Although the total number of family physicians was much lower than those of other physicians, family physicians in Japan distributed more to rural than to urban areas, in stark contrast to the urban-biased distribution of other physicians. This study suggests primary care physicians have a very favourable distribution even in a country with a poor primary care orientation, no regulation on the distribution of physicians, and free access of people to physicians.
The better distribution of family physicians and urban-biased distribution of other specialists were also observed in the United States and Europe14-17. In countries with a strong primary care orientation and a public sector-based healthcare system such as the United Kingdom and the Netherlands, everyone is required to register with his/her general practitioner. It is quite reasonable, in such countries, for general practitioners to distribute according to population. In countries with a private sector-based healthcare system such as the United States, a substantial proportion of population is gate-kept by a family physician designated by each person’s health insurance company. In such a country, it is not surprising that family physicians distribute more equally than other specialists. However, the Japanese healthcare system is unique. The Japanese do not need to register with a certain primary care physician. Their access to any physician is not limited by insurance companies or the government. All the Japanese are covered by public health insurance and they can choose their physicians of any specialty. In addition, physicians can choose where to practice without any governmental regulation. This study showed, even in Japan, primary care physicians distributed quite equally, or even disproportionately torural areas.
Accessibility, both financial and geographical, is a principle of primary care18. To ensure the quality of primary care, physicians need to ensure equal and good accessibility to their patients19. The egalitarian principle of primary care might help family physicians to voluntarily distribute equally or more to places where they are in greatest demand.
Another potential reason for a rural-biased distribution of Japanese family physicians is the cost of practicing in urban areas, especially for young family physicians. In Japan, most clinics are managed by an individual or a family. A relatively few physicians are hired to work in clinics. The initial cost to establish a clinic is estimated, on average, at 94 million yen (758,000 euro), 20 million of which come from the physician’s own savings20. In Japan, early-career physicians are usually hired by a hospital and then open their own clinics in the middle or towards the end of their career. The median age of our study participants was 37. Because early-career physicians do not have 20 million yen in savings, if they become family physicians, they may be limited to working in public clinics established by municipalities in areas with a physician shortage. This might tilt the distribution of Japanese family physicians towards rural areas.
The results of this study suggest that the increase of family physicians might rectify the present urban-skewed distribution of physicians, which has long been a serious social problem in Japan3. However, the number of Japanese family physicians was negligible, because of the short history of JPCA certification and the lack of governmental support for increasing the population of family physicians. A small but important first step to the expansion of this group of physicians was the introduction of ‘general practice’ as one of 19 major clinical disciplines under the new training system for board certification starting in 2018. However, against expectations, the number of applicants to ‘general practice’ was only 1774 (2.1%) of the 8604 applicants in 2019. The low popularity is probably caused by low awareness among population and lack of governmental political support for general practice in Japan21.
Family physicians are pivotal in providing care in Japan where the population is rapidly ageing and more patients than ever are presenting with numerous chronic conditions. The government and professional bodies need to counteract the limited popularity of family medicine. By increasing the number of family physicians, Japan will be in a better position to handle the multi- and complex-morbidity of patients and the geographic maldistribution of physicians in a quickly ageing society.
This study has the following limitations. First, the age of JPCA-certified family physicians was estimated. Therefore, we could not assert that physicians between the ages of 30 and 49 were the most appropriate comparison group. In addition, we could not adjust the factors related to physicians’ choice of practice location such as gender and birthplace because these data were not available.
Article 25 of the Japanese Constitution states that everybody has a right to be healthy regardless of where they live or how much they earn. However, the geographic barrier to healthcare for rural residents has persisted despite half a century of financial and political investment by the government3. To improve the quality of care, streamline the provision of care, and especially to equalise the distribution of care, the Japanese government should increase the number of family physicians through national policies including offering financial incentives to medical students and physicians in training who hope to enter family practice.