Factors associated to the career choice of family medicine among Japanese physicians: the dawn of a new era

Japan has the highest life expectancy in the world [1]. Some unique features of the Japanese healthcare system may contribute to better health outcomes and thus to the long life expectancy. First, the Japanese government has provided universal health insurance coverage since 1961. Second, patients in Japan have the privilege of free access to healthcare without any formal gatekeeping system.

In most of the countries in which a healthcare system is well established, healthcare roles are clearly divided between the provision of primary healthcare by general practitioners, and the provision of secondary to tertiary care by specialists. The Japanese healthcare system, in contrast, has not established any definite division between general practitioners and specialists. In addition, no formal postgraduate training program for family medicine was developed in Japan until 2006.

Most of the conventional primary care physicians in Japan were originally trained as specialists; typically, after completing specialty training and subsequent work experience as a hospital-based specialist for some years, they open their own private clinic without any formal family medicine training. Additionally, Japanese society's increasing demand for quality healthcare has raised a new issue pertaining to the lack of formal training for primary care physicians in Japan [2],[3]. Before the merger of the Japanese Society of Primary Care, the Japanese Academy of Family Medicine (JAFM) and the Japan Society for General Medicine as the Japan Primary Care Association (JPCA) in 2010, the JAFM had implemented a three-year family medicine program for certified physicians since 2006.

In 2012, the Japanese Ministry of Health, Labour and Welfare announced a new board certificate system for physicians' specialties by a third-party organization starting in 2017. Along with this reform, “General Practice” including family medicine has formally become the 19th new specialty. Although the need for formally trained family physicians in Japan is increasing, our preliminary study (2011 unpublished) showed that only 1% of junior doctors are entering the JPCA certified family medicine residency program. To enhance the recruitment of family medicine residents, it is essential to understand the factors that influence the choice to practice family medicine versus other fields of medicine.

In the United States and Canada, aside from a dip in the late 1990s, the number of family physicians has increased significantly over the last few decades. Despite this positive trend, the numbers of residents choosing the family medicine specialty remain well below those nations' needs. Studies from Europe and North America revealed several common factors associated with the career choice of family medicine. In a review article, factors that were positively associated with the choice to practice family medicine were “rural background”, “parents' low socioeconomic status”, “low interest in research career” and “planning on a career in a disadvantaged or rural area” [4]. Negative factors were “concerns about prestige”, “low income”, and “breadth of knowledge required” [4]. “Low intellectual content” was also suggested as a reason for rejecting family medicine [5].

The American Academy of Family Physicians (AAFP) devised a Student Interest “Influencer” Portfolio [6] to explore medical students' interests as documented in four regional Student Interest Stakeholder meetings in 2010 and 2011. The AAFP held the meetings to counteract the stagnation in students' interest in practicing family medicine. The meetings showed that the positive perceptions of family medicine include “diverse and complex patients (never bored)”, “family and life-friendly specialty”, “highest recruited specialty since 2007” and “specialty for all environments/settings practice options.” Negative perceptions, on the other hand, were “too easy/too hard paradox”, “scope of practice paradox (only colds and coughs)”, “doesn't make any money”, “life style — can't do it all (take calls, deliver babies, etc.)”, “bashing from different specialties”, and “medical school — lack of exposure to family medicine”.

In Japan, there have been a few reports about the factors associated to the career choice of “conventional” primary care/rural medicine. For example, toward the goal of increasing the number of primary care providers, Ohtaki et al. proposed that the medical education system in Japan must provide both primary care doctors to act as role models and readily accessible information about postgraduate primary care programs [7]. Ae et al. found that residents who expected to engage in rural practice were significantly more likely to choose primary care as a future career, and residents with training experience in a rural setting had a significantly higher tendency to change careers from a specialty to primary care [8]. Thus, Ae et al. noted that exposure to rural practice during residency training can affect residents' career plans. However, to our knowledge no report on career choices with respect to the newly established family medicine specialty in Japan has been published.

The objective of the present qualitative study was to investigate the possible factors associated to the career choice of the newly established family medicine program in Japan.

