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).
a) Personal background
Characteristics of individuals
Characteristics which affected the choice of family medicine consist of the following two concepts.
Self-reliance
A self-reliant personality not affected by surroundings was one of the common characteristics among the respondents. As one respondent put it:
“I thought that every obstacle would be no surprise, and paying my full attention to surmount the obstacles would be a worthwhile job.”
Pioneering spirit
The other characteristic of note was the pioneering spirit of those who found the frontier field of family medicine worthwhile:
“I expected to be a pioneer and felt excited, because I was certain that family medicine was not yet widely known in Japan.”
Career direction
Two major directions for the choice of family medicine as a career were “community/rural orientation” and “multifaceted orientation”.
Community/rural orientation
“I wanted to be engaged in a doctorless village. I thought family medicine was most suitable for the needs of such a community.”
“Family physicians can stand on the same ground with patients and community residents. It allows me to be myself. That's why I wanted to be a family physician.”
Multifaceted orientation
Many respondents were interested in many fields of medicine and wanted to deal with the entire realm of medical practice. Some respondents initially chose a specialty rather than family medicine but were familiar with a multifaceted orientation; they had not had the opportunity to know family medicine.
“When I became a doctor, I thought I wanted to be a doctor who could deal with any kind of physical problem.”
Experience
Experiences that strongly influenced the family medicine career choice were “pre-medical experience and familiarity with the family medicine concept” and “discomfort with fragmented care”.
Pre-medical experience and familiarity with the family medicine concept
For some of the respondents, the choice of family medicine as a career was based on personal experience: when a family member became ill, the respondent's pre-medical experience with the primary care physician who cared for the family member was a strong influence. Other respondents had career directions aligned with family medicine from a psychosocial standpoint, such as influence by a teacher or a clinical psychotherapist.
“A member of my family became bedridden due to a stroke. When the caregiving had exhausted other family members, I felt the thoughtfulness of the home care doctor was splendid.”
Discomfort with fragmented care
Some respondents had uncomfortable feelings toward the highly specialized and disease-oriented medicine usually seen in large-scale hospitals.
“When an internist saw a patient with pneumonia, the internist simply said 'Pneumonia is not my specialty.' I was really disappointed.”
b) Exposure to the family medicine concept
At various times and in a variety of settings, all of the respondents had been exposed to the family medicine concept although the conventional medical education in Japan offers no official opportunity for learners to be exposed to family medicine. Lectures or seminars outside the university or textbooks were alternative opportunities. After the respondents' exposure to family medicine, there were various first impressions.
“When I first had contact with the family medicine concept, I felt 'This is it!!'”
“I felt dubious about the family medicine concept and not sure if it could be a lifelong career.”
c) Matching with one's ideals
Some of the respondents felt that family medicine matched with their ideals, and they started thinking of family medicine as a career specialty.
“I was impressed at family physicians' role in helping citizens, families and the community. My intuition told me that family medicine was my life's work.”
d) Influencing factors
In the process of choosing family medicine as a career specialty, several important factors had both positive and negative influences.
Supporters
Respondents noted that the existence of family physician role models and empathic support from their family and colleagues were indispensable promoters of the family medicine career choice.
Role models
Some respondents had a family member who was a primary care physician, and other respondents stated that a primary care physician cared for an ill member of his or her family. In each case, the primary care physician was a role model for the respondent.
“A family physician who cared for me and my mother has been my role model. So I was thinking about being the kind of physician who can deal at first with any problem.”
Family/peer support
Empathic support from family and colleagues and the increasing social status of family physicians had positive influences on the respondents' career choice.
“I had a feeling that I wasn't isolated, because of the increased social recognition and increased family medicine applicants among medical students.”
“When my wife told me, 'I guess you are suitable for a family physician,' I was really encouraged.”
Conflict of career choice
Hesitation of career change
The respondents who had practiced a specialty other than family medicine tended to hesitate when it came to re-training for family medicine.
