Japan’s shocking decline of rural doctors

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A new system to certify doctors as specialists in internal medicine and surgery, which is time-consuming and requires them to work in remote areas, is causing an increasing number of young physicians to shun these fields. | BLOOMBERG


Medical doctors specializing in internal medicine and surgery are fast disappearing from many rural municipalities. Such a nightmare may be hard to believe, but it is becoming a reality due to a new system for certifying specialist medical doctors that will take effect this spring.

The new system, initiated jointly by the Japanese Medical Specialty Board (JMSB) and the Health, Labor and Welfare Ministry, is causing an increasing number of young and talented doctors to turn away from internal medicine and surgery, and to seek work in ophthalmology and otorhinolaryngology instead. This is because doctors will not get certified as specialists until after they reach the age of 30 and they will be required to work in remote areas before receiving such certifications in internal medicine and surgery. Although the JMSB and the health ministry claim that the new system is aimed at producing skilled specialists, it will in fact ruin Japan's medical services and unless something is done, deprive residents in rural communities of chances to receive proper medical care.

An analysis of data compiled by the JMSB has revealed shocking facts. In the nine prefectures of Akita, Fukui, Kagawa, Tokushima, Tottori, Shimane, Yamaguchi, Kochi and Miyazaki, the number of new doctors specializing in internal medicine will dwindle to 15 or less each during fiscal 2018, which begins in April. Similarly, the 14 prefectures of Aomori, Gunma, Yamagata, Fukui, Yamanashi, Nara, Shimane, Yamaguchi, Tokushima, Ehime, Kagawa, Kochi, Saga and Miyazaki will each have five or less new surgeons. Of them, Gunma, Yamanashi and Kochi will have only one each.

Should this trend continue, medical services in rural areas will fall apart and a growing number of people will lose the opportunity to be treated properly, making the government's pet slogan of "resuscitation of rural areas" a pie in the sky.

The root cause of this crisis is the JMSB. Until now, specialist certifications have been issued independently by the Japanese Society of Internal Medicine and the Japan Surgical Society. Because of some disparities in the certification standards between the two societies, a call has come for unifying the standards by a neutral third party. Thus the JMSB has been created with the task of certifying specialists in 19 principal fields.

Those seeking specialist certification are usually young doctors who have just completed early clinical training. It is only natural for most of them to try to find employment in Tokyo and other metropolitan areas where many medical institutions are eager to hire them.

A downside of the new scheme is conspicuous in internal medicine and surgery, both of which cover wide fields. For example, those who want to get specialist certification in internal medicine are required to be trained in 12 specialized fields, including gastroenterology and neurology, in addition to general internal medicine. These fields were added at the insistence of experts in each field. With these and other requirements, the age at which doctors are certified as specialists will be 32 at the earliest.

Another problem has surfaced. After being criticized that the new certification system will further aggravate an uneven geographical distribution of doctors, the JMSB has made it mandatory for specialist certification candidates to receive training in remote corners of the country. This has led medical institutions in remote rural areas to have excessive expectations over specialists of internal medicine and surgery, which are the core medical services in those areas. Many of the young doctors seeking to become specialists in internal medicine and surgery have resented this and shifted their area of specialization to other fields.

In November, the JMSB closed the filing of applications for training for specialist certification for fiscal 2018. The number of those who were accepted stood at 7,791, or about 90 percent of those who will have completed their early clinical training. That meant that with the exception of a few who seek to engage in basic medical studies and administrative work, most young doctors decided to apply for the certification.

For this spring, 2,527 have applied for training for certification as specialist internal medicine doctors, down by about 20 percent from an average of 3,224 for the past three years. The comparable figures for surgery are 767, down 6 percent from the fiscal 2010-2014 average of 820 who were chosen for training for specialist certification.

In stark contrast, the number of those aspiring to serve in such "minor" medical fields as ophthalmology is increasing. The number of applicants for specialist certification in ophthalmology is 60 more than the previous year's 228, or an increase of more than 20 percent. This is despite the fact that there already are more eye doctors than needed.

This situation has caught the JMSB off guard because things were moving in a direction completely opposite the board's express goal of evening up the distribution of medical doctors among different fields. According to an insider of a university hospital in central Japan, the JMSB suddenly asked it to reduce from 10 to seven the fixed number of young doctors applying for specialist certification in ophthalmology. Unable to resist the pressure, the university persuaded three young doctors to postpone their training for specialist certification till next year.

Benefiting from the new system are hospitals attached to prominent universities in Tokyo, where the number of internal medicine doctors is increasing. This spring, 520 will start receiving training to be certified as specialists in internal medicine in Tokyo. This represents an increase of 15 percent over 450 who sat for exams in Tokyo to get specialist certification in internal medicine in fiscal 2016.

Tokyo has 3.8 internal medicine doctors per 100,000 residents — 5.5 times higher than the lowest prefectural figure of 0.7 in Kochi. A characteristic feature in Tokyo is the high percentage of doctors who receive training for specialist certification at university hospitals. Of the 520 young doctors in Tokyo seeking to get specialist certification in internal medicine, 387 — or more than 70 percent — are to receive the training at such hospitals, surpassing the national average of 63 percent.

As more and more young doctors want to be trained in Tokyo, its two neighboring prefectures of Saitama and Chiba have felt an adverse impact. Saitama has 67 and Chiba 82 young doctors who will start receiving training for specialist certification in internal medicine this spring, down from the 79 and 102, respectively, doctors who took exams to receive the certification in fiscal 2016, and the third and ninth smallest figures, respectively, among the nation's 47 prefectures.

The blueprint for this new system was drawn up by bureaucrats at the health ministry specializing in medicine. The JMSB, tasked with implementation of the system, is in fact a "mutual aid society" of professors of medicine at universities, according to a journalist well-versed in medical services. A scandal involving a pharmaceutical firm, Novartis Pharma, in 2012 caused a sharp fall in monetary contributions from the pharmaceutical industry to professors in medicine. With the introduction of the new system by the JMSB, says the journalist, well over ¥1 billion will start pouring in annually under the guise of fees for renewing specialist certification and for certifying hospitals as fit for giving specialist training.

The same journalist says that the JMSB has hired 16 staffers and rented office space at the Tokyo International Forum complex near Tokyo Station. Its budget for fiscal 2016 included ¥15.55 million for rent, ¥37.08 million for business trips, ¥33.57 million for dispatch of lecturers and ¥7 million for conferences. The reason why the JMSB expends so much money without much business to do lies in the fact that the board has become a "lucky mallet of good fortune" for university professors, according to the journalist.

In April last year, the Japan Association of City Mayors issued a statement expressing serious concerns over the new specialist certification system for doctors. The plea was ignored, and the new system detrimental to the nation's medical services will start functioning very soon. This will undoubtedly become an overture to the collapse of medical services in rural areas.


-- https://www.japantimes.co.jp --

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