We extracted 77 subordinate concepts from 330 variations. We had set the framework of this study as “family medicine career choice”. Eight concepts were excluded from the conceptualization for two reasons; 1) responses were not specifically related with family medicine (e.g. resistance to detachment from hometown), and 2) responses were beyond our scope of the research (e.g. issues raised after the career was chosen).

The conceptual model consisted of six categories: (a) personal background, (b) exposure to the family medicine concept, (c) matching with one's ideals, (d) influencing factors, (e) seeking one's own solution, and (f) attractiveness of family medicine from practitioners' viewpoints (Figure 1).

This qualitative study aimed to investigate the possible factors associated to the career choice of family medicine and those associated to enrollment in the newly established family medicine program in Japan. The process of choosing a career in family medicine is multifactorial and complex. Several factors appear to be characteristics of the choice to go into family medicine practice. Those factors can have positive or negative influences on the career choice of family medicine.

In Japan at this stage, there are not enough family physician role models or family medicine curricula/residency programs. Previous studies outside of our country describe encounters with family physician during postgraduate training or in medical school curricula [11],[12], but in our study, most respondents' exposure to the family medicine concept was incidental, by way of books or seminars. The responses from participants in this study indicated that medical students and residents who had never known the concept of family medicine did not choose family medicine specialty even if they had felt a “discomfort with fragmented care”.

Although the respondents noted several negative influences on the choice of family medicine as a career (i.e., lack of social recognition and of a guarantee of livelihood, the absence of role models and training systems, and anxiety about an ambiguous identity), the factors of “pioneering spirit” and “self-reliance” can be strong accelerating influences in this newly established field. In addition, the feeling that a new era is dawning in family medicine in Japan may contribute to the choice of family medicine as a career. Some candidates may be attracted by “seeking one's own solution” that family medicine may still require in Japan. In a description of physicians in North America and the UK who chose family medicine, Taylor wrote they were self-confident, visionary, audacious, passionate, and energetic [13].

In our study, unlike previous findings, the factors of lifestyle [11],[14],[15] and short residency program [11],[16] were not shown to be indicative of family medicine's attractiveness. In contrast, we found that “concern about livelihood” was a specific concern in the dawn of the new family medicine era. Achieving career security and/or a guarantee of income seems to be difficult in the present circumstances and thus a pioneering spirit and a sense of self-reliance may be critical to a candidate's choice of family medicine as a career.

Actual clinical family medicine exposure that demonstrates enduring relationships with patients, continuity of care, and preventive medicine are essential to attracting candidates to family medicine [11]. Several common factors such as the amount of exposure to family medicine, existence of a family medicine department and a residency program in his/her medical school have been described as accelerators for the family medicine career choice [11],[12],[15]. Thus, increasing the amount of exposure to family medicine is expected to lead more young physicians to select family medicine in Japan.

Family medicine's “community/rural orientation” as described in the present study has aspects in common with the known premedical attributes familiar to family medicine (humanitarian outlook and rural background) [6],[11],[16]. We also found that family medicine's “multifaceted orientation” is a point of appeal that may be aligned with some physicians' preference for the varied tasks of family physicians described in previous studies [6],[14],[17]. These present and previous results imply that there are several universal orientations among family medicine candidates regardless of cultural or medical system differences. In our study, these universal factors were also found in attractiveness of family medicine from the practitioners' viewpoints, and thus the constructive presentation of these attractive points may positively influence candidates considering the practice of family medicine.

Not only amount of exposure to family physicians, but also existence of good role models could greatly impact on family medicine candidates [11],[18]. Medical school faculty members who can convey the attractiveness of family medicine as a career could also make a significant contribution to this impact [11].

It was unique to our study that the dawn itself could attract those with a “pioneering spirit” and an “attitude of self-training”, although the dawn of a new era seemed a rather negative influencer. The known positive factors such as lifestyle and the short residency program were not shown to be part of family medicine's attractiveness in our study. In contrast, “concern about livelihood” was specific among our respondents and was related to career choice in the dawn period. These dawn-specific factors clarified by this research could contribute to the development of family medicine in countries which have introduced the same changes as Japan. Further studies are needed to confirm whether the characteristics of the choice to practice family medicine identified here will continue to play a role in the future. Moreover, following studies to clarify the reasons why some physicians did not choose family medicine specialty could be useful.