Specialty choice and physicians’ career paths in Japan: An analysis of National Physician Survey data from 1996 to 2006

Why choose paediatrics? A scoping review of factors affecting the choice of paediatrics as a career

Despite being a popular speciality at the undergraduate level, paediatrics lags behind most other medical and surgical specialities for postgraduate recruitment. As many individuals decide on their future career choice while still in medical school, it is essential to identify the factors that attract individuals to a career in paediatrics. To determine the positive influencing factors determining paediatrics as a career choice. A scoping review of primary research articles was conducted using a comprehensive electronic search strategy and reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews recommendations. Studies exploring medical students, junior doctors, and current paediatricians' perceptions of paediatrics were included. Factors affecting career choice were identified. Thirty-six studies out of a possible 3106 met the inclusion criteria and were included in this review. Six key influencing themes were identified. These were early undergraduate and clinical exposure to paediatrics; an attractive work-life balance; the presence of role models and mentors; an enjoyable working atmosphere and varied clinical work; a personal commitment to paediatrics; and working with children.

CONCLUSION

 Medical students are drawn by the wide clinical variety in paediatrics, enjoyable working atmosphere, and enthusiastic colleagues. Given the importance of early clinical exposure in determining student motivation, paediatrics needs to do more to advertise the wide variety of clinical and research work available, starting early in medical school. In addition, medical students need to be offered more opportunities to experience the speciality through student selected components, summer schools, or workshops, requiring coordination between medical schools and regional paediatric departments.

WHAT IS KNOWN

• Research suggests that many medical students make choices on their future career based on medical school experiences. • Paediatrics is a popular subject among medical students, however applications for the specialilty are in decline.

WHAT IS NEW

• Six key factors influencing paediatrics as a career choice have been identified, the most common being early exposure to paediatrics at medical school and lifestyle factors. • Interventions aimed at increasing student involvement in paediatrics at the undergraduate level have been shown to be associated with an increase in the number of individuals applying for the speciality following graduation.

Self-assessment scale for the community-based and emergency practice

BACKGROUND

For current medical education, community-based primary care for the elderly is an essential topic. This study aimed to establish a scale of community-based assessment for clinical and emergency practice (C-CEP).

METHODS

A self-assessment scale for C-CEP was developed according to four steps. Initially, we reviewed publications from the societies of the United States, British, and Japan regarding educational goals. In addition, we searched MEDLINE for educational goals regarding attitude, skills, and knowledge. Getting together, we established 23 items as the educational goals of the C-CEP. Second, we collected responses for these 23 items from 5th-grade medical students (n = 195). Third, we conducted an exploratory factor analysis (EFA) using their responses to determine the fundamental structure of the self-assessment scale. Finally, a confirmatory factor analysis (CFA) was performed to assess the fitness of the self-assessment scale developing the EFA, resulting in modification of the items.

RESULTS

In EFA and CFA results, C-CEP Scale consisted of four factors with 15 items: "Attitude and communication in emergency care," Basic clinical skills," "Knowledge of community healthcare," and "Knowledge of evidence-based medicine perseverance." The model fit indices were acceptable (Goodness of Fix Index = 0.928, Adjusted Goodness of Fit Index = 0.900, Comparative Fit Index = 0.979, and Root Mean Square Error of Approximation = 0.045). The values of McDonald's omega as an estimate of scale reliability were more than 0.7 in all four factors. As for test-retest reliability, the intraclass correlation coefficients were ≥ 0.58 for all factors. All four factors of the C-CEP Scale correlated positively with the Medical Professionalism Evaluation Scale subscales.

CONCLUSIONS

We developed a valid and reliable self-assessment scale to assess student competence.

Career destinations of graduates from a medical school with an 18-week longitudinal integrated clerkship in general practice: a survey of alumni 6 to 8 years after graduation

Background

There is a worldwide recruitment and retention crisis in general practice. Workforce planning has identified the need to train more general practitioners as an urgent priority. Exposure of medical students to general practice as part of the formal and hidden curriculum, the use of longitudinal integrated clerkships, and positive experiences and role models in general practice are all thought to be contributing factors to doctors choosing careers in general practice.

