Physician shortage and maldistribution is one of the urgent health policy issues requiring resolution [1]. Determination of factors associated with regional retention of physicians and development of effective policy interventions will assist in solving this issue.

Many studies have been conducted to identify factors that contribute to the recruitment and retention of physicians in medically underserved regions and communities. Original attributes (nature) and educational perspectives (nurture) are used as frameworks for these studies [2]. Regarding the nature of physicians, originating from a rural area was strongly associated with a desire to work in a rural area, and actual work location as well as being interested in a comprehensive specialty were related to primary care [3]. For the nurture of education, medical students who have experienced a long period of rural training and physicians who have had both middle and high school education and training in the same rural area were likely to remain in the same rural area after training [4]. The salmon homecoming theory, which states that people educated in rural areas often work in rural areas, is also well known [5].

Various policies to secure physicians are in place in different countries. For example, Thomas Jefferson University initiated the Physician Shortage Area Program in 1974. The program selectively admits medical school students who both grew up in and plan to practice in a rural area. The program contributed 12% of all rural family physicians in Pennsylvania and helped to achieve>70% long-term physician retention in rural family medicine after 2025 years [6]. In Thailand, the government has implemented a multi-pronged intervention strategy over several decades to attract and retain doctors in underserved areas, including a special track for recruitment and training that enrolls students with rural backgrounds, trains the students at medical schools and hospitals close to their home towns, and obliges the students to return to their home provinces upon graduation. This track currently accounts for 47% of the total number of new graduates for general practice [7].

The World Health Organization published policy guidelines and recommendations in 2010 [1]. Among the suggested measures, one of the most frequently used approaches is a compulsory placement program, which is implemented in 70 countries [8]. However, there is a limited reliable evidence for the effects of interventions to address the inequitable distribution of health professionals [9], and the evidence is mixed for financial incentives and return of service programs [10, 11].

The issue of uneven distribution and availability of physicians is also a major health policy issue in Japan. Past empirical research has shown that simply increasing the number of physicians is not sufficient to mitigate the maldistribution of physicians [12, 13]. Consequently, there are two major approaches to increase the number of physicians working in the community. One is to establish a medical school that produces physicians for rural medicine (Jichi Medical University [JMU]), and the other is to allocate certain entrance quotas for medical schools to select students engaged in community medicine (regional quotas).

JMU was founded in 1972. Its budget is derived from the national government, as well as all 47 prefectural governments. Several entrance quotas are set for each prefecture. The JMU undergraduate education program is designed to focus on community and rural medicine, as well as other areas of medicine. After students have passed their national medical license and completed a 9-year obligation period including several years of rural service, the tuition fees are waived [3]. A previous study confirmed that JMU graduates who completed their obligation period were four times more likely to work in rural areas than non-JMU graduates [14].

Regarding regional quotas, although the programs vary, most contain at least one of the following components: applicants should have a geographical background in the prefecture where the medical school is located; applicants should undertake a special admission process with an emphasis on their motivation to commit to community medicine in their prefecture; applicants should have more exposure to community-based practice in their undergraduate medical education; and upon graduation, applicants are obliged or expected to work in the prefecture for several years [15]. Most of the regional quota programs are bundled with a scholarship, and in exchange, the graduates must work in the prefecture for a certain period of time. In most programs, one-third to one-half of the required period is dedicated to working in a rural area within the prefecture. Many programs offer special undergraduate curricula and programs. The percentage of medical school enrollment for regional quotas has increased rapidly, reaching 1,723 places, or 18.7% of the enrollment capacity of all medical schools in fiscal year 2021 [16].

In addition to being community medicine-oriented, one of the common features of JMU and regional quotas is the introduction and application of a career development program developed by each prefecture. From the physicians point of view, the obligation to work in a rural area for several years after graduation coincides with a critical period in their career development pathway, and thus it is an important issue how to balance their scholarship-bonded rural service obligation, career development, and other major life events, such as marriage and child-raising, that are often experienced in the same life stage. The introduction of a career development program is designed to solve this dilemma by providing multiple courses for each area of practice and type of medical institution where the physicians work and by visualizing the career paths that can be undertaken in each course including the board certification that can be obtained.

As such, the regional quotas and JMU have much in common and play major roles in securing physicians in community medicine and rural regions. However, there are also differences between the two approaches. The retention rate for contractual rural service was higher among JMU graduates than among regional quota graduates with a scholarship [17]. It was also shown that a higher percentage of physicians from regional quotas work in non-urban areas compared with physicians in general [15]. It was documented that students within regional quotas become less willing to work in the region as the academic year progresses [18]. Meanwhile, the cost forprefecturefor JMU was higher than that for regional quotas [17]. Thus, how to combine these two approaches and determine ways to retain medical school graduates in community medicine and rural regions remains an important issue.

Historically, the Japanese medical specialist system has been operated independently by individual academic societies, and there have been concerns about accreditation standards and quality assurance. In 2013, a national panel recommended the establishment of a third-party organization to unify the evaluation and accreditation of medical specialists and training programs. A new board certification system established general practice as one of the 19 basic specialties. In Japan, general practice and family medicine remain unpopular, and specialists also provide primary care [19]. In this regard, the change in policy has the potential to alter the mode of medical provision. A new training system for board certification was launched in 2018. Nevertheless, the number of students who commenced training to become a board-certified general practitioner in 2023 was only 285, or 3.1% of the 9,325 students who began training in any one of the basic specialties [20].

To mitigate physician maldistribution, it is also important to consider the placement mechanism of physicians. In this regard, ikyoku, a historical and traditional system for physician allocation, should be taken into account. During the modernization process in Japan, the training and personnel system for doctors based on ikyoku (literal translation: the clinical department of a medical school characterized by a professor at the top of the hierarchy) was imported from Germany. Combined with the traditional Japanese apprentice system and the spirit of craftsmanship, the system in Japan has developed in its own way. Its unique feature is the power of professors in university hospitals to rotate physicians among affiliated hospitals [19, 21]. The Japanese postgraduate medical education system is regarded as an apprenticeship-based system [22], with most new graduates trained in a medical school and belonging to that school. Even after their residency is completed, the relationship continues [23]. The physicians in most larger hospitals remain under the influence of this system.

Meanwhile, little is known about the actual conditions and contributing factors that influence the intention to work in rural regions and community medicine, especially with a focus on career development. Therefore, the purpose of the present study was to identify factors associated with regional retention and to discuss their policy implications.

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Factors associated with regional retention of physicians: a cross ... - Human Resources for Health