working at typical acute hospitals such as so-called 7:1 hospitals (OR 1.665 2, 95%CI 1.444 0-1.920 4) and decreases the probability of working at primary care facilities (OR 0.602 6, 95%CI 0.441 2-0.823 0). It is also associated with graduates having a higher probability of becoming medical board certified (OR 1.294 6, 95%CI 1.108 8-1.511 4).

CONCLUSION

Overall, this paper concludes that increased selectivity of medical school admissions predicts a higher quality of physicians in their own specialty, but at the same time, it is associated with a lower supply of physicians who go into primary care.

Geographic Distribution of Regional Quota Program Graduates of Japanese Medical Schools: A Nationwide Cohort Study

PURPOSE

To show the practice location of graduates from two Japanese programs recruiting physicians to rural areas: a regional quota program of medical schools and a prefecture scholarship program (a prefecture is an administrative geographic division). Graduates of each program must work in a designated rural prefecture for a fixed period.

METHOD

A nationwide cohort study was conducted for three groups of participants graduating between 2014 and 2016: quota graduates without scholarship (quota alone), nonquota graduates with scholarship (scholarship alone), and quota graduates with scholarship. A questionnaire was sent via medical school or prefecture office to each potential subject to collect baseline individual data, including home prefecture and graduation year. Data were connected through physician identification number to the Physician Census 2016 of the Ministry of Health, Labour and Welfare to identify the subjects' practice location and compared with data for other physicians in the census. Comparisons were conducted with Mann-Whitney and chi-square tests.

RESULTS

The proportion of physicians working in nonmetropolitan municipalities for quota alone (185/244; 75.8%), scholarship alone (305/363; 84.0%), and quota with scholarship (341/384; 88.8%) was significantly higher than for other physicians (13,299/22,906; 58.1%). Median population density of the municipalities where subjects worked for quota alone (1,042.4 persons per square kilometer), scholarship alone (613.5), and quota with scholarship (547.4) was significantly lower than that for other physicians (3,214.0). These disparities increased with number of years since graduation.

CONCLUSIONS

The regional quota and prefecture scholarship programs succeeded in producing physicians who practiced in rural areas of Japan.

Emigration of regional quota graduates of Japanese medical schools to non-designated prefectures: a prospective nationwide cohort study

OBJECTIVES

This study examined the retention of regional quota graduates of Japanese medical schools and prefecture scholarship recipients within their designated prefectures where they are obliged or expected to work and revealed the personal and regional characteristics associated with their emigration to non-designated prefectures. Regional quota and prefecture scholarship are two of the most ambitious policies ever conducted in Japan for recruiting physicians to practice in rural areas.

DESIGN

Prospective cohort study.

SETTING

Nationwide.

PARTICIPANTS

Regional quota graduates with prefecture scholarship, quota graduates without scholarship and non-quota graduates with scholarship of Japanese medical schools who obtained their physician license between 2014 and 2016.

PRIMARY OUTCOME

The emigration in 2016 of the participants from the designated prefectures.

RESULTS

Total participants were 991 physicians, three of whom were excluded due to the missing values of crucial items, leaving 988 participants for analysis (quota with scholarship 387, quota alone 358 and scholarship alone 243). The percentage of those who emigrated was 11.9% (118/988). The mean (±SD) proportion of subjects who emigrated was 11.7% (±10.3) among all prefectures and the proportion varies widely among prefectures (0%-44.4%). Multilevel logistic regression analysis showed those who received prefecture scholarship (OR 0.23; 95% CI 0.08 to 0.67) and whose designated prefecture has an ordinance-designated city (ie, large city) were less likely to emigrate (OR 0.47; 95% CI 0.24 to 0.90). In contrast, graduates from a medical school outside the designated prefecture (OR 4.20; 95% CI 2.20 to 7.67) and who have a right to postpone their obligatory service (OR 3.42; 95% CI 1.52 to 7.67) were more likely to emigrate.

CONCLUSIONS

A substantial proportion of regional quota graduates and prefecture scholarship recipients emigrated to non-designated prefectures. Emigrations should be reduced by improving the potential facilitators for emigration such as discordance in location between medical school and designated prefecture.

Aging of hospital physicians in rural Japan: A longitudinal study based on national census data

Background

The disparity in the number of urban and rural physicians is a social problem in Japan. There may also be a disparity in the age of physicians. This study longitudinally examines both geographic and age distributions of physicians.

Methods

Individual data from the Survey of Physicians, Dentists and Pharmacists in 1994, 2004 and 2014 and municipality data from the National Population Census were used. The 2015 municipality border was applied to all years, and all municipalities were classified into equal-size quintiles based on population density. Both municipalities and physicians were longitudinally observed.

Results

Between 1994 and 2014, the number of physicians per 100,000 population increased by 31.8% in the most urban group of municipalities and 17.4% in the most rural group. The average age of physicians was highest in the most rural and lowest in the most urban group. The difference in average age between the urban and rural physicians widened from 2.1 years in 1994 to 6.0 years in 2014. This disparity is particularly pronounced among hospital physicians (from 1.5 years in 1994 to 7.6 years in 2014). In the most rural group, the number of hospital physicians younger than 40 years old has decreased by 59.4%, while the number of those 55–70 has grown by 153% and the number older than 70 years old by 41.0%. Between 1994 and 2004, only 23.0% of hospital physicians younger than 40 years old were retained in the most rural group; the retention rate fell to 19.3% between 2004 and 2014, while the rates increased in older physicians.

Conclusions

The uneven distribution of physicians is increasing in Japan, as is the aging of rural hospital physicians. Shortage of physicians in rural areas may be more serious than that shown as their headcount.