Aim

The aim of this study was to identify career destinations of medical school graduates in a medical school with an 18-week longitudinal integrated clerkship in general practice.

Design and setting

This study was conducted in a single graduate entry medical school at the University of Limerick, Ireland.

Participants

Medical school alumni 6–8 years after graduation.

Method

A survey of graduating cohorts of the medical school from 2011 to 2013 was conducted through email and telephone.

Results

There were a total of 175 alumni for the period 2011 to 2013. Data was collected on 92% (161/175) through an online survey, follow-up email and telephone interview, and was triangulated with searches of professional registration databases and information from key informants. Between 6 and 8 years after graduation, a total of 43% of alumni were engaged in general practice as a career.

Conclusion

The reform of the delivery of general practice within medical school curricula should be considered by medical schools, curriculum designers and policy-makers as part of an overall strategy to address the recruitment and retention of general practitioners as part of the global healthcare workforce.

Working to Change Systems: Repatriated U.S. Trained Japanese Physicians and the Reform of Generalist Fields in Japan

Phenomenon: Internationally, efforts to produce an adequate supply of effective generalist physicians commonly encounter resistance. Achieving reform requires changes in educational and clinical practice cultures, and clinician educators play a central role in championing change. In Japan, training in generalist fields has historically been lacking, but for decades the government has advocated alignment with Western models. Meanwhile, some Japanese physicians have pursued U.S. training in generalist fields with intention to help change the clinical education and practice systems back in Japan. This study examines the endeavors of repatriated Japanese International Medical Graduates and provides a lens to understanding national challenges with reform and insights into strategizing next steps. Approach: Individual, semi-structured interviews were conducted with 19 purposively sampled Japanese IMGs who had repatriated across Japan after completing U.S. clinical residency in generalist fields. Iterative data collection and thematic analyses were performed using constant comparison. Findings: Participants identified Japanese medical universities and public sectors as steeped in traditions with systemic inertia. In turn, participants described well-informed career decision making involving connections and teammates, which commonly resulted in employment at new or smaller hospitals. Education-related efforts prioritized direct clinical work with physician trainees in the hope of building expansive lineages of educators. Main challenges were Japanese structural and cultural incongruences with Western generalist-based clinical practice. Participants described a competitive relationship with the long-standing ikyoku-based postgraduate education model and associated organ-based organization of clinical practice. Insights: Japanese IMG championing of clinical education and practice in generalist fields is largely marginalized within Japan's clinical education and practice landscape. National-level reform will require transforming or displacing the structurally and culturally rooted traditional infrastructure. Specific measures must be culturally nuanced but likely include those proven effective for similar reforms elsewhere. Based on Japan's national cultural characteristics, sustained leadership is anticipated to be particularly important.

Future projection of the physician workforce and its geographical equity in Japan: a cohort-component model

INTRODUCTION

The geographical inequity of physicians is a serious problem in Japan. However, there is little evidence of inequity in the future geographical distribution of physicians, even though the future physician supply at the national level has been estimated. In addition, possible changes in the age and sex distribution of future physicians are unclear. Thus, the purpose of this study is to project the future geographical distribution of physicians and their demographics.

METHODS

We used a cohort-component model with the following assumptions: basic population, future mortality rate, future new registration rate, and future in-migration and out-migration rates. We examined changes in the number of physicians from 2005 to 2035 in secondary medical areas (SMAs) in Japan. To clarify the trends by regional characteristics, SMAs were divided into four groups based on urban or rural status and initial physician supply (lower/higher). The number of physicians was calculated separately by sex and age strata.

RESULTS

From 2005 to 2035, the absolute number of physicians aged 25-64 will decline by 6.1% in rural areas with an initially lower physician supply, but it will increase by 37.0% in urban areas with an initially lower supply. The proportion of aged physicians will increase in all areas, especially in rural ones with an initially lower supply, where it will change from 14.4% to 31.3%. The inequity in the geographical distribution of physicians will expand despite an increase in the number of physicians in rural areas.

