There has long been a widespread myth that medical doctors in general prefer not to leave big cities, causing a shortage of physicians in rural parts of the country and the resulting poor medical services accelerating depopulation. This myth has been proved false by a study undertaken by the Health, Labor and Welfare Ministry. But it is the ministry itself that has colluded with university hospitals in major cities to spread this false view in order to protect their vested interests. The study, initiated by health minister Yasuhisa Shiozaki, has exposed an “inconvenient truth” that the ministry did not want publicized.
There is no denying that rural regions of Japan face a serious shortage of doctors. In February, the Iwaki Kyoritsu Hospital run by the municipal government in Iwaki, Fukushima Prefecture, stopped accepting hospitalization of pulmonary tuberculosis patients when no replacement could be found for a full-time pulmonologist who reached mandatory retirement age. Iwaki, population 340,000, now has no full-time doctor to treat respiratory patients. In March, the Tarumizu Tokusuikai Hospital in Tarumizu, Kagoshima Prefecture, closed partly because it could not secure enough doctors. The shutdown of a hospital belonging to the nationwide Tokushukai group in its home turf came as a shock in medical circles.
The annual number of hospitals and clinics that were shut down or dissolved shot up from 121 in 2007 to 347 in 2014. The health ministry attributed this to what it described as a tendency among young doctors to prefer working in metropolitan areas and avoid working outside of big cities. It is ironic that the ministry’s own study has proved this assertion to be totally false.
Rural areas seen as attractive
In the survey, the ministry sent questionnaires to 100,000 doctors, of whom 15,677 responded. Those expressing their willingness to work in rural areas accounted for 44 percent, or nearly half, of the respondents. The ratio of such respondents was the highest among doctors in their 20s at 60 percent, followed by 52 percent among those in their 30s. The figure was the lowest among those in their 60s — but still 41 percent of them said they were ready to work in rural areas — defined in the survey as outside of Tokyo’s 23 wards, prefectural capitals and other specially designated major cities.
Even more surprising than the high proportion of doctors willing to work in rural areas was the finding that many of them would work in small cities in such areas for an extended period of time. Only 3 percent of the respondents said they would not like to work in such areas for longer than one year, while 12 percent said they would stay there for two to four years, 9 percent for five to nine years, and 26 percent for 10 years or longer. The team that conducted the survey was led by Seiya Imoto, a professor of information engineering at the Institute of Medical Science of the University of Tokyo. Even though he is not a medical doctor, Imoto was hand-picked by Shiozaki, who wanted to ensure impartiality of the study by putting a neutral party in charge instead of doctors with a stake in the issue.
Most of the doctors dispatched by major university hospitals to institutions in rural areas stay on the job for a year or two before being given new assignments elsewhere. But the survey indicates that many of those doctors are not happy with such short-term rotations. A doctor who works at a city in Wakayama Prefecture says that doctors wish to refine their skills by treating as many patients as possible, and that chances of obtaining such experience are better at hospital in rural areas than at large university hospitals.
There is also the factor of income disparity. Many of professors at university hospitals in the Tokyo metropolitan area earn less than ¥10 million a year, but it is not unusual for doctors in their 30s working at hospitals in rural areas to make ¥20 million annually.
Among the respondents to the ministry survey who said they do not wish to move to rural areas, those in their 20s cited the presence of organizations of university hospital staff headed by professors, job requirements and working environment, as well as the need to acquire specialized medical skills. Those in their 30s and 40s listed the education of their children, job requirements and the existence of organizations of university hospital staff. Those in their 50s and older mentioned their wish to open their own clinics in big cities, job requirements and work environment, and the need to look after their own parents. These findings suggest that, particularly among doctors in their 40s or younger, the organizations of university hospital staff headed by professors — which often would allow them to work in rural areas even if they wish to — influence their decisions.
The fees that patients pay for medical services are set uniformly throughout the country. It follows that the management of hospitals will be more stable in rural areas where various costs are low, provided that enough doctors can be secured. Doctors will also find it more beneficial to work at such institutions where they can expect higher pay and ample support. What prevents them from working away from big cities is the way university hospitals in metropolitan areas will not let young doctors go because they constitute efficient manpower.
Sway of university hospitals
In discussing the current uneven geographical distribution of doctors, one cannot overlook the role played by major university hospitals. Of the 234,992 licensed doctors younger than 60 nationwide, 50,705 or 22 percent, are employed by universities. About 30 percent of the 170,381 doctors working for hospitals belong to university hospitals. Yet, the “productivity” of doctors at university hospitals is extremely low. While principal medical institutions in rural areas annually accept roughly 140 inpatients per doctor on average, the comparable figure for university hospitals is only about 60.
Another surprise result of the ministry survey was that doctors are engaged in such non-medical chores as clerical work, shipping of goods and transportation of patients to examining rooms, with the respondents saying that 30 percent of such work could be performed by non-medical staff. It is perplexing that doctors have to undertake such chores, despite their overall shortage.
A professor at a private university in the Tokyo area admits that university hospitals want young doctors because “they can be forced to toil at low pay.” A clerical staffer at a university hospital says that young doctors are “more cost-efficient than hiring part-time staff” from temporary agencies. And one of the reasons that keep the young doctors at university hospitals is their wish to get qualified as specialist doctors. Currently, the Japan Society of Internal Medicine and the Japan Surgical Society are developing a self-serving scheme under which doctors would have to work at university hospitals in order to gain specialist qualifications.
Since those medical societies are controlled by professors in medical departments at elite national universities and leading private universities such as Keio, the scheme, if implemented, would benefit those hospitals because they would be able to easily secure large numbers of young doctors. Although the plan to introduce the scheme in April has been pushed back by opposition from young doctors and the Japan Association of City Mayors — which complained that it would result in further decline in medical services in rural areas — the medical establishment seems determined to push ahead with it.
If the “productivity” of university hospitals could be raised to the level of general hospitals, about 20,000 doctors would become available to work in rural areas, contributing to alleviating the doctor shortage in those areas. However, university professors do not seem interested in pushing for such a reform.
Nor is the health ministry willing to support such a reform by severing the bonds that tie young doctors to university hospitals. The ministry does not want to antagonize university professors since that could risk losing post-retirement positions for its bureaucrats at their schools. Satoshi Miura, former director of the ministry’s Health and Welfare Bureau for the Elderly, landed a job as a professor at Keio University Hospital after he retired last year. In 2015, Yukio Matsutani, a former head of the ministry’s Health Policy Bureau, was hired by the International University of Health and Welfare.
Nothing could be more ridiculous than to ask those responsible for creating the doctor shortage problem in rural areas to solve the very same problem. As long as they continue to play leading roles in the discussion, the problem will be exacerbated.
This is an abridged translation of an article from the June issue of Sentaku, a monthly magazine covering political, social and economic scenes. More English articles can be read at www.sentaku-en.com.