“I felt as if I had to lose my original specialty to select family medicine as my career.”
Dilemma between family medicine and specialties
Some respondents reported facing a dilemma between the choice of family medicine and another specialty when they were interested in family physician.
“I was unable to make up my mind whether to continue pediatrics or to change my career to family medicine.”
Anxiety about the diverse/broad practice
“I didn't have confidence that I could deal with such a broad and general field.”
The dawn of a new era in family medicine in Japan
As noted earlier, a three-year family medicine program was started in Japan in 2006, and when the present study's questionnaire was compiled, there were no more than approximately 200 certified family physicians in Japan. In addition, only 1% of junior doctors are entering the family medicine residency program. The main factors that had a negative influence on the choice of family medicine as a career among the present study's 41 respondents were “lack of social recognition”, “concern about livelihood”, “anxiety about an ambiguous identity”, “unestablished training system” and “too few role models”.
Lack of social recognition
Lack of understanding from individual around the respondents had a negative impact on the career choice of family medicine.
“No one around me understood family medicine as a career specialty, so I was not sure if I could do it.”
“During my clinical clerkship, some teaching staff scoffed at my career dream to be family physician, and said, 'Such a specialty doesn't exist (in Japan).' ”
Concern about livelihood
“I felt insecure about my future career and my family's livelihood because family medicine was not acknowledged as a specialty at that time.”
Anxiety about an ambiguous identity
Low social recognition of the family medicine field made it difficult to establish an identity.
“When asked about my specialty, especially what family medicine is, I couldn't really answer....”
Unestablished training system
Lack of a family medicine program, colleagues, and training information were obstacles for the respondents who were interested in family medicine.
“When I was a junior resident, only a few training facilities and colleagues were acknowledged. I even thought of going to the U.S. for family medicine training.”
Too few role models
The respondents had seldom observed a family medicine role model because the number of role models was quite limited.
“I couldn't imagine what I would be like after gaining experience as a family physician.”
e) Seeking one's own solution
Some respondents had a strong will to solve or surmount the problems/obstacles associated with family medicine training by themselves.
“There were very few family medicine training facilities at that time. So I started to gather information about training facilities and visited some of them.”
f) Attractiveness of family medicine from the practitioners' viewpoint
After the respondents chose family medicine as a career, many of them were satisfied with their jobs. The following five family medicine-specific attributes were found to be the most attractive after the respondents had chosen family medicine as a career.
Relationship-based practice in the community
Some respondents felt that having a continuous relationship with their patients was an appealing aspect of family physicians. The concept of “Relationship” implied an ongoing relationship with patients or the community and other healthcare providers.
“I think I can provide compassionate medical treatment by taking good care of not only the disease but also the lives of the patients and people.”
“Family physicians can build up a team in a rural community that eases people's minds and enables large-scale jobs which no one can carry out by themselves. This is an aspect of family medicine that appeals to me.”
“Being with patients, families and the community as a family physician has expanded my perspectives.”
The spirit of cooperation
Some respondents described cooperativeness, flexibility and educational passion as appealing aspects of family medicine.
“I think there is very good environment in this field where we value our peers, and there is not any infighting.”
Multifaceted and diverse practice
Respondents reported that family medicine is attractive because it does not limit one's field but provides various healthcare options for various people.
“In a way, every patient I see is within my field. Besides, understanding patients' familial/social contexts can improve the quality of care.”
Shaping the Japanese health system of the future
Some respondents regarded the possibility of solving healthcare problems and developing a new academic field in Japan to be appealing.
“Academic aspects of family medicine impressed me because forerunners have been verbalizing and deepening the areas not previously well conceptualized in Japan. Furthermore, the aspect of family medicine implies not only a conceptual framework but also practical aspects.”
Comprehensiveness and diversity/depth of the field
The practice of family medicine consists of both broad and deep aspects of all of the fields of medicine.
“The broad field of family medicine is worth spending the rest of my whole life learning.