CONCLUSIONS

We found that the geographical disparity of physicians will worsen from 2005 to 2035. Furthermore, physicians aged 25-64 will be more concentrated in urban areas, and physicians will age more rapidly in rural places than urban ones. The regional disparity in the physician supply will worsen in the future if new and drastic measures are not taken.

Examining changes in the equity of physician distribution in Japan: a specialty-specific longitudinal study

OBJECTIVES

In this longitudinal study, we examined changes in the geographical distribution of physicians in Japan from 2000 to 2014 by clinical specialty with adjustments for healthcare demand based on population structure.

METHODS

The Japanese population was adjusted for healthcare demand using health expenditure per capita stratified by age and sex. The numbers of physicians per 100 000 demand-adjusted population (DAP) in 2000 and 2014 were calculated for subprefectural regions known as secondary medical areas. Disparities in the geographical distribution of physicians for each specialty were assessed using Gini coefficients. A subgroup analysis was conducted by dividing the regions into four groups according to urban-rural classification and initial physician supply.

RESULTS

Over the study period, the number of physicians per 100 000 DAP decreased in all specialties assessed (internal medicine: -6.9%, surgery: -26.0%, orthopaedics: -2.1%, obstetrics/gynaecology (per female population): -17.5%) except paediatrics (+33.3%) and anaesthesiology (+21.1%). No reductions in geographical disparity were observed in any of the specialties assessed. Geographical disparity increased substantially in internal medicine, surgery and obstetrics and gynaecology(OB/GYN). Rural areas with lower initial physician supply experienced the highest decreases in physicians per 100 000 DAP for all specialties assessed except paediatrics and anaesthesiology. In contrast, urban areas with lower initial physician supply experienced the lowest decreases in physicians per 100 000 DAP in internal medicine, surgery, orthopaedics and OB/GYN, but the highest increase in anaesthesiology.

CONCLUSION

Between 2000 and 2014, the number of physicians per 100 000 DAP in Japan decreased in all specialties assessed except paediatrics and anaesthesiology. There is also a growing urban-rural disparity in physician supply in all specialties assessed except paediatrics. Additional measures may be needed to resolve these issues and improve physician distribution in Japan.

Gender Associated with the Intention to Choose a Medical Specialty in Medical Students: A Cross-Sectional Study in 11 Countries in Latin America

Introduction

The selection of a medical specialty has been associated with multiple factors, such as personal preferences, academic exposure, motivational factors and sociodemographic factors, such as gender. The number of women in the medical field has increased in recent years. In Latin America, we have not found any studies that explore this relationship.

Objective

To determine whether there is an association between gender and the intention to choose a medical specialty in medical students from 11 countries in Latin America.

Methods

Secondary analysis of the Collaborative Working Group for the Research of Human Resources for Health (Red-LIRHUS) data; a multi-country project of students in their first year and fifth year of study, from 63 medical schools in 11 Latin American countries. All students who referred intention to choose a certain medical specialty were considered as participants.

Results

Of the 11073 surveyed students, 9235 indicated the name of a specific specialty. The specialties chosen most often in the fifth year were General Surgery (13.0%), Pediatrics (11.0%), Internal Medicine (10.3%) and Obstetrics/Gynecology (9.0%). For women, the top choices were Pediatrics (15.8%), Obstetrics/Gynecology (11.0%), Cardiology (8.7%), General Surgery (8.6%), and Oncology (6.4%). In the adjusted analysis, the female gender was associated with the choice of Obstetrics/Gynecology (RP: 2.75; IC95%: 2.24–3.39); Pediatric Surgery (RP: 2.19; IC95%: 1.19–4.00), Dermatology (RP: 1.91; IC95%:1.24–2.93), Pediatrics (RP: 1.83; IC95%: 1.56–2.17), and Oncology (RP: 1.37; IC95%: 1.10–1.71).

Conclusions

There is an association between the female gender and the intention to choose Obstetrics/Gynecology, Pediatrics, Pediatric Surgery, Dermatology, and Oncology. We recommend conducting studies that consider other factors that can influence the choice of a medical specialty.

Career pathways of board-certified surgeons in Japan

PURPOSE

To investigate the career pathways of board-certified surgeons' and the factors associated with them maintaining their certification in Japan.

METHODS

We analyzed data from the surveys of physicians, dentists and pharmacists. A multivariate logistic regression model was used to investigate whether factors such as gender, year of registration, place of work, and subspecialty board certification were associated with maintaining board certification.

RESULTS

Most Japanese surgeons attain board certification within 5-10 years of initial medical registration. After adjusting for possible confounding factors, the odds of maintaining board certification were significantly lower for women, those who were beyond 20 years post-registration, those who worked in hospitals other than academic hospitals or clinics, and those who had board certification in surgery only. Of the total board-certified surgeons analyzed, 93.2 % continued to work in hospitals and 2.8 % moved to clinics within 2 years. Of those who moved from hospitals to clinics, half continued to practice surgery, while nearly 40 % changed their specialty to internal medicine.

CONCLUSION

It is necessary to establish a special training system for mature surgeons who move from surgery to general practice later in their careers. As the number of female surgeon increases, a support system is also required to secure the future supply of surgeons.

Trends in doctors' early career choices for general practice in the UK: longitudinal questionnaire surveys

BACKGROUND

The percentage of newly qualified doctors in the UK who want a career in general practice declined substantially in the 1990s. The English Department of Health expects that half of all doctors will become GPs.

AIM

To report on choices for general practice made by doctors who qualified in 2000, 2002, 2005, 2008, and 2009.

DESIGN AND SETTING

A structured, closed questionnaire about future career intentions, sent to all UK medical graduates.

METHOD

Questionnaires sent 1 year after qualification (all cohorts) and 3 years after (all except 2008 and 2009).

RESULTS

Percentages of doctors who expressed an unreserved first choice for general practice in the first year after qualification, in the successive five cohorts, were 22.2%, 20.2%, 23.2%, 21.3%, and 20.4%. Percentages who expressed any choice for general practice - whether first, second or third - were 46.5%, 43.4%, 52.6%, 49.5%, and 49.9%. Three years after qualification, an unreserved first choice was expressed, in successive cohorts, by 27.9%, 26.1%, and 35.1%. Doctors from newly established English medical schools showed the highest levels of choice for general practice.

CONCLUSION

The percentage of doctors, in their first post-qualification year, whose first choice of eventual career was general practice has not changed much in recent years. By year 3 after qualification, this preference has increased in recent years. At years 1 and 3, the overall first choice for general practice is considerably lower than the required 50%, but varies substantially by medical school. In depth studies of why this is so are needed.

Cost containment and quality of care in Japan: is there a trade-off?

Japan's health indices such as life expectancy at birth are among the best in the world. However, at 8·5% the proportion of gross domestic product spent on health is 20th among Organisation for Economic Co-operation and Development countries in 2008 and half as much as that in the USA. Costs have been contained by the nationally uniform fee schedule, in which the global revision rate is set first and item-by-item revisions are then made. Although the structural and process dimensions of quality seem to be poor, the characteristics of the health-care system are primarily attributable to how physicians and hospitals have developed in the country, and not to the cost-containment policy. However, outcomes such as postsurgical mortality rates are as good as those reported for other developed countries. Japan's basic policy has been a combination of tight control of the conditions of payment, but a laissez-faire approach to how services are delivered; this combination has led to a scarcity of professional governance and accountability. In view of the structural problems facing the health-care system, the balance should be shifted towards increased freedom of payment conditions by simplification of reimbursement rules, but tightened control of service delivery by strengthening of regional health planning, both of which should be supported through public monitoring of providers' performance. Japan's experience of good health and low cost suggests that the priority in health policy should initially be improvement of access and prevention of impoverishment from health care, after which efficiency and quality of services should then be pursued.